Knowledge and Perception Towards The Keto Diet Among The General Population in Baghdad City, Iraq

Introduction:

The ketogenic diet or keto diet (KD) is a recently used diet regime by a lot of the population for weight loss which is characterized by low carbohydrates, adequate-protein, and high-fat contents 1,2. It was previously used for the treatment of conditions like uncontrolled epilepsy since 1920 3. Later, researchers found the benefit of the keto diet in the management of many chronic diseases like Alzheimer, diabetes, Polycystic Ovarian Syndrome, Parkinson, and cancer 4,5. This diet is depending on the use of fat instead of glucose as a major source of energy when no or low carbohydrates are consumed. When the fat burned inside the human body, it converted to fatty acids and then to ketone bodies 6. These ketones are used for fuel production by the most important organs in the body including the brain, kidneys, heart, and muscles 7. KD was classified into several types according to the carbohydrates limitation including Classical Ketogenic Diet (CKD), Atkins Diet (AD), Modified Atkins Diet (MAD), Medium-Chain Triglyceride Ketogenic Diet (MCTKD), and Low Glycaemic Index Treatment (LGIT) 8. Even the benefits of using KD were established among the population in the treatment and prevention of different types of diseases 2,9-11, there are a lot of short-term disadvantages noticed among users known as keto influenza 12. This occurs due to lower glucose allocation to the brain within the first few days of applying the regime leading to the feeling of headache, muscle pain, tiredness, and gastrointestinal symptoms like diarrhea or constipation 13,14. In addition, an excess of ketones in the body can cause unwilling symptoms as acetone breathing, severe vomiting, and dehydration which may end with coma 15. People have to be cautious when following KD because of side effects in different conditions which proved to be contraindications like pregnancy, breastfeeding, cardiac arrhythmia, and advanced heart failure 16. Previous articles had shown low knowledge (3.4 ±3.6 out of 15) among medical and science college students in Iraq 17. Another study found that only 47 (37.3%) of epileptic patients from Hail city / Kingdom Saudi Arabia have knowledge of about KD 18. While (73.2%) of medical students in Lahore heard about KD and only (40.8%) of them were aware of the low carbohydrate and high-fat contents 19.

People have to be aware and oriented to different aspects regarding KD to be used with safety. To our knowledge there is no published study assessing the knowledge of the Iraqi general population regarding KD, so, this study aimed to determine the knowledge and perception of the general population towards the keto diet in Baghdad city, Iraq.

Methods:

A cross- sectional study was conducted among 203 respondents using internet-based method. Data collection done from October to December 2021. Convenience sampling method was used to collect data. The questionnaires link was distributed to participants through WhatsApp and Facebook groups. A Google document was used as hosting website for the questionnaire. After the participants click on the link, they will be directed to Google documents, they need to read the consent form carefully and then click on ‘yes’ I want to participate in the survey and he/she older than 18 years old. Some of the questionnaires are compulsory to answer, while some are optional.

Questionnaire was adopted from a previous study to measure the knowledge and perception of respondents 20. Knowledge section consist of 18 questions while perception section consists of 9 questions.

Regarding knowledge questions, participants were asked question regarding history and definition of KD, metabolism, diet components, risks and benefits. Perception questions consists of 9 questions and respondents answer based on 5-points Likert scale where a response of (1) meaning strongly disagree and a response of (5) meaning strongly agree.

A consent form was taken from the respondent before answering the questions and ethics approval was taken from the College of Nursing, Al-Bayan University (CON-HE-03). Statistical analysis was done using SPSS version 25. Means and Standard Deviations (SDs) were used for the presentation of numerical variables while frequency and percentage were for categorical variables.

Results

Majority of respondents were female (83.7%) and working (76.3%) with most of them had university degree (56.2%) followed by postgraduate degree (42.95). The mean age of respondents was 31.2±7.34 years old and mean Body mass index (BMI) was 24.4 kg/m2 which indicate normal body weight shown in table 1.

Table 1 socio-demographic characteristics of the respondents
	N	%
Gender Male Female	33170	16.383.7
Working Yes No	15548	76.323.7
Educational level Postgraduate levelUniversity levelSecondary school	871142	42.956.20.9
	Min	Max	Mean	SD
Age	19	54	31.2	7.34
BMI	15.26	34.0	24.4	3.9

Figure 1 shows how respondents feel about the keto diet. Almost all participants (98.5%) had heard of the keto diet and figure 2 shows that 42.0% were currently on it, and 26% had tried it previously. The longest time spent on the keto diet was one month (34.8%), and 52.0% of participants admit toking supplements while on the diet. Around half of the respondents (54.3%) reported that the keto diet helped them lose weight and keep it off.

