Prior to the advent of exogenous insulin for the treatment of diabetes mellitus in the 1920's, the mainstay of therapy was dietary modification. Diet recommendations in that era were aimed at controlling glycemia (actually, glycosuria) and were dramatically different from current low-fat, high-carbohydrate dietary recommendations for patients with diabetes [1,2]. For example, the Dr. Elliot Joslin Diabetic Diet in 1923 consisted of "meats, poultry, game, fish, clear soups, gelatin, eggs, butter, olive oil, coffee, tea" and contained approximately 5% of energy from carbohydrates, 20% from protein, and 75% from fat [3]. A similar diet was advocated by Dr. Frederick Allen of the same era [4].

The aim is far broader than suggested by the article here: It’s not just about what you put in your mouth – it’s also about timing and exercise. There are three ways to be in ketosis – which simply means that “fat burning” and not being dependent on sugars. Fasting puts a man into ketosis in 3 days and a woman by 2 days. Endurance exercise gets you there in a couple of hours. Eating a high fat diet will do it too. The goal however is hidden by the detail – it is to acquire a “Flexible Metabolism”. The aim is to switch on the full fat burning capacity and keep it running – which takes from between 4 to 12 weeks physical adaptation (for the muscles to fully be able to use ketones). The heart runs approximately 27% more efficiently on ketones than on glucose! The brain works better too – Alzheimer’s being referred to by researchers as “diabetes 3”. Once you have a Flexible Metabolism you can consume carbs during or after exercise without dropping out of ketosis – though this depends on your own bio-individuality. I can eat quite a lot of carbs – without losing ketosis – my partner cannot.
The other nutritional remedy for T2 diabetes is carbohydrate restriction. In a large, ongoing university-based study, 60% of patients with Type 2 diabetes reversed their diagnosis of diabetes after just one year on a ketogenic diet, supplemented by support via a mobile phone app.11 On this protocol, 94% of participants reduced or eliminated their need for insulin medications while improving the vast majority of cardiovascular risk factors.12

