Acid-base safety during the course of a very low-calorie-ketogenic diet

The case for a ketogenic diet in the management of kidney disease

Ketogenic diets have been widely used for weight loss and are increasingly used in the management of type 2 diabetes. Despite evidence that ketones have multiple positive effects on kidney function, common misconceptions about ketogenic diets, such as high protein content and acid load, have prevented their widespread use in individuals with impaired kidney function. Clinical trial evidence focusing on major adverse kidney events is sparse. The aim of this review is to explore the effects of a ketogenic diet, with an emphasis on the pleiotropic actions of ketones, on kidney health. Given the minimal concerns in relation to the potential renoprotective effects of a ketogenic diet, future studies should evaluate the safety and efficacy of ketogenic interventions in kidney disease.

Defining Physiological Ketosis Following Very-Low-Calorie Diets

INTRODUCTION

Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance.

MATERIALS AND METHODS

Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005.

CLINICALTRIALS

gov ID: NCT05442918.

RESULTS

Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1.

CONCLUSIONS

Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i.

Diet and Metabolism in CKD-Related Metabolic Acidosis

Metabolic acidosis is a common complication in patients with chronic kidney disease that occurs when the daily nonvolatile acid load produced in metabolism cannot be excreted fully by the kidney. A reduction in urine net acid excretion coupled with a high nonvolatile acid load may play a role in its pathogenesis. Diet is important in generation of the nonvolatile acid load. Acids are produced from metabolism of dietary protein and from the endogenous production of organic anions from neutral precursors. Acids can be balanced by alkali precursors ingested in the diet in the form of combustible organic anions. These typically are reflected indirectly by the excess of mineral cations to mineral anions in a food or diet. These principles underscore widely used methods to estimate the nonvolatile acid load from dietary intake using formulas such as the net endogenous acid production equation and the potential renal acid load equation. Empiric data largely validate these paradigms with high net endogenous acid production and potential renal acid load contributed by foods such as protein, grains, and dairy, and low net endogenous acid production and potential renal acid load contributed by fruits and vegetables along with corresponding dietary patterns. Although further studies are needed to understand the health benefits of altering nonvolatile acid load via diet, this review provides a detailed assessment on our current understanding of the role of diet in chronic kidney disease-related acidosis, providing an updated resource for researchers and clinicians.

Effect of Low-Carbohydrate Diet on Beta-Hydroxybutyrate Ketogenesis Metabolic Stimulation and Regulation of NLRP3 Ubiquitination in Obese Saudi Women

The effects of a ketogenic diet (KD) on anthropometric indices, the lipid profile, and the benefits of the ketone body beta-hydroxybutyrate (BHB) as an inhibitor of the NOD-like receptor pyrin domain-containing 3 (NLRP3) inflammasome in obese women were investigated in this study. From January to March 2021, 23 obese adult women (n = 23) with an average age of 35.30 years and BMI of 33.96 kg/m² followed a KD. Instructions for the KD were given to eligible participants, with a typical plan and a menu for all the main meals, snacks, and drinks permitted over seven days. They were also free to change meals according to their preferences provided that they followed the plan. The participants attended six times throughout the intervention for measurements of their anthropometric indices, BHB levels, interleukin-1beta (1L-1β) levels, and completion of a questionnaire (pre-intervention, mid-intervention, and post-intervention). Following the KD caused significant weight loss, a reduction in waist circumference and BHB levels, as well as a reduction in BMI and appetite. Cholesterol, triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C) increased slightly. However, low-density lipoprotein cholesterol (LDL-C) in serum increased significantly (p < 0.05), and 1L-1β decreased significantly (p < 0.0001). The results show that the KD effectively encouraged weight loss and NLRP3 inflammasome inhibition. Based on the questionnaire results, it was found that a variety of physical symptoms, including overall energy, physical activity, mood, sleep, focus, skin conditions, and menstruation, had significantly improved.

