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International Journal of Case Reports and Images, Vol. 5 No. 10, October 2014. ISSN – [0976-3198]
Int J Case Rep Images 2014;5(10):699–703.
www.ijcasereportsandimages.com
Tóth et al. 699
CASE REPORT OPEN ACCESS
Type 1 diabetes mellitus successfully managed with the
paleolithic ketogenic diet
Csaba Tóth, Zsófia Clemens
ABSTRACT
Introduction: Type 1 diabetes mellitus (T1DM)
patients are usually instructed to follow a low
fat/high carbohydrate diet. A few studies in
literature, however, reported metabolic benefits
and sustainability of carbohydrate restricted
diets. Case Report: Herein, we present a case
of a 19-year-old male with newly diagnosed
T1DM. The patient was first put on an insulin
regime. Twenty days later, he shifted towards
the paleolithic ketogenic diet and was able to
discontinue insulin. Strict adherence to the diet
resulted in normal glucose levels and a more than
three-fold elevation of C-peptide level indicating
restored insulin production. Currently, the
patient is on the paleolithic ketogenic diet for
6.5 months. He is free of complaints, and no
side effects emerged. Conclusion: We conclude
that the paleolithic ketogenic diet was effective
and safe in the management of this case of newly
diagnosed T1DM. Marked increase in C peptide
level within two months indicates that the
paleolithic ketogenic diet may halt or reverse
autoimmune processes destructing pancreatic
beta cell function in T1DM.
Keywords: Type 1 diabetes mellitus, Ketogenic
diet, Paleolithic-ketogenic diet, C-peptide,
Evolutionary medicine
Csaba Tóth1, Zsófia Clemens2
Affiliations: 1MD, Medical Director, Paleomedicina Hungary
Ltd, Evolutionary Medicine Working Group, Hidász u. 3,
H-1026, Budapest, Hungary; 2PhD, Senior Research Fellow,
Department of Neurology, University of Pécs, Rét u. 2,
H-7623, Pécs, Hungary.
Corresponding Author: Zsófia Clemens, Department of
Neurology, University of Pécs, Rét u. 2, H-7623, Pécs, Hungary.
Ph: 003672535900; Email: clemenszsofia@gmail.com
Received: 08 July 2014
Accepted: 31 July 2014
Published: 01 October 2014
How to cite this article
Tóth C, Clemens Z. Type 1 diabetes mellitus
successfully managed with the paleolithic ketogenic
diet. Int J Case Rep Images 2014;5(10):699–703.
doi:10.5348/ijcri-2014124-CR-10435
INTRODUCTION
Diabetic patients are, generally, recommended to
follow a diet that is low in fat and high in carbohydrates
[1]. Clinical studies, conversely, showed metabolic
benefits conferred by carbohydrate-restricted diets
including the ketogenic diet [2, 3] and the paleolithic
diet [4, 5] in type 2 diabetes. Much less data on the use
of low carbohydrate diets in type 1 diabetes (T1DM)
are available. Two studies by Nielsen et al. showed that
a low carbohydrate diet lowers the need for insulin as
well as the number of hypoglycemic episodes in T1DM
[6, 7]. It was also suggested that a low carbohydrate diet
is sustainable on the long-term [6, 7]. Ketogenic diets
have long been used in epilepsy [8]. There are three
cases in literature, where concurrent epilepsy and T1DM
were treated with the classical ketogenic diet and both
conditions improved [9–11]. Recently, we published
a case of childhood absence epilepsy where seizure
freedom was achieved using a modified ketogenic diet we
refer to as the paleolithic-ketogenic diet [12]. Herein, we
present a case of T1DM, where the same diet resulted in
remission of T1DM as assessed by normalization of blood
glucose levels and elevation in C-peptide level allowing
for discontinuation of external insulin replacement.
