Ketogenic Diet and Lymphedema

Ketogenic Diet and Lymphedema

This post will explore the evidence for a ketogenic diet for lymphedema. If you would like to read about other approaches for lymphedema diet then check out my previous post on the topic. This post does contain links to amazon regarding products that I mention that might be helpful for keto and lymphedema. As an amazon associate, I earn from qualifying purchases.

Before you make any changes to your diet, consult your physician or registered dietitian to make sure the diet is appropriate for your needs and goals.

To learn about keto and lymphedema, you can read this entire blog post top to bottom or skip to the parts of keto and lymphedema that are of interest using this Table of Contents

What is Lymphedema?

Lymphedema is a condition in which lymphatic fluid builds up and causes swelling. It is essentially an edema of lymphatic fluid. It is also spelled lymphoedema, in the UK but it is the same condition.

woman with leg lymphedema
This woman has lymphedema in her left leg. Photo by Ann DiMenna for The Complete Lymphedema Management and Nutrition Guide.

What is a Ketogenic Diet?

The ketogenic diet, or keto diet for short, is a high fat, moderate protein, low carbohydrate diet designed to force the body to breakdown fat instead of glucose. It does this by reducing your blood sugars and insulin levels and without that energy source, the body must use fat as the main fuel for the body. When your body uses fat as the main fuel and produces ketones you are ‘in ketosis’.

What is Ketosis?

There are three main macronutrients that the body uses. These are the nutrients that can be used for energy (as opposed to micronutrients which are vitamins and minerals and not energy sources). The macronutrients are: carbohydrate, protein and fat. When presented with all three, carbohydrate is the first energy source the body will use. That means, if you are eating a mixed diet, the body will use the carbohydrate for fuel, and store what it doesn’t need now for later in the form of glycogen and excess beyond that will be stored as fat.

When your body uses up the carbohydrate from your meal and the stored glycogen, it then will go to its second energy source which is fat. The body will break down fat for energy, and in doing this will create ketones. The ketone chemicals are: beta-hydroxybutyrate, acetoacetate and acetone.  If you continue to deprive the body of new carbohydrate, it will continue to keep you in ketosis.

Will the Ketogenic Diet Work for Lymphedema?

While there is plenty of on-line testimonials and Facebook groups that advocate the ketogenic diet for lymphedema, the actual research to support keto diet for lymphedema is extremely limited. I will review that research for you so you can make an informed decision about what diet to use for your lymphedema.

Ketogenic Diet for Lymphedema Research

There is only one research study on keto diet for lympehdema using humans (Keith, 2017). In this pilot study, twelve people (11 women, 1 man) with lymphedema met weekly for a lifestyle modification program. Six of these people did a ketogenic diet and four did not and two dropped out of the study, which lasted for three months. Since it’s the only study in humans on ketogenic diet and lymphedema, I’ll describe it in detail for you.

The Diet

While the authors accurately describe the ketogenic diet as “less than 20 grams of carbohydrate, moderate protein of 50-75 grams, and fat intake to satiation”, the instructions given to the participants were not consistent with this description. Specifically, the participants were instructed on a “no sugar, no starch diet” in which they were allowed:

  • Less than 20 grams of carbohydrate per day
  • As much protein foods as they want (all meats, including sausage, hot dogs, poultry, eggs, fish, seafood)
  • Certain vegetable oils, but no mention of how much
  • Butter, but no mention of how much
  • 2 cups per day of salad greens
  • 1 cup per day of non-starchy vegetables, e.g. broccoli, cauliflower, mushrooms, Brussel sprouts, and eggplant
  • Up to 4 oz per day of cheese: cream, Swiss, cheddar, mozzarella
  • 2 tbsp per day of cream
  • 6 olives per day
  • Up to 1 whole avocado per day
  • Up to 2 tsp lemon and lime juice
  • Up to 2 pickles, dill or sugar-free
  • Zero carb snacks: pork rinds, pepperoni slices, ham, turkey, beef jerky, deviled eggs

My Opinion: This is not a ketogenic diet. There is too much protein and not enough fat here. Like carbohydrate, protein also produces an insulin release which will delay or prevent ketosis. Also, there is no accounting for hidden carbohydrate in ‘free foods’ such as in eggs (0.5 g), hot dogs (4 g)’. The same goes for ‘limited foods’ such as avocado (2 grams net carbs), cheese, (1 gram carbs), pickles ( 1 gram net carbs), and no mention of label reading instructions for items such as beef jerky, ham and pickles that can contain substantial carbohydrate. Typically, dietitian-led ketogenic diets will restrict protein to 1 gram of protein per kg body weight (adjusted or ideal body weight will be used in overweight patients) (Roehl, 2017).

