The Keto Paradox: Fad Diet *and* Life-Saving Medical Treatment

Speaker 1 Here is a diet that goes against all conventional nutrition advice, banning bread, potatoes, and pasta in favor of red meat, eggs, and bacon. What's not to love?

Speaker 2 People all of a sudden are allowed to eat cheese, and all of a sudden they can have a steak a few times a week. They couldn't have before.
They can eat the eggs with the yolk.

Speaker 4 Most of my diet is just meat, wild game meat, ribeye steaks.

Speaker 6 This is something I've heard on and off for literally decades.

Speaker 6 People saying they're cutting out all sorts of things that I love, like grains and beans and bread, and most fruit, and even a bunch of vegetables, in favor of steak and bacon, and that this is a good thing.

Speaker 7 Me too.

Speaker 11 And I hate hearing it for a lot of reasons, some of which are to do with the concept of diets in general, which we talked about in our episode on diets and dieting, and some of which are to do with the fact that eating basically only meat and fat sounds terrible.

Speaker 6 And frankly, like kind of a disaster for the environment. But one of our listeners made us think about this topic in a new way.

Speaker 17 Hi Gastropod. This is Catherine Elkins from St.
Louis.

Speaker 17 And I just listened to your recent podcast on medically tailored meals and it got me thinking about a dietary therapy that we use in patients with epilepsy called the ketogenic diet.

Speaker 19 Catherine is not only a gastropod listener, she's also a pediatric neurologist.

Speaker 17 I treat children with epilepsy.

Speaker 17 And that includes both treatment with medicine and both non-medicine options.

Speaker 17 So of course, course I use a lot of different epilepsy medications, which of course have all of their side effects and whatnot.

Speaker 17 But other non-medicine options do include surgery, and then my favorite type of treatment is the ketogenic diet.

Speaker 19 This was news to me.

Speaker 3 Something I dismissed as celebrity nonsense turned out to be a genuine medical treatment.

Speaker 6 We were intrigued. And since we are Gastropod, be careful about intrigue because side effects may include making an episode.

Speaker 6 Yes, you are listening to Gastropod, the podcast that looks at food through the lens of science and history. I'm Cynthia Graeber.

Speaker 19 And I'm Nicola Twilley, and this episode we are exploring the history and science of keto.

Speaker 8 What actually are ketones and what on earth is going on in our bodies when we're in ketosis?

Speaker 6 Most of the people in the U.S. who are following the keto diet do not have epilepsy, so why are they doing it? Does it do what they think it does?

Speaker 18 And who came up with this plan in the first place?

Speaker 12 All that this episode, plus some Jane Fonda.

Speaker 6 This episode is supported in part by the Burroughs Welcome Fund for our coverage of biomedical research and by the Alfred P.

Speaker 6 Sloan Foundation for the Public Understanding of Science, Technology, and Economics. Gastropod is part of the Vox Media Podcast Network in partnership with Eater.

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Speaker 19 First of all, this word keto, what exactly is keto when it's at home?

Speaker 24 The keto diet is low-carb dieting. It's very low-carb dieting.
It's a technical term.

Speaker 24 The theory goes that you're burning your fat stores for energy rather rather than relying on carbohydrate storage.

Speaker 6 Adrienne Batar is a lecturer in American Studies at Cornell University, and she's the author of the book Diet and the Disease of Civilization.

Speaker 6 So now we know that keto is a diet that's low in carbohydrates, but why call it keto?

Speaker 4 The idea is that it puts you into a state called ketosis, where your body is basically running on these molecules called ketones.

Speaker 10 That's Michael Easter.

Speaker 28 He's a lecturer at the University of Nevada, Las Vegas, and he writes about health and wellness.

Speaker 9 And I have to say, this is beginning to sound like one of those circular arguments where keto is where you have ketones, and ketones are what you get when you do keto.

Speaker 10 But maybe that's because I don't have a clue what ketones are.

Speaker 6 So, what are they? Shivam Joshi is a doctor and a professor of medicine at NYU, and he told us they're a chemical that's created when our bodies break down fat.

Speaker 30 And they can also be used as energy by certain organs within the body. And so, this is why the ketogenic diet gets its name.

Speaker 22 Our bodies break down fat and produce ketones when they don't have access to their number one most preferred source of energy.

Speaker 30 So the body normally fuels itself from carbohydrates. The body takes these carbohydrates, breaks them down, and then uses them for energy.

Speaker 30 And that ultimately is used for energy, and that's the body's preferred source of energy.

Speaker 6 There are lots of reasons the body might not have access to carbs and might have to burn some fat and make ketones to fuel itself instead.

Speaker 6 We naturally go into a bit of ketosis when we we sleep, and if we fast, or if for some reason we're literally starving. Biologically, that's what our fat stores are there for.

Speaker 26 It's fairly seamless that our body is sort of well-designed to utilize whichever fuel sources it can get to power life and to keep functioning.

