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The case for low carbohydrate diets in diabetes management
Surender K Arora, Samy I McFarlane
Nutrition & Metabolism , 2005, DOI: 10.1186/1743-7075-2-16
Abstract: The epidemic of obesity and diabetes in our society over the past three decades has been accompanied by a decline in fat consumption and an apparent attempt to adopt the traditionally recommended low fat diet [1,2]. According to the USDA Continuing Survey of Food Intakes by Individuals (CSFII) [2], the absolute amount of fat and saturated fat consumed has decreased during the obesity epidemic although there is slight increase for women from 1994 to 1995. This apparent failure of low fat diets in curbing the obesity pandemic calls into question the effectiveness and long-term usefulness of such dietary recommendation and has led to renewed interest in alternative dietary interventions, notably those recommending reduced carbohydrate intake. Low fat diets are generally associated with high carbohydrate intake which in turn is associated with several metabolic abnormalities [3,4]. These metabolic abnormalities are more pronounced in the diabetic population, leading to worsening glycemic control, dyslipidemia and increased inflammation to name a few. In this review, we discuss the current evidence for a low carbohydrate diet versus a low fat diet in the management of people with diabetes, highlighting the potential role of low carbohydrate diet in ameliorating various metabolic abnormalities associated with diabetes.It is important to understand that there is no clear cut definition of a low carbohydrate diet in the literature. Various popular versions recommend carbohydrates intake < 20% of caloric intake with absolute amounts < 50–60 gm/day, sometime as low as ≤ 20–30 gm/day at least for short periods. We distinguish between moderate but significant reduction in carbohydrates (LoCHO diet) and very low carbohydrate ketogenic diets (VLCKD) with extreme reductions (< 20 or 30 g/day) as in the early phase of the various popular diets [5-7]. The caloric deficit due to carbohydrate restriction may be balanced with increased intake of proteins and fats although the distribut
Effects of low carbohydrate diets on weight and glycemic control among type 2 diabetes individuals: a systemic review of RCT greater than 12 weeks
Casta?eda-González,L. M.; Bacardí Gascón,M.; Jiménez Cruz,A.;
Nutrición Hospitalaria , 2011,
Abstract: introduction: low carbohydrate diets (lcd) have shown beneficial effects on short-term weight reduction programs for obese individuals without diabetes, but the long-term evidence of efficacy on individuals with type 2 diabetes is not conclusive. objective: to evaluate, the effectiveness of 12 or more weeks of lcd compared to low fat diet (lfd), usual care diet (ucd) or low glycemic index diet (lgid) on weight reduction and aic on type 2 diabetes individuals. methods: a systematic review was conducted on randomized trials registered in pubmed, cochrane and ebscohost from january 1st 2000 to january 1st 2010 including those with an intervention program with lcd in type 2 diabetes subjects and a follow-up ≥ 12 weeks. available data on study design; carbohydrate composition of diet; duration of diet; and the outcomes of weight, lipid levels (total, low density lipoprotein and high-density lipoprotein cholesterol, and triglycerides), hemoglobin a1c percent and/or fasting glucose were extracted. results: five studies showed greater weight reduction with lcd, of which four demonstrated no significant difference. the longest trial intervention studies did not show a difference in weight change. only two studies showed greater reduction of a1c with lcd, including the longest intervention trial with a low carbohydrate mediterranean diet. conclusions: this review shows that there are no consistent differences in weight and a1c changes over the long-term treatment with lcd and lfd, ucd or lgid.
