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September 21, 2018

How were you introduced to keto?
I was first introduced to the ketogenic diet while in school for my nursing degree.  I was trying to think of a subject to use for my research project.  I've always been fascinated by the complexities of the endocrine system.  I had originally thought about looking at research on hypothyroidism but didn't know where I wanted to take that.  So, I looked at the state of health in American in general and wanted to know some of the issues I'd be facing as a new nurse entering practice.  One of the most prominent issues we seemed to be faced with in American (this was before the heroine epidemic of course), seemed to be the ongoing increase in obesity and diabetes prevalence.  Having known people with type I and type II diabetes and having an interest in the endocrine system and the role it plays in diabetes, I thought this may be a good place to start. 

As a nurse, one of my primary roles would be to continue to educate my patients on how to maintain their health and wellness.  So, I started to look at some of the general research surrounding diabetes.  It was around this time that one of my close friends mentioned the ketogenic diet to me.  He works in the tech field so I asked him how and why he knew about it.  He had told me that diabetes ran in his family and that he wanted to avoid this in himself.  He had also done a great deal of academic research on the diet and felt it was the best option for him.  It is worth mentioning that he has been eating this way for over 8 years as of now.

I decided to do my own academic research on this way of eating and looked for research on it as a primary intervention for the type II diabetic.  I was astounded with the amount of research I found suggesting that it was possibly the best approach to managing type II diabetes and even research suggesting that it should be considered for adjunctive therapy in our type I diabetic patients.  The fact that patients also had substantial healthy weight loss that was able to be sustained on this type of diet was incredible.  I was seeing so many great, peer-reviewed/evidence-based articles that I began to wonder why I hadn't learned about this diet in my schooling.  I knew this was something I needed to learn more about, so I've been continuing to research this way of eating since that time, in both graduate school and in my practice as a Nurse Practitioner.

What influenced your decision to follow a ketogenic diet?
I think what made me want to do a ketogenic diet the most was the fact that I could lose a good deal of weight just through eating healthy and have other beneficial health effects from the diet.  Many people reported improved energy levels, decreased inflammation, and clearer mentation (thinking) which all sounded great to me!  So, I started following a ketogenic diet and implemented a lot of exercise as well.  I felt that if I was going to be working in healthcare, I needed to set a good example.  Unfortunately, this was all short-lived when my spouse became pregnant and couldn't stand the smell of almost any food for seven months.  I fell off of the keto way of eating for a few years, gained the 32 lbs I had lost (and then some) and felt horrible.  I went through nurse practitioner school, kept gaining weight, wasn't exercising, and felt like a hypocrite. 

My motivation for getting back on the diet was much the same but more drastic.  I put on a LOT of weight, felt tired all the time, and felt like a serious hypocrite.  I went back on the diet, remained strict, lost over 50 lbs, and have been ketogenic since.  I still occasionally have a cheat day (maybe once or twice a month, if that) but I try to remain quite strict. 

In the cardiology field, what are the views regarding the ketogenic diet?  Do you feel it is stigmatized?
There are few providers who actually know about the ketogenic diet and even fewer who actually understand it.  You generally hear the opposite of the ketogenic diet recommended in cardiology though... "eat low fat, low sat, and high carb."  The big problem is, when you tell people to eat low fat, they're going to fill those calories with something else.  Generally speaking, it is unhealthy carbohydrates.  People think that, because a bag of chips or a bag of twizzlers is a "low fat snack" it is healthy... but it just isn't!  The other big problem is that there isn't a lot of data suggesting that dietary fat intake has anything to do with heart disease.  In fact, there is a LOT of data suggestive of the fact that a high carbohydrate diet may actually be much more harmful than a high fat diet; particularly if the fats are from healthy sources.