The Evolution of Ketosis: Potential Impact on Clinical Conditions

Ketone bodies are small compounds derived from fatty acids that behave as an alternative mitochondrial energy source when insulin levels are low, such as during fasting or strenuous exercise. In addition to the metabolic function of ketone bodies, they also have several signaling functions separate from energy production. In this perspective, we review the main current data referring to ketone bodies in correlation with nutrition and metabolic pathways as well as to the signaling functions and the potential impact on clinical conditions. Data were selected following eligibility criteria accordingly to the reviewed topic. We used a set of electronic databases (Medline/PubMed, Scopus, Web of Sciences (WOS), Cochrane Library) for a systematic search until July 2022 using MeSH keywords/terms (i.e., ketone bodies, BHB, acetoacetate, inflammation, antioxidant, etc.). The literature data reported in this review need confirmation with consistent clinical trials that might validate the results obtained in in vitro and in vivo in animal models. However, the data on exogenous ketone consumption and the effect on the ketone bodies’ brain uptake and metabolism might spur the research to define the acute and chronic effects of ketone bodies in humans and pursue the possible implication in the prevention and treatment of human diseases. Therefore, additional studies are required to examine the potential systemic and metabolic consequences of ketone bodies.

The Use of SGLT-2 Inhibitors Coupled With a Strict Low-Carbohydrate Diet: A Set-Up for Inducing Severe Diabetic Ketoacidosis

A 58-year-old male with a history of hypertension and non-insulin dependent type 2 diabetes mellitus (DM) was brought in by ambulance and admitted to the intensive care unit for weakness, lethargy, and altered mental status and was found to be hypotensive and subsequently diagnosed with severe diabetic ketoacidosis (DKA). A thorough investigation into precipitating factors for his DKA was largely unrevealing; an extensive infectious work- up was negative and the patient’s history was otherwise only significant for starting a ketogenic diet 1 month prior while simultaneously being on a sodium-glucose transport protein 2 (SGLT-2) inhibitor, namely empagliflozin. Literature investigation revealed that a strict low carbohydrate diet can rarely lead to DKA in the setting of SLGT-2 inhibitor use.

Effectiveness and Safety of a Very Low-Calorie Ketogenic Diet on Weight Regain Following Bariatric Surgery

PURPOSE

Obesity is one of the major public health problems worldwide and bariatric surgery is considered the gold standard treatment for severe obesity. Although the literature supports the safety and efficacy of the very low-calorie ketogenic diet (VLCKD) in patients with obesity, there is no study analyzing the use in case of failure or weight regain after bariatric surgery. This work has the purpose of assessing the response to a VLCKD (Pnk® method) in this population.

METHODS

We have conducted an observational, retrospective, and descriptive study with the analysis of medical charts of private offices where patients were examined between 2014 and 2019, totalizing 11 participants who underwent Roux-en-Y gastric bypass (RYGB) without a reduction of 50% in body weight excess or any weight regain after the surgery. The patients followed the first stage of a commercial weight loss program (Pnk® method) which consists of a VLCKD (600-800 kcal/day), low in carbohydrates and lipids.

RESULTS

A significant reduction was observed (p-value < 0.05) in weight, body mass index (BMI), abdominal circumference (AC), and glycated hemoglobin (A1C) post-ketogenic diet. Uric acid, transaminases, urea, and creatinine values did not show differences between pre- and post-ketosis. During the course of the study, no serious adverse events were reported.

CONCLUSION

This study has shown that the ketogenic diet can be recommended as an effective and safe treatment for patients who progressed with insufficient weight loss or regain after bariatric surgery.

Effect of short-term ketogenic diet on end-tidal carbon dioxide

BACKGROUND & AIMS

Previous studies have shown that end-tidal carbon dioxide (EtCO₂) is lower with the presence of supraphysiological ketones as in the case of chronic ketogenic diet (KD) and diabetic ketoacidosis (DKA). This study aimed to determine changes in EtCO₂ upon short term KD.

