A new study, however, shows “keto-like” diets may be linked to a heightened risk of cardiovascular events like chest pain, blocked arteries, heart attacks and strokes.

The results of the study were presented at the American College of Cardiology’s 2023 Annual Scientific Session & Expo Together With World Congress of Cardiology.

Researchers analyzed and compared the diets of 305 people eating a low-carb, high-fat (LCHF) diet, which is considered keto-like, with roughly 1,200 people eating a standard diet.

A low-carb, high-fat diet was defined in the research as a diet with more than 45% of total daily calories coming from fat and no more than 25% coming from carbohydrates. A ketogenic diet is aimed at putting the body into a metabolic state called ketosis, where it burns energy from fat instead of glucose from carbohydrates.

“Diet is a four-letter word,” said Kelley M. McIntyre, M.D., internal medicine physician with Norton Community Medical Associates, who also sees patients seeking medical weight loss. “‘What’s the best diet?’ is always the question that everybody wants to know.”

In the recent study, researchers found, after following the subjects for more than a decade, people who participated in a LCHF diet had significantly higher levels of both low-density lipoprotein (LDL, or “bad”) cholesterol and apolipoprotein B (apoB), the protein that helps carry fat and cholesterol through the body.

“Sometimes I do see the LDL going up [in my patients], the bad cholesterol, with a ketogenic diet,” Dr. McIntyre said. “And oftentimes that could be from the animal fat products, especially full-fat dairy, hamburger, those kinds of things. So I think it’s something to consider, and it definitely could be a concern in certain populations.”

The study also showed people on a LCHF diet had more than two times higher risk of major cardiovascular events, such as arterial blockages requiring stents, heart attacks, strokes and peripheral arterial disease. In total, the researchers found 9.8% of participants on a LCHF diet experienced a new cardiac event, compared with 4.3% of people eating a standard diet.

“That’s why it’s important to discuss diet changes with your physician,” Dr. McIntyre said. ”Because if a patient already has underlying heart disease, or issues like that, or elevated cholesterol — it could possibly raise those, especially if you’re doing a really high animal fat/saturated fat diet.”

Of the participants in the study, 73% were women. The group’s average age was 54.

The study was considered observational, meaning it can show only a correlation between the diets and risks for cardiac events, not causation between the two. However, those who conducted the research believe it merits further research into similar studies.

“The best diet is the one that you’re going to be able to stick with,” Dr. McIntyre said. “So there are lots of studies that have looked at this. And really the bottom line is people can lose weight with any diet,  and the science also supports that people will do better with an eating plan that they can sustain. So that’s a conversation that I have to have with my patients.”

According to the International Food Information Council’s 2020 Food and Health Survey, 43% of Americans reported they had followed a diet in the past year.

Of the responses, a ketogenic (high-fat) diet was the third most-followed, with a 7% follow rate.

To see tips from the American College of Cardiology for a heart-healthy diet, click here.

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What are the types of weight loss surgery?

“Each type of weight loss surgery has its own benefits and drawbacks; in general, the criteria to qualify for each surgery are the same.” said Meredith C. Sweeney, M.D., a general, bariatric and laparoscopic surgeon with Norton Surgical Specialists. 

Sleeve gastrectomy

Sleeve gastrectomy, or gastric sleeve, involves a surgeon removing a large part of the stomach. The part that remains is shaped like a banana and is a fraction of the size of the original stomach. This procedure limits the amount of food you can eat at one time and is almost always done laparoscopically, meaning the surgeon makes only small incisions. After surgery, patients will find that they get full with just a very small meal. 

Gastric bypass

Gastric bypass, also called Roux-en-Y gastric bypass, is a procedure that has been used for over 60 years. In a nutshell, gastric bypass creates a small pouch from your stomach and connects it to the intestines. After surgery, when you eat, the food enters the smaller stomach pouch and then flows directly into the intestines. The surgery usually can be done laparoscopically. Gastric bypass works by limiting the amount of food you can eat and the nutrients that are actually absorbed.

Gastric band

Gastric banding  puts a silicone device around the upper part of the stomach, almost like a belt. The band is then connected via tubing to a port under the skin and can be inflated with saline inserted by the surgeon. This surgery works by limiting the amount of food you can eat at one time and by making you feel full with a small amount of food. The band can be adjusted and even removed. This surgery also is done laparoscopically.

