History of the Ketogenic Diet

Before discussing the theory and metabolic effects of the ketogenic diet, it is useful to
briefly review the history of the ketogenic diet and how it has evolved. There are two primary
paths (and numerous sub-paths) that the ketogenic diet has followed since its inception:
treatment of epilepsy and the treatment of obesity.

Fasting
Without discussing the technical details here, it should be understood that fasting (the
complete abstinence of food) and ketogenic diets are metabolically very similar. The similarities
between the two metabolic states (sometimes referred to as ‘starvation ketosis’ and ‘dietary
ketosis’ respectively) have in part led to the development of the ketogenic diet over the years.
The ketogenic diet attempts to mimic the metabolic effects of fasting while food is being
consumed.

Epilepsy
The ketogenic diet has been used to treat a variety of clinical conditions, the most well
known of which is childhood epilepsy. Writings as early as the middle ages discuss the use of
fasting as a treatment for seizures. The early 1900’s saw the use of total fasting as a treatment
for seizures in children. However, fasting cannot be sustained indefinitely and only controls
seizures as long as the fast is continued.

Due to the problems with extended fasting, early nutrition researchers looked for a way to
mimic starvation ketosis, while allowing food consumption. Research determined that a diet high
in fat, low in carbohydrate and providing the minimal protein needed to sustain growth could
maintain starvation ketosis for long periods of time. This led to development of the original
ketogenic diet for epilepsy in 1921 by Dr. Wilder. Dr. Wilder’s ketogenic diet controlled pediatric
epilepsy in many cases where drugs and other treatments had failed. The ketogenic diet as
developed by Dr. Wilder is essentially identical to the diet being used in 1998 to treat childhood
epilepsy.

The ketogenic diet fell into obscurity during the 30’s, 40’s and 50’s as new epilepsy drugs
were discovered. The difficulty in administering the diet, especially in the face of easily prescribed
drugs, caused it to all but disappear during this time. A few modified ketogenic diets, such as the
Medium Chain Triglyceride (MCT) diet, which provided greater food variability were tried but they
too fell into obscurity.

In 1994, the ketogenic diet as a treatment for epilepsy was essentially ‘rediscovered’ in the
story of Charlie, a 2-year-old with seizures that could not be controlled with medications or other
treatment, including brain surgery. Charlie’s father found reference to the ketogenic diet in the
literature and decided to seek more information, ending up at Johns Hopkins medical center.

Charlie’s seizures were completely controlled as long as he was on the diet. The amazing
success of the ketogenic diet where other treatments had failed led Charlie’s father to create the
Charlie Foundation, which has produced several videos, published the book “The Epilepsy Diet
Treatment: An introduction to the ketogenic diet”, and has sponsored conferences to train
physicians and dietitians to implement the diet. Although the exact mechanisms of how the
ketogenic diet works to control epilepsy are still unknown , the diet continues to gain acceptance
as an alternative to drug therapy.

Other clinical conditions
Epilepsy is arguably the medical condition that has been treated the most with ketogenic
diets. However, preliminary evidence suggests that the ketogenic diet may have other
clinical uses including respiratory failure, certain types of pediatric cancer, and possibly
head trauma .

Obesity
Ketogenic diets have been used for weight loss for at least a century, making occasional
appearances into the dieting mainstream. Complete starvation was studied frequently including
the seminal research of Hill, who fasted a subject for 60 days to examine the effects, which was
summarized by Cahill. The effects of starvation made it initially attractive to treat morbid
obesity as rapid weight/fat loss would occur. Other characteristics attributed to ketosis, such as
appetite suppression and a sense of well being, made fasting even more attractive for weight loss.
Extremely obese subjects have been fasted for periods up to one year given nothing more than
water, vitamins and minerals.

The major problem with complete starvation is a large loss of body protein, primarily from
muscle tissue. Although protein losses decrease rapidly as starvation continues, up to one half of
the total weight lost during a complete fast is muscle and water, a ratio which is unacceptable.

In the early 70’s, an alternative approach to starvation was developed, termed the Protein
Sparing Modified Fast (PSMF). The PSMF provided high quality protein at levels that would
prevent most of the muscle loss without disrupting the purported ‘beneficial’ effects of starvation
ketosis which included appetite suppression and an almost total reliance on bodyfat and ketones
to fuel the body. It is still used to treat severe obesity but must be medically supervised.

At this time, other researchers were suggesting ‘low-carbohydrate’ diets as a treatment for
obesity based on the simple fact that individuals tended to eat less calories (and hence lose
weight/fat) when carbohydrates were restricted to 50 grams per day or less. There was
much debate as to whether ketogenic diets caused weight loss through some peculiarity of
metabolism, as suggested by early studies, or simply because people ate less.

