Is Keto for Diabetes Healthy? What the Science Really Shows

Key Takeaways

• No fat loss despite weight loss: A Nature Medicine study showed that whilst a ketogenic diet leads to greater overall weight loss, a plant-based low-fat diet resulted in 1 kg of body fat loss – whereas keto produced no significant fat loss.
• Muscle loss despite high protein intake: On a ketogenic diet, participants lost fat-free mass (water and muscle), despite consuming more protein than those on the plant-based diet.
• No true diabetes remission: Low-carb diets do not lead to genuine diabetes remission. True remission means being able to eat carbohydrates again – not merely symptom management through carbohydrate avoidance.
• Meta-analysis disproves long-term efficacy: After 12 months, there were only weak to trivial effects on diabetes remission, even though benefits were still apparent at 6 months.
• Concerning rise in LDL cholesterol: Ketogenic diets increase LDL cholesterol, the primary cause of atherosclerotic cardiovascular disease – the number one cause of death worldwide.
• Coronary calcification worsens: Long-term studies show that low-carb groups had the greatest progression of coronary artery calcification – but only with an animal-based keto diet, not a plant-based one.
• American Heart Association ranks keto as the worst diet: In a heart-health ranking of dietary patterns, low-carb ranked in the lowest tier – performing worse than all other dietary approaches.
• Clinically meaningful reduction in quality of life: Meta-analyses report clinically important impairments in quality of life on a ketogenic diet.
• Insulin resistance worsens: Low-carb diets can worsen type 2 diabetes over the long term by exacerbating insulin resistance and increasing carbohydrate intolerance.
• Early adoption increases risk: Following an animal-based low-carb diet in early adulthood is linked to an increased risk of coronary calcification in middle age.

What Is the Ketogenic Diet?

What is the ketogenic diet and how does it work?

The ketogenic diet is an extremely low-carbohydrate, high-fat diet with the following macronutrient distribution: 70–75% fat, 20–25% protein, and only 5–10% carbohydrates. In practice, this means a maximum of 20–50 grams of carbohydrates per day – by comparison, a single slice of wholemeal bread already contains around 15 grams of carbohydrates.

Through this extreme carbohydrate restriction, the body is driven into a metabolic state called ketosis. Normally, our body uses glucose (derived from carbohydrates) as its primary energy source. In ketosis, metabolism shifts towards fat burning, producing ketone bodies in the liver that serve as an alternative fuel source.

This metabolic adaptation typically takes 2–4 days and is frequently accompanied by the so-called “keto flu” – with symptoms such as headaches, fatigue, irritability, and difficulty concentrating.

How does keto differ from other low-carb diets?

Whilst other low-carb diets often permit 100–150 grams of carbohydrates per day, the ketogenic diet is far more restrictive. The crucial difference: ketosis is only achieved below 50 grams of carbohydrates daily. Diets such as Atkins, LCHF (Low Carb High Fat), or the South Beach Diet are low in carbohydrates, but they do not necessarily induce ketosis.

Furthermore, the ketogenic diet differs in its total fat content: while moderate low-carb diets contain 40–50% fat, keto reaches 70–75% fat – with a large proportion often coming from animal sources such as meat, butter, double cream, and cheese.

Keto for Diabetes: What Does the Science Say?

How does a ketogenic diet affect type 2 diabetes?

The scientific literature presents sobering findings. A 2021 systematic review published in the British Medical Journal (BMJ) investigated the efficacy of low-carb diets for diabetes remission. The criteria for remission were clear: HbA1c below 6.5% for at least three months WITHOUT blood glucose-lowering medication.

The surprising finding: after 6 months, there was no significant difference between the low-carb and control groups. After 12 months, the rate of diabetes remission in the low-carb group was actually LOWER – meaning more individuals in the keto group still had diabetes compared with those following standard diabetes diets.

What clinical studies exist on keto for diabetes?

The most rigorous study comes from Nature Medicine (2021) by Hall and colleagues. This tightly controlled inpatient metabolic study compared a plant-based, low-fat diet with an animal-based, ketogenic diet over two-week periods using a crossover design.

Further landmark studies include:

• The CARDIA study (2021): Investigated low-carbohydrate diet scores and coronary artery calcification over 20 years
• The meta-analysis by Goldenberg et al. (2021, BMJ): A systematic review of published and unpublished data on low-carbohydrate diets and diabetes remission
• American Heart Association Scientific Statement (2023): Evaluation of dietary patterns based on cardiovascular health
• European Atherosclerosis Society Consensus (2020): LDL cholesterol as a causal factor in cardiovascular disease

Together, these studies encompass more than 15,000 participants and paint a consistent picture: while short-term improvements in glycaemic control do occur, the long-term cardiovascular and metabolic health risks outweigh the benefits.

