Low-Carbohydrate Diet for Diabetes

A low-carbohydrate diet (LCD) is a therapeutic nutritional strategy for managing diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus by restricting carbohydrate intake to improve glycemic control and reduce medication dependence. By lowering the body's glycemic load and decreasing insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin demand, an LCD can enhance insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin sensitivity. This approach is clinically proven to lower HbA1c HbA1c Products of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes. Diabetes Mellitus, promote weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, and potentially lead to type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches, though it requires close medical supervision to manage risks like hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia.

Last updated: Oct 10, 2025

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition and Purpose

  • Definition: A low-carbohydrate diet (LCD) is a dietary pattern that restricts the intake of carbohydrates Carbohydrates A class of organic compounds composed of carbon, hydrogen, and oxygen in a ratio of cn(H2O)n. The largest class of organic compounds, including starch; glycogen; cellulose; polysaccharides; and simple monosaccharides. Basics of Carbohydrates, typically to less than 130 grams per day or 26-45% of total daily calories. This contrasts with a typical American diet, where carbohydrates Carbohydrates A class of organic compounds composed of carbon, hydrogen, and oxygen in a ratio of cn(H2O)n. The largest class of organic compounds, including starch; glycogen; cellulose; polysaccharides; and simple monosaccharides. Basics of Carbohydrates constitute about 50% of daily calories.
    • Very-Low-Carbohydrate Ketogenic Diet (VLCKD): A stricter form of LCD that limits carbohydrate intake to 20–50 grams per day, inducing a state of nutritional ketosis Ketosis A condition characterized by an abnormally elevated concentration of ketone bodies in the blood (acetonemia) or urine (acetonuria). It is a sign of diabetes complication, starvation, alcoholism or a mitochondrial metabolic disturbance (e.g., maple syrup urine disease). Hyperglycemic Crises.
  • Primary Purpose: The primary clinical purpose of an LCD in the context of diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus is to improve glycemic control, and reduce the reliance on glucose-lowering medications. It is a therapeutic nutritional strategy aimed at managing the underlying metabolic dysfunction of type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus.

Clinical Indications

  • Type 2 Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus Management: An LCD is a well-established medical nutrition therapy option for adults with type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus. The American Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus Association ( ADA ADA An enzyme that catalyzes the hydrolysis of adenosine to inosine with the elimination of ammonia. Purine and Pyrimidine Metabolism) recognizes that reducing overall carbohydrate intake has demonstrated the most evidence for improving glycemia. Clinical trials have shown that LCDs can lead to significant reductions in HbA1c HbA1c Products of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes. Diabetes Mellitus, weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, and a decreased need for medication. 
  • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus Remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches: For some individuals, particularly those early in the course of type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, significant weight loss Weight loss Decrease in existing body weight. Bariatric Surgery achieved through an LCD can lead to diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches, defined as achieving an HbA1c HbA1c Products of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes. Diabetes Mellitus of less than 6.5% after discontinuing diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus medications. The ADA ADA An enzyme that catalyzes the hydrolysis of adenosine to inosine with the elimination of ammonia. Purine and Pyrimidine Metabolism emphasizes the need for individualized meal planning and regular Regular Insulin reassessment, as long-term adherence is challenging and the optimal degree of carbohydrate restriction is not established.
  • Type 1 Type 1 Spinal Muscular Atrophy Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus Management: While less studied, an LCD can be a feasible option for some individuals with type 1 Type 1 Spinal Muscular Atrophy diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus to improve glycemic stability, but it requires intensive management of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin dosing to prevent hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia and ketoacidosis Ketoacidosis A life-threatening complication of diabetes mellitus, primarily of type 1 diabetes mellitus with severe insulin deficiency and extreme hyperglycemia. It is characterized by ketosis; dehydration; and depressed consciousness leading to coma. Metabolic Acidosis.

