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Fernández-Verdejo R, Mey JT, Ravussin E. Effects of ketone bodies on energy expenditure, substrate utilization, and energy intake in humans. J Lipid Res 2023; 64:100442. [PMID: 37703994 PMCID: PMC10570604 DOI: 10.1016/j.jlr.2023.100442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023] Open
Abstract
The potential of ketogenic approaches to regulate energy balance has recently gained attention since ketones may influence both energy expenditure and energy intake. In this narrative review, we summarized the most relevant evidence about the role of ketosis on energy expenditure, substrate utilization, and energy intake in humans. We considered different strategies to induce ketosis, such as fasting, dietary manipulation, and exogenous ketone sources. In general, ketosis does not have a major influence on energy expenditure but promotes a shift in substrate utilization towards ketone body oxidation. The strategies to induce ketosis by reduction of dietary carbohydrate availability (e.g., ketogenic diets) do not independently influence energy intake, being thus equally effective for weight loss as diets with higher carbohydrate content. In contrast, the intake of medium-chain triglycerides and ketone esters induces ketosis and appears to increase energy expenditure and reduce energy intake in the context of high carbohydrate availability. These latter strategies lead to slightly enhanced weight loss. Unfortunately, distinguishing the effects of the various ketogenic strategies per se from the effects of other physiological responses is not possible with the available human data. Highly controlled, inpatient studies using targeted strategies to isolate the independent effects of ketones are required to adequately address this knowledge gap.
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Affiliation(s)
- Rodrigo Fernández-Verdejo
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA; Laboratorio de Fisiología del Ejercicio y Metabolismo (LABFEM), Escuela de Kinesiología, Facultad de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Jacob T Mey
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA
| | - Eric Ravussin
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA.
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Paoli A, Bianco A, Moro T, Mota JF, Coelho-Ravagnani CF. The Effects of Ketogenic Diet on Insulin Sensitivity and Weight Loss, Which Came First: The Chicken or the Egg? Nutrients 2023; 15:3120. [PMID: 37513538 PMCID: PMC10385501 DOI: 10.3390/nu15143120] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
The ketogenic diet (KD) is, nowadays, considered an interesting nutritional approach for weight loss and improvement in insulin resistance. Nevertheless, most of the studies available in the literature do not allow a clear distinction between its effects on insulin sensitivity per se, and the effects of weight loss induced by KDs on insulin sensitivity. In this review, we discuss the scientific evidence on the direct and weight loss mediated effects of KDs on glycemic status in humans, describing the KD's biochemical background and the underlying mechanisms.
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Affiliation(s)
- Antonio Paoli
- Department of Biomedical Sciences, University of Padua, 35127 Padua, Italy
- Research Center for High Performance Sport, UCAM, Catholic University of Murcia, 30107 Murcia, Spain
| | - Antonino Bianco
- Sport and Exercise Sciences Research Unit, University of Palermo, 90144 Palermo, Italy
| | - Tatiana Moro
- Department of Biomedical Sciences, University of Padua, 35127 Padua, Italy
| | - Joao Felipe Mota
- School of Nutrition, Federal University of Goiás, Goiânia 74605-080, Brazil
- APC Microbiome Ireland, Department of Medicine, School of Microbiology, University College Cork, T12 YT20 Cork, Ireland
| | - Christianne F Coelho-Ravagnani
- Research in Exercise and Nutrition in Health and Sports Performance-PENSARE, Post-Graduate Program in Movement Sciences, Institute of Health (INISA), Federal University of Mato Grosso do Sul, Campo Grande 79070-900, Brazil
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Lodi A, Zarantonello L, Bisiacchi PS, Cenci L, Paoli A. Ketonemia and Glycemia Affect Appetite Levels and Executive Functions in Overweight Females During Two Ketogenic Diets. Obesity (Silver Spring) 2020; 28:1868-1877. [PMID: 32875733 DOI: 10.1002/oby.22934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/02/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study sought to investigate how glycemia and ketonemia variations during two ketogenic diet protocols affect appetite, executive functions, and mood in young women with overweight. METHODS Fifty healthy young females with overweight were randomly assigned to (1) a ketogenic diet without any restriction on energy intake, (2) a commercial energy-restricted ketogenic Mediterranean diet, and (3) an energy-restricted Mediterranean diet for 10 days. A visual analogue scale was used to test appetite, and one mood test and two cognitive tasks (working memory and inhibition control) were performed. Moreover, body composition, fasting blood glucose, and β-hydroxybutyrate (BHB) were measured. RESULTS A positive correlation was found between glycemia and appetite (P = 0.019), unfullness score (P = 0.001), and desire to eat (P = 0.030) (pre- and postdiet levels). Postdiet BHB levels showed a positive correlation with fullness score (P = 0.002) and a negative correlation with appetite (P = 0.022) and desire to eat (P = 0.009). A positive correlation was found between prediet levels of glycemia and reaction times in the go-trials of the executive function test (P = 0.018). Postdiet BHB level showed a negative correlation with the accuracy of the no-go trials (P = 0.027). CONCLUSIONS Ketogenic diets, compared with a Mediterranean diet, have a greater effect in terms of appetite reduction but might affect inhibition functions.
