Around this time, Bernarr Macfadden, an American exponent of physical culture, popularised the use of fasting to restore health. His disciple, the osteopathic physician Dr. Hugh William Conklin of Battle Creek, Michigan, began to treat his epilepsy patients by recommending fasting. Conklin conjectured that epileptic seizures were caused when a toxin, secreted from the Peyer's patches in the intestines, was discharged into the bloodstream. He recommended a fast lasting 18 to 25 days to allow this toxin to dissipate. Conklin probably treated hundreds of epilepsy patients with his "water diet" and boasted of a 90% cure rate in children, falling to 50% in adults. Later analysis of Conklin's case records showed 20% of his patients achieved freedom from seizures and 50% had some improvement.[10]

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On the ketogenic diet, carbohydrates are restricted and so cannot provide for all the metabolic needs of the body. Instead, fatty acids are used as the major source of fuel. These are used through fatty-acid oxidation in the cell's mitochondria (the energy-producing parts of the cell). Humans can convert some amino acids into glucose by a process called gluconeogenesis, but cannot do this by using fatty acids.[57] Since amino acids are needed to make proteins, which are essential for growth and repair of body tissues, these cannot be used only to produce glucose. This could pose a problem for the brain, since it is normally fuelled solely by glucose, and most fatty acids do not cross the blood–brain barrier. However, the liver can use long-chain fatty acids to synthesise the three ketone bodies β-hydroxybutyrate, acetoacetate and acetone. These ketone bodies enter the brain and partially substitute for blood glucose as a source of energy.[56]

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If you are seeking fat loss but do not want to follow a strict ketogenic diet, you will be pleased to know that this study found that the weight loss benefits came purely from a low carb diet – whether it was ketogenic or not. If you need help transiting to a lower carb diet, be sure to download my free diet plan or better yet, be sure to view the most effective way to lose fat and keep it off on this page. 
A systematic review in 2018 looked at 16 studies on the ketogenic diet in adults. It concluded that the treatment was becoming more popular for that group of patients, that the efficacy in adults was similar to children, the side effects relatively mild. However, many patients gave up with the diet, for various reasons, and the quality of evidence was inferior to studies on children. Health issues include high levels of low-density lipoprotein, high total cholesterol, and weight loss.[24]

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About 20% of children on the ketogenic diet achieve freedom from seizures, and many are able to reduce the use of anticonvulsant drugs or eliminate them altogether.[18] Commonly, at around two years on the diet, or after six months of being seizure-free, the diet may be gradually discontinued over two or three months. This is done by lowering the ketogenic ratio until urinary ketosis is no longer detected, and then lifting all calorie restrictions.[46] This timing and method of discontinuation mimics that of anticonvulsant drug therapy in children, where the child has become seizure-free. When the diet is required to treat certain metabolic diseases, the duration will be longer. The total diet duration is up to the treating ketogenic diet team and parents; durations up to 12 years have been studied and found beneficial.[9]

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As mentioned, there are a few reasons why the keto diet usually equals weight-loss gold, says Keatley. For starters, people usually reduce their daily caloric intake to about 1,500 calories a day because healthy fats and lean proteins make you feel fuller sooner—and for a longer period of time. And then there’s the fact that it takes more energy to process and burn fat and protein than carbs, so you're burning slightly more calories than you did before. Over time, this can lead to weight loss.
When something is popular, it’s pretty much a guarantee that people are going to come up with new or easier ways of doing it. Enter the lazy keto and dirty keto diets. With lazy keto, people try to limit their carb intake to 20 to 50 grams a day but don’t really track it; with dirty keto, people generally follow the same macronutrient breakdown as "regular" keto, but it doesn't matter where those macronutrients come from.

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Before starting, ask yourself what is really realistic for you, Mattinson suggests. Then get your doctor’s okay. You may also work with a local registered dietitian nutritionist to limit potential nutrient deficiencies and talk about vitamin supplementation, as you won’t be eating whole grains, dairy, or fruit, and will eliminate many veggies. “A diet that eliminates entire food groups is a red flag to me. This isn’t something to take lightly or dive into headfirst with no medical supervision,” she says.
The ketogenic diet is not a benign, holistic, or natural treatment for epilepsy; as with any serious medical therapy, complications may result.[28] These are generally less severe and less frequent than with anticonvulsant medication or surgery.[28] Common but easily treatable short-term side effects include constipation, low-grade acidosis, and hypoglycaemia if an initial fast is undertaken. Raised levels of lipids in the blood affect up to 60% of children[38] and cholesterol levels may increase by around 30%.[28] This can be treated by changes to the fat content of the diet, such as from saturated fats towards polyunsaturated fats, and if persistent, by lowering the ketogenic ratio.[38] Supplements are necessary to counter the dietary deficiency of many micronutrients.[18]
Those issues can be part of what's known as the “keto flu,” Warren says. Other side effects of the keto diet, all of which are tied to carb withdrawal, can include lightheadedness, nausea, mental fog, cramps, and headaches, in addition to tiredness. Luckily, the keto flu doesn't usually last more than a week—which is coincidentally about when people start to see the number on the scale go down, says Warren.

