The Top Myths About Ketosis Debunked by Clinical Trials

The Top Myths About Ketosis
Debunked by Clinical Trials
James McCarter MD PhD
Adjunct Professor, School of Medicine, Washington University in St. Louis
Former Head of Research, Virta Health
Presentation at CrossFit Health, Scotts Valley CA, October 13th, 2019

One Goal For This Talk
Arm You to Answer Any Objection to Ketogenic and Low Carb Nutrition Approaches.

Why? Because the Public is Paying Attention & Defenders of the Status Quo are Nervous.

Diets on Google Trends:
A Spike Each January
From 2004 - 2012

2/12
3/14

“Keto”, short for nutritional ketosis or the ketogenic diet,
is the number #1 diet search term of 2018-19.

3/17
3/18
1/19
“Keto”, short for nutritional ketosis or the ketogenic diet,
is the number #1 diet search term of 2018-19.

By publications, ketogenic research has increased 860% since 2000.
(70+ references in this talk)

Introduction
The Virta-IUH Clinical Trial
Top 12 Keto Myths Debunked
Another 12 Keto Myths Debunked
Even More Keto Myths Debunked
Conclusions
FOR TODAY

Over 10% of U.S. adults
have diabetes and
one-third have
pre-diabetes
JAMA 2015. 314:1021-1029
Diabetes costs the U.S.
$327 billion annually
ADA 2018 estimates

Thank you to our Virta team, co-authors, collaborators ...
… and our tremendous clinical trial participants.
Especially My Co-PIs,
Drs. Sarah Hallberg
Steve Phinney,
and Jeff Volek.

Disclosures for Dr. James McCarter
I am a shareholder of Virta Health.
Founded in 2014 and headquartered in San Francisco, Virta is a nationwide telemedicine
provider and full-stack technology company focused on the reversal of type 2 diabetes.
I chair the Scientific Advisory Board of Readout.
Founded in 2018 and headquartered in St. Louis, Readout is a digital health company that
helps customers manage their health through real-time biomarkers.

My Personal Journey to Ketosis Began in 2012.
McCarter Family, Field Museum, Chicago, 2012

Carbs Result in a Glucose & Insulin Roller Coaster
(Post-breakfast Munchies, Post-lunch Food Coma)

What I Eat
During 7 Years
in Ketosis
…
non-starchy
vegetables,
lots of eggs,
oily fish,
meat
(including liver),
dairy,
bouillon,
olive oil,
other high oleic oils,
nuts & seeds,
nut butters,
85% chocolate,
coffee.

Quantified Self - Tracking Ketosis With Daily Blood BHB
mmol/L Beta-hydroxybutyrate
Points – days, Line – 7 day moving average
AM fasting 2.0±0.9
PM post-meal 0.9±0.6
< 0.1 mM carb-rich diet
> 0.5 mM ketosis

Personal Benefits of Ketosis – Sharp Reduction in Blood Pressure
Twice Daily Scanadu Scout Blood Pressures Averaging 113/71
BP at Physical Down from High of 136/90 in 2009 to 112/71 in 2014-15
quantifiedself.com/blog/effects-year-ketosis-jim-mccarter

Three Clinically Validated Methods Patients May
Choose to “Reverse” Type 2 Diabetes (T2D)
● Bariatric Surgery
● Very Low Calorie Diet (VLCD)
● Low Carbohydrate (including Ketogenic) Nutrition
Hallberg et al. Nutrients 2019, 11:766
As a society we can no longer tolerate the continued rising rates of diabetes … some
[patients] would surely choose reversal if they understood there was a choice. The
choice can only be offered if providers are not only aware that reversal is possible but
have the education needed to review these options in a patient-centric discussion.
“

What is T2D Reversal?
● ADA 2009 Consensus Panel Definition
○ “Remission” - glycemia below diabetic range (HbA1c <6.5%) in the absence of
pharmacologic or surgical therapy.
○ Bariatric Surgery 2013 Recommendation - similar.
● Other definitions have made an exception for metformin (biguanide class)
● Virta Health & IUH Trial Research Team 2019 Definition
○ “Reversal” - glycemia below diabetic range (HbA1c <6.5%) in the absence of
pharmacologic or surgical therapy with the exception of metformin
○ Per guidelines for metformin use in pre-diabetes we continue to prescribe metformin in 64%
of patients de-prescribing only for side effects or at patient request.
○ “Reversal” is NOT cure.
Diabetes Care 2009, 32:2133-2135
BMC Surgery 2013, 13:8
Diabetes Care 2018, 41(Suppl 1)
Hallberg et al. Nutrients 2019, 11:766
Athinarayanan et al. Frontiers in Endocrinology 2019, 10:348

What is Low Carbohydrate Nutrition?
● Very low-carbohydrate, ketogenic
○ ≤ 50 grams/day of total carbohydrate (usually <10% of daily kcals)
○ Can require <30 grams/day to achieve nutritional ketosis (BHB ≥0.5mM)
○ Moderate protein, fat as primary energy source
○ Dietary fat includes saturated, monounsaturated & polyunsaturated
● Low carbohydrate
○ 51 - 100 grams/day or <30% of daily kcals
○ Generally not ketogenic (BHB <0.5mM) unless exercising or fasting
● Anything ≥30% daily kcals is not a low carbohydrate diet
Hallberg et al. Diabetes, Obesity and Metabolism 2019, 21:1769

