Can Keto Be Used to Treat Type 2 Diabetes?

It’s November, Diabetes Awareness Month… and though I DO try not to talk endlessly only about this topic, this certainly is the time. Especially since the science and human evidence is now overwhelming that diet and lifestyle CAN put Type 2 Diabetes into remission, especially a well formulated keto or low carb diet. The American Diabetes Association has even added low carb to their list of accepted diets, and their CEO, Tracy D Brown is low carb/keto herself in managing her own condition. However, the standard of care in most of the world has not caught up to these advancements yet.

04-Nov 2020, by Bronwyn MacRitchie

The Difficult Figures

Four of the 6 GCC countries are in the top 20 countries world wide of diabetes levels according to the International Diabetes Foundation.

The UAE is ranked 13 (16.3 per cent), Saudi Arabia 14 (15.8 per cent), and Bahrain and Qatar tied at 16 (15.6 per cent). Kuwait comes in at 31 (12.2 per cent), and Oman at 51 (10.1 per cent).

These statistics are according to most recent edition of the IDF Diabetes Atlas (1).

But what can we DO about it?

Throughout the world diabetes is an increasing concern, but the speed and volume of the rise of diabetes in the MENA region (95% expected increase by 2045) is second only to the predicted rise in Africa.

Conventional treatment is becoming financially crippling, not producing encouraging results and certainly not reducing these alarming numbers.

The time has come to look elsewhere, and if nothing else Covid-19 has highlighted the need for us to take lifestyle diseases seriously. Study after study is confirming that those with compromised immunity such as that found in diabetic and metabolically ill patients are the ones most at risk for this virus (2,3,4,5,6). A virus which doesn’t appear to be leaving us soon, AND is likely a forbearer of more infectious diseases to come in our current globalised world.

The science is exhaustive and growing daily. As Dr Eric Westman himself famously said, ‘Clinical evidence for keto diets is past the level that would be required for FDA approval of a drug for the treatment of obesity.’

How did we get here?

Type 2 diabetes (T2D) is essentially insulin resistance run riot. Insulin is spiked most by carbohydrates, especially high glycemic index carbohydrates, and even more by processed, carbohydrates where all the fibre, which technically should slow this glycemic response, has been removed.

As Gary Taubes outlines in his book ‘Good Calories, Bad Calories,’ we can draw a clear correlation between the rise of processed carbohydrates (which were scarce in previous times) eaten in conjunction with high levels of unhealthy fats, and the rise of Metabolic Syndrome, which includes obesity and T2D (7).

As we have continued to eat these hyper-palatable foods throughout our lifetimes, insulin responses have been forced higher and higher, eventually making the insulin receptors in the body unable to respond, and as these responders lose their functionality, MORE insulin is needed to clear excess glucose from the blood. This signals the brain to eat more of the foods which spike insulin the most, and so the cycle continues until an individual can no longer effectively remove glucose from the blood themselves…

Our response? Give them more insulin! When excess insulin was the thing that caused this illness in the first place!

Dr Jason Fung, a renowned nephrologist, had this exact realization after treating thousands of patients with T2D; that the treatment he was offering his patients was entirely counterintuitive (8,9).

Fung is not alone, renowned doctors and scientists the world over are questioning the standard of care, being bold enough to change tactics, and producing results with their patients that we had forgotten were possible.

So what's the alternative?

Fung then began using fasting as a tool to treat T2D and obesity in his clinic… and as his research continued he realized that any state in which the body is not continually spiking insulin and glucose has the potential to heal metabolic syndrome, and reverse, yes REVERSE T2D.  

The state of ketosis, attainable by eating a very low carb ketogenic diet (VLCKD), is one such state.

Not to be confused with diabetic ketoacidosis where the liver begins producing ketones in an uncontrolled and dangerous manner, ketosis occurs when the body has become depleted of carbohydrates and the liver begins producing what is increasingly being recognized to be a therapeutic fuel for the body, ketones.

But isn't keto just a weight loss fad diet?

No! Keto, in its various forms has actually been with us from the times of our ancestors, owing to the fact that food was never readily available, and high GI carbs weren't being consumed between 4 and 6 times a day. This means our bodies were given the chance to switch between fuel sources. From ketones to glucose and back again. Keeping us metabolically flexible and lifestyle disease free. In fact, ketosis is SO natural that human babies are born in this state.

However the keto diet pretty much as we know it today truly originated in the 1800s.

Vanessa Emslie, a licensed Nutritionist based in the UAE says,

The real origin of the Keto or Low Carb diet is the Banting diet, after William Banting, a formerly obese English undertaker who published a book in 1863 on his weight-loss success. Under the recommendation of his physician Dr William Harvey, he limited his intake of carbohydrates, especially those of a starchy or sugary nature. He was so successful in this (Keto) approach, he self-published a book on the diet.’