“Each surgery comes with its own risks, side effects and results,” Dr. Sweeney said. “It’s important to talk openly with your surgeon so you can make the best choice for you.”

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Candidates for bariatric surgery

Body mass index (BMI) is a formula that uses weight and height to estimate someone’s percentage of body fat. You may be a candidate for weight loss surgery if you have:

• A BMI of 40 or higher
• At least one obesity-related medical condition such as Type II diabetes
• Participated in at least six consecutive months of supervised weight-loss attempts

Depending on the severity of the obesity-related illness, some people with lower BMI may be eligible for weight loss surgery.

According to Jeff W. Allen, M.D., medical director of bariatric surgery with Norton Weight Management Services, there are also some less concrete criteria for patients to be ideal candidates for weight loss surgery.

“Patients who understand that surgery is a tool, not the only answer [to a weight loss issue], do much better,” Dr. Allen said.

Motivation to do the work at home in terms of eating well and moving their body is just as important as having the required BMI, if not more so, according to Dr. Allen.

Preparing for weight loss surgery

Your medical team will develop a treatment plan for you that may include:

• Weight loss: Losing even a small amount of weight before surgery can lower risks of complications and reduce fat around the liver, which helps the surgeon reach the stomach more easily.
• Smoking cessation: Smoking increases risk of post-surgical complications. You will be asked to stop smoking before weight loss surgery, or asked to join a program to help you quit.
• Behavioral modification: Therapy can help treat eating disorders or other mental health conditions. You may address your self-esteem around body issues or learn new healthy coping skills.
• Nutrition plan: The dietician will guide your meal planning to ensure you get adequate nutrition before and after weight loss surgery. You may need supplements or other support.
• Exercise: A specialist can help you create an exercise plan, set goals and more.
• Liver-shrinking diet: You might be asked to eat a specific diet meant to reduce the size of your liver. If the liver is too large, it is difficult for the surgeon too reach the stomach laparoscopically, which can cause other complications as well.

Types of bariatric surgery

“Patients ask for ‘the best surgery,’ and to that I say, there are several good surgeries we do right now. It really depends on the patient,” Dr. Allen said. “We use these procedures for different people with different situations.”

There are three main types of bariatric surgery:

1. Gastric bypass: During this procedure, the surgeon cuts most of the stomach out and connects the remaining egg-sized pouch to the small intestine. Food goes directly into the small intestine. Not only is the amount of food restricted, but the food eaten is not all absorbed.
2. Gastric banding: A surgeon places an adjustable silicone tube around the top of the stomach, limiting the amount of food the stomach can hold. The band can be adjusted by adding or removing saline in the tube.
3. Sleeve gastrectomy: This procedure removes 80% to 85% of the stomach, creating a banana-shaped pouch. This reduces the amount of food the stomach can hold.

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“I was an active teenager, so it had never been a problem,” Ashley said.

She remained active through college, but after a torn knee ligament put an end to that and she got pregnant in 2008, her weight crept up.

A startling realization

Through her 20s, Ashley tried a few diets and various workout programs.

“I did a boot camp, and I remember one of the other participants being concerned for me because I struggled so hard,” she said.

She walked outside after that, because group workouts felt embarrassing. Ashley did several popular diets, including keto.

“I would lose a few pounds, maybe 10, and then think, ‘Oh wow, now I can go eat McDonald’s,’” she said.

The yo-yo dieting and intermittent activity continued halfheartedly until 2017, when two events had her making some serious changes.

“I went to Kentucky Kingdom with my daughter. I was too big to get on a ride,” she said. “I had to get off the ride, and I was mortified.”

Later that summer, the scale at the doctor’s office showed her weight as 278 pounds. At 5 feet, 6 inches tall, it put her body mass index (BMI) at over 40.

“I knew I had to do something,” she said.

Choosing weight loss surgery

The first step was a free weight loss seminar.

“I had already committed to doing something, and I knew it had to be permanent,” Ashley said. “Doing it all on my own, relying on willpower, it wasn’t working.”

She met with Benjamin D. Tanner, M.D., bariatric surgeon with Norton Weight Management Services.

“I was leaning toward the gastric sleeve, rather than the lap band, because it was going to be permanent,” Ashley said.

The hard part of gastric sleeve surgery

“Surgery was the easy part,” Ashley said. “There were a lot of tears after, until I got used to how things were. Knowing what might happen and actually experiencing it is different.”

