Experts Weigh In On Ketogenic Diet for Diabetes Type 2

Ketogenic diet has taken us by the wind in the recent years. There are numerous resources available online for people who are considering going on one.

A ketogenic diet, in very simple terms, is a very low-carb diet. It has been claimed that going on a ketogenic diet is beneficial for people seeking to lose weight and to improve their health. This probably sounds very charming to a person with diabetes who is looking to lose excess weight and to improve their overall general health to avoid or prevent any diabetes related complications.

But, is it really worth all the hype it has generated?

For someone who has diabetes, a healthy and nutritional lifestyle is extremely important. Though lowering the consumption of carbs from your diet can aid you, is it actually recommended to restrict yourself to a very low carb diet if you have diabetes?

We can’t claim to know but we reached out to respected experts who have shared their thoughts on the diet and whether they recommend it to their patients.

Read on to find out whether or not you could benefit from going on a Ketogenic diet.

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1. Gina Keatley, CDN

I would not recommend the ketogenic diet to any patients other than those suffering with epilepsy. The proper ratio of fat to protein to carbohydrate calories (80-15-5) is extremely difficult to maintain over any period of time. In many research studies over half of the participants drop out of studies before they have completed due to this difficulty and in other studies the researchers do not get institutional approval for such a strict limit of carbohydrates and use one with far more protein and carbohydrate (usually a 60-30-10 ratio). That being said what has been shown to lower blood sugar levels over the long term is losing weight--a diet that is calorie controlled and focuses on lean proteins have shown to be very beneficial and eas(ier) to maintain than a true ketogenic diet.

2. David Wiss, MS, RDN

I do not recommend the ketogenic diet for diabetes. The reason is because it is typically not sustainable for most people. Eventually, most people return to carbohydrate consumption and in some cases, people develop binge eating behavior. As opposed to having periods of low carbohydrate consumption mixed with high carbohydrate consumption, it is typically better to keep carbohydrate consumption stable and consistent, particularly if there are medications being used. Additionally, ketogenic diets are low in fiber. There is evidence that dietary fibers promote the growth of beneficial gut bacteria that is helpful for diabetes. Therefore, ketogenic diets have the potential to be harmful. And I always remind my clients that the best nutritional approach is one that can be sustained over the long run.

3. Dan Benardot, PhD, DHC, RD, LD, FACSM

Assumption: Question refers to Type II Diabetes (not Type I).

Ketones are synthesized by the liver and can be used peripherally as an alternative source of energy when glucose is unavailable. Ketones are also a factor in neurological function because the brain is unable to use fatty acids as an energy substrate when glucose becomes unavailable, but can use ketones as an energy source. It has been intimated that ketones may provide the brain with up to two-thirds of neurological tissue energy needs during starvation. However, the ketones are associated with the generation of oxygen free radicals that cause lipid peroxidation and are, therefore, implicated in diabetes associated vascular disease and, potentially, increased cancer risk.

There have been studies finding that lower-carbohydrate, higher-protein (i.e. Ketogenic diets) are effective in lowering weight in diabetics and may be useful in actually reversing, to a degree, diabetic nephropathy. However, there are also studies suggesting that the effectiveness of ketogenic diets may be the result of caloric restriction rather than ketogenic diets per se (i.e., the benefits are seen because of reduced energy intake rather than reduced carbohydrate intake.) In addition, the outcome measure for most studies assessing ketogenic diets in diabetics is 'weight', which is likely to be the wrong metric.

It would be useful to know whether the weight loss was due primarily to a loss of lean mass or fat mass, as the latter would be a much more powerful indicator of efficacy. Older diabetic patients are also at greater renal disease risk, which could be exacerbated by higher protein intakes that mandate greater nitrogen excretion. So, while I would not eliminate a ketogenic diet as a possibility, I would be highly cautious before recommending a ketogenic diet to a diabetic, and would likely try other means (sustaining a subtle energy deficit, eating more fresh fruits and vegetables, avoiding high-glycemic foods, etc.) that are associated with fat tissue loss and lean tissue maintenance.

