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Diabetes Download: What Should I Know Before Starting the Ketogenic Diet With Diabetes?

In Diabetes Download, Nalani Haviland, a board-certified physician assistant and diabetes expert who has type 1 diabetes herself, answers the Mighty community’s questions.


Editor's Note

People with diabetes may be intrigued by the ketogenic diet, which can help manage weight and blood glucose. Here, Nalani Haviland, PA-C, explains what to keep in mind if you’re thinking about starting the ketogenic diet.

This column is solely for general education and information. It is not intended to provide any medical advice and cannot replace or be a substitute for your relationship with your healthcare provider. Always talk to your clinician for any issues or questions.

The Mighty community asked: “What should I know about starting the ketogenic diet with diabetes?”

This is an awesome question about a diet that is very popular right now! Before I dive into it, I first want to clarify the difference between the ketogenic diet and a simple low carb diet. Both involve restricting carbohydrate intake, however the strict “no-carb” keto diet (carb intake of <5 percent) induces a state of ketosis, causing the body to metabolize fat. I’ll explain further…

The benefits of weight loss and exquisite blood glucose (BG) control makes the keto diet tempting for both myself and the many other type 1’s of the world. But though it is generally accepted as beneficial in type 2 diabetes, the risk of the keto diet in people with type 1 is considered much greater. This is due to the increased possibility of going from ketosis to DKA, or diabetic ketoacidosis.

Both people without diabetes and PWD (people with diabetes) can enter ketosis by restricting carbs, however PWD can also enter ketosis by accidentally or intentionally withholding insulin. While ketosis itself is not dangerous, diabetic ketoacidosis (DKA) is life-threatening and can easily occur when there are too many ketones and not enough insulin circulating. This is most dangerous in people with type 1 diabetes because there is no endogenous insulin being produced, all insulin must be manually injected. DKA is less common in type 2 diabetes because although the cells are resistant, the pancreas still makes enough insulin to prevent the progression of ketosis to ketoacidosis, in most cases.

To better understand how to safely implement the keto diet, we must first understand how our body normally processes glucose, our body’s true and most basic fuel.

Glucose, although an essential source of energy for our cells, cannot be utilized without the help of insulin. Think of insulin as glucose’s transporter. For PWDs, without the presence of insulin, glucose exists in the blood, but is unable to enter the cells (high blood glucose = low cellular glucose). To prevent starvation, our bodies begin to break down fat and proteins resulting in the formation of ketones. This physiology is the basis of many low carb diets including the ketogenic diet. Unlike glucose, ketones can be used by the cells directly without the help of insulin as a transporter. Fat is broken down in the process, hence, the weight loss.

Though DKA is a scary possibility, the ketogenic diet can be a great tool when used correctly and safely, especially in people without diabetes and in people with type 2 diabetes. My fiancé (non-diabetic) and I tried the ketogenic diet together and it easily worked for my fiancé. Though my BGs were under great control during the diet, due to my serious lack of carb intake, I felt like I was walking the edge of a cliff and decided that the risk really wasn’t worth it for me.

That said, I have seen some great success with the keto diet in type 1’s. Interestingly, the key to safely avoiding DKA for PWD, both types 1 and 2, is knowing when to stop the keto diet. This includes situations in which ketones may unknowingly be produced, such as while sick, dehydrated, overly stressed, or while taking an SGLT-2 (Jardiance, Invokanna, Farxiga).

Remember to check ketones regularly using a blood or urine ketone monitor and most importantly, know your symptoms. Before making the decision to use the keto diet, please refresh on the symptoms of DKA. These include nausea, vomiting, abdominal pain, shortness of breath, confusion, and a fruity breath odor. Symptoms of DKA should never be ignored, even when BGs are “normal.”

The ketogenic diet alone will not cause the body to produce enough ketones to cause DKA, but the idea of increasing blood ketones in a type 1 person gives most clinicians a real gut check. But… with proper education it can be done safely. Ultimately, when considering any diet, remember to first have an open discussion with your clinician. He or she can help you weigh the risks vs. rewards and better understand how the diet will affect your body. Your clinician is on your team!

Glossary of Terms

Type 1 Diabetes: A chronic condition that occurs when the pancreas produces little to no insulin. As a result, the body is unable to properly process glucose for energy. It is primarily managed with frequent blood glucose monitoring, diet, exercise, and either insulin pump therapy or multiple daily injections.

Type 2 Diabetes: A chronic condition resulting from insulin resistance and/or an inadequate response to insulin secretion. This results in the body’s inability to properly process glucose. It is managed with frequent blood glucose monitoring, oral or injectable medications, diet, exercise, and sometimes insulin.

Blood Glucose: Another name for blood sugar. Having blood glucose levels that are too high or too low is the hallmark sign of diabetes.

Insulin: A hormone produced by the pancreas. Insulin allows for the regulation of blood glucose and without it, the body cannot process glucose for energy. People with diabetes must get their insulin either through injection or insulin pump therapy.

Diabetic Ketoacidosis (DKA): A complication of uncontrolled diabetes caused by an insufficient amount of circulating insulin. This usually leads to high blood glucose levels and a buildup of blood ketones, byproducts of the breakdown of fatty acids. Untreated diabetic ketoacidosis can lead to coma and death.

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