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There’s also some evidence that it might help with type 2 diabetes. “An emerging body of research is finding that a keto plan may have some real benefits thanks to its ability to improve the body’s ability to use insulin and also help control appetite, which can result in easier weight loss,” says Karen Ansel, R.D.N., co-author of Healthy in a Hurry.
Normal dietary fat contains mostly long-chain triglycerides (LCTs). Medium-chain triglycerides (MCTs) are more ketogenic than LCTs because they generate more ketones per unit of energy when metabolised. Their use allows for a diet with a lower proportion of fat and a greater proportion of protein and carbohydrate,[18] leading to more food choices and larger portion sizes.[4] The original MCT diet developed by Peter Huttenlocher in the 1970s derived 60% of its calories from MCT oil.[15] Consuming that quantity of MCT oil caused abdominal cramps, diarrhea, and vomiting in some children. A figure of 45% is regarded as a balance between achieving good ketosis and minimising gastrointestinal complaints. The classical and modified MCT ketogenic diets are equally effective and differences in tolerability are not statistically significant.[9] The MCT diet is less popular in the United States; MCT oil is more expensive than other dietary fats and is not covered by insurance companies.[18]
When you eat less than 50 grams of carbs a day, your body eventually runs out of fuel (blood sugar) it can use quickly. This typically takes 3 to 4 days. Then you’ll start to break down protein and fat for energy, which can make you lose weight. This is called ketosis. It's important to note that the ketogenic diet is a short term diet that's focussed on weight loss rather than the pursuit of health benefits. 

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Keatley has some…thoughts about those. “Dirty keto is a waste of your time since good habits have not been developed and it is simply too easy to fall back into a high-calorie diet,” he says. If you’re trying to do a lazy keto diet, he recommends following the USDA’s MyPlate instead and monitoring your meals based on proportions vs. macros. “It’s easier, more flexible, and has shown, when combined with moderate exercise, to be effective over the long term,” he says.
^ Freeman JM, Vining EP, Pillas DJ, Pyzik PL, Casey JC, Kelly LM. The efficacy of the ketogenic diet—1998: a prospective evaluation of intervention in 150 children. Pediatrics. 1998 Dec;102(6):1358–63. doi:10.1542/peds.102.6.1358. PMID 9832569. https://web.archive.org/web/20040629224858/http://www.hopkinsmedicine.org/press/1998/DECEMBER/981207.HTM Lay summary]—JHMI Office of Communications and Public Affairs. Updated 7 December 1998. Cited 6 March 2008.

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Carbohydrates have been linked to this skin condition, so cutting down on them may help. And the drop in insulin that a ketogenic diet can trigger may also help stop acne breakouts. (Insulin can cause your body to make other hormones that bring on outbreaks.) Still, more research is needed to determine exactly how much effect, if any, the diet actually has on acne. 

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The keto diet has a massive fan base that has grown at least in part due to the popular Netflix documentary The Magic Pill, which touts a trove of promising keto health benefits. But the fact of the matter is that most of the studies on the keto diet are premature. Meaning: They’re in small populations of humans, or they’re in rats. (And you are very different from a rat.)

A short-lived increase in seizure frequency may occur during illness or if ketone levels fluctuate. The diet may be modified if seizure frequency remains high, or the child is losing weight.[19] Loss of seizure-control may come from unexpected sources. Even "sugar-free" food can contain carbohydrates such as maltodextrin, sorbitol, starch, and fructose. The sorbitol content of suntan lotion and other skincare products may be high enough for some to be absorbed through the skin and thus negate ketosis.[31]

Ketosis has been shown to have anti-inflammatory properties while also assisting with pain relief. Reducing glucose metabolism influences pain, so this could be one potential mechanism of action. In the review The Nervous System and Metabolic Dysregulation: Emerging Evidence Converges on Ketogenic Diet Therapy the authors look at numerous ways that a ketogenic diet can assist with pain and inflammation.

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It’s also common for people starting the diet to experience flu-like symptoms, such as headaches and fatigue. This side effect is so common that there’s a name for it: the keto flu. “You shed a ton of water weight at first, which can lead to dehydration,” Nisevich Bede explains. This can worsen the symptoms of the keto flu. To counter it, she recommends staying hydrated and loading up on electrolytes through electrolyte tablets.

