Some thoughts on the sidelines of an article, appearing in the journal Circulation, regarding the ranking of heart-healthy diets according to the American Heart Association.The researchers selected ten pivotal elements related to heart wellness, assigning scores from 0 to 100 for each diet considered. According to the rankings, there would be four most valuable approaches: Dash, Mediterranean diet and vegetarian model on the podium, then come vegan and low-fat diets that can cause vitamin B-12 deficiency, causing red blood cell abnormalities or anemia. Low-carb and low-fat diets follow with a lower score; these, too, can cause deficiencies in vitamin B-12, essential fatty acids, and protein, leading to anemia and muscle weakness. On the subject of carbohydrate consumption, remember that our lifestyle pattern is unfortunately sedentary in most cases and we do not need large amounts of “fuel” like a farmer in the 1950s.The least recommended dietary regimens for heart health, with scores below 55, finally include paleo and ketogenic diets, which are characterized by very low carbohydrate and sugar content and disproportionate protein intake. A small aside: very often television broadcasts with supposed experts or articles even in scientific journals pontificate about ketogenic diets, but, for me as an expert in the field, what emerges is an almost always superficial and distorted knowledge of the topic in question. Before we get into the issue, let’s start with a question: why does the world’s leading country, the U.S., despite having the world’s highest per capita health care expenditure, not have the world’s highest life expectancy? We analyze what emerges from a research conducted by the U.S. health network NiceRx, which analyzed various data from OECD (Organization for Economic Cooperation and Development) countries including precisely the longevity of their inhabitants.

Average life expectancy

Hong Kong 85.29 (males 82.38 females 88.17)

Japan almost 85.03 (males 81.91 females 88.09)

Switzerland 84.25 (males 82.42 females 86.02)

Singapore 84.07 (males 82.06 females 86.15)

Italy 84.01 (males 81.90 females 85.97 )

This is followed by Spain, Australia, Iceland, South Korea, Israel, Sweden, France, etc.

The U.S. occupies 32nd place with 79.11 (males 76.61 females 81.65 )

Health expenditure per capita

1 U.S. $12,318

2 Germany $7,383

This is followed by Switzerland, Norway, Austria, Denmark, Sweden, Holland, Canada, Ireland, and Australia.

Italy ranks 20th with a per capita health expenditure of $4038.

In the case of the U.S., the cause of this admittedly unexciting result cannot be sought in genetics because they have always been a melting pot. Complex phenomena never have a simple explanation, but there is one very important fact to evaluate.

Obesity rate

1 US 38.2%

2 Mexico 32.4%

3 New Zealand 30.7

Most virtuous countries

1 Japan 3.7%

2 Korea 5.3%

3 Italy 9.8%

The numbers are clear: the U.S. has been hit very hard by what WHO calls globesity i.e., the “global obesity epidemic,” and the trend is for further worsening; over a 20-year period, severe obesity has increased from 4.7 percent to 9.2 percent. Let us now return to the critical remarks made about ketogenic treatment. First major error: it is absolutely not true that a ketogenic diet is necessarily based on inordinate protein intake. If one relies on a serious nutrition professional trained on the ketogenic protocol, the amount of protein will be calibrated to individual needs and such that it is sufficient to preserve muscle mass and related basal metabolism. Another very serious mistake. An ‘accusation that is often levelled at ketogenic treatments is that they involve the intake of excessive amounts of saturated fat. A properly structured ketogenic protocol does not involve excessive consumption of saturated fat because it is based on the disposal of localized adiposity. Even the American Heart Association has an obligation to document itself before giving report cards. Ketogenic treatment has been under study in research centers and universities around the world since the 1970s when Harvard professor George L. Blackburn for his doctorate treated hundreds of patients with this dietary regimen. Way back in 1992, I and the other members of the research team I had formed approached the world of dietetics precisely on the input of Prof. Blackburn’s theories and his insight into sending the patient into ketosis (which occurs when the body, in order to meet its energy needs, exhausted sugars, burns fat) resulting in weight loss. We, taking up this idea, after a series of trials at Avellino Hospital that confirmed our hypotheses, developed a protocol for Europe, disrupting the world of nutrition. Official science considered ketosis a disease while overweight and obesity were becoming an epidemic. It was not until many years later that universities also began to take an interest in this treatment, and the research opportunities of university laboratories enabled the mechanisms by which ketosis works to be better elucidated. Our research group has done pioneering work, and I am proud to have helped to spread in Italy a safe slimming protocol with a high success rate if followed correctly. To speak generically about ketogenic diet referring only to Dukan and Atkins is incorrect: there are normoprotein ketogenic protocols that, while avoiding excessive consumption of saturated fats, include high intake of low-inflammatory fats such as linoleic acid (contained, for example, in large amounts in extra virgin olive oil, which is recommended to be used abundantly, especially raw, to season vegetables, fish, meat) and intake/supplementation of omega 3. The nutritional difference between the various ketogenic diets lies precisely in the choice of fats. In some cases, the use of a tube may also be useful for the purposes of amMino acid treatment. We know well by now, and even the U.S. Center for Disease Control confirms it: obesity-related conditions include heart disease, stroke, type 2 diabetes, and some cancers, and now we better understand the relationship between obesity and autoimmune diseases. In 2019, the estimated annual medical cost of obesity in the United States was nearly $173 billion. Originating as an emergency response (just think of its usefulness before bariatric surgeries and before surgeries in general for obese people for anesthesia purposes), it has been shown that amino acid treatment can be well tolerated by the body even for long periods and ensure adequate nutrition. We know that properly set ketogenic treatment is very effective against inflammation. Overweight and even worse obesity is a major risk factor for the development of many chronic and degenerative diseases: cardiovascular, metabolic, and central nervous system degeneration. Adipose tissue is not just the “flab,” it is also a source of hormones that can affect certain types of cancers such as breast cancer and contains many immune system cells. In short, getting rid of localized adiposity is crucial for our health even before our aesthetic appearance. Ketogenic treatment makes it possible to “attack” not only subcutaneous fat, but also abdominal fat with reduced levels of inflammation and consequent risks. Aging also involves an inflammatory response that is why the English term inflammaging is used, a crasi between the words inflammation and aging i.e., inflammatory aging. To Claudio Franceschi, a world-renowned immunologist and professor emeritus of the University “Alma Mater Studiorum” of Bologna, we owe the discovery in the 1990s of the presence of a state of chronic low-grade inflammation that characterizes the elderly, so in 2000 he identified this process as one of the fundamental biological mechanisms of human aging, calling it “inflammaging.”

In conclusion, before talking about ketogenic treatments, it is necessary to study and document even from prestigious institutions such as the American Heart Association because protocols are not all the same. And then, in the face of globesity and its health risks, is it intellectually honest to give up a method that promotes safe, physiological, and rapid weight loss such as amino acid treatment?

Prof. Mario Marchetti