I have just read the 2019 Standards of Medical Care in Diabetes (Ref. 1). This is a comprehensive document produced annually by the American Diabetes Association (ADA). I have read this document each year since 2008. To their credit, the ADA has gradually changed their dietary recommendations in the right direction, in my opinion. Yes, their changes have been exceedingly slow. And, yes, I believe they have not given any special credence to a very low carbohydrate ketogenic diet (VLCKD) for the treatment of both type 1 diabetes (T1DM) and type 2 diabetes (T2DM). To date, they haven’t mentioned that a low carbohydrate diet can place T2DM in remission. In this study (Ref. 2), 65% of participants were able to achieve a HbA1c < 6.5% with either no medications (25%) or metformin alone (35%). I believe this missing knowledge would motivate many to adopt the VLCKD as a lifestyle. Of course, I am biased in favor of the VLCKD. I am also aware that some persons with T1DM who follow a VLCKD to improve their glycemic control have received discouraging words from their health care provider (HCP) about this choice. In this study (Ref. 3), 20% of the participants felt that their HCP was not supportive of their choice to use a VLCKD.
However, I believe this latest 2019 ADA document makes it quite clear that a variety of dietary choices are acceptable as long as they result in improved glycemic control. Additionally, this is the first time that “shared decision making” has been emphasized. This represents a significant shift from the idea that the HCP knows best and dictates what the patient should do without any input from the patient. This document makes it clear that HCPs should listen to and respect the patients’ individual preferences regarding their own diabetes care including which diet they feel is best. Therefore, I think it is fair to refer this document to your HCP if they do not agree with your dietary choice.
Below I have listed quotes from the 2019 Standards of Medical Care in Diabetes rather than paraphrase or summarize their words. I have added bold lettering to some words and my own thoughts in brackets that are particularly relevant to those who follow the VLCKD for treatment of their diabetes.
- This document is an official ADA position, is authored by the ADA, and provides all of the ADA’s current clinical practice recommendations.
- The field of diabetes care is rapidly changing as new research, technology, and treatments that can improve the health and well-being of people with diabetes continue to emerge.
- A new figure from the ADA-European Association for the Study of Diabetes (EASD) consensus report about the diabetes care decision cycle was added to emphasize the need for ongoing assessment and shared decision making to achieve the goals of health care and avoid clinical inertia. [Just to clarify: shared decision making means that your health care provider should be listening to your desires about your own medical care. Avoiding clinical inertia means the provider should stop just doing the same old thing and be more nimble by updating their medical knowledge. Were they to do so, they would see that the body of published research on the effectiveness of a VLCKD for improved glycemic control continues to grow which is the primary goal of both the patient and the provider.]
- Evidence continues to suggest that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, more discussion was added about the importance of macronutrient distribution based on an individualized assessment of current eating patterns, preferences, and metabolic goals. [This is the ADA’s way of saying that their previously recommended low fat diet is clearly not the best choice for treating diabetes. This should alert physicians that the ADA no longer recommends the low fat diet as the best way to eat. Therefore, there is no reason to discourage a patient from following a VLCKD if he/she so chooses.]
- Additional considerations were added to the eating patterns, macronutrient distribution, and meal planning sections to better identify candidates for meal plans, specifically for low-carbohydrate eating patterns and people who are pregnant or lactating, who have or are at risk for disordered eating, who have renal disease, and who are taking sodium–glucose co- transporter 2 inhibitors. [see my notes in 14. below]
- There is not a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized.
- A recommendation was modified to encourage people with diabetes to decrease consumption of both sugar sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake.
- The sodium consumption recommendation was modified to eliminate the further restriction that was potentially indicated for those with both diabetes and hypertension.
- In addition, in response to the growing literature that associates potentially judgmental words with increased feelings of shame and guilt, providers are encouraged to consider the impact that language has on building therapeutic relationships and to choose positive, strength-based words and phrases that put people first. [This is applicable to any provider who reacts negatively about the patient’s choice to follow the VLCKD.]
- People with diabetes and those at risk are advised to avoid sugar-sweetened beverages (including fruit juices) in order to control glycemia and weight and reduce their risk for cardiovascular disease and fatty liver and should minimize the consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices.
- Data on the ideal total dietary fat content for people with diabetes are inconclusive, so an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular disease risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates.