Effects of low carbohydrate diets on weight and glycemic control among type 2 diabetes individuals: a systemic review of RCT greater than 12 weeks Efectos de las dietas bajas en carbohidratos sobre el peso y el control glicémico en individuos con diabetes tipo 2: revisión sistemática de estudios aleatorizados de más de 12 semanas
L. M. Casta?eda-González,M. Bacardí Gascón,A. Jiménez Cruz
Nutrición Hospitalaria , 2011,
Abstract: Introduction: Low carbohydrate diets (LCD) have shown beneficial effects on short-term weight reduction programs for obese individuals without diabetes, but the long-term evidence of efficacy on individuals with type 2 diabetes is not conclusive. Objective: To evaluate, the effectiveness of 12 or more weeks of LCD compared to Low Fat Diet (LFD), Usual Care Diet (UCD) or Low Glycemic Index Diet (LGID) on weight reduction and AIC on type 2 diabetes individuals. Methods: A systematic review was conducted on randomized trials registered in PubMed, Cochrane and EBSCOhost from January 1st 2000 to January 1st 2010 including those with an intervention program with LCD in type 2 diabetes subjects and a follow-up ≥ 12 weeks. Available data on study design; carbohydrate composition of diet; duration of diet; and the outcomes of weight, lipid levels (total, low density lipoprotein and high-density lipoprotein cholesterol, and triglycerides), hemoglobin A1C percent and/or fasting glucose were extracted. Results: Five studies showed greater weight reduction with LCD, of which four demonstrated no significant difference. The longest trial intervention studies did not show a difference in weight change. Only two studies showed greater reduction of A1C with LCD, including the longest intervention trial with a low carbohydrate Mediterranean diet. Conclusions: This review shows that there are no consistent differences in weight and A1C changes over the long-term treatment with LCD and LFD, UCD or LGID. Introducción: Las dietas bajas en carbohidratos han demostrado, a corto plazo, efectos benéficos sobre la pérdida de peso en individuos obesos sin diabetes, sin embargo la evidencia sobre su efectividad a largo plazo en individuos con diabetes tipo 2 no es concluyente. Objetivo: Evaluar el efecto de dietas bajas en carbohidratos (DBC) en intervenciones mayores a 12 semanas comparadas con dietas bajas en grasas (DBG), dietas de cuidado común (DCC) o dietas con bajo índice glicémico (DBIG), sobre la pérdida de peso y la hemoglobina glucosilada (A1C) en individuos con diabetes tipo 2. Métodos: Se realizó una revisión sistemática de estudios aleatorizados publicados en PubMed, Cochrane y EBSCOhost del 1o de Enero del 2000 al 1o de Enero del 2010. Se extrajeron datos sobre el dise o del estudio, la composición de carbohidratos de la dieta, la duración de la dieta y resultados de cambios en peso, en porcentaje de A1C, glucosa en ayuno y lípidos sanguíneos. Resultados: Cinco estudios mostraron mayor reducción de peso con DBC, de los cuales cuatro no demostraron diferencia estadíst
Is a Calorie Really a Calorie? Metabolic Advantage of Low-Carbohydrate Diets
Anssi H Manninen
Journal of the International Society of Sports Nutrition , 2004, DOI: 10.1186/1550-2783-1-2-21
Abstract: Obesity results from an excess of energy intake over energy expenditure. If the obese individual wants to lose weight, then the solution is extremely simple: energy expenditure must exceed energy intake for a suitable length of time. Obviously, this message is simple in principle, but very difficult to put into practice. Indeed, more than half of the adult population must now be classified as overweight or obese in the USA. It has been suggested that low-fat diets promote fat loss, but Willett and Leibel concluded that fat consumption within the range of 18 to 40 percent energy appears to have little if any effect on body fatness [1]. Thus, they felt that diets high in fat do not appear to be the primary cause of obesity, and reductions in fat will not be the solution. Similarly, the recent Cochrane review concluded that fat-restricted diets are no better than calorie restricted diets in achieving long-term weight loss in overweight or obese people [2]. In fact, participants lost slightly more weight on the control diets. Thus, in reality were low-fat weight loss diets to be marketed according to the laws governing the pharmaceutical industry, they would not pass scrutiny, as they have not been shown to be more effective than control diets. Consequently, progressive scientists and health care professionals are beginning to question the wisdom of recommending the low-fat diets for weight loss. For example, Weinberg suggested that low-fat/high-carbohydrate diets may well have played an unintended role in the current epidemics of obesity, lipid abnormalities, type II diabetes and metabolic syndromes [3]. The popularity of the low-carbohydrate weight loss diets is unquestionable. This review examines the science behind the "metabolic advantage" (i.e., a greater weight loss/fat loss compared to isocaloric high-carbohydrate diet) of low-carbohydrate diets.According to Albert Einstein, "Classical thermodynamics...is the only physical theory of universal content concerning
Metabolic aspects of low carbohydrate diets and exercise
Sandra J Peters, Paul J LeBlanc
Nutrition & Metabolism , 2004, DOI: 10.1186/1743-7075-1-7
Abstract: Exercise, an acute bout of muscular activity, requires an expenditure of energy above resting levels. This required mechanical energy is provided through the conversion of metabolic fuels into ATP, the base currency of chemical energy. Once produced, ATP is the only direct form of energy that is transferred and utilized by the contractile apparatus within the muscle. Fats are the predominant fuel source of resting skeletal muscle and during exercise, there is a complex interaction between skeletal muscle fat and carbohydrate (CHO) metabolism (see [1] for review). When evaluating the effects of exercise on skeletal muscle fuel utilization, there are many facets that must be taken into consideration. These include intensity and duration of the bout of exercise and the training status of the subjects. During low intensity physical activity (25% maximal oxygen uptake (VO2max)), fat supplies the majority of metabolic fuel to exercising skeletal muscle [2]. As physical activity increases to moderate levels (65–70% VO2max), there is a shift to more reliance on CHO, specifically muscle glycogen [2]. However, at this level of physical activity, fat oxidation becomes increasingly important as the duration of exercise increases [2] or as training status improves [3]. The studies presented in this review utilize moderately active subjects (maximal oxygen uptake, 50–60 ml·kg-1·min-1) exercising at a workload of 65–75% VO2max for 30–48 min.The sources of chemical energy that fuel exercising skeletal muscle are available through endogenous depots (intramuscular glycogen and triglycerides) or exogenous sources (plasma glucose and free fatty acids). In turn, these exogenous and endogenous fuel sources are replenished through dietary intake. As a result, there is an important relationship between diet and fuel metabolism in skeletal muscle.Diets low in carbohydrate content have become increasingly popular as a method of weight loss. These diets that limit daily dietary carbohydrate i
Metabolic aspects of low carbohydrate diets and exercise
Peters Sandra,LeBlanc Paul
Nutrition & Metabolism , 2004,
Abstract: Following a low carbohydrate diet, there is a shift towards more fat and less carbohydrate oxidation to provide energy to skeletal muscle, both at rest and during exercise. This review summarizes recent work on human skeletal muscle carbohydrate and fat metabolic adaptations to a low carbohydrate diet, focusing mainly on pyruvate dehydrogenase and pyruvate dehydrogenase kinase, and how these changes relate to the capacity for carbohydrate oxidation during exercise.