• Nutritional ketosis is a metabolic state in which the body is
predominantly fueled by dietary fat or body fat
• Occurs when dietary carbohydrates are limited to <30 grams/day
with moderate protein
• Ketone bodies are natural products of liver metabolism
• During fasting, ketones provide ~60% of the brain’s energy
Benefits of ketosis arise from …
• Alternative energy source to glucose especially in individuals with
insulin resistance
• Lowers insulin levels and restores insulin sensitivity
• Hormonal properties - ketones signal for reductions in oxidative
stress and inflammation
BODY FAT
DIETARY FAT
KETONES
What is Nutritional Ketosis?
Newman & Verdin Diabetes RCP 2014. 106:173
(BHB or BOHB)

Virta-IUH Clinical Trial
• 5-yr, non-randomized prospective
controlled study, 2015-2021
• 465 participants recruited in Central
Indiana, Aug 2015 - Mar 2016
• Patient self-selected intervention
• CCI: continuous care intervention
with individualized nutritional ketosis,
262 w/ T2D, 116 w/ pre-diabetes
• UC: usual care following 2015-16 ADA
guidelines, 87 with T2D
Baseline characteristics for T2D CCI
• Mean age: 54 yrs
• Mean BMI: 40.3 kg/m2
• Mean weight: 257 lbs
• Mean time with T2D: 8.4 yrs
• 67% female
Retention
• 83% at 1 yr
• 74% at 2 yrs 25

The CCI (Virta) Continuous Remote Care Platform
including extensive nutrition
education & individualization

Hallberg et al. Diabetes Therapy
2018. 9:583
Bhanpuri et al.
Cardiovascular Diabetology
2018. 17:56
McKenzie et al. JMIR Diabetes
2017. e5
Significant improvement in
T2D at 1 year
Significant improvement
in cardiovascular risk
factors at 1 year
Rapid improvement in
T2D at 70 days
The Virta - Indiana University Health (IUH) T2D Reversal Trial
Results Have Been Published in Six Peer-reviewed Publications
Papers in progress on
2-year outcomes for
- Pre-diabetes
- Metabolic syndrome
- System Utilization
- Depression
- Joint Function
- Inflammation
Athinarayanan et al.
Frontiers in Endocrinology
2019. 10:348
Sustained improvement in
T2D at 2 years
Vilar-Gomez et al. BMJ Open
2019. 9:e023597
Significant improvement in
fatty liver disease at 1 year
Siegmann et al. Sleep Medicine
2019. 55:92
Significant improvement
in reported sleep at 1 year

Virta-IUH Clinical Trial Demonstrates CCI
Reversal of Type 2 Diabetes Status at 1 Year
Blood Glucose Improvement
1.3% average HbA1c reduction, 70% below 6.5%
of completing
patients
reverse diabetes
Glycemic control without
use of diabetes-specific
medications
60% Medication Reduction
94% of insulin users reduced or eliminated usage
Weight Loss
12% average weight loss (30 pounds)
CVD Risk Improvement including Dyslipidemia
12% improvement in 10-year ASCVD Risk Score
22 of 26 risk factors show significant improvement
Hallberg et al. Diabetes Therapy 2018. 9:583
Bhanpuri et al. Cardiovascular Diabetology 2018. 17:56

HbA1c Reduced While Removing Medications
1.3%
46%
$2,044
Continue Care (CCI)
Usual Care (UC)
CCI
UC

Less-controlled
(A1c ≥ 9%)
1 Year HbA1c Reductions are More Dramatic for
Patients With Poor Glycemic Control at Baseline
Hallberg et al. Diabetes Therapy 2018. 9:583 (Post-hoc analysis)
Well-controlled
(A1c < 9%)
3.45%
CCI UC UCCCI

HbA1c Improvement is Sustained at 2 Years in CCI Versus UCHbA1c(%)
-0.9
HbA1c Reduction
-32%
Insulin Resistance
(c-peptide derived HOMA-IR)
55%
Diabetes Reversal
Continue Care (CCI)
Usual Care (UC)
Athinarayanan et al. Frontiers in Endocrinology 2019. 10:348 (Completers analysis)

At 2 Years …
67%
of all diabetes prescriptions
eliminated
100%
of sulfonylurea prescriptions
eliminated
91%
of insulin prescriptions reduced
or eliminated
81%
mean reduction in insulin doseHallberg et al. Diabetes Therapy 2018. 9:583
Athinarayanan et al. Frontiers in Endocrinology 2019. 10:348
Improved Glycemia Necessitated Diabetes Medication Reductions
Early reduction of sulfonylurea and insulin avoids hypoglycemia during dietary changes.