Mechanism of Action

  • The therapeutic effects of an LCD are rooted in its direct impact on glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance and insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin metabolism.
  • Reduced Glycemic Load: Carbohydrates Carbohydrates A class of organic compounds composed of carbon, hydrogen, and oxygen in a ratio of cn(H2O)n. The largest class of organic compounds, including starch; glycogen; cellulose; polysaccharides; and simple monosaccharides. Basics of Carbohydrates are the macronutrient with the most direct and significant impact on postprandial blood glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance levels. By restricting carbohydrate intake, the diet minimizes large glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance excursions and reduces the overall glycemic load on the body.
  • Decreased Insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin Demand: The reduced influx of dietary glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance leads to a lower demand for insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin, both endogenous and exogenous. This helps to alleviate the metabolic stress on pancreatic beta-cells in type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus and can reduce the required doses of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin and other hypoglycemic medications.
  • Improved Insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin Sensitivity: Lower carbohydrate intake decreases the need for insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin secretion Secretion Coagulation Studies and may reduce insulin resistance Insulin resistance Diminished effectiveness of insulin in lowering blood sugar levels: requiring the use of 200 units or more of insulin per day to prevent hyperglycemia or ketosis. Diabetes Mellitus over time. By lowering circulating insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin levels and promoting weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, an LCD can improve insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin sensitivity, addressing one of the core pathophysiological defects in type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Induction of Ketosis Ketosis A condition characterized by an abnormally elevated concentration of ketone bodies in the blood (acetonemia) or urine (acetonuria). It is a sign of diabetes complication, starvation, alcoholism or a mitochondrial metabolic disturbance (e.g., maple syrup urine disease). Hyperglycemic Crises (in VLCKD): In very-low-carbohydrate ketogenic diets, the depletion of glycogen stores forces the body to utilize fat as its primary energy source. The liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy metabolizes fatty acids Acids Chemical compounds which yield hydrogen ions or protons when dissolved in water, whose hydrogen can be replaced by metals or basic radicals, or which react with bases to form salts and water (neutralization). An extension of the term includes substances dissolved in media other than water. Acid-Base Balance into ketone bodies Ketone bodies The metabolic substances acetone; 3-hydroxybutyric acid; and acetoacetic acid (acetoacetates). They are produced in the liver and kidney during fatty acids oxidation and used as a source of energy by the heart, muscle and brain. Ketone Body Metabolism, which can be used for energy by most cells, including the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification. This metabolic shift is known as nutritional ketosis Ketosis A condition characterized by an abnormally elevated concentration of ketone bodies in the blood (acetonemia) or urine (acetonuria). It is a sign of diabetes complication, starvation, alcoholism or a mitochondrial metabolic disturbance (e.g., maple syrup urine disease). Hyperglycemic Crises and is distinct from the pathological state of diabetic ketoacidosis Ketoacidosis A life-threatening complication of diabetes mellitus, primarily of type 1 diabetes mellitus with severe insulin deficiency and extreme hyperglycemia. It is characterized by ketosis; dehydration; and depressed consciousness leading to coma. Metabolic Acidosis.

Components of the Intervention

Key Principles

  • The diet is based on the restriction of carbohydrate-rich foods, particularly those that are refined or have a high glycemic index, such as white bread, rice, pasta, potatoes, sugar-sweetened beverages, and most sweets.
  • The caloric deficit from carbohydrates Carbohydrates A class of organic compounds composed of carbon, hydrogen, and oxygen in a ratio of cn(H2O)n. The largest class of organic compounds, including starch; glycogen; cellulose; polysaccharides; and simple monosaccharides. Basics of Carbohydrates is compensated for by increasing the proportion of protein and healthy fats Fats The glyceryl esters of a fatty acid, or of a mixture of fatty acids. They are generally odorless, colorless, and tasteless if pure, but they may be flavored according to origin. Fats are insoluble in water, soluble in most organic solvents. They occur in animal and vegetable tissue and are generally obtained by boiling or by extraction under pressure. They are important in the diet (dietary fats) as a source of energy. Energy Homeostasis.
  • Emphasis is placed on whole, unprocessed foods to ensure nutrient density.

