How Is Diabetes Related to Cardiovascular Disease?

Cardiovascular disease (CVD) consists of conditions such as coronary artery disease, heart failure, cerebrovascular disease, and peripheral artery disease.¹ It shares similar risk factors with type 2 diabetes mellitus (T2DM) such dyslipidemia, insulin resistance, and impaired glucose tolerance. Furthermore, comorbidities common to T2DM such as obesity, dyslipidemia, and hypertension are linked to the development of atherosclerosis (the build-up of fat particles in the arterial wall), which underlies the pathogenesis of CVD. Additionally, hyperglycemia and insulin resistance, key characteristics of T2DM, are known to facilitate the development of CVD by promoting oxidative stress, plaque build-up in the arteries, and various cardiac dysfunctions.² As CVD is the leading cause of morbidity and mortality in individuals with both type 1 diabetes mellitus and T2DM, improving key risk factors has significant clinical implications.¹

Potential Benefits of the Ketogenic Diet on Cardiovascular Health

The ketogenic diet, characterized by a very low carbohydrate and high fat intake, has been shown to effectively promote weight loss and improve metabolic profiles,^3,4,5 with some evidence suggesting blood pressure benefits as well.² These findings suggest the potential of the ketogenic diet to improve cardiovascular risk factors. A 2020 expert analysis by the American College of Cardiology (ACC) highlighted weight loss, improved glycemic control, and reductions in triglyceride levels as key potential benefits of the ketogenic diet on cardiovascular health.⁶ However, improvements in cardiovascular risk factors seemed to be short-term, and adherence to the diet can be challenging.^6,7 More studies are needed to establish the ketogenic diet’s effect on long-term cardiovascular health.

Potential Risks of the Ketogenic Diet on Cardiovascular Health

The 2020 ACC expert analysis also highlighted that the ketogenic diet has the potential risk of increasing low-density lipoprotein cholesterol levels and may actually worsen long-term cardiovascular health.⁶ It noted that the diet restricts the intake of beneficial dietary components from fiber-rich grains, fruits, and vegetables (linked to reduced CVD risk) and promotes greater intake of animal protein (linked to increased CVD risk).

Who Should Use Caution or Avoid the Ketogenic Diet?

The ketogenic diet should be used with caution and medical oversight in individuals with diabetes to avoid hypoglycemic events.⁸ Additionally, individuals with atherosclerosis, atrial fibrillation, heart failure, kidney or liver disease, or those who take antihypertensive medications/warfarin should be informed of their greater need for supervision and potential medication adjustment if a ketogenic diet were to be initiated.⁶ Individuals with atherosclerosis should avoid ketogenic diets that liberalize saturated fatty acids intake. The ketogenic diet is not recommended for individuals on SGLT2 inhibitors and should not be initiated for individuals with hypertriglyceridemic pancreatitis, severe hypertriglyceridemia, or familial hypercholesterolemia.