4. Jody Greco

I don't recommend a ketogenic diet and I probably would not regardless of where I worked. Remember, I work with former drug addicts, many of whom are out of control diabetics and yet, won't switch to diet soda from the 2liters of regular soda. And I am not convinced that a ketogenic diet is the way to go with a type 2 diabetic. There are any other options before you start manipulating the diet in a rather unnatural way.

5. Allison Scheinfeld, MS, RD, CDN

A ketogenic diet can be beneficial for Type II Diabetics, but is not recommended for Type I Diabetics, due to the increased risk of developing a life threatening condition called Diabetic Ketoacidosis (DKA.) I would not recommend going keto without supervision by a Physician or Registered Dietitian, especially if you're on an insulin regimen. That being said, restricting dietary carbohydrates can improve insulin levels and promote normoglycemia. Part of this is due to the removal of the typical foods that cause a spike in glucose & insulin, such as simple carbohydrates and sweeteners. The benefits are also due to the weight loss that usually accompanies a ketogenic diet. Overall, I recommend a low carbohydrate diet for Diabetic blood sugar control, but not as extreme as the ketogenic's limit of 30 carbohydrates per day.

6. Hilary Raciti, RDN, CDN

Working day in and day out with various individuals, one thing I have learned as a dietitian is that no ​one “diet” works for everyone. Various diets, medical and some trendy, are frequently topics of interest to my clients. Of course, we want the key that unlocks health and happiness, but in reality is it that straight forward? When it comes to long term diabetes management, I emphasize consistency and moderation in diet, exercise, and stress control.

The Ketogenic diet severely limits carbohydrates and protein intake to about 20% of total intake leaving nearly 80% of the diet to be consumed as fats. In a sense, this diet mimics starvation as the body learns to create energy from fat rather than from carbohydrates. The body produces ketones as it burns fat for energy. This is said to increase insulin sensitivity thus improving blood glucose levels and diabetes-related consequences such as retinopathy, neuropathy, etc (Boden et al., 2005).

I do not recommend the ketogenic diet for two reasons: 1) I do not believe it is a realistic lifestyle for many of my patients with diabetes. 2) the long-term medical consequences are not yet well researched. Before we jump to prescribing extreme diets for disease management, it is critical to evaluate the likelihood that this style of eating can be carried out with leveled satisfaction, mental clarity, social inclusion and happiness. If a diet like the ketogenic does effectively reduce blood glucose levels, but majority of people only execute such a diet for a month before lack of commitment, what is the true benefit? A lifestyle change needs to be carried out in the long-run for results to be valuable. This is why I stress moderation in carbohydrate consumption and education on high fiber options for optimal results. This allows people with diabetes to eat a variety of foods, never feel deprived, but benefit from diabetes management. Carbohydrates (glucose) are our essential fuel source for a reason and this must be kept in mind. Carbohydrates are just as important for those with diabetes as those without such a condition.

The long-term consequences of the ketogenic diet are not well researched. Excess ketones, however, can lead to ketoacidosis, or an increase of acid in the urine and this necessitates careful monitoring of one's urine. What we do know is that excess ketones can result in ​dehydration, kidney stones, dehydration, menstrual changes, bone thinning, and inflammation of the pancreas. Since people with diabetes are already at risk for kidney disease, I do not believe increasing this potential comorbidity is a good idea. In addition to the above risks, vitamin and mineral deficiencies are only a natural result when eliminating an entire food group. Those following a ketogenic diet may need to supplement B vitamins, sodium, potassium and magnesium among other vitamins and minerals. In my opinion, the Ketogenic diet is too extreme to recommend without significant data demonstrating consistent long-term benefits and minimal health consequences.

Imagine going out to eat with family, celebrating a best friend's birthday or simply navigating an office lunch with such diet restrictions. Is this a lifestyle you would want for yourself? If yes, then we can talk how to carefully map out the ketogenic diet, but I genuinely believe education on how to properly incorporate carbohydrates in the right forms and amounts is the best technique to a long, healthful and happy life- for those with diabetes and for those without!

7. Vincci Tsui, RD

I don't recommend a ketogenic diet to most people with diabetes as the evidence doesn't support that it is necessary in order to manage the condition. I believe in the idea that eating should fit a person's lifestyle, not the other way around. For most people, a ketogenic diet would require a complete overhaul to a person's lifestyle, which in turn makes it unlikely to be sustainable in the long run. I work with all my clients individually to assess the changes that they are ready to make that will have the biggest impact on their diabetes.