METHODS

Healthy subjects were screened not to have conditions that exerts abnormal EtCO₂ nor contraindicated for KD. Subjects underwent seven days of KD while the EtCO2 and blood ketone (beta-hydroxybutyrate; β-OHB) parameters were sampled at day zero (t0) and seven (t7) of ketosis respectively. Statistically, the t-test and Pearson's coefficient were conducted to determine the changes and correlation of both parameters.

RESULTS

12 subjects completed the study. The mean score ± standard deviation (SD) for EtCO₂ were 35.08 ± 3.53 and 35.67 ± 3.31 mm Hg for t0 and t7 respectively. The mean score ±SD for β-OHB were 0.07 ± 0.08 and 0.87 ± 0.84 mmol/L for t0 and t7 respectively. There was no significant difference of EtCO₂ between the period of study (p > 0.05) but the β-OHB increased during t7 (p < 0.05). There was also no correlation between the parameters.

CONCLUSIONS

These findings suggest that EtCO₂ may not be utilized to determine short term nutritional ketosis.

Ketogenic Diet-Induced Diabetic Ketoacidosis in a Young Adult with Unrecognized Type 1 Diabetes

Ketogenic diet, a very low-carbohydrate diet and high-fat diet, has emerged as a popular approach for weight reduction, particularly in young adults. However, a serious but rare complication of the ketogenic diet is ketoacidosis associated with low carbohydrate intake, which should be cautiously monitored in people with a predisposition to the condition. We report a 22-year-old Thai woman with an unremarkable past medical history who presented with an acute onset of dyspnea of 2 days' duration. Diabetic ketoacidosis was diagnosed by elevated capillary blood glucose, significant metabolic acidosis, and a high serum beta-hydroxybutyrate level. Low C-peptide level and positive islet autoantibodies confirmed the new diagnosis of type 1 diabetes in this patient. After her conditions were stabilized, the patient revealed that she began a ketogenic diet for weight reduction 4 days before her illness. Other precipitating factors were not identified. This highlights that ketogenic diet may increase diabetic ketoacidosis risk at the presentation of previously unrecognized type 1 diabetes.

Ketotherapy as an epigenetic modifier in cancer

Epigenetic alterations in cancer play a variety of roles. Aberrant DNA methylation, as one of the epigenetic mechanisms, has been widely studied in both tumor and liquid biopsies and provide a useful bench mark for treatment response in cancer. Recently, several studies have reported an association between the type of diet and epigenetic modifications. Whereby there is a growing interest in finding the "anti-cancer diet formula", if such a thing exists. In this sense, ketogenic diets (KD) have reported potentially beneficial effects, which were able to prevent malignancies and decrease tumor growth. Some studies have even shown increased survival in cancer patients, reduced side effects of cytotoxic treatments, and intensified efficacy of cancer therapies. Although the biological mechanisms of KD are not well understood, it has been reported that KD may affect DNA methylation by modulating the expression of crucial genes involved in tumor survival and proliferation. However, there are many considerations to take into account to use ketotherapy in cancer, such as epigenetic mark, type of cancer, immunological and metabolic state or microbiota profile. In this review, we argue about ketotherapy as a potential strategy to consider as coadjuvant of cancer therapy. We will focus on mainly epigenetic mechanisms and dietary approach that could be included in the current clinical practice guidelines.

Severe Metabolic Acidosis: A Case of Triple Hit with Ketogenic Diet, Vinegar, and Metformin in an Obese Patient

Obesity is an epidemic with high burden of disease. It is directly proportional to increased risk of morbidity and mortality. Ketogenic diet and herbal supplements have recently gained popularity amongst patients struggling with weight loss. There are limited data available for most of these supplements contrary to the claims laid by the mainstream media. Due to lack of awareness, this patient population is at high risk of adverse effects. We present a case of severe acidosis secondary to ketogenic diet and acetic acid (vinegar) ingestion. The use of dietary acetic acid is usually well tolerated; however, in this case, the large quantities and presence of acute renal injury and metformin use may have worsened the acidosis. Severe ketosis in setting of ketogenic diets is a serious complication, which is infrequently reported in literature. Many of these diets and supplements may seem harmless, but as our case illustrates, when combined with other risk factors, patients can face serious adverse effects and even require hospitalization. It is imperative that such dietary practices are physician supervised to avoid complications. With the recent surge of over-the-counter weight loss supplements and ketogenic diets, physicians also need to engage in dietary discussion with patients when attempting to lose weight.

