Ketogenic Diet-induced Elevated Cholesterol, Elevated Liver Enzymes and Potential Non-alcoholic Fatty Liver Disease

A 57-year-old woman with class I obesity (BMI = 31.42 kg/m²) and a medical history significant for binge-eating disorder with emotionally-triggered eating, post-traumatic stress disorder, and untreated depression and anxiety, presented for follow-up of weight management with laboratory values revealing acutely-worsened hyperlipidemia and elevated liver enzymes. Abdominal ultrasound showed a mildly heterogenous and echogenic liver, without focal lesions, suggestive of non-alcoholic fatty liver disease. The only significant change from previous consultation four months prior was introduction of a ketogenic diet consisting of eggs, cheese, butter, oil, nuts, leafy green vegetables and milk (almond and coconut). The patient reported a reduction in hunger on this diet. Immediate discontinuation of the diet resulted in modest reduction of low-density lipoprotein cholesterol (LDL-C) and liver enzymes two weeks later. Resolution of liver enzymes was seen within eight months and LDL-C levels normalized one year later. This case report discusses the rationale, benefits and risks of a ketogenic diet and encourages increased vigilance and monitoring of patients on such a diet.