Her procedure was in November, so the holidays were difficult.

“Everyone is eating cookies and turkey, and I’m having a little piece of ham and some green beans and I’m full,” she said.

There have been ups and downs over the last four years. Down times include severe hair loss and gallbladder surgery, both related to weight loss surgery. Her lowest weight was 136 pounds, but it felt unhealthy. Before surgery, Ashley recalls being fat shamed, but her new slim figure led to a different kind of shaming. “People would say, ‘You’re too skinny, you need to eat,’” she said.

Feeling and looking her best

Ashley has gotten back into activity, including running and spin classes. Her relationship with food also drastically improved.

“I don’t eat sugar; I don’t drink soda. I eat as clean and colorful as possible,” she said.

She also doesn’t restrict.

“I eat bread. I eat pasta. I can eat those things in moderation,” she said.

From 278 pounds, Ashley has lost about half of that.

“Women’s bodies fluctuate all the time, but I’m pretty consistently around 150,” she said. “I would recommend weight loss surgery to anyone who’s thinking about it.” These days, she sees her surgery this way: “Bariatric surgery gets you started, and your mindset is what keeps you going. Weight loss surgery is not something you should be ashamed of if it gives you a tool to improve your life.”

Bariatric Surgery Seminar

Led by a board-certified bariatric surgeon, this hourlong educational session includes:

• An overview of the benefits, risks and expected results of each procedure
• Detailed information on the types of surgical solutions we offer
• Details on what to expect, from preoperative preparation through ongoing follow-up care
• Qualifications for surgery and help to determine if you’re a candidate

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What to eat before and after bariatric surgery

Pre-surgery diet

Before bariatric surgery, your doctor might ask you to eat in a specific way to lose some weight — anywhere from 5 pounds to a percentage of your body weight, depending on how heavy you are.

“We want to give you the best shot at success,” said Benjamin D. Tanner, M.D., general and bariatric surgeon with Norton Weight Management Services. “This type of diet before is close to what patients will be consuming after surgery in order to ensure lifelong success anyway, so starting it before surgery only helps develop habits that can continue after surgery.”

Phase 1

For the first few weeks after surgery, you will be on a liquid diet. Fluids such as broth, water and sugar-free Popsicles or gelatin to start with, then after 24 hours, you can add in protein shakes. This continues for about two weeks.

Phase 2

At two weeks post-surgery, you will introduce soft foods including purees, hummus, scrambled eggs and finely chopped meats such as chicken. You still will supplement with protein shakes, and aim to get protein and other nutrients from food as much as possible. At five to six weeks post-surgery, you will slowly integrate tougher textures such as soft fruit and cooked soft vegetables, as well as some grains. This phase lasts through week four.

Phase 3

At five weeks after bariatric surgery, you will be able to eat what will become your “regular” diet. You still will emphasize protein at each meal, include vegetables and supplement as needed.

“There are some foods you might need to reduce or eliminate, based on how your body responds to them,” Dr. Tanner said. “Those include carbonated drinks, spicy food and caffeine. High-sugar and highly processed foods will be greatly reduced as well.”

At this point, you will be able to recognize when you feel full after eating. It will be different from before surgery, and even from the first two phases.

Complications after bariatric surgery

Many patients report experiencing at least mild symptoms of one or more of the following after bariatric surgery.

• Dumping syndrome: Though uncommon, dumping syndrome is when the stomach empties food into the small intestine faster than normal, causing symptoms such as nausea, abdominal cramping and diarrhea. It is caused by eating too much sugar.
• Constipation: Decreased or lack of physical activity, lack of fiber and dehydration contribute to constipation.
• Dehydration: Hydration changes drastically after bariatric surgery. You should not drink fluids with meals and instead should consume about 64 ounces (about 1.9 liters) of mostly water throughout the day.
• Weight gain or failure to lose weight: If you gain weight or don’t lose any weight, talk to your doctor.

“The most successful patients have a combination of tools,” Dr. Tanner said. “They follow the nutrition plan, they pay attention to their bodies’ hunger and satiety [fullness] cues and they have the right mindset. If you haven’t done the mental work, it’s going to be much harder for you.”

Dr. Tanner encourages bariatric surgery patients to have a solid emotional and social support system, as well as a change in their lifestyle to include more activity.

