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NARRATIVE REVIEW ❙
Very low carbohydrate ketogenic diets
and diabetes
Pamela Dyson Abstract
PhD, RD, OCDEM, Oxford University NHS
Very low carbohydrate ketogenic diets (VLCKD) have been widely promoted for the
Foundation Trust, Oxford, UK; and NIHR
Biomedical Research Centre, Oxford, UK management of diabetes. There is confusion among people with diabetes and health
professionals about the efficacy and safety of these diets and this review aimed to explore
the role of VLCKD for people with diabetes.
Correspondence to: An electronic search of English language articles was performed using MEDLINE (1980
Pamela Dyson, PhD, RD, OCDEM, Churchill to January 2020), EMBASE (1980 to January 2020) and the Cochrane Central Register of
Hospital, Oxford OX3 7EJ, UK; email: pamela. Controlled Trials (1980 to January 2020). Randomised controlled trials (RCTs) >12 weeks
dyson@ocdem.ox.ac.uk duration comparing VLCKD, defined as❙ NARRATIVE REVIEW Ketogenic diets and diabetes level of ketone concentrations that indicate dietary ketosis, or accept- able levels of ketosis in those with Records identified through Additional records identified type 1 diabetes.7 Physiological stud- database searching (n=113) through other sources (n=10) ies have demonstrated that diets providing
NARRATIVE REVIEW ❙
Ketogenic diets and diabetes
First Duration Numbers Dietary intervention
author, (weeks)
year Comparator Intervention Comparator Intervention
Saslow, 32 13 12 On-line ‘Create your Plate’ plan from On-line ad libitum very low
201716 the American Diabetes Association. A carbohydrate ketogenic diet providing
low fat diet high in green vegetables, 20–50g carbohydrate per day
lean protein and limited starchy and together with behavioural adherence
sugary foods strategies
Westman, 24 46 38 Low glycaemic index, reduced energy Ad libitum very low carbohydrate
200817 diet providing 55% of energy as ketogenic diet providing❙ NARRATIVE REVIEW
Ketogenic diets and diabetes
in many of these reports, the inter-
vention was self-selected by the 192.8
participants and this may explain 200 Prescribed carbohydrate intake
the positive outcomes. It is intui-
tive that a diet that is self-selected 100 Reported carbohydrate intake at follow-up
Carbohydrate intake (g/day)
will be better tolerated and lead to 90
greater adherence.25 It has been 80
argued that data from observa-
70
tional studies such as these are of
more use than evidence from 60
RCTs, which is not applicable to 50
dietary interventions as it does not 40
allow for the many critical influ- 30
ences on personal choice;26 despite 20
this, RCT evidence is still consid-
10
ered of the highest grade and
remains crucial for establishing 0
efficacy, safety and superiority. Westman17 Iqbal32 Goldstein31 Mayer33 Saslow34,35* Saslow16 Tay36–38**
One of the greatest challenges
for those adopting VLCKD is that of *Saslow34,35 results at 3 and 12 months follow-up, respectively. **Tay36–38 results at 6, 12 and 24
long-term adherence, and over time months follow-up, respectively.
many participants appear to shift Figure 2. Prescribed and reported daily intake of amount of carbohydrate (g/day) in
to higher carbohydrate intakes randomised controlled trials of VLCKD in people with type 2 diabetes
(130–160g/day).27 Of the 14 studies
eligible for inclusion in this review, diabetes differs fundamentally from reported that current HbA1c con-
11 were excluded as reported those with type 2 diabetes as energy centrations were 39±6mmol/mol.43
intakes were >50g/day at fol- restriction for weight loss is not Conclusions from both these
low-up.28–38 Of these, four studies commonly a feature, meaning that studies are limited by the lack of a
prescribed very low carbohydrate those with type 1 diabetes are con- comparator group and data about
intakes (NARRATIVE REVIEW ❙
Ketogenic diets and diabetes
VLCKD should be avoided in those
KEY POINTS treated with SGLT2 inhibitor.55
In two observational studies in
● The role of very low carbohydrate ketogenic diets (VLCKD) for people with diabetes those with type 1 diabetes who
is unclear self-selected a VLCKD, one recorded
● There is little high-quality evidence for VLCKD; two randomised controlled trials (RCTs) in low annual rates of hospitalisation
people with type 2 diabetes reported significantly greater weight loss, but inconsistent for either hypoglycaemia (1%) or
effects on glycaemic control and medication diabetic ketoacidosis (1%), although
● Observational trials and case reports suggest that VLCKD improved glycaemic control in 69% reported at least one episode
type 1 diabetes, but conclusions are limited by the absence of RCTs of symptomatic hypoglycaemia per
● Reported adverse events included dyslipidaemia and hypolgycaemia in type 1 diabetes month.43 In the second study, partic-
● There is insufficient high-quality evidence to support the use of VLCKD ipants were fitted with continuous
glucose monitors for seven days
and higher rates of hypoglycaemia
adverse events include headaches, of VLCKD often make the case that (62% of those with measured therapy who adopted a VLCKD,53,54 base before these diets can be
lipid concentrations.42,43 Supporters and the general consensus is that generally recommended.
Copyright © 2020 John Wiley & Sons PRACTICAL DIABETES Vol. 37 No. 4 125❙ NARRATIVE REVIEW
Ketogenic diets and diabetes
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