by Ayotola Ogunsipe, Edited by Christopher M. Cirino, DO MPH

There are many different approaches to starting a low-carb diet. One option that has garnered significant interest over the years is the ketogenic diet (Keto). This diet is a high-fat, low-carb eating pattern that can help someone to lose weight and cut cravings. It is also an effective option if you are one of the more than 400 million people worldwide who has diabetes.

But there are questions about the effect of a high-fat meal on health, considering that diabetes and fats have been linked to cardiovascular disease. To better understand the keto diet’s impact, especially in diabetes, we will examine how this diet works and evaluate its suitability for those living with the condition.

Keto diet 101

In simple terms, the ketogenic diet is a low-carb, high-fat diet. In context, most of us eat at least 50 percent of carbs for our total intake, but, when you decide to switch to a keto diet, you replace some of those carbs with fat. The typical keto diet contains fats as 60 to 80 percent of your total daily calorie intake, while protein comprises 10 to 15 percent and carbohydrates are 10 percent. 

While fat is a crucial component of the keto diet, it isn’t uncommon for many people to associate ‘fats’ with unhealthy, but not all fats are harmful. Some high-fat foods that are also healthy include avocados, walnuts, cashews, almonds and chia seeds, salmon, sardines, and mackerel.

The science behind the keto diet for diabetes

When on a keto diet, reducing your carbs intake triggers a metabolic state called ketosis, decreasing your blood sugar and insulin levels. This process, also known as nutritional ketosis, is a vital fat-burn mechanism that allows the body to convert fats to ketones, which it then uses as its energy source.

In 2008, a study to evaluate the effect of a low-carb keto diet on people with type-2 diabetes and obesity, which took place over 24 weeks, revealed that the keto diet significantly improved glycemic control and reduced the need for medication in the participants with diabetes. Other research (2013) bolstered the previous study, determining that the ketogenic diet improved blood sugar control, A1c, weight loss, and reduced the need for insulin in some. There was also a 2017 study where the keto diet outperformed a low-fat diabetic diet over 32 weeks, leading to more significant weight loss and lower A1c levels.

Drawbacks of the keto diet

Fatigue

The palatable foods with higher fat generally balance the rigor of low carb intake. At the initial stage of the keto diet, you may start to get unusually tired, which can be a reason why some people are unsuccessful with it. The fatigue, supported by some studies, comes from the lower blood glucoses and increases in ketone bodies (blood beta-hydroxybutyrate.) However, if you continue the diet, regardless of these signs, you will start regaining some of your lost strength because your body will eventually switch its energy source from carbs to fats (ketones). 

Lipid Profile?

The keto diet promotes changes in the lipid profile. There is an improvement in the triglyceride and High-density lipoproteins (HDL) levels. The low-density lipoprotein (LDL) values increases, a pattern associated with an increased risk of atherosclerosis. However, there has yet to be any association found between heart disease and the keto diet. It is possible that the benefits in triglycerides and HDL may lead to a more favorable dynamic. Additionally, another factor not always addressed is the quality of the diet, e.g. certain foods that fit a keto diet may be less healthy than others.

Ketoacidosis Risk?

The Keto diet is named after nutritional ketosis, which is the body’s starvation where glucagon signals cause adipose stores to be converted to triacylglycerols, or “ketone bodies,” while insulin levels remain low. The mechanism of ketoacidosis produces a several-fold higher level of ketones than ketosis, causing the blood to become acidic. This condition primarily occurs in type I diabetes, where the body’s insulin production is absent in the setting of unopposed glucagon.

Certain conditions may make the keto diet challenging to adopt for some people with diabetes. Infections, pancreatitis, and myocardial infarction all can trigger diabetic ketoacidosis (DKA) (in type I). Alcohol intake on a keto diet can stifle progress, slowing the rate of ketosis. If you have liver or kidney problems, starting a keto diet can put a lot of strain on these organs and precipitate kidney or liver injury. 

The keto diet is not usually recommended for a long-term diet in type 1 diabetes or Latent-Autoimmune Diabetes in adults (LADA), sometimes referred to as type 1.5 diabetes. In the past before insulin was available, doctors recommended very low carbohydrate diets (<10gm/day). With the benefit in weight loss and glycemic control, a keto diet may be an ideal short-term diet to optimize glucose control and lose weight. However, a keto diet may rarely precipitate ketoacidosis in some persons with type I diabetes.

Remember, ketoacidosis results from the lack of insulin in the setting of unchecked glucagon. A keto diet for type I diabetes requires close monitoring and supervision. You should regularly monitor your sugar and ketones levels when on the keto diet to ensure it isn’t affecting your body negatively. Along with at-home regular glucose checks, a urine test kit for the ketone levels is helpful.  If you are on an insulin regimen or taking medications that lower your blood sugar, combining the diet with your medications can increase your risk of developing hypoglycemia.

You can also know once your body has switched to a state of ketosis based on initial signs, such as thirst, tiredness, frequent urination, and a fruity breath smell. An effective keto diet should maintain a low or moderate level of ketones in your urine or blood. If you use the at-home urine test kit, a goal for the urine ketone levels is between 0.5 and 3 mmol/L. If it goes above 3mmol/L, you are at risk of developing diabetic ketoacidosis. Some signs of DKA include dehydration, frequent urination, nausea, abdominal pain, and difficulty breathing.

Things to consider when starting a keto diet:

As a person with diabetes starting a keto diet, here are some additional things to consider:

• Following a keto diet may mean losing out on some important nutrients for your body like selenium, magnesium, phosphorus, B vitamins, and vitamin C. To avoid this, ensure you incorporate various fruits, grains, and low-carb vegetables like cabbage, broccoli, and leafy greens (arugula, spinach, kale, chard, etc.)
• When switching to a high-fat diet, you have to be wary of your saturated fat intake, usually from processed foods and refined oil.
• If you have gallstones, a high-fat diet may lead to some gallbladder activity. You may have to introduce the diet slowly.

Conclusions

Diabetes is a chronic disease that causes high blood sugars and affects more than 400 million people worldwide. While no cure exists for the condition, strategies such as eating a low-carb diet, losing weight, and exercising can help people living with the condition.

Anyone living with diabetes should talk to their doctor to clear any doubts or concerns before starting the keto diet. Sometimes their doctor can make dose adjustments to insulin or other medications, if they would like to consider this diet for weight loss and diabetes management.

If you have prediabetes, here is a YHF link for the Keto diet in prediabetes.