Potential benefits of a ketogenic diet to improve response and recovery from physical exertion in ME/CFS, 2020, Cossington et al

[Tom Kindlon]

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International Journal of Sport, Exercise and Health Research 2019; 3(2): 33-39

IJSEHR 2019; 3(2): 33-39
© 2019, All rights reserved
www.sportscienceresearch.com
Received: 02-10-2019
Accepted: 28-11-2019

Potential benefits of a ketogenic diet to improve response and recovery from physical exertion in people with Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): A feasibility study

Jo Cossington1, Dr. Shelly Coe2, Yaomeng Liu3, Helen Dawes4

1 B.Sc, Department of Sport, Health Sciences and Social Work, Centre for Movement Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK
2 PhD, Department of Sport, Health Sciences and Social Work, Centre for Movement Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK
3 M.Sc., Department of Sport, Health Sciences and Social Work, Centre for Movement Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK
4 Professor, Department of Sport, Health Sciences and Social Work, Centre for Movement Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK

Abstract

Background:

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) affects approximately 250,000 people in the UK. The condition varies in severity causing long-term physical and cognitive fatigue which is not alleviated by rest. Whilst the pathology is not understood, recent evidence suggests metabolic abnormalities may be associated with the manifestation of symptoms, particularly involving the metabolism of glucose and energy production. The use of ketone bodies as an alternative energy substrate may be beneficial to people with ME/CFS, in order to by-pass the glycolytic pathway, enhance energy production and reduce fatiguing outcomes.

Study Design and Methods:

Using a pragmatic collective case study with repeated measures methodology we investigated the feasibility of following a ketogenic diet and potential effects of the high fat, low carbohydrate diet on response to physical activity in people with ME/CFS (n=3) and healthy controls (n=3) using a submaximal exercise stress test both with and without dietary intervention. Exercise tolerance (mins), rate of oxygen consumption (VO2) to workload (75W), respiratory exchange ratio (RER), rate of perceived effort (RPE) and lactate response were measured throughout and descriptive statistics performed.

Results:

We found that the ketogenic diet was followed, with compliance higher in the pwME/CFS. Variations in response following the ketogenic diet was observed across individuals in minutes performed, VO2, HR, RER, and RPE post diet but the KD only limited exercise capacity in the control individuals. Individuals responded differently to the KD but group trends have been reported as means and standard deviation. The KD resulted in a decrease in RER at submax in the controls with a mean change of 0.07 from baseline (0.86 ± 0.1) to post intervention (0.79 ± 0.1) compared to a mean change of 0.02 in the ME/CFS from baseline (1.03 ± 0.1) to post intervention (1.01 ± 0.1). A decrease in VO2 (L/min) at submax showed a mean change of 0.06 (L/min) in the pwME/CFS at baseline (1.34 ± 0.1) to post intervention (1.27 ± 0.2) compared to a mean change of 0.07 (L/min) in the controls at baseline (1.40 ± 0.3) to post intervention (1.33 ± 0.2). HR (bpm) at submax decreased in all individuals, with a mean change of 4 (bpm), with pwME/CFS at baseline (139 ± 8.2) to post intervention (135 ± 14) and control individuals at baseline (107 ± 7.8) to intervention (103 ± 3.2). RPE at submax decreased in the pwME/CFS from baseline (6 ± 1.0) to post intervention (5 ± 2.1) whereas the controls increased from baseline (2 ± 1.0) to post intervention (3 ± 1.5).

Conclusion: Our observations suggest individualised but metabolic flexibility in healthy individuals is achievable via dietary manipulation showing the ability to switch from glucose to fats under controlled conditions. The different response in substrate utilisation in individuals with ME/CFS suggests that potential metabolic abnormalities may be present in ME/CFS. Further investigation is now warranted in order to assess whether the KD is beneficial for people with ME/CFS.

Keywords: Myalgic Encephalomyelitis, Chronic Fatigue Syndrome, Ketogenic Diet, Diet, Energy Metabolism, Fatigue.

 

[Tom Kindlon]

In case anyone wants to share it:

 

[Hutan]

I'm glad that they are looking at this; it would be good to know if the ketogenic diet helps, and we need more teams looking at exercise physiology.

I'd have to read this paper a lot more carefully to understand it. But, I like

• that the group has done a genuine feasibility study to work out their protocol for a larger study.
• they use the term ME/CFS and the introduction acknowledges the impact of the disease
• that Jo Cossington got funding from the Nutrition Society Summer Studentship and may well be interested enough to do more studies of ME/CFS physiology
• that there's obvious care for the participants
• that a professor, Professor Helen Dawes, appears to have taken an active part in the research

I don't think we can conclude much from such a small pilot study (PwME/CFS n=3; control n=3), other than this team has made a decent start.

From the process evaluation it showed the pwME/CFS accepted the diet more so than the controls and were all considering continuing the diet after completion of the study. There was a consensus that the diet had improved their symptoms, generally experiencing less feelings of fatigue, an improvement in energy levels and sustained cognitive ability. Importantly, we observed that the ketone diet normalised the high levels of glycolytic energy production during submaximal exercise activity in individuals with ME/CFS. Our findings suggest that ketone diet may enhance submaximal energy production during everyday activities and the impact of diet should be investigated on cognitive and physical functioning and levels of fatigue.

