THE KILLER KETO DIET

Abstract

Therapeutic Area: Nutrition/Exercise Case Presentation: A 62-year-old man with a history of peptic ulcer disease, as well as a myocardial infarction (MI) in his father at age 57 began a ketogenic diet for weight loss in January 2023. A screening lipid panel 16 years prior showed a total cholesterol (TC) 205 mg/dL, triglycerides (TG) 129 mg/dL, high-density lipoprotein (HDL) 36 mg/dL, and low-density lipoprotein (LDL) 143mg/dL. He had two prior Commuted Tomography (CT) Coronary Artery Calcium Scores (CACS), with an Agatston score of 6 (2019) and 3 (2022). In July 2023 he presented to the emergency room with a ventricular fibrillation cardiac arrest in the setting of an ST-segment elevation myocardial infarction (STEMI). He underwent emergent catheterization and stenting of his mid left anterior descending (LAD) artery which was 100% occluded. Upon admission his lipid panel revealed a TC of 627 mg/dL, TG 114 mg/dL, HDL 62 mg/dL, and LDL 542 mg/dL. He noted adhering to a strictly carnivorous diet the five weeks preceding his STEMI. He was initiated on evolocumab, bempedoic acid, and ezetimibe; atorvastatin was discontinued due to neuropathic pain. Genetic testing did not reveal LDL-receptor associated mutations. At four months post-STEMI his TC was 163 mg/dL, TG 81 mg/dL, HDL 61 mg/dL, and LDL 86 mg/dL. He is now following a Mediterranean diet. Background: The American Heart Association recommends adherence to a “heart healthy” diet consisting of varied fruits, vegetables, whole grains, and lean or plant-based proteins. The ketogenic diet was first developed in 1911, after a reduction of epileptic seizures while fasting was observed. It emphasizes restriction of carbohydrates and a high intake of fat, with the goal of depleting glycogen stores and utilizing free fatty acids for energy metabolism through ketosis. While effective for epilepsy, adherence to a ketogenic diet can raise cholesterol levels, and has been associated with increased cardiovascular events. Conclusions: This case illustrates that fad diets may not be benign. A ketogenic diet can raise lipids to levels diagnostic of familial hypercholesterolemia and accelerate progression of atherosclerosis. Further studies are needed to examine what determines an individual's response to a ketogenic diet.