The Study: Nutritional ketosis to treat pulmonary hypertension associated with obesity and metabolic syndrome: a case report

Overview: This paper is new case report of a 62 year old female with pulmonary hypertension and metabolic syndrome and details the results following adherence to a ketogenic diet over a one year period.   

Key Points: 

·         This study follows a 62 year old, morbidly obese female with mild pre-capillary pulmonary hypertension and metabolic syndrome after she was treated with a medically-supervised ketogenic diet delivered by a telehealth healthcare team via a continuous remote care platform. The program provided “frequent communication and medical supervision from the care team to initiate and sustain nutritional and behavioral changes and also can engage with a peer community for social support.”

 ·         At the onset of the program the patient was started with CPAP with oxygen to help with her sleep apnea/hypoxemia and she required supplemental oxygen as she suffered difficult breathing and fatigue with even minimal walking.

 ·         Metabolic syndrome is characterized by insulin resistance/hyperinsulinemia and/or Type 2 diabetes, atherogenic dyslipidemia (elevated triglycerides, low HDL), and hyperglycemia.

 ·         For decades, the treatment of type 2 diabetes mellitus (T2DM) and MetS has centered around drug treatments focused on reducing  elevated blood glucose levels and dyslipidemia without any attempt to modify the lifestyle factors which contribute to MetS.. 

 ·         MetS has also been show to be highly prevalent in pulmonary hypertension (PH) and is associated with worse outcomes. 

 ·         The authors cite prior studies which have shown supervised dietary interventions designed to sustain nutritional ketosis as “safe, sustainable and effective.” This patients program utilized “carbohydrate-restriction therapy including nutritional ketosis” “to reduce hyperglycemia and weight in patients with insulin resistance.”

 ·         The authors cite previous studies where after ”one year on this intervention, 94% of patients on insulin were able to reduce or eliminate insulin, 60% of patients were able to sustain a hemoglobin A1c < 6.5% with no diabetes medication or with only metformin, and average weight loss was 12%”.

 ·         They also cite prior publications showing ketogenic diets have been shown to improve “inflammatory markers, liver enzymes and triglycerides.”

 ·         In addition the patient was prescribed a statin medication (atorvastatin) after the initial patient encounter.

Results: The patient lost 34 kg over the one year period (25% of her initial body weight), her Body Mass Index reduced from 45.5 to 34.1, she normalized her triglycerides, reduced her LDL cholesterol and improved her oxygen requirement and symptoms. At the end of the study she was “able to walk her dog one mile at her home elevation without oxygen.”  Her lung spirometry showed significant improvement as did her hemodynamics.

 Author’s Conclusions:  The authors speculate “that her hemodynamic improvements were a downstream effect of weight loss with resultant improvement in lung volumes” and hypoxemia. They hasten to add that due to limitations of the study, “We cannot ascertain from this case whether independent of weight loss, the induction of nutritional ketosis, and the attendant metabolic and metabolomic alterations improved PVR (pulmonary vascular resistance) and/or cardiac function.”  Parenthesis ours.

 Reviewer's Comments: Normally we don’t cover many case studies because of the limitations involved. This study certainly doesn’t allow us to separate out the benefits of weight loss from the state of ketosis or every factor involved.  But more importantly, what we do see is that substantial weight loss occurred and was sustained as a result of a reduced carbohydrate intake and the resulting nutritional ketosis and important metabolic markers as well as the patient’s general vitality and endurance improved significantly.

Reviewer:  Mark R. Payne DC

 Reference:  Kim D, Roberts C, McKenzie A et al. Nutritional ketosis to treat pulmonary hypertension associated with obesity and metabolic syndrome: a case report. J. Pulmonary Circulation. Feb.16, 2021

Link to Full Text: https://journals.sagepub.com/doi/10.1177/2045894021991426