Benlloch, María

Carrera, Sandra

Cerón Madrigal, José Joaquín

Chirivella, Javier

Cuerda Ballester, María

de la Rubia Ortí, Jose Enrique

Drehmer, Eraci

Fernández García, David

López Rodríguez, María Del Mar

Tvarijonaviciute, Asta

Nutrients

English

Repositorio Institucional de la Universidad de Almería

Reply to “When Is a Ketogenic Diet Ketogenic? Comment on Satiating Effect of a Ketogenic Diet and Its Impact on Muscle Improvement and Oxidation State in Multiple Sclerosis Patients. Nutrients 2019, 11, 1156”

Repositorio Institucional de la Universidad de Almería (Spain)

nutrientsReplyReply to “When Is a Ketogenic Diet Ketogenic?Comment on Satiating Effect of a Ketogenic Diet andIts Impact on Muscle Improvement and OxidationState in Multiple Sclerosis Patients. Nutrients 2019,11, 1156”María Benlloch 1, María Mar López-Rodríguez 2,* , María Cuerda-Ballester 1, Eraci Drehmer 3,Sandra Carrera 4, Jose Joaquin Ceron 5, Asta Tvarijonaviciute 5, Javier Chirivella 6 ,David Fernández-García 1 and Jose Enrique de la Rubia Ortí 11 Department of Nursing, Catholic University San Vicente Mártir, 46001 Valencia, Spain2 Department of Nursing, University of Almería, 04120 Almería, Spain3 Department of Physical Activity and Sports Sciences, Catholic University San Vicente Mártir,46001 Valencia, Spain4 Department of Health Sciences, Catholic University San Vicente Mártir, 46001 Valencia, Spain5 Interdisciplinary Laboratory of Clinical Analysis, Campus of Excellence Mare Nostrum,University of Murcia, 30100 Murcia, Spain6 Fundación FIVAN, 46005 Valencia, Spain* Correspondence: mlr295@ual.es; Tel.: +34-950-015374Received: 15 July 2019; Accepted: 18 July 2019; Published: 15 August 2019In response to the questions raised in the comment to the editor of R.J. Klement [1], the authors of“Satiating Effect of a Ketogenic Diet and Its Impact on Muscle Improvement and Oxidation State inMultiple Sclerosis Patients” [2] would like to list the following aspects.1. As Dr. Klement indicates, the diet prescribed to the patients in this study does not fit thedefinition of “ketogenic diet” as such, since it is characterized by a total carbohydrateintake of lessthan50 g per day and a moderateproteinintake of approximately 1.5 g per day per kg of referenceweight [3,4].Therefore, we agree that it would be more correct to change the title to “Satiating Effect of CoconutOil-Enriched Mediterranean Diet and Its Impact on Muscle Improvement and Oxidation State inMultiple Sclerosis Patients”.2. Our goal was to administer coconut oilinthe diet as the main source of fat, since it is asubstance that presents a large amount of medium-chain fatty acids (MCFAs), which are absorbedand metabolized more quickly and efficiently than long-chain fatty acids (LCFAs) [5]. Furthermore, aspreviously stated, through the administration of this oil, a ketogenic state is produced with respect tothe beginning of the study, asthe ketones representan alternative brain fuel to glucose [6]. Moreover,it has been shown that the intake of coconut oil may improve brain health by directly activatingketogenesis in astrocytes and, thereby by providing fuel to neighboring neurons [7]. This fact meansthat, regardless of the ketone values in blood, coconut oil is the best alternative in order to reach thisbrain ketogenesis, with enormous resulting potential benefits in neurodegenerative diseases in general,and in MS in particular in neurodegenerative diseases in general, and in Multiple Sclerosis (MS) inparticular. In addition, our amounts of coconut oil were very high (60 mL/day divided into two 30 mLdoses), so we believe that our results are not comparable to those in the reference indicated by Dr.Klement, where 20 mL were administered daily.It should also be taken into account that our main objective was to see the improvements achievedwith our diet, comparing the variables measured in the study before and 4 months after the intervention.Nutrients 2019, 11, 1919; doi:10.3390/nu11081919 www.mdpi.com/journal/nutrientsNutrients 2019, 11, 1919 2 of 3For this, although ketone bodies were not measured postprandially, we were already able to seesignificant differences in ketone bodies before and after the intervention, which correlated with thesignificant change in satiation (expected with the elevation of ketone bodies in blood). This fact,together with the significant anthropometric improvements, suggests that the diet could be consideredthat have positive effects for these patients, and that it fulfilled the objectives of the study.3. As Dr. Klement indicated, the patients were advised to eat five meals a day. This way ofproviding the nutrients is healthier in this type of patients, since, after