Norton Weight Management Services is recognized for superior care by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery. Norton Women’s & Children’s Hospital is designated as a Blue Distinction Center+ by Anthem for expertise and efficiency in bariatric surgery. These designations may be a requirement of your health insurance plan.

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Does insurance cover weight loss surgery?

Many insurance plans do cover bariatric surgery, but there are variations in that coverage. Insurance coverage also may be affected by a facility or program’s accreditation by a recognized institution. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is just such an institution. According to its website, MBSAQIP accredits inpatient and outpatient weight loss surgery centers in the U.S. and Canada that have undergone an independent, voluntary, and rigorous peer evaluation in accordance with nationally recognized bariatric surgical standards. This accreditation not only promotes uniform standard benchmarks, but also supports continuous quality improvement. Norton Weight Management has recently received this accreditation.

“Once you decide to undergo a bariatric [weight loss] procedure, you have time to do research on insurance coverage, because you’ll be preparing your body for surgery,” said Meredith C. Sweeney, M.D., a general, bariatric and laparoscopic surgeon with Norton Surgical Specialists. Dr. Sweeney sees weight loss surgery patients at Norton Weight Management Services.

If your insurance covers weight loss surgery, you can begin looking for a facility and surgeon. Most programs offer free seminars for weight loss procedure candidates. If your health insurance policy doesn’t cover weight loss surgery, you can look into financing the procedure.

Bariatric surgery seminars

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Wegovy and Ozempic are brand names for semaglutide. Ozempic was approved in 2017 for medical use in the treatment of diabetes. In 2021, Wegovy was approved for use in weight management. It’s the same drug, so what’s the difference?

Wegovy vs. Ozempic

Semaglutide initially was developed to treat Type 2 diabetes in adults and marketed under the brand name Ozempic. Used along with diet and exercise, the drug improves glycemic control in adults with Type 2 diabetes. The injectable form of semaglutide is given once a week and can be administered at home by the patient with an injection pen, similar to an EpiPen.

“Researchers began to see other effects of the drug, such as reduced hunger and cravings and weight loss,” said Kelley M. McIntyre, M.D., internal medicine physician with Norton Weight Management Services.

In 2021, the U.S, Food and Drug Administration approved semaglutide to be used for weight loss. It is marketed under the brand name Wegovy.

What’s the difference between Wegovy and Ozempic?

Wegovy is specifically indicated for the treatment of overweight and obesity. Ozempic is indicated for the treatment of Type 2 diabetes. Both have been shown to be safe and effective for weight loss when used in combination with lifestyle changes (including healthy food choices and exercise). Most insurance companies will cover Ozempic only for a Type 2 diabetes diagnosis.

“It boils down to the dosage,” Dr. McIntyre said. “Wegovy is available in slightly higher doses: 0.25 milligram (mg), 0.5 mg, 1.0 mg, 1.7 mg and 2.4 mg pens. Ozempic is available in 0.25 mg, 0.5 mg,1.0 mg and 2.0 mg pens.” 

Both medications typically are started at the same 0.25 mg weekly dose and then gradually increased over the course of several months. With Wegovy, patients ramp up to a higher sustained dose of semaglutide of 2.4 mg per week. 

Who should take Wegovy and Ozempic?

You might be a candidate for Wegovy if you meet these criteria:

• Your BMI (body mass index) categorizes you as obese (greater than or equal to BMI 30) or overweight (greater than or equal to BMI 27).
• You have certain weight-related medical conditions, such as Type 2 diabetes, hypertension (high blood pressure) or high cholesterol.

The drug is to be used for long-term weight management in conjunction with a reduced-calorie meal plan and increased physical activity.

You might be a candidate for Ozempic if you meet these criteria:

• You have Type 2 diabetes.
• Your A1C level is uncontrolled with other interventions.
• You have cardiovascular disease or are at a high risk of developing cardiovascular disease.
• You have kidney disease or heart failure.

“These are revolutionary drugs, and your doctor can help you decide the best way to use them,” Dr. McIntyre said.

It is important to remember that your health care provider may not know your insurance coverage for these medications. Unfortunately, coverage for Wegovy is dependent on the employer or insurance plan, and many patients do not have coverage. These medications have high out-of-pocket costs. Patients should check with their insurance company to learn more about their coverage. 

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Cancer and weight

Although researchers don’t know exactly why, cancer risk rises in proportion with higher body weight. Being overweight or obese can lead to more inflammation and increased levels of insulin, growth factor and sex hormones.

