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The Longest Low Carb Study Ever Conducted is Finally Finished (the results are surprising)

Thomas DeLauer

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TL;DR

The four things you'd lose by not watching

4 items

TL;DR

The four things you'd lose by not watching

4 items

A 10-year case report on a type 1 diabetic patient on a ketogenic diet showed normalized HbA1c (5.5%) and zero coronary calcium score, despite elevated LDL.

HbA1c is the #1 risk factor for cardiovascular disease in type 1 diabetes, far outweighing LDL (ranked #10), according to a 2016 Diabetes Care paper.

The ketogenic diet improved cardiovascular physiology to levels better than age/sex-matched non-diabetics, suggesting glucose control is paramount over LDL elevation.

Dr. Andrew Kutnik advocates for informed patient choice and institutional guidelines for therapeutic carbohydrate reduction, filling a gap in standard care.

Protocols

Concrete recipes — what, when, how much, and why

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Ketogenic diet for type 1 diabetes

WhatA very low-carbohydrate, high-fat diet that reduces glucose variability and insulin requirements, aiming to normalize HbA1c.

WhenAs a long-term dietary intervention, under medical supervision.

DoseLong-term (10 years in the case report); macronutrient ratios not specified, but typically <50g carbs/day.

For whomType 1 diabetics seeking to improve glycemic control, especially those with elevated HbA1c despite standard care.

WhyBy minimizing carbohydrate intake, postprandial glucose spikes are reduced, leading to lower HbA1c and insulin needs, which may mitigate cardiovascular risk despite potential LDL elevation.

CaveatsRequires careful insulin adjustment to avoid hypoglycemia; may elevate LDL cholesterol; should be done with healthcare provider guidance.

Dr. Kutnik explained that high and variable glucose directly damages tissues and drives cardiovascular disease. The ketogenic diet addresses the #1 risk factor (HbA1c) by minimizing glucose fluctuations. The case report showed that despite elevated LDL, the patient had zero calcium score and better vascular function than non-diabetics, suggesting the net effect is protective.

Mechanism

Reducing carbs lowers glucose exposure, which reduces oxidative stress and inflammation on vascular walls. Lower insulin levels may also reduce insulin resistance. The diet may also suppress NLRP3 inflammasome via beta-hydroxybutyrate.

A ketogenic diet for those who aren't aware... is a diet that's very low in carbohydrates. So, you reduce the carbohydrates dramatically. The amount of total glucose exposure in the blood is much lower and as a result, you often have much lower glucose spikes due to food and also lower subsequent insulin requirements.

Also said

“The patient had confirmed elevations in ketones on a ketogenic diet over a 10-year period... they were able to re achieve something that's only happens in 1% of patients with type 1 diabetes which is normal normal normal glycemia.”— Demonstrates efficacy.

CGM-guided insulin adjustment on low-carb diet

WhatUsing continuous glucose monitors to fine-tune insulin dosing when following a low-carb diet to maintain time-in-range and avoid hypoglycemia.

WhenDaily, with each meal and insulin dose.

DoseInsulin doses must be reduced significantly to match lower carb intake; specifics depend on individual.

For whomType 1 diabetics on low-carb diets.

WhyLow-carb diets reduce the need for bolus insulin; without adjustment, hypoglycemia risk increases.

CaveatsRequires frequent monitoring and healthcare provider guidance.

Dr. Kutnik mentioned that the patient in the case report used a CGM and adjusted insulin accordingly. He also noted that standard time-in-range (70-180 mg/dL) is not optimal; normal glycemia is lower. The ketogenic diet helps achieve tighter control.

Mechanism

Lower glucose intake means less insulin needed to cover meals; basal insulin may also need reduction.

In the context of type 1 diabetes, the average HBA1C is north of 8%... These patients are also set up for a 10 to 18 year shortened life expectancy. Again, all of this is associated with poor glucose control.

Advanced cardiovascular screening for early atherosclerosis

WhatUsing vascular hemodynamics (pulse wave velocity, arterial stiffness) to detect early signs of cardiovascular disease before calcium score changes.

WhenFor high-risk individuals (e.g., type 1 diabetes) starting early, even in childhood.

DosePeriodic screening as recommended by a cardiologist.

For whomPeople with type 1 diabetes or other high cardiovascular risk.

WhyEarly detection of vascular stiffening can prompt interventions before irreversible plaque forms.

CaveatsNot a replacement for standard lipid panels and calcium scoring; complementary.

Dr. Kutnik emphasized that calcium score is a late marker. Vascular stiffening occurs within 4 years of type 1 diabetes diagnosis. By measuring hemodynamics, they could assess the ketogenic diet's impact on early disease progression.