analyzing their eating habits,it was determined that most of them ate in a disorganized way and had only a few meals, whichwere typically based mainly on simple carbohydrates. This is the reason why, despite the five dailymeals, it was possible to significantly increase the concentration of ketone bodies in the blood, thusimproving satiation.4. We believe that a fasting increase of almost double the blood concentration of the ketone bodybeta-hydroxybutyrate (BHB) indicates ketogenesis with respect to the same group before changingtheir diet. In addition, the fact that BHB was measured on an empty stomach, despite having beenmeasured after a meal in other studies, suggests that these levels were comparatively much higherthroughout the day than before the patients received the treatment. This indicates that there was asustained (and therefore more effective) elevated level of BHB, which allowed the aforementionedimprovements to be achieved in the patients.On the other hand, responding to the comment regarding transporters, in Figure 1. A we indicatedthat MCT1 and MCT4 are ketone body transporters, based on the publications of Hernández et al. [8,9].Finally, we appreciate the information related to the “Spanish Ketogenic Mediterranean Diet” andwe will take it into account for future studies, asit is highly interesting. However, we consider that thetype of prescribed diet does not fit into the characteristics of the diet in this study, since our main sourceof fat (as previously discussed) was coconut oil, whereas in the “Spanish Ketogenic MediterraneanDiet” it is olive oil [6].After reviewing your contributions, we would like to sincerely thank you for all the informationand opinions you provided. We appreciate this opportunity to improve of our methodology for futurestudies, and thus be able to better contribute to scientific knowledge.Conflicts of Interest: All the authors declare no conflicts of interest.References1. Klement, R.J. When is a Ketogenic Diet Ketogenic? Comment on “Satiating Effect of a Ketogenic Diet and ItsImpact on Muscle Improvement and Oxidation State in Multiple Sclerosis Patients. Nutrients 2019, 11, 1156”.Nutrients 2019, 11, 1909. [CrossRef]2. Benlloch, M.; López-Rodríguez, M.M.; Cuerda-Ballester, M.; Drehmer, E.; Carrera, S.; Ceron, J.J.;Tvarijonaviciute, A.; Chirivella, J.; Fernández-García, D.; de la RubiaOrtí, J.E. Satiating Effect of a KetogenicDiet and Its Impact on Muscle Improvement and Oxidation State in Multiple Sclerosis Patients. Nutrients2019, 11, 1156. [CrossRef] [PubMed]3. Gibson, A.; Seimon, R.; Lee, C.; Ayre, J.; Franklin, J.; Markovic, T.; Caterson, I.D.; Sainsbury, A. Do ketogenicdiets really suppress appetite? A systematic review and metaanalysis. Obes. Rev. 2015, 16, 64–76. [CrossRef][PubMed]4. Volek, J.S.; Phinney, S.D. The Art and Science of Low Carbohydrate Living, Beyond Obesity; LLC: Miami, FL,USA, 2011.5. Gallagher, M.L. Intake: The Nutrients and Their Metabolism. In Krause’s Food and the Nutrition Care Process;Mahan, L.K., Escott-Stump, S., Raymond, J.L., Eds.; Elsevier: St. Louis, MO, USA, 2012.6. Pérez-Guisado, J.; Muñoz-Serrano, A.; Alonso-Moraga, Á. Spanish Ketogenic Mediterranean diet: A healthycardiovascular diet for weight loss. Nutr. J. 2008, 7, 30. [CrossRef]7. Nonaka, Y.; Takagi, T.; Inai, M.; Nishimura, S.; Urashima, S.; Honda, K.; Aoyama, T.; Terada, S. Lauric AcidStimulates Ketone Body Production in the KT-5 Astrocyte Cell Line. J. Oleo Sci. 2016, 65, 693–699. [CrossRef][PubMed]Nutrients 2019, 11, 1919 3 of 38. Hernandez, A.R.; Campos, K.T.; Truckenbrod, L.M.; Sakarya, Y.; McQuail, J.A.; Carter, C.S.; Bizon, J.L.;Maurer, A.P.; Burke, S.N. The Antiepileptic Ketogenic Diet Alters Hippocampal Transporter Levels andReduces Adiposity in Aged Rats. J. Gerontol. Ser. A Boil. Sci. Med. Sci. 2017, 73, 450–458. [CrossRef][PubMed]9. Hernandez, A.R.; Hernandez, C.M.; Campos, K.; Truckenbrod, L.; Federico, Q.; Moon, B.; McQuail, J.A.;Maurer, A.P.; Bizon, J.L.; Burke, S.N. A Ketogenic Diet Improves Cognition and Has Biochemical Effects inPrefrontal Cortex That Are Dissociable from Hippocampus. Front. Aging Neurosci. 2018, 10, 391. [CrossRef][PubMed]© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open accessarticle distributed under the terms and conditions of the Creative Commons Attribution(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

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Reply to “When Is a Ketogenic Diet Ketogenic? Comment on Satiating Effect of a Ketogenic Diet and Its Impact on Muscle Improvement and Oxidation State in Multiple Sclerosis Patients. Nutrients 2019, 11, 1156”

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