Episode 59 - The Keto Diet - a podcast by Rio Bravo Family Medicine Residency Program

Episode 59: What is Keto?  

Discussion about the benefits and risks of the keto diet. Introduction about the CDC Contraceptive app.

Introduction: Contraception App Update (CDC)
By Cecilia Covenas, MD, and Hector Arreaza, MD

Today is July 16, 2021.

 

What is the CDC Contraception App? 

The CDC has updated their contraception app to assist health care providers in counseling women, men, and couples on the different contraceptive methods. The app is called Contraception. When you open the app, it has three main sections. MEC by Condition, MEC by Method and SPR. 

 

MEC stands for Medically Eligibility Criteria, it is a guide to choose the safest contraceptive for patients with certain medical conditions. SPR stands for Selected Practice Recommendations. It is a guide for common topics such as initiation of a particular method, or tests needed before starting a contraceptive, or follow up, etc. The last update to the app was this past March, and it includes new features. Now, you can select up to three conditions at once, move from one condition to another easily, and see additional info for a particular condition and method.

 

How to use it?

There are three main sections: MEC by condition, MEC by method, and SPR. 

 

The US MEC recommendations are divided into four categories, from 1 through 4.

Category 1 means no restriction to use that contraceptive (it’s good to use, it’s displayed with a dark green background).

Category 2 means the advantages of using the method generally outweighs the risk (OK to use, it’s marked with a light green color).

Category 3 means the risks of the method generally outweighs the advantages (this is not a good choice choose something else, it’s shown with a light red color).

Category 4 means there is an unacceptable health risk for using that method with that specific condition (do not use this contraceptive method! It is shown with a dark red color background).

 

For example, a 36-year-old female with obesity (BMI 32) and migraines with aura would like to start Combined Hormonal Contraceptives (CHC or the “pill”), will this be safe for her?

 

Open the app, choose MEC by condition, then select the conditions “Menarche to <40 years for CHC”, then under Headaches, tap on “Migraines with aura,” and under Obesity, choose “BMI >30”. Tap on Continue.

 

The recommendations for each condition are displayed, and we can move to each condition easily by tapping on the arrows on the top of the page. In this patient, for example, the “pill” (CHC) is category 1 for her age, category 2 for obesity with BMI >30, but it’s category 4 for migraines with aura. You can see more info by tapping on the plus sign in each recommendation. Based on the evidence, this patient is not a good candidate for CHC. So, do not prescribe it!

 

Let's say the same patients asks about IUD (Mirena®), acronym LNG IUD, is it a good choice? Let’s tap on MEC by Method, then find the IUD and select the same conditions: age, migraine with aura, and obesity. The IUD is category 1, you can prescribe it safely.

 

To expand your knowledge even more, tap on the SPR icon and select the recommendations on initiation of the IUD. According to the Selected Practice Recommendations (SPR), the IUD can be inserted at any time if it is reasonably certain the patient is not pregnant. You can insert IUD after obtaining consent, and going over the risks, benefits, and alternatives, under proper supervision if you are a resident.

 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

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What is Keto?   
By Constance Baker, MS3, Valerie Civelli, MD, and Hector Arreaza, MD.  

 

What is it/history? 

High fat, low carbohydrate diet 

Goal is to have most of your calories come from fat followed by protein with <50g/day coming from carbohydrates. 

There are many different variations of this diet in regards to amounts of fats and proteins used but carbohydrates should be <50g/day.

Most used today for weight loss and the fight against obesity.

Created in 1921 by Dr. Wilder and Dr. Woodyatt at the Mayo Clinic.

The ketogenic diet was first created as a treatment for epilepsy in children. It was the first line treatment until the creation of antiepileptic medication

At this time, it was also used for treatment in diabetic patients.

 

 

How does it work? 

The logic behind the ketogenic diet is to put the body in “starvation” mode by limiting carbohydrate intake and increase use of stored fat in the body. This decreased insulin secretion causing the body to use its glycogen stores until depleted. When those are depleted, the body enters gluconeogenesis. A process where the body makes its own glucose out of the precursors lactic acid, glycerol, and amino acids. This process can only be used for a short time, eventually the body will run out precursors and will have to switch metabolic processes one more. This time, the body switches to ketogenesis. During ketogenesis, the body makes ketones bodies for the primary source of energy in the place of glucose. 

So, the whole goal is to keep the carbohydrates intake as low as possible in order to force the body to use ketones as the primary source of energy instead of glucose.

Insulin promotes storage of fat and glucose in the body. Decreasing the utilization of glucose in the body has a negative feedback on insulin secretion. So overall, insulin is decreased in the body which decreases the overall storage of fat and glucose which is beneficial in someone who has excess fat stores.

 

Benefits 

Weight loss with a decrease in overall body mass 

Proven to help epilepsy in children 

Decreases cardiovascular risk factors 

Helps with a wide array of metabolic diseases

 

Adverse effects

At the start of a diet, people can have GI upset like nausea, vomiting and constipation. Some people often report bad breath, headaches and sleeping problems.