8. Kim Schwabenbauer, MS, RD, CSSD, NASM-CPT

The ketogenic diet, by definition, is a very low carbohydrate diet (less than 20 grams per day) that limits and/or removes many food groups including dairy, fruits, vegetables and grains. As a dietitian, it is always difficult for me to endorse or promote a diet to anyone that is so limiting for any period of time. Very few long-term studies with adequate numbers of participants have examined the health implications of this type of diet on those with diabetes. In addition, every individual is so different that it is hard to recommend one type of diet to those many individuals that have a similar disease state because their genetics, medical history, weight history and eating patterns are so vastly different. My opinion is that while some modified version of the ketogenic diet may be appropriate for some individuals with diabetes to help control blood sugar, lose weight or lower HbA1C, each person should work with a registered dietitian, preferably one trained in diabetes education, to determine what type of diet might bring the most improvement and be sustainable.

9. Steve Della Croce, MS, RDN, CDN

In some cases a mild ketosis is safe and effective. We have found that lowering the carbohydrate intake of people who are overweight and/or have elevated blood sugar levels has significant benefits in losing weight and normalizing blood sugar levels. Often that means a higher percentage of good quality and high Omega-3 fatty acid intake. When doing so, the body burns fat for energy and creates an environment of ketosis. Thankfully, the brain and body can get the energy they need from fat. That being said, we help our clients avoid a full ketosis that would increase acid levels in the blood to a point that causes damage. We do so by including large amounts of non-starchy vegetables and moderate amounts of legumes/nuts. We have seen great results with this approach.

10. Tracy Lockwood, MS, RD, CDN

There are many risks in a ketogenic diet and there are even more risks in a diabetic who wants to experiment with the ketogenic diet. On the ketogenic diet we are drastically increasing our fat intake to about 70%, a moderate protein intake of about 20-25% and an extremely low intake of carbohydrates, less than 5%. There have been a small amount of cases in which the reduction of carbohydrates have shown to decrease and sometimes improve blood sugars levels and numbers in diabetics but it comes with some a slew of risks. These risks can start with symptoms such as headaches, fatigue, fogginess and if left untreated, possible coma and death.

There biggest risk is diabetic ketoacidosis which is the result of too many ketones in the blood, a lack of insulin and blood glucose spiking too high. Left untreated, diabetic ketoacidosis can be potentially fatal.

Another risk can very simply be the issue with yo-yo dieting, the constant back and forth of different diets and lack of consistency can be extremely dangerous to a diabetic. In addition, a ketogenic diet must be closely monitored by a health care professional. Because you are changing your bodies main energy source from carbs to using fat/ketones as the main energy source, your blood sugars can dip drastically during this process known as ketosis.

All in all, the ketogenic diet may pose some benefits on a diabetic with extremely close attention and consistent glucose monitoring. Moreover, with the potential risks factored in and the reality of truly sticking to the diet, the ketogenic diet for a diabetic may be very dangerous so the patient will have to evaluate what will provide them with the safest outcomes in the long run.

11. Alix Turoff, MS, RD, CDN, CPT

A ketogenic diet is definitely not appropriate for everyone and my recommendations would definitely depend on the individual client. I have personally worked with Type 2 diabetic patients on a ketogenic diet before and I have witnessed fantastic improvements in blood sugar control and weight management. Anecdotally, I've seen the ketogenic diet work very well for people with Type 2 Diabetes. My reservations in recommending a ketogenic diet for all type 2 Diabetics comes from the lack of long term research that we have on the safety of treating diabetes with a ketogenic diet. I would love to see more research done on this population. A ketogenic diet is not for everyone, it's very hard to follow and fairly restrictive, as you really can't eat any carbohydrates other than vegetables, and even then you have to limit those to non-starchy vegetables. That said, if a client is willing and able to follow a ketogenic diet, I would be willing to work with them on it for weight loss and blood sugar management.