The Intervention

This intervention in this study was modelled after a lifestyle based occupational therapy intervention called Lifestyle Redesign, which is designed to slow age-related declines among independently living elders (aged 60+).  It has previously shown benefit in bodily pain, vitality, social functioning, mental health, mental functioning, life satisfaction and depression. It is designed to promote well-being in older people (Clark, 2012). It was adjusted to include lymphedema and weight management by the authors of the study.

The group sessions were held at a local restaurant for 1 1/2 hours every week for 12 weeks. The sessions were all led by the same principle investigator that selected the participants. On week two, they were introduced to the ketogenic diet and they were allowed to decide themselves if they wanted to follow it or not.

Six people choose to do a “ketogenic diet”, while four did not. Then the interviewer who knew what treatment they selected delivered the program. But the degree to which they followed a ketogenic diet was not assessed other than to ask the participant privately to “confirm or deny if they were using a ketogenic diet”. Diet adherence was not measured nor were ketones.

They also had the option of individual sessions every two weeks. Participants completed three different quality of life questionnaires (Obesity and Weight-Loss QOL (OWLQOL), Weight-Related Symptoms Measure (WRSM) and Lymphedema Life Impact Scale (LLIS)). In addition, they had their body weight and lymphedema measured, before, during and 1 month after the trial ended.

The Results

Nine of out ten participants lost weight and this weight loss corresponded to loss of lymphedema volume. In this small pilot trial, the six patients who did the “ketogenic diet” lost more weight than the non-ketogenic diet folks. This is consistent with other very low carb research that shows that people on very low carb diets lose more weight at six months but that the diet is difficult to maintain and by one year, very low carb and low fat diet eaters have lost the about the same amount of weight (Bueno, 2013).

The data in this trial was collected for only four months, so we can’t see any longer term results despite the fact that the author is promoting this as a lifestyle and not a diet. In addition, we don’t get to follow them long enough to see that most people have difficulty with long term adherence to a very low carb diet (Bueno, 2013)

My Opinion

While I applaud the authors for being the first to study ketogenic diet in lymphedema, the study suffers from poor methodology which makes it difficult to rely on. For example, the same investigator selected the participants, taught the intervention, took the measurements, all of which introduces many biases including selection bias, interviewer bias and observation bias (Medical Research Council, 2020).

The participants self-selected the ketogenic diet and merely reported if they were following it which opens to door to more selection bias and introduces recall bias. The investigator was not blinded to who did the “ketogenic diet” and who didn’t and because they got to select their diet, it is not randomized.

The fact that the six people on the “ketogenic diet” lost more weight over four months  compared to those that didn’t do ketogenic diet is not surprising. But, I feel like this study missed the whole point of the ketogenic diet, which is to produce ketones and not just weight loss. For me, the real magic of a ketogenic diet, is that your body goes through a metabolic switch to change from using carbohydrate as the main fuel to using fat as the main fuel. This fat burning produces ketones.

It’s possible to easily measure ketones in the urine, blood or breath to confirm that you are in fact in ketosis, but that was not done in this study. So, it’s impossible to say what benefit ketosis had on the lymphedema versus just simply a low carb weight loss diet. We know already from other research, that weight loss reduces lymphedema (Shaw 2007 and Shaw 2007). I would love to know what role ketosis plays in lymphedema, and for me, that question remains unanswered.

What I would conclude from this study is that a low carb diet allows for faster weight loss in the short term (which is consistent with other studies), but I could not say from this study that a ketogenic diet specifically is helpful for lymphedema, I also can’t say that it’s not. I’m really not convinced this was even a ketogenic diet or that the participants were in ketosis, given that they were allowed to eat as much protein as they wanted, there were no minimum amounts of fat prescribed, no accounting for hidden carbs and ketones were not measured.

Upcoming Human Research on Ketogenic Diet and Lymphedema

Thankfully, there is a new trial underway in Belgium called “Ketogenic Diet: A Novel Metabolic Strategy to Treat Lymphedema Patients?”. The researchers are hoping to recruit 100 participants and the study will be properly blinded and randomized. The trial will compare a strict ketogenic diet and a modified Atkins diet (keep reading to find out what this is).