CASE REPORT
A 19-year-old male complained of increased thirst,
polyuria, itchy skin, malaise, and weight loss. The
symptoms were present for about two weeks prior to
International Journal of Case Reports and Images, Vol. 5 No. 10, October 2014. ISSN – [0976-3198]
Int J Case Rep Images 2014;55(10):699–703.
www.ijcasereportsandimages.com
Tóth et al. 700
diagnosis. On November 24, 2013 self monitoring of
blood glucose showed 384 mg/dL. Previous medical
history was unremarkable. Anamnestic data included
consuming of muscle boosting protein through a month
prior to symptom onset. Laboratory assessment on
November 25, 2013 (Table 1) showed elevations in glucose
(218 mg/dL) and HbA1c (9.2%). Testing for glutamic acid
decarboxylase (GAD) antibodies showed positivity
(52 U/mL; normal range 0–10 U/mL) and mild positivity
for pancreatic islet cell autoantibodies (ICAs). C-peptide
level was not measured at this time. He was diagnosed
with T1DM. He was put on insulin replacement therapy
(38 IU of insulin) and standard conventional diabetes
diet with six meals containing 240 grams carbohydrate
daily. He followed this regime for 20 days. While on this
regime his glucose levels fluctuated between 68–267
mg/dL (Figure 1).
Carbohydrate he consuming before was less than 240
grams. Since his malaise did not improve the patient
consulted the first author in December 2013. To ascertain
T1DM laboratory examination of C-peptide was carried
out. C-peptide level of 0.6 ng/mL measured on January
08, 2014 indicated subnormal insulin secretion (Figure
2). The patient was suggested to switch to the paleolithic-
ketogenic diet which he initiated on December 21, 2013.
From this time, he was also taking 5,000 IU of vitamin
D3 but nothing else as supplement. His diet consisted
of meat, organ meat, fat and eggs. In his diet, red and
fat meats dominated over lean meats. He was eating
vegetables in insignificant amounts. His diet had a
ketogenic ratio (fat : protein + carbohydrate) of at least
2:1. No oil of plant origin or artificial sweeteners were
allowed. The patient was under our close control and
reported daily food records and blood glucose levels.
Upon shifting toward the paleolithic ketogenic diet
glucose levels returned to normal and no major elevations
were seen postprandially either. Insulin was therefore
discontinued. The tapering of insulin was done promptly:
following the first paleolithic-ketogenic meal glucose level
was only 86 mg/dL thus there was no need for external
insulin. Similar blood glucose levels were measured on
subsequent meals on the diet. Thus, the patient required
no insulin subsequently either. Home glucose monitoring
was carried out preprandially as well as postprandially
and tracked once a day for consecutive meals (that is on
consecutive days measures were taken for breakfast, lunch
and dinner, respectively). Average blood glucose level
while on the standard diabetes diet with insulin was 119
mg/dL while 85 mg/dL on the paleolithic-ketogenic diet
without insulin. Fluctuations in glucose levels decreased
as indicated by a reduction of standard deviation values
from 47 mg/dL on the standard diabetes diet to 9 mg/dL
on the paleolithic-ketogenic diet. Average postprandial
glucose elevation on the standard diabetes diet was 23
mg/dL while only 5.4 mg/dL on the paleolithic-ketogenic
diet (Figure 1).
C-peptide measurement was repeated on the 10th
week of the diet (on March 06, 2014). This indicated
an elevation to a value of 2.2 ng/mL (Figure 2). A
comprehensive laboratory workup carried out on March
14, 2014 indicated normal laboratory parameters with
the exception of total cholesterol and LDL cholesterol
which were slightly elevated. Glucose level was 88 mg/
dL while HbA1c was 5.5% (for all laboratory values see
Table 1). Urinary ketone was positive. On March 21, 2014
antibody testing for ICA showed no change in the mild
Table 1: Laboratory data at the time of diagnosis on a normal diet
(on November 25, 2013) and at 10 weeks after diet initiation,
on the paleolithic-ketogenic diet without insulin (on March 14,
2014). Note the normal level of glucose, HbA1c and low level
of triglyceride while on the paleolithic-ketogenic diet. Dashes
indicate that the given parameter was not measured.