The diet was then found to be an effective intervention for epilepsy in the early 1900s, but only in the 1970s did it rise to fame again with Dr Robert Atkins’ diet book publication.

Many people lost weight on the Atkins Diet, which was also considered a fad, and whilst not low enough in carbs to be truly ketogenic, it was certainly low enough to induce the fat loss effects of carbohydrate restriction.

Since then ketosis has been researched as therapeutic for everything from autism to Alzheimer’s, but its most compelling use for which we have the most undeniable data is as a treatment for type 2 diabetes and obesity.

But surely there isn't enough data or my doctor would be telling me?

Deep research into the ketogenic diet as a treatment for T2D began to mount in the early 2000’s spearheaded by Dr Eric Westman (on ingfit’s Board of Advisors), and later his colleagues Dr Jeff Volek and Dr Stephen Phinney, amidst strong pushback from the medical community about the safety of the dietary model which was in such direct opposition to the long held nutritional guidelines (10,11,12,13,14,15).

Between 2001 and October 2020, Eric Westman has published 64 peer reviewed articles on the low carb or keto diet, 41 of them with specific reference to its role as a treatment of insulin resistance (pre-diabetes) and Type 2 Diabetes (16,17,18,19,20). The others examining the diet’s positive impact on lipid profiles, and its application in other conditions such as polycystic ovarian syndrome and cancer (21,22,23,24).

Subjects in these studies improved HBA1C, waist circumference, fasting blood glucose and a variety of other blood markers over simply reducing calories in the control groups. Many were able to either reduce their medication or stop taking it completely.

In 2010 Dr’s Westman, Phinney and Volek published the book, ‘A New Atkins For a New You,’ hoping to bring the knowledge to more of the public. Slowly their mission is being realized as more and more people learn about keto.

However, while the internet and social media have made it possible for the diet to become almost viral, many medical professionals have not caught up with the science.

Because of the way the diet trends like a fad, and the old misconceptions about saturated fat and heart disease, coupled with a lack of training in nutrition, doctors, for the large part, remain unwilling to give it much consideration when treating patients. They warn patients against the dangers of the diet and state that there is not enough science to back it up.

This is simply not the case. The science is exhaustive and growing daily. As Dr Eric Westman himself famously said, ‘Clinical evidence for keto diets is past the level that would be required for FDA approval of a drug for the treatment of obesity.’

Westman’s latest book on the Keto Diet is now available for pre-order here.

We are happy to be slowly growing a network of doctors in the UAE who are willing to work with this nutritional intervention and are changing people’s. lives on a daily basis.

Join our community here for access to these professionals and an active support network.

But what about cholesterol?

Lee Sandwith, Registered Nutritionist and GM of ingfit explains,

'This has long been the medical community’s standard comeback. Centrepoint to this apprehension is the widely accepted association between heart disease and dietary fat, in particular saturated fat which formed the basis of the diet-heart hypothesis proposed by Ancel Keys in the 1960s.

Fast forward to 2018 and there is mounting evidence that the link between dietary fat and heart disease is at best exaggerated and at worst potentially one of the most damaging pieces of information to become firmly embedded in society.

As research on the connection between cholesterol and heart health mounts, it is being noted that although “required” for the development of atherosclerosis, LDL is not “sufficient”.

Of particular interest at the cutting edge of lipidology is the role of inflammation and the different types of LDL, in particular particle size and particle number as opposed to the molecular weight which is the measure provided through the standard cholesterol test.'

In fact, the majority of the above mentioned studies DO take lipid markers into consideration while assessing the overall effect of the diet on their subjects. All saw an almost uniform decrease in triglycerides in the VLCKD compared to the control group. Most noted very little change in HDL or LDL.

It must be noted that a small subset of people will see a marked rise in LDL cholesterol on this diet, these people are becoming known as lean mass hyper-responders. For more information about this check out this page. However these people are the exception, and definitely not the rule.

Lipid markers can also rise in correlation with initial fat loss and then settle a few months into the lifestyle, which is why we always advocate regular testing.

A 2006 study compared a VLCKD to a low fat diet and monitored lipoprotein subclasses and noted a shift in LDL particle size. Small, dense (suggested to be most damaging) particles decreased while large particles increased (26).

Perhaps the most compelling and encouraging VLCKD dietary intervention and study on humans yet is still underway in the USA.

The Virta Study

Virta Health is an organization in the US which is currently treating adults with T2D with their doctor-coach model. Overseen by some of the leading names in low carb and ketogenic diet research, such a Drs Phinney and Volek, Virta is now in its third year, and has been publishing its findings regularly throughout, from its first significant impact on biomarkers (27) onwards.

