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February 24, 2021 / Brittany Cardwell, RDN, LD

Keto Diet for Diabetics: Your Complete Guide

Man in a plaid shirt holding a glass of water and a fork that is stabbing a cucumber salad with chicken and tomatoes.

Diabetes is a metabolic disease that impacts how a person’s body uses blood glucose (sugar), an important source of energy for the body’s cells. According to the National Diabetes Statistics Report, 2020, one in 10 Americans have diabetes, with over 90% of cases being type 2. Unlike type 1 diabetes, type 2 diabetes is largely influenced by modifiable risk factors including smoking, obesity, physical inactivity, high blood pressure, and poor diet.

Insulin is an important hormone, produced by the pancreas, that allows the glucose to move from the bloodstream into the body’s cells. With type 2 diabetes, the pancreas no longer produces enough insulin, or the cells in the muscle, fat, and liver become resistant to insulin, causing blood sugar levels to rise too high. If left untreated, high blood glucose can damage your blood vessels, which can lead to more serious complications including heart and kidney disease, blindness, and nerve damage.

The good news: the onset of type 2 diabetes can be largely prevented and managed through weight loss and improved dietary choices. Let’s take a look at the use of the keto diet for diabetes and explore how it can be an effective intervention for improving blood sugar control. We’ll also discuss some tips for planning a keto meal.

What is the Keto Diet?

The keto diet is a high fat, moderate protein, low carbohydrate eating plan that was initially introduced in the 1920s as a treatment for epilepsy. Over the past 15 years it has been researched more for treating endocrine disorders, including type 2 diabetes and obesity.

The preferred energy source for the body is glucose, which is primarily made from the carbohydrate-rich foods we eat, such as bread, pasta, and fruit. The goal of the keto diet is to induce a state of nutritional ketosis, where the body uses fat (rather than glucose) as its primary energy source. In order to reach a state of ketosis, carbohydrate intake must be severely restricted to prevent the liver from producing enough glucose to meet the body’s energy needs.

Although the amount can vary depending on the person, this typically means limiting carbohydrate intake to no more than 50 grams per day, or less than 10% of total calories consumed. The bulk of the day’s calories then come from fat, averaging 55-60% of total calories.

In order to preserve lean body mass, but still reach a state of ketosis, it’s recommended the remaining 30-35% of calories come from protein. This macronutrient distribution causes the liver to resort to breaking down fat into fatty acids, which produces ketones. This process is known as ketogenesis and creates an alternative fuel source for the body and stabilizes insulin levels, which is significant for weight loss and improving blood sugar levels.

Due to the restrictiveness of the keto diet and its influence on a wide range of hormones, an important question arises: is the keto diet safe and effective for all populations, specifically those with diabetes?

Is the Keto Diet Safe for People With Diabetes?

It’s important to distinguish between type 1 and type 2 diabetes when considering the safety of the keto diet for diabetics. Although research has proven the keto diet to be an effective option in improving blood sugar control and reducing insulin requirements for those with diabetes, the existing evidence for use of the diet with type 1 diabetes is limited, and more studies are needed to support its long-term use in practice.

A serious complication, more commonly with type 1 diabetes, is ketoacidosis. Diabetic ketoacidosis (DKA) is a life-threatening complication in which blood sugar and ketone levels are excessively high. When ketones are produced too quickly, they build up and cause the blood to be acidic. This can be toxic if ignored and is usually triggered by chronic elevated blood sugar levels or non compliance with medications prescribed.

Nutritional ketosis is a state in which the body is producing ketones and using them as an energy source. The goal with a keto diet is to reach this metabolic state, where ketones are detectable in the blood. While on the ketogenic diet, it’s normal to have blood ketone levels of 0.5-3.0 millimoles per liter (mmol/L). Nutritional ketosis is not the same as diabetic ketoacidosis, although both involve the production of ketones in the body.

The ketogenic diet for diabetics can help with weight loss and managing symptoms of diabetes, however, it’s not appropriate for everyone, especially those with an eating disorder, or history of disordered eating, kidney disease, heart disease, pancreatitis, or other conditions affected by fat intake. Before committing to a keto meal plan, it’s important to consult with your medical professional to ensure it’s the right dietary intervention for you.