Even the 40% of CCI Patients that Did Not Reverse Diabetes
at 1 Year Had Very Favorable Outcomes
81%
Percentage of insulin-users
who reduced or eliminated
insulin
Insulin Use
45%
Rx Elimination
17%
Average relative reduction in
10-yr ASCVD risk score
10-yr ASCVD Risk Score
27%
Average reduction in
triglycerides
Triglyceride Reduction
1.2
Average decrease
in HbA1c to 7.0%
A1c Reduction
23 lbs
Average weight loss (9.8%)
Weight Reduction
Percentage of diabetes
prescriptions eliminated
Hallberg et al. Diabetes Therapy 2018. 9:583 (Post-hoc analysis)

Myth 1. Keto is Unsustainable. - False
1. Nearly all T2D intervention patients achieved nutritional ketosis by daily beta-
hydroxybutyrate (BHB) tracking.
2. BHB was still elevated 50% over baseline at 2 years as carbohydrate restriction was
individualized.
3. 74% of patients completed 2 years of the clinical trial with extensive tracking demands
and most agreed to extend their participation to 5 years.
4. In commercial clinical practice, Virta sees retention of >90% at 1 year and >80% at 2 years.

BHB Was Still Elevated 50% Over Baseline at 2 Years
Daily values
Lab values

Significant Weight Loss of 12% Sustained at 2 Years
Clinically Significant Weight Loss -5%
at 2 years
-12%
75% of patients lost > 5%
49% of patients lost > 10%
Athinarayanan et al. Frontiers in Endocrinology 2019. 10:348 (Completers analysis at 2 years)

Most Dietary
Interventions
Display Return of
Weight and
HbA1c Toward
baseline.
CCI Outcomes are
More Sustainable
at 2 Years.
CCI
Tay et al. Diabetes Obes Metab 2018. 20:858
Lean et al. Lancet Diabetes Endo 2019. 7:344 (DIRECT)
Look AHEAD. Archives of Internal Medicine 2010. 170:1566

Myth 2. Keto Will Cause Diabetic Ketoacidosis (DKA). - False
1. There were no DKA events in the trial.
2. There was no evidence of metabolic acidosis or anion gaps in our patients.
3. DKA has not been an issue in other ketosis clinical trials.
Rosenstock and Ferrannini. Diabetes Care 2015. 38:1638
Clinical management: We usually de-prescribe SGLT-2 inhibitors (canagliflozin, dapagliflozin,
empagliflozin) as these medication are associated with increased risk of euglycemic DKA.

State
Ketones
(mmol/L)
Moderate-carbohydrate diet
(fed state)
<0.1
Moderate-carbohydrate diet
(fasted state)
0.1 to 0.3
Very low-carbohydrate diet
(<50 g/day)
0.5 to 3.0
Very low-carbohydrate diet
(post-exercise)
1.0 to 5.0
Keto-acidosis
(insulin insufficiency)
10 to 20+
Nutritional Ketosis is Not Diabetic Ketoacidosis.
• Nutritional ketosis results in moderate ketone levels
(0.5 to 3.0 mM beta-hydroxybutyrate), no insulin
insufficiency and no metabolic acidosis
• Diabetic ketoacidosis (DKA) results in high ketone
levels (10 – 20 mM BHB) due to insulin insufficiency
resulting in metabolic acidosis

Myth 3. Keto Will Cause Hypoglycemia. - False
1. There were no instances of symptomatic hypoglycemia while patients were in ketosis.
2. Hypoglycemia has not been an issue in other ketosis clinical trials except in cases of
continued use of high dose insulin and sulfonylureas (e.g. glyburide, glipizide).
Clinical management: In the trial, we reported one patient no longer following dietary changes had
a hypoglycemic event due to insulin use beyond the prescribed dose.

Myth 4. Keto Will Deprive the Brain of Required Glucose. - False
1. Blood glucose levels are not low in ketosis.
2. With reduced dietary carbohydrate, the liver produces
glucose by gluconeogenesis.
3. The brain metabolizes ketones in preference to glucose.
4. Patients reported improved daily mood and energy and
reduced symptoms of depression.
5. Ketosis is used to treat brain disorders such as epilepsy
and migraine and improves cognitive performance.
Courchesne-Loyer et al. J Cerebral Blood Flow Metabolism 2016. 37:2485
Adams et al. Abstract. Society of Behavioral Medicine, 2019
Kossoff et al. Epilepsia Open 2018. 3:175
Di Lorenzo et al. Nutrients 2019. 11:1742
Ketones spare the brain’s need for glucose.
11-C labeled acetoacetate.
18-F labeled fluorodeoxyglucose.

Myth 5. Keto Will Impair the Heart & Cause Vascular Damage. - False
1. At one year, the mean 10-yr ASCVD risk score of our patients improved 12%.
2. Significant improvements were observed in 22 of 26 CVD risk factors versus 0 of 26 in the
usual care group.
3. Recent studies indicate ketosis may improve congestive heart failure.
Horton et al. JCI Insight 2019. 4:e124079*
Nielsen et al. Circulation 2019. 139:2129

Myth 5. Keto Will Impair the Heart & Cause Vascular Damage. - False
1. At one year, the mean 10-yr ASCVD risk score of our patients improved 12%.
2. Significant improvements were observed in 22 of 26 CVD risk factors versus 0 of 26 in the
usual care group.
3. Recent studies indicate ketosis may improve congestive heart failure.
* Animal models with incorrectly formulated diets are
responsible for many keto myths. Correctly formulated
ketogenic diets extend lifespan and healthspan in mouse
models. Animal model papers are noted with a star*.
Roberts et al. Cell Metabolism 2017. 26:539*
Newman et al. Cell Metabolism 2017. 26:547*

12% Improvement in 10-year ASCVD Risk Score at 1 Year
Intent-to-treat
P = 4.9 X 10-5
Continue Care (CCI)
Usual Care (UC)
The atherosclerotic cardiovascular disease (ASCVD) risk score was developed by
the American College of Cardiology and American Heart Association.