Very low calorie ketogenic diets in overweight and obesity treatment: Effects on anthropometric parameters, body composition, satiety, lipid profile and microbiota

According to the World Health Organization (WHO) the prevalence of obesity tripled worldwide since 1975. Obesity prevention and treatment is based upon lifestyle changes involving eating habits, physical activity and behaviour therapy. Various dietary patterns have been used as nutritional strategies and, in recent years, interest has been shown in very low calorie ketogenic diets (VLCKD) that provide less than 800 calories (kcal), no more than 20-50 g/day of carbohydrates and 0.8-1.5 g/kg ideal body weight of protein. We conducted a literature review of all clinical trials published between January 2014-November 2019 on people with obesity (PWO) that evaluated VLCKD effects on anthropometric parameters, body composition, satiety, lipid profile and microbiota. Findings from literature showed that VLCKD could be useful to ameliorate the quality of life and sleep of PWO. It leads to a rapid weight loss and results in improvements in body mass index (BMI = kg/m²), waist circumference and fat mass reduction preserving lean body mass and resting metabolic rate. This eating pattern reduced the desire to eat and increased satiety. Little is known regarding the effects of VLCKD on the microbiota of PWO for which it is important to conduct further studies.

Ketosis in patients undergoing medically supervised therapeutic fasting-results from an observational trial

BACKGROUND/AIM

Medically supervised fasting has long tradition and broad acceptance in some European countries. The exact amount to which ketone bodies are produced as well as their possible contribution to beneficial effects in this procedure are open.

METHODS

Open-label observational trial with in-patients undergoing medically supervised fasting with supplementation of approximately 40 g/d carbohydrates as part of an established routine care. Daily finger-stick blood samples for measurement of glucose and ß-hydroxybutyrate. Descriptive analysis for all data.

RESULTS

Complete sets of data of 17 patients (5 m, mean age 63.1) could be evaluated. Mean concentrations of ß-hydroxybutyrate rose continuously to a mean maximum of 3.6 mmol/L with an individual maximum of 5.1 mmol/L, while glucose decreased within normal range. Two patients with type 2 diabetes produced significantly less ß-hydroxybutyrate. Courses for ß-hydroxybutyrate and glucose showed a weak inverse correlation, while no serious adverse effects could be observed.

CONCLUSION

Medically supervised fasting with definite small amounts of carbohydrates by fluid intake may lead to limited increases of ketone bodies in their biopositive range, as known e.g. from epileptology or sports medicine. Clinical consequences deserve further research.

Very-Low-Calorie Ketogenic Diets With Whey, Vegetable, or Animal Protein in Patients With Obesity: A Randomized Pilot Study

CONTEXT

We compared the efficacy, safety, and effect of 45-day isocaloric very-low-calorie ketogenic diets (VLCKDs) incorporating whey, vegetable, or animal protein on the microbiota in patients with obesity and insulin resistance to test the hypothesis that protein source may modulate the response to VLCKD interventions.

SUBJECTS AND METHODS

Forty-eight patients with obesity (19 males and 29 females, homeostatic model assessment (HOMA) index ≥ 2.5, aged 56.2 ± 6.1 years, body mass index [BMI] 35.9 ± 4.1 kg/m2) were randomly assigned to three 45-day isocaloric VLCKD regimens (≤800 kcal/day) containing whey, plant, or animal protein. Anthropometric indexes; blood and urine chemistry, including parameters of kidney, liver, glucose, and lipid metabolism; body composition; muscle strength; and taxonomic composition of the gut microbiome were assessed. Adverse events were also recorded.

