In addition to the several types of therapeutic ketogenic diets mentioned in the previous post, such as the Classic Ketogenic Diet (KD), the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) used in the treatment of epilepsy and seizure disorder and as adjunct treatment in glioblastoma, there is another type of therapeutic ketogenic diet used in the treatment of type 2 diabetes and for weight loss which is referred to in the literature as a Very Low Carbohydrate Diet (VLCD). This post outlines two examples of this type of therapeutic ketogenic diet, and how it differs considerably from the popularized “keto diet”.
When compared with a Very Low Carbohydrate Diet (VLCD), the popularized “keto diet” which focuses on high intake of eggs and fatty cuts along with copious amounts of added fat in the form of ‘fat bombs’ and ‘bulletproof coffee’ is like a caricature compared with a portrait. A portrait seeks to accurately represent physical attributes, and a caricature uses hyperbole to exaggerate some, and over-simplify others.
This new article picks up from the previous one in outlining another type of therapeutic ketogenic diet used for putting type 2 diabetes into remission as well as for weight loss, and how it is very different from the popularized “keto diet”.
A Therapeutic Ketogenic Diet
A ketogenic diet is one that induces and sustains a state of ketosis which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate. What makes any diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains.
In reference to the treatment of type 2 diabetes and obesity, ketogenic diets are often referred to in the literature as a “Very Low Carbohydrate Dies (VLCD)”, which is where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake. It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate and at this very low level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis.
Ketosis is where the ketone betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L (and up to 4.0 mmol/L for therapeutic ketogenic diets used in the treatment of epilepsy, seizure disorder and glioblastoma). In a Very Low Carbohydrate Diet (VLCD) used in the treatment of type 2 diabetes, BHB levels are usually set between 1.5-3.0 mmol/L, a level described as nutritional ketosis .
A drug or diet is said to be therapeutic when it is used in the treatment of a disease or medical condition(s). When implemented by a Dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) .
Use of a Very Low Carbohydrate Diet (VLCD) as Medical Nutrition Therapy in the treatment of type 2 diabetes is recognized by numerous organizations around the world, including the European Association for the Study of Diabetes (EASD).
The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included both a low carbohydrate (LC) and very low carbohydrate (VLC) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report, and has included both in their 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020). This year, Diabetes Canada released a Position Statement outlining that a low carbohydrate (LC) and very low carbohydrate diet (VLCD) are both safe and effective treatment for non-pregnant or lactating adults with type 2 diabetes.
The American Diabetes Association’s Consensus Report defines low carbohydrate and very low carbohydrate as follows;
“In this review, a low carbohydrate (LC) eating patterns is defined as reducing carbohydrates to 26-45% of total calories .”
“In this review a very low carbohydrate (VLC) eating pattern is defined as reducing carbohydrate to <26% of total calories .”
Diabetes Canada also defines low carbohydrate and very low carbohydrate diets in terms of the amount of carbohydrate the diet contains. Low carbohydrate diets are defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate, and very low carbohydrate diets as <50 g of carbohydrate per day .
Very Low Carbohydrate Diet (VLCD) for Treatment of Type 2 Diabetes
Back in 2018, the American Diabetes Association cited Virta Health’s one-year study data  as evidence for the safety and efficacy of a Very Low Carbohydrate Diet (VLCHD) in lowering blood sugar and diabetes medication usage and the new Diabetes Canada’s recommendations refers to the same study. As a result, Virta Health’s study is a good place for defining what a Very Low Carbohydrate Diet (VLCD) for the treatment of type 2 diabetes looks like.
Note: It should be noted that at the time the ADA’s 2019 Standards of Medical Care in Diabetes was published, Virta Health’s 2-year data had not yet been published, so the ADA and in turn, Diabetes Canada recommendations which were based on it, as well as other international organizations support for low and very low carbohydrate diets were only able to say conclusively that low carbohydrate diets and very low carbohydrate diets were safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months).
Virta Health’s Approach
- <30 g per day of total dietary carbohydrate
- daily protein intake was targeted to a level of 1.5 g / kg based on ideal body weight
- Participants were coached to incorporate dietary fats until they were no longer hungry (i.e. to satiety)
Note (August 31, 2020): To put the protein requirements in perspective, a male whose ideal body weight is 150 pounds (68 kg) would be eating over 100 g of protein per day and a female whose ideal body weight is 135 pounds (61 kg) would be eating 92 g of protein per day. That is, protein is targeted for its nutrient-density and satiety, and fat is incorporated only until satiety is reached.
