Ketogenic Diet Success with Type 1 Diabetes
Health-e-Solutions comment: Csaba Tóth is a General Practitioner from Hungary with 20 years of experience in intensive care medicine, internal medicine and family medicine. He has had ketogenic diet success treating chronic medical illnesses, including type 1 diabetes, cancer, other autoimmune diseases and epilepsy for more than five years. He operates a private practice in Budapest and in a few other cities in Hungary. He strives for the full recovery of his patients.
Dr. Tóth has had success managing patients with type 1 diabetes by changing their diet, as we shall see in this case study below. His approach, although somewhat different than ours in the foods chosen to produce ketosis, is similar in that it achieves much improved #BloodSugarControl and fewer complications than the #TypicalWesternLifestyle.
Introduction: Type 1 diabetes mellitus (T1DM) patients are usually instructed to follow a low fat/high carbohydrate diet. A few studies in literature, however, reported metabolic benefits and sustainability of carbohydrate restricted diets.
Case Report: Herein, we present a case of a 19-year-old male with newly diagnosed T1DM. The patient was first put on an insulin regime. Twenty days later, he shifted towards the paleolithic ketogenic diet and was able to discontinue insulin. Strict adherence to the diet resulted in normal glucose levels and a more than three-fold elevation of C-peptide level indicating restored insulin production. Currently, the patient is on the paleolithic ketogenic diet for 6.5 months. He is free of complaints, and no side effects emerged.
Conclusion: We conclude that the paleolithic ketogenic diet was effective and safe in the management of this case of newly diagnosed T1DM. Marked increase in C peptide level within two months indicates that the paleolithic ketogenic diet may halt or reverse autoimmune processes destroying pancreatic beta cell function in T1DM.
Diabetic patients are, generally, recommended to follow a diet that is low in fat and high in carbohydrates . Clinical studies, conversely, showed metabolic benefits conferred by carbohydrate-restricted diets including the ketogenic diet   and the paleolithic diet   in type 2 diabetes.
Much less data on the use of low-carbohydrate diets in type 1 diabetes (T1DM) are available. Two studies by Nielsen et al. showed that a low-carbohydrate diet lowers the need for insulin as well as the number of hypoglycemic episodes in T1DM  . It was also suggested that a low-carbohydrate diet is sustainable on the long-term  .
Ketogenic diets have long been used in epilepsy . There are three cases in literature, where concurrent epilepsy and T1DM were treated with the classical ketogenic diet and both conditions improved   . Recently, we published a case of childhood absence epilepsy where seizure freedom was achieved using a modified ketogenic diet we refer to as the paleolithic-ketogenic diet . Herein, we present a case of T1DM, where the same diet resulted in remission of T1DM as assessed by normalization of blood glucose levels and elevation in C-peptide level allowing for discontinuation of external insulin replacement.
A 19-year-old male complained of increased thirst, polyuria, itchy skin, malaise, and weight loss. The symptoms were present for about two weeks prior to diagnosis. On November 24, 2013 self monitoring of blood glucose showed 384 mg/dL. Previous medical history was unremarkable. Anamnestic data included consuming of muscle boosting protein through a month prior to symptom onset. Laboratory assessment on November 25, 2013 showed elevations in glucose (218 mg/dL) and HbA1c (9.2%). Testing for glutamic acid decarboxylase (GAD) antibodies showed positivity (52 U/mL; normal range 0–10 U/mL) and mild positivity for pancreatic islet cell autoantibodies (ICAs). C-peptide level was not measured at this time. He was diagnosed with T1DM. He was put on insulin replacement therapy (38 IU of insulin) and standard conventional diabetes diet with six meals containing 240 grams carbohydrate daily. He followed this regime for 20 days. While on this regime his glucose levels fluctuated between 68–267 mg/dL.
Carbohydrate he was consuming before was less than 240 grams. Since his malaise did not improve the patient consulted the first author in December 2013. To ascertain T1DM laboratory examination of C-peptide was carried out. C-peptide level of 0.6 ng/mL measured on January 08, 2014 indicated subnormal insulin secretion.
The patient was suggested to switch to the paleolithic-ketogenic diet which he initiated on December 21, 2013. From this time, he was also taking 5,000 IU of vitamin D3 but nothing else as supplement. His diet consisted of meat, organ meat, fat and eggs. In his diet, red and fat meats dominated over lean meats. He was eating vegetables in insignificant amounts. His diet had a ketogenic ratio (fat: protein + carbohydrate) of at least 2:1. No oil of plant origin or artificial sweeteners were allowed. The patient was under our close control and reported daily food records and blood glucose levels. Upon shifting toward the paleolithic ketogenic diet glucose levels returned to normal and no major elevations were seen postprandially either. Insulin was therefore discontinued. The tapering of insulin was done promptly: following the first paleolithic-ketogenic meal glucose level was only 86 mg/dL thus there was no need for external insulin. Similar blood glucose levels were measured on subsequent meals on the diet. Thus, the patient required no insulin subsequently either. Home glucose monitoring was carried out preprandially as well as postprandially and tracked once a day for consecutive meals (that is on consecutive days measures were taken for breakfast, lunch and dinner, respectively). Average blood glucose level while on the standard diabetes diet with insulin was 119 mg/dL while 85 mg/dL on the paleolithic-ketogenic diet without insulin. Fluctuations in glucose levels decreased as indicated by a reduction of standard deviation values from 47 mg/dL on the standard diabetes diet to 9 mg/dL on the paleolithic-ketogenic diet. Average postprandial glucose elevation on the standard diabetes diet was 23 mg/dL while only 5.4 mg/dL on the paleolithic-ketogenic diet.