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Affiliation(s)
- Alessandra Lodi
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | | | - Patrizia Silvia Bisiacchi
- Department of General Psychology, University of Padua, Padua, Italy
- Padua Neuroscience Center PNC, University of Padua, Padua, Italy
| | - Lorenzo Cenci
- Human Inspired Technology Research Center, University of Padua, Padua, Italy
| | - Antonio Paoli
- Department of Biomedical Sciences, University of Padua, Padua, Italy
- Research Center for High Performance Sport, UCAM, Catholic University of Murcia, Murcia, Spain
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Friedman MI, Appel S. Energy expenditure and body composition changes after an isocaloric ketogenic diet in overweight and obese men: A secondary analysis of energy expenditure and physical activity. PLoS One 2019; 14:e0222971. [PMID: 31815933 PMCID: PMC6901216 DOI: 10.1371/journal.pone.0222971] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 09/09/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND A previously published pilot study assessed energy expenditure (EE) of participants with overweight and obesity after they were switched from a baseline high-carbohydrate diet (BD) to an isocaloric low-carbohydrate ketogenic diet (KD). EE measured using metabolic chambers increased transiently by what was considered a relatively small extent after the switch to the KD, whereas EE measured using doubly labeled water (EEDLW) increased to a greater degree after the response in the chambers had waned. Using a publicly available dataset, we examined the effect of housing conditions on the magnitude of the increase in EEDLW after the switch to the KD and the role of physical activity in that response. METHODS The 14-day EEDLW measurement period included 4 days when subjects were confined to chambers instead of living in wards. To determine the effect on EEDLW only for the days subjects were living in the wards, we calculated non-chamber EE (EEnonchamber). To assess the role of physical activity in the response to the KD, we analyzed chamber and non-chamber accelerometer data for the BD and KD EEDLW measurement periods. RESULTS In comparison with the increase in average 14-day EEDLW of 151 kcal/d ± 63 (P = 0.03) after the switch to the KD, EEnonchamber increased by 203 ± 89 kcal/d (P = 0.04) or 283 ± 116 kcal/d (P = 0.03) depending on the analytical approach. Hip accelerometer counts decreased significantly (P = 0.01) after the switch to the KD, whereas wrist and ankle accelerometer counts did not change. CONCLUSIONS Switching from the BD to the KD substantially increased EEDLW, but apparently only on days subjects were living in the ward outside the metabolic chamber. Increased physical activity as measured by accelerometry did not appear to account for this effect.
