By Joseph E. Scherger, MD, MPH

Vice President, Primary Care, Eisenhower Medical Center; Clinical Professor, Keck School of Medicine, University of Southern California

Dr. Scherger reports no financial relationships relevant to this field of study.

SYNOPSIS: A very low-carbohydrate ketogenic diet demonstrated superiority to the plate method diet recommended by the American Diabetes Association for controlling and even reversing type 2 diabetes.

SOURCE: Saslow LR, Mason AE, Kim S, et al. An online intervention comparing a very low-carbohydrate ketogenic diet and lifestyle recommendations versus a plate method diet in overweight individuals with type 2 diabetes: A randomized controlled trial. J Med Internet Res 2017;19(2):e36. doi: 10.2196/jmir.5806.

This randomized, controlled trial conducted at the University of California, San Francisco compared a very low-carbohydrate ketogenic diet with the “create your plate” diet recommended by the American Diabetes Association for managing type 2 diabetes. Saslow et al previously conducted an in-person randomized, controlled trial;1 the most recent study was conducted online. Both studies were small (25 patients) and showed the same results. HbA1c dropped more than twice as much with the very low-carbohydrate ketogenic diet compared to the plate method (average 0.8% vs. 0.3%). With an average HbA1c of 7.1% or 7.2% at baseline, more than half the very low carbohydrate subjects dropped their HbA1c to below 6.5%.

A very low-carbohydrate diet consisted of only 20-50 grams of nonfiber carbohydrates for ketones to appear in urine, reflecting fat metabolism. Patients in both groups were mailed diet plans. Patients in the very low-carbohydrate group were mailed urine test kits for ketones.

The only diabetes medication allowed by the study subjects was metformin, both before and during the trial. Patients were excluded if they had been on other medications. The trial lasted 32 weeks, with measurements made at 16 and 32 weeks. The very low-carbohydrate subjects also lost significantly more weight (12.7 kg vs. 3 kg) and significantly lowered their triglycerides (60.1 mg/dL vs. 6.2 mg/dL).

This study depended on careful patient selection and trusting subjects to report their nutrition accurately. The subjects were equally reliant online as in person, with similar results.


Type 2 diabetes reversal clinics are opening across the United States. Eric Westman MD, an internist at Duke University, is a pioneer of this therapy as part of the Duke Lifestyle Medicine Clinic he directs. Dr. Westman is a champion of the ketogenic diet, and has been part of research showing its superiority for managing diabetes.2 Sarah Hallberg, MD, is an internist at Indiana University who reverses type 2 diabetes as part of a medically supervised weight loss program that relies on a very low-carbohydrate ketogenic diet. Dr. Hallberg started an online company, Virta Health, to help patients reverse their diabetes much the same way as is in this study.3

A very low-carbohydrate diet may be the natural human diet we consumed for the vast majority of our time as a species.4 Eating only the foods of nature as primitive hunter-gatherers did turns out to be eating mostly fat and protein from nuts, seeds, coconut, avocado, meat (especially the organs), and fish. The carbohydrates in our “foods of nature” diet usually were around 10% of calories. The Inuit in the Artic and the Samburu and Maasai tribes in Africa do not consume any carbohydrates in their diet.5

When blood sugar is derived from fat and protein, the blood sugar level is steady throughout the day and night and serum insulin is very low.6 It is becoming clear that insulin resistance, prediabetes, and type 2 diabetes are a stress response from eating excessive carbohydrates.

A ketogenic diet is gaining in popularity among the general population and among endurance athletes. Stephen Volek, RD, PhD, at The Ohio State University, has studied the ketogenic diet extensively, including its use among and effects on athletes.7,8 Using fat for energy is time-honored and superior to fluctuating blood sugar levels that can occur by consuming so-called energy drinks and loading carbohydrates. It is time to rekindle Maimonides’ admonition that “no disease that can be treated with diet should be treated by any other means.”


  1. Saslow LR, Kim S, Daubenmier JJ, et al. A randomized pilot trial of a moderate carbohydrate diet compared to a very low carbohydrate diet in overweight or obese individuals with type 2 diabetes mellitus or prediabetes. PLoS One 2014;9(4):e91027.
  2. 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;31:1-13.
  3. Virta Health. About Sarah Hallberg. Available at: Accessed June 7, 2017.
  4. Lieberman D. The Story of the Human Body: Evolution, Health and Disease. New York: Vintage Books; 2013.
  5. Teicholz N. The Big Fat Surprise: Why Butter, Meat & Cheese Belong in a Healthy Diet. New York: Simon and Schuster, 2014.
  6. Hyman M. Eat Fat, Get Thin. New York: Little, Brown and Co.; 2016.
  7. Feinman RD, Volek JS. Carbohydrate restriction as the default treatment for type 2 diabetes and metabolic syndrome. Scand Cardiovasc J 2008;42:256-263.
  8. Volek JS, Phinney SD. The Art and Science of Low Carbohydrate Performance. Beyond Obesity LLC; 2011.