This document discusses a study that examined the effect of a ketogenic diet on HbA1c levels in patients with type 2 diabetes. Seven studies were identified that met criteria for inclusion. All studies found a decrease in HbA1c levels with the ketogenic diet. Four studies found these decreases to be statistically significant. The ketogenic diet also resulted in weight loss and reduced use of diabetes medications. While the studies had small sample sizes and some limitations, the findings suggest that a ketogenic diet may improve glycemic control in patients with type 2 diabetes. Larger and more rigorous studies are still needed.

1. THE EFFECT OF NUTRITIONAL KETOSIS ON HBA1C
IN PATIENTS WITH TYPE 2 DIABETES
Jillian Messina, BSN, RN, CCRN
University of Texas Houston Health Science Center

2. TYPE 2 DIABETES: A MODERN EPIDEMIC
➤ Hyperglycemia
➤ Due to insulin resistance and decreased insulin production
➤ ~9.4% of population in U.S. have DM
• 90-95% of those have type 2 DM
➤ 7th leading cause of death in U.S.
➤ Estimated annual cost to U.S.: $327 billion
(ADA, 2018b; ADA, 2019; CDC, 2017a)

3. COMPLICATIONS OF DIABETES
➤ Microvascular
• Nephropathy
• Neuropathy
• Retinopathy
➤ Macrovascular
• Atherosclerotic cardiovascular disease/Coronary
artery disease (CAD)
• Cerebral vascular attack (CVA)
(CDC, 2014; Fowler, 2008; Healthy People
2020, 2014; National Eye Institute, 2015)

4. CURRENT STANDARDS OF CARE
➤ 1st line pharmacologic agent: Metformin
➤ Other medications selected by co-morbidities
➤ Lifestyle modifications:
• Diabetes self-management education and support
(DSMES)
• Medical nutrition therapy (MNT)
• Physical activity
• Smoking cessation
• Psychosocial care
(ADA, 2018a)

5. MEDICAL NUTRITION THERAPY (MNT)
Current dietary advice from the ADA includes:
➤ Individualized diets with consideration to
• Current eating patterns
• Personal preferences (i.e. tradition, culture,
religion, health beliefs and goals, economics)
• Goals for weight loss and glycemic control
➤ Mediterranean diet
➤ Dietary approaches to stop hypertension (DASH) diet
➤ Plate method
(ADA, 2018a)

6. WHAT IS A KETOGENIC DIET?
Daily Caloric Intake
70%
20%
10%
Carbohydrates
Protein
Fat

7. WHY KETO?
➤ Quick and effective weight loss
➤ Established therapeutic uses:
• Epilepsy
➤ Current areas of research for application:
• Cancer
• Metabolic syndrome, PCOS
• Obesity management (Alder, Caplin, Filloux, Henderson & Lyon, 2006;
Bueno, de Rocha Ataide, de Melo & de Oliveira, 2013;
Gibas & Gibas, 2017; Masood & Uppaluri, 2019)

8. THE RESEARCH QUESTION…
➤What is the effect of nutritional
ketosis on HbA1c in patients
with type 2 diabetes mellitus?

9. THEORETICAL FRAMEWORK
Natural History of Disease
➤ Preclinical phase
➤ Clinical phase
➤ Levels of prevention:
• Primary
• Secondary
• Tertiary
(Sahoo, 2014)

10. VARIABLES
➤ Independent: ketogenic diet
➤ Dependent: HbA1c
➤ Controls: Diagnosis of T2DM, measurement of urinary
ketones to confirm state of ketosis

11. SEARCH METHODS
➤ Databases
• Ovid Medline
• Cumulative Index to Nursing and Allied Health Literature (CINAHL)
• Embase
➤ Titles, abstracts, keywords and database subject headings
➤ Terms
➤ Ketogenic diet: ketosis, keto and diet within 3 words, vlcld (very low
carbohydrate ketogenic diet), very low carb within 3 words of diet
➤ HbA1c: glycated hemoglobin A, hba1c, hgba1c, hemoglobin a1c,
haemoglobin a1c, glycosylated/glycated within 3 words of hemoglobin/
haemoglobin
➤ Type 2 diabetes: diabetes mellitus type 2, diabetes within 3 words of type
2/type two/type ii/noninsulin dependent, niddm

12. SEARCH METHODS (CONTINUED)
➤ Boolean operators
• “OR” between each of the various expressions of the 3
terms
➤ Truncations used
• Keto*
• Diabet*
➤ Limits
• Published in English
• Human subjects

13. RESULTS OF SEARCH
Figure 1. PRISMA flow chart illustrating the retrieval and evaluation of research that resulted from
database searches (2015).

