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BGEN 2010 - Applied Nutrition for Pharmacy Practice > Unit 5 - Ketogenic Diets > Flashcards

Unit 5 - Ketogenic Diets Flashcards

1
Q

What are Carbohydrate (CHO)-restricted diets, including ketogenic diets, been used as?

A

As a dietary strategy for epilepsy & weight reduction

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2
Q

There is growing interest in low-CHO & very-low-CHO ketogenic diets (KDs) for pts w/…

A

type II diabetes to improve their sugar level and reduce cardiovascular risk factors including high blood pressure, dyslipidemia, and stroke.

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3
Q

These CHO restricted-diets have been proposed to improve other conditions such as…

A

acne, cancer, neurological diseases, cognitive function, energy levels, and performance of athletes.

In addition, they are perceived as being healthier than contemporary recommended diets.

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4
Q

Ketosis or ketogenesis is a metabolic state:

A

which is characterized by increased level of ketone bodies in the body tissues, when less glucose is available or during fasting.

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5
Q

During this metabolic state, there is…

A

no hunger, and the liver converts free fatty acids (FFA) to ketones (ketosis), glycerol to glucose (gluconeogenesis), and some amino acids to glucose (gluconeogenesis).

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6
Q

The ketone bodies are…

A

beta-hydroxybutyrate, acetoacetate, and acetone.

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7
Q

Extrahepatic organs such as the brain, kidneys, heart, and muscle…

A

utilize ketones as metabolic fuels.

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8
Q

In addition, the following metabolic changes occur (Figure 1):

A
  • Increased lipolysis (lipids metabolized to fatty acids and glycerol)
  • Reduction in blood triglyceride levels
  • Minimal muscle loss
  • Improvement in triglyceride to high density lipoprotein level
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9
Q

In the normal state, the level of ketones in the blood is in the…

A

micro molar (μM) range.

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10
Q

Nutritional ketosis:

A

occurs when there is a small increase in ketone levels (0.5-3 mM), which is safe to feed vital organs in the body, when there is limited supply of glucose or carbohydrates.

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11
Q

The state of starvation ketosis:

A

occurs when there is a moderate increase in ketone levels (3-7 mM).

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12
Q

Metabolic ketoacidosis:

A

occurs when there is high level of ketones (> 7 mM) during prolong starvation.

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13
Q

In the ____, fasting, prolonged exercise or a very low carbohydrate diet triggers both gluconeogenesis (reverse glycolysis) to maintain adequate blood glucose and conversion of Acetyl CoA (product of fatty acid beta-oxidation) to ketones, which are then released into circulation.

A

Liver

The ketones are taken up by extra-hepatic tissues and converted back into Acetyl CoA, which can enter the Krebs cycle to fuel oxidative phosphorylation and ATP production.

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14
Q

There are several types of CHO-restricted diets, some of which restrict CHO to very low levels without changing protein and fat (_________), whereas others allow moderate CHO intake with moderate protein and fat intake (______________), and others allow very-low-CHO diets, limit protein to moderate levels to induce ketosis without restricting fat or total calories.

A

Atkins-style diet

South Beach, Zone diets

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15
Q

In general, a CHO-restricted diet is defined as…

A

CHO intake below the lower boundary of the acceptable macronutrient distribution range for healthy adults (45–65%) of the total daily energy (TDE).

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16
Q

A moderate-CHO diet is defined as…

A

26–44% TDE from CHO (130–225 grams CHO/d for a reference 2000 kcal diet), a low-CHO diet as 10–25% TDE from CHO (50–130 grams CHO/d), and a very-low-CHO diet as 10% TDE from CHO (>50 grams CHO/d).

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17
Q

The classic KD (cKD) is a very-low-CHO diet…

A

which is precisely calculated to induce ketosis while providing adequate nutrition to prevent malnutrition and promote normal growth and development in individuals. This cKD limits protein to moderate levels to induce ketosis without restricting fat or total calories.

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18
Q

Low- and moderate-CHO diets can be…

A

moderate or high in fat and moderate or high in protein and do not result in nutritional ketosis due to higher contents of both CHO and protein.

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19
Q

Ketosis can be predicted for a CHO-restricted diet based on…

A

its ketogenic ratio (the ratio of the sum of ketogenic factors to the sum of anti-ketogenic factors):

Ketogenic ratio (KR) = (0.9 F + 0.46 P)/ (1.0 C + 0.58 P + 0.1 F), where F is grams of fat, P is grams of protein, and C is grams of CHO.

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20
Q

The ratio that consistently induces ketosis is ________, with ____ typically being the lower ketogenic threshold.

