Is there a difference between the Doctor Bernstein’s Diabetes Solution diet and the ketogenic diet? While the two may look the same from afar, a careful study will show important differences in emphasis.
The most important thing to note is that nutritional ketosis– the eponymous goal of the ketogenic diet – is not in any way a stated goal of Dr. Bernstein’s diet. The most recent edition of Dr. Bernstein’s indispensable tome has precisely zero discussion of nutritional ketosis. It’s just not something that he pays attention to.
In practice, anyone strictly limiting their carbohydrate intake is likely to find themselves in the state of nutritional ketosis at least intermittently, if not perpetually. So if a person with Type 1 diabetes on the Dr. Bernstein diet is likely to be in ketosis anyway, what’s the difference?
It can be a big deal. If you have Type 1 diabetes you simply cannot be concerned with achieving or maintaining nutritional ketosis because of the risk of hypoglycemia. Even a well-controlled person with T1D will occasionally need to consume sugar in order to raise his or her blood sugar. You just cannot turn down a potentially life-saving glucose tab, juice box or Skittle out of concerns that you might get knocked out of ketosis.
Conversely, do you need to be worried about high levels of ketones on the Dr. Bernstein diet? Can one accidentally stumble into diabetic ketoacidosis? Check out our earlier article on the topic: When to Worry About Ketones.
This is the one place where there is very little disagreement between the two diets. Dr. Bernstein recommends an upper limit of 30g of carbohydrates per day. Keto guidelines tend to recommend as few as 20-25g per day, at least to begin with. Some dieters, based on activity level and body type, may find that they can comfortably stay in ketosis while eating 25-50g per day.
All of Dr. B’s carbohydrates are in the form of slow-acting carbs, and by “slow-acting” he does not mean bananas, whole grain breads and lentils, which still spike blood sugar so quickly that they might just as well be Fun Dip. The approved carbs of the Bernstein way of eating are limited almost entirely to non-sweet, non-starchy vegetables, along with the tiny amounts of carbs present in some protein sources, such as nuts, shellfish, tofu and eggs.
Keto? Pretty much the same menu.
By the way: why eat carbohydrates at all? The good doctor notes that “as stunning as it sounds … you can quite easily survive on a diet in which you eat no carbohydrate.” But while carbohydrates may not be essential, strictly speaking, they are marvelous sources of health-giving vitamins, minerals and phytochemicals. Phytochemicals were only identified relatively recently, and Dr. Bernstein speculates that even more benefits will be discovered in the future. As far as I’m concerned, the deliciousness of vegetables is more than enough argument to keep them in my own diet.
Here is where we can begin to draw a distinction. The keto diet is commonly referred to as a Low Carb High Fat (LCHF) diet, but Dr. Bernstein distinguishes his own regimen by calling it a Low Carb High Protein (LCHP) diet.
In practice, the difference is often slight. For a sedentary adult, Dr. Bernstein recommends a rock bottom of 0.8g of protein per 1kg of body weight, and a recommended “starting point” of 1.2g, a number that should go up with increased activity levels. These are in step with most mainstream keto guidelines, which tend to recommend numbers between 1.0 and 2.0g/kg.
While those numbers are all in the same ballpark, the difference in emphasis between “high fat” and “high protein” can become more important in some special cases.
Dr. Bernstein recommends dramatically larger ratios for children and for more active adults: growing children and teens should start at 2.4g/kg, and a professional athlete could require as much as an immense 5g/kg! You’re unlikely to find a keto expert recommending protein intake this high.
One reason that many keto experts avoid huge amounts of protein is that many in the keto community assert that excessive protein can actually kick you out of ketosis. It seems logical: your body does slowly convert protein into glucose via the process of gluconeogenesis. After all, anyone with Type 1 diabetes can see that his or her blood sugar will usually slowly rise after a low-carb and high-protein meal. It sounds rather as if your body is slowly turning the steak you’ve eaten into pure sugar. Is this something we need to avoid?
In a word, no. The gluconeogenesis process is actually quite stable and even immense protein meals don’t make your body create excess sugars, which is why keto dieters with healthy pancreases will not in fact experience a blood sugar rise from protein. The real reason a T1D’s blood sugar increases after a heavy protein mealis that the liver will release glucagon in response to protein consumption, dumping sugars that the bodily had previously stored back into the bloodstream. Insulin prevents that from happening. When you properly dose insulin for that high protein meal and achieve a flat glucose line, it’s not because you’ve accurately metabolized those dumped sugars, it’s because you’ve prevented their release in the first place!
Fat is your friend on each diet, and either way, you’ll be consuming more fat than the food pyramid ever asked you to.
But only the keto diet is avowedly “high fat.” Dr. Bernstein’s approach is more modest.
While most keto and Dr. B dieters likely consume similar levels of fat, the differences between the two diets become increasingly obvious as caloric consumption rises. While the active keto dieter is told to eat more and more fat in order to satisfy his or her hunger, Dr. Bernstein asks his patients to eat more and more protein.
This emphasis becomes evident in the most extreme of ketogenic practices. Lattes made with heavy cream, “fat bombs” and shots of coconut oil are all the hallmarks of an extreme emphasis on fat consumption, and emphasis that just does not exist in Diabetes Solution. In fact, Dr. Bernstein does not track fat consumption at all:
“I’m not telling people, go out and buy some fat and eat it. The fat is whatever comes along with the protein. It’s a matter of whatever it takes to make you feel comfortable.”
In practice, Dr. Bernstein’s diet and the ketogenic diet are broadly similar, similar enough that Bernstein dieters can, for example, choose to cook most keto recipes with confidence. In the most important matter of carbohydrate content, the two diets are the same.
But they can diverge at the extremes. Protein and fat goals are in the same ballpark for most adults, but differ, sometimes significantly, for youths and for the very active. The keto diet recommends an upper limit on protein and asks you to add fat if you’re still hungry. Dr. Bernstein asks you to keep adding protein.
Most importantly, if you have Type 1 diabetes, you’re better off thinking of ketosis as a red herring. Ketosis is the goal of the ketogenic diet, but the goal of the Bernstein diet is superior glucose control. Ketosis is a mere byproduct, and it’s far more important to prioritize your healthy blood sugars.