What is true diabetes remission versus symptom management?

This is where a fundamental misunderstanding lies. If someone with a peanut allergy avoids peanuts and experiences no symptoms, the allergy is not cured – it is merely being avoided. A true cure would mean being able to eat peanuts again without an adverse reaction.

The exact same principle applies to keto for diabetes: if blood sugar levels are normal only because carbohydrates are strictly avoided, that is symptom management, not disease remission. Even worse: studies show that low-carb diets can worsen insulin resistance and INCREASE carbohydrate intolerance over time.

Genuine diabetes remission means restoring the body’s ability to handle carbohydrates normally, just like someone without diabetes – and that is precisely what the keto diet fails to deliver.

The Hall Study: Plant-Based vs Animal-Based Keto

Why do you initially lose water and muscle on keto?

The Hall study revealed unexpected findings: whilst participants on the ketogenic diet lost more total body weight, closer examination showed that this was not fat loss. What was actually lost? Fat-free mass – specifically water and muscle tissue.

In comparison: the plant-based, low-fat group lost 1 kg of body fat in two weeks, whereas the keto group showed NO significant fat loss. The low-fat diet preserved lean muscle mass, whereas fat-free mass declined on keto – despite a HIGHER dietary protein intake.

Why does this happen? Under severe carbohydrate restriction, the body first empties glycogen stores in the liver and skeletal muscles. Each gram of glycogen binds approximately 3 grams of water. This rapid initial weight loss is therefore primarily water loss. In addition, during ketosis, the body breaks down muscle protein to synthesise glucose for essential physiological functions (gluconeogenesis).

How does a plant-based keto diet differ from an animal-based one?

A crucial distinction: plant-based low-carb diets in clinical studies do NOT show the same detrimental cardiovascular effects observed with animal-based keto. The CARDIA study identified accelerated coronary calcification only with animal-based low-carb patterns, not with plant-based approaches.

The explanation: animal fats contain substantial quantities of saturated fat, which elevates LDL cholesterol. In contrast, plant fats (such as avocados, nuts, seeds, and extra virgin olive oil) are rich in unsaturated fatty acids, exerting favourable effects on cholesterol profiles and cardiovascular risk.

Furthermore, plant-based low-carb options provide more dietary fibre, protective phytonutrients, and less saturated fat – all factors that positively influence type 2 diabetes and long-term heart health.

LDL Cholesterol: The Deal-Breaker of the Keto Diet

Is the keto diet good for diabetics with high cholesterol?

The BMJ meta-analysis identified the rise in LDL cholesterol as the ultimate “deal-breaker” of the ketogenic diet. But why is this so problematic?

LDL cholesterol (low-density lipoprotein) is commonly referred to as “bad cholesterol”. The European Atherosclerosis Society states unequivocally: LDL cholesterol is the PRIMARY CAUSAL FACTOR for atherosclerotic cardiovascular disease – the leading cause of death worldwide.

A keto diet high in saturated fat from red meat, butter, and cheese significantly elevates LDL cholesterol. A 2017 study in the Journal of the American College of Cardiology demonstrated that even with “normal” LDL cholesterol levels and optimal readings for other risk factors, subclinical atherosclerosis still progresses.

Cardiologists give clear guidance: keep LDL as low as possible for as long as possible (“lower for longer”). Any diet that raises LDL puts long-term cardiovascular health at risk – regardless of short-term improvements in blood sugar.

How does the ketogenic diet affect heart health?

If we could ask only ONE question about any diet, experts suggest it should be: “What does this diet do to my LDL cholesterol?” With a ketogenic diet, the answer is clear: it increases it – and with it, your overall cardiovascular risk.

The American Journal of Preventive Cardiology (2024) emphasises that lowering LDL cholesterol is of PARAMOUNT importance in preventing heart disease. Even when all other metabolic risk factors appear optimal, LDL must be strictly managed.

For individuals living with type 2 diabetes, this is doubly concerning: they already carry a 2- to 4-fold higher risk of heart disease. A diet that further magnifies this risk by elevating LDL is indefensible from a cardiology perspective.

Coronary Calcification and Heart Health

What are the long-term risks and dangers of ketosis for diabetics?

The CARDIA study (Coronary Artery Risk Development in Young Adults) tracked over 3,000 individuals across 20 years. Researchers evaluated how a low-carbohydrate diet influences coronary artery calcification – a direct marker of atherosclerosis and heart attack risk.