At 1 year, Examining All Available
Cardiovascular Risk Biomarkers,
22 of 26 in CCI Treatment
Show Statistically Significant
Improvement Versus
0 of 26 for Usual Care
including markers of
• hypertension
• atherogenic dyslipidemia
• chronic inflammation
• fatty liver
Intent-to-treat
for 22 significant changes
P < 0.0019
Continue Care (CCI)
Usual Care (UC)

Ketosis May Improve Congestive Heart Failure

Myth 6. Keto Will Worsen the Blood Lipid Profile. - False
1. Patients showed improvement in triglycerides and HDL cholesterol.
2. While calculated LDL rose, there was no change in mean LDL particle number as
measured by both apolipoprotein B (Apo B) and NMR lipoprofile (LDL-p).
3. There was a favorable shift of LDL subtype from small dense LDL to large buoyant LDL.
4. Other clinical trials of low carbohydrate and ketogenic diets have observed no mean
increase in LDL by Apo B.
Hays et al. Mayo Clinic Proceedings 2003. 78:1331
Noakes M et al. Nutrition & Metabolism 2006. 3:7
Wood et al. Journal of Nutrition 2006. 136:384
Tay et al. Journal of the American College of Cardiology 2008. 51:59
Brinkworth et al. AJCN 2009. 90:23

LDL Profile: While we observe a rise in mean LDL-C
(+9.6%, P=4.9x10-5), overall LDL particle number is
unchanged as measured by both Apo B (-1.9%,
P=0.37) and LDL-P (-4.9%, P=0.02).
Atherogenic Dyslipidemia: All measures improve
including mean fasting triglyceride reduced
24.4% (P<10-16) and triglyceride/HDL-C ratio,
reduced 29.1% (P<10-16)
Continue Care (CCI)
Usual Care (UC)Hallberg et al. Diabetes Therapy 2018. 9:583

Mean LDL-P is Unchanged While Small LDL and VLDL are Reduced
Continue Care (CCI)
Usual Care (UC)
LDL Profile: Particle number shows distribution of
response in both CCI & UC
CCI: LDL-P (-4.9%, P=0.02).

Myth 7. Keto Will Cause Inflammation. - False
1. Chronic inflammation was sharply reduced including a 39% reduction in high sensitivity
C-reactive protein (hsCRP) and a 9% reduction in white blood cell (WBC) count at 1 year.
2. In surveys, patients reported improvement in joint function with reduced pain.
3. Other clinical trials of ketogenic diets have also seen reduction in inflammatory markers.
4. BHB is known to inhibit the NLRP3 inflammasome.
Forsythe et al. Lipids 2008. 43:65
Youm et al. Nature Medicine 2015. 21:263*
Goldberg et al. Cell Reports 2017. 18:2077*
Shimazu et al. Science 2013. 339:211*
Newman & Verdin Diabetes RCP 2014. 106:173*

Inflammation: High sensitivity C-reactive protein (hsCRP) was reduced 39.3% (P<10-16) and
white blood cell count (WBC) was reduced 9.1% (P<3.2x10-11) indicating a substantial
reduction in inflammation. Testing of additional inflammatory markers is in progress.
Continue Care (CCI)
Usual Care (UC)

The picture
can't be
displayed.
In Clinical Studies, Ketogenic Diets Reduce Inflammation
as Measured by Multiple Biomarkers
Forsythe et al. Lipids 2008. 43:65

β-Hydroxybutyrate Inhibits Inflammation and Oxidative Stress
Shimazu et al. Science 2013. 339:211*
Newman & Verdin Diabetes RCP 2014. 106:173*
Youm et al. Nature Medicine 2015. 21:263*
Goldberg et al. Cell Reports 2017. 18:2077*

Myth 8. Keto Will Cause Hypothyrodism. - False
1. Mean thyroid hormone (T4) was unchanged in
our patients.
2. Thyroid stimulating hormone (TSH) showed a
numeric decrease rather than an increase that
would be expected with an under-active thyroid.
3. There were no new cases of symptomatic
hypothyroidism.
4. Hypothyroid has not been an issue in other low
carbohydrate clinical trials.
blog.virtahealth.com/does-your-thyroid-need-dietary-carbohydrates

Myth 9. Keto Will Harm the Liver and Increase Liver Fat. - False
1. Patient liver function was greatly improved as measured by markers of non-alcoholic fatty
liver disease at one year and two years.
2. The liver fat score (N-LFS) improved.
3. The liver fibrosis score (NFS) improved.
4. Other clinical trials of ketogenic diets have also seen improvement in liver markers.
Vilar-Gomez et al. BMJ Open 2019. 9:e023597
Mardinoglu et al. Cell Metabolism 2018. 27:1
Gepner et al. J Hepatol 2019. 71:379
Cotter et al. J. Clin. Investigation 2014. 124:5175*

