Introduction
Diabetes is a leading cause of disability and death that currently affects more than 500 million people worldwide and is expected to affect 1.3 billion people by 2050. As of 2021, more than 38 million people in the US were living with diabetes. In addition to known diabetes comorbidities like cardiovascular disease, chronic kidney disease, and impaired circulation leading to amputation of limbs, new complications such as cancer, dementia, and fatty liver disease have been linked to diabetes.
The American Diabetes Association (ADA) has historically taken a cautious stance on low-carb and ketogenic diets for diabetes, in recent years acknowledging their potential benefits but stopping short of recommending them as primary treatments. This position of mere acceptance is no longer sufficient given the mounting evidence supporting therapeutic carbohydrate reduction for diabetes management. It is imperative that the ADA transition from acceptance to active recommendation of low-carb and ketogenic diets, embracing their potential to improve the lives of millions.
Background
Before insulin was discovered, when type 1 and type 2 diabetes had not yet been identified as different diseases, dietary management was the primary means of controlling diabetes. Low-carbohydrate diets were a cornerstone of treatment, offering the only effective way to manage blood glucose levels. The advent of insulin in 1921 meant that the lives of people with type 1 diabetes could not only be extended but greatly improved. However, although insulin was arguably one of the most important discoveries of the century, its use shifted people away from a dietary approach to help control diabetes –– including those with type 2 diabetes, who produce their own insulin.
In 1989, the ADA published their first Standards of Medical Care in People with Diabetes, which was focused on medications and complications, mentioning diet only briefly and nonspecifically in the context of having patients meet with a registered dietitian. Over the years, the ADA’s dietary recommendations have evolved, but they often lag behind emerging research. For example, in 2007, the organization cautioned against consuming less than 130 grams of carbohydrates per day because the effects of carbohydrate restriction weren’t known. This was two years after the US Institutes of Medicine published a Dietary Reference Intakes guide that stated, “The lower limit of dietary carbohydrate compatible with life is apparently zero, provided that adequate protein and fat are consumed,” followed by examples of the Inuit, Masai, and other indigenous populations who subsist on little to no carbohydrates.
In 2019, the ADA published a consensus report stating that a low-carbohydrate diet is one of several eating patterns that are appropriate for people with diabetes. Yet although the ADA acknowledges the potential benefits of low-carb and ketogenic diets, it does not recommend them as the standard of care. This cautious stance misses the opportunity to leverage these diets as powerful tools for managing diabetes and in many cases reversing type 2 diabetes or putting it into remission.
How can we persuade the ADA to recommend ketogenic and low-carbohydrate diets as first-line therapy for people living with diabetes? There are two approaches to consider: an adversarial one and a scientific one. Each has its advantages and disadvantages.
Pros and Cons of Taking an Adversarial Approach
Many people who have dramatically improved their blood glucose control or reversed their diabetes –– along with some low-carb medical professionals –– have called out the ADA for not promoting therapeutic carbohydrate reduction and for maintaining financial relationships with the pharmaceutical industry and food manufacturers. The criticisms are typically made as social media posts to get the widest circulation and often include links to articles critical of the ADA.
Pros:
- Drawing attention to financial ties: Pointing out the financial relationships between the ADA, pharmaceutical companies, and food manufacturers can reveal potential conflicts of interest. This scrutiny can drive transparency and accountability, potentially prompting the organization to reconsider its ties with such companies.
- Highlighting treatment problems: Emphasizing the issues with recommending insulin over dietary interventions can spotlight the need for more sustainable, effective treatments that do not lead to weight gain, hypoglycemia, and other complications.
- Increasing public awareness: Informed patients and families can advocate more effectively for ketogenic and low-carbohydrate approaches that could significantly improve their health and quality of life.
Cons:
- Alienation and defensiveness: An adversarial approach risks antagonizing ADA stakeholders, leading to defensiveness rather than open-minded consideration of new evidence. This can create barriers to progress.
- Perceived confrontational stance: This approach can be seen as confrontational, potentially hindering collaboration with key players within the organization. Those who were previously becoming more supportive of therapeutic carbohydrate reduction may be put off by tactics they view as hostile.
Pros and Cons of Taking a Scientific Approach
Researchers are continuing to explore how ketogenic and low-carb diets can reverse type 2 diabetes and improve blood glucose control in people with type 1 diabetes. Focusing on the robust evidence base and growing number of case reports can be a productive way to move the ADA toward making therapeutic carbohydrate reduction the standard of care for diabetes.
