Parsing the fat
Despite its growing popularity and a number of followers in Thailand, the ketogenic diet is still a source of debate, especially medically
The idea of shedding kilos in this weight-obsessed society has gone beyond paying pricey gym membership fees and hiring a personal trainer to build the perfect body. A number of women who feel they're overweight shift from one diet to the next in hope of possessing a figure that is as close as possible to the standards of the fashion and beauty industries.
So it's not surprising that an extreme eating regimen like the ketogenic diet has become a craze here in this country. Online communities like Thai Keto Pal or ThaiKeto Friends, which see many thousands of followers, have been established for the like-minded to share ideas and tips so that they all can stick to the pattern with a guiding light from fellow members.
But a ketogenic diet -- characterised broadly as very low-carb and high-fat -- is controversial in itself. While many believe in its proven benefits, especially in terms of weight loss, others frown upon it. Recent findings published in the world's leading independent general medical journal, The Lancet, report that a low-carb diet has been found to be associated with mortality risk.
Clinical nutrition specialist Dr Phaisit Trakulkongsmut said that the ketogenic diet -- or keto diet -- is actually not new but dates back to the 1970s, when American cardiologist Dr Robert Atkins introduced this very low-carb eating pattern to the world. In the medical field, the ketogenic diet is mostly prescribed as a means to treat type 2 diabetes, epilepsy in children that cannot be curbed by medication, polycystic ovarian syndrome (women's hormonal disorder characterised by infrequent or prolonged menstrual periods) and acne.
"In the ketogenic pattern, people are allowed no more than 20g of carbohydrates per day during the first two weeks, which is called an induction period. After that is an ongoing or maintenance period where carbohydrates can slightly be increased to a maximum of 40g per day. In a nutshell, ketogenic diet's food proportion is 60% fat, 30% protein and only 10% carbs," explained Dr Phaisit.
Thanit Vinitchagoon, instructor and dietitian at Mahidol University's Institute of Nutrition, pointed out that the amount of fats can sometimes go as high as 80% of one's entire daily food intake.
"It is an extreme regimen," he said. "A cult, even."
With such a high-percentage fat intake, the ketogenic diet simply turns the body into a fat burning machine. When a meal is eaten and digested, glucose and carbohydrates are turned into glycogen and stored in the liver and muscles. When energy is needed, glycogen is quickly mobilised to deliver to the body the fuel that it needs. However, if the body has little carbohydrate, glycogen storage will eventually be depleted. The body will then be tricked into believing there is no more glycogen as an energy source, so it will turn to burning fat instead.
To turn fats into energy, the fatty acids are shipped to the liver, which begins the process of ketosis. The liver then breaks down the fatty acids into ketone body -- the brain's energy and the end product of this whole process.
"People who practise a ketogenic diet usually feel good because their body weight significantly reduces," said Dr Phaisit. "Such weight loss is caused by glycogen being depleted. Each gramme of glycogen has an ability to store 3g of water. So as the glycogen is lost, it means the water is lost too. While they lose weight, they also lose water."
While the keto diet is clearly associated with weight loss through the aforementioned mechanism, Thanit said, as a dietitian he never recommends such an approach to his patients given the numerous drawbacks, both physical and psychological. "When it comes to the keto diet, I think the drawbacks do outweigh the benefits," he said.
First, according to Thanit, although the ketogenic diet pattern can quickly shed some kilos in a short period of time, there are studies that suggest that the approach can cause yo-yo effects after 12 months. Also, if keto followers fail to choose good-quality fats or tend to opt too much for saturated fats, then they put themselves at risk of developing cardiovascular disease.
Constipation is another common side effect of eating low-carb and high-fat foods, due to a lack of fibre. And apart from dehydration, risks include osteoporosis, kidney stones, bad breathe and hair loss.
"A ketogenic diet, if practised in the long run, triggers the release of a toxic chemical called methylglyoxal, which is likely to damage the arterial walls. The chemical is also toxic to cells and could potentially lead to protein and organ damage as well as ageing," added Dr Phaisit.
"The ketogenic diet is not a normal eating pattern. It is against the usual eating habits of most Thais, whose staple food is rice," said Thanit, adding that 70-95% of ketogenic followers do quit after a while, meaning the majority of them might follow the approach not long enough to see its physical impact.
This explains why the dietitian is concerned more about the psychological than the physical consequences of the low-carb plan.
The ketogenic diet, said Thanit, can turn into an eating disorder or psychological illness if practised long-term. Here the nutritionist cited the new diagnosis of Arfid, or avoidant/restrictive food intake disorder.
"Arfid is a psychological condition whereby patients unreasonably avoid eating certain foods until it leads to malnutrition, extreme weight loss or other ailments that affect their lives.
"Also, failing to lose weight is likely to affect self-esteem and self-satisfaction," Thanit added. "They will see themselves as being of little value, which can bring about other, more serious mental conditions like depression if left unattended."
While Thanit doesn't recommend a ketogenic diet at all, Dr Phaisit said that the pattern should be practised only under the close supervision of a specialist or dietitian, and should not be carried on for over six months.
"Consultation with a doctor or nutritionist is a must, especially for those who have underlying diseases," advised Dr Phaisit. "After practise, the level of ketone body must be followed up closely. Long-term practice of the ketogenic diet is likely to cause micronutrient deficiency, so people should first weigh the advantages and disadvantages carefully before giving it a go.
"This extreme low-carb plan can help one lose weight fast but comes with tons of adverse side effects."
Thanit believes that the keto diet, just like other diet trends, is not here to stay. But in the meantime, while the eating pattern is still being practised by a certain group of followers here, the dietitian wishes to see Thais become less obsessed with losing weight and stop addressing plus-sized people with negative connotations.
"Fat people are usually discriminated and branded as vulnerable to diseases and premature death," said Thanit. "This makes them worried sick about their body shape and would subsequently do whatever it takes to lose weight. While we should care about our physical health, I think it's time to focus more on our emotional well-being. Large-sized people should be addressed with positive reinforcement -- encourage them to have regular exercise, cut sugar and eat healthy diets. If we continue blaming the fat or addressing them in a negative way, they will never stop searching for extreme approaches to achieve the shape they desire, even though there is a high price to pay."