Phinney and Volek’s Approach
Dr. Stephen Phinney MD, PhD, a medical doctor and Dr. Jeff Volek, RD, PhD a Registered Dietitian with a PhD have decades of combined scientific and clinic research experience in the area of low carbohydrate diets. In 2011 they published their expert guide titled The Art and Science of Low Carbohydrate Living  documenting the clinical benefits of carbohydrate restriction and how it can be used for weight loss.
In Phinney and Volek’s book , the Very Low Carbohydrate Diet (VLCD) outlined is one that is higher protein during the weight loss phase than during the weight maintenance stage, with ~30% of caloric intake coming from protein during weight loss, but which decreases to ~21% of caloric intake during weight maintenance. Fat is 60% of calories during the weight loss phase, and is increased to 65-72% during weight maintenance. Carbohydrate intake is kept very low (7.5-10% of calories for men, 2.5-6.5% of calories for women) in order to induce nutritional ketosis.
The reason dietary fat intake is lower during the weight loss phase in Phinney and Volek’s approach is to allow for the using of body fat stores for energy.
In Phinney and Volek’s approach;
- Carbohydrate intake is 7.5-10% of calories for men, 2.5-6.5% of calories for women
- Protein intake is up to 30% of calories during weight loss, 21% during weight maintenance
- Fat is 60% of calories during weight loss, 65-72% of calories during weight maintenance
Note (August 31, 2020): Protein intake for someone eating 2000 kcals per day is 150 g and for someone eating 1700 kcals per day is 141 g per day. Again, protein is targeted for its nutrient-density and satiety, and fat is only 60% of calories during weight loss. This is very different than the popularized “keto diet”.
Popularized “Keto Diet”
The popularized “keto diet” is described as 70 – 80% fat, 15-20% protein* and 5% carbohydrate, with websites and articles promoting it frequently show plates laden with bacon and eggs, large fatty steaks with added butter melting on top, and loads of whipping cream over berries, and lots of avocado.
*while many “keto” proponents still stick with the lower protein intake , others have more recently increased the protein macro to 20% of calories, with fat at 70%.
This popularized “keto diet” is not the Very Low Carbohydrate Diet (VLCD) used by either Virta Health for putting type 2 diabetes into remission, or the VLCD approach used by Phinney and Volek for weight loss.
The popularized “keto diet” has ~50% less protein than a Very Low Carbohydrate Diet (VLCD) and ~20% more fat which has twice the energy density as protein.
Furthermore, the popularized “keto diet” is a very high fat, very low carbohydrate diet and is often promoted along with periods of intermittent fasting (IF), as frequent periods of less than 24 hours, or longer fasting periods which may include 5:2 (5 days of normal diet, 2 days restricting total calories to 500 per day), alternate day fasting, 36 hour fasts, or 42 hour fasts. This approach may suit some, but one has to ask if only eating ~1/3 of the time, is any weight loss really due to eating super high fat all the time, or due to the periods of fasting?
Like a caricature, the “keto diet” exaggerates some aspects of a Very Low Carbohydrate Diet (VLCD) and over-simplifies others. It exaggerates the fallacy that one needs to add extra fat into everything in order to lose weight, and overlooks the satiety of protein.
[Personal note: Approximately 1/3 of clients come to me for support after having followed this popularized “keto diet” without the fasting, and having failed to lose more than a bit of weight initially, or having gained weight.]
There is no one-sized-fits-all low carb or ketogenic diet for weight loss, because each person’s nutrition needs are different. As covered in the preceding article, for those seeking safe and effective weight loss, there are a range of low carbohydrate diets available to choose from, with some that includes periods of ketosis, and others that don’t.
For those seeking to put type 2 diabetes into remission, a well-designed ketogenic diet using the Virta Health approach, or for weight-loss using Phinney and Volek’s approach are both safe and effective, if individualized for each person and done with adequate oversight.
Remember, if you are taking any medication for type 2 diabetes, please read this article for why it can be dangerous to begin a very low carbohydrate diet (VLCD) / ketogenic diet without the involvement of your diabetes team.
If you would like more information about type of low carb or ketogenic diet that might be best suited to you, please send me a note using the Contact Me form on the tab above.
To your good health!
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- Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13
- U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415
- Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
- Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
- Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583–612
- Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
- Zoe Harcombe, LCHF and Butter, January 29, 2018, https://www.zoeharcombe.com/2018/01/lchf-and-butter/
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