Speaker 2 Tanya McDonald is a neurology professor at Johns Hopkins, and she says, it makes evolutionary sense that your body can go into ketosis naturally if it has to.

Speaker 3 But say for whatever reason you wanted to force yourself into ketosis, starving yourself is not the only option.

Speaker 20 You can also eat a ketogenic diet. And what is that?

Speaker 4 So of as a percentage of your calories across the day, 90% of your calories that you eat, or rather an easier way to put that is 90% of the food you eat, has to be from fat.

Speaker 4 Roughly 4% is carbohydrates and 6% is protein. That's like the standard ketogenic diet.

Speaker 6 So Dickie and I both have perhaps unusual memories in that we almost always remember what we've been eating, what we ate yesterday, what we ate last week, maybe even last year. We love food.

Speaker 6 We love to think about it, but that doesn't mean either of us has any idea what percent of any meal is carbs or protein or fat. So what would a diet like this be like?

Speaker 4 Practically, this means that people would say wake up and for breakfast they might have an egg with the yolks. We're not messing with the whites here.

Speaker 4 And we're going to cook them in butter and we're going to maybe put some olive oil on them and we'll maybe have like a little bit of spinach with that.

Speaker 4 And you might have coffee that has butter in it for lunch, maybe a salad. But granted, you got to go easy on the carrots because carrots are heavy in carbohydrates comparatively, right?

Speaker 4 So you need to be very picky with the vegetables you eat. And then, you know, people might have salmon because that's a pretty fatty fish.
Has protein, but also a lot of fat. Dinner.

Speaker 4 Standard issue dinner for people on keto would be like a really fatty cut of steak. I don't know my steak cuts.
Topped in butter, maybe some more more spinach. So it's a lot of, it's a lot of fat.

Speaker 4 It's very, um, it's greasy. It's a greasy diet.
Among diets, I would say it's the king of grease. Yum.

Speaker 29 And curiously enough, eating this kind of way, all this grease, it's often done with the intention of losing weight.

Speaker 7 That's why the very first person to publicly follow and write about this way of eating, cutting out carbs in favor of protein and fat, he was called William Banting, and that's why he did it.

Speaker 24 William Banting, 1863, He pioneered the low-carb diet that included some of the benchmarks of low-carb dieting that we see in the 1970s to today, which is a lot of meat, a lot of fat, just low-carb vegetables.

Speaker 35 Few fruits.

Speaker 6 We talked about Banting on our History of Diets episode. He was a British undertaker who was quite obese.

Speaker 6 He had a hard time even tying his own shoes, and he had apparently started to go deaf because of the fat deposits in his ears.

Speaker 6 And he tried and failed to lose weight until his ear doctor told him to cut out carbs. Which Banting did.

Speaker 8 In the pamphlet he later wrote about his diet, he said that he had beef, mutton, kidneys, and bacon for breakfast, fish and more meat for lunch, and poultry and game, yes, more meat, for dinner.

Speaker 22 And he not only regained his hearing, he also lost lots of weight.

Speaker 6 That pamphlet was called A Letter on Corpulence, and tens of thousands of people read it. But doctors and scientists at the time weren't convinced.

Speaker 7 Especially because in the late 1800s, the hot new science of food and weight was the calorie.

Speaker 33 We've made an episode about that too.

Speaker 3 But although the experts were all about calories, it took some time and another book to filter down to the public consciousness.

Speaker 24 The most important figure here is Dr. Lulu Hunt Peters, who in 1918 wrote Diet and Health was key to the calories.

Speaker 24 And she just pushed this calorie message that we saw coming again and again, not only from popular dieters, but also from later on from the federal government, from nutrition policy research, from the medical field, and so on.

Speaker 6 And so begins a kind of battle in the public domain. Cut out the carbs.
No, it's the calories. No, cut out bread and potatoes.

Speaker 24 The pendulum swings, right? It goes carbs, cals, carbs, cals, carbs, cals.

Speaker 14 And of course, once you have a mainstream point of view, you also have to have the doubters, the rebels, the ones who dare question.

Speaker 3 So when the government was pushing cals, the carb haters were the outsiders.

Speaker 24 So the people who were rebelling against Nulu Hunt Peters already had that sort of renegade aspect in the 1920s.

Speaker 24 And some of those people were like Bernard McFadden, who changed his name to sound more virile.

Speaker 6 He started life as just ordinary Bernard, but he swapped out that boring D at the end for an extra R.

Speaker 24 So he's Bernard, like a lion roaring.

Speaker 5 I leap out of bed at the crack of dawn, as graceful as an elf, as nimble as a fawn.

Speaker 5 The life I lead would gladden

Speaker 5 the heart of Bernard McFadden.

Speaker 6 Yes, Bernard was famous enough to make it into a song from Gentlemen Prefer Blondes.

