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Keto Diet

Ketogenic Diet for Diabetes: Benefits, Risks, Tips, and More



You’ve probably seen dozens of headlines about the ketogenic diet by now. Called keto for short, it has made its way into popular culture largely through the celebrities and supermodels who have given the long-standing fad diet a repeated stamp of approval. Is the keto diet the plan to follow if you have diabetes?

The diet is undoubtedly risky for people with type 1 diabetes, but in terms of type 2 diabetes management, several studies suggest the answer isn’t so simple. Some science shows that the keto meal plan may be helpful, while other research, like one study published in September 2016 in Nutrients, highlights the importance of whole grains in the diets of people with diabetes — a healthy yet restricted food category in the keto diet.

While the keto diet may offer many potential benefits for diabetes management, following it requires a pretty serious commitment. So take a beat before you take the plunge — and consider these questions that can help you and your medical team determine if it’s right for you.

How the Ketogenic Diet Works

There’s a good reason why the keto diet is also referred to as a low-carb, high-fat diet. Following the keto diet means reducing intake to typically less than 50 grams (g) of carbohydrates per day while increasing fat and moderating protein intake, according to a review published in July 2021 in Frontiers in Nutrition.
To put that into perspective, a person on an average nonrestricted diet can easily eat more carbohydrates than that in one typical meal. For instance, a turkey, cheese, and veggie sandwich on whole-grain bread with a 1-ounce bag of classic potato chips comes in at around 52 g of carbs. The keto dietary changes drive down insulin levels, eventually leading your body into a state of ketosis, during which it is burning fat rather than carbohydrates, according to the Harvard T.H. Chan School of Public Health.

Possible Benefits of the Ketogenic Diet for Type 2 Diabetes

Here’s how the keto diet may help if you’re managing type 2 diabetes: “With a higher protein and fat intake, individuals may feel less hungry and are often able to lose weight, since protein and fat take longer to digest than carbohydrates,” says the Manhattan Beach, California–based Lori Zanini, RD, CDCES, the author of Eat What You Love Diabetes CookbookIt may also help keep your energy levels up.

The diet may offer additional benefits. A review published in January 2021 in BMJ suggests that a low-carbohydrate diet like keto may help bring a person with diabetes into remission, which is defined as having an A1C test result of less than 6.5 percent or fasting glucose of less than 7.0 mmol/L, with or without the use of diabetes medication. (A1C shows a three-month average of blood sugar levels.) That remission is not extremely likely, and whether it is permanent is unclear — long-term diet adherence is typically required for maintenance of remission.

The diet may help lower triglycerides, too, and may assist with weight loss, which is a benefit for people with diabetes, who are at a greater risk for heart disease.
Furthermore, a keto diet may be 3 times more effective for weight loss than a low-fat one — important because losing as little as 5 to 10 percent of your body weight can offer health benefits such as improved cholesterol, blood pressure, and blood sugar control, according to the Centers for Disease Control and Prevention.
Keeping the weight off long term with diet and exercise changes can only increase the benefits you’ll see.
But while keto diets may be effective at weight loss, they are not more effective than other diets when followed long term and matched for calorie intake, according to the Frontiers in Nutrition review.
What’s more, another review found that a keto diet may help improve cholesterol levels and fasting blood sugar levels.
In the same Frontiers in Nutrition review, authors note that low-carbohydrate diets may increase LDL (“bad”) cholesterol levels.

Health Risks of the Ketogenic Diet for Type 2 Diabetes

A study published in July 2016 in the Journal of Obesity & Eating Disorders suggests that people with type 2 diabetes who take oral medication to lower their blood sugar may be more at risk for hypoglycemia, or low blood sugar, when following a keto diet.
A keto diet could cause other unpleasant effects, including bad breath, dizziness, nausea, headache, fatigue, confusion, excessive thirst and hunger, fast heartbeat, fever, and chills. Also, the Frontiers in Nutrition review reveals potential elevations in LDL cholesterol when following a low-carbohydrate diet, as well as a possible increased risk of cardiovascular disease, cancer, and Alzheimer’s disease. And pregnant women in the review were more likely to have a child with a neural tube defect when following a keto diet.

Overall, study findings on the potential benefits — and risks — of the keto diet for diabetes are mixed. More studies are needed before scientists understand the long-term implications of the eating plan for this group.

People With Diabetes Who Shouldn’t Try the Keto Diet

What’s certain is this diet isn’t for you if you have kidney disease — one reason being that you want to limit protein in that case, Zanini says.

Also be wary of the keto diet if you have type 1 diabetes. Ketones, which are produced by the body during ketosis, are a risk factor for diabetic ketoacidosis, which is more common in people with type 1 diabetes than people with type 2 diabetes, according to the American Diabetes Association.
You would need to be very diligent about monitoring other potential symptoms of DKA, notes White.
Additionally, anyone with a personal history of heart disease should be cautious about the keto diet. Cholesterol levels tend to spike during the initial stages of the diet, which could increase the risk of heart disease, according to Harvard Health Publishing.
Yo-yo dieting, which can happen easily on a restrictive diet like keto, can strain the heart as well, increasing the risk for stroke and heart attack, per a large study published in October 2018 in Circulation.