Markers of Non-Alcoholic Fatty Liver Disease (NAFLD)
Improve Significantly Following 1-yr of the Intervention
CCI Treatment, n=262 Usual care, n=87
Vilar-Gomez et al. BMJ Open 2019. 9:e023597 ALT = alanine aminotransferase

Myth 10. Keto Will Harm the Kidneys. - False
1. Mean estimated glomerular filtration rate (eGFR) improved.
2. There were no cases of worsening kidney function.
3. Other clinical trials of low carbohydrate diets have also seen improvement in eGFR.
Tirosh et al. Diabetes Care 2013. 36:2225
Poplawski et al. PLOS One 2011. 6:e18604*

Myth 11. Keto Will Cause Muscle Loss. - False
1. Average weight loss in trial completers at 2 years was 12% (about 30 lbs).
2. Dual energy absorptiometry (DEXA) scan demonstrated that most of the weight loss was
due to loss of body fat including abdominal fat.
3. In another trial that examined this issue in detail, 87% of the weight loss was fat mass.
Much of the non-fat weight loss was water. There was no change in muscle strength.
Gomez-Arbelaez et al. J Clin Endo Metab 2016. 102:488

Myth 12. Keto Will Cause Loss of Bone Mineral Density. - False
1. DEXA scan demonstrated no change in spine bone mineral density at both 1 and 2 years.
2. In another trial that examined this issue in detail, there was no change in bone mineral
density.

Myth 13. Keto is Just a Fad. - False
1. Fasting and low carbohydrate diets resulting in ketosis are ancient. Documentation in the
diabetes medical literature dates to the 1800’s.
2. More diabetes trials have examined carbohydrate restriction than any other diet.
Myth 14. Keto is Not the Standard of Care. - False
1. The 2019 ADA Standards of Care and Nutrition Consensus Statement incorporate very
low-carbohydrate nutrition as an established eating pattern for treatment of T2D.
2. Low carbohydrate patterns were included in the 2018 ADA – EASD Joint Consensus
Statement and 2017 Veterans Administration / Dept. of Defense Clinical Practice Guidelines.
Fan et al. Int J Clin Med 2016. 9:11166
Meng et al. Diabetes Research Clin Prac 2017. 131:124
Huntriss et al. Euro J Clin Nutrition 2018. 72:311
Hallberg et al. Diabetes, Obesity and Metabolism 2019. 21:1769
Evert et al. Diabetes Care 2019. 42:731-754
Diabetes Care 2019. 42:S46–S60
Davies et al. Diabetes Care 2018. 41: 2669-2701
www.healthquality.va.gov/guidelines/CD/diabetes

The Origins of Carbohydrate Restriction for Diabetes
- Low carb ancestral eating patterns (e.g. Native Americans of Great
Plains and Pacific Northwest, Inuit, Masai, Mongol Nomads, etc.)
- Fasting ketosis – religious practice and ancient treatment for disease
Medical Practice & Scientific Publications for Diabetes:
- Rollo, Latham - England, 1811
- Brunton - England (BMJ), 1874
- Cantani - Italy, 1875
- Ebstein - Germany, 1892
- Naunyn - Germany, 1898
- Allen - US (Rockefeller), 1913
- Joslin - US (Boston), 1919
- Newburgh & Marsh - US (Michigan), 1920
- Wilder - US (Mayo), 1924 - epilepsy
- Newburgh & Conn, 1942 T2D “reversal”
Fell out of favor with availability of insulin & diet-heart hypothesis.
Henderson, Journal of Diabetes and Metabolism 2016. 7:8
Bernhard Naunyn
1839-1935
Germany
Frederick Allen
1879–1964
United States

More Diabetes Trials Have Examined Carbohydrate
Restriction Than Any Other Dietary Pattern
> 30 RCTs & meta-analysis
10 other trials
Almost all observed HbA1c
reduction and/or medication
reduction following carbohydrate
restriction for diabetes treatment.
Fan et al. Int J Clin Med 2016. 9:11166
Meng et al. Diabetes Research Clin Prac 2017. 131:124
Huntriss et al. Euro J Clin Nutrition 2018. 72:311
Hallberg et al. Diabetes, Obesity and Metabolism 2019. 21:1769

The 2019 American Diabetes Association (ADA) Standards of
Care and Nutrition Consensus Statement Incorporate Very
Low-Carbohydrate Nutrition as an Established Eating Pattern
for Treatment of T2D
”
“Low-carbohydrate eating patterns, especially very low-
carbohydrate (VLC) eating patterns, have been shown to reduce
HbA1c and the need for antihyperglycemic medications. These
eating patterns are among the most studied eating patterns for
type 2 diabetes … this eating pattern does not appear to
increase overall cardiovascular risk, but long-term studies with
clinical event outcomes are needed.
Evert et al. Diabetes Care 2019. 42:731-754 (ADA Nutrition Consensus)
Diabetes Care 2019. 42:S46–S60 (ADA Standards of Care)
Davies et al. Diabetes Care 2018. 41: 2669-2701 (ADA – EASD Joint Consensus)

