Starting low carb or keto with diabetes medications
For instance, we want you to know that it’s very important to adapt diabetes medications when starting a low carb diet. In particular, insulin doses may need to be lowered to avoid low blood sugar, and SGLT2 inhibitors may need to be deprescribed (see below).
However, we also want you to discuss any changes in medication and relevant lifestyle changes with your doctor before making any changes. Full disclaimer
So you have diabetes and want to try eating low carb or keto? Good for you! Making these dietary changes has the potential to reverse type 2 diabetes. Or, if you have type 1 diabetes, doing so could dramatically improve your blood sugar control.1
However, you need to know what you are doing, and you need to communicate frequently with your healthcare team. Once you start eating low carb you will likely have to lower your insulin doses as well as some other diabetes medications, frequently by quite a lot.2
Avoiding the carbohydrates that raise your blood sugar level decreases your need for medication to lower it. Taking the same dose of insulin or insulin-stimulating oral medication as you did prior to adopting a low-carb diet might result in low blood sugar, something that can potentially become dangerous.
You need to test your blood sugar frequently when starting this diet and adjust your medication accordingly. This should always be done with the assistance of a physician or other health professional with expertise in diabetes (find a low-carb doctor).
Insulin-treated type 2 diabetes
As a general guide, you will need to lower your doses when starting a strict low-carb diet.3
Work with your doctor to find the right initial reduction. Many find they need to reduce long acting insulin between 30 and 50%.4 If you take insulin once or twice daily, consider reducing both doses by the same proportion. If you are on a basal bolus regimen (taking fast-acting insulin before meals, and long-acting insulin once or twice a day), you may want to reduce your mealtime doses more than your basal. This is part of the careful experimentation you should do in conjunction with your healthcare provider!
If you remain low carb, it is possible you will be able to stop mealtime insulin altogether. You can then begin to more aggressively reduce your long-acting insulin, if your blood sugar levels remain stable.5 Many people on a low carb diet are able to come off insulin completely.6
Unfortunately, there’s no way of knowing how much insulin is required in advance. You will have to test your blood sugar frequently and, with the assistance of a knowledgeable physician or healthcare team, lower insulin doses based on your blood sugar readings.
Note that as a general rule, many feel it is better to err on the low side of insulin doses. If your blood sugar goes a bit high you can take more insulin later to help bring it down. That’s OK for the short-term.7 If instead you take too much insulin and end up having low sugar, that is potentially far more dangerous.
You’ll also have to quickly eat or drink glucose or another form of rapid-acting carbohydrate in order to raise your sugar to a safe level, and that likely reduces the beneficial effect of the low-carb diet.
Insulin in type 1 diabetes
Much of the above advice on insulin also applies to people with type 1 diabetes. A low-carb, high-fat diet can be fantastic for empowering people with type 1 diabetes to get steady blood sugars.8 It often results in much fewer and milder highs or hypos, as long as insulin doses are reduced appropriately.9
However, eating low-carb with type 1 diabetes requires even greater attention to blood sugar levels and insulin adjustment, and an even closer working relationship between you and your healthcare team. This section will review general guidelines to help you discuss potential changes with your doctor.
Many people with type 1 diabetes use an insulin to carbohydrate ratio (ICR) for their mealtime insulin. In this case, with a low carb diet you may continue to give the same ratio of insulin to the carbohydrates you eat. But, as you eat less carbohydrate, you will automatically inject less overall insulin.
In some cases, a slightly higher ICR may be required due to the effect of protein increasing insulin requirements.10 In other cases, a lower ICR may be required as some people will lose weight with a low carb diet and become more insulin sensitive.
People who use relatively fixed mealtime doses of insulin, or those on twice daily insulin, should use the same approach as those with type 2 diabetes. The difference is of course that people with type 1 diabetes will always need some insulin, even on a very low carbohydrate diet.
It is important to be aware that a diet with less than 50 grams of carbs each day can lead to ketosis. This is a normal physiological state that results from the body burning fat for energy.
A very strict low-carb diet can result in physiologic (in other words, safe) ketone levels (e.g. between 0.5 and 3.0 mmol/L, but sometimes as high as 4 or 5mmol/L). This should not be confused with ketoacidosis, which is a dangerous complication of type 1 diabetes when there is insufficient insulin.11
Ketosis is a normal response to using fat for energy. It is fine for healthy people, but in type 1 diabetes this means that you need to be sure you can differentiate ketosis from the much more dangerous ketoacidosis. The latter is associated with high blood sugar levels and dehydration, as well as high ketones.
We therefore recommend that when starting a low carb diet, a person with type 1 diabetes starts with a more liberal low-carb diet, with at least 50 grams of carbs a day.12 If you wish, you can then begin to reduce your carb intake to 30-40 grams of carbs per day while working closely with your healthcare team and carefully monitoring your ketone levels.
We do not recommend starting a ketogenic low-carb diet (below 20 grams a day) unless you’re certain of how to handle this risk and are working closely with a very experienced healthcare practitioner. You also have to be able to test your ketones often, and use extra care if you feel even slightly ill, practice intermittent fasting or have been exercising.13
It’s also important to remember that while people with type 2 diabetes can often reverse their disease enough to stop taking insulin injections entirely, someone with type 1 diabetes will always need to replace the insulin they lack.
