Why I Chose a Ketogenic Diet For Diabetes Management

Often people use the term “diet” to mean something that is temporary for a specific purpose, usually weight loss. For me, it is a permanent way of eating now. I am a retired physician living with Type 1 diabetes since 1998. I started to exercise regularly in 2007 to help ward off complications, particularly cardiovascular disease. I was unaware at the time that aerobic exercise alone would have little impact on the development of cardiovascular disease. It wasn’t until 2011 when I contemplated doing an ironman distance triathlon, that I discovered diet is the most important determinate in the development of most chronic diseases, including cardiovascular disease. My research led me to begin a very low carbohydrate, ketogenic diet in February 2012.

Why I Chose a Low Carb Ketogenic Diet for Diabetes Management

Carbohydrate is the macronutrient that raises blood glucose the most, so keeping consumption low is my primary goal. Of next importance is using whole foods that naturally have the necessary micronutrients and enough complete proteins to support my exercise. I had to add fat to my meals to replace calories from the omitted carbohydrates. My protein intake did not change after starting a ketogenic low carb high fat diet. This way of eating has resulted in a significant improvement in my blood glucose control and a 1.2% reduction in HbA1c. Most importantly, the diet supplies my body with the energy, substrates, and nutrients to enable daily resistance and aerobic/endurance exercise, with minimal need for sports nutrition (sugar), or development of hypoglycemia. I completed The Great Floridian Triathlon in October 2012 without any sugar, food, or hypoglycemia thanks to my low carbohydrate ketogenic lifestyle.

Nutritional Ketosis

My diet keeps me in a state of nutritional ketosis*, the natural result of a low carbohydrate diet that instructs the fat cells to release fat and the liver to convert some of that fat into ketones. Ketones, including acetoacetate and beta-hydroxybutyrate, are small energy molecules clipped from long fatty acids to replace a portion of the glucose requirements of many key organs, particularly the brain. The body over time becomes metabolically flexible, and able to utilize glucose, fat, and ketones, instead of just glucose and fat. This is especially important for those with diabetes who may experience hypoglycemia since ketones can supply the brain with fuel when blood glucose is temporarily low. The low carbohydrate ketogenic diet has also been found to be anti-inflammatory and improves cardiovascular risk factors in persons with metabolic syndrome.

To stay in continuous nutritional ketosis I keep my total carbohydrate content at about 50 grams/day, but others may require as little as 20 grams/day. By monitoring urine ketones, blood ketones, and/or breath ketones, I have confirmed nearly continuous nutritional ketosis. My dietary protein intake is about 1.4 grams/kg body weight/day, so for my 5’8″ height and 166 lb. weight, that’s about 105 grams of protein/day. My dietary fat intake is fairly high as a percentage of calorie intake (about 75%), but the quantity of dietary fat (about 209 grams/day) is just enough to feel energetic and maintain a lean body composition.

Hunger has never been a problem for me, but has become even less noticeable since starting my diet. I eat breakfast at 8 a.m. and dinner at 6 p.m.. I started skipping lunch (thus eating two meals a day) in 2001 to avoid taking insulin with lunch, and thereby decrease the likelihood of hypoglycemia while at work. Eating at regular times is not absolutely necessary when type 1 is treated with insulin analogs, but I prefer a regular schedule because insulin sensitivity changes throughout the day particularly after exercise and this affects the mealtime insulin doses needed. Persons with diabetes often ask me how difficult it is to maintain such a rigid diet. It’s really not all that difficult. Here’s what I eat.

What I Cook And Eat

• Beef, grass-fed, including skeletal muscle (65% lean), heart, liver, and kidney
• Fish, mainly wild Alaskan salmon
• Pork sausage and bacon (both uncured)
• Lamb occasionally
• Chicken & Turkey occasionally
• Eggs (chicken)
• Non-starchy vegetables (about 5% carbohydrate content by weight): Cabbage (Red, Green, Napa), Kale, Collard Greens, Spinach, Bell Peppers, Carrots, Leeks, Onions, Mushrooms, Brussels sprouts, Home-made Sauerkraut from Red Cabbage, Bok-Choy, Broccoli, Cauliflower, Yellow Squash, Zucchini, Cucumber, Lettuce (Iceberg & Romaine), Turnip Root, others I’m not recalling.
• Fruit – Avocado, Tomatoes, Olives, Strawberries, Blueberries, Blackberries, lemon juice on fish and salads
• Nuts & Seeds – Pepitas, Macadamia, Brazil, Pecan, Walnut, Pistachio, Cashew
• Fat – Butter, Coconut & Olive Oils often, Cheese rarely (all these added fats are admittedly processed)
• Note: I developed an intolerance to milk prior to my diagnosis of T1D. I did try heavy whipping cream after starting my KLCHF diet, but am also intolerant of it.

What I Drink

Water (filtered by reverse osmosis), Unsweetened Tea And Coffee.

What I Don’t Eat

• Grains – Wheat, Corn, Rice, Oats (there are many more) or anything made from them, which is too numerous to list here. Gluten is a protein present in a number of grains (all varieties of wheat including spelt, kamut, and triticale as well as barley and rye.) which can cause a number of medical problems for a significant portion of the population with gluten sensitivity or celiac disease. In my case, I avoid them due to their carbohydrate content.
• Starchy vegetables – potatoes, sweet potatoes, yams, most root vegetables (turnip root okay), peas
• Legumes – peas, beans, lentils, peanuts, soybeans
• High sugar fruits – includes most fruits except berries, see above.
• Sugar and the fifty other names given to sugar.
• Vegetable Oils (really seed oils) – Canola, Corn, Soybean, Peanut, Sunflower, Safflower, Cottonseed, Grape seed, Margarine & Butter substitutes, Shortening.
• All Processed Food-like Substances (except as listed above) i.e., most of what is in the grocery store.
• I avoid restaurants except when traveling, and then order fish or steak with plain steamed non-starchy vegetables (no gravy or sauces that typically contain sugar, cornstarch, or flour).

What I Don’t Drink

• Colas (both sweetened and unsweetened).
• Fruit Juice except small amounts of lemon juice.
• Alcohol (can cause hyperglycemia or hypoglycemia in persons with diabetes).
• No artificial sweeteners, don’t need or like them.

*Be sure not to confuse nutritional ketosis and diabetic ketoacidosis (DKA)

Dr. Keith Runyan

Dr. Keith Runyan is a retired physician who practiced Emergency Medicine, Internal Medicine, Nephrology, and Obesity Medicine during his 28 year career. In 1998, he developed type 1 diabetes at the age of 38 and struggled to manage his blood glucose due to hypoglycemic episodes. When he started regular exercise in 2007, his sports nutrition (sugar) exacerbated his glycemic control further. While preparing for an ironman distance triathlon, he discovered the ketogenic low carbohydrate diet that had been used for all persons with diabetes prior to the discovery of insulin in 1921. It was resurrected by Dr. Richard K. Bernstein and Dr. Runyan adopted his method of diabetes management. To Dr. Runyan’s surprise, his hypoglycemic episodes dramatically improved as did his glycemic control. He remains active with swimming, cycling, scuba diving, and more recently olympic weightlifting. He writes about his experiences to help educate others with diabetes in his blog, Ketogenic Diabetic Athlete.