Why I dislike 'keto'

I've done it all, from the Israeli army diet to fruitarian-ism and I’m still apologising to my son for the raw food years. Although working out what healthy eating is for me personally hasn't' qualified me to give dietary advice to anyone else, as a lymphoedema therapist I was frequently asked to do so by my clients. Which is not surprising when you consider the strong links between lymphatic disease and fat disorders, they are reciprocal risk factors for each other.

While I wasn't qualified to give any specific dietary advice, weight gain and how difficult it is to lose it were frequent topics of conversation. Many people attested to an improvement in all signs and symptoms when they lose weight, even a few kilos will usually make a noticeable improvement, but repeated bouts of yo-yo dieting seem to aggravate disease progression. I’m still not a nutritionist but I am deeply concerned when I see people affected by lympho-lipo-dystrophies jump too quickly onto the next diet fad-wagon. We have additional risk-factors that people without chronic inflammatory conditions don't need to consider, and if your lower body is affected then you should also think about what is happening in your gut lymphatics.

People affected by chronic diseases must learn how to manage their symptoms on a daily basis, and conscious eating is a good option for many. The problem with ‘doing it with food’ is that it is really hard to maintain restrictive or complex diets, or pay for expensive supplements. So we also need to consider sustainability in the long term, “Can I keep eating like this for the rest of my life?”

In fact, sustainability more broadly has become the most important factor in my own eating habits, and involves another whole set of personal values unrelated to my weight issues or lymphoedema. Since reading ‘The ethics of what we eat’ by Peter Singer I have tried to adopt a mostly plant-based diet, but nothing is off the menu if it was produced ethically and sustainably.

After decades of self-experimentation and weight fluctuation, and hundreds of weighty conversations with my lymphoedema clients, I have some simple observations to share.

Firstly, more than any calorie counting or protein ratio system, the most important consideration for those of us with lymphoedema is how our own bodies react to various foods in terms of systemic inflammation. This one is actually a problem for anyone who is dieting to lose weight as we know there are links between inflammation and obesity. Even more so for those of use who have chronic inflammatory disorders already, we just don't need our daily diets fuelling even more inflammation.

The type of fats we consume also matters, especially if you have lower body issues. This is because long chain fatty acids in the diet are absorbed by gut lymphatics and do not immediately enter the blood stream like other digested nutrients. They then pass through the abdominal lymph pathways to the cisterna chyli where they join with lymph from the legs and travel up to the veins above the heart via the thoracic duct.

These large lipid molecules help us absorb the fat soluble vitamins from our food and lymphatic diseases which affect absorption of these long chain fatty acids may require vitamin supplementation.

Many people with lower limb lymphoedema have found it useful to moderate the amount of these long chain fatty acids in their diet to reduce the load on their central lymphatics and notice and improvement in lymph drainage from their legs.

This can be achieved with some simple substitutions. Using coconut oil for cooking - its a medium chain fatty acid and doesn't denature at high heat, and use olive oil sparingly (its long chain) and uncooked (denatures at high heat) in dressings etc.

Notice that long/short - which are about molecule size - are not synonymous with saturated/unsaturated - which describe the shape of the molecules. It's only the very big molecules that must be handled by the lymphatics. Using ghee instead of raw butter is another useful change from long chain fats to short-chain versions (I don’t have any objection to dairy products if the cows are having a good life).

Generally speaking, plant-based foods are less inflammatory than flesh foods and generally higher in fibre. We already know that systemic inflammation has a generally negative effect on lymphoedema symptoms, and recent discoveries between systemic inflammation and obesity help to explain why some pole struggle more with weight issues after they develop lymphoedema. I'm hoping that someone will investigate the importance of the gut microbiome and lymphatic function.

So why am I a bit anti 'keto'? Its not the principle actually, its the the use of a label and all the hype around it which bothers me. There is some evidence that the principle may be of benefit for people with lipoedema (1) but I still have concerns about how long-term ketosis affects other body systems as there are also known adverse effects (2,3). And by all accounts a strict keto-diet is not sustainable, with most people relapsing after 12 months or so (2,3). Other health professionals like Dr Michael Mosley assert that keto should only be used for 8 weeks and then progress to a balanced diet for lifestyle*.