Endocrine Abstracts

Introduction: It is known that very-low-calorie-ketogenic-diet (VLCKD) has beneficial effects on body weight in overweight diabetic patients. Adopting this diet with artificial meals or natural foods in type 2 diabetes (T2DM) has been largely studied, and conflicting results have been reported regarding its effects on glycemic profiles, dyslipidemia, and liver function. In fact, the high level of fat content in natural foods could have a negative impact on hepatic steatosis, and high protein content in artificial meals may affect renal function.

Case: We describe a 62-year-old female patient with T2DM complicated by diabetic nephropathy who underwent a VLCKD. When T2DM was diagnosed in 2010, her glycated hemoglobin (HbA1c) was 61 mmol/mol and body mass index (BMI) was 37.1 kg/m². She also had dyslipidemia and severe hepatic steatosis. She was initially managed with metformin and a Mediterranean diet with an improvement in glycemic control and discrete weight loss (HbA1c 49 mmol/mol, BMI 34.8 kg/m²). Three years later, she presented poor glycemic control (HbA1c 65 mmol/mol), regain of body weight and diabetic nephropathy appeared (estimated glomerular filtration rate, eGFR, 49 ml/min/1.73m², albuminuria 266 mg/l). Therefore, metformin was discontinued, basal insulin therapy was started, and liraglutide (until 1.8 mg/day) was added to improve weight loss. Metabolic control improved quickly and remained stable over time, but she only had minimal weight loss (BMI from 35.5 to 35.1 kg/m2 in four years despite therapy). Therefore, in August 2019, she was advised to start a VLCKD. Just one month after, she had a remarkable improvement in glycemic control, so she discontinued all therapy. After six months of diet, not only the excellent glycemic control (HbA1c 37 mmol/mol) persisted, but there were also an important weight loss (BMI 29.9 kg/m2), together with amelioration of dyslipidemia, hepatic steatosis, and diabetic nephropathy (eGFR 61.5 ml/min/1.73m², albuminuria 1.6 mg/l). In February 2020, VLCKD was replaced by a low-calorie-diet followed for one year, in which she had partial weight gain and worsening renal function. Then, she switched a low-carbohydrate-diet and all parameters improved again.

Discussion: The best dietary approach in subjects with T2DM remains debated. However, in literature, it has been suggested that not only VLCKD seems to be safe and effective in obese diabetic patients with impaired renal function and liver disease, but that it may even help significantly improving both, as in this case.