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Affiliation(s)
- Mark I. Friedman
- Nutrition Science Initiative, San Diego, California, United States of America
| | - Scott Appel
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Hall KD, Guo J, Chen KY, Leibel RL, Reitman ML, Rosenbaum M, Smith SR, Ravussin E. Reply to DS Ludwig et al. Am J Clin Nutr 2019; 110:1255-1256. [PMID: 31667517 PMCID: PMC7307317 DOI: 10.1093/ajcn/nqz157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Kevin D Hall
- From the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD,Address correspondence to KDH, e-mail:
| | - Juen Guo
- From the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Kong Y Chen
- From the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Marc L Reitman
- From the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Steven R Smith
- The Translational Research Institute for Metabolism and Diabetes, Baton Rouge, LA
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Hall KD, Guo J, Chen KY, Leibel RL, Reitman ML, Rosenbaum M, Smith SR, Ravussin E. Methodologic considerations for measuring energy expenditure differences between diets varying in carbohydrate using the doubly labeled water method. Am J Clin Nutr 2019; 109:1328-1334. [PMID: 31028699 PMCID: PMC6499509 DOI: 10.1093/ajcn/nqy390] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Low-carbohydrate diets have been reported to significantly increase human energy expenditure when measured using doubly labeled water (DLW) but not by respiratory chambers. Although DLW may reveal true physiological differences undetected by respiratory chambers, an alternative possibility is that the expenditure differences resulted from failure to correctly estimate the respiratory quotient (RQ) used in the DLW calculations. OBJECTIVE To examine energy expenditure differences between isocaloric diets varying widely in carbohydrate and to quantitatively compare DLW data with respiratory chamber and body composition measurements within an energy balance framework. DESIGN DLW measurements were obtained during the final 2 wk of month-long baseline (BD; 50% carbohydrate, 35% fat, 15% protein) and isocaloric ketogenic diets (KD; 5% carbohydrate, 80% fat, 15% protein) in 17 men with a BMI of 25-35 kg/m2. Subjects resided 2 d/wk in respiratory chambers to measure energy expenditure (EEchamber). DLW expenditure was calculated using chamber-determined RQ either unadjusted (EEDLW) or adjusted (EEDLWΔRQ) for net energy imbalance using diet-specific coefficients. Accelerometers measured physical activity. Body composition changes were measured by dual-energy X-ray absorptiometry (DXA) which were combined with energy intake measurements to calculate energy expenditure by balance (EEbal). RESULTS After transitioning from BD to KD, neither EEchamber nor EEbal were significantly changed (∆EEchamber = 24 ± 30 kcal/d; P = 0.43 and ∆EEbal = -141 ± 118 kcal/d; P = 0.25). Similarly, physical activity (-5.1 ± 4.8%; P = 0.3) and exercise efficiency (-1.6 ± 2.4%; P = 0.52) were not significantly changed. However, EEDLW was 209 ± 83 kcal/d higher during the KD (P = 0.023) but was not significantly increased when adjusted for energy balance (EEDLWΔRQ = 139 ± 89 kcal/d; P = 0.14). After removing 2 outliers whose EEDLW were incompatible with other data, EEDLW was marginally increased during the KD by 126 ± 62 kcal/d (P = 0.063) and EEDLW∆RQ was only 46 ± 65 kcal/d higher (P = 0.49). CONCLUSIONS DLW calculations failing to account for diet-specific energy imbalance effects on RQ erroneously suggest that low-carbohydrate diets substantially increase energy expenditure. This trial was registered at clinicaltrials.gov as NCT01967563.