Myth 15. Keto Benefit is Just Weight Loss. - False
In a recent clinical trial, even when weight is held constant, ketosis reversed metabolic
syndrome in the majority of participants.
Myth 16. Keto Weight Loss is Just Water. - False
While natriuresis causes water loss early in ketosis, a clinical trial tracking sources of 20 kg
average weight loss over four months found it was approximately 87% fat mass, 8% water
mass and 5% lean mass.
Hyde et al. JCI Insight 2019. 4:e128308

Even Without Weight Loss, a Low Carbohydrate Diet Improves Metabolic
Syndrome More than High or Moderate Carbohydrate Diets
In a randomized order study holding weight constant,
significantly more participants reversed metabolic syndrome
following a low carbohydrate diet for just 4 weeks.
Baseline
High carb
Moderate carb
Low carb

Myth 17. Keto Will Cause “Keto Flu”. - False
Electrolyte (salt) management can avoid most if not all of the symptoms associated with the
transition to ketosis including fatigue, headache, and weakness.
Myth 18. Keto Will Cause Constipation. - False
Electrolyte (salt) management can avoid most if not all of the symptoms associated with the
transition to ketosis including constipation.
blog.virtahealth.com/potassium-sodium-ketogenic-diet/
DeFronzo et al. J Clinical Investigation 1975. 55:845
Spark et al. NEJM 1975. 292:1335

Electrolyte Management Requires Extra Attention to Avoid
Unnecessary Side Effects During Keto-Adaptation
Sodium - 5 grams per day necessary for most patients (salt, broth, bouillon, tablets)
- In high carbohydrate diets, high insulin levels signal sodium retention by the kidneys.
- In ketosis, low insulin levels result in sodium excretion by the kidneys (natriuresis).
- Sodium depletion can lead to hypovolemia, headache, fatigue and constipation.
Potassium – 4 grams per day dietary or supplementation to avoid muscle cramps, etc.
Magnesium – 400 mg per day dietary or supplementation to avoid muscle cramps, etc.
blog.virtahealth.com/potassium-sodium-ketogenic-diet/
DeFronzo et al. J Clinical Investigation 1975. 55:845
Spark et al. NEJM 1975. 292:1335

Myth 19. Keto Will Require Too Much Sodium- False
While U.S. dietary guidelines recommend low sodium (2.3g), multiple studies tracking Na+
excretion associate low salt consumption with increased mortality risk. Therefore, higher
Na+ intake (5 g) is advisable.
Myth 20. Keto Sodium Will Cause Hypertension. - False
Blood pressure is reduced with low carbohydrate and ketogenic diets as is the need for
antihypertensive medication.
Clinical management: “One of the biggest challenges we encounter in managing people following a ketogenic diet is to
get them to pay adequate attention to their sodium and potassium intakes. Part of this stems from the past 50 years of
salt demonization, in which we were all taught that the less sodium intake, the better.”
O’Donnell et al. NEJM 2014. 371:610
Mente et al. Lancet 2018. 392:496
Unwin et al. Int J Env Research and Public Health. 16:2680.

Studies Tracking Na+ and K+ Excretion Associate
Low Salt Consumption with Increased Mortality Risk
PURE Study of 102,000 People in 17 Countries
O’Donnell et al. NEJM 2014. 371:610
Mente et al. Lancet 2018. 392:496

Blood Pressure is Reduced with Low Carbohydrate Diets
as is the Use of Antihypertensive Medication
Unwin et al. Int J Env Research and Public Health. 16:2680.
Continue Care (CCI)
Usual Care (UC)
Mean systolic BP decreased 4.8% from 132 to 126
(P=1.3x10-8) while mean diastolic BP decreased
4.3% from 83 to 79 (P=7.2x10-8) simultaneous with
reduced use of antihypertensives (-17.0%) and
diuretics (-24.8%).
Mean systolic BP decreased 7.7%
from 143 to 132 (P<0.0001) while
mean diastolic BP decreased
7.1% from 84 to 78 (P<0.0001)
simultaneous with reduced use of
antihypertensives (-20%).

Myth 21. Keto Will Cause Adrenal Fatigue. - False
There is no evidence that ketosis inhibits adrenal function. However, sodium restriction
during ketosis will trigger adrenal activity through the renin - angiotensin - aldosterone
system so it is advisable not to overly restrict sodium when in ketosis.
Myth 22. Keto Will Cause Gall Stones &
Requires a Gall Bladder. - False
1. Gall stone formation is associated with very low-calorie liquid diets (VLCD) lacking in fat
where gallbladder emptying is not stimulated.
2. Many patients who have had gall bladder removal perform well on a ketogenic diet.
Clinical management: Reduced circulating sodium can trigger the adrenal gland to increase production of aldosterone
and also increase adrenal production of the stress hormone cortisol and the fight-or-flight hormone adrenaline.
blog.virtahealth.com/sodium-nutritional-ketosis-keto-flu-adrenal-function/
blog.virtahealth.com/ketogenic-diet-no-gallbladder/
Clinical management: “If dietary fat tolerance is reduced, consume dietary fats as emulsions (e.g., high oleic mayo,
cream, sour cream, yogurt), and spread fat intake throughout the day rather than large amounts with any one meal.