Speaker 6 Bernard, as an adult, was a multi-multi-millionaire, but he actually grew up poor and was pretty skinny and kind of sickly as a kid.

Speaker 6 So he got into lifting weights, and then when he was in his 20s, he became a pro wrestler.

Speaker 6 He started writing pamphlets on exercise and fitness, and then he launched a magazine and he wrote books with names like Foot Troubles, The Natural Cure for Rupture, and The Virile Powers of Supreme manhood.

Speaker 16 Heck yeah.

Speaker 2 But all of that is a distraction for us.

Speaker 22 We care nothing for the virile powers of supreme manhood.

Speaker 20 We are here for Bernard's diet advice.

Speaker 24 He was arguing for intermittent fasting, which some keto dieters do today as well. Well, they'll eat a lot of fat and proteins over a short period of time and then fast.

Speaker 24 He also argued for sometimes a liquid diet like the milk diet.

Speaker 6 Sounds like keto to us. Adrian says that Bernard and the people who followed him, even though his diet advice was really well known at the time, his people felt like they were outside the mainstream.

Speaker 6 They were fighting the man.

Speaker 24 I think that gave what Atkins later picked up on, the sort of rebellious or sort of maverick, kind of off-the-beaten path atmosphere or personality of these diet gurus who rejected this sort of persnickety, fussy calories in, calories out, but instead says, you know, you don't need to count calories.

Speaker 24 All you have to do is count carbohydrates. And if you just eat animal products, you don't even need to do that.

Speaker 24 You can just just eat and eat and eat and luxuriate in these like high-class foods like cream and martinis and animal fats and you'll lose weight magically.

Speaker 24 And that's really what gave it to that countercultural edge.

Speaker 7 Countercultural high-class decadence sounds like a winning formula.

Speaker 11 And it certainly was for Atkins of Atkins Diet Revolution fame.

Speaker 24 Robert Atkins, it was, I would argue, was the most influential diet leader in American history.

Speaker 6 Atkins was a cardiologist who saw patients in a private practice and he was overweight.

Speaker 6 He wanted to lose that weight and he read an article about low-carb diets and decided to give the whole thing a try. It worked for him and so he decided to start putting his patients on it too.

Speaker 1 The low-carbohydrate approach to dieting had been kicking around the medical world for over 100 years, but it took Atkins to make it a hit.

Speaker 29 This, by the way, is from a terrible documentary about Atkins on the Biography Channel.

Speaker 1 He began putting more patients on a low-carb regimen, and when the high-fashion magazine Vogue published an article about it, socialites began beating a well-heeled path to his door.

Speaker 36 He was, of course, the diet doctor to the chic and well-known at that time.

Speaker 37 And everybody was flocking to his offices because the word spread that he had this revolutionary new diet where you can eat, not be hungry, and lose a lot of weight.

Speaker 6 A lot of those everyones were women. Atkins basically bullied them into following his diet and would yell at them if he thought they weren't.

Speaker 6 And he also used his practice as a dating pool and slept with a lot of those women he just made feel bad about what they were eating.

Speaker 24 He was sort of a man about town in New York City. He luxuried in sort of the finer things in life.
He rented homes in the Hamptons.

Speaker 24 He was a bachelor, a committed sort of bachelor until his late 50s when he married his wife. I think he was 57.

Speaker 24 And he saw his diet as being part of his lifestyle. You know, he was drinking, he was eating filet mignon, he was, you know, enjoying the finer things.

Speaker 19 So far so gross, but what was this revolutionary new diet?

Speaker 11 Oh wait, it's the old diet, low carb, just wrapped up in a greasy new Atkins package. Here he is explaining it on a different documentary.

Speaker 38 It's the evolution of really basic biochemistry.

Speaker 38 The fact that carbohydrates really can contribute to the formation of fat and that the restriction of carbohydrates can allow for a person to lose weight.

Speaker 38 And the revolution is really really the urging of the populace to give a second thought as to this old hackneyed idea about counting calories in order to lose weight.

Speaker 24 He saw carbohydrates, a low-carbohydrate diet, which induced ketosis in the first phase of it, the induction phase, as the sort of magic bullet for weight loss.

Speaker 10 Atkins was really the first one to introduce this word, ketosis, or keto, in a mainstream, popular weight loss kind of context.

Speaker 2 Technically speaking, not not all low-carb diets are strict enough to make you go into ketosis, and even Atkins is only strict enough in the first phase.

Speaker 10 But keto was a key part of the Atkins magic.

Speaker 1 With requests for copies of his diet flooding in, Atkins decided to publish it in book form. Dr.
Atkins' Diet Revolution hit the stores in 1972.

Speaker 1 The Diet Revolution sold over 10 million copies and remains one of the 50 best-selling books of all time.

Speaker 6 That is kind of a shocking statement, and not a happy one, if I'm gonna be honest with you all.

Speaker 3 It makes me despair for humanity. The 50 best-selling books of all time includes Dr.