Normal diet Paleolithic-ketogenic diet
WBC 5.9 5.4 G/l
RBC 5.7 5.3 T/l
Hemoglobin 16 15.2 G/dL
Hematocrit 48 45 %
Iron 136.3 98.9 µg/ dL
Thrombocyte 230 150 G/l
Sodium 134 139 mEq/l
Potassium 3.9 3.8 mEq/l
Calcium 9.52 10 mg/dL
Magnesium ─2.02 mg/dL
Carbamide 10.6 14.8 mg/dL
Creatinine 0.88 0.97 mg/dL
eGFR >90 >90
Glucose 218 88 mg/dL
Hb1Ac 9.2 5.5 %
Total cholesterol 143 301 mg/dL
HDL cholesterol ─54.8 mg/dL
LDL cholesterol ─224 mg/dL
Triglyceride 168 111 mg/dL
Uric acid 6.12 ─ mg/dL
GOT 31 19 U/l
GPT 44 18 U/l
GGT 17 16 U/l
Total bilirubin 0.94 ─mg/dL
TSH 3.53 ─mIU/l
CRP 1.1 ─mg/L
Abbreviations: WBC - white blood cell count, RBC - red blood
cell count, eGFR - estimated glomerular filtration rate, HbA1c -
glycated hemoglobin, HDL - high density lipoprotein, LDL - low
density lipoprotein, TSH - thyroid stimulating hormone, CRP
- C-reactive protein
International Journal of Case Reports and Images, Vol. 5 No. 10, October 2014. ISSN – [0976-3198]
Int J Case Rep Images 2014;55(10):699–703.
www.ijcasereportsandimages.com
Tóth et al. 701
positivity measured before and some elevation in GAD
antibodies (86 U/mL). At the time of writing this case
report, the patient is on the paleolithic ketogenic diet for
6.5 months and still exhibit low glucose levels. No side
effects emerged and he is completely free of symptoms.
The patient gave written informed consent for writing
this case study.
DISCUSSION
This is a first report of T1DM being successfully
managed with the paleolithic-ketogenic diet. In literature,
a few studies are available on the use of carbohydrate
restricted diet in the treatment of T1DM [6, 7]. Low
carbohydrate diet in these studies resulted in reduced
number of hypoglycemic episodes and also lowered
the need for insulin. In our case, however, insulin
replacement was not just reduced but could be stopped.
Importantly, insulin discontinuation was paralleled by
a marked increase in C peptide level indicating restored
pancreatic insulin production.
Shortly before diabetes onset our patient consumed
muscle boosting protein which contained bovine milk
protein. Consumption of cow’s milk has repeatedly been
shown to increase risk of T1DM [13, 14]. It is suggested
that bovine milk protein may promote autoimmune
processes giving rise to T1DM [15]. Also in two case
reports from literature, where epilepsy was treated
with the classical ketogenic diet, which contains large
amount of dairy, T1DM developed subsequently [9, 11].
A major difference between the classical ketogenic diet
and the paleolithic ketogenic diet is that milk and dairy
are excluded in the latter. We suggest that the paleolithic
ketogenic diet not only normalize glucose levels but
may also halt autoimmune processes mediated by non-
paleolithic substances including milk protein [16].
While on the paleolithic-ketogenic diet glucose levels
remained low both during preprandially and postprandially.
Follow-up laboratory assessment indicated laboratory
parameters remaining in the normal range except for
elevations in total cholesterol and LDL cholesterol. In fact,
these elevations are expected on a diet rich in animal fat
and cholesterol and were also reported in studies with the
classical ketogenic diet [17] as well as in our previous case
of childhood absence epilepsy treated with the paleolithic
ketogenic diet [12]. Moreover, it is now acknowledged that
neither dietary nor serum cholesterol represent a risk factor
for cardiovascular disease [18]. On follow-up antibody
testing ICA remained mildly positive while GAD antibodies
elevated to some extent. Although these parameters are
frequently associated with T1DM they do not seem to be
specific nor indicate progression of disease [19].
Type 1 diabetes mellitus is considered as a lifelong
metabolic condition due to the exhaustion of insulin-
secretory cells of the pancreas. Therefore, T1DM is
generally believed to be untreatable by any diet. There
are indications, however, that residual pancreatic beta
cell functioning may extend well beyond the time of
diagnosis [20]. Nevertheless C-peptide levels decrease
monotonically through years after diagnosis [20]. We are
not aware of any data from literature indicating elevation
of C-peptide resulting from a dietary intervention. A
recent case study of a child with T1DM reported remission
without insulin on gluten-free diet [21]. However, in that
case C-peptide continued to decline while on the gluten-
free diet.