12. Ryan Turner, RD, CSSD, CDN

Physicians refer diabetic patients to me specifically to be placed on a ketogenic diet. Have I seen positive research promoting it? Yes. Have I seen positive outcomes from it? Yes, though mainly with my more active population. The challenge with the ketogenic diet is patient satisfaction and compliance. The majority of my patients presented with a diet to promote ketosis are turned off by the lack of variety and restriction. They feel it's not practical in their day-to-day lifestyle. My patients tend to thrive with a bit of food education, a discussion regarding practical lifestyle changes, personalized meal planning which includes carb control and promotes protein and fiber. I don't recommend a ketogenic diet for my patients. I'm not an anti-keto Dietitian, however it is not my initial recommendation.

13. Jim White, RD, ACSM

Under the supervision of a registered dietitian, I think it is fine for someone with type 2 diabetes to try the ketogenic diet. It is well-documented that weight loss is associated with improvements in blood sugar and overall health for individuals with type 2 diabetes. Research has shown that, when followed carefully, a very low-calorie-ketogenic (VLCK) diet can be a safe and effective approach to weight loss for these individuals. Compared to patients with diabetes who follow the “Create Your Plate” diet recommended by the American Diabetes Association, those who follow the VLCK diet have been shown to experience greater reductions in their HgbA1c values. More than half of patients following the VLCK diet have lowered their HgbA1c below 6.5%, compared to 0% of those following the “Create Your Plate” diet.1,2,3 Over an approximately 8-month time period, people with type 2 diabetes following the VLCK diet have lost over 20 pounds more than those adhering to the “Create Your Plate” diet (equating to almost 25% more weight loss for individuals on the VLCK diet).1,2

Recent research has shown that 90% of patients with type 2 diabetes who follow the VLCK diet lose at least 5% of their body (a treatment recommendation routinely provided to patients with type 2 diabetes), compared to just 29% of patients following the “Create Your Plate” diet.1,2 In addition to weight loss, those with type 2 diabetes following the VLCK diet have been shown to lower their triglyceride levels by ten times more than those adhering to the “Create Your Plate” diet.1,2Though there is new research to support the efficacy of the VLCK diet for patients with type 2 diabetes, those wishing to try this extremely restrictive diet should consult a registered dietitian prior to beginning this dietary regimen and should remain under the supervision of a registered dietitian throughout their course of adherence. Since the majority of current research on the ketogenic diet for individuals with diabetes has been centered around type 2 diabetes (for purposes of weight loss in this population), I would currently not recommend the ketogenic diet for patients with type 1 diabetes who are of a healthy weight.

14. Manuel Villacorta, MS, RD

I would not recommend the ketogenic diet to anyone, not even people with diabetes. In my practice, I have helped many regulate their glucose control without going to extremes. Yes, carbohydrates affect people differently, thus the treatment should be customized to each individual. I normally put my diabetic clients on a 40-45% carbohydrate ratio and have them eat them throughout the day in combination with protein to prevent blood glucose spikes. I have found that this is sufficient and effective enough.

15. Kacey McCoig MPH, RDN, CLT, CMT

Though there is evidence supporting the safety and efficacy of low (<130g/day or <26% of total kcals) and very-low (20-50g/day or <10% of total kcals) carbohydrate diets for diabetic patients, it's important to individualize macronutient ratios for clients depending on a variety of factors such as their current eating patterns, food preferences and level of glycemic control. Though the ketogenic diet is proving safe and effective, other eating patters/diets such as the DASH diet, plant-based and My Plate Method also work well for people.

16. Elana Natker, MS, RD

I'm not an expert on the Ketogenic diet, but generally – no, I would not recommend the Ketogenic Diet to diabetics. I find that carb-counting – the standard in diabetes management – is simple enough and effective. It reinforces the need for some carbohydrates at each meal and snack (just not too much). The fear with the ketogenic diet is that it's too low in carbohydrates, but more than that – it's also lacking in protein, which is important in a diabetic diet.

17. DR. KAREN REZNIK DOLINS, EdD, RD, CSSD, CD-N

I do not recommend a ketogenic diet for individuals with diabetes. Carbohydrate foods from unprocessed or minimally processed sources provide essential nutrients, antioxidants, fiber, and help ensure a healthy gut microbiota. Blood sugar can be well controlled when carbohydrate is consumed in appropriate amounts and distributed properly throughout the day. Exercise is recommended for those with diabetes, and carbohydrates are an essential fuel.