Myth 23. Keto Increases Mortality in Nutritional
Epidemiology Studies. - False
Nutritional epidemiology has not studied ketogenic diets. While some studies based on food
surveys have extrapolated higher mortality with higher fat diets, other studies have reached
the opposite conclusion. In clinical trials, replacing saturated fat with polyunsaturated fat or
carbohydrates has not improved mortality.
Myth 24. Keto Requires Meat Consumption. - False
Ketogenic diets have been formulated for vegetarians. While more challenging, even vegan
ketogenic diets are possible.
Dehghan et al. Lancet 2017. 390:2050
Siri-Tarino et al. Am J Clin Nutr 2010. 91:535
Ramsden et al. BMJ 2016. 353:11246
Nutritional epidemiology is a field in need of radical reform (Ioannidis, 2018). Epidemiological studies are not designed to prove causation
and even associations are usually wrong because of over-interpretation of small changes in hazard ratios, residual confounding, data
dredging, selective publication and investigator bias. One analysis found that of 52 claimed health benefits or harms based on associations
from nutritional epidemiology, none were validated when tested in randomized clinical trials (Young and Karr, 2011).
Ioannidis. JAMA 2018. 320:969
Young and Karr Significance 2011. 8:116
blog.virtahealth.com/vegan-vegetarian-low-carb-keto/

Myth 25. Keto Will Increase Cancer Risk. - False
1. There is no evidence that ketogenic diets increase cancer risk.
2. In fact, several dozen clinical trials are currently examining ketogenic diets as an adjuvant
treatment to chemotherapy (e.g. with PI3K inhibitors to counter insulin rise).
Myth 26. Keto Increases Circulating Saturated Fat. - False
In a randomized order study holding body
weight constant, plasma saturated fat levels
were lowest during the low carbohydrate diet
despite higher saturated fat consumption.
Hopkins et al. Nature 2018. 560:499*
Tan-Shalaby et al. Federal Practitioner 2017. 34:37S

Myth 27. Keto Provides Inadequate Dietary Fiber. - False
There is no evidence that ketogenic diets provide inadequate dietary fiber. Fiber is not an
essential nutrient and there is no RDA. A well formulated ketogenic diet provides ~12 grams
of fiber per day (from vegetables, nuts, seeds, etc.) versus the AHA guideline 25 g per day.
1. While the gut microbiome varies with
diet, there is no evidence that
ketogenic diets result in an inferior
microbiome.
2. A key role of the gut microbiome on
a high fiber diet is butyrate production,
a metabolic role fulfilled on a
ketogenic diet by BHB production.
David et al. Nature 2014. 505:559
blog.virtahealth.com/fiber-colon-health-ketogenic-diet/
Myth 28. Keto Interferes with the Gut Microbiome. - False

Example of Daily Fiber on a Well Formulated Ketogenic Diet
Serving of
vegetables
½ cup cooked or
1 cup raw
Breakfast
½ cup cooked
spinach
(3.5 g) 2.4 g fiber
Lunch
2 cups Romaine
(3 g) 2 g fiber
1/2 cup peppers
(4.5) 1.5 g fiber
Dinner
½ c mushrooms
(2.5 g) 1.7 fiber
½ c cauliflower
(2.5 g) 1.2 fiber
24 g carb; 12.8 g fiber
Snacks
1 oz macadamias
(4 g) 2.4 g fiber
1 c celery
(4 g) 1.6 g fiber

Myth 29. Keto is Environmentally Unsustainable. - False
In the plant versus animal agriculture debate, the advantages of plant-based diets are often overstated.
According to a recent study, removing all animal agriculture would reduce U.S. greenhouse gas
emissions by only 2.6% while resulting in nutrient-deficient food. (Ketogenic diets can be animal or
plant-based.)
Myth 30. Keto Foods are Too Expensive. - False
1. Among the 3 macronutrients, protein is the most expensive per kcal (e.g. lean cuts of meat).
Ketogenic diets replace carbs with fat and are moderate in protein (15-20%).
2. There is no requirement for expensive processed foods, premium ingredients or keto supplements.
White and Hall. PNAS 2017. 114:E10301
Fat: The New Health Paradigm. Credit Suisse Report. 2015.
Zinn et al. Nutrition & Dietetics 2019. DOI: 10.1111/1747-0080.12534

Carbohydrate restriction to achieve
nutritional ketosis (initially <30 grams)
Highly personalized - budget, culture,
religion, omnivore vs. vegetarian, etc.
Education & problem solving,
not meal delivery/replacement
Eat delicious, whole foods
until satisfied, no calorie counting
Not zero carb - 5 daily servings of
vegetables, plus nuts, berries, etc.
Nutritional Ketosis Through
Individualized Dietary Guidance

