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
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.
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.
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.
- Paoli A, Rubini A, Volek JS, Grimaldi KA. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2013;67(8):789-796.
- Mobbs CV, Mastaitis J, Isoda F, Poplawski M. Treatment of diabetes and diabetic complications with a ketogenic diet. J Child Neurol. 2013;28(8):1009-1014.
- Kohli A, Samour PQ. Use of the ketogenic diet in adults. Topics Clinic Nutr. 2013;28(2):105-119.
- Kosinski C, Jornayvaz FR. Effects of ketogenic diets on cardiovascular risk factors: evidence from animal and human studies. Nutrients. 2017;9(5):517.
- Southern L, Fitzsimmons G, Cross H. The ketogenic diet in drug-resistant epilepsies. British J Neurosci Nurs. 2015;11(3):137-141.
- Nelms M, Sucher K. Nutrition Therapy and Pathophysiology. 3rd edition. Boston, MA: Cengage Learning; 2016.
- Escott-Stump S. Nutrition and Diagnosis Related Care. 8th edition. Philadelphia, PA: Wolters Kluwer; 2008.
- Urbain P, Bertz H. Monitoring for compliance with a ketogenic diet: what is the best time of day to test for urinary ketosis? Nutr Metab. 2016;13:77.
- National diabetes statistic report, 2017. Centers for Disease Control and Prevention. August 8, 2017. https://www.cdc.gov/features/diabetes-statistic-report/index.html. Accessed November 16, 2018.
- Genuth S, Eastman R, Kahn R, et al; American Diabetes Association. Implications of the United Kingdom prospective diabetes study. Diabetes Care. 2003;26(suppl 1):S28-S32.
- Nathan DM, Genuth S, Lachin J, et al; for The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.
- American Diabetes Association. Obesity management for the treatment of type 2 diabetes: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(suppl 1):S65-S72.
- Hussain TA, Mathew TC, Dashti AA, Asfar S, Al-Zaid N, Dashti HM. Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes. Nutrition. 2012;28(10):1016-1021.
- Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes. 2017;7(12):304.
- Saslow LR, Kim S, Daubenmier JJ, et al. A randomized pilot trial of a moderate carbohydrate diet compared to a very low carbohydrate diet in overweight or obese individuals with type 2 diabetes mellitus or prediabetes. PLoS One. 2014;9(4):e91027.
- Saslow LR, Mason AE, Kim S, et al. An online intervention comparing a very low-carbohydrate ketogenic diet and lifestyle recommendations versus a plate method diet in overweight individuals with type 2 diabetes: a randomized controlled trial. J Med Internet Res. 2017;19(2):e36.
- Tay J, Luscombe-Marsh ND, Thompson CH, et al. A very low-carbohydrate, low-saturated fat diet for type 2 diabetes management: a randomized trial. Diabetes Care. 2014;37(11):2909-2918.
- Sato J, Kanazawa A, Makita S, et al. A randomized controlled trial of 130 g/day low-carbohydrate diet in type 2 diabetes with poor glycemic control. Clin Nutr. 2017;36(4):992-1000.
- Westman EC, Yancy WS Jr, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. NutrMetab. 2008;5:36.
- Goday A, Bellido D, Sajoux I, et al. Short-term safety, tolerability and efficacy of a very low-calorie-ketogenic diet interventional weight loss program versus hypocaloric diet in patients with type 2 diabetes mellitus. Nutr Diabetes. 2016;6(9):e230.
- Mueller C, Masri B, Hogg J, Mastrogiacomo M, Chiu Y. Carbohydrate- vs fat-controlled diet effect on weight loss and coronary artery disease risk: a pilot feeding study. Nutr Clin Pract. 2010;25(5):542-547.
- Cicero AF, Benelli M, Brancaleoni M, Dainelli G, Merlini D, Negri, R. Middle and long-term impact of a very low carbohydrate ketogenic diet on cardiometabolic factors: a multi-center, cross-sectional, clinical study. High Blood Press Cardiovasc Prev. 2015;22(4):389-394.
- Dehghan M, Mente A, Zhang X, et al. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from 5 continents (PURE): a prospective cohort study. Lancet. 2017;390(10107):2050-2062.
- Abbasi J. Interest in the ketogenic diet grows for weight loss and type 2 diabetes. JAMA. 2018;319(3):215-217.
This article originally appeared on Clinical Advisor