The end of year one study reported on 349 adults, 92% obese and 88% on medication. Patients were divided into Continuous Care Intervention (CCI) and Usual Care (UC). CCI patients were supported by a physician, as a VLCKD can dramatically lower blood glucose, and so medications must be closely monitored. Patients wore continuous glucose monitors which fed data back to an application which the physician had access to and could be immediately alerted if glucose levels shifted dangerously.

Patients were also assigned a health coach who supported them to continuously make the correct diet and lifestyle choices to keep them on track. Patients were able to watch their own glucose spikes in real time in response to eating high carbohydrate food. This dramatically improved compliance. The health coach was able to educate the patients in real time on which foods were surprisingly high in carbohydrates (like onions and bell peppers for example) and show them where hidden carbs were sneaking in, as well as provide emotional support and strategies for staying on track and driving change.

This is what it said about T2D markers, ‘After 1 year, patients in the CCI, on average, lowered HbA1c from 7.6 to 6.3%, lost 12% of their body weight, and reduced diabetes medicine use. 94% of patients who were prescribed insulin reduced or stopped their insulin use, and sulfonylureas were eliminated in all patients (28).’

In terms of cholesterol, HDL increased, triglycerides decreased, and Apolipoprotein 4 (a proxy for LDL particle size) was unchanged.

The end of year two study reported on these same participants. To quote, ‘Use of any glycemic control medication (excluding metformin) among CCI participants declined (from 55.7 to 26.8%) including insulin (-62%) and sulfonylureas (-100%). The UC group had no changes in these parameters (except uric acid and anion gap) or diabetes medication use. There was also resolution of diabetes (reversal, 53.5%; remission, 17.6%) in the CCI group but not in UC (29).’

The study is ongoing and more personal triumphs are being achieved for these patients daily. It has also been cited in the American Diabetes Association Guidelines in both 2019 and 2020.

Time to catch up?

The question we have to ask ourselves in this region, where nothing we do seems to curb the uncontrolled increase in diabetes and obesity, is when are we going to wake up? When are we going to realize that these diseases do not develop unaided by the chronic overeating of highly processed foods, sugars and starches, but in perfect unison with their appearance?

The examples of tribes without who had lived on their natural diets until the introduction of western processed foods are many, and the rise in heart disease, diabetes and obesity can virtually be drawn in perfect parallel to the increase in consumption of these foods. The United Arab Emirates itself being one such example.

When are we going to give our patients the information that they deserve, that their pre-diabetes or diabetes cure is completely in their own hands, and as practitioners, pair up with coaches to heal this epidemic?

The data is HERE, the solution is in our hands, all we need to do is act.