Myth 31. Keto Will Interfere with Exercise. - False
1. In elite athletes following ketoadaptation, performance can exceed high carbohydrate
results (e.g. ultra-endurance world record holder Zach Bitter). Full ketoadaptation likely
requires at least 12 weeks. (Performance may vary by sport & energetic needs.)
2. A study of elite athletes found peak fat oxidation was 230% higher in the ketoadapted
athletes versus high carbohydrate consuming athletes.
Myth 32. Keto Will Deplete Muscle Glycogen. - False
The study of elite athletes found no differences in muscle glycogen pre and post-workout in
the high carbohydrate and ketogenic adapted groups. High fat oxidation is glycogen-sparing.
Phinney et al. Metabolism 1983. 32:757
Volek et al. Metabolism, 2016. 65:100

Studies of Keto-Adapted Athletes Demonstrates that
Nutritional Ketosis Can Sharply Increase Fat Oxidation.
Volek et al. Metabolism, 2016. 65:100
• Comparing 20 male ultra-
runners consuming either a low
carb (<20%) or high carb (>55%)
diet for at least 6 months
• Peak fat oxidation was 230%
higher in the low carb group
• Mean fat oxidation was 59%
higher in the low carb group
• Muscle glycogen levels did not
differ between the groups.

Myth 33. Keto Will Raise Long-Term Risk of Gout.- False
1. While uric acid can show a transient increase during ketoadaptation, uric acid levels were
unchanged at 1 and 2 years. No new cases of gout were observed.
2. Other clinical trials of ketogenic diets have seen similar changes in uric acid levels.
3. Mechanism studies suggest ketosis may prevent gouty flares by inhibition of IL-1β.
Myth 34. Keto Will Raise Long-Term Risk of Kidney Stones. - False
1. Kidney stones have been described in ketogenic diets for pediatric epilepsy.
2. We observed one case of a kidney stone in the second year of the trial.
3. There are no trials documenting a higher rates of kidney stones in adults in ketosis.
Athinarayanan et al. Frontiers Endo 2019. 10:348
Hussain et al. Nutrition 2012. 28:1016
Goldberg Cell Reports 2017. 18:2077*
Sampath et al. J Child Neurology 2007. 22:375
Clinical management: “And after a month or two, the kidneys adapt to maintaining normal uric acid
excretion. At Virta, we devote considerable attention to hydration, adequate but not excessive
dietary sodium and calcium, and plenty of green vegetables, nuts, and seeds (dietary sources of
magnesium). We also supplement magnesium when there are early clinical signs of depletion.”

Myth 35. Keto Will Cause “Keto Crotch”. - False
It does not exist. The term appears to have been promoted by a public relations (PR) firm in
February of 2019 as a paid media campaign to counter the keto trend.
Myth 36. Keto Will Cause “Keto Bloat”. - False
It does not exist. There is no evidence that ketosis causes bloating.
Gibson and Shepherd. J Gastroenterology & Hepatology 2010. 25:252
Lomer. Aliment Pharmacol Ther 2015. 41:262
Clinical management: Instruct patients to be aware of irritable bowel syndrome (IBS) that can occur
upon introduction of new foods following any dietary change (not just ketogenic diets) including FODMAP
containing foods (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols)
especially sugar alcohols used as artificial sweeteners in sugar-free processed foods.

Myth 37. Keto Will Confuse the Public. - False
This is an excuse. In other words, if “experts” embrace the benefits of a high fat diet, the last
40 years of nutrition guidelines and advice is in doubt. Yes, there is good reason for doubt!
Myth 38. Keto Will Undermine Science. - False
This is another excuse. Ketogenic diets are based on rigorous
and increasing scientific study.
Johnston et al. Annals of Internal Medicine 2019. 10.7326/M19-1621
www.hsph.harvard.edu/nutritionsource/2019/09/30/flawed-guidelines-red-processed-meat

Myth 39. Keto Will Cause Diabetes. - False
There is no evidence that ketosis causes diabetes. This myth derives from poorly designed
animal studies with improperly formulated “high fat” diets (e.g. high fat, high sugar).
Myth 40. It’s Better Just to Stay with Usual Care. - False
Usual care does not reverse type 2 diabetes. In a Kaiser Permanente study of 122,781 adults,
“The 7-year cumulative incidence of partial, complete, or prolonged remission was 1.47%,
0.14%, and 0.007%.” (Even allowing for metformin use, rates of diabetes reversal are very low
with usual care.)
Karter et al. Diabetes Care 2014, 37:3188

Conclusions – Overcoming Keto Myths.
• Nutritional ketosis is a viable patient choice for type 2 diabetes (T2D) reversal.
• Low carbohydrate nutrition patterns including ketosis have extensive clinical trial
evidence for T2D improvement including the Virta-IUH trial 1 and 2-year outcomes.
• The ADA and other organizations have updated their guidelines to include low
carbohydrate eating patterns for T2D treatment.
• Focus on electrolyte management. 8 of the 40 myths are basically about salt!
• Be informed. Talk with your patients. Debunk myths meant to cause fear.
• Let patients know they have a CHOICE to reverse diabetes. The decision is THEIRS.

Thank you!
Twitter and Medium: @jpmccarter
LinkedIn: jamesmccarter

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