Recommended Food Groups

  • The following table outlines the food groups that are emphasized, moderated, or limited in a typical low-carbohydrate diet.
Dietary Component Role in Diet Examples for Patient Education
Non-Starchy Vegetables Emphasized Leafy greens (spinach, kale), broccoli, cauliflower, bell peppers, zucchini, asparagus
Lean LEAN Quality Measurement and Improvement Proteins Proteins Linear polypeptides that are synthesized on ribosomes and may be further modified, crosslinked, cleaved, or assembled into complex proteins with several subunits. The specific sequence of amino acids determines the shape the polypeptide will take, during protein folding, and the function of the protein. Energy Homeostasis Emphasized Poultry, fish FISH A type of in situ hybridization in which target sequences are stained with fluorescent dye so their location and size can be determined using fluorescence microscopy. This staining is sufficiently distinct that the hybridization signal can be seen both in metaphase spreads and in interphase nuclei. Chromosome Testing (especially fatty fish FISH A type of in situ hybridization in which target sequences are stained with fluorescent dye so their location and size can be determined using fluorescence microscopy. This staining is sufficiently distinct that the hybridization signal can be seen both in metaphase spreads and in interphase nuclei. Chromosome Testing like salmon), seafood, lean LEAN Quality Measurement and Improvement cuts of meat, eggs, tofu
Healthy Fats Fats The glyceryl esters of a fatty acid, or of a mixture of fatty acids. They are generally odorless, colorless, and tasteless if pure, but they may be flavored according to origin. Fats are insoluble in water, soluble in most organic solvents. They occur in animal and vegetable tissue and are generally obtained by boiling or by extraction under pressure. They are important in the diet (dietary fats) as a source of energy. Energy Homeostasis Emphasized Avocado, olive oil, nuts (almonds, walnuts), seeds (chia, flax)
Low-Fat Dairy Moderated Plain Greek yogurt, cheese
Low-Carbohydrate Fruits Moderated Berries (strawberries, blueberries, raspberries)
Legumes Moderated Lentils, chickpeas, black beans (note: these contain carbohydrates Carbohydrates A class of organic compounds composed of carbon, hydrogen, and oxygen in a ratio of cn(H2O)n. The largest class of organic compounds, including starch; glycogen; cellulose; polysaccharides; and simple monosaccharides. Basics of Carbohydrates and should be portion-controlled)
Starchy Vegetables & Grains Limited/Avoided Potatoes, corn, peas, bread, pasta, rice, oats, quinoa
Sugary Foods & Drinks Limited/Avoided Soda, fruit juice, candy, pastries, desserts, sugar-sweetened beverages

Implementation and Monitoring

Practical Guidance for Implementation

  • Patient Selection and Education: A thorough pre-diet evaluation is necessary. Individuals who are pregnant, lactating, children, those with kidney disease, or those at risk of disordered eating should be excluded. Patients must be educated on identifying and counting carbohydrates, reading food labels, and understanding portion sizes. The “Diabetes Plate Method” can be a useful visual tool for basic meal planning, where half the plate is non-starchy vegetables, one-quarter is lean LEAN Quality Measurement and Improvement protein, and one-quarter is carbohydrate-containing foods. 
  • Medication Management: This is the most critical aspect of implementation. For patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship taking insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin or insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin secretagogues (e.g., sulfonylureas Sulfonylureas Sulfonamides and Trimethoprim), a proactive and significant reduction in medication dosage Dosage Dosage Calculation is required upon initiating the diet to prevent severe hypoglycemia Severe Hypoglycemia Hypoglycemia. For those on SGLT2 inhibitors SGLT2 inhibitors Non-insulinotropic Diabetes Drugs, avoid excessive alcohol and monitor for signs of ketoacidosis Ketoacidosis A life-threatening complication of diabetes mellitus, primarily of type 1 diabetes mellitus with severe insulin deficiency and extreme hyperglycemia. It is characterized by ketosis; dehydration; and depressed consciousness leading to coma. Metabolic Acidosis. This must be done under close medical supervision.
  • Initial Side Effects: Patients starting a VLCKD may experience the “keto flu,” a constellation of symptoms including headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess, fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, and nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics, which typically resolves within a few days to a week. The “keto flu” can be managed by carbohydrate reduction, maintaining hydration, and ensuring adequate electrolyte intake.