The findings: the low-carb group exhibited the GREATEST progression of coronary calcification. Particularly alarming: individuals who adopted animal-based, high-protein, high-fat low-carb diets in early adulthood demonstrated significantly greater calcification of the coronary arteries by middle age.

These long-term findings are troubling: whilst short-term studies (2–12 months) often show neutral or seemingly positive effects on glycaemic control, long-term data reveal insidious vascular damage driven by chronically elevated LDL cholesterol.

Further long-term risks include:

• Increased risk of atrial fibrillation
• Impaired kidney function due to high dietary protein loads
• Osteoporosis resulting from urinary calcium loss
• Non-alcoholic fatty liver disease
• Increased all-cause mortality associated with very low carbohydrate intakes

What do health organisations and the NHS say about keto?

UK health guidelines and the British Dietetic Association (BDA) recommend that around 50% of daily energy should come from carbohydrates – prioritising wholemeal foods, pulses, and vegetables. Total fat intake should remain around 30–35%, with an emphasis on unsaturated fats.

A ketogenic diet delivering 70–75% fat and only 5–10% carbohydrates directly contradicts these evidence-based guidelines. Dietitians and the NHS warn that such extreme dietary restriction can lead to nutritional deficiencies and poses serious long-term health risks.

Similarly, Diabetes UK does not recommend a ketogenic diet for people living with diabetes. Instead, evidence-based recommendations advise a balanced Mediterranean-style or plant-forward dietary pattern with moderate, high-fibre carbohydrate sources.

True Diabetes Remission vs Symptom Management with Keto for Diabetes

Why Does a Ketogenic Diet for Diabetes Type 2 Not Lead to True Remission?

When evaluating keto for diabetes, a consensus report in Diabetes Care (2021) defines diabetes remission precisely: an HbA1c below 6.5% (48 mmol/mol) for at least 3 months following the cessation of ALL diabetes medications. Crucially, this remission must remain stable even with a normal carbohydrate intake.

A ketogenic diet does not meet this criterion. Whilst blood glucose levels and glycaemic control may improve initially, this occurs solely because carbohydrates are no longer being consumed. As soon as carbohydrates are reintroduced, blood sugar levels often spike higher than before starting the diet. Why?

Very low-carbohydrate diets can actually worsen insulin resistance. As demonstrated in controlled metabolic research, including the Hall study, the body adapts to a carbohydrate-restricted intake and loses its capacity to metabolise glucose efficiently. This phenomenon is termed “physiological insulin resistance” and represents a metabolic adaptation to chronic carbohydrate deprivation.

How Does the Keto Diet Impact Quality of Life?

A meta-analysis published in the BMJ highlighted “clinically important impairments in quality of life” associated with ketogenic dietary patterns. What does this mean in everyday practice?

• Social restrictions: eating out at restaurants, dining with friends or attending family celebrations becomes exceptionally difficult
• Keto flu: headaches, fatigue and irritability during the initial transition period
• Digestive problems: constipation due to a lack of dietary fibre, or diarrhoea caused by high fat consumption
• Bad breath: a distinct acetone odour triggered by ketone bodies during ketosis
• Increased stress: constant calorie counting and macronutrient tracking
• Mental strain: feelings of guilt following dietary “slips”, fostering an unhealthy obsession with food

For the vast majority of people, following a strict keto diet is unsustainable over the long term – and this is precisely where the hazard lies: weight cycling and yo-yo dieting further aggravate type 2 diabetes and underlying metabolic health.

Allowed and Prohibited Foods on the Keto Diet

Which Foods Are Allowed on a Ketogenic Diet?

The following foods are permitted on a ketogenic eating plan:

• Meat & poultry: Beef, pork, lamb, chicken, turkey (preferably fattier cuts)
• Fish & seafood: Salmon, mackerel, sardines, prawns (oily fish preferred)
• Eggs: Free-range, prepared in any style
• Dairy: Butter, double cream, cheese (Cheddar, mozzarella, brie), whole Greek yoghurt
• Oils & fats: Olive oil, coconut oil, avocado oil, MCT oil, butter, lard
• Nuts & seeds: Almonds, walnuts, macadamias, chia seeds, flaxseeds (in moderation)
• Low-carb vegetables: Salad leaves, spinach, kale, broccoli, cauliflower, courgette, asparagus, cucumber
• Avocados: Rich in monounsaturated fats and dietary fibre
• Berries: Raspberries, blackberries, strawberries (in strictly controlled portions)

Which Foods Are Prohibited on Keto?