RESULTS

Body weight, BMI, blood pressure, waist circumference, HOMA index, insulin, and total and low-density lipoprotein cholesterol decreased in all patients. Patients who consumed whey protein had a more pronounced improvement in muscle strength. The markers of renal function worsened slightly in the animal protein group. A decrease in the relative abundance of Firmicutes and an increase in Bacteroidetes were observed after the consumption of VLCKDs. This pattern was less pronounced in patients consuming animal protein.

CONCLUSIONS

VLCKDs led to significant weight loss and a striking improvement in metabolic parameters over a 45-day period. VLCKDs based on whey or vegetable protein have a safer profile and result in a healthier microbiota composition than those containing animal proteins. VLCKDs incorporating whey protein are more effective in maintaining muscle performance.

Ketogenic diets as treatment of obesity and type 2 diabetes mellitus

During the last decades, several interventions for the management of overweight and obesity have been proposed. Among diets, the first studies focused on the effect of water only and total fasting diets with or without proteins. Unfortunately, they were found to be associated with adverse events which lead to the abandon of these strategies. Interestingly, despite the radical approach, total fasting was effective and generally well tolerated. A strict connection between protein-calorie malnutrition and increased in morbidity and mortality in hospitalized patients was found at that time. Then, the seminal works of Blackburn and his collaborators lead to the introduction of the protein-sparing modified fast. Encouraged by the early results using this intervention, diets evolved to the current very-low-calorie ketogenic diets (VLCKD). In the present review, results of studies on the VLCKDs are presented and discussed, with a particular reference to the protocolled VLCKD. Also, a recent proposal on the nomenclature on the ketogenic diets is reported. Available evidence suggests VLCKDs to be effective in achieving a rapid and significant weight loss by means of an easily reversible intervention which could be repeated, if needed. Muscle mass and strength are preserved, resting metabolic rate is not impaired, hunger, appetite and mood are not worsened. Symptoms and abnormal laboratory findings can be there, but they have generally been reported as of mild intensity and transient. Preliminary studies suggest VLCKDs to be a potential game-changer in the management of type 2 diabetes too. Therefore, VLCKDs should be considered as an excellent initial step in properly selected and motivated patients with obesity or type 2 diabetes, to be delivered as a part of a multicomponent strategy and under strict medical supervision.

Short-Term Physiological Effects of a Very Low-Calorie Ketogenic Diet: Effects on Adiponectin Levels and Inflammatory States

Adipose tissue is a multifunctional organ involved in many physiological and metabolic processes through the production of adipokines and, in particular, adiponectin. Caloric restriction is one of the most important strategies against obesity today. The very low-calorie ketogenic diet (VLCKD) represents a type of caloric restriction with very or extremely low daily food energy consumption. This study aimed to investigate the physiological effects of a VLCKD on anthropometric and biochemical parameters such as adiponectin levels, as well as analyzing oligomeric profiles and cytokine serum levels in obese subjects before and after a VLCKD. Twenty obese subjects were enrolled. At baseline and after eight weeks of intervention, anthropometric and biochemical parameters, such as adiponectin levels, were recorded. Our findings showed a significant change in the anthropometric and biochemical parameters of these obese subjects before and after a VLCKD. We found a negative correlation between adiponectin and lipid profile, visceral adipose tissue (VAT), C-reactive protein (CRP), and pro-inflammatory cytokines such as tumor necrosis factor-α (TNF-α), which confirmed the important involvement of adiponectin in metabolic and inflammatory diseases. We demonstrated the beneficial short-term effects of a VLCKD not only in the treatment of obesity but also in the establishment of obesity-correlated diseases.

Diet-induced Ketoacidosis in a Non-diabetic: A Case Report

Introduction

Anion gap metabolic acidosis is a common disorder seen in the emergency department. The differential can include toxicological, renal, endocrine, infectious, and cardiogenic disorders. Ketosis, however, is one of the rarer causes of metabolic acidosis seen by the emergency physician in developed nations.

