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The application to fragile subjects such as the elderly, those with a history of mental disorder, eating behaviour or substance abuse must benefit from an appropriate support in the daily routine for the KD to be potentially considered as a feasible treatment for concomitant conditions. Some of these, such as pregnancy, breastfeeding and perioperative timing, find no reason in not being followed, given the short nonapplicable time and the potential major adverse events that could develop. Finally, subjects with acute intermittent porphyria should avoid the KD as the lack of carbohydrates in is a well‐known precipitating factor causing relapse of the condition.107 Severe mental illness, similar to impaired cognitive ability and aging, may lead to reduced compliance in adequate water consumption and constant use of prescribed electrolyte and vitamin supplement crucial to maintain a good safety profile especially during a VLCKD among all KDs, thus increasing the risk of side effects. Altogether, it seems reasonable to foresee that more studies will become available in the next years, possibly confirming a beneficial effect of ketone bodies on all stages of cardiac failure, thus shortening the list of contraindications to the KD. Noteworthy, it has been proven that the human failing heart shifts to ketone bodies as a significant fuel source,86 and myocardial lipid analysis conducted on hearts of nondiabetic, lean, advanced heart failure patients undergoing cardiac transplant confirmed increased ketone utilization.87 Infusion of βOHb was harmless, and even increased cardiac output significantly in 34 patients at an NYHA II‐III stage,38 suggesting that the present contraindication should be at least reduced to those with NYHA stage IV, for which no safety evidence is available to date. Current evidence on the effect of ketone bodies on ischaemia‐reperfusion injury outcomes is promising overall but only present at a preclinical level. It should be noted that some evidence, upon superficial evaluation, seems to suggest opposite effects. Given the potentially serious adverse events and the limited time that these conditions make KD not recommendable, it is reasonable to conclude that the KD should never be suggested in pregnant and breastfeeding women. Lactation ketoacidosis is rarely described to happen spontaneously in women, but a few case reports show an increased risk when KD is a precipitating factor.21 Unsurprisingly, no clinical study is available relative to the use of KDs in pregnant women, with one case‐series on two women suggesting a possible teratogenic effect of an HFKD as a treatment to refractory epilepsy.20 Preclinical studies report a significant reduction in the cerebral blood flow, reduced glucose utilization similar to metabolic encephalopathies, and embryonic growth retardation,77 but it should be noted that the KD given to rodent models is highly insufficient in protein and not comparable to a KD usually prescribed to human beings, making results scarcely translational.78 The reportedly normal glucose levels make such a diagnosis difficult to be formulated unless suspected. Since the introduction of the glucose lowering class of drugs sodium–glucose cotransporter‐2 inhibitors (SGLT2‐i), several reports have been published regarding the risk of euglycaemic diabetic ketoacidosis (DKA) in those consuming HFKDs while on SGLT‐2 treatment for type 2 diabetes.15, 16, 17, 18, 19 SGLT2‐i increase glucose urinary excretion by inhibiting the sodium and glucose reuptake in the kidney. The latest American Diabetes Association (ADA) guidelines do not support one eating plan over another, but education on carbohydrate counting is highly encouraged.72 Type 1 diabetes (T1D) is possibly the most well‐described contraindication to the KD due to the increased risk of diabetic ketoacidosis and possible hypoglycaemia. Moreover, in the initial phase of a KD, increased diuresis will require careful monitoring of goal dry weight if the patient is on haemodialysis treatment. 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