Low Carb Diet For Two Months

Low Carb Diet For Two Months

In July our family moved from Pennsylvania to South Carolina and along with packing up all of our belongings, I packed on about ten new pounds. Trying to learn a new place, setting up a new home, making new friends, worrying about my kids, left me filled with all the feels. Instead of coping with these feelings appropriately, I did what many educated, adult women do when stressed. I ate ice cream and gobbled down baked goods. 🍦🍩🍪🍨🤦🏼‍♀️

Fast forward to New Year's Eve and I decided enough was enough. It was time to stop feeling sorry for myself, neglecting my health, and not taking responsibility for my actions. I committed to making healthier mind, body, and spirit choices in 2018! I joined a gym. I signed our family up for a small group at the church we've been attending. I reached out to an acquaintance and invited her to lunch. And I started eating a ketogenic diet.

What is keto?

A ketogenic diet is a high fat, low carb, moderate protein diet. It's often touted as being the same thing as other low-carb diets such as Atkins or South Beach, but it is definitely different. Atkins is a much higher protein diet and South Beach allows for more carbs and has various stages. A keto diet has you eliminate practically all carbs from your diet with the exception of those found in leafy greens and avocados. You essentially starve your body of carbs in order to induce a state called ketosis, which forces your liver to use fat to produce ketones for energy. Typically your body uses glycogen as energy which is converted from carbs. Ketosis forces your body to use the ketones as energy and helps convert the fat that you're eating into energy. Unfortunately, ketosis doesn't necessarily help you burn your own fat stores more rapidly or effectively than other diets. You still have to watch your calories, really watch your carb intake, and exercise while eating keto. Some people respond dramatically to keto and rapidly lose weight. This has not been the case for me. Don't get me wrong. I HAVE lost weight so far but it hasn't been dramatic. However, I have seen many other non-scale benefits since going keto that I'll outline further down in the post!

Why keto instead of another diet?

I was on keto a few years ago and found it fairly easy to stick to which is the main reason I decided to give it a go again. On keto a person can eat meat, leafy greens, high fat dairy, seeds and nuts, avocados, and some berries. You can use a no-carb, no sugar sweetener to sweeten coffee or tea. You can have dark chocolate in moderation and some no-sugar sweets. My goal in losing weight and making lifestyle changes needs to make sense, allow for enjoyment, and above all not cause suffering. I don't do well and can't commit to suffering. If a diet makes me feel deprived, hungry, light-headed, or in anyway sick I just won't be able to stick to it long-term. After adjusting to keto, I feel great and truly do not have uncontrollable cravings, mood swings, or hunger.

What is the keto flu?

Also known as carb flu, the keto flu is a real thing. It is what many experience the first week of transitioning to a keto diet and is a withdrawal from carbs and sugar. During this time you might experience headaches, nausea, dizziness, insomnia, irritability, brain fog, and fatigue. Basically you feel crappy and want to eat carbs to alleviate your symptoms! To avoid the dreaded keto flu or to lessen its effect you should eat a few more lean carbs (like those in veggies), drink broth, up your magnesium, sodium, and potassium, eat a few more calories, drink more water, and exercise. I had a few keto flu symptoms for about two days and then felt fine.

One symptom I DID have upon starting keto is something most won't have to worry about. It is called a "keto rash" and happens to a small subset of those beginning a ketogenic diet. I actually experienced this same rash the first time I tried keto and another time when I did a low carb diet so I wasn't quite as alarmed this time around when it made an appearance. My thighs, stomach, back, upper arms and back of my neck broke out in a small, red, raised rash that was mildly itchy. It looked terrible and coconut oil seemed to help quiet it. There are many theories as to why this happens. Some claim it's candida die off, others claim it's fat detoxing through your pores, and some say it's an allergic reaction to your ketones in your sweat. Whatever the cause, know that it goes away within a week or two.

What do you eat on a keto diet?

To properly follow a keto diet, you will need to eliminate grains, sugar, most fruit and tubers, and stick to only 20 grams of net carbs a day. Net carbs are the amount of carbs a particular food has minus the amount of fiber. And not, unfortunately you are NOT able to take a fiber supplement to negate carbs. The fiber has to already be naturally occurring in the food you are eating. So for example, if I was served something like the above picture I would eat the olives, the cheeses, the meats, the prosciutto wrapped cheese, the radishes, a few raspberries and maybe a strawberry. I wouldn't eat many of the tomatoes or carby fruits, and of course I'd avoid the crackers, breads, and stuffed grape leaves.

What does a typical day on keto look like for you?

My diet varies day to day but this will give you a brief snapshot of what I might eat in a day. This isn't meant to be a meal plan for you to follow but just to give you the general gist of what the diet might look like. I aim to keep my calories between 1200-1300 calories a day and a little more on days that I workout. Fat is very calorie dense so monitoring your calories is important! If you like green salads, eggs, bacon, salmon, hard cheeses, and nuts, then keto should be easy for you to implement

Keto Cream Cheese Pancakes: 1 egg, 1 ounce cream cheese, baking powder, vanilla, and cinnamon blended together in blender and cooked like pancakes on a buttered griddle. Serve with sugar free syrup.

