BITESIZE: Keto Outperformed Mediterranean and Low-Fat Diets in New RCT for Fatty Liver and Prediabetes

Does reducing carbohydrates improve metabolic health beyond what can be explained by weight loss alone?

Dr. Bret Scher breaks down a new randomized controlled trial published in Cell Metabolism that compared three diets in people with prediabetes and fatty liver disease: a ketogenic diet, a higher-carbohydrate Mediterranean diet, and a very low-fat, plant-forward diet.

One challenge with ketogenic diet research is that participants often lose more weight than those in comparison groups, making it difficult to separate the effects of carbohydrate reduction from those of weight loss itself.

In this trial, researchers provided all of the meals, and participants achieved greater than 95% dietary compliance. Importantly, all three groups ultimately lost the same 10% of their body weight. That gave researchers an unusual opportunity to compare metabolic outcomes across the three diets without differences in weight loss muddying the picture.

And even with weight loss held constant, the outcomes differed.

The ketogenic group reduced liver fat by 67%, compared with 45% in the Mediterranean and plant-forward groups, and saw larger improvements in liver insulin sensitivity. Prediabetes remission also occurred in 50% of the ketogenic group, compared with 29% of the Mediterranean group and 7% of the low-fat, plant-forward group.

Dr. Scher covers:

Why similar weight loss across the three groups makes this trial especially informativeHow all three diets affected skeletal muscle insulin sensitivityWhy liver insulin sensitivity improved more with the ketogenic dietThe differences in liver fat reduction between the three groupsPrediabetes remission rates across each dietary approachHow carbohydrate reduction may suppress liver fat productionChanges in the glucagon-to-insulin ratio on ketogenic therapyWhat the study found about saturated fat, LDL cholesterol, and ApoBImprovements in triglycerides, VLDL, and lipoprotein insulin resistanceThe study’s limitations, including its small size and 4- to 5-month duration

For people with fatty liver disease or prediabetes, this study adds evidence that carbohydrate reduction may produce metabolic benefits beyond those achieved through weight loss alone.

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