The CDC estimates about 12% of the U.S. population has diabetes, and although measurement methods differed, when compared to 0.9% in 1958, the increase is striking (CDC, 2017, 2026). Prediabetes also affects more than one-third of U.S. adults.

Although genetics, age, and factors matter, eating habits, excess body fat, and physical inactivity are important modifiable contributors to type 2 diabetes.

As a registered dietitian, many clients with prediabetes or type 2 diabetes, particularly those seeking weight loss, ask whether I can design a ketogenic diet for them.

Mediterranean, plant-forward, higher-fiber, calorie-restricted, and moderately low-carbohydrate approaches can all help manage diabetes. However, when someone is motivated toward keto and has no contraindications, it can be a viable option.

With a necessarily high fat contribution of 60% to 75% of calories, 20% to 30% from protein, and 5% to 10% from carbohydrates, people sometimes translate this to mean high bacon, butter, cheese, and fatty meat. However, this type of keto may be counterproductive.

Type 2 diabetes is characterized primarily by insulin resistance. Insulin is a hormone that ultimately facilitates glucose’s entry into cells. Replacing saturated fat with monounsaturated fat can improve insulin sensitivity (Vessby et al., 2001). I therefore favor nuts, seeds, avocado, olive oil, and fish over butter, high-fat dairy, and fatty meats. Many animal fats contain substantial palmitic and myristic saturated fatty acids, which have been associated with insulin resistance (Ebbesson et al., 2010).

If done improperly, ketogenic diets can raise LDL and total cholesterol. So, a poorly designed keto diet could improve one metabolic problem while worsening another. When done properly, however, it can raise the favorable HDL cholesterol and favorably lower LDL cholesterol and triglycerides.

Plant fiber actually reduces cholesterol and supports digestive health and gut microbes. The American Diabetes Association recommends at least 14 grams per 1,000 calories. So, adequate fiber intake should be part of a strategic keto diet.

Substantially reducing carbohydrates can reduce post-meal glucose spikes and the insulin needed to manage them and sometimes produce diabetes remission, particularly short term (Goldenberg et al., 2021).

Lower insulin also releases a brake on lipolysis, allowing stored body fat to break into fatty acids and glycerol. The liver can use fatty acids for energy and convert some into ketones. However, increased fat burning does not necessarily mean greater body-fat loss because keto also provides considerably more dietary fat to burn. Losing stored fat still depends largely on energy balance.

Meanwhile, glucagon, a hormone that counterbalances insulin, helps maintain blood glucose through glycogenolysis, releasing stored liver glucose, and gluconeogenesis, making new glucose from substances including glycerol and amino acids.

As liver glycogen declines, ketone production increases. The brain increasingly uses ketones, reducing, but not eliminating, its glucose requirement and potentially reducing reliance on amino acids for glucose production. Ketones may also reduce the liver’s overall glucose output under certain conditions, although gluconeogenesis continues during ketosis (Miles et al., 1981).

Conclusion

Supervised carbohydrate restriction might reduce glucose spikes, medication needs, and body fat. Nutrient-dense carbohydrates could then be gradually reintroduced while emphasizing unsaturated fats, fiber, physical activity, and weight management to improve insulin sensitivity.

Medical coordination is essential. Insulin and sulfonylureas may require adjustment to prevent dangerously low blood glucose. Combining keto with SGLT2 inhibitors can increase diabetic ketoacidosis risk, a potentially life-threatening buildup of acids in the blood.

Keto is neither necessary for diabetes prevention nor appropriate for everyone. However, when blood glucose remains difficult to manage or someone is motivated to try keto, a registered dietitian trained in diabetes care can help make it nutritionally adequate, heart-conscious, and safely coordinated with medical treatment.

About the Author

Patrick Traynor, PhD, MPH, RD, CSOWM, CPT, is a registered dietitian and founder of MNT Scientific, LLC (MNTScientific.com), an insurance-based nutrition practice serving South Lake Tahoe, CA; Minden, NV; and Ashland, OR. He holds the Interdisciplinary Specialist Certification in Obesity and Weight Management (CSOWM) from the Commission on Dietetic Registration. Virtual appointments are available via telehealth. For inquiries or appointments, visit MNTScientific.com, call (530) 429-7363, or email patricktraynordietitian@nym.hush.com.