“We don’t understand it fully, but hormones play a role in the development of various cancers,” said Jeff W. Allen, M.D., a bariatric surgeon with Norton Surgical Specialists and Norton Weight Management Services.

Weight loss reduces cancer risks

The study published in the American Medical Association’s journal looked at more than 30,000 American adults for about 10 years. For those who had WLS, their risk of developing cancer decreased by 32%, and their chances of dying from it decreased by 48 %, compared with  those who did not have WLS. The study found that the more weight people lost, the greater reduction in cancer risk.

“This study is significant, in terms of its scope and results,” Dr. Allen said. “There is a good chance that any weight loss will result in lower cancer instances, including weight loss through medication or lifestyle modification.”

It is important to remember that being overweight does not automatically mean you will develop cancer, just that research shows a high correlation between the two. Correlation means there is a connection between two variables — such as the connection between weight and cancer.

What’s next?

“Obviously, more research will need to be conducted,” Dr. Allen said. “But this is an important step in understanding the relationship between weight and cancer.”

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Dieting, trying to stay the same weight or losing weight in the second or third trimester of your pregnancy can deprive your baby of nutrients needed to grow and develop. Obesity or being overweight during pregnancy can lead to high blood pressure, preeclampsia and issues with blood clotting, as well as gestational diabetes and other complications.

“The best way to have a healthy pregnancy is to optimize your health prior to pregnancy,

including achieving a healthy weight,” said Kara B. Knapp, M.D., an OB/GYN with Norton Women’s Care. “It generally is not recommended to ‘diet’ or attempt to lose weight during pregnancy, because it could keep the fetus from getting essential nutrients.”

Weight gain recommendations during pregnancy

Source: Centers for Disease Control and Prevention.

Being overweight or obese can make conception more difficult, interfere with ultrasound testing and make it more difficult to monitor the baby’s heart.

Complications of being overweight during pregnancy

Preeclampsia – This condition is becoming more common, increasing 25% over the last two decades. Preeclampsia symptoms usually occur after the 20th week of pregnancy up until your due date and can up until six weeks postpartum.

Preeclampsia can range from an elevation in blood pressure up to maternal seizures called eclampsia.

Gestational diabetes – If the body is not able to make and use all the insulin it needs for pregnancy, glucose cannot leave the blood and provide energy. As glucose builds up, the result is gestational diabetes.

Pregnant patients with gestational diabetes are more likely to develop Type 2 diabetes later in life, and high blood sugar can cause rapid fetus growth and delivery complications.

How to not gain too much weight during pregnancy

• Early in your pregnancy, talk to your obstetrician about how much weight you should gain. If possible, work with your obstetrician before you’re pregnant to determine how best to get your body ready for a baby.
• Stay away from high-calorie snacks and empty calories such as chips and candy. Focus instead on healthier foods, including vegetables.
• Monitor your weight gain and make adjustments to your eating habits throughout your pregnancy.
• Continue to exercise to keep your entire body healthy and strong. Talk to your doctor about safe exercise, especially after the 12th week of pregnancy.

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New weight loss drug is a game-changer

Wegovy is injected once a week under the skin, with the dosage increasing every four weeks until it reaches 2.4 milligrams per week. Participants in a study had Wegovy injections for 68 weeks and lost an average of 15% to 18% of their body weight. The average for weight loss drugs already on the market is 7% to 9%.

“No other weight loss drugs have been able to achieve these results, which are comparable to bariatric surgery,” said Kelley M. McIntyre, M.D., an internal medicine physician and medical weight management specialist at Norton Weight Management Services.

The science of semaglutide

Semaglutide is similar to a hormone naturally occurring in the body that regulates your appetite. It also increases insulin release, which is why the drug has been used in lower doses to treat diabetes. But higher doses act on the brain to suppress appetite. Patients on Wegovy felt full sooner when eating and therefore lost weight as their calorie intake decreased.

“One of the benefits of Wegovy would be that it is effective for a wide variety of patients,” Dr. McIntyre said. “It can be used for adults who are not pregnant.”

Getting the most from Wegovy

Although this medication shows promising results, Dr. McIntyre cautioned patients not to rely on the drug alone to do all the work of losing weight.

“Wegovy is a great tool in a weight loss toolbox, but you have to eat a lower-calorie diet and get regular exercise to really maximize the benefits of the drug,” Dr. McIntyre said.

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