References

  1. https://www.diabetesatlas.org/en/resources/
  2. Muniyappa, R., & Gubbi, S. (2020). COVID-19 pandemic, coronaviruses, and diabetes mellitus. American Journal of Physiology-Endocrinology and Metabolism, 318(5), E736-E741.
  3. Maddaloni, E., & Buzzetti, R. (2020). Covid‐19 and diabetes mellitus: unveiling the interaction of two pandemics. Diabetes/Metabolism Research and Reviews, e33213321.
  4. Hussain, A., Bhowmik, B., & do Vale Moreira, N. C. (2020). COVID-19 and diabetes: Knowledge in progress. Diabetes research and clinical practice, 108142.
  5. Mantovani, A., Byrne, C. D., Zheng, M. H., & Targher, G. (2020). Diabetes as a risk factor for greater COVID-19 severity and in-hospital death: a meta-analysis of observational studies. Nutrition, Metabolism and Cardiovascular Diseases, 30(8), 1236-1248.
  6. Singh, A. K., Gupta, R., Ghosh, A., & Misra, A. (2020). Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes & Metabolic Syndrome: Clinical Research & Reviews.
  7. Taubes, G. (2008). Good calories, bad calories: fats, carbs, and the controversial science of diet and health. Anchor.
  8. Fung, J. (2016). The obesity code: Unlocking the secrets of weight loss. Greystone Books.
  9. https://www.sciencedirect.com/topics/medicine-and-dentistry/lipid-oxidationFurmli, S., Elmasry, R., Ramos, M., & Fung, J. (2018). Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. Case Reports, 2018, bcr-2017.  
  10. Westman, E. C., Yancy, W. S., Edman, J. S., Tomlin, K. F., & Perkins, C. E. (2002). Effect of 6-month adherence to a very low carbohydrate diet program. The American journal of medicine, 113(1), 30-36.
  11. Yancy Jr, W. S., Vernon, M. C., & Westman, E. C. (2003). A pilot trial of a low-carbohydrate, ketogenic diet in patients with type 2 diabetes. Metabolic syndrome and related disorders, 1(3), 239-243.
  12. Vernon, M. C., Mavropoulos, J., Transue, M., Yancy Jr, W. S., & Westman, E. C. (2003). Clinical experience of a carbohydrate-restricted diet: effect on diabetes mellitus. Metabolic Syndrome and Related Disorders, 1(3), 233-237.
  13. O'Neill, D. F., Westman, E. C., & Bernstein, R. K. (2003). The effects of a low-carbohydrate regimen on glycemic control and serum lipids in diabetes mellitus. Metabolic syndrome and related disorders, 1(4), 291-298.
  14. Vernon, M. C., Kueser, B., Transue, M., Yates, H. E., Yancy Jr, W. S., & Westman, E. C. (2004). Clinical experience of a carbohydrate-restricted diet for the metabolic syndrome. Metabolic syndrome and related disorders, 2(3), 180-186.
  15. Westman, E. C., Yancy Jr, W. S., Haub, M. D., & Volek, J. S. (2005). Insulin resistance from a low carbohydrate, high fat diet perspective. Metabolic Syndrome and Related Disorders, 3(1), 14-18.
  16. Yancy, W. S., Foy, M., Chalecki, A. M., Vernon, M. C., & Westman, E. C. (2005). A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutrition & metabolism, 2(1), 34.
  17. Yancy Jr, W. S., Olsen, M. K., Guyton, J. R., Bakst, R. P., & Westman, E. C. (2004). A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Annals of internal medicine, 140(10), 769-777.
  18. Feinman, R. D., Pogozelski, W. K., Astrup, A., Bernstein, R. K., Fine, E. J., Westman, E. C., ... & Nielsen, J. V. (2015). Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. Nutrition, 31(1), 1-13.
  19. Westman, Eric C., Justin Tondt, Emily Maguire, and William S. Yancy Jr. "Implementing a low-carbohydrate, ketogenic diet to manage type 2 diabetes mellitus." Expert review of endocrinology & metabolism 13, no. 5 (2018): 263-272.
  20. Westman, E. C., & Yancy Jr, W. S. (2020). Using a low-carbohydrate diet to treat obesity and type 2 diabetes mellitus. Current Opinion in Endocrinology, Diabetes and Obesity, 27(5), 255-260.
  21. Beatty, S. J., Mehta, B. H., & Rodis, J. L. (2005). Decreased warfarin effect after initiation of high-protein, low-carbohydrate diets. Annals of Pharmacotherapy, 39(4), 744-747.
  22. Mavropoulos, J. C., Yancy, W. S., Hepburn, J., & Westman, E. C. (2005). The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutrition & metabolism, 2(1), 35.
  23. Austin, G. L., Thiny, M. T., Westman, E. C., Yancy, W. S., & Shaheen, N. J. (2006). A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Digestive diseases and sciences, 51(8), 1307-1312.
  24. McClernon, F. J., Yancy Jr, W. S., Eberstein, J. A., Atkins, R. C., & Westman, E. C. (2007). The effects of a low‐carbohydrate ketogenic diet and a low‐fat diet on mood, hunger, and other self‐reported symptoms. Obesity, 15(1), 182-182.
  25. Tendler, D., Lin, S., Yancy, W. S., Mavropoulos, J., Sylvestre, P., Rockey, D. C., & Westman, E. C. (2007). The effect of a low-carbohydrate, ketogenic diet on nonalcoholic fatty liver disease: a pilot study. Digestive diseases and sciences, 52(2), 589-593.
  26. Westman, E. C., Yancy Jr, W. S., Olsen, M. K., Dudley, T., & Guyton, J. R. (2006). Effect of a low-carbohydrate, ketogenic diet program compared to a low-fat diet on fasting lipoprotein subclasses. International journal of cardiology, 110(2), 212-216.

  27. McKenzie, A. L., Hallberg, S. J., Creighton, B. C., Volk, B. M., Link, T. M., Abner, M. K., ... & Phinney, S. D. (2017). A novel intervention including individualized nutritional recommendations reduces hemoglobin A1c level, medication use, and weight in type 2 diabetes. JMIR diabetes, 2(1), e5.
  28. Hallberg, S. J., McKenzie, A. L., Williams, P. T., Bhanpuri, N. H., Peters, A. L., Campbell, W. W., ... & Volek, J. S. (2018). 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. Diabetes Therapy, 9(2), 583-612.
  29. Athinarayanan, S. J., Adams, R. N., Hallberg, S. J., McKenzie, A. L., Bhanpuri, N. H., Campbell, W. W., ... & McCarter, J. P. (2019). Long-term effects of a novel continuous remote care intervention including nutritional ketosis for the management of type 2 diabetes: a 2-year non-randomized clinical trial. Frontiers in endocrinology, 10, 348.

 

 

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