With that said, a low-carb diet can have fantastic results for people with type 1 diabetes:
Some pills for type 2 diabetes work by stimulating the pancreas to produce more insulin. These medications can also result in low blood sugar on a low-carb diet.
Common examples of these pills are either in the group known as sulfonylureas (this includes gliclazide, glipizide, glibenclamide, glyburide, and tolbutamide) or meglitinides (repaglinide and nateglinide).
You will need to reduce the dose or stop these drugs when starting a low-carb diet in order to avoid low blood sugar levels.14 We recommend you discuss this with your doctor in advance.
Individuals with type 2 diabetes can can safely take metformin on a low-carb diet. There is a very low risk of low blood sugar from taking metformin.15
GLP-1 agonists and DPP-4 inhibitors
GLP-1 agonists typically have generic names ending in -tide like semiglutide, liraglutide, or exenatide. DPP-4 inhibitors typically have generic names ending in -gliptin like sitagliptin or linagliptin.
These drugs should rarely lead to low blood sugar on a low-carb diet by themselves.16 But be observant, check your blood sugar often, and discuss with your doctor as needed.
SGLT2 inhibitors (e.g. Farxiga, Jardiance, Invokana)
These drugs lower blood sugar in type 2 diabetes, and can be helpful in people on a more liberal low carb diet as they directly remove glucose (blood sugar) from the bloodstream.17 However, they can increase the risk of a dangerous condition called euglycemic ketoacidosis.18
The risk of this could be increased by a strict low-carb diet.19 It is therefore advised to stop SGLT2 inhibitors before starting a strict low carb diet, and this should be discussed with your doctor.
It’s worth noting that when ketoacidosis occurs while taking SGLT2 inhibitors, the blood sugar level is not necessarily high, making it harder to detect.20
Low carb for doctors
Are you a doctor or do you know one? Here’s our low carb for doctors resource, with information on how to safely handle medications on a low-carb diet:
Type 2 diabetes:
Type 1 diabetes:
Asia Pacific Journal of Clinical Nutrition 2016: A randomised trial of the feasibility of a low carbohydrate diet vs standard carbohydrate counting in adults with type 1 diabetes taking body weight into account [moderate evidence]
This is true for people with type 1 diabetes as well as those with type 2 who take mealtime insulin. It is also true of many oral hypoglycemic agents
How much need to reduce your insulin dosage depends on several factors, including carb intake and blood sugar control before starting a low-carb diet. Generally speaking, the lower your average blood sugars before you start eating low carb, the more you will need to reduce insulin when lowering your carb intake. Similarly, the higher your carb intake before switching to low carb, potentially the greater the need for reducing insulin.
There is no universal agreement of what defines stable or acceptable blood sugar levels. The details will vary depending on an individual’s concern about hypoglycemia verses their interest in strict glucose control. These criteria should be set between each individual and their healthcare team. ↩
In one study, people with type 1 diabetes reported 82% less hypoglycemia at the one-year mark of following a low-carbohydrate diet providing about 75 grams of carbs per day:
Other studies have also shown that lower carb intake coupled with low insulin does can result in significantly fewer hypoglycemic episodes in those with type 1 diabetes:
Diabetes, Obesity and Metabolism 2017: Short-term effects of a low carbohydrate diet on glycaemic variables and cardiovascular risk markers in patients with type 1 diabetes: a randomized open-label crossover trial [moderate evidence]
Asia Pacific Journal of Clinical Nutrition 2016: A randomised trial of the feasibility of a low carbohydrate diet vs standard carbohydrate counting in adults with type 1 diabetes taking body weight into account [moderate evidence] ↩
All of these factors increase ketone production in the liver. In people who don’t have diabetes, the pancreas responds to rising ketone levels by releasing more insulin, which signals the liver to produce fewer ketones. Because this feedback loop is absent in those with type 1 diabetes, higher ketone levels may lead to diabetic ketoacidosis unless sufficient insulin is taken.↩
In low-carb studies, sulfonylurea medications often need to be discontinued within just a few days due to rapid improvement in blood sugar levels.
Nutrition and Diabetes 2017: Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes [moderate evidence]
Metformin improves insulin sensitivity and decreases the amount of sugar released by your liver but does not increase the amount of insulin released by your pancreas. Therefore, your blood sugar remains stable and doesn’t drop too low, no matter how few carbs you eat.
Many ketogenic diet trials, including the trials by Virta Health, kept patients on metformin without any complications.
Unlike sulfonylureas, GLP-1 receptor agonists and DPP-4 inhibitors predominately lower blood sugar only when it is elevated, resulting in very low risk of hypoglycemia.
The Journal of Clinical Endocrinology and Metabolism 2019: SGLT2 inhibitors increase the risk of diabetic ketoacidosis developing in the community and during hospital admission [weak evidence]
Low-carbohydrate diets have been identified as a contributing factor to diabetic ketoacidosis in those taking SGLT2 inhibitors.
Although relatively rare, diabetic ketoacidosis without elevated blood sugar (referred to as euglycemic DKA) has been found to occur in both people with type 1 and type 2 diabetes who take SGLT2 inhibitors.