Ketosis: Keto + HMR Diets

Introduction

I am not an evangelist for any diet. But, as a subscriber requested my opinion on a ketosis-diet, I wanted to respond. I have used all my usual medical sources, Journals, and some others such as PopularScience, LiveScience, and HVMN (a VERY pro Keto Diet supplement provider) as references, so feel free to research this yourself.

There are three well known ketosis-type diets.

• Health Management Resources Program (HMR) is a medically monitored program featuring meal replacements to minimize carbohydrate consumption leading to ketosis, along with nutritional and diet instruction.
• WebMD defined Keto Diet (KD) is a self-directed high fat, low carb, nominal (or adequate) protein diet leading to ketosis.
• HVMN defined The Atkins Diet as a self-directed high fat, high protein, and low carb diet leading to ketosis.

Remember I am not a medical doctor, dietitian, or nutritionist. I am just a cook who has a website and blog. I believe, however, that no one should start a restrictive diet to move into ketosis without talking with their doctor to make sure they are healthy enough to follow its food recommendations, and getting them to agree to monitor your health while in that state.

So What is Ketosis?

MedicalNewsToday: Ketosis is a normal metabolic process. When the body does not have enough glucose for energy, it burns stored fats instead. A version of ketosis is a natural response when people fast, as a result of long duration athletic activities, or sometimes occurs during lactation (1). The point is, our body is a wonderous thing that has kept open multiple ways to feed itself when carbs are not consumed. So what is ketosis?

Ketosis is a biological process that starts when a person does not consume enough carbohydrates, or insulin levels are too low, to provide our body with energy as glucose (its preferred meal). As a result of lower glucose in the blood, our body first starts to use up stores in the liver. Then when that runs out, signals are sent and our bodies start to release fatty acids from storage (aka body fat), which are sent to the liver for oxidation into ketones. Those ketones are then used as fuel and, as a result, body fat is used up, weight is lost, and we feel less hunger.

But circulating acidic ketones bodies makes blood a bit too acidic. Too acidic and Type 1 Diabetics can go into potentially deadly ketoacidosis. For others our body may draw calcium from bones to use as a buffer and there can be an increase in calcium leaching via urine. And, since your body really craves glucose, it may break the amino acids in muscle to create glucose, which means a loss of muscle mass. (The heart is a muscle, right?) So even with this simple overview, and certainly I have not listed all the interrelationships of body processes, any ketosis diet is obviously a biologically complex diet to go on.

So one would think that since ketosis is a natural process, pushing our body into ketosis should be safe. But knowledgeable people (2) call using ketosis as a weight loss strategy controversial; because of the complexity of the biological response to ketosis, the multitude of unanswered questions over its short-term and long-term safety, and its long-term sustainability.

My Personal HMR – Ketosis Story

In 2017 I lost 80# after I went through a Kaiser Permanente sponsored OPTIFAST medical weight loss program. It was a ~12 month intensive that did not focus on a specific diet, but on resetting our body and metabolism while giving us opportunities to learn about food, nutrition, and revising our eating habits. This type of diet is called Health Management Resources Program (HMR); it focused on extreme calorie reduction, which triggered ketosis, through eating a set meal replacement.

The medical and nutritional experts involved in this program were very clear, going into ketosis can be dangerous for many people, and should be closely monitored. In fact, several people had to be let go from the program, we surmised due to health issues. To even start in the program, a full medical exam and blood work was required; I even had to take a heart stress test before they took me. (Yes, I passed.) Also there was a review of all prescriptions and I had to go off some of the medications (like NSAIDS and proton pump inhibitors) because of the diet and monitoring they were going to do.

The program had weekly group sessions and weigh-ins, monitoring of our blood pressure and pulse, and occasional blood work. For a few weeks we talked about food and our relationship to it. Then we slowly went on a controlled diet of 960 calories a day, eating 6 small prescribed “meals” to put us into ketosis. (The meals were a combination of specific Nestle products: shakes, soups and bars.) The state of ketosis was achieved and went on for a number of weeks more. Then, slowly, we reintroduced food, and had followup weekly meetings for several months more.