Someone can have a false positive breathalyzer test due to the ketones that are produced.

Long term compliance is often difficult to achieve due to the strict dietary restrictions and fatigue.

The American College of Cardiology and American Heart Association do not recommend utilizing the ketogenic due to unknown effects on cardiovascular disease. 

 

Populations 

BMI >25

Most common population that utilizes the ketogenic diet 

Well liked because weight loss happens quick (within months) as opposed to other diets which take longer to show progress 

Works as an appetite suppressant 

The body has to work harder for its fuel, so you burn more calories through metabolism and increases the breakdown of fat in the body.

 

Diabetes 

Promotes the body to use the excess glucose for fuel instead of turning it into fat in order to decrease glucose levels in the blood. 

Ketones have a negative correlation with glucose released from the liver. Which means increased ketones = less glucose in blood = better glycemic control. In the long run, this will low an individual’s HbA1c as well. 

The effect on glucose control only seems to affect diabetic patients. A study which compared diabetic and non-diabetic fasting glucose level on the ketogenic diet, and it only lowered the diabetic fasting glucose. 

Caution should be taken in an individual who is taking hypoglycemic causing medications to treat their DM. Medication adjustment is most likely needed, and they should consult their physician. 

 

Epilepsy 

Ketogenic diet has been a treatment for epilepsy since 1920 when the diet was created. 

The use of this treatment decreased as antiepileptic drugs became more popular and effective at treating. 

Studies have shown that ketogenic diet is just as effective as medications.

Today, ketogenic diet is most commonly used in refractory epilepsy where surgery is not an option. 

Athletes 

During exercise, the body uses fatty acids during oxidative metabolism, so the thought is the use of a high fat diet will increase the utilization of oxidative metabolism and aid in endurance of the athlete. 

Most studies have included endurance (aerobic) athletes over any other kind. The studies have shown that fat consumption increased causing improved body composition in athletes. They have not shown to influence athletic performance in males, but in females, one study showed a decrease in athletic performance when compared to their male counterpart. 

In anerobic athletes, they require more protein overall in their diet due to the need to repair/build their muscles. When utilizing a ketogenic diet, fat is the prominent source of nutrition followed by protein. Their glycogen stores are low which promotes the body to have an affinity for the gluconeogenic pathway which can have negative effect on performance. Some studies have shown a decrease in lean body mass and skeletal muscle thickness which could be detrimental to a body builder or power athlete.

 

For many years, ketogenic diet has been the treatment option for glucose transporter protein 1 (GLUT-1) deficiency and pyruvate dehydrogenase deficiency.

 

Individuals with kidney disease, liver failure, pancreatitis and fatty acid metabolism disorders should use caution and are contraindicated, and they should consult with their physician before beginning a ketogenic diet because it can worsen their condition.

 

Conclusion

Research is still limited for the ketogenic diet overall. Long term complications are still widely unknown because of long term compliance is difficult and research studies have been limited thus far. 

 

It is a widely used diet in today’s world. 

 

It has showed great promise in helping in the fight against metabolic diseases 

 

It has been proven to help with epilepsy in children 

 

There are mixed reviews for how it is beneficial to athletes. It is reliant on what the goal of training is as well as type of training being utilized. 

 

This diet is not beneficial to everyone and before you decide to begin it, you should consult with your physician. 

 

 

 

 

Now we conclude our episode number 59 “The Keto Diet.” Is this a fad diet or the tool you were waiting for to help your patients lose weight? You can decide. Keep reading, keep learning, and keep trying.. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Cecilia Covenas, Valerie Civelli, and Constance Baker. Audio edition: Suraj Amrutia. See you next week! 

 

References:

Gershuni VM, Yan SL, Medici V. Nutritional Ketosis for Weight Management and Reversal of Metabolic Syndrome. Curr Nutr Rep. 2018 Sep;7(3):97-106. doi: 10.1007/s13668-018-0235-0. PMID: 30128963; PMCID: PMC6472268. https://pubmed.ncbi.nlm.nih.gov/30128963/

 

Harvey KL, Holcomb LE, Kolwicz SC Jr. Ketogenic Diets and Exercise Performance. Nutrients. 2019;11(10):2296. Published 2019 Sep 26. doi:10.3390/nu11102296. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835497/

 

Masood W, Annamaraju P, Uppaluri KR. Ketogenic Diet. [Updated 2020 Dec 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499830/

 

Paoli, A., Rubini, A., Volek, J. et al. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr 67, 789–796 (2013). https://doi.org/10.1038/ejcn.2013.116

 

Ułamek-Kozioł M, Czuczwar SJ, Januszewski S, Pluta R. Ketogenic Diet and Epilepsy. Nutrients. 2019; 11(10):2510. https://doi.org/10.3390/nu11102510

 

Wheless, J.W. (2008), History of the ketogenic diet. Epilepsy, 49: 3-5. https://doi.org/10.1111/j.1528-1167.2008.01821.x

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