Mechanism

High glucose and inflammation cause vascular smooth muscle to be replaced by collagen, stiffening arteries. This can be measured by pulse wave velocity.

What we wanted to do was looking at these early markers, advanced markers of cardiovascular progression through measures of the stiffening of the vascular wall.

Also said

“In the context of type 1 diabetes, we see signs of early stiffening within the first four years, even in childhood.”— Justifies early screening.

What's new

Personal practice updates, fresh positions, predictions

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10-year ketogenic diet case report in type 1 diabetes

First longitudinal case report of a type 1 diabetic patient on a ketogenic diet for 10 years, showing normalized HbA1c and excellent cardiovascular health despite elevated LDL.

Why this matters: Longest ever report on ketogenic diet in high cardiovascular risk patient; challenges the LDL-centric view of cardiovascular risk.

Background

Prior to this, there was almost no data beyond 1-2 years on ketogenic diets and cardiovascular outcomes. Concerns about elevated LDL on keto led to fears of increased cardiovascular risk, especially in high-risk populations like type 1 diabetes.

The patient had type 1 diabetes, which confers a 10-fold higher risk of cardiovascular disease. On a standard American Diabetes Association diet, they had poor glycemic control. After switching to a ketogenic diet, they maintained an average HbA1c of 5.5% over 10 years, which is normal glycemia and only achieved by 1% of type 1 diabetics. Despite elevated LDL and APOB, advanced cardiovascular assessments (vascular hemodynamics, calcium score) showed no signs of atherosclerotic progression; in fact, cardiovascular physiology was better than age/sex-matched non-diabetics. This suggests that glucose control may outweigh LDL elevation in determining cardiovascular outcomes in this population.

This patient not only had com remarkable measures of cardiovascular disease through advanced cardiovascular assessments, they also had a calcium score of zero.

Also said

“We saw that the ketogenic diet not only normalized the key biomarkers related to cardiovascular disease progression but in concert in alignment with that they showed remarkable cardiovascular physiology and health sometimes better than people even without the disease of the same age and sex.”— Summarizes the surprising result.

HbA1c is the primary cardiovascular risk factor in type 1 diabetes

A 2016 paper ranked HbA1c as the #1 risk factor for cardiovascular disease in type 1 diabetes, while LDL was #10.

Why this matters: Challenges the common focus on LDL; shows glucose control is far more critical.

Background

In type 1 diabetes, cardiovascular risk is 10-fold higher. The DCCT trial showed that intensive glucose control reduced cardiovascular events by 99% over 30 years, proving causality.

Dr. Kutnik cited a 2016 paper from Diabetes Care that ranked risk factors for cardiovascular disease in type 1 diabetes. HbA1c was #1, followed by age, blood pressure, triglycerides, etc. LDL was only #10. This ranking, combined with the DCCT trial showing that improved glycemic control almost completely explained cardiovascular benefits, demonstrates that glucose is the primary driver. The ketogenic diet's ability to normalize HbA1c thus becomes a powerful intervention, even if it elevates LDL.

The research overwhelmingly shows that glucose levels are the driving force, at least the primary driving force for cardiovascular disease risk.

Also said

“LDL was actually only number 10 on the list.”— Quantifies the low ranking of LDL.

“Improvements in glycemic control almost completely explained 99% of the cardiovascular benefits derived from the group with more insulin, demonstrating the causal relationship between glycemic control and cardiovascular disease.”— Cites the DCCT trial evidence.

Advanced cardiovascular assessments beyond calcium score

The study used vascular hemodynamics (stiffening, pulse wave velocity) to detect early atherosclerotic changes, not just calcium score.

Why this matters: Explains why calcium score alone may miss early damage; validates the comprehensive approach.

Background

Calcium score is the gold standard for plaque, but it may not appear until later in life. In type 1 diabetes, vascular stiffening can occur within 4 years of diagnosis, even in children.

Dr. Kutnik explained that vascular stiffening is an early sign of atherosclerosis. They measured how blood moves through vessels, compliance, and wave reflection. These markers are validated to predict future cardiovascular events. The patient showed no signs of stiffening, indicating no early atherosclerotic progression.

What we wanted to do was looking at these early markers, advanced markers of cardiovascular progression through measures of the stiffening of the vascular wall.

Also said

“In the context of type 1 diabetes, we see signs of early stiffening within the first four years, even in childhood.”— Emphasizes the importance of early detection.

International guidelines for therapeutic carbohydrate reduction in type 1 diabetes

Dr. Kutnik and colleagues developed guidelines for safely implementing low-carb diets in type 1 diabetes due to lack of institutional support.

Why this matters: Addresses the gap between patient practice and clinical guidance; empowers healthcare professionals.