Case Report

A 53-year-old female presented after starting a low-carbohydrate ketogenic diet for weight loss. She reported xerostomia, nausea with abdominal pain and a 17-pound weight loss over the previous 22 days. Labs revealed an anion-gap metabolic acidosis with ketosis. She was treated with 5% dextrose in normal saline and a sliding scale insulin coverage. Her anion gap corrected during her hospital course and was discharged on hospital day three.

Discussion

The ketogenic diet typically consists of a high-fat, adequate protein and low carbohydrate diet that has previously been thought to be relatively safe for weight loss. However, when carbohydrates are completely removed from the diet an overproduction of ketones bodies results in ketoacidosis. Treatment should be aimed at halting the ketogenic process and patient education.

Conclusion

Although rarely included in the differential for metabolic acidosis, diet-induced ketosis should be included by the emergency physician when faced with a patient who recently changed their eating patterns.

Efficacy and safety of very low calorie ketogenic diet (VLCKD) in patients with overweight and obesity: A systematic review and meta-analysis

Very low calorie ketogenic diet (VLCKD) has been proposed as a promising option to achieve a significant weight loss in a short time period. We conducted a systematic review and meta-analysis to evaluate its efficacy and safety in patients with overweight and obesity. Four databases were searched on May 2019. Studies reporting data on body weight, body mass index (BMI), waist circumference, body composition, blood pressure, HbA1c, lipids, and markers of liver and kidney function were selected. Discontinuation was also assessed. Twelve studies were included. VLCKD was associated with weight losses of -10.0 kg (I² = 6%) and - 15.6 kg (I² = 37%) in studies with a ketogenic phase up to and of at least four weeks, respectively. The weight lost during the ketogenic phase was stable in the subsequent follow-up up to two years (p = 0.12). Also, VLCKD was associated with reductions of BMI (-5.3 kg/m²), waist circumference (-12.6 cm), HbA1c (-0.7%), total cholesterol (-28 mg/dl), triglycerides (-30 mg/dl), AST (-7 U/l), ALT (-8 U/l), GGT (-8 U/l), systolic and diastolic blood pressure (-8 and - 7 mmHg, respectively). No changes in LDL cholesterol, HDL cholesterol, serum creatinine, serum uric acid and serum potassium were found. Serum sodium increased during VLCKD (+1.6 mEq/l). The overall prevalence of patients discontinuing VLCKD was 7.5% and this was similar to patients undergoing a low calorie diet (p = 0.83). The present review supports the use of VLCKD as an effective strategy for the management of overweight and obesity. Future guidelines should include a specific recommendation for this intervention.

Inducing ketogenesis via an enteral formulation in patients with acute brain injury:a phase II study

Objective: Although extensively studied in children, the safety and tolerability of ketone supplementation in adults is unclear, particularly in the acute brain injury population. The purpose of this study was to examine the feasibility and safety of inducing ketosis using an enteric ketogenic formulation and determine its impact on intracranial and cerebral perfusion pressures and metabolic parameters.Methods: Prospective interventional Phase II trial of ventilated critically ill patients with acute brain injury administered a ketogenic feed over a 6 day period.Results: 20 patients were recruited, 5 females and 15 males, 3 with stroke, 2 with subarachnoid haemorrhage and 15 with traumatic brain injury. Feeds were well tolerated with 19 patients completing study. There was a significant increase in both plasma beta-hydroxybutyrate and acetoacetate from 0.24± 0.31 mmol/l and 0.19 ± 0.16 mmol/l to 0.61 ± 0.53 mmol/l (p =0.0005) and 0.52 ± 0.40 mmol/l (p<0.0001) respectively over the 6 day period. Total daily Ketocal® caloric intake was positively correlated with plasma beta-hydroxybutyrate concentrations (p=0.0011). There was no significant correlation between the cerebral hypertension and cerebral hypoperfusion indices and plasma ketone concentrations. In 95% of patients there were no clinically significant changes in acid/base status over the 6 days with pH remaining within normal range.Conclusion: In patients with acute brain injury, an enterally administered ketogenic formulation increased plasma ketone concentrations, was well tolerated, did not impact on cerebral hemodynamics and can be safely administered.Clinical trial registered at the Australian New Zealand Clinical Trials Registry (ACTRN12616000332426)Abbreviations: BHB: betahydroxybutyrate; AcAc: acetoacetate; ABI: acute brain injury; TBI: traumatic brain injury; CSF: cerebrospinal fluid; SAH: subarachnoid injury; CVA: cerebrovascular accidents; ICP: intracranial pressure; CPP: cerebral perfusion pressure; ICU: intensive care unit; EVD: external ventricular device; CHI: cerebral hypoperfusion index; IHI: intracranial hypertension index; GCS: Glasgow Coma Scale.