The largest increase in public awareness of the ketogenic diet as a fat loss diet was due to
“Dr. Atkins Diet Revolution” in the early 1970’s. With millions of copies sold, it generated
extreme interest, both good and bad, in the ketogenic diet. Contrary to the semi-starvation and
very low calorie ketogenic diets which had come before it, Dr. Atkins suggested a diet limited only
in carbohydrates but with unlimited protein and fat. He promoted it as a lifetime diet which
would provide weight loss quickly, easily and without hunger, all while allowing dieters to eat as
much as they liked of protein and fat. He offered just enough research to make a convincing
argument, but much of the research he cited suffered from methodological flaws.

For a variety of reasons, most likely related to the unsupported (and unsupportable)
claims Atkins made, his diet was openly criticized by the American Medical Association and the
ketogenic diet fell back into obscurity. Additionally, several deaths occurring in dieters
following “The Last Chance Diet” – a 300 calorie-per-day liquid protein diet, which bears a
superficial resemblance to the PSMF – caused more outcry against ketogenic diets.

From that time, the ketogenic diet (known by this time as the Atkins diet) all but
disappeared from the mainstream of American dieting consciousness as a high carbohydrate,
lowfat diet became the norm for health, exercise performance and fat loss.

Recently there has been a resurgence in low carbohydrate diets including “Dr. Atkins New
Diet Revolution”  and “Protein Power” by the Eades but these diets are aimed primarily
at the typical American dieter, not athletes.

Ketogenic diets and bodybuilders/athletes
Low carbohydrate diets were used quite often in the early years of bodybuilding (the fish
and water diet). As with general fat loss, the use of low carbohydrate, ketogenic diets by athletes
fell into disfavor as the emphasis shifted to carbohydrate based diets.

As ketogenic diets have reentered the diet arena in the 1990’s, modified ketogenic diets
have been introduced for athletes, primarily bodybuilders. These include so-called cyclical
ketogenic diets (CKD’s) such as “The Anabolic Diet” and “Bodyopus”.

During the 1980’s, Michael Zumpano and Daniel Duchaine introduced two of the earliest
CKD’s: ‘The Rebound Diet’ for muscle gain, and then a modified version called ‘The Ultimate Diet’
for fat loss. Neither gained much acceptance in the bodybuilding subculture. This was most
likely due to difficulty in implementing the diets and the fact that a diet high in fat went against
everything nutritionists advocated.

In the early 1990’s, Dr. Mauro DiPasquale, a renowned expert on drug use in sports,
introduced “The Anabolic Diet” (AD). This diet alternated periods of 5-6 days of low carbohydrate,
moderate protein, moderate/high fat eating with periods of 1-2 days of unlimited carbohydrate
consumption. The major premise of the Anabolic Diet was that the lowcarb week would
cause a ‘metabolic shift’ to occur, forcing the body to use fat for fuel. The high carb consumption
on the weekends would refill muscle carbohydrate stores and cause growth. The carb-loading
phase was necessary as ketogenic diets can not sustain high intensity exercise such as weight
training.

DiPasquale argued that his diet was both anti-catabolic (preventing muscle breakdown) as
well as overtly anabolic (muscle building). His book suffered from a lack of appropriate
references (using animal studies when human studies were available) and drawing incorrect
conclusions. As well, his book left bodybuilders with more questions than it provided answers.

A few years later, bodybuilding expert Dan Duchaine released the book “Underground
Bodyopus: Militant Weight Loss and Recomposition”. Bodyopus addressed numerous topics
related to fat loss, presenting three different diets. This included his approach to the CKD, which
he called BODYOPUS. BODYOPUS was far more detailed than the Anabolic Diet, giving specific
food recommendations in terms of both quality and quantity. As well, it gave basic workout
recommendations and went into more detail regarding the physiology of the diet.

However, “Bodyopus” left many questions unanswered as evidenced by the numerous
questions appearing in magazines and on the internet. While Duchaine’s ideas were accepted to
a limited degree by the bodybuilding subculture, the lack of scientific references led health
professionals, who still thought of ketogenic diets as dangerous and unhealthy, to question the
diet’s credibility.

A question
Somewhat difficult to understand is why ketogenic diets have been readily accepted as
medical treatment for certain conditions but are so equally decried when mentioned for fat loss.
Most of the criticisms of ketogenic diets for fat loss revolve around the purported negative health
effects (i.e. kidney damage) or misconceptions about ketogenic metabolism (i.e. ketones are made
out of protein).

This begs the question of why a diet presumed so dangerous for fat loss is being used
clinically without problem. Pediatric epilepsy patients are routinely kept in deep ketosis for
periods up to 3 years, and occasionally longer, with few ill effects. Yet the mention of a brief
stint on a ketogenic diet for fat loss and many people will comment about kidney and liver
damage, ketoacidosis, muscle loss, etc. If these side effects occurred due to a ketogenic diet, we
would expect to see them in epileptic children.

It’s arguable that possible negative effects of a ketogenic diet are more than outweighed by
the beneficial effects of treating a disease or that children adapt to a ketogenic diet differently
than adults. Even then, most of the side effects attributed to ketogenic diets for fat loss are not
seen when the diet is used clinically.

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