Table 1.

Strong and weak indications and contraindications to VLCKD of SIE.

VERY LOW-CALORIE KETOGENIC DIETS (VLCKDS)
STRONG RECOMMENDATIONS	CONTRAINDICATIONS
Severe obesity	Pregnancy and breastfeeding kidney failure
Severe obesity before bariatric surgery	Moderate-to-severe chronic kidney disease
Sarcopenic obesity	Liver failure
Obesity associated with: T2DM (preserved beta cell function) Hypertriglyceridemia Hypertension	Rare disorders: porphyria, carnitine deficiency, carnitine palmitoyltransferase deficiency, carnitine-acylcarnitine translocase deficiency, mitochondrial fatty acid β-oxidation disorders, and pyruvate carboxylase deficiency
Pediatric obesity associated with epilepsy and/or with a high level of insulin resistance and/or comorbidities, not responsive to standardized diet	Respiratory failure unstable angina, hearth failure (NYHA III–IV), recent stroke or myocardial infarction (<12 months), and cardiac arrhythmias
WEAK RECOMMENDATIONS Obesity associated with dysbiosis; Obesity associated with dyslipidemia; Obesity associated with NAFLD; Obesity associated with heart failure (NYHA I–II); Obesity associated with atherosclerosis; Male obesity secondary hypogonadism; Obesity associated with PCOS; Menopausal transition-related obesity; Neurodegenerative disorders.	Eating disorders and other severe mental illnesses, alcohol, and substance abuse
	Type 1 diabetes mellitus, latent autoimmune diabetes in adults, β-cell failure in T2DM, use of SGLT2 inhibitors
	Active/severe infections and frail elderly patients,
	48 h prior to elective surgery or invasive procedures and perioperative period

SIE, Italian Society of Endocrinology; T2DM, type 2 diabetes mellitus; NAFLD, non-alcoholic fatty liver disease; NYHA, New York Heart Association; PCOS, polycystic ovary syndrome; SGLT, sodium-dependent glucose cotransporters.