The first thing we learned was to avoid caffeine, and drink more water, as the Keto process can cause your hydration levels to get all screwed up. Plus drinking water initially helps one feel full. Only later did I learn that if you are not adequately hydrated, ketosis causes some people to acquire painful kidney stones (3).

The first few weeks of ketosis were a bit miserable as we all experienced a version of the “keto flu.” For me it was a combo of fatigue and diarrhea that had me fighting dehydration. I was put on some medication which helped immediately. Some experienced dizziness, brain fog, constipation, and others just felt “unwell.” I think that from the first complaint to the last, was about three weeks. Then we became used to the feelings, and were okay enough to do our daily lives. However, we all continued to experience brain fog and fatigue, that never really went away.

Did I lose weight? Yes, but initial losses, although dramatic, were mainly water weight. Did I keep it off? Mostly, in the years since, I have regained 20# so I have a net -60#. Statistically, most people who take off weight via ketosis will put all the weight back on (or even more) within a year after going off the program. What the HMR ketosis process did was help spark the dramatic weight loss. But really, it was the nutritional information and a change of habit that has allowed me to keep most of the weight off.

Where Research Indicates Ketosis Helps

There are some health conditions where a ketosis- type diets can be medically recommended.

• This diet was created because somehow a person realized it could assist in pediatric refractory epilepsy (Epilepsy Society), although no one apparently knows why.
• I imagine that for significantly (or “morbidly”) obese people, with a BMI over 40, and who are under medical care, a ketosis diet is guaranteed to cause weight loss which, in turn, can provide the initial success to spur non-surgical continued weight loss.
• For those candidates for knee replacements, some medical surgeons have suggested that a ketosis diet can help quickly reduce BMI, that in turn can help with a successful surgery and aid recovery.
• Studies are underway to see if a ketosis diet could assist fighting certain cancers.

There are small studies that signal ketosis may help other illnesses such as Parkinson’s, Alzheimer’s, etc. But it is premature to say ketosis does help, much more research is needed.

Where Ketosis is Not Safe

Even when monitored, ketosis is not safe for everyone. Some of the articles I read minimized the risks, others dwelled on them. I am taking the middle road by acknowledging risks exists with this restrictive diet, restricting calories or carbs, because of what food it indicates one should eat.

Ketosis is the wrong way to go for anyone already underweight (or low BMI) or anyone with an eating disorder like anorexia. Ketosis diets are also not appropriate for anyone with existing liver or kidney issues.

People who have Crohn’s disease should reconsider going on ketosis diets focused on meat and dairy products. HealthPrep writes, [r]esearch shows that a bug known as MAP that is found in animal products such as milk and meat may be the cause of Crohn’s disease. Thus, the KD featuring these foods could cause additional damage.

If you have Cardiovascular Disease ketosis diets focused on meat, dairy, saturated fats is not considered a safe diet, again it has you eating the foods that may exacerbate your medical problem.

• MayoClinic: The Keto Diet is a concern for long-term heart health. They and others, argue that what you should not be eating is saturated animal fats, and instead should be eating lots of protective plant-based antioxidants. So their perspective is that a Keto Diet may further increase your risk of developing cardiovascular disease.
• MedicalNewsToday: The American Heart Association (AHA), American College of Cardiology, and the Obesity Society have concluded that there is not enough evidence to suggest that low-carbohydrate diets such as the ketogenic diet provide health benefits to the heart.

Diabetics need fiber, which comes from carbohydrate rich plant food and not from meat. But, ketosis can assist in weight loss, better control of glucose and fewer spikes which can actually assist those who are borderline or type 2 diabetics.

• While ketosis and ketoacidosis are two different things, they actually are on the same spectrum.
• Type 1 Diabetics: High ketones along with high blood sugars can lead to ketoacidosis, a potentially life threatening circumstance. Do not do ketosis-based diets without medical supervision and monitoring.
• Type 2 Diabetics: Although more rare, it is possible for type 2 diabetics to have a similar issue (4). A ketosis diet may assist with weight loss and all the great things that come from that, but you should also be monitored medically.

Some (anecdotal) reports that KD may help some women trying to get pregnant. The concern is that once you are pregnant or breast feeding you need to get off the diet. Breastfeeding and pregnant moms and moms-to-be need a well rounded diet. A Keto Diet may harm a fetus according to some studies (3).