Pros:
- Strong physiological basis: Making the case for carb reduction from a first principles approach could be a persuasive strategy. Researchers have established that hyperinsulinemia, insulin resistance, and excess visceral fat are primary drivers of most forms of type 2 diabetes. When an individual dramatically lowers their carbohydrate intake, insulin levels drop and insulin sensitivity improves as the body switches from using glucose to using fat and ketones as its main fuel. This shift dramatically improves glycemic control and facilitates loss of excess body fat. By contrast, using exogenous insulin to control type 2 diabetes is known to cause weight gain.
- Extensive research in type 2 diabetes: Several meta-analyses of randomized controlled trials demonstrate the effectiveness of very-low-carbohydrate diets in decreasing blood glucose levels, promoting weight loss, and providing other metabolic health benefits in people with type 2 diabetes.
It’s important to point out that some highly impressive results have occurred in larger, longer non-randomized studies. During Virta Health’s continuous remote intervention, more than 250 people with type 2 diabetes followed a dietary intervention focused on sustained nutritional ketosis. At two years, more than 50% of the participants had reversed their diabetes, meaning they maintained an HbA1C < 6.5% without any medication other than metformin, along with losing an average of 10% of their body weight. In addition, the retention rate was exceptionally high at 74% –– almost unheard of for a diet-focused study lasting two years.
- Emerging evidence in type 1 diabetes: While much less research has been published on ketogenic and low-carb diets for people with type 1 diabetes, a growing number of studies show that these approaches are beneficial for this population. A notable 2018 paper surveyed over 300 adults and children with type 1 diabetes who followed a very-low-carb diet and experienced stable blood glucose levels, an average HbA1c below 5.7%, lower insulin requirements, and less frequent hypoglycemia. Concerns have been raised about elevated risk of diabetic ketoacidosis (DKA) in people with type 1 diabetes who eat a ketogenic diet. However, recent research suggests that people with type 1 diabetes who follow a ketogenic or very-low-carb diet and take appropriate insulin doses maintain ketone levels well within the safe range.
- Enhanced credibility: Emphasizing peer-reviewed research and evidence-based practice increases the likelihood of ADA acceptance. A scientific approach aligns with the ADA’s mission, making it more credible and persuasive.
Cons:
- Slower change process: Scientific approaches may take time to influence change, requiring extensive research and validation.
- Dissemination challenges: Widespread dissemination and discussion of findings are resource-intensive, requiring time, money, and expertise.
- Entrenched guidelines and beliefs: Changing established practices and beliefs is challenging and may face initial resistance even in the face of compelling scientific evidence. Although we may persuade some key players within the ADA to promote therapeutic carbohydrate reduction as the standard of care, we might not be able to change positions across the board.
Why Keto-Mojo Stands Behind the Scientific Approach
Taking a scientific approach is more likely to bring about true change than being adversarial. Importantly, it builds collaboration rather than risking alienation. Presenting robust evidence — including physiological data and patient outcomes — makes a strong case for low-carb and ketogenic diets as first-line treatment. Real-world patient improvements backed by data are hard to dismiss and may lead to open discussion. Conversely, ADA stakeholders are inclined to ignore those who solely criticize the organization without recognizing the steps it has taken toward acceptance of therapeutic carbohydrate reduction.
Historical precedents show the ADA’s capacity to adapt to new scientific advancements. For example, the authors of a 2020 paper published in the organization’s Diabetes Spectrum journal concluded that ketogenic and low-carbohydrate diets are effective for improving glycemic control, reducing medications, and losing weight. They also offered practical pointers for clinicians interested in using these approaches with their patients.
Constructive engagement with ADA stakeholders fosters a more receptive environment than confrontation. The ADA is making strides in the right direction, albeit slowly. We should acknowledge this and work with them to continue the momentum and move toward the goal of making therapeutic carbohydrate reduction the standard of care for diabetes.
In the meantime, we need to promote grassroots education and empower individuals to take control of their health by adopting low-carb or ketogenic approaches now, without waiting for an official change from the ADA. By spreading awareness and providing resources at the community level, Keto-Mojo aims to help individuals make informed choices that can significantly improve their metabolic health and well-being.
How Can We Work Together to Help Facilitate Change?
Conducting and Disseminating High-Quality Research
Ongoing high-quality research and clear communication are crucial for persuading the ADA to recommend therapeutic carbohydrate reduction as first-line therapy for people with diabetes. Recognizing gaps and areas for additional studies –– such as type 1 diabetes and gestational diabetes –– can lead to greater understanding of the applications and advantages of low-carb and ketogenic diets. Disseminating results through reputable journals boosts credibility and visibility.