Speaker 29 Atkins' diet revolution.

Speaker 6 The thing was, people were looking for answers, and they loved that Atkins told them they could eat all sorts of things they usually thought they were supposed to avoid.

Speaker 39 You're eating things that you think, how could this be on a diet? How could this steak, this rack of lamb, how could this lobster and drawn butter be on a diet?

Speaker 39 And I could eat all the whole portion and come back with six, seven pounds off the first week.

Speaker 24 It seemed like everyone was following the Atkins plan. You know, no matter your class status, no matter your occupation, no matter your gender.

Speaker 24 It really brought men into the fold of weight loss dieting.

Speaker 11 Because, of course, steaks are much more manly than salads, which were what was on the menu for low-cowl dieters. And honestly, why shouldn't men share in the fun?

Speaker 6 There were other low-carb diets floating around at the time in the 70s.

Speaker 24 So at that time, we had the Air Force diet, the martinis and whipped cream diet, the drinking man's diet. They use similar language that I can say.

Speaker 24 They called carbohydrates the villain, but also emphasized the pleasures of eating cooking and claimed that the diet, like the martinis and whipped cream diet, would allow you to enjoy eating as you lose weight.

Speaker 24 So really pushing back against the earlier idea that hunger alone was useful, that pain was productive.

Speaker 24 Like Lulu Hunt Peters actually celebrated hunger and said, with every hunger paying, you know that you're losing weight. So that's a good indication.

Speaker 24 But the 1960s and 70s, you saw pushback against that by saying, you don't need to forego pleasure. You can enjoy eating.
You can enjoy cooking. You can luxuriate in the pleasures of the table.

Speaker 24 but you have to do so by eating a low carbohydrate plan, not a low calorie plan.

Speaker 18 To be fair, not all the low carb plans were enjoyable or even compatible with continued existence.

Speaker 9 One One of them was called the Last Chance Diet. It was invented by a guy named Roger Lynn.

Speaker 2 He created shakes to make it easy to follow his diet, but unfortunately the name was a little on the nose.

Speaker 4 You were just supposed to eat, drink only those shakes, but he didn't formulate them well with vitamins and minerals. And literally, like, people died.
because they didn't get adequate nutrition.

Speaker 34 For maybe obvious reasons, none of these other low-carb diets were as popular.

Speaker 31 Atkins was really it until along came the 80s.

Speaker 24 Low fat came back.

Speaker 24 The exercise mania also picked up.

Speaker 28 Are you ready to do the workout?

Speaker 24 And I think that was not as compatible

Speaker 3 with

Speaker 24 the sort of more luxurious way of eating that Atkins pioneered that really sort of dwelled in the idea of like, you know, sitting down to your steak and your spirits and bring to mind like wood-paneled steakhouses and not sort of Muscle Beach in California.

Speaker 24 It didn't have that sort of fresh feel that I think a lot of diets in the 80s and 90s picked up.

Speaker 40 Stretch it out.

Speaker 5 One, two, three.

Speaker 6 It does seem like it'd be hard to put on some purple leg warmers and a leotard and do Jane Fonda after drinking heavy cream.

Speaker 7 For a while, the pendulum had really swung.

Speaker 31 Low carb was out, and low-fat was in.

Speaker 8 Everything, everything

Speaker 12 was low-fat, even sausages.

Speaker 41 I'm half the fat, proud of that. When I'm frying or I'm grilling.
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Speaker 6 But yes, once again, there was some blowback because people were still having a hard time losing the weight they wanted to lose. So they looked for something new that was, of course, actually old.

Speaker 6 That's coming up after the break.

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Speaker 24 So in 1992, Dr. Atkins publishes the new diet revolution.
It spent five years on the New York Times bestseller list.

Speaker 10 It knocked Harry Potter off the top spot.

Speaker 6 Wow. But Atkins knew that a book and even his personal coaching in his office weren't enough.
People lived busy lives. He wanted to make sure everyone could follow his diet orders.

Speaker 6 So he started making pre-made snacks and low-carb bread and low-carb ice cream.

Speaker 24 His line of low-carbohydrate foods really brought this diet to the masses.

Speaker 24 So even if you didn't have the initiative to pick up a diet book, you still might encounter these energy bars or these packaged foods in your grocery store.

Speaker 11 The first time around in the 60s and 70s, a lot of Dr.

Speaker 18 Atkins patients were well-known and well-off.

Speaker 16 The second time around, the star power wattage was even more intense.

Speaker 44 But then I found Atkins. I lost 30 pounds and I did it without starving myself.

Speaker 6 Sharon Osborne made an ad for Atkins. Alyssa Milano Milano did too.

Speaker 31 Everybody has it.

Speaker 3 That certain weight where you look and feel your best.

Speaker 6 You're happy weight.

Speaker 26 Atkins helped me get there deliciously.