Figure 1 : Did you heard about keto diet before

Figure 2: following Keto diet

In general, most of the participants had good knowledge of the keto diet, with the exception of two parts, nutritional ketosis where 70.9% answered do not know and regarding if there are any long-term studies on the effect of the keto diet, 43.3% answered we do not know. In terms of perception, around half of the respondents (42.8%) agreed that the keto diet should only be prescribed by doctors or nutritionists and (40%) disagreed that the keto diet is safe to follow for the rest of one's life as shown in table 2.

Table 2: Knowledge regarding keto diet (correct answers)
Knowledge Questions	N	%
The ketogenic diet was initially developed as a therapeutic treatment for epileptic patients.	123	61.0
The ketogenic diet consists of a high-fat, high-protein, moderate-carbohydrate diet.	137	67.4
The ketogenic diet attempts to force the body to use ketone bodies as fuel rather than glucose.	169	83.2
Carbohydrates are the primary dietary source of ketone bodies.	143	70.4
The ketogenic diet promotes the oxidation and utilization of fatty acids.	144	71.0
Being in a metabolic state of ketosis means that ketone bodies are being used as the primary fuel source.	186	91.6
As an energy source, the brain can only use glucose and ketone bodies.	109	53.6
In extreme cases of fasting, ketone bodies are used as a fuel source.	166	81.7
The ketogenic diet aims to mimic a fasted metabolic state without restricting calories.	120	59.1
The type of fat consumed on the ketogenic diet (saturated, monounsaturated, polyunsaturated, and trans fats) is unimportant.	131	64.5
The ketogenic diet comes in a variety of flavours.	142	70.0
The ketogenic diet aids in the improvement of hunger cues (makes you feel fuller and less hungry).	193	95.0
Weight loss is not induced by the ketogenic diet.	181	89.1
The ketogenic diet has no effect on blood sugar levels.	163	80.3
The ketogenic diet improves blood cholesterol control (it raises HDL cholesterol while decreasing LDL cholesterol).	144	71.0
Nutritional ketosis occurs when the blood ketone body concentration is between 1-3 mmol/dL.	43	21.1
The ketogenic diet does not cause stomach upset, nausea, or vomiting.	101	49.8
The ketogenic diet has been the subject of numerous long-term studies.	33	16.2

Around two-thirds of the respondents answered that ketogenic diet was originally developed as atherapeutic treatment for individuals suffering from epilepsy (61.0%). Around 95% answered correctly that The ketogenic diet helps to improve hunger cues.

Regarding perception on keto diet, Table 3 shows that majority of respondents agreed that keto diet is a popular way to lose weight (55.2%), around 46.3% believe that following the keto diet, ensures weight loss. 35.5% agree that following the keto diet is easy and possible. Majority 42.9% agreed that keto diet should prescribed only by doctors. (34.0%) disagreed that keto diet is dangerous.

Table 3 Perception on Keto diet
	N	%
I think the keto diet is a popular way to lose weight
Disagree	6	2.96
Neither agree nor disagree	18	8.87
Strongly agree	64	31.53
Agree	112	55.17
Strongly disagree	3	1.48
Following the keto diet, I believe, ensures weight loss.
Disagree	10	4.93
Neither agree nor disagree	32	15.76
Strongly agree	67	33.00
Agree	94	46.31
I think the keto diet recommendations are high in fat and not enough in protein and carbs
Disagree	82	40.39
Neither agree nor disagree	36	17.73
Strongly agree	8	3.94
Agree	75	36.95
Strongly disagree	2	0.99
I think the keto diet has more health benefits than health risks
Disagree	47	23.15
Neither agree nor disagree	29	14.29
Strongly agree	49	24.14
Agree	71	34.98
Strongly disagree	7	3.45
I think following the keto diet is easy and possible
Disagree	60	29.56
Neither agree nor disagree	18	8.87
Strongly agree	15	7.39
Agree	72	35.47
Strongly disagree	38	18.72
I think the keto diet is safe enough to follow for life
Disagree	79	38.92
Neither agree nor disagree	26	12.81
Strongly agree	8	3.94
Agree	58	28.57
Strongly disagree	32	15.76
I think the keto diet should only be recommended by a doctor
Disagree	30	14.78
Neither agree nor disagree	32	15.76
Strongly agree	39	19.21
Agree	87	42.86
Strongly disagree	15	7.39
I think the keto diet is dangerous (i.e. increases a person's risk of developing diseases such as cardiovascular disease, etc.
Disagree	69	33.99
Neither agree nor disagree	48	23.65
Strongly agree	14	6.90
Agree	26	12.81
Strongly disagree	46	22.66
I think the keto diet puts people at risk of nutritional and mineral deficiencies
Disagree	53	26.11
Neither agree nor disagree	13	6.40
Strongly agree	36	17.73
Agree	84	41.38
Strongly disagree	17	8.37

Discussion

The main finding of our study was that general population have good knowledge and perception toward keto diet and that was consistent with another study conducted at Fatima Memorial Hospital, College of Medicine and Dentistry, Lahore by Butt 2020 (19) in which a total of 250 participants were interviewed. Among all 183 (73.2%) of the participants heard about ketogenic diet. It was also consistent with another study conducted by Omar AlHaj et al., 2021 21 which studied KD followers in seventeen Arab countries.