Figure 1: Blood glucose levels while on the standard diabetes
diet containing 240 g carbohydrate with insulin therapy and
while on the paleolithic-ketogenic diet without insulin. Glucose
was measured preprandially and postprandially once a day for
consecutive meals (that is on consecutive days measures were
taken for breakfast, lunch and dinner, respectively). Note low
glucose levels and the absence of major postprandial elevations
while on the paleolithic ketogenic diet. Due to stable glucose
levels through five months, from May 15, 2014 the patient
switched to self-monitoring his glucose levels only once a week.
Figure 2: C-peptide levels shortly after diet initiation (on the
18th day of the paleolithic ketogenic diet) and two months later.
Note the more than three-fold increase in C-peptide within two
months.
International Journal of Case Reports and Images, Vol. 5 No. 10, October 2014. ISSN – [0976-3198]
Int J Case Rep Images 2014;55(10):699–703.
www.ijcasereportsandimages.com
Tóth et al. 702
In the standard care of T1DM insulin is a cornerstone.
It is important to emphasize that the paleolithic-
ketogenic diet as a standalone therapy may be applied
only in those cases with residual insulin secretion. In
cases with no internal insulin secretion the paleolithic-
ketogenic therapy may be only used as an adjunct to
insulin replacement.
CONCLUSION
We suggest that an intervention with the paleolithic
ketogenic diet in an early stage of the disease with residual
insulin secretion may halt or reverse type 1 diabetes
mellitus (T1DM). Follow-up at sixth month in the case of
our patient is relatively short and the positive results may
appear as a honeymoon effect. However, this term is used
in relation to the beginning of insulin therapy not the end
of it. We believe that with normalized insulin secretion
and a further adherence to the diet the patient may be
managed on the long-term.
*********
Author Contributions
Tóth Csaba – Substantial contributions to conception and
design, Acquisition of data, Analysis and interpretation
of data, Drafting the article, Revising it critically for
important intellectual content, Final approval of the
version to be published
Zsófia Clemens – Substantial contributions to
conception and design, Acquisition of data, Analysis
and interpretation of data, Drafting the article, Revising
it critically for important intellectual content, Final
approval of the version to be published
Guarantor
The corresponding author is the guarantor of submission.
Conflict of Interest
Authors declare no conflict of interest.
Copyright
© 2014 Tóth Csaba et al. This article is distributed
under the terms of Creative Commons Attribution
License which permits unrestricted use, distribution
and reproduction in any medium provided the original
author(s) and original publisher are properly credited.
Please see the copyright policy on the journal website for
more information.
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ABOUT THE AUTHORS
Article citation: Tóth C, Clemens Z. Type 1 diabetes mellitus successfully managed with the paleolithic ketogenic
diet. Int J Case Rep Images 2014;5(10):699–703.
Csaba Tóth is General Practitioner from Hungary with 20 years experience in intensive care medicine,
internal medicine and family medicine. He is using the paleolithic-ketogenic nutrition in the treatment
of chronic medical illnesses including diabetes, cancer, autoimmune diseases and epilepsy for ve
years. He is operating private practice in Budapest and in a few other cities in Hungary. In 2013, he
organized a course on evolutionary medicine in the mandatory training of GPs at the University of
Szeged, Hungary. With an evolutionary medical attitude he strives for the full recovery of his patients.
Email: csaba@paleomedicina.com
Zsóa Clemens is Biologist and clinical researcher specialized in nutrition, nutritional therapy and
brain research. She earned her PhD in electroencephalograpy of sleep and epilepsy from Semmelweis
University, Budapest, Hungary in 2005. Currently, she is Senior Research Fellow at the Neurological
Department, University of Pécs, Hungary and is also afliated with the Evolutionary Medicine Working
Group of Paleomedicina Hungary Ltd. In international academic journals, she has published 29 research
articles with more than 500 citations. Email: clemenszsoa@gmail.com
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