Speaker 45 Early on in the Atkins diet, it was really all about Jennifer Anniston because,

Speaker 45 you know, she's on TV every week and her pictures on every magazine cover.

Speaker 46 The tabloids gleefully told us that Jennifer wasn't the only one of the friend stars allegedly into Atkins. Matthew Perry's famously fluctuating weight was also linked to the diet.

Speaker 11 This is from a documentary on Channel 4 from the height of second wave Atkins.

Speaker 13 The British film crew didn't actually interview any celebrities, but they did find some random person from LA to comment.

Speaker 26 There's a bagel shop in Brownwood that will scoop out the bre inside of the bagel and put in turkey or cream cheese.

Speaker 45 You will really not see bread at parties. You know, it's just not polite.
You barely ever see a potato in LA. I mean, potatoes are just gauche.

Speaker 6 Poor potatoes, I've always loved you. I've never considered you gauche.

Speaker 9 You are welcome in my house in Los Angeles anytime, Mr.

Speaker 28 Potato.

Speaker 6 Atkins was so popular that, of course, there were other copycats.

Speaker 6 I don't know which diet a family friend was on at the time, but I remember him coming to my parents' house and picking the cheese off the pizza and only eating that, leaving the rest behind. So sad.

Speaker 20 Back then, I knew people on the South Beach diet.

Speaker 11 I knew people on the Duquesne diet, which was French, so you know, obviously sophisticated.

Speaker 47 My diet starts with the attack phase.

Speaker 47 The results are so spectacular, you will feel motivated and encouraged. This phase is strict,

Speaker 47 but so short and so effective on the scale that you will feel no pain and no frustration.

Speaker 6 That sounds so great. Why wouldn't you want to try it?

Speaker 29 Side note: Dr.

Speaker 3 Duquesne was later struck off the French medical register.

Speaker 6 And Atkins didn't do so well at the end of his life. He had a heart attack in his early 70s, although he and his doctors insisted it had nothing to do with his diet.

Speaker 6 And then a year later, he fell, went into a coma, and died.

Speaker 24 So there's a lot of mystery surrounding Atkins' health. When he died in 2003, he died, you know, he was an old age, but he was premature for someone who wanted to have a long, long life.

Speaker 24 His widow would not allow an autopsy because there was speculation that he actually had suffered from heart conditions earlier that may or may not have been the result of his diet.

Speaker 9 Atkins was dead and low carb started to seem so 2000.

Speaker 2 All the cool kids needed something newer and cooler.

Speaker 24 So paleo exploded around the turn of the decade, 2009, 2010, and so on.

Speaker 6 We're not going to go into the story of what paleo is and how it exploded. Very quickly, the idea is to eat like our paleo ancestors.

Speaker 6 Yes, that makes no sense because they ate whatever was around them and that varied dramatically depending on where they lived.

Speaker 6 But the point is, that was a fad and then people realized it was kind of silly.

Speaker 24 And then the keto people came over when paleo became so ridiculed as it wasn't in vogue anymore. And keto picked up on a lot of the themes that paleo first brought in.

Speaker 24 So the best example of this is the diet leader Mark Sisson, who wrote the primal blueprint in 2009, but then he transitioned to keto less than 10 years later. And he wrote the keto reset diet in 2017.

Speaker 2 Yep, this is the latest and greatest version of the ketogenic diet.

Speaker 32 And this time around, it was less about scooping out bagels or drowning in lobster and drawn butter and more about these super fun 20 teens buzzwords like big data and productivity.

Speaker 4 The ketogenic diet became popular, you know, starting in, say, 2015

Speaker 4 because of this weird intersection between Silicon Valley technology.

Speaker 4 Silicon Valley tech workers who are really into this idea of optimization and like we've got to optimize our lives in any way we can.

Speaker 6 Michael says Tim Ferriss is kind of like the king of optimizing. He wrote a book called The Four Hour Work Week, and he followed that up with things like The Four Hour Body and The Four Hour Chef.

Speaker 24 This Tim Ferrissian ideal of optimal health, where it's not just about your six-pack abs or getting into the BMI category, but rather like really becoming your best self in all of its facets.

Speaker 9 But how, you might be wondering, does ketosis help you be your best self?

Speaker 19 Well, as Shakespeare would say, let me count the ways.

Speaker 4 The sales pitch is that you're going to burn more fat, but you're also going to increase your focus. So by running on ketones, people report clearer thinking.

Speaker 4 One of the first things that I noticed, the benefits, one of the first benefits was cognitive, was

Speaker 48 like clarity,

Speaker 4 lack of fogginess towards the middle of the day, the no desire to take a nap.

Speaker 6 Joe Rogan, otherwise known as the king of scientific accuracy. Yes, I'm being extraordinarily sarcastic.

Speaker 6 He's talking to a guy named Dom D'Agostino, who's a keto expert who's been on both Tim Ferriss and Joe Rogan's podcasts.

