Keto Diet May Worsen Coronary Artery Disease: Insights from Bethsaida Hospital’s Plant-Based Diet Experience

The ketogenic (keto) diet, characterized by high fat, moderate protein, and minimal carbohydrate intake, has surged in popularity due to its perceived efficacy in rapid weight loss. Nevertheless, accumulating evidence highlights significant health risks, particularly exacerbating cardiovascular morbidity in patients with Coronary Artery Disease (CAD), mediated primarily through increased Low-Density Lipoprotein (LDL) cholesterol, systemic inflammation, oxidative stress, and endothelial dysfunction. Conversely, Bethsaida Hospital, under the leadership of Prof. Dasaad Mulijono (DM), has adopted an evidence-based Whole-Food Plant-Based Diet (WFPBD) that is deeply embedded within compassionate, holistic patient care, achieving remarkable clinical outcomes. These successes include reversal of hypertension, diabetes control without reliance on insulin, substantial reductions in LDL cholesterol, sustained normalization of body weight, renal function stabilization, notable recovery in heart failure patients, mitigation of chronic inflammation, and remarkably low restenosis rates (~2%) following Drug-Coated Balloon (DCB) angioplasty. This review critically examines the pathophysiological mechanisms underlying keto-induced cardiovascular harm, explores the socio-psychological drivers of its widespread acceptance despite inherent risks, outlines the acute and chronic adverse effects, and robustly contrasts these findings with the proven efficacy and sustainability of plant-based dietary interventions.

CAD continues to be a leading cause of global mortality, with dietary choices significantly influencing disease progression [1-8]. The ketogenic diet, highly publicized for quick weight-loss outcomes, has increasingly attracted individuals despite growing concerns about its long-term cardiovascular risks. The diet's reliance on animal-derived foods, which are rich in saturated fats and cholesterol, raises serious health concerns. In contrast, Bethsaida Hospital has championed a different dietary paradigm-a WFPBD-grounded in scientific evidence and full of compassion. Over nearly seven years, this integrative approach has demonstrated unprecedented clinical outcomes, reversing chronic conditions such as hypertension and diabetes, regressing atherosclerotic plaques, improving heart failure prognosis, and achieving exceptionally low restenosis rates (~ 2%) following DCB angioplasty. This article comprehensively addresses the scientific basis for the cardiovascular dangers associated with the keto diet, critically examines its widespread popularity, describes its adverse effects, and presents Bethsaida Hospital’s successful experience with WFPBD as a superior and sustainable alternative.

Why the keto diet is detrimental to CAD patients

The keto diet's emphasis on high saturated fat and cholesterol intake raises concerns regarding cardiovascular safety. High-fat animal-derived foods, staples in keto plans, increase serum LDL cholesterol, elevate inflammation markers, and worsen endothelial dysfunction-All critical drivers of atherosclerosis. Additionally, keto diets limit fibre-rich vegetables and fruits, which are essential in managing oxidative stress and promoting arterial health.

The detrimental effects of animal products on cardiovascular health include several mechanisms:

• Saturated fats and cholesterol: Animal-derived foods, particularly red meats, dairy, and eggs, are rich in saturated fats and dietary cholesterol. These components significantly elevate plasma LDL cholesterol levels, initiating endothelial dysfunction and foam cell formation, crucial events in atherosclerosis [9,10].
• Obesity, hypertension, and cardiometabolic burden: Animal-based diets promote obesity through their high caloric density and low fiber content, which increases systemic inflammation, insulin resistance, hypertension, and the risk of restenosis [11-13].
• Fibre deficiency and gut dysbiosis: Animal diets often lack fibre, which can impair the production of anti-inflammatory Short-Chain Fatty Acids (SCFAs) such as butyrate and propionate. Reduced fibre disrupts gut microbiota, promoting inflammation and systemic vascular injury [14-18].
• Antioxidant deficiency and oxidative stress: Animal products lack essential antioxidants, leading to elevated Reactive Oxygen Species (ROS), oxidative damage to vascular tissues, endothelial dysfunction, and plaque instability [19-21].
• Nitric Oxide (NO) deficiency: Diets deficient in plant nitrates impair NO synthesis, which is crucial for maintaining vascular tone and endothelial health, and can facilitate restenosis [22-26].
• Production of Trimethylamine-N-oxide (TMAO): Animal proteins generate TMAO, a metabolite strongly linked to endothelial dysfunction, enhanced platelet reactivity, and increased cardiovascular risk [27-31].
• ROS amplification: Thermal processing of animal proteins increases harmful ROS-inducing compounds (Advanced Glycation End products (AGEs) and heterocyclic amines), accelerating endothelial damage and inflammation [32-35].
• Hyperinsulinemia and insulin resistance: A high intake of saturated fats from animal sources can lead to insulin receptor dysfunction, thereby increasing cardiovascular risk [36-40].
• Inflammatory amino acid profiles: The excessive intake of Branched-Chain Amino Acids (BCAAs) and methionine from animal proteins exacerbates inflammation and oxidative stress, thereby contributing to endothelial injury [41-47].
• Elevated IGF-1 levels: Dairy products significantly elevate insulin-Like Growth Factor 1 (IGF-1), stimulating vascular cell proliferation and restenosis post-intervention [48-50].
• AGEs and endothelial damage: Animal products, especially those cooked at high temperatures, produce AGEs, which trigger chronic vascular inflammation and endothelial damage [51-57].
• Gut microbiota disruption by antibiotics: Antibiotic residues in animal foods can disrupt the human gut microbiota, leading to inflammatory metabolic conditions and vascular dysfunction [58-61].
• Heme iron and free radical formation: The heme iron in red meat catalyzes the formation of free radicals, lipid peroxidation, and endothelial injury, significantly accelerating atherosclerosis [62-69].
• Soluble urokinase Plasminogen Activator Receptor (suPAR) and chronic inflammation: Animal protein intake increases suPAR levels, thereby exacerbating chronic inflammatory states associated with poor cardiovascular outcomes [70-74].
• Neu5Gc-induced inflammation: Non-human sialic acid Neu5Gc from animal products triggers chronic inflammation and endothelial damage [75-78].
• Persistent Organic Pollutants (POPs): Toxins from animal adipose tissue promote oxidative stress and inflammatory responses, contributing to vascular injury [79-82].
• Nitrates, nitrites, and carcinogenicity: Processed meats contain harmful nitrites and nitrates, which are converted to carcinogenic nitrosamines, thereby exacerbating inflammation and vascular damage [83-89].
• Mitochondrial dysfunction: Animal-based diets compromise mitochondrial function, leading to decreased ATP production, increased oxidative stress, and impaired vascular repair [90-92].
• Telomere shortening and aging: Diets high in animal fats accelerate telomere shortening, promoting premature cardiovascular disease and restenosis [93-97].
• Systemic acidosis and vascular dysfunction: Acidogenic loads from high-animal-protein diets induce chronic metabolic acidosis, endothelial dysfunction, and vascular calcification, significantly contributing to the development of atherosclerosis and restenosis [98-100].

Reasons behind keto popularity despite health risks

The allure of rapid weight loss and simplified dietary guidelines drives the widespread appeal of the keto diet. Short-term visible results, celebrity endorsements, and compelling social media portrayals overshadow potential long-term cardiovascular harm. Many individuals experience temporary improvements in metabolic parameters following initial weight reduction, which further promotes its adoption despite insufficient evidence of sustained cardiovascular benefits.