Organizing or Participating in Symposia, Conferences, and Webinars
Symposia and conferences can create platforms for knowledge exchange and discussion. These events bring together experts, practitioners, and ADA stakeholders, fostering a collaborative environment for innovation and advocacy. Participating in live and poster presentations at an ADA conference can be an effective way to accomplish this. For several years, Virta Health has presented findings from their ongoing research at the ADA’s annual Scientific Sessions conference, including ten abstracts in 2024. At the 2023 event, Dr. Will Yancy gave a talk entitled “Very Low Carb Eating Is Best.” Online platforms can also be effective for sharing evidence and prompting interest and inquiry. For instance, Andrew Koutnik, PhD, a researcher living with type 1 diabetes, was a presenter at an ADA webinar entitled “Going Keto for Diabetes? Evidence in Type 1 and Type 2 Diabetes” in April of 2024.
Shift to Unbiased Funding Practices
A major criticism of the ADA is its financial ties to food manufacturers that produce highly processed, carb-heavy foods and beverages, which creates a conflict of interest in their mission to improve diabetes outcomes. This relationship can undermine the ADA’s credibility and effectiveness in promoting better health for people with diabetes. However, there are numerous less processed, low-carb products that the ADA could recommend, which would align better with their goals. By partnering with reputable food companies for funding, the ADA can move away from conflicted dollars and ensure their dietary recommendations are both effective and unbiased.
As long as industry sponsorships are allowed, the field should strive to reduce bias by partnering with a diverse range of companies, including reputable low-carb companies. However, it would be even more beneficial to move away from industry sponsorship altogether in the future.
Address Misconceptions about Ketogenic and Low-Carb Diets
Speaking to people’s concerns about the safety and sustainability of ketogenic diets respectfully and citing scientific evidence can help us make headway with ADA stakeholders more effectively than insulting their intelligence and criticizing their motives.
Here are two common examples:
- Keto is extreme and unsustainable: While a ketogenic diet might seem too challenging to follow long term, its benefits for those with diabetes can be significant and life changing. Although it requires a major lifestyle shift, many find it manageable with the right support and resources, including meal planning, education on low-carb options, and frequent contact with their medical provider to decrease or deprescribe medications.
In addition to the two-year data from Virta Health’s remote ketogenic intervention mentioned earlier, UK general practitioner Dr. David Unwin published a paper discussing 186 of his patients who followed a very-low-carbohydrate diet for an average of 33 months. Of this group, 51% achieved diabetes remission, meaning they maintained an HbA1c < 6.5% while eliminating all medication, resulting in substantial cost savings. Moreover, 77% of those who switched to a very-low-carb diet within a year of being diagnosed with type 2 diabetes achieved remission. These published results are in line with the reported experiences of many physicians whose patients with diabetes have successfully followed a ketogenic or low-carb diet for years.
- LDL may rise and increase disease risk more than diabetes: In general, people with type 2 diabetes who follow a ketogenic or very-low-carb diet have been shown to experience little to no change in LDL cholesterol, while HDL cholesterol and triglyceride levels improve, reflecting decreased cardiovascular risk. It is true that a subset of people who follow a ketogenic diet experience a sharp increase in LDL cholesterol. However, a recent analysis of more than 1,300 people strongly suggests that this occurs mainly in lean individuals rather than those with higher body weights. Moreover, the significance of high LDL levels in these metabolically healthy individuals known as “Lean Mass Hyper-responders” has yet to be determined, with early evidence suggesting that it does not increase their CVD risk.
Utilizing Media and Publications
Raising awareness through media is crucial for persuading the ADA to promote ketogenic and low-carb diets as first-line therapy for diabetes. Leveraging articles, expert interviews, and social media can reach a wide audience, informing and inspiring action among patients, healthcare providers, and policymakers. Highlighting success stories, robust clinical data, and potential healthcare cost savings can encourage the ADA to adopt a more progressive stance, ultimately improving health outcomes for millions of people with diabetes and reducing reliance on medications.
Conclusion
At Keto-Mojo, we call on the ADA to move from merely accepting low-carb and ketogenic diets to actively recommending them. This shift –– supported by strong scientific evidence, real-world outcomes, and a collaborative approach –– has the potential to transform diabetes management and improve countless lives.
The journey from acceptance to recommendation is not just a change in guidelines; it is a commitment to better health, brighter futures, and the possibility of a world where diabetes no longer defines lives. Together, we can elevate ADA standards and create a healthier future for all.
