Pregnancy‑Smart Keto in November 2025: What WHO’s New Diabetes‑in‑Pregnancy Guideline Means—and a Low‑Carb Plan That Stays Out of Ketosis

Why this matters today

WHO’s November 14, 2025 guideline calls for individualized diet and glucose targets for diabetes in pregnancy and embeds nutrition alongside optimal monitoring and medication when needed. It does not endorse ketogenic diets; instead, it emphasizes patient‑centered care and regular home glucose checks. ^[2]

In the U.S., the American Diabetes Association (ADA) sets glycemic targets most teams use: fasting <95 mg/dL; 1‑hour post‑meal <140 mg/dL; or 2‑hour post‑meal <120 mg/dL. Continuous glucose monitoring (CGM) can help. ^[3]

What the newest evidence says about carbs, keto, and pregnancy

1) WHO (Nov 14, 2025): individualized nutrition + monitoring

WHO’s new global guideline for diabetes in pregnancy prioritizes tailored diet advice, regular blood glucose checks, and integrated prenatal care. It underscores equity of access to essential technologies and medications but does not set a universal carbohydrate gram target—leaving room for individualized, culturally appropriate counseling. ^[5]

2) Endocrine Society 2025: room for carbohydrate restriction—with supervision

A July 2025 summary of Endocrine Society guidance notes clinicians may use either a “carbohydrate‑restricted diet (<175 g/day) or usual diet (>175 g/day)” in pregnant individuals with pre‑existing diabetes, reflecting a suggestion (not a strong recommendation) and the need for careful monitoring to avoid ketonemia. ^[6]

3) ADA targets remain your daily north star

Use ADA’s glucose targets (fasting <95; 1‑hr <140; 2‑hr <120 mg/dL) and consider CGM to improve time‑in‑range. ^[7]

4) What randomized trials in gestational diabetes (GDM) actually show

• Moderately lower‑carb (~135 g/day) vs ~200 g/day for 6 weeks: no increase in ketones and similar infant outcomes; adherence to the lower target was challenging. ^[8]
• 40% vs 55% calories from carbohydrate: insulin need and outcomes were similar. ^[9]
• Higher‑complex‑carb/low‑fat pattern improved fasting glucose and adipose insulin resistance vs a lower‑carb/higher‑fat pattern in a small, controlled pilot. ^[10]
• Prevention angle: a real‑world feasibility trial targeting 130–150 g/day found high retention but modest actual carb reduction; larger outcome‑powered trials are needed. ^[11]

The practical playbook: “Keto‑minded,” not ketogenic

Goal: Achieve post‑meal glucose targets and adequate fetal nutrition without entering sustained ketosis.

Macronutrient guide (default starting point)

If fasting or post‑meal glucose remains above target despite the plan, a clinician‑supervised trial of a modestly lower‑carb range (e.g., 135–175 g/day) can be considered with frequent glucose checks—and ketone checks if intake goes below 175 g. Medication adjustments (often insulin) are safer than pursuing ketosis in pregnancy. ^[18]

Build your plate (each main meal)

• Non‑starchy vegetables (half plate)
• Lean protein (palm‑size)
• Low‑GI carb (fist‑size): beans/lentils, intact whole grains, or fruit
• Healthy fat (thumb‑size): olive oil, nuts, seeds, avocado

Carb timing and pairing

• Distribute carbs over 3 small‑to‑moderate meals + 2–4 snacks; breakfast tends to need fewer carbs. ^[19]
• Open meals with veggies/protein to blunt glucose spikes; walk 10–15 minutes after meals when possible. ^[20]

Micronutrients and supplements (pregnancy‑specific)

• Prenatal vitamin that covers folate (600 mcg DFE), iron (27 mg), iodine (220 mcg), vitamin D (600 IU), and B‑complex. ^[21]
• Choline: target 450 mg/day (eggs, lean meats, soy; consider a choline‑containing prenatal if diet is low). ^[22]
• DHA: aim for 8–12 oz/week of low‑mercury fish (e.g., salmon, sardines); algae‑DHA is an option. ^[23]