18. Alana Kessler, MS, RD, CDN, Ayurveda Nutritionist and E-RYT

I believe diet to be be two fold. On one hand it nourishes the body and on the other in nourishes the mind and heart. The Ketogenic diet, where from a physiological perspective helps to manage diabetes type 1 and 2 by helping to regulate insulin needs and adipose storage, I believe it is important to also pay attention to the mood and energetic effects of adopting this kind of diet.

Diabetes Type 1 and 2 is both a genetic, environmental and lifestyle acquired disease respectively, and for type 2 there are often underlying psycho-social issues with lead these individuals to overeat and choose foods high in carbohydrates. Grains in Ayurveda, have a grounding, nourishing and calming effect, and naturally stimulates production of serotonin. Serotonin is essential not only to control your appetite and stop you from overeating; it's essential to keep your moods regulated. High Protein diets in excess result in an overproduction of acid causing irritability, impatience and anger and can lead and or trigger depression and overeating in and of itself.

Ultimately, the body breaks all nutrients down to sugar if eaten in excess. Therefore, I believe it is important to not only manage the symptom of diabetes, but also take into consideration the individual before prescribing any extreme diet plan, and to address, respect and support the cause of any disease.

19. Samantha Heller, MS, RD CDN

Ketogenic diets have been in use since the 1920's. There is some evidence that they have beneficial effects children aged over 1 year, adolescents and adults diagnosed with drug resistant epilepsy or an inherited neurometabolic disorder, for example, Glut-1 Deficiency Syndrome or Pyruvate Dehydrogenase Deficiency1,2 . Studies suggest a ketogenic diet may be beneficial for some people with type 2 diabetes who may experience symptomatic as well as objective improvements in biomarkers of disease risk1. However, the studies have been small and of rather short duration (for example 3 weeks, 56 weeks). The participants were likely highly motivated.

Ketogenic diets are very restrictive and long term compliance is an on going problem. It has been my experience in working with patients with type 2 diabetes that lifestyle changes that include significant dietary changes e.g. decreasing carbohydrate intake, are challenging; even when the therapeutic diet prescribed is carefully individualized per the patient's lifestyle and preferences. Suggesting patients subscribe to a ketogenic diet, for most patients is unrealistic. Many patients struggling with pre-diabetes or type 2 diabetes have long term, complex, relationships with food, and recommending a highly restrictive approach to diet such as the ketogenic diet would be off putting to say the least. Patients need to be able to adopt dietary and lifestyle changes that they can adhere to for a lifetime, that include a healthy, balanced diet, blood pressure control, lipid management, and glycemic control.

Goals of Nutrition Therapy:

• General recommended goals from the American Diabetes Association for these markers are as follows:
  - A1C <7%.
  - Blood pressure <140/80 mmHg.
  - LDL cholesterol <100 mg/dL; triglycerides <150 mg/dL; HDL cholesterol >40 mg/dL for men; HDL cholesterol >50 mg/dL for women.
• Achieve and maintain body weight goals.,
• Delay or prevent complications of diabetes.

1. It remains to be seen whether long term adherence to ketogenic diets can provide all the nutrients that a healthy, balanced, lower carbohydrate diet does.

20. Alexis Beck MPH, RD, LDN

I would not recommend the ketogenic diet to somebody with diabetes—type 1 or type 2 for the same as well as distinctive reasons.

While at first blush it sounds like a cogent solution I believe the risks outweigh any perceived benefits.

The Ketogenic diet ostensibly changes your body's primary energy source from carbohydrates to fat resulting in the body using fat for energy instead of carbohydrate or glucose. This fact leads to the body's reduced requirement for insulin—which might sound like “just what the dietitian (RD) ordered”.

Not so. There are some complications/dangers worth noting.

 

21. Inna Topiler, MS, CNS

A ketogenic diet can be helpful in various conditions including diabetes. When it comes to diabetes, it is essential that blood sugar is controlled and we prevent fluctuations where blood sugar swings up and down. When blood sugar is consistently high, more and more insulin needs to be produced to bring it down. This then leads to insulin resistance resulting in higher glucose levels. To control diabetes, we need to reduce the amount of carbohydrates as they raise blood sugar levels. A ketogenic diet is high in protein and healthy fats while low in carbohydrates. This is very helpful in diabetes because proteins and fats do not elevate blood sugar the way carbohydrates do, therefore preventing blood sugar spikes and reducing the need for insulin.