Keto breath, on the other hand, is less of a side-effect and more of a harmless inconvenience (your breath literally smells like nail polish remover). Basically, when your body breaks down all that extra fat on the keto diet, it produces ketones—one of which is the chemical acetone, Keatley previously told WH. (Yes, the same stuff that's in nail polish remover.)
And while some fats can be healthy, there’s a risk that in following a high-fat diet, you’ll increase your intake of unhealthy trans and saturated fats. These “bad” fats are found in things like red meat, poultry skin, cheese, and butter, and can lead to an increase in LDL, or “bad” cholesterol and increased risk of heart disease. (14) This is a controversial issue, as some experts do recommend adopting a low-carbohydrate diet to lower heart disease risk. If you’re at risk or have heart disease, it’s important to speak with your doctor first about your health needs.
A short-lived increase in seizure frequency may occur during illness or if ketone levels fluctuate. The diet may be modified if seizure frequency remains high, or the child is losing weight.[19] Loss of seizure-control may come from unexpected sources. Even "sugar-free" food can contain carbohydrates such as maltodextrin, sorbitol, starch, and fructose. The sorbitol content of suntan lotion and other skincare products may be high enough for some to be absorbed through the skin and thus negate ketosis.[31]

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“Combining a super restrictive diet with long periods of non-eating is not good,” says Keatley. “The body will cannibalize its own muscle for energy if intake from food is too low but the body does not differentiate between something like a calf muscle or a heart muscle. Keep in mind all your important organs are made of smooth muscle and going on a diet like this may harm something like your bladder or lungs just as much as provide fat loss.”
In the 1960s, medium-chain triglycerides (MCTs) were found to produce more ketone bodies per unit of energy than normal dietary fats (which are mostly long-chain triglycerides).[15] MCTs are more efficiently absorbed and are rapidly transported to the liver via the hepatic portal system rather than the lymphatic system.[16] The severe carbohydrate restrictions of the classic ketogenic diet made it difficult for parents to produce palatable meals that their children would tolerate. In 1971, Peter Huttenlocher devised a ketogenic diet where about 60% of the calories came from the MCT oil, and this allowed more protein and up to three times as much carbohydrate as the classic ketogenic diet. The oil was mixed with at least twice its volume of skimmed milk, chilled, and sipped during the meal or incorporated into food. He tested it on 12 children and adolescents with intractable seizures. Most children improved in both seizure control and alertness, results that were similar to the classic ketogenic diet. Gastrointestinal upset was a problem, which led one patient to abandon the diet, but meals were easier to prepare and better accepted by the children.[15] The MCT diet replaced the classic ketogenic diet in many hospitals, though some devised diets that were a combination of the two.[10]

When in the hospital, glucose levels are checked several times daily and the patient is monitored for signs of symptomatic ketosis (which can be treated with a small quantity of orange juice). Lack of energy and lethargy are common, but disappear within two weeks.[17] The parents attend classes over the first three full days, which cover nutrition, managing the diet, preparing meals, avoiding sugar, and handling illness.[19] The level of parental education and commitment required is higher than with medication.[44]

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Insulin is a hormone that lets your body use or store sugar as fuel. Ketogenic diets make you burn through this fuel quickly, so you don’t need to store it. This means your body needs -- and makes -- less insulin. Those lower levels may help protect you against some kinds of cancer or even slow the growth of cancer cells. More research is needed on this, though.

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Perhaps the biggest anecdotal evidence on ketosis slowing down MS is the story of Dr. Terry Wahls. Dr. Wahls overcame being wheelchair bound after trying various drugs and conventional therapies without success. Eventually, she turned to dietary changes – including following a ketogenic diet – and a lot of her symptoms disappeared. She now lives an active life, riding horses and going on long treks. She shares her story and the protocol she developed in the book The Whals Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles.
The ketogenic diet is a mainstream dietary therapy that was developed to reproduce the success and remove the limitations of the non-mainstream use of fasting to treat epilepsy.[Note 2] Although popular in the 1920s and '30s, it was largely abandoned in favour of new anticonvulsant drugs.[1] Most individuals with epilepsy can successfully control their seizures with medication. However, 20–30% fail to achieve such control despite trying a number of different drugs.[9] For this group, and for children in particular, the diet has once again found a role in epilepsy management.[1][10]

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Variations on the Johns Hopkins protocol are common. The initiation can be performed using outpatient clinics rather than requiring a stay in hospital. Often, no initial fast is used (fasting increases the risk of acidosis, hypoglycaemia, and weight loss). Rather than increasing meal sizes over the three-day initiation, some institutions maintain meal size, but alter the ketogenic ratio from 2:1 to 4:1.[9]
Because people with type 2 diabetes are at an increased risk for cardiovascular disease, there’s a specific concern that the saturated fat in the diet may drive up LDL, or “bad,” cholesterol levels, and further increase the odds of heart problems. If you have type 2 diabetes, talk to your doctor before attempting a ketogenic diet. They may recommend a different weight-loss diet for you, like a reduced-calorie diet, to manage diabetes. Those with epilepsy should also consult their doctor before using this as part of their treatment plan.

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It usually takes three to four days for your body to go into ketosis because you have to use up your body's stores of glucose, i.e., sugar first, Keatley says. Any major diet change can give you some, uh, issues, and Keatley says he often sees patients who complain of IBS-like symptoms and feeling wiped out at the beginning of the diet. (The tiredness happens because you have less access to carbs, which give you quick energy, he explains.) 

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