The following foods are strictly off-limits when adhering to a ketogenic regimen:

• Grains & cereal products: Bread, pasta, rice, porridge oats, quinoa, muesli
• Sugar & confectionery: Table sugar, honey, agave syrup, sweets, cakes, biscuits
• Starchy vegetables: Potatoes, sweet potatoes, sweetcorn, peas
• Pulses & legumes: Beans, lentils, chickpeas
• Most fruits: Bananas, apples, oranges, grapes, mangoes
• Alcohol: Beer, sweet cocktails, most commercial wines
• Sugary drinks: Fizzy drinks, fruit juices, energy drinks
• Low-fat / “diet” products: Frequently loaded with added sugar to compensate for removed fat

Particularly problematic is that many cardioprotective foods are excluded, whilst saturated fat from animal sources dominates daily intake.

Which Vitamins and Minerals Are Lacking on Keto?

Eliminating entire core food groups puts individuals on a keto diet at substantial risk of micro- and macronutrient deficiencies:

• Fibre: Drastically depleted by cutting out wholemeal grains and pulses (UK guidelines recommend 30g/day; keto intake is often below 15g)
• Thiamine (Vitamin B1): Primary dietary sources are whole grains and legumes
• Folate (Vitamin B9): Abundant in pulses, dark greens and wholemeal cereals
• Vitamin C: Most fruit varieties are excluded, and vegetable options are severely limited
• Magnesium: Whole grains and pulses represent key dietary sources
• Potassium: Bananas, potatoes and pulses are forbidden
• Phytochemicals: Deficient due to the restricted diversity of plant foods

Furthermore, excessive protein consumption can increase urinary calcium excretion, potentially compromising long-term bone density and skeletal health.

Side Effects and Dangers of Ketosis for Diabetics

What Are the Side Effects and Risks of Keto for Diabetes?

Adopting a ketogenic dietary pattern can cause a wide spectrum of adverse effects:

Short-term (initial weeks):

• Keto flu: headaches, fatigue, light-headedness, nausea
• Constipation resulting from severe fibre deficiency
• Diarrhoea triggered by sudden, excessive fat intake
• Halitosis (acetone breath)
• Muscle cramps caused by rapid electrolyte depletion
• Sleep disturbances and insomnia
• Irritability and frequent mood swings

Long-term (months to years):

• Elevated LDL cholesterol and significantly heightened cardiovascular risk
• Accelerated coronary calcification and atherosclerosis
• Worsened peripheral insulin resistance
• Kidney stones (promoted by excessive purines, high protein load and chronic dehydration)
• Hepatic steatosis (non-alcoholic fatty liver changes)
• Bone mineral loss (osteoporosis)
• Hormonal imbalances (particularly observed in women)
• Compromised gut health: dysbiosis induced by chronic fibre deprivation

What Is Keto Flu and How Long Does It Last?

Keto flu typically strikes during the first 2–7 days of carbohydrate restriction. Symptoms include headaches, persistent fatigue, irritability, difficulty concentrating (“brain fog”), nausea and dizziness.

The physiological cause: as glycogen stores are emptied, the kidneys excrete significant volumes of water along with vital electrolytes (sodium, potassium, magnesium). Concurrently, the central nervous system must adapt from metabolising glucose to utilising ketone bodies produced during ketosis.

Typically, keto flu subsides within 3–7 days, although it can persist for up to a fortnight. Some individuals experience negligible symptoms, whereas others suffer severely – depending largely on baseline diet and individual metabolic flexibility.

What Happens to Gut Health on a Ketogenic Diet?

The gut microbiome suffers considerably under ketogenic conditions. Dietary fibre provides essential sustenance for health-promoting gut bacteria. On keto, fibre intake plummets – falling from the recommended 30g daily to under 15g per day.

Consequences for gastrointestinal health include:

• Marked reduction in microbiome diversity (loss of beneficial bacterial species)
• Sharp decline in protective taxa, such as Bifidobacteria
• Diminished synthesis of short-chain fatty acids (SCFAs, vital for gut barrier integrity and immune regulation)
• Elevated inflammatory markers across the gut lining
• Persistent constipation and sluggish bowel transit times

A resilient microbiome is vital for immune function, mental wellbeing, appetite regulation and effective glycaemic control – ironically, the very outcomes keto for diabetes aims to achieve.

What Do Health Organisations Say About Keto for Diabetes?

How Does the American Heart Association Rate Ketogenic Diets?

In a comprehensive 2023 scientific statement, the American Heart Association (AHA) evaluated prominent dietary patterns against evidence-based criteria for cardiovascular health.

