Many weight loss diet procedures continue to focus on the reduction of fat content and controlled protein intake, however our results appear to demonstrate that the KEMEPHY diet, which is a modification of the VLCKD, is effective not only for weight and fat loss but also leads to improvements in the values of various biomarkers which are associated with increased risk of metabolic and cardiovascular disease. The weight loss effect of VLCKD diets may be caused by several factors:
Satiety effect of proteins leading to appetite reduction [28–36] in which also ketone bodies may have a role [37, 38], although the mechanism is not clear ;
Reduction in lipid synthesis and increased lipolysis mechanisms [40–44];
Reduction in at rest respiratory quotient and therefore an increase in fat metabolism for energy use [22, 45];
Increased metabolic expenditure caused by gluconeogenesis and the thermic effect of proteins [46–51]
The beneficial effects on cardiovascular risk factors involve the reduction of blood triglycerides
[17, 18, 22] and also the reduction of total and LDL cholesterol along with a rise in HDL cholesterol [17, 18, 22, 52–54]. Furthermore the VLCKD can cause modifications in LDL-C particles leading to increased size  which may reduce cardiovascular risk since smaller LDL particles have been shown to be more atherogenic .
The cholesterol lowering effect of VLCKD is also mediated by the well known facilitating action of insulin on HMGCoA reductase and inhibition of the latter by cholesterol and fats . Insulin then increases the production of endogenous cholesterol while exogenous cholesterol has the opposite effect .
The KEMEPHY diet protocol used in this study maintains some advantages of the Mediterranean diet such as the use of olive oil  and some vegetables  (selected to avoid stimulating insulin production) but at the same time by inducing a physiological ketosis  promotes beneficial modifications in cardiovascular risk factors and body composition . The use of the phyoextracts in this study may have contributed to the absence of commonly reported mild effects of ketosis (e.g. weakness, constipation, bad breath, headache). During the first three weeks of the KEMEPHY diet subjects avoided fructose completely and during the second three weeks only a moderate amount of fructose, exclusively from fruit, and therefore together with starch, was permitted. As a matter of fact fructose may stimulate fat biosynthesis via mechanisms which are not yet fully characterised , also several studies have reported that excessive concentrations of fructose can induce some or all of the features of metabolic syndrome independently of energy intake. Clinical and epidemiologic data further suggest that excessive fructose intake can contribute to the causes of metabolic syndrome .
Adjusted compliance in this study was 93.4% which is higher than reported compliances of standard VLCK diets (in the 20% to 58% range). [22, 60, 61]. It is tempting to speculate that the inclusion of "carbohydrate-like" formulated foods is one of the reasons for high compliance - however this, along with the potential benefits of the phytoextracts, requires further verification in a future study with a matched control group.
If we assimilate de facto, which is not always correct, ketogenic diets with high protein diets then the risks proposed by critics of this type of dietary approach are essentially those of possible kidney damage due to high levels of nitrogen excretion during protein metabolism which can cause an increase in glomerular pressure and hyper-filtration . There is not wide agreement between studies however, some infer the possibility of renal damage from animal studies [62, 63] while others, looking at both animal models and human studies propose that even high levels of protein in the diet do not damage renal function [64, 65]. In subjects with intact renal function higher dietary protein levels caused some functional and morphological adaptations without negative effects . Also it should be underlined that ketogenic diets are only relatively high in protein [49, 67] and that some recent studies have demonstrated that VLCKD can even cause a regression of diabetic nephropathy in mice . With regard to possible acidosis during VLCKD since the concentration of ketone bodies never rises above 8 mmol/l [40, 42] this risk is virtually inexistent in subjects with healthy insulin function.