I am looking forward to the results of this study, which is taking the necessary steps to create proper blinding and randomization and will use an actual ketogenic diet taught by a registered dietitian. If you live in Belgium and are reading this blog post, then at the time of writing, this study is still recruiting, see the link below in the references for more information and how to get involved (Thormis, 2019).

Why a Ketogenic Diet for Lymphedema?

Why are we even talking about a ketogenic diet for lymphedema? One obvious reason why a ketogenic diet could be considered for lymphedema is that ketogenic diets produce weight loss (Ting, 2018). Weight loss can help to reduce lymphedema (Shaw 2007 and Shaw, 2007), but not all studies show this (Schmitz, 2019).

Secondly, some mice research indicates that ketones can trigger lymphatic vessels to grow, a process called lymphangiogenesis and for lymphatic function to improve and for a reduction in lymphedema (García-Caballero, 2019). But, remember, you can’t just restrict carbs and eat as much protein as you like. A true ketogenic diet is high fat, protein sufficient to meet your needs and low carb, it’s the ketones that are expected to help here, not just weight loss. Also, we’re not mice, so of course, we can’t be sure of a positive result unless human lymphatic vessels are examined under these conditions.

Thirdly, some people with lymphedema also have other illnesses, including metabolic syndrome and/or non-alcoholic fatty liver disease. A ketogenic diet, at least a Spanish Modified Ketogenic Diet (virgin olive oil as the principle fat (at least 2 Tbsp per day), moderate red wine (200-400 ml/day), green vegetables and salads as the main carb and fish as the main protein) showed improvement in both metabolic syndrome and non-alcoholic fatty liver disease (Pérez-Guisado, 2011). For other conditions often seen with lymphedema such as diabetes, and heart disease, some positive results have been seen as well (Kosinski, 2017).

But it’s not all positive, most results are time-limited and some negative results were found such as insulin resistance. Weight maintenance on a ketogenic diet is also a major drawback, as many people have difficulty following the diet long term, and if they do, the long term side-effects are still not known (Kosinski, 2017).

In addition to the above reasons to consider a ketogenic diet for lymphedema, I am especially interested to know if ketosis might be able to target lymphedema fat. Many people with lymphedema can have a build up of fat. Over time, lymphedema changes the composition in the affected area of the body.

Because the lymph fluid is not moving or stagnant, called “lymph stasis“, this changes the tissue.  The slow movement of lymph generates new fat cells (this process is called lipogenesis) and deposits the new fat cells in the lymphedema limb. This creates inflammation and the inflammatory cells called macrophages increase in number and are transformed into fat cells. If left untreated, soft lymphedema tissue can turn into fatty and fibrotic lymphedema (Hoffner, 2018).

You can tell if you have more fat and fibrosis in your lymphedema because when you press your finger into the lymphedema there is no pitting. This tells you that the fat and fibrosis in the limb are making it more solid and not fluid. I’ve heard this called “fat dominant lymphedema” and “fluid dominant lymphedema“.

I hypothesize that fat dominant lymphedema could benefit most from the fat burning feature of ketosis. While there is no research to confirm, I think it’s possible that the fat oxidation that comes from being in ketosis could actually mobilize this dense fatty tissue that makes up the fat dominant lymphedema limb. But, until there is research on this I can’t say for sure, but I remain open to the possibility that ketogenic diets could be therapeutic for lymphedema if done properly.

 

 

a foot and ankle with pitting and non-pitting edema
The foot on the left shows pitting edema. This is indicative of “fluid dominant lymphedema”. The ankle on the right have very little pitting. This is indicative of “fat dominant lymphedema”. Photo provided by patient with permission, may not be copied.

 

Ketogenic Diet Concerns

I’ve spent some time on the benefits of a ketogenic diet in general and potential benefits for lymphedema. I want to be fully transparent and highlight some of the concerns of the ketogenic diet so you can make a fully informed decision.

These of some of the risks of a ketogenic diet (from several sources):

  • Acidosis
  • Constipation
  • Exacerbation of gastroesophageal reflux disease (GERD)
  • Excessive ketosis
  • Fatigue
  • Hypoglycemia
  • Nutrient deficiency
  • Liver problems
  • Kidney problems
  • Difficult to sustain
  • Social isolation
  • Increased LDL, and inflammation

In addition to these known side effects, I do wonder about all the fat on a ketogenic diet, and knowing that the lymphatic system is responsible for transporting all the long chain fatty acids (read more about that in my lymphedema diet blog), it begs the question, will the ketogenic diet aggravate lymphedema?