Additional factors behind keto's sustained popularity include [101-104]:

• Quick visual results: Rapid initial weight loss, mainly due to water loss, provides immediate visible changes, which are highly motivating for individuals seeking fast results.
• Perceived simplicity: The keto diet simplifies meal planning by emphasizing clear macronutrient guidelines (High fat, moderate protein, and very low carbohydrates), reducing decision fatigue, and making it attractive for those seeking straightforward dietary instructions.
• Celebrity and media Influence: Endorsements by prominent celebrities and influencers promote the keto diet as trendy, desirable, and practical, significantly influencing public perception and acceptance.
• Short-term metabolic benefits: The early stages of the keto diet can temporarily improve blood glucose control, reduce appetite, and lower triglycerides, providing positive reinforcement despite potential long-term adverse effects.
• Cultural trend and social pressure: The keto diet has become culturally fashionable, with widespread online communities and peer-driven support groups amplifying its attractiveness and fostering a sense of belonging.
• Economic and marketing influences: Robust marketing campaigns and profitable keto-related industries, including dietary supplements, meal plans, and cookbooks, further reinforce its popularity.
• Psychological satisfaction: The discipline required by restrictive diets like keto can psychologically gratify individuals, offering a sense of control, accomplishment, and identity.
• Limited public awareness: The potential health risks associated with keto diets, especially long-term cardiovascular harm, are often underrepresented in mainstream discourse, leading to insufficient awareness and underestimation of health consequences.

Collectively, these factors contribute significantly to the keto diet's continued popularity despite clear concerns regarding its sustainability and cardiovascular risks.

Short-term and long-term adverse effects of keto

While the ketogenic diet is widely promoted for quick weight-loss results, it carries significant short-term and long-term adverse effects [102,103-110].

• Short-term effects
• Fatigue and reduced exercise capacity: Initial adaptation to a keto diet, often termed "keto flu," includes fatigue, dizziness, headaches, and reduced physical performance due to decreased glycogen stores and altered metabolic pathways.
• Nutrient deficiencies: Strict carbohydrate restriction drastically reduces intake of essential nutrients found in fruits, grains, and vegetables, leading to deficiencies in vitamins (particularly B vitamins and vitamin C), minerals (like potassium and magnesium), and dietary fibre.
• Gastrointestinal issues: Constipation is common due to low fibre intake, which impacts digestive health and contributes to discomfort and poor gut health.
• Altered gut microbiome: Reduced dietary fibre negatively affects gut microbial diversity, shifting microbiota toward a pro-inflammatory profile, impairing gut barrier function, and potentially increasing systemic inflammation.
• Mood and cognitive changes: Many individuals experience mood swings, irritability, anxiety, and impaired cognitive function due to low glucose availability, particularly in the early stages of adopting the keto diet.
• Long-term effects
• Elevated LDL cholesterol and cardiovascular risk: Persistent high saturated fat intake from animal-based keto diets significantly raises LDL cholesterol, a critical risk factor for coronary artery disease and stroke.
• Increased risk of kidney stones: High animal protein and low fiber intake increase calcium and uric acid excretion, significantly elevating the risk of kidney stones.
• Bone health and osteoporosis: Chronic keto diets can lead to calcium loss, reduced bone mineral density, and an increased risk of osteoporosis, primarily due to systemic acidosis resulting from high animal protein consumption.
• Impaired glucose tolerance and insulin resistance: Over the long term, chronic high-fat diets may promote insulin resistance and glucose intolerance, particularly when reintroducing carbohydrates, which can increase the risk of metabolic syndrome and diabetes.
• Hepatic issues: Elevated fat intake, particularly saturated fats, may contribute to Non-Alcoholic Fatty Liver Disease (NAFLD) by increasing liver fat deposition and inflammation.
• Endocrine disruptions: Long-term carbohydrate restriction can disrupt hormonal balance, affecting thyroid function and reproductive hormones, which may lead to menstrual irregularities, reduced fertility, and hormonal imbalances.
• Gut microbial dysbiosis: Prolonged adherence severely compromises gut health, decreasing beneficial bacterial diversity and promoting chronic inflammation, immune dysregulation, and increased disease susceptibility.
• Risk of chronic inflammation: Long-term ketogenic dieting may exacerbate chronic inflammatory states due to high intake of inflammatory foods such as processed meats, dairy, and saturated fats.
• Dietary sustainability and psychological effects: Long-term adherence is notoriously difficult, often leading to psychological stress, dietary restriction-induced anxiety, and increased likelihood of binge-eating episodes, resulting in weight regain or "yo-yo dieting."