A

2 or >2

1.5

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21
Q

Low- and moderate-CHO diets allow…

A

the consumption of CHO-containing foods that are components of cardioprotective dietary patterns, including vegetables, fruits, whole grains, nuts, seeds, and legumes.

These foods are important sources of fiber, magnesium, B-vitamins, and bioactive compounds, such as polyphenols, all of which have been associated with lower risks for cardiovascular disease and type 2 diabetes (TD2). Contemporary very-low-CHO KDs have become popular.

22
Q

The current popular version is very low in CHO (w20–50 g/d or 5–10% TDE), high in fat (70–80% TDE), and emphasizes…

A

the replacement of CHO with fat; thus, it is a very- low-CHO, high-fat diet, which results in ketosis.

23
Q

Achieving ketosis is ___________, and less than _____ of CHO may be needed in some individuals.

A

highly individualized

20 g/d

24
Q

In addition, at a given level of CHO intake, protein quantity appears to…

A

influence the degree of ketosis because some amino acids are used for gluconeogenesis, and stimulate insulin secretion, which may reduce hepatic ketone production.

25
Q

Therefore, current very-low-CHO and high fat KDs (VLCHF/KDs) are typically…

A

moderate in protein intake (1.2–1.5 g/kg/d).

26
Q

Typically, there is _____ emphasis on the type of fat that replaces CHO in VLCHF/KDs. This may result in a high intake of saturated fatty acids and cholesterol.

A

little

27
Q

Furthermore, the severe restriction of CHO in a VLCHF/KD limits…

A

CHO intake to non-starchy vegetables and eliminates fiber-rich starchy vegetables, as well as most fruits, legumes, and whole grains, which are foods that have been associated with reduced cardiometabolic risk.

28
Q

It is important to note that very low CHO diets done poorly (e.g., with high saturated fat intake) can…

A

increase circulating LDL, a well-established risk factor for cardiovascular disease, which is why ketogenic diets are typically not recommended except under very specific conditions or under strict monitoring.

This might change as we learn more and as data starts to emerge from longer-term studies. There are some popular and controversial MDs in the US promoting extreme ketogenic dieting right now (e.g., eat as many Big Macs as you want, just skip the bun), prompting big, angry debates at Nutrition conferences.

29
Q

Currently, there are four major Ketogenic diet therapies:

A
  1. Classic ketogenic diet (cKD),
  2. Modified Atkins diet (MAD),
  3. Medium chain triglyceride ketogenic diet (MCTKD) and the
  4. Low glycemic index treatment (LGIT).
30
Q

The cKD is usually initiated with a macronutrient ratio of ____ to provide __ grams of fat for every ___ gram of combined protein and carbohydrate relative to 80%-90% of the Recommended Dietary Allowances (RDA)⃰ for kcalories of energy (Table 1).

A

4:1

4

1

31
Q

This diet allows for…

A

adequate amount of protein to prevent malnutrition and promote growth and development.

32
Q

Other types of ketogenic diets that provide less restrictive interventions use the macronutrient ratio of____ or ____to provide ___ grams of fat for every __ gram of combined protein and carbohydrate.

A

3:1

2:1

3

1

Micronutrient supplementations of vitamins and minerals are prescribed as indicated, alongside the KDs for patients.

33
Q

Example for a 5-year-old:

A

1200 kcal and 19 g protein per day (divided among four meals per day)

34
Q

Meal 1:
Cream, 56 g
Canola oil, 6 g
Fresh egg, 16 g
Crisp bacon, 5 g
Strawberries, 14 g

A

30 g fat

7.5 g protein + CHO

35
Q

Meal 2:
Cream, 45 g
Canola oil, 4 g
Ranch dressing, 20 g
Iceberg lettuce, 16 g
Fresh spinach, 16 g
Grilled chicken breast, 9 g

A

30 g fat

7.5 g protein + CHO

36
Q

Meal 3:
Cream, 46 g
Canola oil, 4 g
Butter, 6 g
Spaghetti squash, 20 g
Cheddar cheese, 15 g

A

30 g fat

7.5 protein + CHO

37
Q

Meal 4:
Sugar-free mayo, 32 g
Shredded chicken breast, 16 g
Dill pickles, 11 g
Red grapes, 11 g

A

30 g fat

7.5 g protein + CHO

38
Q

Total for day:

A

120 g fat

30g protein + CHO

39
Q

Diet ratio 4:1:

A

1200 kcal per day

40
Q

RDA:

A

is a set of values for the average daily amounts of nutrients that are adequate nutrient needs of practically all healthy in a particular life stage and gender group.

