Is The Ketogenic Diet A Superior Choice For The Dietary Management Of Type 2 Diabetes?

Expanding on last week’s discussion of the effects of the ketogenic diet on weight loss, I wanted to explore whether or not the keto diet could be justly considered a superior dietary pattern for the management of blood glucose levels of type 2 diabetes.

A recent documentary, “The Magic Pill”, used an anecdotal case to “demonstrate” that following a ketogenic diet allowed a woman with type 2 diabetes to greatly improve her blood sugar management while drastically reducing her medication needs over a period of less than a year.

Given that 1 in 10 Canadians are currently living with diabetes (with Type 2 diabetes representing 90% of cases), there is no question that claims like these are always going to draw interest and attention.

Further to that point, there is a very good chance that each and every person reading today’s blog knows or has, at the very least, encountered someone living with type 2 diabetes.

With that in mind, I will put the notion that the ketogenic diet is a superior method of nutritional diabetes management to the test.

Why The Keto/ Type 2 Diabetes Connection?

Type 2 diabetes is essentially a chronic disease of troubled carbohydrate metabolism which may be brought about by a variety of genetic, environmental and lifestyle factors.

People living with type 2 diabetes may struggle to properly control the levels of glucose in their blood because insulin, the key hormone in cellular glucose uptake, is either not being produced as effectively as it used to, or is not being properly recognized by their cells.

When we eat carbohydrate containing foods ( including fruits, whole grains, starchy vegetables) our body’s breakdown this carbohydrate into glucose which ends up in our blood stream and stimulates the release insulin from our pancreas which allows the glucose in our blood to enter our cells for use as energy ( as I mentioned, this process is compromised in type 2 diabetes).

The concept behind using a ketogenic diet to help manage blood glucose levels in type 2 diabetes is that, if you cut almost all carbohydrate containing foods out of your diet, your body no longer needs to deal with this specific process, because there is barely any new glucose entering your bloodstream from you food.

Greatly simplified on paper this sounds like a reasonable and wonderful thing, but is the ketogenic diet actually a superior diabetes management solution in practice?

Let’s find out…

What Do The Pros Say?

Despite having previously worked for Diabetes Canada, I am NOT a current diabetes science expert and so I defer to expert opinion and the latest research to make a sound judgement as to the potential effectiveness of the ketogenic diet in managing blood glucose levels in type 2 diabetes.

Let’s see what some notable figures and studies have to say…

Here is a quote from Harvard Nutrition Professor Dr. David Ludwig ( MD, PhD) on the efficacy of the ketogenic diet in diabetes management

“For people with type 2 diabetes or related metabolic problems, very low carbohydrate diets including the ketogenic diet may offer an excellent long-term option. In some cases, a very low carbohydrate diet can reverse diabetes rapidly, without severe calorie deprivation. Much more research is needed into this area. But despite their potentially dramatic effects, very low carbohydrate diets can be difficult to maintain over the long-term. Replacing added sugars and refined starchy foods with unprocessed carbohydrate, healthful fats and proteins may provide many of the benefits of a very low carbohydrate diet, without having to eliminate an entire class of nutritious (and delicious) foods.”

Dr Ludwig’s sentiment is echoed by a very recent 12-month randomized control trial carried out by Saslow et al in 2017 found that  both A1C ( a long-term measure of blood glucose control)  and medication needs were reduced more on a ketogenic rather than conventional diet.

Another shorter term RCT by Goday et al in 2016 came to similar conclusions.

Both of these studies excluded people living with type 2 diabetes on insulin (which I  believe represents ~ 25% of the American adult population living with type 2).

The story, however, does not end there.

Pamela Dyson PhD RD from Oxford University and the current Co-chair of the Diabetes UK Nutrition Working Group, is slightly less enthralled about the current state of pro-keto evidence:

“Recent studies suggest that low carbohydrate diets appear to be safe and effective over the short term, but show no statistical differences from control diets with higher carbohydrate content and cannot be recommended as the default treatment for people with type 2 diabetes.”

In essence, she is saying that “ if the shoe fits, wear it”.

Meaning that tried and tested conventional means of diabetes management remain effective solutions but that a ketogenic diet is a tool that can be used with caution ( given the inherent challenges with sustainability, risk for inadequacy and still an incomplete knowledge of long-term effects) but has not merited being identified as a superior approach.

Diabetes Canada’s most recent 2018 Practice Guidelines, which are assembled and reviewed by scientific and medical experts, had this to say:

“No evidence from controlled trials that low carb diets ( including from diets as low as 4% energy from carbohydrates AKA keto diets) are superior for improving A1C in Type  2 Diabetes. “

They also claim that:

“Ketogenic diets may be a concern for those at risk of diabetic ketoacidosis who are taking insulin or the SGLT2 inhibitor class of medications  (ie: Invokana®)”

With these points in mind, it is important to acknowledge that  people living with type 2 diabetes can, and have, enjoyed an improved quality of life and enhanced glycemic control while enjoying a carbohydrate rich diet.

Losing weight,  making better quality carbohydrate ( fibre, glycemic index, nutrient density) choices, and improving consistency in carbohydrate intake are all steps one can take to achieve this goal while still enjoying the nutrient dense carbohydrate rich foods that so many of us love.

Final Thoughts

The ketogenic diet is not proven to be a  superior diabetes management solution, but when implemented with the appropriate professional guidance it may be an effective option for disciplined individuals who have struggled to manage glucose levels using other approaches.

In my mind the ketogenic is, and remains to be, an impractical and unsustainable option for all but the most disciplined individuals but cannot be excluded as an alternative course of action when more balanced, conventional approaches have become undesirable or ineffective for the individual in question.

Ultimately, these are the types of questions that only the individual and the healthcare professionals responsible for their care can truly answer.

Until next time,

Andy De Santis RD MPH