Myths & Facts

A ketogenic diet is high in fat and very low in carbohydrates.

Here we will address the 12 most common anti-keto claims found in the media. While we are not suggesting a ketogenic diet is appropriate for all, this diet is clearly a safe and highly effective option for people with metabolic diseases (obesity, diabetes, heart disease, etc.), and therefore should not be falsely portrayed as a dangerous fad.

Claim #1: Keto is bad for athletes

Fact:

Numerous studies show that the ketogenic diet has helped athletes improve their body composition, trim fat, maintain performance and improve recovery. These studies have included marathon runners,1 triathlon competitors,2 CrossFit athletes,3 gymnasts,4 and other athletes performing high intensity5 and interval6 exercises.

One study found that after 12 weeks eating a ketogenic diet, endurance athletes cut body fat, increased oxidation and sprint power, and performed better overall on a critical power test compared to athletes on high-carb diets.7

Claim #2: Keto is dangerous if you have diabetes

Fact:

The ketogenic diet has actually been endorsed by the American Diabetes Association as the best diet to control blood sugar for people with Type 2 diabetes. Some studies have shown that extreme caloric restriction can also reverse diabetes, but continued starvation is largely unsustainable.

No other diet has demonstrated more promising results for Type 2 diabetes than one very low in carbohydrates.

Upwards of 17 scientific studies8 support the idea that carbohydrate restriction works to manage blood sugar, or glycemia, in patients with diabetes.

Claim #3: Keto causes fatigue and flu-like symptoms

Fact:

Upon starting the diet, some patients report symptoms like fatigue, headaches, and muscle aches. However, these short-lived symptoms are, in fact, a sign that the diet is working, and the body is switching over from burning glucose as fuel to burning fat. This transition involves upregulating certain enzymes and down-regulating others; it is a profound shift for the human body that can have uncomfortable symptoms. However, these side effect usually last only 3-4 weeks.

Claim #4: Keto is bad for heart health and will raise your cholesterol

Fact:

While it’s true that low-carb diets do raise the so-called bad LDL-cholesterol in some people, it’s important to note that LDL-C, when influenced by diet, has never been shown to have any effect on cardiovascular risk.

More importantly, the ketogenic diet also reliably raise the “good” HDL-cholesterol, while also improving most other cardiovascular markers, including blood pressure, as this study shows.9 Thus, the overall effect on cholesterol and other markers for heart disease is positive.

Claim #5: Keto will make you break out

Fact:

One study10 found carbs to be the “main culprit” in causing acne. However, another study found that low-glycemic diets lessened acne.11What’s more, a review12 conducted by Italian researchers suggested that the keto diet could target acne by reducing inflammation and levels of insulin and IGF-1 — all known causes of acne.13

Claim #6: Keto is not good for your gut

Fact:

Patients with gastroesophageal reflux disease (GERD) have been shown to improve after eating very low carbohydrate diets.14, 15 Another study found increased carb-intake worsened GERD, while a high-fat, low-carbohydrate diet reduced symptoms.16 And two studies have linked esophageal diseases, including Barrett’s esophagus (BE)17 and GERD,18 to sugar and carbohydrate intake.

Claim #7: Keto causes, or worsens, fatty liver disease

Fact:

The European Association for the Study of the Liver actually cites a low-carbohydrate diet as a way to treat the disease.19 Studies show that cutting carbohydrates20 and particularly fructose,21 or sugar from plants, works to improve liver fat metabolism.

What’s more, high-carbohydrate diets have been associated with worsening non-alcoholic fatty liver disease. Find evidence here,22 here23 and here.24

Claim #8: You’ll lose sleep on a ketogenic diet

Fact:

There seems to be no foundation for this claim. People eating diets very low in carbohydrates and high in fats and proteins have been found, in one study,25 to enjoy better sleep quality, meaning they spent more time in deep sleep than those on high-carbohydrate, low-fat diets. A survey of 1,580 low-carb consumers published by the Journal of Insulin Resistance26 found that while more than 11% of respondents reported using sleep-aids before beginning their low-carb diet, less than 5% reported using them after their diet.