41
Q

Currently, there are four major ketogenic diet therapies:

A
  1. cKD;
  2. Modified Atkins diet (MAD);
  3. Medium chain triglyceride ketogenic diet (MCTKD) and
  4. Low glycemic index treatment (LGIT).
42
Q

Initiation of KD therapy is preferred…

A

under supervision in hospitals, where patients or parents receive training in measuring food on gram scale, monitoring the level of ketones in urine, and reducing exposure to CHO.

43
Q

Ketogenic diets are prescribe taking into consideration the following three factors:

A
  1. Diet type
  2. Features of the diet
  3. Suitability of the diet
44
Q

Adequate energy, mineral, vitamin, and protein intakes, which is an important component of KD therapy, must be determined for…

A

individual patient (adjusted for changes in weight and growth).

45
Q

Initiation and administration of a KD therapy involves a careful stepwise plan, as follows:

A
  1. Diet initiation is performed by a non-fasting protocol beginning with a diet ratio of 1:1, with daily steps of increasing the calories and ratio.
  2. The ratio can be increased (2.5 or 2:1) or even higher (3.5 or 4:1) based on level of ketosis and tolerance.
  3. Careful calculation to check individual requirements are met is highly recommended especially when a 4:1 ratio is applied.
  4. Energy required must be determined based on the RDA for age, gender, and recent growth.
  5. When the ketosis does not reach the adequate range (0.5-3mmol/l in blood) within 2 weeks after diet initiation and careful calculation, it is important to adjust the diet (ratio) to optimize the diet effect.
  6. It is also important to exclude medication, including IV, which may contain significant amounts of glucose or other carbohydrates.
  7. Periodic monitoring of the patient’s health including laboratory assessment of ketogenic or ketosis markers are required. In most cases, beta-hydroxybutyrate (common blood ketone) is monitored as a ketosis marker and therefore, an indicator of diet compliance.
  8. There is a risk of hypoglycemia, acidosis, dehydration, and high levels of ketones on commencing a KD, therefore adverse effects must be monitored.
  9. Considering the possible occurrence of side effects including growth consequences, a shorter duration of KD therapy might be considered.
  10. Weaning from KD back on to normal diet should be done gradually using a stepwise approach over weeks or months.
46
Q

There continues to be interest in and proposed benefits of using low-carbohydrate and very-low carbohydrate diets for…

A

weight loss, glycemic control in patients with pre-diabetes and T2D, reduction in cardiovascular risk factors (e.g., high blood pressure and atherogenic dyslipidemia).

47
Q

In addition, there are reports of proposed benefits of these diets for the treatment of…

A

polycystic ovary syndrome, cancer, acne, and neurological diseases, and for improvement in cognitive function, energy levels and performance of athletes.

However, most of the proposed benefits and anecdotal reports of improvement for these diseases and conditions are not supported by rigorous controlled studies.

48
Q

Based on systematic reviews and meta-analyses (NLA-Statement. 2019)3, low-carbohydrate, and very-low carbohydrate (including ketogenic) diets:

A
  1. Can be consumed without the feeling of hunger and increased appetite.
  2. Have advantages for the treatment of intractable epilepsy in children and adults, which is
    considered a standard option.
  3. Can contribute to reduction in weight but are not superior to other dietary approaches for
    weight loss.
  4. Are associated with reduction in blood triglyceride levels.
  5. Are useful in reducing the use of medication in the management of T2D.
  6. Have no advantage in using them for the treatment of cancer, acne, and polycystic ovary
    syndrome, and other neurological diseases.
  7. Have no significant effects on the improvement in cognitive function.
  8. Have no significant effects on the improvement of energy levels and athletic
    performance.
49
Q

Safety and Adverse Effects of Carbohydrate –restricted Diets:

A

Most of the data on the safety and harmful effects of CHO-restricted diets are less than two years. These effects largely depend on the level of carbohydrate restriction, nutritional status, and medical and biochemical profiles of the individuals. There are common side effects for these diets including constipation, nausea, and abdominal pain. Some people who follow a combination of low-CHO diets and VLCHF/KDs experience symptoms described as the “keto flu” that may occur as the body adapts to using ketone bodies for fuel, which may last for one week. These symptoms include fatigue, poor sleep, and dizziness, muscle cramp, diarrhea, and hypoglycemia.

People with certain diseases and disorders may have additional safety concerns to consider with the use of KDs, such as those with lipid disorders, taking medications for diabetes, hypertension and anticoagulation.,

50
Q

Conclusion:

A

Ketogenic diets remain as “fad” diets, until the emerging evidence for their therapeutic effectiveness are supported by controlled experiments in the long-term.

BGEN 2010 - Applied Nutrition for Pharmacy Practice (5 decks)

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