What is the ideal diet for a patient with type 2 diabetes taking an SGLT‑2 inhibitor?

Ideal Diet for Patients with Type 2 Diabetes Taking SGLT2 Inhibitors

Patients on SGLT2 inhibitors must avoid very-low-carbohydrate and ketogenic diets due to the significant risk of euglycemic diabetic ketoacidosis, and should instead follow a balanced eating pattern emphasizing high-fiber, minimally processed carbohydrates from vegetables, legumes, whole grains, and fruits. 1

Critical Dietary Restriction: Avoid Very-Low-Carbohydrate Diets

The most important dietary consideration for SGLT2 inhibitor users is avoiding very-low-carbohydrate eating patterns (<26% total energy) and ketogenic diets. 1 The 2025 American Diabetes Association guidelines explicitly state that very-low-carbohydrate eating plans should be used with caution in those taking SGLT2 inhibitors because of the potential risk of ketoacidosis. 1

Multiple case reports document that diabetic ketoacidosis (DKA) or euglycemic DKA can occur in people with type 2 diabetes using SGLT2 inhibitors in combination with very-low-carbohydrate or ketogenic eating patterns. 1 The risk is substantial enough that patients have developed euglycemic DKA after only one week on a ketogenic diet while taking an SGLT2 inhibitor. 2

The mechanism is clear: SGLT2 inhibitors promote ketosis by altering the insulin-to-glucagon ratio, and when combined with carbohydrate restriction (which independently induces ketosis), the risk of dangerous ketoacidosis increases dramatically. 3, 4

Recommended Carbohydrate Approach

Focus on adequate carbohydrate intake from high-quality, fiber-rich sources:

• Emphasize vegetables, legumes, fruits, whole grains, and dairy products as primary carbohydrate sources. 1
• Consume a minimum of 14 g of fiber per 1,000 kcal, with at least half of grain consumption being whole, intact grains. 1
• Avoid sugar-sweetened beverages and processed foods with refined grains and added sugars, as these contribute to increased mortality and cardiovascular disease. 1
• Maintain consistent carbohydrate intake to prevent prolonged periods of reduced caloric intake, which is a precipitating factor for euglycemic DKA. 3, 4

The evidence strongly supports high-fiber carbohydrate sources, as dietary fiber intake is inversely associated with risk for type 2 diabetes and lower all-cause mortality. 1

Protein Recommendations

Maintain protein intake at 0.8–1.5 g/kg body weight/day (15–30% of total calories):

• There is no evidence that adjusting protein intake beyond this range improves health outcomes or glycemic management. 1
• Protein goals should be individualized based on current eating patterns. 1
• In type 2 diabetes, ingested protein increases insulin response without raising plasma glucose, so high-protein carbohydrate sources should be avoided when treating hypoglycemia. 1

Fat Recommendations

Emphasize a Mediterranean-style eating pattern rich in monounsaturated and polyunsaturated fats:

• Include fatty fish (EPA and DHA) and nuts/seeds (ALA) for cardiovascular disease prevention. 1
• The ideal total dietary fat content remains inconclusive, but Mediterranean-style patterns improve glucose metabolism and lower cardiovascular risk. 1
• This approach is an effective alternative to low-fat, high-carbohydrate diets. 1

Additional Critical Dietary Considerations

Alcohol restriction is essential:

• Avoid excessive alcohol intake when taking SGLT2 inhibitors, as alcohol is a precipitating factor for euglycemic DKA. 1, 3
• Limit alcohol to no more than one drink per day for women and two drinks per day for men. 1

Sodium intake:

• Limit sodium to <2,300 mg/day, with further restriction if hypertension is present. 1

Avoid prolonged fasting:

• Patients should adhere to regular meal patterns and avoid prolonged starvation, as reduced caloric intake and fasting are major precipitants of euglycemic DKA. 1, 3, 4

Special Situations Requiring SGLT2 Inhibitor Discontinuation

Stop SGLT2 inhibitors immediately if:

• Starting a very-low-energy/liver reduction diet before bariatric surgery (typically 800-1,000 calories/day, very low in carbohydrates). 1
• Planning elective surgery—discontinue at least 3 days before procedures requiring fasting. 1, 4
• Experiencing acute illness, dehydration, or inability to maintain normal oral intake. 3, 5

Common Pitfalls to Avoid

The most dangerous pitfall is prescribing or allowing patients to follow popular low-carbohydrate or ketogenic diets while on SGLT2 inhibitors. 1, 2 Many physicians prescribing these medications may not be aware of this association, despite it being well-documented in guidelines. 2

Another critical error is failing to provide sick-day rules that include temporarily discontinuing SGLT2 inhibitors during acute illness or when unable to eat normally. 1, 3

Weight Management Integration

For patients needing weight loss (≥5% body weight reduction):

• Achieve this through portion control and reduction of total calorie intake rather than severe carbohydrate restriction. 1
• The combination of calorie reduction and lifestyle modification benefits overweight or obese adults with type 2 diabetes. 1
• If very-low-carbohydrate approaches are considered for weight loss, SGLT2 inhibitors must be discontinued first. 1