Do I feel the diet is stigmatized?  In cardiology, absolutely!  The unfortunate part is that this is largely out of ignorance to the diet itself.  Many people confuse the ketogenic diet with the Atkins diet or just have no idea what the Ketogenic diet is.  In truth, those two diets are very different.  For the longest time, the Atkins diet had an emphasis on high protein intake, somewhat low carbohydrate intake, and mentioned little about fat intake or micronutrient requirements.  It also had an end goal of increasing your carbohydrates which, to me, seems like a sure way to undo all your success!  Top that off with all the Atkins branded products that used poor, highly processed ingredients and you have a great recipe for poor health.  Eating that way for many was unsustainable, unclear, and unhealthy.  A ketogenic diet has a foundation built on real science and has clear guidelines as to how and what to eat.  While people may take slightly different approaches, the end goal is the same... maintain a metabolic state of ketosis to optimize fat metabolism and adipose (body fat) burn.

What is the most common cardio related misconceptions surrounding the ketogenic diet? Can you dispel those myths?
There are a number of misconceptions about the ketogenic diet in cardiology.  As I mentioned above, the biggest is confusing it with the Atkins diet.  The other one I hear a lot is, "so you just eat burgers and bacon all the time?"  No!  Of course we don't!  The ketogenic diet is meant to be a healthy balance of meats, fruits, and vegetables that meet your individual macronutrient requirements for calories, fats, protein, and carbohydrates.  The emphasis is primarily on healthy fats but those can come from meats, dairy, and vegetables in whatever balance will fit your macros.  I always emphasize the importance of vegetables on the ketogenic diet for those who don't understand the importance of getting in vital micronutrients (all the vitamins and minerals your body requires to maintain optimal functioning). 

The other main thing I hear is that the ketogenic diet will cause a heart attack or stroke.  Again, comes from people who think I sit there with a jar of bacon grease all day.  Current research actually suggests that maintaining a ketogenic lifestyle may reduce many individuals risk for stroke and heart disease.  This is due to the impact this lifestyle has on a number of risk factors for these health concerns.  Losing weight alone tends to reduce your risk due to the reduction in excess body fat and the coinciding reduction of blood pressure.  However, on a ketogenic diet, people often experience more benefits than just weight loss such as a reduction of circulating bad cholesterol when the diet is maintained past the primary weight loss period, reduction in blood pressure beyond the benefits seen with weight loss (as it is a naturally diuretic diet), reduction in inflammation (which can help reduce likelihood for injury to coronary and carotid blood vessels), decreased fatigue (which can increase likelihood for individuals to want to exercise), and many many more.  Recent cardiology research suggests that the ketogenic diet can and SHOULD be used in patients with congestive heart failure due to the natural diuretic process of the diet.  For those who may not know what that means, this diet causes you to shift fluids into the kidneys and out of the body as urine without the need for a diuretic medication.  Some neurology and psychology studies even suggest that this way of eating can be a therapy for depression and neurocognitive disorders when done under medical advisement.

The last myth I'd like to dispel involves protein intake. Many people have this misconception that the ketogenic diet means you can eat as many calories as you want as long as they are from fat or protein and MANY people think there is no restriction on protein intake.  If you truly understand this diet and how it works in the body than you must understand two things.

  1. To lose weight sustainably and healthily, there must be some level of a caloric deficit.
  2. The ketogenic diet is high fat (percentage wise), very low carbohydrate, and moderate to moderately low protein. Essentially, protein fills the calories not filled by fats or the very little amount of carbs you take in.  It is not meant to be your primary source of calories.

Eating too much protein (or calories in general) on this diet when trying to lose weight will impair your ability to do so.  Protein is able to be turned into glucose somewhat easily by the body when you are deprived of carbohydrates.  While the protein itself may not cause a large spike in your blood glucose levels, once it converts to glucose you will have an elevation in your serum (in the blood) levels of insulin.  This is something you want to avoid on this diet (particularly if you are already diabetic). You will also not maintain a fat adapted state because your body will be trained to convert protein into glucose for energy rather that to utilize your fats that you are eating, that your body generates (cholesterol), or that you have stored (adipose/body fat). 