When in the hospital, glucose levels are checked several times daily and the patient is monitored for signs of symptomatic ketosis (which can be treated with a small quantity of orange juice). Lack of energy and lethargy are common but disappear within two weeks.[17] The parents attend classes over the first three full days, which cover nutrition, managing the diet, preparing meals, avoiding sugar and handling illness.[18] The level of parental education and commitment required is higher than with medication.[43]
The Mediterranean diet has been shown to reduce the risk of heart disease. It’s also associated with a reduced incidence of cancer, Parkinson’s and Alzheimer’s diseases. This diet emphasizes eating primarily plant-based foods including fruits, vegetables, whole grains, legumes, nuts, olive and canola oil, fish and poultry. It also encourages getting plenty of exercise, enjoying red wine in moderation and focusing on meals with family and friends.
The DASH diet is especially recommended for people with hypertension (high blood pressure) or prehypertension. The DASH diet eating plan has been proven to lower blood pressure in studies sponsored by the National Institutes of Health (Dietary Approaches to Stop Hypertension). In addition to being a low salt (or low sodium) plan, the DASH diet provides additional benefits to reduce blood pressure. It is based on an eating plan rich in fruits and vegetables, and low-fat or non-fat dairy, with whole grains. It is a high fiber, low to moderate fat diet, rich in potasium, calcium, and magnesium. The full DASH diet plan is shown here. The DASH diet is a healthy plan, designed for the whole family. New research continues to show additional health benefits of the plan.
I would just like to share with you that my patients are HORRIFIED if their physicians ask them to cut out “everything white” in their diet. This is what some doctors ask for…essentially asking for the Ketogenic diet and most of my patients are in shock! Not only would I never want to skip a year of my birthday cake, but I wouldn’t ask my patients to either! One slice of cake is certainly not going to harm anyone with diabetes and hopefully you know enough about carbohydrates and their short term effect on BG levels to know this too! I am not a Registered Dietitian, so I couldn’t speak to this diet in regard to children with epilepsy. Are you a Neuro RN? TheDiabetesCouncil did just post another article where 25 Registered Dieticians weighed in regarding the Ketogenic Diet, so I would encourage you all to check that out!
From baseline to week 16, the mean body weight decreased significantly from 131.4 ± 18.3 kg to 122.7 ± 18.9 kg, BMI decreased from 42.2 ± 5.8 kg/m2 to 39.4 ± 6.0 kg/m2, and waist circumference from 130.0 ± 10.5 cm to 123.3 ± 11.3 cm (Table ​(Table3).3). The percent change in body weight was -6.6%. The mean percent body fat decreased from 40.4 ± 5.8% to 37.0 ± 6.0%. Systolic and diastolic blood pressures did not change significantly over the 16 weeks. The mean heart rate decreased from 81.2 ± 12.9 beats per minute to 74.6 ± 14.0 beats per minute (p = 0.01).
Variations on the Johns Hopkins protocol are common. The initiation can be performed using outpatient clinics rather than requiring a stay in hospital. Often there is no initial fast (fasting increases the risk of acidosis and hypoglycaemia and weight loss). Rather than increasing meal sizes over the three-day initiation, some institutions maintain meal size but alter the ketogenic ratio from 2:1 to 4:1.[9]
From an outpatient clinic, we recruited 28 overweight participants with type 2 diabetes for a 16-week single-arm pilot diet intervention trial. We provided LCKD counseling, with an initial goal of <20 g carbohydrate/day, while reducing diabetes medication dosages at diet initiation. Participants returned every other week for measurements, counseling, and further medication adjustment. The primary outcome was hemoglobin A1c.
The subjects had a mean BMI of 42.2, mean age of 56 years, and were of either African-American or Caucasian descent. In their intervention, subjects consumed a LCKD diet with the goal of eating less than 20 grams of carbohydrates per day while reducing dosages of diabetes medication. Subjects also received nutritional counseling and medication adjustment every two weeks.
On keto, I’ve adjusted my basal rates and I barely need to bolus at all. My blood glucose numbers have definitely improved and what I find really extraordinary is that I’m needing about 60% less total daily insulin, than I did before starting keto. What’s even more fascinating to me is seeing a steady straight line across my pump for 6, 12, and even 24 hours – no crazy spikes or dips in my blood sugar.
One of the keto researches commented, (I think it was Steve Phinney) that change will come about only because enough of the the public will be become educated about this and will demand that the ADA change their recommendations because those recommendations are just wrong. What is the proof they are wrong? If you eat 45-60 g of carb daily, you will continue to have diabetes, and the epidemic will continue as it has for the last 25 years.
Lele says that it’s important to remember that, while keto is a “high fat” diet, the goal is to use your body fat as an energy source, not the fat that’s on your plate. “You don’t need to necessarily add more fats to your diet to adhere to keto. For instance, if your dinner consists of avocado, bacon, and eggs, you really don’t need to add butter to that to make it ‘more keto’,” she says.
When carbohydrates are used by the body as an energy source, the blood sugar levels become unstable. As the energy source is not consistent it is difficult for your brain to stay focused for long periods of time. On the other hand, when you are in ketosis and the brain uses ketones as a fuel source, which has a consistent fuel source and you can focus for longer periods of time. Hence, you also tend to feel more active and alert.
My pick for the healthiest meal plan for diabetes? My favorite is the Mediterranean Diet. It’s high in fiber, low in saturated fats and includes no processed foods which is the challenge for all of us at this point in history. If we could all eat like they do in Italy and Greece! Think of Sicily and the coasts of Greece where their diet consists of fresh fish, fresh fruits and vegetables, nuts, beans, seeds, olives and olive oil, lean meats such as chicken and pork, some eggs and little red meat. The American Heart Association recommends it as well as the American Diabetes Association as being one healthy diet choice for people with diabetes.

The remaining calories in the keto diet come from protein — about 1 gram (g) per kilogram of body weight, so a 140-pound woman would need about 64 g of protein total. As for carbs: “Every body is different, but most people maintain ketosis with between 20 and 50 g of net carbs per day,” says Mattinson. Total carbohydrates minus fiber equals net carbs, she explains.
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