Type 2 diabetes

A key factor in managing type 2 diabetes is the development of a healthy diet. With most of the studies on nutritional ketosis and diabetes management being conducted in the type 2 diabetes/overweight population, the keto diet is more confidently recommended as a dietary intervention for individuals with type 2 diabetes compared to type 1 diabetics. More studies are needed to determine the long-term safety and effectiveness of the ketogenic diet for diabetics, however, greatly limiting carbohydrate intake has been shown to be effective in reducing medication usage and improving the following in people with type 2 diabetes:

Certain health conditions may be exacerbated by a keto diet and there’s limited research on its use in treating children, pregnant women, people with a history of hypoglycemia, and those who are underweight with diabetes. It’s recommended to consult with your health care provider before starting the keto diet, especially if you are taking any medication for diabetes or blood pressure.

Prediabetes

Prediabetes is an intermediate stage in the development of type 2 diabetes in which blood sugar levels are elevated, but not yet to a level to be diagnosed with diabetes. Lifestyle intervention is important at this period to prevent not only the progression of type 2 diabetes, but also to minimize the risk of heart disease and stroke. Research suggests that the risk of developing type 2 diabetes can be significantly lowered by losing just 5-10% of your body weight.

A prediabetes diet plan, paired with increased physical activity, can actually return blood sugar levels to a normal range. Research suggests that adults with prediabetes have greater reductions in blood sugar levels, lose more weight, and reduce more medications on a keto diet compared to those who follow a less carb restrictive plan.

Type 1 diabetes

If you have type 1 diabetes and are wanting to try the keto diet, it’s critical that you talk to your doctor first. As your carbohydrate intake decreases, it’s quite common for oral medications and insulin regimens to need to be adjusted. If not monitored closely, potential complications can arise including hypoglycemia and DKA. Data suggests a keto diet for diabetics has the potential to improve blood glucose control in individuals with type 1 diabetes, but it should not be started without the close supervision of a medical professional. Caution should be taken as more high-quality studies are needed to review the long-term outcome of following a keto diet.

How to Keto Diet Meal Plan for Diabetics

The goal of the ketogenic diet is to put the body in a state of nutritional ketosis, which has been shown to be effective for weight loss and in managing type 2 diabetes in the short-term. The obvious concern that arises is the long-term sustainability of following a restrictive eating plan. Before diving into a keto diet, work with your healthcare practitioner to ensure it’s done safely and is the right approach for your health state.

Although carb-rich foods are excluded from the keto diet, it’s essential to incorporate plenty of healthy fats and nutrient-rich whole foods that contain antioxidants and fiber. With proper meal planning, you’re more likely to include a variety of unprocessed, keto-friendly foods and stick to a keto lifestyle. To make it easier and less overwhelming, PlateJoy can help you create diabetic meal plans, including keto meals! Here are some tips to help you get started.

Tip #1. Calculate your daily caloric needs

Carbohydrates, fats, and proteins are macronutrients that the body needs in large amounts for energy. Entering a state of nutritional ketosis requires a very specific macronutrient ratio:

Estimating your body’s daily energy (caloric) needs is helpful for determining the appropriate amount you should consume from each food group on a keto diet for diabetics. One of the easiest ways to estimate your energy needs is using the Mifflin-St Jeor equation. This formula is used to calculate your basal metabolic rate (BMR), which is the amount of energy your body needs to fuel its most basic functions. Your BMR is determined by your height, weight, age, and gender. Once you know your BMR, you can then calculate your total energy expenditure (TEE) by indicating your daily activity level. It’s important to note that this equation is used as a predictor of your body’s energy needs and does not account for your body composition and other variables.

Tip #2. Adhere to macronutrient percentages

Knowing your total caloric needs for the day is not for calorie counting, but to give you insight into how your macronutrient distribution should look to reach a state of nutritional ketosis. For example, if your TEE is 2,000 calories, your daily macronutrient ratio would be as follows:

There is no set rule on how many meals you should eat each day on the keto diet for diabetics – some people prefer eating three meals, while others prefer four-to-six smaller meals. Establish a meal pattern that works for you, but be guided by your hunger cues; eat when you’re hungry and stop when you feel full. The number of meals eaten each day is not as important as quantity and quality of the macronutrients consumed. Here’s a one-day keto meal plan with a breakfast, lunch, and dinner recipe.

