TLDR
A low-calorie ketogenic dietary pattern that focuses on polyunsaturated and monounsaturated fats (not saturated fat) can lead to weight loss when calories are tightly controlled. The concern in the real world is that when a ketogenic diet was tested in an 'ad libitum' style (like someone practicing intuitive eating), those people ate on average 500-700 kcal more per day to feel full when compared to those same people eating a low-fat diet... and too many calories eaten over time leads to weight gain.
As weight loss is the biggest factor in reversing Type 2 Diabetes, a dietary pattern that naturally allows for more fiber and less calories is optimal (ie, a plant predominant dietary pattern). Notice that I am not encouraging saturated fat intake because calorie for calorie, saturated fat increases insulin resistance and fat storage in the liver. Saturated fat intake also increases the risk of heart attack and stroke. If you're set on following a ketogenic diet, choose polyunsaturated and monounsaturated fats in place of saturated fat and ensure that you're eating the right amount of calories to reach your goal.
The treatment of Type 2 Diabetes has changed drastically over the last 20 years.
Prior to 2009, patient facing information clearly stated that there is “no cure” (1). While it is still difficult to find patient information on the American Diabetes Association (ADA) about reversal, in 2009 the ADA first published a consensus statement acting to define remission (1)(2). To date, there are two strategies in treating Type 2 diabetes: maintenance of the disease within an acceptable A1c range (ie, focusing on control) versus reversal through significant weight loss. As a lifestyle medicine practitioner in primary care, I specialize in leveraging a plant predominant dietary pattern in the clinic to help patients succeed with disease reversal.
The ketogenic diet, was originally used as a treatment for medication resistance epilepsy (3). Today, ketogenic diets have been purported to be beneficial for "the microbiome, the epigenome, diabetes, weight loss, cardiovascular health and cancer” (4). While any dietary pattern that reduces processed foods is generally a step in the right direction, the concern with ketogenic diets is saturated fat intake, which in turn raises LDL cholesterol, and cardiovascular risk. It is certainly possible to follow a ketogenic diet with minimal saturated fat intake, and when we look at weight maintaining high poly-unsaturated fat ketogenic diets for prevention of diabetes onset in healthy adults there does appear to be a benefit on LDL-cholesterol and insulin resistance (5).
We know, from Roy Taylor’s work in the United Kingdom (UK), that Type 2 Diabetes is reversible with adequate weight loss in both overweight and normal weight patient’s living with this condition (6). Roy Taylor won the Banting award in 2013 for his theory of the twin cycle hypothesis of Type 2 Diabetes and has since gone on to publish studies in the UK on reversal of Type 2 Diabetes (7) .
The problem in Type 2 Diabetes is build-up of fat in the skeletal muscle, liver and pancreas (7). The genetic role in the weight at which individuals get Type 2 Diabetes is attributed by Taylor to “the personal fat threshold”(7). This personal fat threshold is the weight at which an individual has exceeded their metabolically safe storage of adipose tissue as subcutaneous fat (7). Taylor has gone on to test this theory in normal weight individuals with Type 2 Diabetes showing that the mechanism of reversal is no different regardless of weight (8).
So, if excess calories and particularly fat in the muscle, liver and pancreas is a problem, can the ketogenic diet be a solution?
Well, aside from the concern about saturated fat increasing LDL cholesterol and cardiovascular disease (which does matter!), saturated fat has also been shown to worsen fat deposition in the liver, referred to as fatty liver disease (9). Calorie for calorie, in overweight adults, swapping added sugar in place of saturated fat did not worsen fatty liver or insulin resistance (9). In contrast, swapping saturated fat for added sugars lead to more fat deposition in the liver and worsening insulin resistance (9). So, a ketogenic diet that is low in saturated fat could be a solution for prevention. Think avocado, nuts, olive oil and fish in leu of coconut oil, meat, cheese, and dairy.
Okay, but isn't there something magical about ketogenic diet? Will it not lead to more fat loss? What about the importance of lowering insulin levels for added weight loss?
We know from Kevin Hall’s work that iso-caloric low-calorie low-fat high-carbohydrate (plant-based) and low-calorie high-fat low-carbohydrate (ketogenic) diets BOTH lead to weight loss and beneficial metabolic effects (10). Sorry, that was a mouthful!
Weight loss in general reduces insulin resistance and can even improve LDL cholesterol (which is the opposite to what one might expect to see when someone is following a ketogenic diet high in saturated fat) (6)(11). That said, there is a slight advantage in fat loss in the high-carbohydrate low-fat diet (plant-based diet) (10).
So, while low-calorie ketogenic diets can cause weight loss, there is no advantage to this strategy for fat loss over a low-fat plant based diet (10). As Kevin Hall reports in his presentation on this research, the idea that weight gain is due to carbohydrates and their influence on insulin does not hold up in metabolic ward studies (12). The carbohydrate-insulin model (CIM) of obesity is not currently considered an accurate model (12). More on that in the Lifestyle Medicine Maine Online Courses: Learn more here.
So what do I think?
a low-calorie ketogenic diet that is high in mono-unsaturated and poly-unsaturated fats and low in saturated fat could be an option for someone with Type 2 Diabetes. On large caveat is that better alternatives exists: a plant predominant dietary pattern. When it comes to reversal of Type 2 Diabetes and Prediabetes, weight loss and lowering saturated fat intake matter most.