22. Jalpa Sheth, MS, RD

I DO NOT recommend Ketogenic diet to anyone with diabetes. Here's why:

1. Ketogenic diet (all fat, least protein and no carbs) is a very restrictive diet and hard to follow long term.
2. Ketogenic diet emphasizes on one macronutrient (Fat) while ignoring the importance of others (carb, protein and natural sources of vitamin & minerals). Thus, leading towards nutritional deficiencies if followed long term.
3. Diabetes, most of the time, is accompanies by cardiovascular disorders as a part of Metabolic Syndrome. While trying to control blood sugar levels in diabetics through ketogenic diet, one can exacerbate the symptoms of cardiovascular disorders, or may increase the risk of developing it in case of absence.
4. It is well proven in literature that regular exercise regimen that can help you build your muscle mass is very helpful to control and improve blood sugar levels as muscular tissue is the most Insulin sensitive tissue. All fat diet, by no means, can feed your muscles.

All in all, despite some research being published in favor of the use of ketogenic diet for diabetes, it is no less than any other fad/crash dietary approach. Thus, consumption of slow realising carbs (carbs with fiber and protein such as whole grains) as a part of nutritionally balanced diet along with regular exercise regimen still remains the best advice for diabetics.

23. Arlene I. Semeco MS, RD, LD/N, CISSN

The ketogenic diet is my number one recommendation for diabetic patients, whether it is Type 1 or Type 2 diabetes. For Type 1 diabetics, the ketogenic diet will help them control their blood sugar levels and be able to maintain more steady levels and a more defined area. They will also be more likely to reduce their hyperglycemic episodes and therefore help them reduce their regular dose of insulin to a minimal. For type 2 diabetes, less carbohydrate intake will help patients reduce their blood sugar levels and similarly reduce the need for high insulin doses and carbs counting for those in insulin. For those taking oral medications, patients will be able to reduce their regular doses as well.

The combination of ketogenic diet and exercise is the best approach, of course. There is plenty of data that shows that limiting carbohydrate intake and combining low carbohydrate diet and exercise (which can help achieve a healthy body weight) can help diabetic patients reduce their insulin or oral medication regimen and potentially stop the need for it all together.

24. Fiona McKiernan, MS, RD, CSG,

The ketogenic diet, if followed under direct medical supervision, for a short period of time, results in many beneficial outcomes for Type 2 Diabetics – mainly rapid weight loss and improvement in blood glucose/A1c levels. However, if an individual is on medication to control blood sugars it places them at increasedrisk of hypoglycemia. This demands much tighter blood glucose monitoring and physician-directed medication adjustments. Due to the lack of variety, unpalatability and restrictive nature of the diet it is also very difficult to maintain long term. It increases the risk of nutritional deficiencies, sets the stage weight regain once higher carbohydrate foods are reintroduced, and creates increased stress around eating, particularly in social settings.

Individuals also respond differently to the ketogenic diet. Some experience an increase in memory, while others report increased brain fog and irritability.Emerging evidence, from the Alzheimer's research field, suggests this difference may depend on an individual's genetic profile.

For these reasons, I prescribe a personalized nutrition plan, tailored specifically to an individual's needs. As a starting point, I recommend a diet rich in nutrient dense, organic fruits and vegetables, grass fed, pasture-raised, organic proteins, and a moderate amount of healthy fats. If needed, I include medium-chain triglycerides rather than long-chain triglycerides as these are more palatable and better tolerated. This approach is easier to follow long term, limits blood glucose swings from highly processed carbohydrates, provides adequate protein for muscle building, and supplies healthy fats for optimal health.

If an individual still wishes to try a strict ketogenic diet I would recommend seeking the advice of a registered dietitian nutritionist or physician with experience in the field. It is difficult to get into a true ketogenic state and it can be detrimental to a person's health, particularly if Type 1 Diabetic, if not done under medical supervision.