Tip #3. Focus on whole foods and avoid processed foods

When you think of a high-fat diet, the image of bacon, butter, and cheese drenched dishes may pop into your head. Although these are all keto-friendly foods, it’s important to also incorporate plant-based fats in your diet, in addition to a variety of low-carb, nutrient-rich foods. The healthiest keto diet for diabetics is built around whole, single-ingredient foods, including:

Having a variety of whole foods at your meals helps to provide your body with essential minerals, vitamins, fiber, antioxidants, and electrolytes needed to prevent nutrient deficiency and diet fatigue.

Whole foods can be defined as those that are as close to their natural form as possible. Although whole foods are preferred for a healthy diet, it’s important to note that not all processed foods are bad; in fact, most food we get at the grocery store has been processed in some way through canning, cooking, freezing, dehydration, or milling.

Foods that should be avoided on any diet are those that are highly processed. The main concern with these foods is their reduced nutritional value. Highly processed foods commonly contain added sugars, salts, hydrogenated fats, and artificial ingredients that can negatively affect your health. Although the selection of “keto-friendly” foods at the store is increasing, be cautious! While some processed foods offer valuable nutrients as well as convenience, others can be loaded with the less-than-desirable ingredients listed above.

Tip #4. Aim for heart-healthy fats

The keto diet for diabetics consists mainly of fats, but the type of fat you eat matters. Dietary fat is broken down into three categories: unsaturated, saturated and trans fats. Despite each of these types of fats fueling the body with nine calories per gram, they are not created equal.

Saturated fats are primarily found in animal-based products such as red meat, cheese, and butter. This fat has previously been referred to as “bad” fat due to the association between a diet high in saturated fats and the increased risk of heart disease. However, newer evidence suggests that the quality of saturated fats in the diet, not quantity, has a greater influence on heart health.

Heart-healthy fats include foods that are rich in mono- and poly-unsaturated fats. These “good” fats have been shown to have a cholesterol and inflammation reducing effect in the body. Numerous studies show that substituting saturated for unsaturated fats improves blood cholesterol levels and insulin sensitivity. Good sources of fats/oils include:

The third category of fat is trans fats, and these are the most harmful and should be avoided. Trans fats are found in many highly processed foods such as fried foods, baked goods, refrigerated doughs, margarines, and other spreads. Eating trans fats, and partially hydrogenated oils, not only increases your risk of developing heart disease and stroke, but can also increase your risk of developing type 2 diabetes.

Aim for heart-healthy fats when building your keto diet for diabetics. Substituting healthy unsaturated fats for saturated fats is ideal for preventing heart disease for adults with type 2 diabetes.

The Takeaway

Type 2 diabetes is largely influenced by lifestyle choices and diet. The ketogenic diet is not just a fad diet, but a researched, effective dietary approach for managing obesity and diabetes. Like any restrictive diet, the concern arises over the long-term sustainability of following a high fat, moderate protein, low carb eating plan. It’s important to talk with your doctor before deciding if a ketogenic diet is the right lifestyle intervention for your short and long term health.

Once you’ve consulted with your health care provider, the PlateJoy meal planner and a keto shopping list can help you get started on creating an enjoyable and sustainable keto diet and lifestyle.

Brittany Cardwell, RDN, LD
Health Coach and Registered Dietitian Nutritionist @ PlateJoy

Brittany is a registered dietitian nutritionist with the Commission on Dietetic Registration and a licensed dietitian with the Ohio Board of Dietetics and the Tennessee Board of Dietitians. She is a graduate of Miami University (Ohio) with a Bachelor of Science in kinesiology and health, and holds a Certificate of Training in Adult Weight Management. An Ohio native, Brittany currently resides in Nashville with her husband, son and their fur baby. In her free-time she enjoys exploring new restaurants and coffee shops, attending barre classes and being outdoors.

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