Where Ketosis Need Monitoring

Although there are no scientific studies I could find, if you have Chronic Fatigue or Fibromyalgia I imagine ketosis cannot be good. Being in ketosis is absolutely tiring and I, and others, felt more lethargic than usual the whole time we were in ketosis. This diet will potentially make you feel even more exhausted, as you are overtaxing your digestive system with hard-to-digest fatty-meat food. Essentially stressing an already stressed body. But for some people there are anecdotal stories of how it helped. I would just be cautious.

People who have gout may also need to be monitored as ketosis can cause an increase in uric acid.

Lower blood pressure can be one of the great outcomes of losing weight. But during the initial process, people on blood pressure medications need to take extra precautions. Losing weight will change your blood pressure, and if on medication at the same time, ketosis can put you in a dangerous situation where pressures go too low. That is why we had nurse evaluated weekly blood pressure reviews. If too low we saw a doctor immediately.

• All the articles and research I read indicate that anyone with uncontrolled hypertension should not be on the Keto Diet and those on medication need to be monitored.

Where the Keto-Diet Needs Monitoring

The KD diet specifically, can disrupt your lipid metabolism. RuledMe writes that people with familial hypercholesterolemia, [when they start] increasing fat intake will most likely cause … cholesterol levels to rise in an unhealthy way. In this case, you will usually do better with a lower fat diet. Obviously, I think this needs monitoring. Studies show it can also cause a rise in triglycerides, although for me, losing weight lowered mine.

People with Osteoporosis should take care. There is reported in animal studies they are seeing an increased risk of bone fractures due to acidosis caused by the Keto Diet. I’ve already mentioned the leaching of calcium from bone to counter the acidity of ketones in the blood.

Anyone with an existing vitamin or mineral deficiency will need to consider not going on the Keto Diet — this diet restricts all the vitamins and minerals the body usually gets from a varied plant and cereal enriched diet. Minimally, there are several critical items you will need to monitor; for example, potassium, magnesium and salt levels. There is a big business in selling Keto people supplements.

If you have gallbladder issues or had yours removed consuming lots of meat-based protein and fats may cause extreme discomfort. Pancreatic insufficiency, and those who have had gastric bypass are in the same situation of not being able to easily digest large amounts of fats.

Laco-intolerant people will have issues on the diet as well since it often calls for heavy cream and other milk-based product. While not impossible, you will have to plan out your eating carefully. This is also true for people with food allergies, vegans and vegetarians.

Better Diets for Life?

The medical sites I go to for my medical info were in agreement that the ketosis-type diets work for short term quick weight loss. But are not sustainable (5). Some people have recommended going on the diet for a short period of time, or if trying to lose a large amount of weight, perhaps a couple of times a year. Most sites suggested medical care while on a ketosis triggering diet.

USWorldandNews: Rated forty-one 2019 diets based on a review by a panel of nationally recognized experts in diet, nutrition, obesity, food psychology, diabetes and heart disease.

• Best Overall Diet: #1 was the Mediterranean Diet, #2 DASH, #3 Flexitarian. HMR was rated #30, Keto #38 (out of 41) in this category.
• Weight Loss: #1 Weight Watchers, #2 Volumetrics, #3 Flexitarian and Vegan tied. HMR was ranked #9, Keto was ranked #12 in this category.
• Best Healthy Eating: #1 best overall diet was the Mediterranean Diet, #2 DASH, #3 Flexitarian. HMR was ranked #29, Keto was ranked last at #41 in this category.
• Best Fast Weight Loss: #1 HMR, #2 Atkins, #3 Keto.

In closing I am going to reference the conclusion of a JMA study: Low-carbohydrate and low-fat dietary programs were associated with more weight loss than no dietary intervention over a 12-month period; behavioral support and exercise enhanced weight loss. The weight loss differences between individual named diets were small with likely little importance to those seeking weight loss. This supports the practice of recommending any diet that a patient will adhere to in order to lose weight.

Whew! This was an intensive post to write and caused me to update my Diet page. What do you think?

— Patty