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Affiliation(s)
- Kevin D Hall
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Juen Guo
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Kong Y Chen
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Marc L Reitman
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Steven R Smith
- The Translational Research Institute for Metabolism and Diabetes, Orlando, FL
| | - Eric Ravussin
- Pennington Biomedical Research Center, Baton Rouge, LA
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Ebbeling CB, Feldman HA, Klein GL, Wong JMW, Bielak L, Steltz SK, Luoto PK, Wolfe RR, Wong WW, Ludwig DS. Effects of a low carbohydrate diet on energy expenditure during weight loss maintenance: randomized trial. BMJ 2018; 363:k4583. [PMID: 30429127 PMCID: PMC6233655 DOI: 10.1136/bmj.k4583] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine the effects of diets varying in carbohydrate to fat ratio on total energy expenditure. DESIGN Randomized trial. SETTING Multicenter collaboration at US two sites, August 2014 to May 2017. PARTICIPANTS 164 adults aged 18-65 years with a body mass index of 25 or more. INTERVENTIONS After 12% (within 2%) weight loss on a run-in diet, participants were randomly assigned to one of three test diets according to carbohydrate content (high, 60%, n=54; moderate, 40%, n=53; or low, 20%, n=57) for 20 weeks. Test diets were controlled for protein and were energy adjusted to maintain weight loss within 2 kg. To test for effect modification predicted by the carbohydrate-insulin model, the sample was divided into thirds of pre-weight loss insulin secretion (insulin concentration 30 minutes after oral glucose). MAIN OUTCOME MEASURES The primary outcome was total energy expenditure, measured with doubly labeled water, by intention-to-treat analysis. Per protocol analysis included participants who maintained target weight loss, potentially providing a more precise effect estimate. Secondary outcomes were resting energy expenditure, measures of physical activity, and levels of the metabolic hormones leptin and ghrelin. RESULTS Total energy expenditure differed by diet in the intention-to-treat analysis (n=162, P=0.002), with a linear trend of 52 kcal/d (95% confidence interval 23 to 82) for every 10% decrease in the contribution of carbohydrate to total energy intake (1 kcal=4.18 kJ=0.00418 MJ). Change in total energy expenditure was 91 kcal/d (95% confidence interval -29 to 210) greater in participants assigned to the moderate carbohydrate diet and 209 kcal/d (91 to 326) greater in those assigned to the low carbohydrate diet compared with the high carbohydrate diet. In the per protocol analysis (n=120, P<0.001), the respective differences were 131 kcal/d (-6 to 267) and 278 kcal/d (144 to 411). Among participants in the highest third of pre-weight loss insulin secretion, the difference between the low and high carbohydrate diet was 308 kcal/d in the intention-to-treat analysis and 478 kcal/d in the per protocol analysis (P<0.004). Ghrelin was significantly lower in participants assigned to the low carbohydrate diet compared with those assigned to the high carbohydrate diet (both analyses). Leptin was also significantly lower in participants assigned to the low carbohydrate diet (per protocol). CONCLUSIONS Consistent with the carbohydrate-insulin model, lowering dietary carbohydrate increased energy expenditure during weight loss maintenance. This metabolic effect may improve the success of obesity treatment, especially among those with high insulin secretion. TRIAL REGISTRATION ClinicalTrials.gov NCT02068885.
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Affiliation(s)
- Cara B Ebbeling
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Henry A Feldman
- Harvard Medical School, Boston, MA, USA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Gloria L Klein
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Julia M W Wong
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Lisa Bielak
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sarah K Steltz
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Patricia K Luoto
- Department of Food and Nutrition, Framingham State University, Framingham, MA, USA
| | - Robert R Wolfe
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - William W Wong
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - David S Ludwig
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA, USA
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Howell S, Kones R. "Calories in, calories out" and macronutrient intake: the hope, hype, and science of calories. Am J Physiol Endocrinol Metab 2017; 313:E608-E612. [PMID: 28765272 DOI: 10.1152/ajpendo.00156.2017] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/11/2017] [Accepted: 07/26/2017] [Indexed: 01/05/2023]
Abstract
One of the central tenets in obesity prevention and management is caloric restriction. This perspective presents salient features of how calories and energy balance matter, also called the "calories in, calories out" paradigm. Determinants of energy balance and relationships to dietary macronutrient content are reviewed. The rationale and features of the carbohydrate-insulin hypothesis postulate that carbohydrate restriction confers a metabolic advantage. According to this model, a large amount of fat intake is enabled without weight gain. Evidence concerning this possibility is detailed. The relationship and application of the laws of thermodynamics are then clarified with current primary research. Strong data indicate that energy balance is not materially changed during isocaloric substitution of dietary fats for carbohydrates. Results from a number of sources refute both the theory and effectiveness of the carbohydrate-insulin hypothesis. Instead, risk for obesity is primarily determined by total calorie intake.
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Affiliation(s)
- Scott Howell
- Tudor Bompa Institute, Kingsport, Tennessee; and
| | - Richard Kones
- The Cardiometabolic Research Institute, Houston, Texas
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