How a Ketogenic Diet May Help Manage Diabetes

November is National Diabetes Awareness Month. As we venture into the holiday season filled with multiple, food-centered holidays (i.e. Thanksgiving, Christmas, Hanukkah, Kwanzaa, New Year’s Eve) occurring in close proximity to each other, it is beneficial to provide education on diabetes and the impact of diet in managing and controlling this chronic disease. In this white paper, we’ll answer the questions: What is diabetes? Are there modifiable behaviors (e.g. diet, exercise, medications) that can help manage this disease? What does the latest research suggest regarding a high-fat diet in relation to diabetes prevention and management?

What is Diabetes?
Out of the 323 million people living in the United States, an estimated 29 million individuals (or 9% of our population) have diabetes. Approximately 25% of those with diabetes are undiagnosed (Centers for Disease Control and Prevention, 2016) and therefore unmanaged, placing them at risk for life-threatening comorbidities secondary to diabetes. Diabetes is a disease where the individual is resistant to insulin and, therefore, intolerant to carbohydrates. In healthy individuals, carbohydrates are broken down into simple sugars and utilized for energy. In diabetics, these carbohydrates are instead sent to the liver where they are converted into fat (Paoli et al., 2013). Individuals with insulin sensitivity, converting carbohydrates into fat through the liver, are at a greater risk for developing diabetes (Paoli et al., 2013).

There are three types of diabetes: gestational, type I, and type II. Gestational diabetes occurs during pregnancy, placing the mother and baby at risk for complications such as high blood pressure, preeclampsia and a higher risk for a type II diabetes diagnosis in the future. Type I diabetes, also known as juvenile diabetes, results from a lack of insulin production, is often genetic, and is typically diagnosed in childhood. Type II diabetes is the most common type of diabetes and results from the body’s inability to properly utilize its insulin. Risk factors for type II diabetes include: overweight and obesity, 45 years of age or older, a family history of type II diabetes, limited physical activity, poor nutrition, and/or a history of gestational diabetes (CDC, 2016).  Many of the risk factors for type II diabetes are modifiable. Through education and awareness, we can lower our risk for type II diabetes as well as reduce many of the potential comorbidities that go hand-in-hand with this disease. This white paper focuses on type II diabetes because of its high prevalence and our ability to modify many of the risk factors that contribute to unstable, uncontrolled blood sugar levels.

Modifiable Behaviors
Managing diabetes is important and necessary to prevent comorbidities such as hypertension, gum disease, stroke, blindness, kidney failure, and infection-related amputations resulting from poor blood circulation (CDC, 2016). Management of type II diabetes targets improving lifestyle behaviors (diet, exercise) while controlling blood sugar levels through medication. As a general guideline, intake of salt and sugar should be minimized while intake of non-processed foods, such as fruits and vegetables, should be increased. Additionally, striving to get 10 to 20 minutes of consistent physical activity will help with weight management (CDC, 2016). While we commonly associate physical activity with a traditional gym-based setting, any movement is beneficial, including walks through the park, or swimming at a local pool, among other non-traditional forms of exercise. Monitoring blood sugar levels in relation to timing of medication, food intake and physical activity is an important component of diabetes management.

What about Diet?
Although research surrounding diet and diabetes is mixed, studies have shown that a high-fat diet can slow the progression of diabetes. In rats and mice, a high-fat diet demonstrated a reduction in high blood sugar and low insulin levels (Ishii et al., 2010). Similarly, in another study conducted with mice, a ketogenic (low-carbohydrate/high-fat) diet was associated with a reduction in glucose and insulin resistance (Zhang et al., 2016). Not only has a ketogenic diet been proven to reduce weight, but several studies have also shown a high-fat, low-carbohydrate diet to improve insulin sensitivity while reducing hemoglobin A1c levels (Paoli et al., 2013). Hemoglobin A1c is a measure of blood sugar that provides an average of blood sugar levels spanning over several months, providing insight into the individual’s disease status over time.

While these studies indicate that dietary restrictions are an important piece to diabetes management, there is still ambiguity surrounding whether improvement in insulin sensitivity and glucose control is a result of dietary macronutrient composition (percentage of fats, proteins and carbohydrates in our diet), or if it is a result of weight loss (Mobbs et al., 2013). Interestingly, when investigating diabetes-related complications, such as neuropathy in mice, these complications were reversed with the prescription of a ketogenic diet for an 8-week duration (Mobbs et al., 2013). Perhaps a low-carbohydrate/high-fat diet would have the same benefits in diabetic humans.

Conclusion
A low-carbohydrate/high-fat diet may be beneficial in maintaining glucose control, improving insulin resistance and reversing diabetes-related complications. While nutrition is important, physical activity is equally important in preventing weight gain and reducing our risk for diabetes. Because diabetics are intolerant to carbohydrates, a low-carbohydrate diet, such as the ketogenic diet, may prove to be beneficial. In summary, minimizing carbohydrates (e.g. wheat, starches, and sugars), while supplementing your diet with healthy fats (e.g. avocados, olive oil, full-fat cheese, and eggs) can help keep blood sugar levels stable, reducing insulin spikes and lowering risk for diabetes through weight loss reduction (Shifflett, 2017).

References:
Centers for Disease Control and Prevention. (November 1, 2016). It’s Your Life. Treat Your Diabetes Well. Retrieved October 28, 2017 from http://www.cdc.gov/features/livingwithdiabetes/index.html
Ishii, Y., Ohta, T., Sasase, T., Morinaga, H., Hata, T., Miyajima, K., . . . Matsushita, M. (2010). A high-fat diet inhibits the progression of diabetes mellitus in type 2 diabetic rats. Nutr Res, 30(7), 483-491. doi: 10.1016/j.nutres.2010.06.013
Mobbs, C. V., Mastaitis, J., Isoda, F., & Poplawski, M. (2013). Treatment of diabetes and diabetic complications with a ketogenic diet. Journal of Child Neurology, 28(8), 1009-1014. doi: 10.1177/0883073813487596
Paoli, A., Rubini, A., Volek, J. S., & Grimaldi, K. A. (2013). Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. European Journal of Clinical Nutrition, 67(8), 789-796. doi: 10.1038/ejcn.2013.116
Shifflett, T. (September 26, 2017). Diabetes & Ketogenic Diet: Can You Manage Your Diabetes On A Ketogenic Diet? Retrieved October 29, 2017 from http://www.thediabetescouncil.com/can-you-manage-your-diabetes-on-a-ketogenic-diet/
Zhang, X., Qin, J., Zhao, Y., Shi, J., Lan, R., Gan, Y., . . . Du, B. (2016). Long-term ketogenic diet contributes to glycemic control but promotes lipid accumulation and hepatic steatosis in type 2 diabetic mice. Nutr Res, 36(4), 349-358. doi: 10.1016/j.nutres.2015.12.002