The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus
Eric C Westman, William S Yancy, John C Mavropoulos, Megan Marquart, Jennifer R McDuffie
Nutrition & Metabolism , 2008, DOI: 10.1186/1743-7075-5-36
Abstract: Eighty-four community volunteers with obesity and type 2 diabetes were randomized to either a low-carbohydrate, ketogenic diet (<20 g of carbohydrate daily; LCKD) or a low-glycemic, reduced-calorie diet (500 kcal/day deficit from weight maintenance diet; LGID). Both groups received group meetings, nutritional supplementation, and an exercise recommendation. The main outcome was glycemic control, measured by hemoglobin A1c.Forty-nine (58.3%) participants completed the study. Both interventions led to improvements in hemoglobin A1c, fasting glucose, fasting insulin, and weight loss. The LCKD group had greater improvements in hemoglobin A1c (-1.5% vs. -0.5%, p = 0.03), body weight (-11.1 kg vs. -6.9 kg, p = 0.008), and high density lipoprotein cholesterol (+5.6 mg/dL vs. 0 mg/dL, p < 0.001) compared to the LGID group. Diabetes medications were reduced or eliminated in 95.2% of LCKD vs. 62% of LGID participants (p < 0.01).Dietary modification led to improvements in glycemic control and medication reduction/elimination in motivated volunteers with type 2 diabetes. The diet lower in carbohydrate led to greater improvements in glycemic control, and more frequent medication reduction/elimination than the low glycemic index diet. Lifestyle modification using low carbohydrate interventions is effective for improving and reversing type 2 diabetes.The dietary macronutrient that raises postprandial serum glucose and insulin most potently is carbohydrate [1]. This observation led to the use of diets low in carbohydrate for the treatment of diabetes before insulin or other medication therapies were available [2]. In like fashion, individuals who are insulin-deficient are instructed to estimate the amount of carbohydrate in the meal and then to administer the insulin dosage based upon the amount of dietary carbohydrate. This strong relationship between dietary carbohydrate and postprandial serum glucose led to the development of medications that block carbohydrate absorption for th
Low-carbohydrate diet in type 2 diabetes: stable improvement of bodyweight and glycemic control during 44 months follow-up
J?rgen V Nielsen, Eva A Joensson
Nutrition & Metabolism , 2008, DOI: 10.1186/1743-7075-5-14
Abstract: Retrospective follow-up of previously studied subjects on a low carbohydrate diet.The mean bodyweight at the start of the initial study was 100.6 ± 14.7 kg. At six months it was 89.2 ± 14.3 kg. From 6 to 22 months, mean bodyweight had increased by 2.7 ± 4.2 kg to an average of 92.0 ± 14.0 kg. At 44 months average weight has increased from baseline g to 93.1 ± 14.5 kg. Of the sixteen patients, five have retained or reduced bodyweight since the 22 month point and all but one have lower weight at 44 months than at start. The initial mean HbA1c was 8.0 ± 1.5%. After 6, 12 and 22 months, HbA1c was 6.1 ± 1.0%, 7.0 ± 1.3% and 6.9 ± 1.1% respectively. After 44 months mean HbA1c is 6.8 ± 1.3%.Of the 23 patients who have used a low-carbohydrate diet and for whom we have long-term data, two have suffered a cardiovascular event while four of the six controls who never changed diet have suffered several cardiovascular events.Advice to obese patients with type 2 diabetes to follow a 20% carbohydrate diet with some caloric restriction has lasting effects on bodyweight and glycemic control.Type 2 diabetes reflects a disturbance in the glucose-insulin axis of metabolism and has insulin resistance as a defining feature. As such, it is expected that carbohydrate restriction would be the first line of attack and, in one form or another, this was the primary approach before the discovery of insulin [1]. In addition, at least anecdotally, some degree of carbohydrate reduction is a component of much clinical treatment. Health agencies have generally been reluctant to recommend carbohydrate restriction although the recent American Diabetes Association guidelines recognize that such diets are at least as effective as low fat diets for weight loss [2] and, while not recommending low carbohydrate diets, recognizes that dietary carbohydrate is the major factor in controlling blood glucose. Short term studies [3-7] in fact, demonstrate dramatic improvements in glycemic control even in the absen
