Facts & Fallacies on the Ketogenic Diet, Part 2

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With the growth in popularity of the ketogenic diet, we wanted to get the facts on how it works, who the ideal candidate is, and what the misconceptions are. We talked to three experts on the topic. This is our second interview, with Dr. Scott L. Bergman.

Tell us a little about your practice.

I’m a chiropractor in the San Francisco Bay Area. I specialize in functional medicine and sports performance in my clinic.

What is the ketogenic diet?

The ketogenic diet is a diet that focuses on high-fat, very low-carb, and moderate amount of protein so that the body can no longer use glucose and glycogen but starts to use ketone bodies as fuel not only for every cell in the body, but, more importantly, the brain, as well.

What are some common misconceptions about the ketogenic diet?

Common misconceptions of the ketogenic diet are: I need carbs for fuel; I need to glycogen-load for competition; if I eat fat, I’ll get fat; if I eat fat, my cholesterol will go up; my recommendations have been to stay off of fat. We’ve been ingrained in our society since the 1970s that we need to be on a high-carbohydrate, low- to no-fat diet, moderate your protein, so we’re looking at 45 years of reeducation.

What roles do exogenous ketones play?

If I feel we’re going to have a hard time trying to get someone into ketosis, someone who is a little bit more overweight, definitely endurance athletes whose cortisol levels are high and blood sugar is a little on the high side, they have a hard time keto-adapting. Exogenous ketones raise blood ketones immediately. It kind of introduces the idea of ketones to the individual’s metabolism, saying, “Maybe we might want to use these as fuel.”

What are adverse reactions or warnings should practitioners be aware of?

Most people are worried about the ketogenic diet because of ketoacidosis, and that is a physiological pathology. That’s something that only occurs when our ketone levels get 2-3 times higher than what nutritional ketosis is. I haven’t come across that.

What are the optimal biomarkers to check?

Certainly there are blood ketones that we can check. There are inexpensive meters you can purchase online and look not only on a daily basis, but you can look and see what a particular meal will do, whether that will raise your ketone levels or not.

The blood work, the clinical work that we do—it’s all based on the patient’s condition. Are we looking at their blood glucose? Are we looking at their A1C, c-reactive proteins, homocysteine levels? Certainly a lipid panel, looking at fractionated LDL and HDL levels. We’ll look at other markers like the bioimpedance because we want to make sure that visceral fat is going down, subcutaneous fat, we want to make sure that extracellular waters are dropping, make sure that we’re not losing muscle.

Other than that, we just want to make sure we’re looking at things periodically and seeing that we’re in a positive trend.

Which patients would not be advised to follow the diet?

The only time I advise against a ketogenic diet in my office is pregnancy or nursing moms. I have seen some things with nursing moms that while in ketosis, milk production goes down, and we certainly don’t want to starve the baby; however, someone has also written a paper that the breast milk over time will increase. I’m just not comfortable suggesting that. I think pregnancy and nursing moms for now would be the only contraindication.

What’s the difference between keto and paleo?

A lot of people ask what the difference between a paleo diet and a keto diet is, and there are only maybe one or two major differences. Certainly we’re looking at whole foods. Both the paleo and the keto, we’re taking out all refined carbohydrates. The paleo diet seems to be a little more proteincentric. They will have fats but not as many fats, but the carbohydrates are always coming from a vegetable or a fruit source. The paleo diet is carb-protein focused, whereas in the ketogenic diet, it’s definitely fat, then protein, moderately, and very low carbohydrate.

If we’re taking in more protein than what our bodies need, we break the proteins down to amino acids. Those amino acids through the liver will convert through gluconeogenesis and become sugar. So a high-protein diet can actually cause blood sugar to go up. I think with a lot of paleo people, they’re eating too many proteins, which is then converting to sugar.

We give the adequate amount of protein. The way that I determine protein levels for people is, we do a bioimpedence, we look at their fat-free muscle mass, we base their needs on their metabolism, so we only go about 20% of their overall basal-metabolic rate, and we stick with that amount of protein. It’s about 25-30 grams less than what I used to prescribe when we were doing the paleo diet. So the ketogenic diet is very muscle-sparing. You don’t need as much protein. By sticking with that 20%, we know that that’s not going to convert to sugar.

What are common objections from patients?

There is pushback from patients because of what we’ve been taught: that we need to be on a high-carbohydrate diet, no fat, no eggs, no butter, no saturated fats ever. We need to stick with the polyunsaturated vegetable oils. That’s the only way that we’re going to have good heart health. “My cholesterol is going to go sky-high. I don’t want to go on statins.”

That is just old science. We know there is no study that correlates cholesterol with cardiovascular disease. And cholesterol has very little to do with the lipid panels that we perform. We’re testing the LDLs and HDLs, the low-density lipo-proteins. That’s not cholesterol. LDLs carry cholesterol to repair tissue, to reduce inflammation, to create a state of recovery. HDLs take old cholesterol and recycle it back to the liver. Blaming cholesterol on heart disease is like coming to a building on fire and blaming the firefighters for being there.

Interested in learning more about the ketogenic diet? Read the first interview  in the series, with Ryan Lazarus, MS, CNS, DC.

About Scott Bergman: Dr. Scott Bergman is a Chiropractor, Board Certified Naturopath and a Certified Functional Medicine Practitioner in Walnut Creek, California. Since 1993 he has been the director of Chiro Kinetics, an integrative health clinic combining Chiropractic Care, Rehabilitation, Pilates, Core Yoga Therapy, Functional Medicine and Biological Resonance. For over 25 years, Dr. Bergman has been presenting health, nutrition and fitness information internationally to a variety of business, education, social, and community groups. He is a member of the California Chiropractic Association, Contra Costa County Chiropractic Society and Institute of Functional Medicine.