Monitoring Efficacy and Adherence

  • Glycemic Control: Efficacy is primarily monitored through self-monitoring of blood glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance and regular Regular Insulin HbA1c HbA1c Products of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes. Diabetes Mellitus testing. Continuous glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance monitoring (CGM) can provide valuable real-time feedback to improve patient understanding and adherence.
  • Lipid Profile Lipid profile Lipid Disorders: A baseline and follow-up lipid panel is recommended. Typically, triglycerides Triglycerides Fatty Acids and Lipids decrease and HDL cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism increases, but LDL cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism may increase in some individuals and should be monitored.
  • Renal Function: While high-protein diets are generally considered safe for individuals with normal kidney function, periodic monitoring of renal function is prudent.
  • Ketone Levels: For patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship on a VLCKD, urine or blood ketone monitoring can confirm that nutritional ketosis Ketosis A condition characterized by an abnormally elevated concentration of ketone bodies in the blood (acetonemia) or urine (acetonuria). It is a sign of diabetes complication, starvation, alcoholism or a mitochondrial metabolic disturbance (e.g., maple syrup urine disease). Hyperglycemic Crises has been achieved and maintained.

Clinical Considerations

Additional Health Benefits

  • Weight Loss Weight loss Decrease in existing body weight. Bariatric Surgery: LCDs are an effective strategy for weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, which is a key component of type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus management.
  • Blood Pressure Reduction: Many individuals experience a reduction in blood pressure.
  • Improved Triglyceride and HDL Levels: The diet consistently shows favorable effects on triglycerides Triglycerides Fatty Acids and Lipids and HDL cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism.

Potential Challenges and Side Effects

  • Hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia: This is the most significant and immediate risk if insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin or sulfonylurea dosages are not appropriately reduced before starting the diet.
  • Increased LDL Cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism: A subset of individuals may experience a significant rise in LDL cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism, particularly with very-low-carbohydrate ketogenic diets, which requires clinical assessment and shared decision-making regarding the continuation of the diet.
  • Nutrient Deficiencies: The restriction of certain food groups may lead to a lower intake of fiber, vitamins, and minerals Minerals Electrolytes. Counseling should emphasize the inclusion of high-fiber, non-starchy vegetables, nuts, and seeds. Ensure adequate dietary fiber (minimum 14 g/1,000 kcal) to mitigate risks. 
  • Long-Term Adherence: The restrictive nature of the diet can be a barrier to long-term adherence. Individualizing the carbohydrate goal to be as liberal as possible while still meeting therapeutic targets can improve sustainability.

References

  1. American Diabetes Association. (n.d.). Eating for Diabetes Management. https://diabetes.org/food-nutrition/eating-for-diabetes-management
  2. Centers for Disease Control and Prevention. (2024). Diabetes Meal Planning. https://www.cdc.gov/diabetes/healthy-eating/diabetes-meal-planning.html
  3. Goldenberg, J. Z., et al. (2021). Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data. The BMJ, 372, m4743. https://doi.org/10.1136/bmj.m4743
  4. Alarim, R. A., et al. (2021). Low Carbohydrate Dietary Approaches for People With Type 2 Diabetes—A Narrative Review. Frontiers in Nutrition. https://www.frontiersin.org/journals/nutrition/articles/10.3389/fnut.2021.687658/full
  5. Unwin, D., et al. (2023). What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutrition, Prevention & Health. https://committees.parliament.uk/writtenevidence/117121/html/
  6. Mayo Clinic. (2024). Diabetes diet: Create your healthy-eating plan. https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-diet/art-20044295
  7. Evert, A. B., Dennison, M., Gardner, C. D., Garvey, W. T., Lau, K. H. K., MacLeod, J., Mitri, J., Pereira, R. F., Rawlings, K., Robinson, S., Saslow, L., Uelmen, S., Urbanski, P. B., & Yancy, W. S., Jr (2019). Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes care, 42(5), 731–754. https://doi.org/10.2337/dci19-0014
  8. American Diabetes Association Professional Practice Committee; 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes—2025. Diabetes Care 1 January 2025; 48 (Supplement_1): S86–S127. https://doi.org/10.2337/dc25-S005

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