14. CHARACTERISTICS OF THE STUDIES
7 studies included
➤ Types
• 4/7 were RCTs
• Others: uncontrolled single arm studies & case series
➤ Publish dates: 2005-2019
➤ Sample sizes: 2-262 participants
• Mean n=77
➤ Duration: 10-52 weeks
➤ Locations:
• United States (4)
• Canada
• Israel
• Spain

15. FINDINGS
➤ Decrease in HbA1c in ALL studies
➤ Statistically significant in 4/7 studies (p=0.009-0.03)
➤ Weight loss
➤ Reduction in use of anti-diabetic agents

16. WHAT DO THE FINDINGS MEAN?
➤Improved glycemic control

17. WEAKNESSES
➤ Small sample sizes
➤ Lack of certain controls
• Anti-diabetic medications
STRENGTHS
➤ Unanimous improvement in
glycemic control
➤ Multiple RCTs included
➤ Recent data

18. IMPLICATIONS OF THE STUDY
On clinical practice
➤ Ketogenic diet as therapeutic management of type 2
diabetes
• Improved glycemic control
• Reduction in polypharmacy
• Cost-effective compared to expensive
medications such as insulin and sglt2 inhibitors
On research
➤ Need for large RCT
➤ Further investigation of long-term safety

19. CONCLUSIONS
➤ Ketogenic diet may be a viable low-cost effective option
➤ Attractiveness to patients includes
• Not calorie restrictive
• Produces quick results
• Biofeedback through measurement of urinary ketones
serves as motivation
• Alternative to polypharmacy and subcutaneous routes of
administration
• Also produces weight loss
➤ Might be great short-term method for achieving glycemic target

20. Questions
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21. REFERENCES
Alder, S., Caplin, D., Filloux, F., Henderson, C., & Lyon, J. (2006). Efficacy of the ketogenic diet as a treatment option for epilepsy: meta-analysis. Journal of Child Neurology,
21(3), 193-198. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16901419
Bueno, N., da Rocha Ataide, T., de Melo, I., & de Oliveira, S. (2013). Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of
randomized controlled trials. British Journal of Nutrition, 110(7), 1178-1187. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23651522
American Diabetes Association. (2018a) . Standards of medical care in diabetes—2019: abridged for primary care providers. Retrieved from https://clinical.diabetes-
journals.org/content/diaclin/early/2018/12/16/cd18-0105.full.pdf
American Diabetes Association. (2018b). The cost of diabetes. Advocacy. Retrieved from http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html
American Diabetes Association. (2019). Standards of medical care in diabetes—2019. The Journal of Clinical and Applied Research and Education: Diabetes Care, 42(1).
Retrieved from http://care.diabetesjournals.org/content/42/Supplement_1
Centers for Disease Control. (2017a). National Diabetes Statistics Report, 2017: Estimates of diabetes and its burden in the United States. National Center for Chronic Disease
Prevention and Health Promotion. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
Centers for Disease Control. (2014). National diabetes statistics report, 2014. National Center for Chronic Disease Prevention and Health Promotion. Retrieved from https://
www.cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-burden-in-the-unitedstates.pdf
Fowler, M. J. (2008). Microvascular and macrovascular complications of diabetes. Clinical Diabetes, 26(2), 77-82. Retrieved from http://clinical.diabetesjournals.org/content/
26/2/77.full
Gibas, K. J., & Gibas, M. K. (2017). Induced and controlled dietary ketosis as a regulator of obesity and metabolic syndrome pathologies. Diabetes & Metabolic Syndrome:
Research & Reviews, 11(1), S385-S390. Retrieved from https://www.sciencedirect.com/science/article/pii/S1871402116303137#bib0015
Healthy People 2020. (2014). Diabetes. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes
Masood, W., & Uppaluri, K. (2019). Ketogenic diet. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499830/
National Eye Institute. (2015). Facts about diabetic eye disease. National Institutes of Health. Retrieved from https://nei.nih.gov/health/diabetic/retinopathy
PRISMA. (2015). PRISMA flow diagram. Retrieved from http://prisma-statement.org/
Sahoo, S. S. (2014). Natural History of Disease [PowerPoint slides]. Retrieved from Linkedin SlideShare: https://www.slideshare.net/drswaroopsoumya/natural-history-
ofdisease-35398316