25. Carrie Gabriel MS, RDN

Research done on the ketogenic diet have shown effects such as reducing high blood pressure, triglyceride levels, raising good (HDL) cholesterol levels and reducing blood sugar fluctuations, which would mean that the effects on diabetics could potentially be positive. Since this is a high fat diet, I would say to focus on eating healthier fats like salmon, avocado, walnuts and flaxseed oils and be moderate in consumption of greasy, heavy meats, cheeses and saturated oils.

26. Dr. Susan Shapiro, PhD, MS, MS, RDN, FAND, CAMS-II

I would not give a blanket yes or no response, as I would have to evaluate the person with either condition. However, this is the type of plan that might be beneficial for someone with either type of DM, who also has excess of body weight, aka body fat. The goals of the dietary plan are the same for both types of DM. The primary focus is to shift the body's need for fuel from carbohydrates (CHO), to being able to utilize Fats (F) instead. The benefit of this metabolic change is that people need less medication, their blood sugar levels are lower and they can lose a lot of weight. This metabolic change is achieved by limiting the daily intake of carbohydrate (CHO) to no more than 30 grams/day. Please note that this adaptation may take up to FOUR (4) weeks to achieve, and the side effects can be life threatening and or make staying on the diet difficult. This is why it is important to be monitored by a registered Dietitian as well as an MD.

27. Mike Lovell, N.C.

When I deal with diabetics in my clinic, I find that for the most part they are a slow oxidizer. This means that they are not producing adequate energy for demand at the cell level. There are many reasons for this, but what is most common is the body's inability to utilize glucose (blood sugar). Again, there are a number of reasons for this (all can be corrected through diet and supplementation). The main cause is low Potassium at the cell level. Potassium is needed to transport glucose across the cell membrane to be used as fuel.

A modified ketogenic diet is recommended for these clients due to the fact that they can't utilize the glucose efficiently nor can they utilize high amounts of fats. Our target is 6 to 8 cups of cooked vegetables a day with increased protein intake (real meat), and good fats (real butter, olive oil, coconut oil, dairy, etc.).

28. Dr. Michael Todd Greene, Ed.D., M.S., R.D.

I would not recommend a ketogenic diet for someone with DM unless they also suffered from epilepsy. The diet is primarily recommended for hard to control epilepsy in children. I would consider suggesting the Consistent Carbohydrate Diet that is outlined by organizations like Academy of Nutrition and Dietetics and American Diabetic Association.

29. Judith Mabel, RD, PhD, CLT

First of all, I do not work with Type 1 diabetics; only Type 2. I never considered a ketogenic diet per se, but my plans are very low carb and low GI/GL.

I think I stay away from ketogenic for long term eating because it is hard to stick to. My plans also vary with the person I am seeing re: age and weight. One size does not fit all.

The other very simple reason I don't use it is that I wasn't trained that way. I have changed in how I work with menu plans, but not that one.

30. Katie Chapmon, MS, RD

I am very thoughtful about recommending a ketogenic diet to a patient with diabetes. I feel that it is a type of diet that needs to be closely monitored so that it isn't taken into a direction that can be harmful. Additionally, some people may be sensitive to that low of carbohydrate intake and may need to have additional adjustments to this diet. The Ketogenic diet is not one of my first choices in diets that I recommend, however, it can be a consideration for a patient that I think would do well with it.

31. Emma Gaskin, RD

Currently there is a lot of debate around carbohydrate intake -specifically low carbohydrate diets- in those with diabetes. The theory behind this is that these are the most suitable for those with diabetes.

First let's look at what a ketogenic diet is:

A ketogenic diet is a high fat and low in carbohydrate diet. There are different definitions of the amount of carbohydrate to include in a ketogenic or very low-carbohydrate diet. These vary from 20g per day to 50g per day (or less than 10% of overall energy intake) . To put this into context current intakes of carbohydrates in the diet in America & the UK are around 50% of overall energy intake (this equates to 250g to 330g per day – dependent on age & gender).1

Ketogenic diet & diabetes: A reason this is such an area of interest is because carbohydrates have the biggest effect on a person's glucose levels. Restriction of carbohydrate has shown the greatest reduction on glucose levels1. There has also been a large body of research within this area, however as many studies contradict each other it can be difficult to know what the evidence means.

