To keto or not to keto

Why this fad diet seems to have fallen out of favour.
Published March 15, 2020

Diet fads come and go, and one of the most recent ones that may be on its way out is keto. As Global News recently reported, a ranking of the best and worst diets listed keto as one of the worst out of a group of 35.


For those unfamiliar with keto, here’s a quick primer: The ketogenic diet, or keto, is a way of eating that prioritizes high fat, moderate protein and low carbohydrates. The goal here is to put the body into a forced state of ketosis – a natural metabolic state that occurs whenever the body doesn’t have enough glucose to turn into energy and instead turns to the body’s fat stores. Carbohydrates are the body’s preferred way to use energy..


On the flip side of that ranking, Global News noted that a recent survey of dietitians found that keto remains the most popular diet in the United States. The reason why might have something to do with the marketing around keto – it’s a message people already want to hear.


“One of the longest-believed myths I see is that people think that ‘carbs are bad”, says Amanda A. Kostro Miller, RD, LDN, who serves on the advisory board for Smart Healthy Living. “So, a low-carb diet like the ketogenic diet seems to always be attractive to many people.”


She adds, “Also, there is a misconception that the keto diet is high protein, but it is, in fact, supposed to be moderate protein.”


Considering this misconception, combined with a long-standing belief among many that “protein is king”, it’s not surprising that a diet seemingly rich in protein would be appealing, Kostro Miller says.


“Marketing for keto tends to be very attractive as well,” she adds, “whether you’re seeing keto programs in magazines, keto supplements online or if you are following keto supporters on Instagram. There’s lots of keto marketing that tells people that you can lose more weight on keto or improve blood sugar, but this is not supported by substantial research.”


While keto may still hold appeal for some, it is losing favour among others.


“The keto diet is losing in popularity because people are taking a more holistic look at wellness and want to think about food as a value-added part of their lives as a whole,” says Andrea Marcellus, a Los Angeles-based celebrity trainer, author and CEO of AND/life. “A restrictive program such as keto is not only time-intensive and thought- intensive, it makes socializing difficult and can be very isolating.”


She explains that highly restrictive or methodical diet programs are appealing at first because people feel part of a community. Such programs also “give the impression that you are really doing something about your perceived shortcomings. We get a dopamine hit in our brain for achievement. Following a program where you can check the boxes of ‘yes I did this’ and ‘yes I eliminated that’ and ‘I counted my macros and my micros’ gives you a sense of achievement each day. But the problem is, that sort of daily self-scrutiny is not a long-term lifestyle solution.”


The research – or lack thereof


Kostro Miller says there is some research about ketogenic diets, but a lot of it has been focused on people with epilepsy, and there are currently limited guidelines on how to properly conduct a true ketogenic diet.


She notes that this way of eating may help improve insulin sensitivity, but that more research is needed to understand this.

“Currently, those with diabetes are recommended to consume carbohydrates in a controlled amount, rather than completely restricting/greatly reducing carbohydrates,” she says, adding that it’s helpful to see a local registered dietitian for your specific carbohydrate needs.


“Also, unless you’re being followed closely by a dietitian (and I mean followed really close), you may not even be in ketosis. Having too much carbohydrate and/or protein in one single meal can kick your body out of ketosis immediately. You may be hovering in and out of ketosis (if you ever get there in the first place) and never really achieve ketosis.”


The cons


Because ketosis is such an exact metabolic state, it’s difficult to achieve – and the way you need to eat to achieve it can carry some health risks, Kostro Miller explains.

  • Finger pricks: “You may have to do daily finger pricks to analyze if and when you are in ketosis. Ouch! Urine test strips do not necessarily tell you if you are in ketosis.”
  • Risk of low blood sugar: “If you completely cut out all carbs, you may be at risk of hypoglycemia (low blood sugar), which can be deadly.”
  • Complications with diabetes/insulin medications: “Some diabetes medication and insulin regimens are based on your carbohydrate intake. So, if you go keto without having your medications adjusted, you may be in danger of hypoglycemia.”
  • Risk of nutrient deficiency: “A ketogenic diet can be pretty limited over the long term,” she says. Since many carbohydrate-containing foods are fortified with or naturally contain various vitamins and minerals, cutting them out may mean you’re missing out on important nutrients. Following the diet long-term could put you at risk for becoming deficient in Vitamins A, C, K, and folate, in particular, as well as prebiotics and probiotics. Kostro Miller also notes that following a keto diet may prevent you from getting adequate fibre from fruits, vegetables, starches, grains, and legumes.
  • Risk of disordered eating patterns: “The ketogenic diet requires focus, attention and daily analysis of what you are eating. While being aware of your nutrition is helpful, diets that require strict adherence can lead to someone developing disordered eating and/or a food obsession,” she says, noting that for some people, disordered eating can lead to eating disorders.
  • Complications related to other health issues: Keto may contradict what your doctor or dietitian tells you to eat, Kostro Miller says. For example, if you have hypertension, you may be trying to control your sodium intake, but living on keto might mean you find yourself eating a lot of sodium in processed meats. Keto also may promote foods that are high in saturated fat, she explains, such as red meat and full-fat dairy, which could increase your risk of heart disease. She advises consulting your doctor before starting keto, especially if you have a history of pancreatic disease, liver disease, gallbladder disease (or if you have had your gallbladder removed), eating disorders or thyroid issues.

While some people may lose weight quickly on the keto diet, Kostro Miller says, “the weight loss tends to be temporary and the weight is gained back since the diet is very hard to follow long-term.”


That’s the thing about keto – it’s difficult to get right.


“The keto diet is very hard to actually do correctly and actually continue to do, so it is not surprising that people fall off the diet,” Kostro Miller says, adding that it’s a very limiting diet, and therefore difficult to sustain. 


Ultimately, any program that restricts calories will help people lose weight, Marcellus says. “So, in that sense, [keto] can be successful for people. The question is, for how long? And for most people, the answer is, not very.”