Last, if you have a history of struggling with an eating disorder, work with your doctor to determine if this is the right diet for you. Despite what you may have read online, the keto diet and a personal history of binge eating disorder do not mix. In fact, “Because of the severe carb limits imposed by the ketogenic diet, the risks of bingeing, compulsive overeating, and other eating disorders is much higher,” says White.

How to Start the Keto Diet if You’re Living With Type 2 Diabetes

If you decide to start the keto diet, don’t go it alone.

Some clinics have introduced therapeutic ketogenic programs for their patient with type 2 diabetes. The Cleveland Clinic has one, and Virta Health, which offers a keto-style diet and lifestyle program through telemedicine, has sponsored research showing that using online support may help people with type 2 diabetes lose weight, lower their A1C, and get off diabetes medication more successfully than the diet recommended by the American Diabetes Association. The study was published in February 2018 in Diabetes Therapy.

You’ll also find heat-and-eat keto meals that you can order online at Factor. Subscribe and you get a complimentary session with a registered dietitian.

Above all, if you’re interested in trying keto to manage diabetes, talk with your diabetes medical team — including your endocrinologist and a registered dietitian who is also a certified diabetes care and education specialist — before trying this eating plan. Start the diet slowly, cutting carbohydrates gradually, Zanini recommends. Dramatic reductions could lead to hypoglycemia, especially if you’re on oral diabetes medications or insulin.

Regularly test both your blood sugar and ketone levels to prevent serious side effects. “Doing so is very important for avoiding DKA,” says Sylvia White, RD, CDCES, who works in private practice in Memphis, Tennessee. “Warning signs of DKA include consistently high blood sugar, high ketone levels, dry mouth, nausea, vomiting, and frequent urination — and complications can cause a diabetic coma.”

Consume a balance of nutrients — all those important vitamins, minerals, fiber, and more — as well as the proper amount of calories and healthy keto-friendly fats. “Healthy fats include monounsaturated fats and omega-3s, which may help reduce inflammation in the body and improve cholesterol levels,” says White. Look to fatty fish like salmon for omega-3s and avocado, almonds, peanut butter, and sunflower seeds for monounsaturated fats.

If you’re not sure what to reach for, ask your dietitian. “While this sounds so simple, often people are only thinking about what not to eat,” says Zanini. “They don’t pay attention to the nutritious foods they should be including, like nonstarchy vegetables, healthy monounsaturated fats, lean proteins, and more.” Don’t have a dietitian? You can find one who is a certified diabetes educator through the Academy of Nutrition and Dietetics “Find an Nutrition Expert” tool.

Tips for Sticking to the Low Carb Count on the Keto Diet

“Simply put, it is not easy to eat just 20 to 60 g of carbohydrates per day, which is how many carbs are permitted on the ketogenic diet,” says Zanini. “To follow this strict guideline, people must not only change the food they’re eating but their entire lifestyle.”

Foods that are a typical part of the American diet, like sandwiches, burgers, and milkshakes, won’t easily fit into the food plan, and foods considered staples of a balanced diet, such as sweet potatoes and whole-grain bread, may need to be limited. These changes can be tough to implement, even for people who’ve already started making their diets healthier. Tracking what you eat can help. You can do so either with a written food diary or through various apps on your smartphone.

You can’t take days off the diet, though. You must stick with the diet if you want to see the benefits — otherwise you’re really just eating a high-fat diet.

A Diabetes-Friendly Keto Diet Food List

When in doubt, keep in mind that you will want to avoid or limit any foods that are high in carbohydrates while loading up on foods that are high in protein and healthy fat.

Here are some common foods in a keto diet plan that can also be diabetes-friendly:

  • Poultry and meat
  • Fish
  • Avocado
  • Nuts and seeds
  • Eggs
  • Non-starchy veggies
  • Olive oil

Here are some foods to limit or avoid in a keto diet plan, regardless of whether you have diabetes:

  • Grains, including healthy whole grains, like brown rice, and whole-wheat bread and pasta
  • Alcohol
  • Fruit, especially high-carb fruits such as tropical fruits
  • Sugar in all forms (granulated sugar, brown sugar, corn syrup, baked goods, candy)
  • Processed food, including crackers and corn or potato chips

Are Other Diet Plans Better Than Keto if You’re Managing Type 2 Diabetes?

Even if your healthcare team deems keto safe for you, the keto diet isn’t necessarily the best path for everyone with diabetes. Some studies suggest that other eating plans, like the Mediterranean diet — which is rich in lean meats, fish, nuts, fruits, vegetables, olive oil, and whole grains — can be beneficial for people with the disease. A review published in April 2021 in the journal Nutrients found that some research links the Mediterranean diet to a reduced risk of developing type 2 diabetes.
A review published in August 2020 in Nutrients suggests that following a Mediterranean diet may lower the risk of diabetes. The eating style may also aid people already diagnosed with diabetes. The review cites some studies that associate following a Mediterranean diet with better blood sugar control.
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