Starvation Ketoacidosis due to the Ketogenic Diet and Prolonged Fasting - A Possibly Dangerous Diet Trend

Patient: Male, 60

Final Diagnosis: Starvation ketoacidosis

Symptoms: Nausea • syncope • vomiting

Medication: —

Clinical Procedure: —

Specialty: Metabolic Disorders and Diabetics

Effect of a Very-Low-Calorie Ketogenic Diet on Circulating Myokine Levels Compared with the Effect of Bariatric Surgery or a Low-Calorie Diet in Patients with Obesity

: The preservation of muscle mass and muscle function after weight loss therapy is currently a considerable challenge in the fight against obesity. Muscle mass secretes proteins called myokines that have relevant functions in the regulation of metabolism and health. This study was aimed to evaluate whether a very low-calorie ketogenic (VLCK) diet may modulate myokine levels, in addition to changes in body composition, compared to a standard, balanced low-calorie (LC) diet or bariatric surgery in patients with obesity. Body composition, ketosis, insulin sensitivity and myokines were evaluated in 79 patients with overweight/obesity after a therapy to lose weight with a VLCK diet, a LC diet or bariatric surgery. The follow-up was 6 months. The weight loss therapies induced changes in myokine levels in association with changes in body composition and biochemical parameters. The effects on circulating myokine levels compared to those at baseline were stronger after the VLCK diet than LC diet or bariatric surgery. Differences reached statistical significance for IL-8, MMP2 and irisin. In conclusion, nutritional interventions or bariatric surgery to lose weight induces changes in circulating myokine levels, being this effect potentially most notable after following a VLCK diet.

Ketogenic Diet-Induced Severe Ketoacidosis in a Lactating Woman: A Case Report and Review of the Literature

The ketogenic diet (KD) is a high-fat, adequate-protein, and low-carbohydrate diet that leads to nutritional ketosis and weight loss. It is known to induce ketosis but is not an established cause of clinically significant ketoacidosis. Lactation ketoacidosis is well established in bovine literature but remains a rare phenomenon in humans. Here we present a life-threatening case of severe ketoacidosis in a nondiabetic lactating mother on a strict ketogenic diet. We review the available case reports of lactation ketoacidosis in humans and the mechanisms thereof. Although ketogenic diet has been shown to be safe in nonpregnant individuals, the safety of this diet in lactating mothers is not known. Health professionals and mothers should be made aware of the potential risk associated with a strict ketogenic diet when combined with lactation. Prompt diagnosis and immediate treatment cannot be overemphasized. To our knowledge, this is the first reported case of life-threatening lactation ketoacidosis associated with ketogenic diet while consuming an adequate number of calories per day.

Severe anion gap metabolic acidosis associated with initiation of a very low-carbohydrate diet

Low carbohydrate diets have been popularized as an effective solution for weight loss. Although rare, life-threatening anion gap metabolic acidosis has been reported in patients on these diets. We present a case of a 31-year-old man with atypical symptoms of chest pain and shortness of breath found to have severe metabolic acidosis after starting low carbohydrate diet for a week.