If you are looking for intensive guidance on weight loss and/or reversal of Pre-diabetes or Type 2 Diabetes, then you've come to the right place. Jessica Krol, FNP, DipACLM of Lifestyle Medicine Maine offers concierge, personalized management for accountability and coaching to get the results that you want. Currently serving Maine State residents. Sign up for your FREE new patient consult today to get started. Let's do this!
Side note for people still interested in following a ketogenic dietary pattern for Type 2 Diabetes reversal
There is a company in the US named Virta Health that purports to leverage a ketogenic diet to reverse Type 2 Diabetes. In research funded by Virta examining the effects of a ketogenic dietary program on reversal of Type 2 Diabetes, they report a significant benefit for disease reversal of 54.7% (13). While this sounds fantastic, this rate is significantly skewed when we see that their definition of reversal is an hemoglobin A1c of less than 6.5% with Metformin (13). The program’s 2-year rate of "complete remission" (ie, no medications) is reportedly only 6.7% as compared to 2.5% for those following usual care in the US (13). These numbers are much lower than seen in the DiRECT Trial which found 46% remission using a standard very-low calorie diet (14). So again, while a low-calorie low-saturated fat ketogenic diet is certainly an option for reversal and prevention of Type 2 Diabetes, there are clearly better alternatives. I do not at all endorse the use of a ketogenic dietary pattern that is high in saturated fat. I would also caution about the tendency to over-eat on high-fat diets as seen in Kevin Hall's follow-up study (15).
References (1) American College of Lifestyle Medicine (ACLM). Remission of Type 2 Diabetes and Reversal of Insulin Resistance. Course Lecture. Module 01. https://lifestylemedicine.org/project/remission-of-type-2-diabetes/
(2) How do we define cure of diabetes? Buse et al. Diabetes Care (2009). https://diabetesjournals.org/care/article/32/11/2133/26120/How-Do-We-Define-Cure-of-Diabetes (3) History of the ketogenic diet. Wheless. Epilepsia (2008). https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1528-1167.2008.01821.x (4) The potential health benefits of the ketogenic diet: a narrative review. Dowis and Banga. Nutrients (2021). https://www.mdpi.com/2072-6643/13/5/1654/htm?__cf_chl_jschl_tk__=pmd_8qbyqWLIgZ5lUgC.DN77obptcy5DxYKckpWXQbPwS8g-1630028598-0-gqNtZGzNAiWjcnBszQil (5) Differential metabolic effects of saturated versus polyunsaturated fats in the ketogenic diets. Fuehrlein et al. Journal of Clinical Endocrinology. (2004). https://academic.oup.com/jcem/article/89/4/1641/2844241?login=false (6) Type 2 diabetes: the problem and the solution. Roy Taylor. British Journal of Diabetes. (2022). https://www.bjd-abcd.com/bjdvd/index.php/bjd/article/download/1055/1307 (7) Banting Memorial Lecture 2012 Reversing the twin cycles of Type 2 diabetes. Roy Taylor. Diabetes Medicine. (2013). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3593165/ (8) Return to Normal Glucose Control by Weight Loss in Nonobese People with Type 2 Diabetes: The ReTUNE Study. Al-Mrabeh et al. Diabetes. (2021). https://diabetesjournals.org/diabetes/article/70/Supplement_1/1184-P/140639 (9) Intrahepatic Fat and Postprandial Glycemia Increase After Consumption of a Diet Enriched in Saturated Fat Compared With Free Sugars. Parry et al. Diabetes Care. (2020). https://diabetesjournals.org/care/article/43/5/1134/35703 (10) Energy expenditure and body composition changes after an isocaloric ketogenic diet in overweight and obese men. Hall et al. American Journal of Clinical Nutrition. (2016). https://pubmed.ncbi.nlm.nih.gov/27385608/ (11) Nutritional Management of HyperapoB. Lamantia et al . Nutrition Research Reviews. (2016). https://www.cambridge.org/core/services/aop-cambridge-core/content/view/FF922E54AB1189F1AF2194888D99DA0F/S0954422416000147a.pdf/nutritional-management-of-hyperapob.pdf (12) Calories, Carbs or Quality? What Matters Most for Body Weight. Kevin Hall. Inside Scientific Lecture. (2021). https://www.youtube.com/watch?v=zumrAR5qHX0&t=2639s (13) Two Year Clinical Trial Outcomes Provide Evidence for Long-Term Benefits of the Virta Treatment for Type 2 Diabetes. Hallberg and Adams. Virta Health Blog. (2019). https://www.stage.virtahealth.com/blog/2yr-t2d-trial-outcomes-virta-nutritional-ketosis (14) Primary care weight-management for type 2 diabetes: the clusterrandomised Diabetes Remission Clinical Trial (DiRECT). The Lancet. (2018). https://nrl.northumbria.ac.uk/id/eprint/35606/1/Primary%20care-led%20weight%20management.pdf (15) Effect of a plant-based, low-fat diet versus an animal-based, ketogenic diet on ad libitum energy intake. Hall et al. Nature Medicine. (2021). https://pubmed.ncbi.nlm.nih.gov/33479499/
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