Critically, despite initial enthusiasm, the keto diet is challenging to maintain sustainably, frequently resulting in dietary relapse, metabolic disturbances, and compromised cardiovascular health. These profound short-term and long-term adverse effects underscore the need for careful consideration and medical supervision when adopting restrictive dietary regimens (Table 1) (Figure 1).

Figure 1: Illustrative representation of potential cardiovascular distress associated with high-fat ketogenic meals. The image depicts an adult male experiencing chest discomfort while consuming a high-fat, low-carbohydrate meal, emphasizing the possible adverse cardiac effects linked to prolonged ketogenic diet patterns.

Bethsaida hospital's success with WFPBD

At Bethsaida Hospital, initiated by Prof. DM, adopting a WFPBD has dramatically transformed cardiac patient outcomes. For nearly seven years, our comprehensive nutritional program, grounded in deep love and compassion, has shown remarkable clinical successes:

• Hypertension reversal: Patients achieved medication-free normotension through high-potassium, nitrate-rich diets.
• Diabetes control: Numerous patients discontinued insulin therapy while maintaining glycaemic control via fibre-rich, low-fat WFPBDs.
• LDL reduction: Profound cholesterol reductions were accomplished using a combination therapy of PBDs, statins, and Ezetimibe, avoiding costly Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors.
• Sustainable weight loss: Long-term Body Mass Index (BMI) normalized naturally without calorie restriction.
• Renal function improvement: Significant kidney function stabilization or improvement in Chronic Kidney Disease (CKD) patients.
• Heart failure outcomes: Patients with heart failure with reduced ejection fraction (HFrEF) achieved improved ejection fraction and significant symptom relief.
• CAD regression and low restenosis rates: Exceptionally low restenosis rates of approximately 2% following DCB angioplasty, markedly superior to the national average of 10-20%.
• Chronic inflammation modulation: Enhanced management and reduction of symptoms in autoimmune and inflammatory diseases.

Moreover, during the COVID-19 pandemic, our WFPBD program played a critical role in safeguarding thousands of patients, particularly elderly individuals with multiple comorbidities, by enhancing immune resilience, improving metabolic parameters, and reducing the severity of disease outcomes.

Despite initial skepticism from some sectors, Bethsaida Hospital’s holistic approach, rooted in evidence, compassion, and integrity, has become a transformative exemplar of adequate and compassionate healthcare in Indonesia. This approach has achieved superior clinical outcomes and enhanced patient adherence, quality of life, and overall wellness, showcasing the profound potential of integrating evidence-based medicine with genuine compassionate care (Table 2).

The ketogenic diet poses significant cardiovascular risks, particularly in individuals with CAD, by elevating LDL cholesterol, exacerbating systemic inflammation, enhancing oxidative stress, and impairing endothelial function. Although initially attractive due to rapid weight loss and perceived simplicity, ketogenic diets exhibit considerable limitations in sustainability and are associated with numerous adverse health outcomes. Conversely, Bethsaida Hospital’s innovative WFPBD program, spearheaded by Prof. DM and renowned for its empathetic and holistic approach, has consistently demonstrated superior clinical outcomes. These include the profound reversal of chronic diseases, enhanced metabolic regulation, substantial mitigation of cardiovascular risk, improved quality of life, and remarkably low rates of restenosis following interventional cardiology procedures. The evidence overwhelmingly supports integrating a WFPBD approach as an essential, sustainable, and clinically validated strategy for CAD prevention and management, significantly enhancing cardiovascular health and overall patient well-being.

D.M.; Conceptualization, writing, review, and editing.

This research received no external funding.

Data are contained within the article.

The authors declare no conflict of interest.

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