Speaker 49 And for me, I could eat a keto meal in the morning and I could hammer out 12 hours of work in the lab and not even get any cravings to eat at all.

Speaker 49 And that, for me, translated into, you know, more grants, more publications, more work done in the lab. And I kind of attribute it in some way that, you know, my career has gotten a really big boost.

Speaker 14 He's Superman, Superman.

Speaker 3 All thanks to keto, which was essentially just the first phase of Atkins with the shiny new name.

Speaker 24 It's a similar diet, but they just plastered it with science and pseudoscience.

Speaker 24 And one of the key things that made keto different, which is actually what Atkins advised in 1972, was to monitor and quantify the amount of ketones by using urine strips.

Speaker 24 So they're sometimes called keto sticks. They're not particularly particularly expensive.

Speaker 6 You dip these keto sticks in your urine and they turn shades of purple and the color tells you the amount of ketones floating around.

Speaker 24 So it lent a real scientific air of credibility to the endeavor. That wasn't just like embracing your inner caveman and pounding your chest.
It was very scientific. It was very calculated.

Speaker 24 So that really picked up on this masculine...

Speaker 24 desire for what we call the quantified self.

Speaker 11 All this data was extremely sexy for the people who were into that kind of quantified, optimized self-thing.

Speaker 7 It gave the keto diet a crucial air of authority, and it also made it very shareable.

Speaker 4 People would also, I think, tend to share whatever their millimolars of ketones in their blood numbers too, I think becomes shareable to show that you're in there.

Speaker 4 Basically, people like, you know, to back up about like why, why care about the numbers in the first place, is I think it confers an element of certainty to people. Like, okay, I've reached this.

Speaker 4 Like, the diet is working because I am, I have this medical tool that is telling me I am doing this thing right.

Speaker 4 Not many diets can do that. And so this has this element of, you know, scientism almost.

Speaker 6 And the folks who did keto could see those numbers, those measurements, but they also saw something else.

Speaker 4 So when people go on ketogenic diet, they tend to dump a lot of water weight. That means the scale number is going to move really fast.
So you could lose like 10 pounds very quickly.

Speaker 4 Now, it's all from water, but still, that's like, I lost 10 pounds. That's very shareable.

Speaker 6 But it's not all great.

Speaker 30 There are downsides to the diet. The biggest pitfalls that I see are high cholesterol and then also kidney stones, which are also a big problem.

Speaker 18 Shivam told us, you also have to think about what nutrients you're missing out on because you're not eating whole grains and fruits and beans.

Speaker 30 The biggest one is fiber.

Speaker 30 Fiber has a lot of health benefits and the ketogenic diet can be low in fiber, but because fiber is found in these foods that tend to have a lot of carbohydrates and you're restricting carbohydrates, what happens to getting those benefits from fiber?

Speaker 30 Those in the ketogenic community say, well, you can eat low-carbohydrate, fiber-rich foods, but I think that's a challenge to meet the recommended fiber requirements.

Speaker 6 He says there are micronutrients that keto folks are missing too. And Adrian points out that you often feel pretty crappy physically when you start doing keto.

Speaker 24 The downsides to the ketogenic are many. From a health perspective, there's the nausea, there's the constipation, there's the GI problems.

Speaker 24 From a social perspective, it completely limits, unless you're only socializing with fellow keto fans, limits where you can go out to eat, you know, how you can socialize, how you can celebrate events because your diet is so limited.

Speaker 24 And then sitting here with a vantage point of 2023, we definitely know about the environmental and climate impacts of a high animal content diet.

Speaker 24 That eating animal products is just, this isn't an argument, this is just a fact, is very bad for the environment. And eating lower down on the food chain, they've been saying this since the 1970s,

Speaker 24 is far better for the environment and for greenhouse gas emissions. So there's the health aspect, there's this sort of social aspect, there's the environmental aspect.

Speaker 24 There's many sort of downsides to following a ketogenic diet. Plus, it's very difficult.

Speaker 27 All of this sounds terrible.

Speaker 10 Remind me why people are doing it again.

Speaker 6 Well, a lot of people want to lose weight, and this whole keto story sounds super compelling. I mean, all the websites promoting keto aren't going around hyping the downsides of the diet.

Speaker 22 But ignoring for a moment all of those downsides, which are hard to ignore, and assuming that you do want to lose weight, we already pointed out that people on keto lose weight at the beginning, but it's just water weight.

Speaker 14 So, is this diet useful over the long term for people who want to lose weight?

Speaker 30 When you look at all these studies, these really well-done randomized controlled trials published in big-name journals that have been done over the years that have compared various diets.

Speaker 30 There's these controlled trials that look at the Standard American diet and the Atkins diet and then they look at a Mediterranean diet and they look at other diets.

Speaker 30 And the studies vary according to which diet they looked at. But no matter what the study is, what the diets are being compared, the most important thing is that people are restricting calories.

Speaker 30 And that is what leads to weight loss, which is not surprising.

