A little over a century after the term ketogenic diet (KD) was coined at the Mayo Clinic in the United States, it is today ‘a mainstream treatment for paediatric epilepsy, offered in approximately 75 countries’ with the International Neurologic Ketogenic Society continuing ‘to advocate for expanded use and organise biannual scientific conferences www.neuroketo.org.’ This is cited in Ketogenic, which not only describes the myriad applications of KDs beyond the treatment of epilepsy, but as Professor Tim Noakes notes in its preface, ‘definitively establishes that therapeutic carbohydrate restriction (TCR) is perhaps the most studied and definitely the most effective dietary intervention known to modern medicine.’
This is an indispensable textbook for all healthcare professionals involved in providing evidence-based nutritional advice and lifestyle help to patients. A decade ago, reducing carbohydrate intake was considered a ‘fad’ and went against the prevailing dietary guidelines, but as Nutrition Network's Managing Director Jayne Bullen makes clear in the Introduction: ‘The same guidelines have contributed to an epidemic of diabetes, obesity and most other chronic and metabolic diseases.’
So, what is a KD? Whereas a daily intake of less than 130 g of carbohydrate is considered low, ‘[i]f the dietary carbohydrate is sufficiently low to cause an increase in blood or urine ketone bodies, typically less than 50 g of total dietary carbohydrate per day, then the diet is called a very-low carbohydrate or KD.’
The origins of Ketogenic can be traced back to December 2010 when the University of Cape Town's Professor Tim Noakes – a world leader in sports science and nutrition – was ‘mortified’ to read a book titled The New Atkins for a New You (2010) by Drs Westman, Phinney and Volek. They rejected the so-called ‘hearthealthy’, low-fat diet familiar to us all, and instead promoted a low-carbohydrate high-(healthy) fat diet, or TCR. Convinced by the science underpinning this approach, Noakes adopted TCR and his personal health transformation ‘included putting my type 2 diabetes (T2D) into a medically impossible remission’.
Established in 2014, The Noakes Foundation Research & Teams – The Noakes Foundation later founded Nutrition Network Global Leaders in Online Low-Carbohydrate Nutrition Training – Nutrition Network (nutrition-network.org) an education, connection, and learning platform. It was a team from Nutrition Network who ‘argued that a novel medical discipline often requires the compilation of a textbook to show sceptical healthcare providers that, yes, there is indeed a large body of published scientific evidence backed up by extensive clinical experience, examining TCR.’
The evolution of dietary guidelines
Ketogenic is a collaborative venture and a work of scholarship from 62 eminent contributors from around the world, whose accumulated wisdom is presented in some 540 pages that include thousands of peer-reviewed references. Six pages of contents show how the text is organised into four parts – nutritional fundamentals; medical nutritional therapy; TCR for health and fitness; and managing the patient – with each part providing historical perspectives, clinical insights, explanatory diagrams, and helpful summaries.
The opening chapter – replete with 458 references – considers, inter alia, the evolution of our modern Western diet; the rise of sugar consumption and its attendant dangers; the emergence of ultra-processed food; and the roles of insulin resistance and hyperinsulinaemia in relation to diabetes. However, it is in his forensic analysis of the adoption and evolution of dietary guidelines that Prof Noakes lays bare the ignorance, hubris and political machinations that led to the 1977 US Dietary Guidelines coming to rest on the flimsiest of evidential foundations.
With these facts established, Ketogenic proceeds to build a solid evidence base supporting a range of keto-related topics. For example, in ‘Cardiovascular disease and its association with insulin resistance and cholesterol’, we learn that cholesterol is essential for life and ‘an integral part of neural function, nerve conduction, precursor of steroid hormones like testosterone, oestrogens, and cortisol, and essential in the synthesis of vitamin D in the skin.’ Traditional and alternative mechanisms of atherosclerosis are also considered, and it is eye-opening to learn of the statistical sleight of hand that is often used to support the claims of those who promote cholesterollowering medications.
The section on neurology considers a host of applications of TCR in ameliorating and/or treating a range of neurological and/or mood disorders. For instance, gut-brain connection is evaluated, and the role of TCR is analysed in relation to epilepsy, Alzheimer's, depression, multiple sclerosis, Parkinson's, autism spectrum disorder, migraine, and other conditions.
In chapter 6 cancer as a modern disease is investigated, including its relationship with T2D and sugar consumption, and describes how Nobel Laureate Otto Warburg was ‘the first to suggest that a particular abnormality in glucose metabolism is the defining chemical abnormality in all cancer cells.’
While physiological mechanisms, studies and TCR strategies are discussed in detail, Ketogenic also provides practical evidence-based advice and support for those dealing directly with patients. Chapter 11 is titled ‘Psychological, behavioural, and ethic considerations’ and makes the point that ‘[a] dietary intervention is only effective in the long term if it is sustainable … [and] … There are techniques healthcare practitioners can employ to guide patients towards behaviour change, while encouraging them to take responsibility for their own health and achieve lasting improvements.’ The importance of listening to a patient is underlined by a quote from the unlikely realm of rock music, specifically Jimi Hendrix: ‘Knowledge speaks, but wisdom listens.’
Chapter 11 also includes the persuasive case that advocates for change in public health. This is advanced is by Joan Adams, a lawyer, who notes that scientific advances often produce ‘new knowledge that will and must ultimately change medical dogma, dietary guidelines, and nutrition recommendations. Science is, after all, not static and is continually evolving.’
As well as being a work of erudition, Ketogenic is a model of clarity with well-presented arguments leading to logical conclusions, and all tempered with an awareness that TCR does not only have practical application for improving the health of patients but shows how healthy dietary goals for all can be achieved – and maintained – in a life-enhancing and life-prolonging manner.