I do have concerns about how well a person with lymphedema can handle all of this fat. I think it would be especially problematic if someone were attempting to follow ketogenic diet, by increasing their fat intake but not actually getting the proper ratio that puts them into ketosis. In this way, they are giving the lymphatic system more fat to absorb and transport from the GI tract without any of the ketogenic fat burning compensation.

Who Should Not Follow A Ketogenic Diet?

People with the following conditions should not do a ketogenic diet:

  • Beta-oxidation defects
  • Fatty acid defects (MCAD, LCAD, SCAD)
  • Carnitine deficiency
  • Porphyria
  • Women who are pregnant or nursing
  • Yo-Yo dieting history or difficultly following low carb diets

The following are relative contraindications

This means that caution is required and you may be able to follow it, but definitely need to discuss with your physician first and there are added risks.

  • Pancreatitis
  • Active liver, kidney or gallbladder disease
  • Impaired digestion such as irritable bowel disease
  • Gallstones
  • Gallbladder removed
  • Osteoporosis

How Do I Follow A Ketogenic Diet?

When you google ketogenic diets, it seems like there is only one, but in fact there are several, which vary in the ratio of fat to protein and carbohydrate. I would like you to know the different types of ketogenic diets, and understand them as you consider if this diet is right for you. These descriptions are based on the guidelines from The Charlie Foundation, an organization that supports the use of the ketogenic diet for medical use (Zupic-Kania, 2020).

4:1 Ketogenic Diet

This is also called 4:1 keto, “four to one” or Classic Keto. This means that for every 4 grams of fat, you consume 1 gram of protein plus carbohydrate combined. To achieve this ratio, you would need to get a food scale and weigh your food to the nearest gram and eat all the food calculated for that meal. It is the highest fat of all the protocols.

3:1 – 1:1 Modified Ketogenic Diet

The 3:1 keto diet, targets 3 grams of fat for every one gram of protein plus carbohydrate combined, so less fat than 4:1. The 2:1 is 2 grams of fat for every 1 gram of carb plus protein and so on for 1:1. The lower the ratio becomes the less fatty the diet. Collectively, these are also called Modified Keto Diets.

MCT Diet

This diet still limits carbs but not as strictly and people would consume MCT oil. MCT stands for medium chain triglyceride and it is absorbed by the body differently from oils made up of long chain triglyceride. Not only does MCT oil help to get your body into ketosis, it also appears to be beneficial for lymphedema (read more about that here Lymphedema Diet).

0.8:1 Modified Atkins

In this version of a ketogenic diet, you limit your carbohydrates, have no limits on your protein and fat is encouraged. If you eat carbohydrate you consume it with a fat source. It is similar to the “no sugar, no starch diet” described in the research study above, but Modified Atkins does not limit fat and has you combining it with carbs. Because it is a lower ratio, the ketones produced by the body would be lower as well. 

 

Table showing ketogenic diets and macronutrient percentages
This chart shows the percentages of fat, protein and carbohydrate for the various ketogenic diets, based on The Charlie Foundation guidelines which can be found at https://charliefoundation.org

How Do I Calculate my Macros?

To calculate how many grams of fat, protein and carbohydrate you need to follow a ketogenic diet, you first need to know your calorie needs. Let’s use 2000 calories as an example. I will show you how to calculate your macros for a 2:1 ketogenic diet.

2000 Calorie 2:1 Ketogenic Diet

Calculate Grams of Fat

70% of 2000 calories = 0.7 x 2000 = 1, 400 calories

Each gram of fat is 9 calories per gram, so to calculate the number of grams: 1400 calories / 9 = 155 grams of fat

Calculate Grams of Protein

Protein can be calculated based on your protein needs per body weight such as 1 g/kg but for this example, we will use the percentages in the chart.

12% of 2000 calories = 0.12 x 2000 = 240 calories

Each gram of protein has 4 calories per gram, so to calculate the number of grams: 240 / 4 = 60 grams of protein

Calculate Grams of Carbohydrate

6% of 2000 calories = .06 x 2000 = 120 calories

Each gram of carbohydrate has 4 calories per gram, so to calculate the number of grams: 120 / 4 = 30 grams of carbohydrate

For a 2:1 keto diet of 2000 calories you should aim to consume per day:

  • 155 grams of fat
  • 60 grams of protein
  • 30 grams of carbohydrate

Rather than do all these calculations by hand there are also apps you can use to calculate and track your macros when following a keto diet. When in doubt, consult a registered dietitian that works with ketogenic diets, to ensure that you are following an appropriate diet. As mentioned in the beginning you should consult your physician before beginning a ketogenic diet.