Can someone explain to me what they mean by the bit in bold? 'Glycolytic' is burning sugar , isn't it? But aren't they saying that the glycolytic pathway is broken?

If glycolytic metabolism is indeed impaired in pwME/CFS the KD may have potentially provided a metabolic shift in substrate utilisation that enabled an increase in physical activity capacity

And I'd like this bit explained too.

In this study, RER values produced by the controls suggest that they were utilising lipids at the 75W work rate in comparison to the pwME/CFS who were utilising carbohydrates at the same comparable work rate (Table 3). These results, alongside the reported hard rate of perceived effort, suggest the pwME/CFS were already working close to high levels of exertion at the 75W time point which agrees with findings by Snell et al. [21] who found pwME/CFS to have higher RER levels compared to healthy controls under similar conditions.

One suggestion:

The 24hr dietary recalls for both the pre and post dietary intervention were analysed using Nutritics© software

They had a nutritionist query each participant about what they ate the day before. I think they'd do better to teach participants how to use a food logging app, and have people record what they eat as they go.

Edited for formatting

 

[Midnattsol]

First of all. more studies using diet as intervention, please! Especially with measurements like these on exercise performance

@Hutan I believe they are refering to glycolysis when they are talking about "glycolytic energy production". In the introduction they mention increased lactate due to glycolysis. But if that's the case, I'm not quite sure what normalization they are talking about. Neither the lactate measurements or RER makes me think anything has been improved.

I'm not sure about the second bit you want explained. What the RER values mean or what RER you would expect at certain levels of exertion? OR something else entirely?

Re the 24h recall, it's one of the easiest ways to get the data fast. Which might have been of importance if there were some deadline that had to be met. I'm not particularly fond of them as they rely on recall and people tend to overestimate healthy foods and underestimate unhealthy foods, in this case high carbohydrate foods (but this would also be the case if partcipants had a food diary, they could just not register something that did not adhere to the diet). I'm glad they checked for this using ketones.

I have some more comments on this, but I have other cognitive tasks to perform today so I can't go into much detail right now, but:
- I would wish for the pwME and controls to be better matched
- In the introduction they say susceptibility to oxidative stress may be a factor in abnormal metabolism in pwME, and then they don't discuss the effects a ketogenic diet can have on this?
- The wash out period seems short, also the time for the body to get used to fat as a primary energy source
- More data on the diet, the calories alone and macronutrients are perhaps fine for showing adherence to a ketogenic diet, but for therapeutic use there are a few things to consider (also, the two controls that had dietary data had reduced their caloric intake by a lot.. while the pwME had increased it)
- Feeling better on a dietary intervention that you believe will make you feel better does not actually mean you are better..

I'm not anti-ketogenic diet per se, I believe they have their uses, but I know they do not work for me and some of the negative effects may hit pwME harder than a healthy person.

 

[Hutan]

But if that's the case, I'm not quite sure what normalization they are talking about. Neither the lactate measurements or RER makes me think anything has been improved.

Yeah, it was this that puzzled me mostly.

I would wish for the pwME and controls to be better matched

I guess they just grabbed people close to hand for this trial run.

The wash out period seems short, also the time for the body to get used to fat as a primary energy source

Yes, I wondered about that. If the ketogenic diet was having an effect on inflammation say, then maybe a longer time might be needed for the full benefits to show? Maybe they intend to have a longer period when they do the actual trial?

More data on the diet

Yes. I wasn't sure if the mild benefits I felt were from the ketogenic diet or the fact that I was eating a hell of a lot of celery and nuts to get the right amount of fibre every day, which I was tracking carefully. It's easy for there to be a lot of noise in the data, with some people in ketosis but eating rubbish, and others eating more whole food than they might have otherwise.

 

[Midnattsol]

I guess they just grabbed people close to hand for this trial run.

Not unlikely. For a summer project there are a lot of limitations.

Yes, I wondered about that. If the ketogenic diet was having an effect on inflammation say, then maybe a longer time might be needed for the full benefits to show? Maybe they intend to have a longer period when they do the actual trial?

Yes. And the same goes for negative effects, like sleep issues. And it could also be closely linked to diet quality, like you say people can be in ketosis and eat rubbish. I'm not sure if there will be a larger study building on this assessment, but it would be interesting.

Yes. I wasn't sure if the mild benefits I felt were from the ketogenic diet or the fact that I was eating a hell of a lot of celery and nuts to get the right amount of fibre every day, which I was tracking carefully. It's easy for there to be a lot of noise in the data, with some people in ketosis but eating rubbish, and others eating more whole food than they might have otherwise.

Exactly. Not everyone thinks about getting enough fibre, I'm happy you did

 

[Jonathan Edwards]

Can someone explain to me what they mean by the bit in bold? 'Glycolytic' is burning sugar , isn't it? But aren't they saying that the glycolytic pathway is broken?

If I remember correctly glycolysis means the oxygen-independent (anaerobic) breakdown of sugars to pyruvate. So it is not actually the 'burning' of sugar of aerobic respiration. I am not sure I can comment more usefully on the lactate results. Snow Leopard tends to be good on this.