10 differences between evidence-based vs. internet-based keto diet teachings

Many misconceptions about the ketogenic diet are spread on the internet, an expert told attendees at the Obesity Medicine Association fall conference.

“It's confusing out there. It’s so terrible,” Eric Westman, MD, MPH, FOMA, an associate professor of medicine at Duke University and founder of the Duke Keto Medicine Clinic, said during a presentation. “I listen carefully to patients who say that ‘I'm doing this and it's not working’ and I say to them ‘I bet you've learned [how to diet] from Dr. Google’.”

Westman discussed a class where he taught several thousand participants about an “evidence-based, low-carbohydrate, ketogenic diet,” in which people can daily consume as many meats, poultry, fish, shellfish and eggs until they are what he dubbed “comfortably full.” The diet also includes eating as much as 2 cups of raw leafy greens; 1 cup of raw non-starchy vegetables; limited amounts of foods such as cheeses, creams, oils and olives; and moderate amounts of zero-carb snacks such as sugar-free Jell-O, pepperoni slices and low-carb jerky.

Westman said that all the class participants had some knowledge of the keto diet from the internet before taking his class. In addition, 75% of the participants had already been following the keto diet for some time, while the remaining participants had only recently started it. According to Westman, surveys taken after the class was completed indicated that 94% of the participants learned something new about the keto diet from the class.

At the Obesity Medicine Association meeting, Westman discussed the top 10 differences between internet-based keto diet teachings and the lessons taught during his evidence-based, low-carbohydrate, keto diet class.

Measuring ketones is ‘not required’

Many people on the keto diet believe they must measure ketones, according to Westman.

“We never asked people to measure ketones, but a lot of people do,” he said. “That’s why some people think [the keto diet] is so complicated.”

Macro calculation is ‘not required’

Westman said that downloading apps or using other devices that count substances like protein is not an essential component of the keto diet’s success.

Medium chain triglyceride oils, ketone drinks and pills are ‘not required’

While these products or products that contain them might increase ketone levels, their calorie count and fat content must also be considered, Westman said. He added that patients have told him they tried keto-friendly cupcakes with 350 calories but ate several of them.

“It’s not really keto-friendly if you’re having 900 calories from little cupcakes,” Westman said.

Fasting is ‘not required’

Although Westman acknowledged that intermittent fasting can help people lose weight, he said there are not enough data for him to recommend it.

“We don’t know that it’s the healthiest way to do it. We don’t know the safety parameters about it,” he said. “I’m talking about data from randomized trials over the last 20 years. Show me a paper with fasting as the primary intervention with 50 people over 6 months and I’ll comment on it.”

Conversely, evidence supporting the keto diet’s benefit to patients with various forms of CVD, as well as diabetes, obesity and polycystic ovary syndrome, has grown over the past century, Westman said.

Nuts, almond-based flours are not OK

“Can you really [limit yourself] to a handful of nuts for the whole day?” Westman asked rhetorically. “Or are you like me? You get a tub of nuts and you’re wondering ‘Gosh, where did they go?’”

According to Westman, studies have shown these products are “trigger foods” for a lot of people. Therefore, nuts and almond flour are not recommended on the keto diet.

Intake of vegetables must be limited

Because vegetables contain carbs, their consumption should be limited daily, according to Westman. The maximum amount of carb consumption on the keto diet often ranges from 20 g to 50 g daily.

Net carbs are not as ‘strong’ as total carbs

Some products will list both net carbs and total carbs, Westman said. However, “net carbs ... thwart people who are fixing diabetes or have a couple hundred pounds to lose. Just the change from net carbs to total carbs can be enough to make [the keto diet] work.”

Artificial sweeteners are not ‘forbidden’

“Artificial sweeteners are like the methadone or suboxone maintenance of getting people off opioids,” Westman said. “I don't know any health benefit of having these things, but I do know the harms of sugar, so I use it as a stopgap.”

Clean food is ‘not required’

Clean foods — those that have undergone changes during processing and are often found at farmers markets and newer restaurants — are beneficial, but often cost-prohibitive as a long-term staple, Westman said.

“I’m not advocating people go to eat all these kinds of restaurants. But when compared to something like a drug or having an operation to accomplish something, [clean foods] are a lot less risky,” he said.

Intake of cheese, fats and oils must be limited

While it’s true that some cheese, fats and oils may have few or no carbs, that information must be balanced with how many calories a particular food has, Westman said. For example, while most butters have very few or no carbs, a little amount of it has a lot of calories and thus, may negate some of the low carb benefits, he said.

Take-home message

The key to the keto’s diet success is monitoring the amount and type of food eaten daily, Westman said. Specifically, it involves looking at the carb content of foods and beverages and eating as many foods that contain “less than one [carb] or zero” as possible, he said.

“I’m convinced after delivering food to people and seeing people on metabolic wards that keto works for everyone, when it’s done right,” Westman continued.