Speaker 4 I could say, eat foods that begin with the letter B, only that. And by doing that, you would get someone to eat less food.

Speaker 3 Basically, anytime you restrict what you eat and eat less, you lose weight.

Speaker 2 The big question is whether you can stick to it or not.

Speaker 20 There's no doubt that keto is challenging.

Speaker 3 It's really restrictive, like Adrian said. It really limits your social options.

Speaker 6 People who are on it sometimes say they can stick to it because it helps to control hunger, but there's no data to support that. And frankly, it could be the placebo effect.

Speaker 6 They're working really hard to stay on this diet. They've already bought into the fact that this is going to work.

Speaker 6 And as we talked about in our recent episode on hunger, there's a lot we don't understand about it.

Speaker 30 The whole appetite suppression area, I question, because it's hard. How do you measure appetite suppression? I've seen people say that high-protein diets can suppress appetite.

Speaker 30 People have said high-fat diets can suppress appetite.

Speaker 30 Some people say that eating high-carb diets can even suppress appetite. I have not seen really well-designed studies showing that ketogenic diets suppress appetite.

Speaker 16 So color me shocked, but it seems like, wait for it, keto does not in fact have magical powers when it comes to weight loss and becoming superman or woman.

Speaker 18 I mean, of course it doesn't.

Speaker 4 My opinion is like if there was a diet that conferred such grand, incredible benefits beyond any other way of eating, we would all be doing it.

Speaker 6 So nothing magic about it. Unless, as it turns out, you have one very particular disease that's coming up after the break.

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Speaker 4 So I believe as far back as like 500 BC,

Speaker 4 people noticed that epileptics who didn't eat for like two days, they would stop having seizures.

Speaker 4 So there's okay, great, but the advice can't be like, okay, if you're epileptic, just don't ever eat again because then you've got another problem on your hands.

Speaker 16 Indeed, you do.

Speaker 11 But in the early 1920s, some epilepsy doctors figured out what was happening metabolically when their patients were fasting, that they were burning fat and producing ketones.

Speaker 7 And they were the ones to figure out that if you cut carbs so that your body was forced to burn fat, you'd also produce ketones.

Speaker 7 And maybe this would work to help calm seizures without the inconvenience of starving.

Speaker 26 But it was doctors Wilder and Winter at the Mayo Clinic in Rochester who first sort of formalized the diet and sort of put it into human use at the time for a treatment for seizures and epilepsy.

Speaker 26 And they published one of the first reports about the efficacy of the diet for seizure control in the late 1920s, early 1930s.

Speaker 6 Tanya McDonald says it was popular for a while back in the 1900s before it was replaced.

Speaker 26 Not too long after the ketogenic diet came out in the 1930s, one of the first anti-seizure medications, Dilantin or phenytoin, and then subsequent to that, phenobarbital came out, and then a number of other anti-seizure medications.

Speaker 26 I think we have in our arsenal 30 different anti-seizure medications at this point.

Speaker 26 And so, yes, because of the ease of use of a pill compared to a diet, for many patients, the ketogenic diet did sort of fall out of favor in that time period.

Speaker 3 A few doctors still used it, but it wasn't mainstream and it wasn't really being researched until it popped back on people's radars again thanks to none other than Meryl Streep.

Speaker 3 Hurry, Mom! Hurry!

Speaker 6 Meryl starred in a movie in 1997 called First Do No Harm that was based on a true story about a kid with epilepsy who didn't respond to any of the medications available.

Speaker 6 It was the keto diet that saved him.

Speaker 26 And since then, literature, publications, and knowledge about ketogenic diets for epilepsy, not only in kids, but now also in adults, has grown.

Speaker 6 To the point where these days, Tanya regularly uses keto to treat some of her patients.

Speaker 26 And so I tend to think about it in any person with epilepsy that has failed to drugs or meets criteria for drug-resistant epilepsy.

Speaker 31 This is actually a lot of people.

Speaker 11 Tanya told us that a third of patients with epilepsy don't respond well to medication, and epilepsy is thought to affect 68 million people around the world, right?

Speaker 26 So it's a pretty large chunk of patients that could potentially benefit from a ketogenic diet.

Speaker 6 Tanya works with both children and adults, but as we've already pointed out, this diet is hard to stick to. Tanya says about half of her adult patients stop.

Speaker 6 For some of them, it's because it's not working for them, but for most of them, it's just because it's really hard.

Speaker 6 It's a little easier for kids to follow it because their parents are helping prepare their meals. Often they only have to be on it for a few years to make a difference.

Speaker 6 And Tanya works carefully with her patients to avoid the health risks that Shivam talked about.

Speaker 27 One thing you might be wondering at this point is how on earth ketones work to help prevent seizures? The answer is we have some clues, but we don't know for sure.

Speaker 26 There have been a number of studies that suggest that ketones themselves can dampen abnormal electrical excitability in the brain. And that's basically what a seizure is.