What Can I Actually Eat on a Ketogenic Diet?

If you were to translate these macros into 3 meals in a day, then it could look like this:

Breakfast                            Fat      Protein       Carb

2 egg                                      10              12               1

3 tsp olive oil                        15               0               0

1 cup Spinach greens          0               1                  0

1/2 cup heavy cream           44             5                 7

Lunch

1/2 cup chopped chicken     9               18             0

1 tbsp full fat mayonnaise   10              0               0

2 tbsp olive oil                      28              0                0

1/2 cup asparagus                0                1                1

1/2 cup broccoli                    0                1                1

Dinner

4 oz fish                                  13             25              0

2 cups salad greens               0              2                1

3 tsp olive oil                           15            0                0

1 cup blueberries                   0              1                17

4 tbsp heavy cream               12              0                0

Total                                    156           65           28

Numbers used in calculation are based on USDA nutrient database.

How to Decide Which Ketogenic Diet to Follow?

The real dietitian experts in ketogenic diets are those dietitians that work in the field of childhood epilepsy, where the ketogenic diet is a life saving therapy. If I take a lead from their work, then the way to choose which diet is based on their standard protocols for implementation and trial and error. You need to know what outcome you are looking for. In the case of kids with epilepsy, it is the number of seizures they have per day and target blood ketone levels, which they will have monitored regularly. In the case of lymphedema, it would be weight loss and reduction in lymphedema volume. Ideally, you want to be on the least strict diet that gives you the results you are after.

If we discover through research that the ketosis is beneficial for lymphedema beyond just weight loss, then there would likely be a target of blood ketone level to achieve. But for now, I don’t have a target to recommend, as this hasn’t been studied.  If you do try it, measure your lymphedema before and throughout your trial to know if you are achieving your goal. In addition to measuring your lymphedema you should track symptoms like pain and heaviness and track any diet side effects.

Bottom Line on Ketogenic Diet for Lymphedema

The diet alone can not treat lymphedema. You need to continue with complete decongestive therapy, namely; bandaging, compression, skin care and exercise. Not everyone can tolerate the ketogenic diet and many don’t even want to try it. If the ketogenic diet is not right for you, I have a lymphedema diet that I can recommend.

If you are going to use a ketogenic diet, I suggest you test for ketones by using keto urine test strips, ketone blood tests or ketone breath tests. Also, don’t buy into a lot of the so called ketogenic diets that are on-line, many of which have too much protein to be truly ketogenic. Maybe it’s just semantics for some, but for me, a ketogenic diet means, you are in ketosis, which may not be true for all the low carb, high protein diets.  Also, eat real food and not packaged, processed “keto” foods.

In addition, there are potential harms (listed above) to being on the ketogenic diet and the only way to justify the risk, is there needs to be some benefits that outweigh the risks.

Best Diet for Lymphedema

So what is the best diet for lymphedema? Is it an anti-inflammatory, low sodium, low fat, intermittent fasting diet described in Lymphedema Diet? Or, is it a ketogenic diet for lymphedema?

I think the answer is; it depends.

First off, it depends on you. Does following a keto diet sound appealing? Does it sound like something you can stick with long term? Remember a ketogenic diet will likely lead to weight loss, but if you are just going to yo-yo your weight by doing the keto diet until your goal weight and then stopping it, or “falling off the wagon” and getting back on,  you may be better off not doing it. Do you want to keep carbs in your diet and feel satisfied to take the slow and steady approach to weight loss? Then the non-keto approach may be better. In addition, the long term health effects of ketogenic diets are not known.

Keep in mind, the ketogenic diet is not the only way to achieve ketosis. You can also achieve ketosis with intermittent fasting, In addition, giving your GI tract a rest for 12+ hours per day, can help reduce the production of lymph from the gut. I recommended a form of intermittent fasting for lymphedema called “Time Restricted Feeding“. You can read more about intermittent fasting in my blog called Intermittent Fasting for Women Over 40. If you currently have, or had cancer in the past, read my post called How to Starve Cancer which discusses the intermittent fasting research related to cancer treatment and prevention.