So in summary, you cannot just eat all the calories and protein you want, we don't all just suck down bacon and burgers, and you do need vegetables in your diet.  You can do without the fruits if you like but I feel having berries is helpful at times for getting in your micronutrients as well. If you find that you are low in certain vitamins or minerals, you may need to talk to your provider about a healthy supplement.  Alternatively, look at your diet and see how you can get them naturally from whole foods!  This is a wonderful way of eating and I plan to stay ketogenic for life.  I also can't wait to see more peer-reviewed research come to the forefront so it can make its way further into the world of modern medicine as a primary prevention method for many of these chronic diseases!

As a cardiology Nurse Practitioner in the hospital, you see many patients at their worst as far as their cardiac health is concerned.  Is the ketogenic diet something you would recommend to your patients?
This is somewhat of a difficult question.  In the hospital, your main focus is getting the person well enough to get them back in to their home setting.  Hospital medicine is rather expensive and evidence shows that people tend to do better in a home setting once they are no longer acutely ill.  With that in mind, we can't address everything in a short hospital stay.  Lifestyle choices are influenced by so many things that we may never even learn about during our interactions with our patients in the hospital so we are often ill-equipped to be able to identify some of the barriers to compliance with a diet such as the ketogenic diet. 

Fortunately for me, I am also able to follow-up with some of these patients in the office setting.  This is a much better setting for addressing things like medication compliance, dietary changes, exercise, and social issues that impact the patient's health.  This is the time that I would make recommendations as to what type of diet changes to make.  I will say, however, that I let every patient I work with understand the importance of reducing and/or eliminating simple carbohydrates (sugars) from the diet.  Whether they are diabetic, suffer from metabolic syndrome, or have no endocrine issues at all, we can all afford to reduce the amount of sugar in our diet substantially.  Many of my patients are overweight which, in and of itself, contributes a great deal to heart disease.

What advice would you give your patients wanting to start the ketogenic diet?  Any warnings?
So let's start with the warnings.  I would warn my patients that there are a few things that may make this way of eating difficult.  The first is that you have to retrain how you think about food.  If you are someone who likes to eat simply to eat (much like myself), you need to train yourself that you are only eating to fuel your body.  For those who like car analogies, food is the gasoline that keeps our engines firing throughout the day and sleep is like the alternator that recharges our batteries for the next day.  We need food and we can even enjoy food.  Heck, I enjoy eating more than ever on this diet.  However, we can't allow ourselves to be controlled by our cravings.  That can be quite difficult for some. 

The other warning I would give my patients is that many people are fairly ignorant (or uneducated) in regards to the truths behind nutrition and the societal motivations for keeping people eating unhealthy foods.  With that in mind, they are likely to meet a lot of resistance when discussing the way they eat.  I find that if you provide a list of foods you eat rather than telling someone you follow a ketogenic diet, you get a lot less negative feedback and a lot more encouragement.

Advise for my patients is usually pretty straight forward.  The key to success on any lifestyle change is sustainability.  If you can't commit to whatever it is you are doing for an indefinite amount of time, you'll likely never be successful.  So, starting slow and simple tends to work best.  I encourage my patients to start by eliminating the obvious things like sugary drinks, candies, and unhealthy snacks and replacing them with healthy alternatives.  This change relates to my most important piece of advise (in my opinion), which is, "It is much easier to say no once in the grocery store than it is every time you open your cabinets or pantry or refrigerator at home." Once they've managed to stick to that, I encourage they start to keep a diet journal and figure out what it is they eat regularly.  Is it healthy or unhealthy?  Is it rich in simple carbs or does it contain a good balance of fats, protein, and fiber?  If it falls in to what I have defined as unhealthy for them, we look at ways to modify or replace that meal.  I find that if you are able to work within the "realm of substitution" (as I call it),  you are likely to be more successful because you don't feel like you are having to give up every food you enjoy. 

