There are several special considerations when initiating any type of ketogenic diet. The ketogenic diet is low in fiber and calcium and insufficient in folic acid and vitamins B6 and B12; therefore, supplementation is recommended.6,7  Low-carbohydrate diets (<40% of calories from carbohydrates) also have a diuretic effect, increasing the risk for kidney stones with inadequate hydration.6 A renal ultrasound and nephrology consultation may be recommended if there is a family history of kidney stones.3 For individuals with inborn errors of metabolism, a ketogenic diet may affect the transport and/or oxidation of long-chain fatty acids, which can lead to catabolic crises. For this reason, the ketogenic diet is contraindicated in the following: primary carnitine deficiency, carnitine palmitoyltransferase I or II deficiency, carnitine translocase deficiency, porphyria, fatty acid oxidation defects, and pyruvate carboxylase deficiency.3

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There are also challenges involving food allergies, food intolerance, and cultural/religious dietary needs. Certain dietary requirements or preferences may make long-term adherence difficult. Each patient should be evaluated on an individual basis to determine suitability for initiation of the ketogenic diet.3,4 Providing sample meal plans may help individuals determine feasibility and understand how to plan suitable menus. It is also important to keep in mind that initiation of a ketogenic diet in individuals with diabetes should be approached under the supervision of a medical practitioner, as immediate adjustments in diabetic medications may be indicated to prevent hypoglycemia.

Future Direction

Finding alternative strategies for clinicians to incorporate into their practice that are safe and cost effective for the management of diabetes could be extremely beneficial and should be looked at in more detail. Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss (although is helpful in weight loss), and can lead to a reduction or elimination of medication. The ketogenic diet also has significantly less side effects than pharmaceutical alternatives. Many studies have shown that a low-carbohydrate ketogenic diet in people with T2D can be effective in improving glycemic control and in turn decreasing HbA1c. Since T2D has long been known as a disease of carbohydrate metabolism, effective dietary modifications can be incorporated by clinicians as part of an overall strategy in managing this chronic condition.

Ketogenic diets are also being explored in the management of other disease states such as cardiovascular disease and cancer. A very-low-carbohydrate ketogenic diet has been shown to be effective at managing some cardiovascular risk factors such as obesity and hyperlipidemia.1 However, there have remained concerns regarding safety among individuals with osteoporosis, kidney disease, or high levels of low-density lipoprotein cholesterol.21 Although previous studies have raised concern regarding deleterious effects on cholesterol levels and triglycerides, more recent studies suggest that the induction of ketosis may actually improve blood lipid profiles. Cicero et al observed a group of patients over a period of one year and concluded that a clinic-monitored ketogenic diet showed improvement in a large number of anthropometric, hemodynamic, and metabolic parameters.22

The PURE study has in recent months gained the most interest as it followed the dietary intake of 135,335 individuals from 18 countries and evaluated the association between dietary carbohydrate and fat intake with regard to cardiovascular disease and total mortality. The resulting data concluded that high carbohydrate intake was associated with a higher risk of total mortality and that total fat and individual types of fat were related to a lower mortality.23

Despite dietary guidelines promoting low-fat eating, obesity rates are at an all-time high with 40% of US adults and 19% of US children meeting criteria for obesity.24 Obesity has long been known to contribute to metabolic syndrome, which is a combination of increased blood pressure, increased blood sugar, and abdominal fat that places an individual at increased risk for diabetes and cardiovascular disease. As the evidence continues to point toward the effectiveness of a ketogenic diet in the management of obesity and accompanying comorbidities, further research is needed to investigate the long-term feasibility and compliance factors associated with the induction of a ketogenic diet.

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In analyzing the results of various trials, it appears that individuals on ketogenic diets tend to lose weight and have improvement in blood sugars and HbA1c values. Future research may reveal that individuals can have a decreased reliance on costly pharmaceutical management of many chronic conditions through nutritional intervention and carbohydrate restriction variations of a ketogenic diet.

Managing diabetes through ketosis is still a novel idea. There is limited research in the effectiveness of a ketogenic diet in the treatment of diseases other than epilepsy. Due to complex nutrition issues when treating diabetes and cardiovascular disease, it is recommended that a registered dietitian skilled in implementing medical nutrition therapy be part of the interdisciplinary team in the implementation of a modified ketogenic diet in persons with diabetes and/or cardiovascular disease.

The use of a ketogenic diet in conjunction with other evidence-based strategies may prove to be an effective tool for clinicians to incorporate with certain patient populations to assist in management of chronic diseases.  Based on limited data and research, it is clear that future studies are needed to guide the direction of nutritional implementation of ketogenic diets, as well as to address compliance issues and long-term safety and efficacy.

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This article originally appeared on Clinical Advisor