This transcript has been edited for clarity. Jay H. Shubrook, DO: Hi. I'm Jay Shubrook, a family physician and diabetologist at Touro University California. We're here at the 79th Scientific Sessions of the American Diabetes Association (ADA) in San Francisco. I'm happy to have Dr Rucha Mehta with me. Dr Mehta is an endocrinologist at Apollo Hospital in India and a frequent presenter at the ADA. I want to talk about a topic that has really been a hot topic at this year's meeting: ketogenic diets in patients with type 2 diabetes. Dr Mehta, let me tell you about a new patient of mine who recently moved here from Southern India. She was diagnosed with type 2 diabetes about 6 years ago, 4 years before moving to the United States. Since moving here, she has had trouble managing her diabetes. Her A1c is in the mid-8% range. She has gained a fair amount of weight.
She is asking me what kind of diet or program she can follow. She has heard about the ketogenic diet. She is vegetarian, and I'm struggling to give her good advice. Do you have any advice for me about this patient? Rucha J. Mehta, MD: Jay, this is right up my alley. As you're all aware, there are an increasing number of Indian patients in the United States. I'm currently practicing in India, where we have started using all sorts of diets for our patients. For this patient, certainly, we would begin with a detailed 3-day dietary questionnaire, which we have not yet validated. We also ask about physical activity, dietary preferences, micronutrient intake, and how much processed food they are eating per week. We don't want out patients to be miserable while they're on the diet, so we try to take their dietary activities or practices into consideration. In the first week after we start seeing a patient like this woman, we would evaluate her fasting glucose, postprandial sugars, and any current medications.
When we begin to change a patient's diet, the first week we generally start with a low-carb diet (100 g per day), which is not, in fact, very low-carb. For example, if our patient was consuming 200 g of carbohydrates per day-our data demonstrate that most of our patients are eating an average of 200 g of carbs per day-we would probably cut that down by 50% in the first week to a 100-g carbohydrate diet. This is not a ketogenic diet. Mehta: A warmup, yes-the first week. Thereafter, we titrate the medications down. With a lower-carb diet, we need to cut back on the patient's medication to avoid low blood sugars. Usually, in the second week, we then begin the ketogenic diet-an Indian or vegetarian version of the ketogenic diet. I also would like to add that if the patient is overweight, we make this a hypocaloric diet. Many of our Indian patients are considered lean diabetic patients. They are not obese, but they're overweight.
Their BMI may be in the range of 27 kg/m2. So we do not want to make it very hypocaloric. If the individual is morbidly obese, that's when we would consider a hypocaloric diet. Bear in mind that our diet usually turns out to be hypocaloric compared with the previous dietary pattern. The low-carb diet, ketogenic diet, brings carbohydrates down to 40-50 g or less. By definition, it needs to be less than 30 g, but some individuals may not tolerate that. What I like to do in my practice is called a cyclical ketogenic diet. We put the patient on a keto diet. We monitor them with urinary ketone sticks. When they go into ketosis, that's when we will collect a blood sample, usually a day or two later. Everyone is variable. Some people go into ketosis within 3 days; some people go into ketosis after 4-5 days. It depends on your body's storage types. When the individual is in ketosis, we collect a blood sample to document ketosis, which can be done by assessing either breath acetone or serum beta-hydroxybutyric acid levels.
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