Is the ketogenic diet safe in type I diabetes?

A ketogenic diet is not currently recommended for people with type 1 diabetes, and there is not a lot of research available in this population yet. Several published case studies and small observational studies have shown that the ketogenic diet could improve HbA1c levels and keep blood sugar levels more stable. However, this diet strategy is not without risks, because it can lead to hypoglycemia (low blood sugar) and increase LDL cholesterol levels and cardiovascular disease risk.^[1][2][3]

Particularly in children, the risks seem to outweigh the benefits. Children on a ketogenic diet are more at risk for hypoglycemic episodes and do not tolerate the severely restricted diet. This restriction can cause long-term psychological effects.^[4]

In adults with type 1 diabetes who choose to try the ketogenic diet, several strategies can help decrease risk. People who use insulin will likely need to decrease the dose and should discuss this with their doctor. Any other medication should also be reviewed, and all SGLT2 inhibitors (sodium-glucose cotransporter-2 inhibitors), such as empagliflozin, should be stopped, because they increase the risk for euglycemic diabetic ketoacidosis (a type of diabetic ketoacidosis in which the typical features of raised blood sugar and urinary ketones are hidden and make it more difficult to diagnose). Slowly lowering carbohydrate intake over a period of weeks (instead of dropping immediately down to 50 grams daily) may lower the risk of hypoglycemia. Finally, a continuous glucose monitor should be used, because it is necessary to monitor glucose levels very closely during the transition period.^[3][2][1]