Once people who struggle to lose weight start to see their weight come down, I delve a little deeper into the specifics of the ketogenic diet.  I find that most people become notably more motivated once they actually see those numbers on the scale start to drop.  Likewise, when they realize there are a large number of delicious recipes that they can make in under 30 minutes at home, they also tend to get excited about this way of eating.  Making sure that they have good resources to pull information from, be it studies, macronutrient calculators, diet trackers, or even myself, tends to keep my patients honest and successful.  I've obviously had a great deal more experience with this when I worked in primary care as a primary care provider, but I'm starting to implement this into my job as a cardiology provider.  I can't wait to see what the future brings us for better research and clearer guidelines for how implementation of the ketogenic diet can be helpful for different health conditions.  It is a confusing but exciting world we work in here in modern western medicine... but there is hope for positive change.

For the final question, where do you stand on testing ketone levels?  Do you check your own?  Do you recommend your  patient’s check theirs?  What method do you prefer?
I feel that checking your own ketone levels is a great way to successfully maintain optimal ketosis.  While I don’t feel it is necessarily required and while I may not recommend it to patients who may have difficulty doing so, it can really help to show the individual who is deeply invested in their overall health where they stand in regards to their dietary control.  Knowing you are maintaining ketosis on foods that you thoroughly enjoy can help also increase buy-in from patients who may feel that this is too difficult of a diet to follow.

Regarding the method of tracking, I feel that the most accurate is certainly the blood ketone monitoring method, although it may not be the most practical for all of my patients.  Ketone monitoring is largely not covered by insurance providers which can be a barrier for some, although an HSA or FSA card can often be used to purchase one.  Many patients in the cardiology field are on multiple medications and live on a very fixed income (we see a lot of 65 year and older patients).  For those who would like to be strict in their diet, Keto-Mojo makes a very affordable meterthat our diabetic patients can sometimes get reimbursed due to the fact it can also monitor glucose levels.  Likewise, while their ketone strips may not be covered, they are more affordable than any other company I’ve found out there. 

For many patients, the urine strips can be a good place to start.  It lets them know that ketones are being produced, even though it doesn’t really let them know what level of ketosis they are in.  The breath meter has a little bit of a “sticker shock”, coming in at $200 and up to $700.  That is a big deal for these patients that are already having to pay monthly premiums/copays for prescriptions and office visits.  The one major issue (other than affordability) with the breath meter, however, is that it is somewhat complicated to use and takes a great deal of explaining to the patient in regards to what its values actually mean.  The blood ketone monitor is just as simple to understand as any glucose monitor (which is extremely straight forward) which many patients are familiar with.  There is also a lot more information out there as to what the optimal levels for ketosis  are when blood monitoring for those patients who like to do a little independent research.  The blood ketone monitor is also less affected by certain foods or beverages so you can trust that the value it is reporting is actually accurate. This provides my patient with an easy, affordable way to track their progress and put them in the captain’s chair of their health. By monitoring they can keep daily or weekly logs for me to review, but also be able to make adjustments to their diet on a daily basis based on their readings, empowering them to make decisions that impact their health personally.

Do I test my own ketone levels?  Not on a very regular basis… but yes.  I will check if I feel I am not being strict enough, if I want to know how a food affects me, or if I was unable to resist temptation and had a cheat day at a family gathering or other special event.  I use the ketone blood monitor method of checking my levels because, as I stated earlier, this is the most accurate way to do so.  All in all, I find that, while it can be extremely helpful and is important in maintaining optimal ketosis, I wouldn’t allow whether or not you can afford to or are willing to track your ketones to be a barrier to following this way of eating.  Getting you healthy is the first step.  Having more data to support your optimal level of health is the added bonus.

Eric C., BSN, RN, MSN, APRN, FNP-C


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