Our periodic correspondent Dan Fleshler is a New York-based writer, media strategist and longtime type 1. Like the rest of us, he struggles with finding the right balance of foods to eat.

In his latest take on hot topics in diabetes news, today he dissects the trendy "keto diet" for those of us whose lives depend on insulin. 


Counter-Claims and Confusion About Ketogenic Diets, by Dan Fleshler

Help! There is buzz about yet another diet that supposedly helps people with diabetes (PWDs): the “ketogenic diet.”

Smart nutritionists and physicians don’t agree on whether keto diets are appropriate for PWDs, just as they don’t agree on Paleo, vegan, high carb-low fat, Mediterranean, macrobiotic diets and a zillion other options for eating. How in the world are the rest of us supposed to figure this out?

While not an expert on nutrition, I have unique credentials to write about this: I’ve had T1D for 54 years, but it took me about 53 years to find a diet/insulin combination that could keep my blood glucose on a reasonably flat line throughout the day and night. More on that later, but if you’re uncertain how to choose from all of the available dietary options, take comfort in the fact that I’ve been uncertain for much of my life.

What is Keto?

The keto diet is a form of low-carb eating that prompts “ketosis,” a state in which the body breaks down fat and produces, as Erika Gebel puts it,  “fat-like molecules called ketone bodies.” When not enough glucose is available, ketones serve as an alternative energy source for certain kinds of cells, including brain cells. Ketosis should not be confused with ketoacidosis, in which the ketone levels are so high that the body becomes dangerously acidic and dehydrated.Ketogenic Diet

There seems to be no universally accepted way to distinguish the ketogenic diet from other very low-carb diets. But “in the classic keto diet,” says Everyday Health, “you get about 80% of your calories from fat and 20% from proteins and carbohydrates.” Some of these diets will let you eat as many as 50 grams of carbs per day and others call for fewer carbs. Many ketogenic advocates promote the increasingly popular maxim that foods with lots of saturated fats and cholesterol won’t boost the risk of cardiovascular disease, contrary to claims of the American medical establishment.

Blood Sugar Impact & Safety

Over at ASweetLife, on Feb 23, Keith Runyan made a powerful, personal case for ketogenic diets. A physician, T1D and triathlete, he asserted, “This way of eating has resulted in a significant improvement in my blood glucose control and a 1.2% reduction in HbA1c,” among other benefits.

A web site called ruled.me cites studies that supposedly show benefits of keto diets for T2Ds, especially those who need to lose weight, although it notes that there is no convincing research on whether T1Ds could benefit from them. A nutritionist at verywell, Laura Dolson, cites a June 2013 paper in the European Journal of Clinical Nutrition, which indicated there was “strong evidence” that these diets were helpful to people with T2D as well as epilepsy, obesity and other conditions.

On the other hand, Diabetes.co.uk says “diets which induce ketosis tend to come under scrutiny and are not often recommended by the medical profession as there are doubts over the safety of prolonged periods of ketosis.” While it notes that “low levels of ketosis” are “perfectly normal…high levels of ketosis in the short term can be serious and the long term effects of regular moderate ketosis are only partially known at the moment.”

Alice Lichtenstein, a professor of nutrition at Tufts University, echoes the still-conventional medical wisdom that “people who eat more saturated fat have higher cholesterol levels and an increased risk for cardiovascular disease.” That is, in effect, a shot off the bow at keto diet proponents, some of whom give us permission to eat oodles of butter and cream.

In an interview, Hope Warshaw — a well-known dietitian and diabetes educator who's currently incoming president of the AADE (American Association of Diabetes Educators) — expressed concerns about ketogenic diets, because “with this level of restrictive eating there’s potential for some vitamin and nutrition deficiencies.” More generally, like other diabetes nutrition experts, she worries that ketogenic and other very low-carb diets are hard for the majority of people to maintain over time. “People will have diabetes the rest of their life so they need to find a healthy way of eating that they can follow long-term and not just run from one way of eating to another.”

Don't Shoot the Messenger

I’ve tried to give both sides, but by now, I’m sure some readers are angry at me, since it’s impossible to write anything about diets and diabetes without offending someone. Keto diets are caught up in the larger, longstanding dispute over low-carb diets, which often feels like a passionate religious war.

Warshaw, for example, is a favorite target of ultra-low-carb devotees. They critize her for articles like this one, where she makes research-based assertions that following a very low-carbohydrate eating plan “can add up to unhealthy eating and doesn’t ensure glycemic control… (and) aids and abets medication avoidance,” among other problems. If you are thinking about taking the ketogenic route or other very low-carb pathways, her perspective and the studies she mentions are worth reviewing carefully. But so are the perspectives and studies by people who disagree with her.

The most well-known low-carb warrior targeting PWDs is Dr. Richard Bernstein. He has long accused the American Diabetes Association of irresponsibly hyping high carb-low fat diets and large doses of insulin. Indeed, in a very mischievous videotape made in 2015, Bernstein said the “most popular ketogenic diet is the diet espoused by the American Diabetes Association.” He claims that diet is ketogenic because “it causes very high blood sugars” and makes PWDs more prone to ketoacidosis.

Are you unsure about which diet experts to trust and believe? I am... Sad to say, highly skilled guides through the wilderness of dietary options are hard to find.

Contrary to the impression left by Bernstein, there is no such thing as a standard “ADA diet,” and low-carb eating is now one of the options the group deems to be acceptable. Its 2013 Dietary Guidelines say that “eating patterns” worth considering include Mediterranean-style, DASH (Dietary Approaches to Stop Hypertension), vegetarian or vegan, low-carbohydrate, and low fat. It doesn’t explicitly mention keto diets, but when it comes to saturated fats, the ADA says “people with diabetes should follow the guidelines for the general population,” which means “consuming less than 10% of calories from SFAs (saturated fatty acids) to reduce CVD (cardiovascular disease).”

That rules out the ketogenic route.

Finding Your Own Path

Are you unsure about which experts to trust and believe? I am.

If you are a PWD who is thinking of moving to a keto diet or making other radical dietary changes, it’s very unwise to do so until you consult with a registered dietician, certified diabetes educator or physician.

At the same time, sad to say, highly skilled guides through the wilderness of dietary options are hard to find. In particular, few physicians study nutrition very carefully or think a lot about it, as Runyan notes in another recent piece. And even if we find authoritative third-party experts, most PWDs are still on our own much of the time,  overloaded by information and conflicting claims, collateral damage in the Great On-line Low-Carb Wars, where the keto diet controversy is just another front.Keto diet meal

Take heart, though. During the last half-century, I tried more than a few approaches to my diet and insulin regimen, including Bernstein’s, but my BG control was not as good as I wanted it to be. I kept tinkering, and –with the help of more than one diabetes educator and a lot of reading—last year I finally found a diet and insulin combination that works really well for me.

Now I generally eat about 70 carbs per day, relying mostly on fish, cheese, nuts, non-starchy vegetables and fruits… and occasional sweet indulgences covered by extra bolus insulin. That might not suit your metabolism or your personality or your lifestyle. But, trust me, if I can find the right diet, you can, too. If you’re not happy or healthy on your current eating plan, despite all the dizzying dietary choices, you will be able to sort all of this out as long as you have patience, diligence and determination.