- Studies have demonstrated that a variety of eating plans, varying in macronutrient composition, can be used effectively and safely in the short term (1–2 years) to achieve weight loss in people with diabetes. This includes structured low-calorie meal plans that include meal replacements and the Mediterranean eating pattern as well as low-carbohydrate meal plans.
- Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control.
- Providers should maintain consistent medical oversight and recognize that certain groups are not appropriate for low-carbohydrate eating plans, including women who are pregnant or lactating, children, and people who have renal disease or disordered eating behavior, and these plans should be used with caution for those taking SGLT2 inhibitors due to potential risk of ketoacidosis. [See the warnings from the Food and Drug Administration (FDA) (Ref. 4). I agree with avoiding the use of SGLT2 inhibitor drugs for those with T1DM or those with type 2 diabetes (T2DM) who require exogenous insulin especially if they follow a VLCKD. Although very few persons with T1DM would be prescribed any of these drugs since they are not FDA approved, doctors can prescribe them off-label at their discretion. In those with T2DM (not on insulin) who follow a VLCKD, caution should also be used if an SGLT2 inhibitor drug is prescribed. The rationale for this caution is that some persons with T2DM have an impaired ability to make insulin somewhat like a person with T1DM. Additionally, a VLCKD significantly reduces insulin requirements as does an SGLT2 inhibitor due to its ability to cause the kidney to excrete glucose. Therefore, combining the VLCKD with an SGLT2 inhibitor drug results in low insulin levels and increases the risk of euglycemic diabetic ketoacidosis (EDKA). During EDKA the same symptoms (abdominal pain, nausea, vomiting) develop, but the patient may not cognate that DKA is a possibility due to the normal or near-normal blood glucose level caused by the SGLT2 inhibitor. Thus, it is best to avoid SGLT2 inhibitor drugs while following a VLCKD.
As far as children with T1DM using a VLCKD, Dr. Richard Bernstein and numerous other physicians have been treating children with a low carb diet for many years. The facebook group, TYPEONEGRIT, has thousands of children using Dr. Bernstein’s approach, and a research study of this group has been published (Ref. 3).
I have read several case reports of pregnant women who developed ketoacidosis and reported following a low carb diet. However in each of these case reports, there was no careful analysis of what the women were eating prior to hospital admission, but more importantly each of them also had a superimposed illness that caused them to be unable to eat for several days. Thus, they likely had superimposed starvation ketoacidosis, not related to the prior low carb diet. I would argue that these case reports certainly do not settle the issue about using a low carb diet with pregnancy or lactation. That said, I do admit that the use of a low carb diet with pregnancy or lactation has hardly been studied. Thus, caution should be exercised in using a VLCKD during pregnancy or lactation.]
- There is inadequate research about dietary patterns for type 1 diabetes to support one eating plan over another at this time.
- However, for special populations, including pregnant or lactating women, older adults, vegetarians, and people following very low-calorie or low-carbohydrate diets, a multivitamin may be necessary. [A well-formulated VLCKD should not require a multivitamin supplement IF one chooses whole, real (not processed) foods rich in micronutrients. I suggest using cronometer.com to calculate the micronutrient content of your VLCKD. IF after entering and adjusting your VLCKD foods in cronometer.com, you determine you cannot meet your micronutrient needs, then a multivitamin or individual supplement with the specific deficient micronutrient(s) is indicated. Although vitamin supplements in general can be useful, they are not regulated in the U.S. and likely other places around the world. That means you can never be sure that the supplement contains the vitamin/mineral you are needing, it may contain more or less than what the label states, or it may contain toxic substances not listed on the label. Also, real food likely contains other nutrients which have not necessarily been identified by nutrition science. Thus, you should really make the effort to get as many of your micronutrients (vitamins/minerals) from food rather than supplements if you can.]
I hope anyone contemplating or following a VLCKD can use the above information from the ADA to discuss their approach with their HCP without fear of criticism.
For more information about using the VLCKD to improve glycemic control for those with type 1 diabetes (T1DM) consider purchasing my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.
- American Diabetes Association, Standards of Medical Care in Diabetes, 2019 http://care.diabetesjournals.org/content/suppl/2018/12/17/42.Supplement_1.DC1
- Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study https://www.ncbi.nlm.nih.gov/pubmed/29417495
- Management of Type 1 Diabetes With a Very Low-Carbohydrate Diet. http://pediatrics.aappublications.org/content/early/2018/05/03/peds.2017-3349.