A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabetes  [PDF]
Laura R. Saslow, Sarah Kim, Jennifer J. Daubenmier, Judith T. Moskowitz, Stephen D. Phinney, Veronica Goldman, Elizabeth J. Murphy, Rachel M. Cox, Patricia Moran, Fredrick M. Hecht
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0091027
Abstract: We compared the effects of two diets on glycated hemoglobin (HbA1c) and other health-related outcomes in overweight or obese adults with type 2 diabetes or prediabetes (HbA1c>6%). We randomized participants to either a medium carbohydrate, low fat, calorie-restricted, carbohydrate counting diet (MCCR) consistent with guidelines from the American Diabetes Association (n = 18) or a very low carbohydrate, high fat, non calorie-restricted diet whose goal was to induce nutritional ketosis (LCK, n = 16). We excluded participants receiving insulin; 74% were taking oral diabetes medications. Groups met for 13 sessions over 3 months and were taught diet information and psychological skills to promote behavior change and maintenance. At 3 months, mean HbA1c level was unchanged from baseline in the MCCR diet group, while it decreased 0.6% in the LCK group; there was a significant between group difference in HbA1c change favoring the LCK group (?0.6%, 95% CI, ?1.1% to ?0.03%, p = 0.04). Forty-four percent of the LCK group discontinued one or more diabetes medications, compared to 11% of the MCCR group (p = 0.03); 31% discontinued sulfonylureas in the LCK group, compared to 5% in the MCCR group (p = 0.05). The LCK group lost 5.5 kg vs. 2.6 kg lost in MCCR group (p = 0.09). Our results suggest that a very low carbohydrate diet coupled with skills to promote behavior change may improve glycemic control in type 2 diabetes while allowing decreases in diabetes medications. This clinical trial was registered with ClinicalTrials.gov, number NCT01713764.
Effects of a low-carbohydrate diet on glycemic control in outpatients with severe type 2 diabetes
Hajime Haimoto, Tae Sasakabe, Kenji Wakai, Hiroyuki Umegaki
Nutrition & Metabolism , 2009, DOI: 10.1186/1743-7075-6-21
Abstract: Carbohydrate-restricted diets (CRDs) have been reported to be effective for glycemic control [1-7] in type 2 diabetes (T2DM). We recently demonstrated that a loosely restricted 45%-carbohydrate diet (carbohydrate-reduced diet: CRD) led to a significant reduction in hemoglobin A1c (HbA1c) levels with a tapering off of sulfonylureas compared to a 60%-carbohydrate diet (high-carbohydrate diet: HCD) over 2 years among outpatients with mild T2DM (mean HbA1c = 7.4%) [8].Little is known about the long-term effects of CRDs on patients with severe T2DM. We therefore tried to determine whether good glycemic control can be achieved with a stricter CRD (30%-carbohydrate), even in outpatients with severe T2DM in an outpatient clinic.We recruited outpatients with T2DM having HbA1c levels of 9.0% or above between September 2005 and September 2007 in Haimoto Clinic, and followed their HbA1c levels, body mass index (BMI) and doses of antidiabetic drugs monthly for 6 months. We also followed their serum lipid profiles, serum creatinine and blood pressure. Patients with serum creatinine levels > 1.5 mg/dl, severe diabetes complications (proliferative retinopathy, symptomatic neuropathy and diabetic foot), ketoacidosis, soft drink ketosis [9] and malignant tumor were excluded. Five patients who developed ketosis received fluid therapy for a few days, and did not require any inpatient care or insulin therapy. We intended to taper the dose of sulfonylureas as soon as the patients' HbA1c levels were controlled, and to prescribe metformin, acarbose and pioglitazone. The patients were instructed to maintain their usual level of physical activity throughout the study. Changes in activity levels were investigated by questionnaire. The study protocol was identical to that of the previous study [8] and was approved by the Ethical Committee of the Nagoya Tokusyukai General Hospital. All patients provided written informed consent.The main principle of the CRD was to eliminate carbohydrate-rich fo
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