Dietary modifications for weight loss and weight loss maintenance

Worldwide obesity rates remain at a rise, and to treat obesity is at the top of the global public health agenda. In 2013, the AHA/ACC/TOS obesity management guidelines were published, in essence suggesting that any dietary scheme seems to be effective for weight loss, as long as it can induce a sustainable energy deficit. In the present review, we update and critically discuss available information regarding dietary modifications for weight loss and weight loss maintenance, published after the 2013 guidelines. Regarding weight loss, we found no proof to support that a single dietary scheme, be it nutrient-, food group- or dietary pattern- based, is more efficacious of the other for achieving weight loss. For weight loss maintenance, published interventions point towards the same direction, although inconclusively. Most research explores the effect of weight loss regimes on weight loss maintenance and not the effect of the diet during weight loss maintenance, and this literature gap should be more thoroughly investigated.

Weight loss, improved physical performance, cognitive function, eating behavior, and metabolic profile in a 12-week ketogenic diet in obese adults

The ketogenic diet (KD) is being increasingly promoted as a strategy to fight obesity. Although the KD is effective for weight loss and weight control, comprehensive determination of its relationship with biochemical, physiological and psychological changes is still largely unexplored. We hypothesized that a 12-week KD (12KD) would significantly affect body weight, physical performance, cognitive function, eating behaviors, the metabolic and hormonal profile in obese adults, although differently in men and women. In an uncontrolled intervention, 35 sedentary obese adults (13 men, 25 women), aged 37 ± 7 years with a BMI 36.1 ± 5.6 kg/m² underwent a 12KD between March 2017 and June 2017 at the University of Primorska. The 12KD resulted in decreased appetite, significant weight loss of participants (-18 ± 9 kg men vs. -11 ± 3 kg women; P < .001), decreased emotional and external eating (P < .001 for both), increased body image satisfaction (P < .001) and improved physical performance (P < .001). Biochemically, a significant drop in glucose (P = .026), and a significant increase in LDL-cholesterol (P = .031), CRP (P = .007), and BDNF (P = .035) were observed in the first 2 weeks; then, all listed parameters returned to baseline. On the other hand, a significant reduction in insulin (P < .001) and leptin levels (P < .001), and a significant increase in adiponectin (P = .008) and NPY (P = .009) were detected throughout the duration of the 12KD. Our results show the efficacy of the 12KD on weight loss, physical performance, cognitive function, eating behaviors and metabolic profile. However, the long-term effects of a KD on these outcomes needs to be further studied before general recommendations can be made.

Effect of A Very Low-Calorie Ketogenic Diet on Food and Alcohol Cravings, Physical and Sexual Activity, Sleep Disturbances, and Quality of Life in Obese Patients

Psychological well-being and hunger and food control are two relevant factors involved in the success of weight-loss therapy in treating obesity. Thus, this study aims to evaluate food and alcohol cravings, physical and sexual activity, sleep, and life quality (QoL) in obese patients following a very low-calorie ketogenic (VLCK) diet, as well as the role of weight lost and ketosis on these parameters. A battery of psychological test was performed in twenty obese patients (12 females, 47.2 ± 10.2 year and BMI of 35.5 ± 4.4) through the course of a 4-month VLCK diet on four subsequent visits: baseline, maximum ketosis, reduced ketosis, and endpoint. Each subject acted as their own control. Relevantly, the dietary-induced changes in body composition (7.7 units of BMI lost, 18 kg of fat mass (1.2 kg of visceral fat mass)) were associated with a statistically significant improvement in food craving scores, physical activity, sleepiness, and female sexual function. Overall, these results also translated in a notable enhancement in QoL of the treated obese patients. Therefore, the rapid and sustained weight and fat mass (FM) loss induced by the VLCK diet is associated with good food control and improvements in the psychological well-being parameters in obese subjects, which could contribute to the long-term success of this therapy.