In addition, given the poor success of long term weight loss, you may want to forgo a weight loss approach all together and focus on Health at Any Size (HAES). This is a legitimate approach to obesity, and promotes a positive body image, which has been shown to be protective against weight gain (Gallant, 2018). This approach recognizes the complexity of obesity and acknowledges that for many, diets simply just don’t work (Gallant, 2018).

Added Support

Book Cover for The Complete Lymphedema Management and Nutrition Guide

If you need help deciding which is the best approach for you, and getting on track with your nutrition and I feel that I can offer assistance, then please get in touch with me jean@jeanlamantia.com and we can have a virtual nutrition assessment.

If you would like to learn about self care for lymphedema, including step-by-step photos of multilayer bandaging, exercise, skin care, and compression as well as details about a lymphedema diet including 50 delicious recipes, get a copy of The Complete Lymphedema Management and Nutrition Guide.

You can purchase it directly from my web site or from amazon or your favourite book seller.

 

References for Ketogenic Diet and Lymphedema

Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr. 2013;110(7):1178-1187. doi:10.1017/S0007114513000548

Clark F, Jackson J, Carlson M, et al. Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: results of the Well Elderly 2 Randomised Controlled Trial [published correction appears in J Epidemiol Community Health. 2012 Nov;66(11):1082]. J Epidemiol Community Health. 2012;66(9):782-790. doi:10.1136/jech.2009.099754

Hoffner M, Peterson P, Månsson S, Brorson H. Lymphedema Leads to Fat Deposition in Muscle and Decreased Muscle/Water Volume After Liposuction: A Magnetic Resonance Imaging Study. Lymphat Res Biol. 2018;16(2):174-181. doi:10.1089/lrb.2017.0042

Gallant, J and Lamb M. Health at Every Size (HAES) – What’s It All About? Obesity Canada. April 6, 2018. Accessed Aug 15, 2020.

García-Caballero M, Zeechin A, Souffreau J et al. Role and therapeutic potential of dietary ketone bodies in lymph vessel growth. Nature Metabolism 1, 666-675, 2019.

Keith L, Rowsemitt C, Richards L. Lifestyle Modification Group for Lymphedema and Obesity Results in Significant Health Outcomes. American Journal of Lifestyle Medicine. 2017. doi: 10.1177/1559827617742108

Kosinski C, Jornayvaz FR. Effects of Ketogenic Diets on Cardiovascular Risk Factors: Evidence from Animal and Human Studies. Nutrients. 2017;9(5):517. Published 2017 May 19. doi:10.3390/nu9050517

Medical Research Council and Chief Scientist Office. Understanding Health Research A Tool for Making Sense of Health Studies. Accessed August 14, 2020.

Pérez-Guisado J, Muñoz-Serrano A. The effect of the Spanish Ketogenic Mediterranean Diet on nonalcoholic fatty liver disease: a pilot study. J Med Food. 2011;14(7-8):677-680. doi:10.1089/jmf.2011.0075

Rosenbaum M, Hall KD, Guo J, et al. Glucose and Lipid Homeostasis and Inflammation in Humans Following an Isocaloric Ketogenic Diet. Obesity (Silver Spring). 2019;27(6):971-981. doi:10.1002/oby.22468

Schmitz KH, Troxel AB, Dean LT, et al. Effect of Home-Based Exercise and Weight Loss Programs on Breast Cancer-Related Lymphedema Outcomes Among Overweight Breast Cancer Survivors: The WISER Survivor Randomized Clinical Trial [published online ahead of print, 2019 Aug 15]. JAMA Oncol. 2019;5(11):1605-1613. doi:10.1001/jamaoncol.2019.2109

Shaw C, Mortimer P, Judd, PA. A randomized controlled trial of weight reduction as a treatment for breast cancer-related lymphedema. Cancer, 2007 Oct 15;110(8):1868-74.

Shaw C, Mortimer P, Judd, PA. Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema. Cancer, May, 2007;109:1949-56.

USDA. Food Data Central. Accessed Aug 17, 2020.

Thormis, 2019. Ketogenic Diet: A Novel Metabolic Strategy to Treat Lymphedema Patients? Clinical Trials.gov. Last updated June 21, 2019. Accessed Aug 12, 2020

Ting R, Dugré N, Allan GM, Lindblad AJ. Ketogenic diet for weight loss. Can Fam Physician. 2018;64(12):906.

Zupic-Kania, B. 2020. Keto Therapies. The Charlie Foundation. Copyright 2020. Accessed Aug 12, 2020.