Type 1: There have been studies which have shown that by adopting a low carbohydrate diet of <75g per day, has resulted in significant improved HbA1c levels, and as a result reduced insulin doses. Though promising, these were small studies. In addition, there have been studies that have shown no significant difference in glycaemic control when following a low carbohydrate diet . Due to the lack of evidence and lack of long term data,DiabetesUK&the American Diabetic Association do not recommend low carbohydrate diets for type 1 diabetes. The current evidence suggests that to improve glycaemic control in type 1 diabetes is by carbohydrate counting .7

Type 2: Data from systematic reviews and meta-analysis have shown that a low carbohydrate diet is effective for weight loss, improved glycaemic control and reduced cardiovascular risk , , , . This type of evidence is a lot stronger than that for type 1 diabetes. However, it is worth noting that ketogenic diets were not found to be superior to other methods of weight loss . In addition, though ketogenic diets were found to produce the greatest weight loss compared to other diets, in the long term there was no difference . This means ketogenic diets are not superior to other weight reducing methods. Both Diabetes UK and the American Diabetes Association recommend long term weight loss and for individuals to find the right lifestyle changes that suit them. This could include a low-carbohydrate diet as we know it is safe for those with diabetes, or another diet.5,6

It is not recommended to use low-carbohydrate diets in children as this can lead to growth failure and nutritional deficiencies. If you choose to go low-carb:

• Inform your healthcare professional as it is likely your diabetes medication may need adjusting.
• Consider the amount of carbohydrates you want to include; many studies that have shown beneficial effects have been because of low to moderate carbohydrate intakes (130g-225g per day) rather than very low carbohydrate intake (around20g-50g per day).
• Monitor glucose levels closely, if you are experiencing hypoglycaemia or hyperglycaemia, you should seek advice about the diet and managing your glucose levels by a healthcare professional.
• Often by reducing the carbohydrate in your diet means the fat in your diet may increase. Choose fat sources that are unsaturated such as avocados, olive oil, olives, rapeseed oil, unsalted nuts, seeds and oily fish. Avoid saturated fats such as butter, lard, ghee, suet, coconut oil or cream, fat on meat, full fat dairy products, processed foods such as cakes, biscuits, pies, pastries and takeaways.
• Carbohydrates will still be in your diet (even if in small amount) – consider wholegrain options (such as brown rice, granary breads and wholegrain pasta) and include fruit and vegetables. Avoid including refined carbohydrates such as white bread, white rice and pasta.

32. Shefali Ajmera, MS, RDN, LDN, CDE

Ketogenic is next popular diet after paleo. Ketogenic diet has tons of researches done in last decade, more precisely in last few years. Ketogenic diets are consisted of high fat food options which supposed to feel you up, control your hunger and keep you stay full for longer than typical meal. As a professional we always say that it requires in depth nutrition assessment to really say if you are good fit for ketogenic diets depending on your current lifestyle, presence of various risk factors more specifically cardiovascular risk factors (lipid profile, blood pressure), age, status of your digestive track, and history of other chronic medical conditions.

For someone with diabetes, ketogenic diet is okay if done in moderation with professional supervision along with regular check up of blood sugar to make sure that individual does not go in chronic state of hypoglycemia without signs and symptoms which happens rare, but if it does happen it can be fatal. It is always advisable to add some plant based high fat options not only animal based to balance out MUFA, PUFA, and saturated fat, along with smaller quantity of whole grain healthier, more complex carbohydrates options.

Conclusion

It is really hard to go on a diet, whether you are looking to lose or maintain your weight. Add on to that the restrictions that come with having diabetes. The experts above share their reasons for why they do not generally recommend a ketogenic diet to their patients who have diabetes. We hope you have gained some insight to help you educate in understanding the impacts of a diet on your body. Please keep in mind that it is also very important that you speak to your family doctor or your specialist before deciding to go on any diet as it can have a dramatic impact on your overall diabetes management. Please share any comments and tips you may have in the box below. We love to hear from our readers.

TheDiabetesCouncil Article | Reviewed by Dr. Sergii Vasyliuk MD on September 14, 2018