While research shows that successful weight management plans combine diet, exercise, and behavioural therapy, students turn to FAD Diet like the KD in the hopes of losing weight quickly 22,23. It is important to note that the KD was not created as a weight-loss method. In fact, the KD was initially developed as a seizure-reduction treatment for patients suffering from epilepsy and other seizure-related disorders 22. The KD strict nutrition recommendations (which significantly reduce overall carbohydrate intake) and comes with benefits and risks associated with the chronic use of KD, including its metabolic, endocrinological, and cardiovascular effects 24.

According to the current study's findings, approximately 42 percent of respondents use a KD. This result is significantly higher than that of other studies, which show that 18.1 percent of students reported involvement with the KD. Although there are numerous other studies examining KD use, the majority of them concentrate on KD use for chronic disease treatment and prevention rather than weight management or weight loss 25.

In this study, 34.8 percent of users have been following or following the KD for less than a month, and only 12.3 percent of users have responded to using the KD for more than 26 weeks (6+ months). These findings show that One-thirds of the respondents stayed on a KD for a month or less, supporting current research that suggests KD, are not effective long-term weight management methods 26,27. Another study found that most of the users are between 1-6 months, and they believe it is a good short-term diet for weight loss 28. One of the reasons why KD, are difficult to maintain long-term is the extreme dietary restrictions that users must immediately adhere to. Such recommendations may necessitate severe calorie and food restrictions, as well as rigorous exercise, both of which are difficult for most people to maintain over time 29.

Following the KD, users were also asked about their outcome (or result). KD users could respond with 'weight loss and kept it off,' 'weight loss but gained it back,' 'no change,' or 'other.' Approximately 54.3 percent of users responded to 'weight loss and keeping it off.' This result is consistent with previous studies indicating that the KD is not long-term sustainable 22.

Overall, students seemed to struggle with identifying the correct blood ketone body (KB) for nutritional ketosis (question 17). The purpose of the KD is by restricting carbohydrate intake and increasing fat intake, the body is forced to enter a state of nutritional ketosis, where fat becomes the primary fuel source over carbohydrate 30. Blood ketone body concentration is the most accurate measurement when testing for nutritional ketosis. The current study results suggest all respondents, have a poor understanding of ketosis biomarkers. This result proposes a disconnect between KD users perceived usage of the KD versus they’re actual usage of the KD.

Regarding the ketogenic diet perception among respondents, the results showed that overall perception scores of the KD were significantly higher or more ‘favourable’ among males and users versus females and non-users. Overall, the study showed that on average, health related major groups, and non-health related non-users, who were males, had the highest perception scores among all groups. These findings show that for males, higher perception scores were significantly affected by health related major and non-user groups. Among females, non-health related majors who were users had the strongest feelings towards the KD. These findings show that for females, higher perception scores were significantly impacted by major type and user groups. Overall, females within both major groups, who were non-users, were not in favour of the KD, with the lowest mean perception scores of, 2.70 + 0.5 (health related) and 2.79 + 0.49 (non-health related). Among these groups, female, health related, non-users, were responsible for two of the lowest scoring perception questions (question 6 & 9), 1.88 + 1.0 and 1.93 + 0.8 respectively. This data suggests female, health related non-users (1) do not believe that the KD is safe enough for someone to follow for the long-term (2) believe the KD does not put individuals at risk for nutrient deficiencies.

Overall, male, health related majors, who were users, seemed to be most in favour of the KD, scoring the highest (3.53 + 0.35) among all students in this section. Although this result was considered significant, even this group conveyed an overall neutral perception of the KD. Thus, the true significance of this result suggested an overall neutral feeling towards the KD among students. Male, health related majors, who were users, were also responsible for the highest scoring question (4.5 + 0.5 for question 1), which stated, ‘I believe the ketogenic diet is a popular weight loss method used today.’ and that parallel with the findings from another study (Butt et al., 2020). This result shows overall, respondents agree that the KD is a frequently chosen weight management method utilized today. This outcome supports current research, that college students are aware of their overweight and obesity risk and are taking an initiative to become more health conscious by shifting their attention to weigh loss and weight management methods 31. While that result was not supported by other findings from other studies which found all sociodemographic variables; gender, age, area of living, living status and family income have shown no association with using KD 17.

Conclusion

The keto diet is a popular weight loss diet nowadays, and the general public is aware of it, but more health promotion and education are required.

Conflicts of interest

The authors declare no conflicts of interest

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