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Diabetes Diet
Should you take the Ketogenic Diet seriously?
September 25, 2020

As the world gets fatter, the ultimate low-carb, high-fat eating regimen emerges as the fashionable diet trend of the moment. But is it right for you? Here’s the lowdown from experts

With new fad diets popping up every now and then, you are bound to wonder what they are all about. The “it” diet of the moment is the ketogenic diet. Celebrities can’t get enough of it, stars swear by it. Food and beverages manufacturers are launching new keto snacks every day. The global ketogenic diet industry estimated at USD 10.3 billion is rising at a fast clip of 8 per cent a year.

This diet was created way back in the 1920s as a treatment for epilepsy. It was widely used until anti-epileptic drugs came on the market in 1938. It started gaining attention once again from the 1990s. Not so much for epilepsy, as for providing metabolic protection against the ailments of modern times: obesity, diabetes, heart disease and so on.


Here, we dig into a recent article by Shilpa Joshi and Dr Viswanathan Mohan¹. Joshi is a dietician with the Mumbai Diet and Health Centre. Dr Mohan is the Chairman of Dr Mohan’s Diabetes Specialities Centre & President of Madras Diabetes Research Foundation in Chennai.

Published in the Indian Journal of Medical Research, September 2018, their research—“Ketogenic diets: Boon or bane?”—analyses threadbare the pros, cons and controversies around the diet. Although meant for the academic community, here we present the easy-to-understand facts, to make it accessible to all.


The ketogenic diet is, typically, an eating pattern marked by very low carbohydrates and very high protein and fat. In fact, extremely high percentage of fat is often used in this diet plan. The classic keto diet requires about 90 per cent calories from fat, 6 per cent from proteins and 4 per cent from carbohydrates. And there are no restrictions on the type of fat to be consumed.

The purpose of this diet is to drastically reduce carbohydrate consumption (below 50 g/day) and shift the body’s primary fuel source from carbs to fat. As carbs are cut out, the glucose reserves of the body become insufficient. And the body starts to mimic the effects of fasting. An alternative source of energy emerges: the ketone bodies, produced in the liver by the breakdown of fats.


One of the unique aspects of the keto diet is its flexibility. Although the basic principles are universal, there are several ways to do this diet. Explore the different types of keto diets:

— The Standard Ketogenic Diet (SKD) is very low-carbohydrate (about 10 per cent), with moderate-protein (20 per cent) and high-fat diet (about 70 per cent).

— Cyclical Ketogenic Diet (CKD) involves periods of higher-carbohydrates in between the Keto diet cycles. For instance, five Ketogenic days, followed by two high-carbohydrate days.

— Targeted Ketogenic Diet (TKD) permits the addition of more carbohydrates, to coincide with intensive physical workout regimes.

— High-protein Ketogenic Diet (HPKD) allows 35 per cent protein, 60 per cent fat and five per cent carbohydrates.

The SKD is the most researched and recommended. HPKD has also been tried out extensively. CKD and TKD are recent additions, used mostly by bodybuilders or athletes. The SKD is the most researched and recommended, and the rest of this article will deal with SKD.


To Joshi and Mohan, the context of the keto diet is the rising wave of obesity in the last few decades, globally and in India. Obesity puts people at risk of type 2 diabetes, high blood pressure, heart disease, bone and sleep disorders, some forms of cancer and even depression. Yet, it is hard to manage obesity medically. “This leads to frustration among individuals with obesity,” write Joshi and Mohan, leading many to resort to extreme dietary interventions. Latest research shows that people who follow the diet lose more weight than those who follow balanced diets.

The keto diets seem to benefit in blood sugar control, reduce total cholesterol, serum triglycerides and increase high-density lipoprotein cholesterol. There are reported benefits on cancer and neurological disorders—Alzheimer’s disease to epilepsy. There are adverse effects, too: muscle cramps to bad breath, changes in bowel habits, keto-flu and loss of energy. “Monitoring individuals on keto-diet closely, once or twice a month, for blood glucose, ketones, cardiac and other parameters is essential,” point out Joshi and Mohan.


Indian health and diet have complicated relationship with carbohydrates. Study after study has shown in the last few years, that Indians consume very high percentage of calories in their diets from carbohydrates.

— In 2009, The Chennai Urban Rural Epidemiology Study (CURES)² conducted by Dr Mohan and others on people with newly-detected type 2 diabetes had revealed how carbs constituted the major source of calories in South India.

— It was followed by the STARCH study³ of 2014. Conducted by endocrinologist Dr S.R. Joshi, this dietary survey on people with type 2 diabetes showed how Indians got 65 per cent of their dietary calories from carbs³.

— In 2017, came the PURE Study4, conducted across 18 countries from five continents. Dr Mohan, a collaborator of the study that probed the linkages between fat-carbohydrate intake and heart disease-death. It was found that high carb intake (more than about 60% of calories) was associated with high death toll. In contrast, higher fat intake was found to have lower risks.

