Therapeutic Ketogenic Diet and How it Differs from “the Keto Diet”

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Introduction

In addition to the several types of therapeutic ketogenic diets, such as the Classic Ketogenic Diet (KD) used in the treatment of epilepsy, there is another type of therapeutic ketogenic diet used in the treatment of type 2 diabetes and for weight loss. This is referred to in the clinical literature as a Very Low Carbohydrate Diet (VLCD). This post outlines how it differs considerably from the popularized “keto diet.”

The popularized “keto diet”—which often focuses on copious amounts of added fat in the form of ‘fat bombs’ and ‘bulletproof coffee’—is like a caricature compared with a clinical portrait. A portrait seeks to accurately represent physical attributes, while a caricature uses hyperbole to exaggerate some and over-simplify others.

Defining a Therapeutic Ketogenic Diet

What makes any diet ketogenic is not how much fat it contains, but the low amount of carbohydrate. In the treatment of type 2 diabetes and obesity, a VLCD is defined as a diet where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake [1]. This results in the body using fat as its primary fuel, reaching a state of nutritional ketosis [2].

Use of a VLCD as Medical Nutrition Therapy (MNT) [3] is recognized by the European Association for the Study of Diabetes (EASD), the American Diabetes Association (ADA), and Diabetes Canada [4,5]. These organizations confirm that reducing carb intake has the strongest evidence for improving blood sugar levels.

Virta Health’s Clinical Approach

Back in 2018, the ADA cited Virta Health’s study data [6] as evidence for the efficacy of a VLCD. In this model, participants typically consumed:

  1. <30 g per day of total dietary carbohydrate
  2. Daily protein intake targeted to 1.5 g / kg based on ideal body weight
  3. Dietary fats incorporated only to satiety (until no longer hungry)

In this approach, protein is prioritized for its nutrient-density and satiety, while fat is used as a lever rather than a primary goal.

Phinney and Volek’s Clinical Approach

In their expert guide, The Art and Science of Low Carbohydrate Living [7], Dr. Stephen Phinney and Dr. Jeff Volek outline a VLCD that is higher in protein during the weight loss phase. Fat intake is set at 60% during weight loss to allow the body to utilize its own stored fat for energy. This is a far cry from the 80% fat often recommended in internet “keto” forums.

The Popularized “Keto Diet” vs. Clinical Reality

The popularized “keto diet” is often described as 70-80% fat and 15% protein. This version typically has 50% less protein and 20% more fat than the clinical VLCD used for diabetes remission. By over-simplifying the diet to “just eat fat,” many people fail to achieve their weight loss goals because they overlook the critical role of protein satiety.

Final Thoughts

There is no one-sized-fits-all low carb diet. For those seeking to put type 2 diabetes into remission, a well-designed clinical ketogenic diet is safe and effective when individualized and done with professional oversight.

Remember: If you are taking medication for type 2 diabetes, it is dangerous to begin a VLCD without medical supervision from your diabetes team.

More Info?

If you would like more information about the type of low-carb or ketogenic diet that might be best suited to you, you can learn about me and the Comprehensive Dietary Package that I offer.

To your good health!

Joy

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References

  1. Feinman RD, Pogozelski WK, Astrup A, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015 Jan;31(1):1-13. [https://pubmed.ncbi.nlm.nih.gov/25287761/]
  2. Bhanpuri NH, Hallberg SJ, Williams PT, et al. Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study. Cardiovasc Diabetol. 2018 May 1;17(1):56. [https://doi.org/10.1186/s12933-018-0698-8]
  3. U.S. Department of Health and Human Services. Final MNT regulations. CMS-1169-FC. Federal Register. 2001 Nov 1. [https://www.federalregister.gov/documents/2001/11/01/01-26210/medicare-program-medical-nutrition-therapy-services-for-beneficiaries-with-diabetes-or-renal-disease]
  4. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019 May;42(5):731-754. [https://doi.org/10.2337/dci19-0014]
  5. Diabetes Canada. Diabetes Canada Position Statement on Low Carbohydrate Diets for Adults with Diabetes: A Rapid Review. Canadian Journal of Diabetes. 2020 Jun;44(4):295-299. [https://doi.org/10.1016/j.jcjd.2020.04.001]
  6. 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 Apr;9(2):583-612. [https://doi.org/10.1007/s13300-018-0373-9]
  7. Volek JS, Phinney SD. The Art and Science of Low Carbohydrate Living: An Expert Guide. Beyond Obesity LLC. 2011.
  8. Harcombe Z. LCHF and Butter. zoeharcombe.com. 2018 Jan 29. [https://www.zoeharcombe.com/2018/01/lchf-and-butter/]
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