C-peptide measurement was repeated on the 10th week of the diet (on March 06, 2014). This indicated an elevation to a value of 2.2 ng/mL. A comprehensive laboratory workup carried out on March 14, 2014 indicated normal laboratory parameters with the exception of total cholesterol and LDL cholesterol which were slightly elevated. Glucose level was 88 mg/dL while HbA1c was 5.5%. Urinary ketone was positive. On March 21, 2014 antibody testing for ICA showed no change in the mild positivity measured before and some elevation in GAD antibodies (86 U/mL).
At the time of writing this case report, the patient is on the paleolithic ketogenic diet for 6.5 months and still exhibit low glucose levels. No side effects emerged and he is completely free of symptoms.
This is a first report of T1DM being successfully managed with the paleolithic-ketogenic diet. In literature, a few studies are available on the use of carbohydrate restricted diet in the treatment of T1DM  . Low carbohydrate diet in these studies resulted in reduced number of hypoglycemic episodes and also lowered the need for insulin. In our case, however, insulin replacement was not just reduced but could be stopped. Importantly, insulin discontinuation was paralleled by a marked increase in C peptide level indicating restored pancreatic insulin production.
Shortly before diabetes onset our patient consumed muscle boosting protein which contained bovine milk protein. Consumption of cow’s milk has repeatedly been shown to increase risk of T1DM  . It is suggested that bovine milk protein may promote autoimmune processes giving rise to T1DM . Also in two case reports from literature, where epilepsy was treated with the classical ketogenic diet, which contains large amount of dairy, T1DM developed subsequently  . A major difference between the classical ketogenic diet and the paleolithic ketogenic diet is that milk and dairy are excluded in the latter.
We suggest that the paleolithic ketogenic diet not only normalize glucose levels but may also halt autoimmune processes mediated by non-paleolithic substances including milk protein .
While on the paleolithic-ketogenic diet glucose levels remained low both during preprandially and postprandially. Follow-up laboratory assessment indicated laboratory parameters remaining in the normal range except for elevations in total cholesterol and LDL cholesterol. In fact, these elevations are expected on a diet rich in animal fat and cholesterol and were also reported in studies with the classical ketogenic diet  as well as in our previous case of childhood absence epilepsy treated with the paleolithic ketogenic diet . Moreover, it is now acknowledged that neither dietary nor serum cholesterol represent a risk factor for cardiovascular disease . On follow-up antibody testing ICA remained mildly positive while GAD antibodies elevated to some extent. Although these parameters are frequently associated with T1DM they do not seem to be specific nor indicate progression of disease .
Type 1 diabetes mellitus is considered as a lifelong metabolic condition due to the exhaustion of insulin-secretory cells of the pancreas. Therefore, T1DM is generally believed to be untreatable by any diet. There are indications, however, that residual pancreatic beta cell functioning may extend well beyond the time of diagnosis . Nevertheless C-peptide levels decrease monotonically through years after diagnosis . We are not aware of any data from literature indicating elevation of C-peptide resulting from a dietary intervention. A recent case study of a child with T1DM reported remission without insulin on gluten-free diet . However, in that case C-peptide continued to decline while on the gluten-free diet.
In the standard care of T1DM insulin is a cornerstone. It is important to emphasize that the paleolithic-ketogenic diet as a standalone therapy may be applied only in those cases with residual insulin secretion. In cases with no internal insulin secretion the paleolithic- ketogenic therapy may be only used as an adjunct to insulin replacement.
We suggest that an intervention with the paleolithic ketogenic diet in an early stage of the disease with residual insulin secretion may halt or reverse type 1 diabetes mellitus (T1DM). Follow-up at sixth month in the case of our patient is relatively short and the positive results may appear as a honeymoon effect. However, this term is used in relation to the beginning of insulin therapy not the end of it. We believe that with normalized insulin secretion and a further adherence to the diet the patient may be managed on the long-term.
Health-e-Solutions comment: Similar to the researchers for this case study, we think we may have halted or reversed autoimmune processes destroying pancreatic beta cell function in our two boys with type 1 diabetes. We cannot prove it was our actions, but the diet and lifestyle were the only things we changed. We use very little in the way of animal protein to reach ketosis and improve blood sugar control. Our approach is to focus on #VeryLowGlycemic, low #InsulinDemand foods. This has worked exceedingly well for us since 2008.
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