Background

Many patients are already using low-carb diets to manage type 1 diabetes, but healthcare providers lack training and guidelines. Standard of care does not include therapeutic carbohydrate reduction.

Dr. Kutnik reached out to major institutes to create guidelines, but they required RCT-level evidence which doesn't exist. So he assembled international experts to build guidelines through the Institute of Personalized Therapeutic Nutrition. The goal is to provide evidence-based guidance for clinicians and patients, balancing benefits of glycemic control against hypothetical risks of elevated LDL.

Personal experience

Dr. Kutnik initiated the project after reaching out to major institutes.

We actually had medical doctors, international professionals, people living with this disease, people treating the people with this disease to build international institutional backed guidelines for how to safely implement therapeutic carbohydrate reduction in the context of type 1 diabetes.

Also said

“There is nothing in standard of care for type 1 diabetes on how to manage this as a healthcare professional. That does not exist.”— Highlights the gap.

Recommendations

Products, supplements, and tools mentioned in the episode

2 items

Ketogenic diet for metabolic disease

Practice

Recommended as a therapeutic intervention for type 1 diabetes to improve glycemic control.

Dr. Kutnik advocates for the ketogenic diet as a tool to normalize HbA1c and reduce cardiovascular risk, despite potential LDL elevation. He emphasizes that the benefits outweigh risks when glucose is controlled.

vs alternatives

Compared to standard American Diabetes Association diet, which often results in poor glycemic control and higher cardiovascular risk.

The ketogenic diet not only had better blood like vascular measurements, heart measurements, early signs of atherosclerotic progression that were better than not only people of the same age and sex match with type 1 diabetes but in many cases actually had better cardiovascular physiology than people without type 1 diabetes.

Find Ketogenic

Institute of Personalized Therapeutic Nutrition guidelines for therapeutic carbohydrate reduction

Service

Guidelines for healthcare professionals to safely implement low-carb diets in type 1 diabetes.

Dr. Kutnik and colleagues developed these guidelines to fill the void in standard of care. They are designed to help clinicians manage patients who choose therapeutic carbohydrate reduction.

Personal experience

Dr. Kutnik initiated the project after reaching out to major institutes.

Find Institute

Disclosed sponsorships2speaker disclosed

Thrive Market

Product Sponsored · disclosed

Online grocery delivery with transparent ingredients, high-protein snacks.

DisclosureSponsored segment; host Thomas DeLauer provides a discount link.

Thomas DeLauer (host) promotes Thrive Market, highlighting its convenience and ingredient transparency. He notes that it saves time and ensures quality, especially for high-protein snacks.

Personal experience

Thomas DeLauer says he uses it to avoid reading labels in-store.

Thrive Market takes that guesswork out of the equation for me and it makes it accessible to me, but it makes it accessible to people all over the country.

Find Thrive

Andrew Kutnik's online resources

Service Sponsored · disclosed

Website AndrewKutnik.com, X/Twitter @akutnik, Instagram/TikTok @AndrewKutnikPhD, Substack.

DisclosureSelf-promotion; he provides free resources.

He offers free resources and information on topics like this study.

I provide a lot of free resources on AndrewKutnik.com.

Find Andrew

Notable quotes

Lines worth pulling out — contrarian, specific, or perfectly phrased

6 items

The research overwhelmingly shows that glucose levels are the driving force, at least the primary driving force for cardiovascular disease risk.

Concise summary of the central thesis.

LDL was actually only number 10 on the list.

Quantifies the low ranking of LDL, challenging conventional focus.

This patient not only had com remarkable measures of cardiovascular disease through advanced cardiovascular assessments, they also had a calcium score of zero.

Highlights the striking result of zero calcium score despite elevated LDL.

It's analogous to buying a car that the engine breaks and you're like, 'Okay, well, I got some nice rims though.'

Memorable analogy for prioritizing primary risk factors over ancillary ones.

You can't look at any diet just at face value of one particular biomarker change. You have to look at this holistically.

Key takeaway about evaluating diets based on overall health outcomes, not single markers.

There is nothing in standard of care for type 1 diabetes on how to manage this as a healthcare professional. That does not exist.

Underscores the gap that the guidelines aim to fill.

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Topics covered

ketogenic-diettype-1-diabetescardiovascular-diseasehba1cldl-cholesterolglucose-controlvascular-healththerapeutic-carbohydrate-reductionpatient-guidelinesnutritional-ketosisadvanced-cardiovascular-screeninginsulin-resistanceglycemic-variabilitypatient-empowerment

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Educational summary of the cited expert source — not medical advice. Open the source recording linked above and consult a qualified physician before acting on any protocol.