Speaker 26 There have also been some studies that show that ketones coupled with reductions in carbohydrates can also have some anti-inflammatory properties.

Speaker 26 And there's some thought that in some forms of epilepsy, excess inflammation can lead to the development of seizures.

Speaker 26 And so there's a lot of varied hypotheses as far as which impacts the ketogenic diet can have, but there is no one solid mechanism as far as this is the immediate way that it works for all patients with epilepsy.

Speaker 6 Despite this lack of certainty, scientists have been looking into other ways that keto might have medical benefits in the brain.

Speaker 26 There are some studies that are looking at the ketogenic diet for brain tumors, particularly like glioblastoma, for example, which is a key brain tumor in adults that has very poor outcomes with standard of care therapies.

Speaker 26 And the thought here is that tumor cells like glucose, right? They like sugar as a principal fuel source, right? Whereas your native cells that aren't tumors can use either glucose or ketones, right?

Speaker 26 And so by reducing your intake of glucose, you're sort of trying to starve the tumor cells, right? And only feed your healthy cells.

Speaker 26 And so that might be one mechanism where they could be beneficial for helping to treat your potential brain tumor.

Speaker 9 Unlike for seizures, this use of the keto diet as a medical treatment hasn't been proven yet.

Speaker 28 It's still a theory.

Speaker 26 There's also some look at such diet therapies for dementia or other sort of neurodegenerative disorders for Alzheimer's disease.

Speaker 6 On the other hand, Shivam told us there's some data suggesting that consuming a lot of animal and saturated fat is not good for long-term cognition and risk of dementia.

Speaker 26 None of these other fields have had the amount of literature that has been been reported and studied as epilepsy does.

Speaker 26 And so the work is still new in a lot of these areas, and a lot of clinical trials are actually underway for a lot of these other conditions.

Speaker 6 Unsurprisingly, as you hear frequently on Gastropod, more research is needed.

Speaker 3 Meanwhile, unless you have drug-resistant epilepsy, Michael says keto is over. The tech bros and the optimizers have found a new belief system.

Speaker 4 I think a lot of them have now moved on to the carnivore diet.

Speaker 35 Which literally excludes all produce.

Speaker 10 It's zero carb.

Speaker 6 If it's possible, this sounds even worse. But so keto had its time and place.
It was very of the moment.

Speaker 4 I think keto allowed us to get data that was something that that crowd really liked and wanted and felt like could bring them into a better place.

Speaker 5 And

Speaker 4 then they got asked to go to lunch at Subway and the train derailed. And so you've seen keto sort of rise and fall depending on the story.

Speaker 3 At the end of the day, unless, again, you've got drug-resistant epilepsy, that's what this is all about.

Speaker 19 Stories.

Speaker 7 Stories we get told and we tell ourselves.

Speaker 24 If I believe that going on this diet, that eating eggs and duck and bacon and drinking whipped cream is going to help me with my stress level, likely it will. I mean, that's just who we are as humans.

Speaker 24 We're very malleable.

Speaker 6 We've said this before on Gastropod. These types of stories might sound kind of harmless, but diet culture in general is actually really harmful.

Speaker 6 To our surprise, this diet turns out to be able to help some people with epilepsy live happy and healthy lives.

Speaker 6 For the rest of us, diet culture is so pervasive in our society that it's easy to get swept up in it. But diets and this whole thought pattern can genuinely hurt us both mentally and physically.

Speaker 24 And that's where it gets really...

Speaker 24 Sort of insidious because we all have problems, right? Even if it's not with our weight, it's with our brain or stress or relationships. So we all are looking for, you know, a fix.

Speaker 24 And that's where the diet can really speak to not just those who are concerned about their weight, but those who just sort of longing for something more, something better.

Speaker 9 Thanks this episode to listener Catherine Elkins for your suggestion and for listening. It's always fun to hear from you all.

Speaker 6 Thanks also to all our guests this episode, Adrian Batar, Michael Easter, Shivam Joshi, and Tanya McDonald.

Speaker 6 You can find more about their research, their books, and their reporting on our website, Castropod.com.

Speaker 15 And of course, thanks to our awesome producer, Claudia Guib.

Speaker 29 We're back with a fishy tale in just a couple of weeks.

Speaker 14 Till then.

Speaker 40 This month on Explain It To Me, we're talking about all things wellness. We spend nearly $2 trillion on things that are supposed to make us well.

Speaker 40 Collagen smoothies and cold plunges, Pilates classes, and fitness trackers. But what does it actually mean to be well? Why do we want that so badly?

Speaker 40 And is all this money really making us healthier and happier? That's this month on Explain It To Me, presented by Pureleaf.

Speaker 51 Support for this show comes from Capital One. With the VentureX business card from Capital One, you earn unlimited double miles on every purchase.

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Speaker 48 Capital One: What's in your wallet?