Three day‑one, pregnancy‑safe, low‑GI meal ideas (≈190–200 g carbs total)

Electrolytes, fluids, and “keto‑flu” questions

Do not use high‑dose sodium or exogenous ketone supplements in pregnancy. Prioritize hydration and typical prenatal electrolyte needs from food; seek clinical guidance if vomiting limits intake. ^[25]

Exercise add‑ons that lower glucose without lowering carbs

• 150 minutes/week moderate cardio (walking, swimming, stationary cycling). ^[26]
• 2 non‑consecutive days/week of light‑to‑moderate resistance (bands or bodyweight). Avoid supine positions after the first trimester. ^[27]

Red flags: when to avoid “keto‑minded” restriction

• Type 1 diabetes, history of DKA, hyperemesis gravidarum, underweight, renal/hepatic disease—follow individualized medical nutrition therapy. ^[28]

What’s proven vs. what’s anecdotal

• Proven/Guideline‑level: Individualized nutrition + monitoring improves outcomes in diabetes‑in‑pregnancy; use ADA glycemic targets; exercise is beneficial and safe for most. ^[29]
• Supported by RCTs (small to moderate): Modestly lowering carbs (~135 g/day) doesn’t increase ketones and can aid glycemia; very low‑carb/high‑fat patterns haven’t shown superiority over higher‑complex‑carb diets in GDM. ^[30]
• Insufficient/Not advised: Strict ketogenic diets in pregnancy (risk of ketonemia; safety concerns). ^[31]

Tip grid: how to make this work this week

FAQs

Can I stay on strict keto while pregnant? No. Professional societies and today’s WHO guideline emphasize individualized care and safety; sustained ketosis is avoided in pregnancy due to DKA risks. Opt for a carb‑smart, low‑GI plan instead. ^[37]

What if my glucose is still high at 175–200 g carbs? Discuss medication (often insulin) and consider a supervised step‑down toward 135–175 g/day with close monitoring before any further restriction. ^[38]

Actionable summary (start today)

• Adopt a low‑GI, carb‑controlled plate at ~175–200 g carbs/day; track fasting and 1‑hr glucose. ^[39]
• Walk 10–15 minutes after meals; aim for 150 minutes/week of moderate activity. ^[40]
• Ensure prenatal micronutrients, add choline to reach 450 mg/day, and eat low‑mercury fish 2–3 times/week. ^[41]
• Avoid ketosis and exogenous ketone products; escalate to medication rather than deeper carb cuts if needed. ^[42]
• Partner with your OB/endocrinology/RDN team; WHO’s new guideline reinforces coordinated, individualized care. ^[43]

References (selected)

WHO. Global guideline for diabetes during pregnancy (news release, Nov 14, 2025). ^[44]

ADA. Standards of Care in Diabetes—pregnancy glucose targets and CGM guidance. ^[45]

Endocrine Society (summary, July 2025). Diet options including carbohydrate‑restricted approaches under supervision. ^[46]

AJCN RCT: Modestly lower carbohydrate (~135 g/day) vs ~200 g/day in GDM—no rise in ketones, similar outcomes. ^[47]

RCT: 40% vs 55% carbohydrate in GDM—similar insulin need/outcomes. ^[48]

Pilot RCT: Higher‑complex‑carb/low‑fat improved fasting glucose and adipose IR vs lower‑carb/higher‑fat in GDM. ^[49]

DKA in pregnancy and euglycemic DKA risks. ^[50]

DRI: ≥175 g/day carbohydrate during pregnancy (AHRQ/DRI overview). ^[51]

Protein needs in pregnancy (RDA 1.1 g/kg/day; higher late‑gestation needs in emerging data). ^[52]

Seafood guidance in pregnancy (EPA/FDA advice; low‑mercury choices). ^[53]

Use this guide as a conversation starter with your care team—and remember, in pregnancy the safest “keto‑smart” move is carb‑smart nutrition that keeps you out of ketosis while keeping glucose in range. 🥑💪