The verdict was unequivocal: very low-carbohydrate and ketogenic diets ranked in the LOWEST tier – scoring worse than every other dietary pattern assessed. Even when meticulously designed, low-carb regimens:

• Enforce severe restriction of cardioprotective food groups (pulses and wholemeal grains)
• Contain excessive quantities of saturated fat derived from red meat and dairy
• Substantially increase circulating LDL cholesterol
• Contradict established clinical evidence for long-term cardiovascular prevention

The AHA recommends instead: the Mediterranean diet, the DASH diet or balanced plant-forward eating patterns – all of which supply unrefined carbohydrates from whole grains, legumes, vegetables and fruit.

Is the Keto Diet Good for Diabetics with High Cholesterol? Who Should Avoid It?

Potentially suitable (strictly under clinical supervision):

• Paediatric patients with drug-resistant epilepsy (the original medical indication)
• Select rare inborn errors of metabolism
• Short-term clinical intervention for severe obesity to achieve initial weight loss (maximum 3–6 months)

NOT suitable:

• Individuals with existing cardiovascular disease or elevated cardiovascular risk
• Anyone asking: is the keto diet good for diabetics with high cholesterol? Clinical guidelines strongly advise against it, as saturated fat elevates atherogenic lipoproteins
• Pregnant and breastfeeding women
• Children and adolescents (outside of specialist epilepsy management)
• Individuals with chronic kidney disease or impaired renal function
• People with hepatic dysfunction or liver disease
• Those with a history of disordered eating
• Competitive athletes (with the exception of select ultra-endurance disciplines)

For individuals living with type 2 diabetes, leading clinical evidence indicates that a keto diet is NOT advisable – despite short-term reductions in blood glucose, the long-term cardiovascular and metabolic risks heavily outweigh the temporary benefits.

Frequently Asked Questions

How Healthy Is a Ketogenic Diet in Reality?

Over the short term (2–6 months), a ketogenic diet is relatively tolerable for healthy adults, producing rapid initial weight loss (predominantly water and glycogen stores) and lower blood glucose readings. Over the long term (beyond 12 months), however, concerning clinical trends emerge: elevated LDL cholesterol, increased arterial calcification, failure to achieve genuine diabetes remission, impaired quality of life and micronutrient shortfalls. Leading cardiovascular authorities classify keto as the least heart-healthy dietary model. Summary: potentially viable as a brief clinical tool, but concerning for long-term health.

Can a Ketogenic Diet for Diabetes Type 2 Cure the Condition?

No. A ketogenic diet suppresses blood sugar readings only for as long as carbohydrates are strictly avoided – this constitutes symptom management, not a cure. True diabetes remission requires maintaining normal glycaemic control whilst consuming unrefined carbohydrates. Studies demonstrate that sustained low-carb diets actually exacerbate underlying insulin resistance and increase carbohydrate intolerance over time. After 12 months, meta-analyses demonstrate only negligible to trivial effects on lasting diabetes remission. Concurrently, cardiovascular risk climbs due to raised LDL cholesterol and saturated fat intake – an acute danger for individuals with type 2 diabetes, who already face a two- to four-fold higher risk of heart disease.

Is a Plant-Based Ketogenic Diet Healthier Than an Animal-Based One?

Yes, significantly so. Findings from the CARDIA study revealed that accelerated coronary artery calcification and atherosclerosis occurred exclusively with animal-based low-carb patterns, not plant-based variations. The mechanism: animal fats deliver abundant saturated fatty acids that drive up atherogenic LDL cholesterol. Plant fats (such as avocados, nuts, seeds and extra virgin olive oil) provide unsaturated fatty acids that support a healthier lipid profile. A plant-based approach also delivers more dietary fibre and protective antioxidants. Nonetheless, even plant keto restricts vital health foods like whole grains and lentils – an evidence-based, balanced plant-rich diet containing moderate complex carbohydrates remains far superior to any keto variant.

Why Do the NHS and British Dietetic Association Warn Against Keto for Diabetes?

The NHS and the British Dietetic Association (BDA) recommend obtaining roughly 50% of total energy from carbohydrates (emphasising wholemeal grains, pulses and vegetables) and limiting fat to no more than 35%. A ketogenic diet – containing 70–75% fat and just 5–10% carbohydrates – directly conflicts with these evidence-based UK guidelines. Health authorities caution against severe nutritional deficits (dietary fibre, B vitamins, magnesium and protective phytochemicals), heightened cardiovascular risk from saturated fat, and an absence of robust long-term safety data. Similarly, Diabetes UK does not endorse a strict keto diet for managing type 2 diabetes, advocating instead for Mediterranean or well-balanced dietary patterns featuring high-quality, high-fibre carbohydrates.

Scientific References

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