Claim #9: Keto causes gallbladder problems

Fact:

Multiple studies have found that diets higher in fat prevent gallstone formation. Examples are here27 and here.28 Meanwhile, diets low in fat actually increase gallbladder volume29 and may increase the risk of gallstone development, as do diets high in sugar and carbohydrates.30

Claim #10: Keto is not good for long-term weight management31

Fact:

Studies have demonstrated that the keto diet may in fact be ideal for long term weight management. One meta-analysis32 found that individuals following very low-carbohydrate ketogenic diets lost more weight in one year than those on low-fat diets.

A survey published in the Journal of Insulin Resistance33 found that three of four respondents on a low-carb diet reported losing 10 pounds or more; one-third reported losing more than 30 pounds. Six out of 10 respondents who were on the diet two years or more reported losing 20 pounds or more and 46% said they lost 3 inches from their waists.

Claim #11: People just can’t stay on keto

Fact:

The ketogenic diet does not limit calories; people can eat as much as they like so long as they restrict carbohydrates. This means that people don’t have to endure long periods of feeling hungry—which is why the ketogenic diet tends to be sustainable.

The survey in Journal of Insulin Resistance found that before respondents started their low-carb diets, nearly nine of 10 experienced intense hunger between meals. Once on the diet, only 3.5% said they grew hungry between meals. Respondents reported similar improvements in other aspects of their physical and psychological well-being.34

Of the 1,580 survey participants, more than half reported staying on a low-carb diet for at least one year, and 34% reported more than two years. Further, those on the diet for two years or more said that they had largely maintained their weight loss.

Claim #12: Keto shortens life

Fact:

The widely reported Lancet Public Health study 35 that made this claim is based on very thin data. The questionnaire underlying the report left out questions regarding popular foods, such as pizza and energy bars, and did not consider alcohol consumption. Moreover, the “low-carb” diet group in this study included people eating up to 37% of calories as carbohydrates—not low-carb according to the latest science. Ultimately, this is the kind of data that can show association but not establish causation, which means it is the kind of data one can use to generate hypotheses but not prove them. This kind of data would never be considered sufficient to approve a drug, for instance. The same standards should be applied to diet. Quite a few researchers had their critiques published in Lancet Public Health.36 The authors replied but did not respond to most of the criticisms.

Meanwhile, more than 70 trials have examined the health effects of a low-carb diet. They attest to the benefits37 associated with ketosis and low-carb diets, including a reduction in body weight and body mass index, improved cardiovascular risk factors including blood pressure, and the reversal of Type 2 diabetes. It is virtually impossible to imagine that a diet with so many health improvements in the ‘near term’ (2 years) could ultimately shorten life—and the study authors offer no possible mechanism to explain how this might happen.

The larger question is why we are seeing such a sudden rash of anti-keto stories. So many of them quote no experts sources and do not provide citations for their claims. Skeptics with little acquaintance with the diet are quoted exclusively instead. From a journalistic perspective, this lack of balance of viewpoints and the failure to back up claims with evidence falls below basic reporting standards. Offenders on this list include even the Harvard School of Public Health, which recently published more than one  unsourced, one-sided article on the keto diet (This is in addition to the Lancet Public Health article cited above, by Harvard researchers, which suggests that a low-carb diet kills you). These stories could reflect lazy reporting or they could very well be scare tactics to steer people away from the keto diet. Now why would reporters or scientists at Harvard be doing such a thing?

Expert contacts who helped compile source material for this article:

Tro Kalayjian, D.O., Internal Medicine, Yale New Haven Health
tro@doctortro.com

Shebani Sethi-Dalai, M.D., MS: Psychiatry & Obesity Medicine, shebanis@stanford.edu, Stanford University Department of Psychiatry

Angela A Stanton, Ph.D. angela@migraine-book.com independent researcher, migraine specialty

Col. Rob Oh, M.D., MPH, CAQSM – robert.c.oh.mil@mail.mil   Family Medicine, Sports Medicine

Many other low-carb practitioners who have familiarity with the scientific research can be found here:
https://www.lowcarbusa.org/low-carb-providers/lchf-doctors/

Other experts can be found by going to pubmed.com and searching for “keto” or “ketogenic” to find scientists who are studying this diet. 