— A 2018 study5 now shows a long-term adverse effect on life-expectancy with both low-carb and high-carb diets. Led by Dr S.B. Seidelmann of Brigham and Women’s Hospital, Boston, US, the study suggests extremely high-carb diet (60% and above) as well as very low-carb (<30% carbs) diets increases the risk of dying. In fact, the risk was lowest when the carb intake was between 50 and 55 per cent; plant-based proteins and fats were also found to be more protective than animal-based proteins and fats.

— And finally the latest study in 20206 from the PURE study with Bhavadharini Balaji as the lead author and Dr.V. Mohan as the Second author has conclusively shows an association between excess white rice intake and new-onset type 2 diabetes. 


Should you go for the keto diet? Joshi and Mohan suggest “moderation.” The diet shows a dramatic improvement in the short-term. But is it sustainable? The researchers explain that initially people are thrilled with the weight-loss and the excellent diabetes control they get from keto diets. Gradually, however, they get bored, many feel weak and slowly increase carbohydrate intake. “Soon they are back to their original weight and diabetes control,” they add.

What is the long-term impact of not having all food groups on the plate? Low-carb diets lead to lower intake of vegetables, fruits, grains and greater intake of fat—a detrimental slope in the long term because it is likely to stimulate inflammatory pathways, oxidative stress and biological ageing. There are issues of serious complications like sensitivity of the liver to insulin, micronutrient deficiency. As “the pendulum of nutrients swing on either side, one must be vigilant of the balance and interplay of nutrients,” they warn.

Here are some recommendations from them, if you plan to follow the keto diet:

  • Keep carbohydrates consumption to 50-55 per cent of your diet
  • Use complex carbs and whole grains (brown rice or whole wheat)
  • Take about 20-25 per cent protein (preferably vegetable proteins, such as legumes        and pulses)
  • The remaining 25-30 per cent from healthy fats like monounsaturated fats (groundnut oil or mustard oil), nuts and seeds
  • Take plenty of green leafy vegetables.This will make your diet sustainable for long, make it less risky, more healthy and also help prevent non-communicable diseases such as diabetes, cardiovascular disease and certain cancers.

So, pause, take care before you embrace any extreme diet. Many more studies are needed before keto diets can be accepted widely.


  1. Shilpa J, Mohan V. Ketogenic diets: Boon or bane? Indian Journal of Medical   Research. 2018;148: 251-253. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6251269/
  2. Mohan V, Radhika G, Sathya RM, Tamil SR, Ganesan A, Sudha V. Dietary carbohydrates, glycaemic load, food groups and newly detected type 2 diabetes among urban Asian Indian population in Chennai, India (Chennai Urban Rural Epidemiology Study 59). British  Journal of  Nutrition. 2009; 102: 1498-1506. https://pubmed.ncbi.nlm.nih.gov/19586573/
  3. Joshi SR, Bhansali A, Bajaj S, et al. Results from a dietary survey in an Indian T2DM population: a STARCH study. BMJ Open2014;4:e005138. https://bmjopen.bmj.com/content/4/10/e005138
  4. Dehghan M, Mente A,  Zhang X, Swaminathan S,  Li W, Mohan V, Iqbal R, Kumar R,  Wentzel-Viljoen E, Rosengren A,  Amma LI,  Avezum A,  Chifamba J,  Diaz R, Khatib R,  Lear S, Lopez-Jaramillo P,  Liu X, Gupta R,  Mohammadifard N,  Gao N, Oguz A, Ramli AS, Seron P,  Sun Y,  Szuba A,  Tsolekile L, Wielgosz A,  Yusuf  R, Yusufali AH,  Teo KK,  Rangarajan S,  Dagenais G,  Bangdiwala SI, Islam S, Anand SS, Yusuf  S, on behalf of the Prospective Urban Rural Epidemiology (PURE) study investigators. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.  Lancet. 2017;390:2050-2062. https://pubmed.ncbi.nlm.nih.gov/28864332/
  5. Seidelmann SB, Claggett B, Cheng S, Henglin M, Shah A, Steffen LM, Folsom AR, Rimm EB, Willett WC, Solomon SD. Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. Lancet Public Health. 2018;3:e419-e428. https://pubmed.ncbi.nlm.nih.gov/30122560/
  6. Bhavadharini B, Mohan V, Dehghan M, Rangarajan S, Swaminathan S, Rosengren A, Wielgosz A, Avezum A,Lopez-Jaramillo P, Lanas F, Dans AL, Yeates K, Poirier P, Chifamba J, Alhabib KF, Mohammadifard N,Zato K´Khatib R, Keskinler MV, Wei L, Wang C, Liu X,Iqbal R, Yusuf R, Wentzel-Viljoen E, Yusufali AH, Diaz R, Keat NGK, Lakshmi PVM, Ismail N, Gupta R, Palileo- Villanueva LM, Sheridan P, Mente A, Yusuf S. White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries. Diabetes Care 2020;43:1–8. https://care.diabetesjournals.org/content/early/2020/08/31/dc19-2335


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