1 https://www.ncbi.nlm.nih.gov/m/pubmed/29108901/
https://journals.lww.com/acsm-msse/Pages/articleviewer.aspx year=2018&issue=05001&article=01656&type=Fulltext
https://www.ncbi.nlm.nih.gov/m/pubmed/29910305/
https://jissn.biomedcentral.com/articles/10.1186/1550-2783-9-34
https://journals.lww.com/acsm-msse/Pages/articleviewer.aspx?year=2018&issue=05001&article=02616&type=Fulltext
6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5950743/
7 https://www.sciencedirect.com/science/article/pii/S0026049517302986
8   A. https://www.ncbi.nlm.nih.gov/pubmed/29269890

B. https://www.ncbi.nlm.nih.gov/pubmed/16476868
C. https://www.ncbi.nlm.nih.gov/pubmed/28750216
D. https://www.sciencedirect.com/science/article/pii/S0168822714003982
E. https://www.ncbi.nlm.nih.gov/pubmed/24390522
F. http://annals.org/aim/article-abstract/718265/effect-low-carbohydrate-diet-appetite-blood-glucose-levels-insulin-resistance
G. http://ebn.bmj.com/content/18/3/74
H. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5329646/
I. https://onlinelibrary.wiley.com/doi/full/10.1111/dom.13164
J. https://www.ncbi.nlm.nih.gov/pubmed/28345762
K. https://dmsjournal.biomedcentral.com/articles/10.1186/1758-5996-4-23
L. http://pediatrics.aappublications.org/content/early/2018/05/03/peds.2017-3349
M. http://pediatrics.aappublications.org/content/early/2018/05/03/peds.2017-3349
N. https://academic.oup.com/ajcn/advance-article-abstract/doi/10.1093/ajcn/nqy096/5051863
O. https://drc.bmj.com/content/5/1/e000354
P. https://www.ncbi.nlm.nih.gov/pubmed/29522789
Q. https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/1743-7075-5-14

9 https://cardiab.biomedcentral.com/articles/10.1186/s12933-018-0698-8
10 http://jddonline.com/articles/dermatology/S1545961614P0428X
11 https://academic.oup.com/ajcn/article/86/1/107/4633089
12 https://www.ncbi.nlm.nih.gov/pubmed/22327146
13 https://www.dietdoctor.com/low-carb/benefits/acne
14 https://www.ncbi.nlm.nih.gov/pubmed/16871438
15 https://www.ncbi.nlm.nih.gov/pubmed/11712463
16 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5048546/
17 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725502/
18 https://www.ncbi.nlm.nih.gov/pubmed/29339035
19 http://www.easl.eu/medias/cpg/2016-04/EASL_CPG-NAFLD.pdf
20 https://www.cell.com/cell-metabolism/fulltext/S1550-4131(18)30054-8
21 https://www.ncbi.nlm.nih.gov/pubmed/28579536/
22 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC507283/
23 https://academic.oup.com/ajcn/article/96/4/727/4576835
24 https://www.ncbi.nlm.nih.gov/pubmed/17032189
25 https://doi.org/10.1179/147683008X301540
26 https://insulinresistance.org/index.php/jir/article/view/30
27 https://www.nature.com/articles/0800634
28 https://www.sciencedirect.com/science/article/pii/S1542356513018375
29 https://link.springer.com/article/10.1007/BF01536623
30 https://gut.bmj.com/content/54/6/823
31 https://www.rgj.com/story/life/wellness/2018/07/12/heavy-duty-planning-and-plenty-willpower-may-necessary-success-keto-diet/780845002/
32 https://doi.org/10.1017/S0007114513000548
33 https://insulinresistance.org/index.php/jir/article/view/30
34 https://insulinresistance.org/index.php/jir/article/view/30
35 https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30135-X/fulltext
36 https://www.thelancet.com/journals/lanpub/issue/vol3no11/PIIS2468-2667(18)X0011-5 (scroll down to “Correspondence”)
37 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2716748/

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