BREAKFAST:

LUNCH:

DINNER:

• Grilled salmon with dill
• Steamed broccoli

DESSERT:

• A few small squares of 85% Green & Black's dark chocolate with natural nut butter, or macadamia nuts

I don't typically need to snack while on keto. If I'm run down, I might eat a few almonds or a few olives and that seems to do the trick. Typing that just sounds utterly ridiculous. To be clear, I'm not an "oh, all I need is a few olives to sustain me," kind of girl. I've always been a "five cookies might do the trick if I'm lucky" type. But like I said before, eating a ketogenic diet really does help curb the cravings and tame your tendency to binge. On keto, I am pretty much sugar free and mostly gluten free which helps stabilize my blood sugar. On days that I work out I might add a half of a Quest protein bar, or some extra protein but otherwise I am happy and content with the macros.

What online tools are helpful for someone wanting to begin keto?

1. Macro Calculator: Speaking of macros, I recommend you use a keto macro calculator to determine the percentage and grams of fat, protein, and net carbs you should be consuming each day.
2. Weight Loss Calculator: In addition to knowing you daily macros, it's a good idea to use this weight loss calculator to get a rough estimate on how long it might take to lose the weight. When I entered in today's date, I received a date five months from now to be at my goal weight. That is five months to lose 22 pounds. You might lose weight much quicker than this, but I lose weight incredibly slowly and have found this calculator helpful .
3. My Fitness Pal:I use My Fitness Pal to track my macros and calories. I just use the free version and it works great for me.
4. Keto Recipe Sites: Some of my favorite keto recipe blogs are I Breathe I'm Hungry, Ruled Me, and All Day I Dream About Food.

I don't bake a lot of keto treats because I think it's best to keep things simple starting out, but I have enjoyed fathead bagels, sugar free peanut butter chocolate cookies, and chocolate chip scones. These are the only treats I've made in the last two months and honestly they may have slowed my progress down. But I figure staying in ketosis while enjoying a treat is better than falling out of ketosis by cheating. These are tasty alternatives to the real deal.

What about exogenous ketones? Are they necessary?

Exogenous ketones are ketones you ingest to help your body get into ketosis faster or give you more energy while in ketosis. I personally don't find them necessary although those trying to sell them to you through their MLM's will swear they are miraculous and vital. I have tried MCT oil which is a type of good fat that is easily converted into ketone energy. I use it on days I workout to boost my energy levels but I'm not sure they are vital.

Should you take supplements while on keto?

I have watched my daily vitamin recommendations on My Fitness Pal and I am typically low in the following while eating keto:

• Potassium
• Magnesium
• Calcium
• Iron
• Vitamin D

I also think you should take a probiotic while on keto because the lack of sugar can change your gut flora. I take all of the supplements above and also take Zint collagen daily.

How much weight have you lost so far on keto?

If you do a "before and after keto" search on the internet you will find myriads of inspiring weight loss stories and images. Many have incredible success at shedding the pounds quickly and easily. This just is never my experience no matter which weight loss program I've tried. I workout 3-4 times a week in addition to walking and I keep my net carbs between 20-30g every day. I have lost ten pounds in the last two months on keto and most of that weight loss was in the first month. I know this isn't incredibly impressive, but I am pleased with the results! I know my body and I know that I just lose weight at a snail's pace. I'm pear-shaped, have a slow metabolism, and it takes a lot of training and macro watching in order for me to drop in weight. Sure I wish it was coming off faster, but I feel good while on keto and don't feel like I'm missing out!

Any non-scale keto gains to note?

Yes! My skin has never been clearer and my allergies are amazingly better. A few months ago, I began having cystic acne for the first time in my life. Every month right before my period began my chin would break out something fierce. The only thing I had changed in my diet was eating a cup of 2% Greek Yogurt for breakfast. You would think eating Greek Yogurt would be healthy! I did some research and found that the excess of dairy can cause inflammation and result in cystic acne. Although I eat dairy while on keto, my skin has completely cleared to the point I rarely break out at all.

My allergies are typically horrible year round and since moving to South Carolina have really escalated. In December before beginning keto my husband suggested I look into getting allergy shots. My attacks each night were fierce and frequent! Since eating a ketogenic diet I can't recall the last time I had an allergy attack. Keto is supposed to reduce inflammation in the body and I'm a firm believer that it indeed does so! Many people adopt a keto lifestyle simply for its anti-inflammatory benefits.

Should I try a keto diet?

This diet is NOT for everyone. I repeat. It's just plain not good for everyone!  You should discuss with your physician whether it might be right for you and do your own internet research. If you have kidney issues, gallbladder issues, diabetes, or other health concerns you should of course check with your doctor.  There is a ton of good research both for and against a keto diet online. Don't take my word or experience for it! Do your own research and see what works best for you and your health.

Click the links below for more keto posts!

Keto Diet: What I've Experienced After Six Months on a Ketogenic Diet

Easy Keto Portobello Mushroom Cream Cheese Chicken Recipe

Shakshuka with Cream Cheese Recipe: Poached Eggs in Tomato Bisque

Keto Pumpkin Cranberry Scones

25+ Fresh Salad Recipes

Low Carb Diet For Two Months

Source: https://www.homestoriesatoz.com/weight-loss/keto-diet-what-ive-experienced-after-two-months.html

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Simple Low Carb Diet Plan For Weight Loss

Simple Low Carb Diet Plan For Weight Loss

10 Diet Pills to Kickstart Your Weight Loss Efforts

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If you're struggling to lose weight, a diet pill can give you the boost you need to reach your goals. Some are available over-the-counter (OTC), while others require a prescription from your doctor. Either way, for the best results, combine any weight loss pill with lifestyle changes (like exercising more or eating a healthier diet). Here are a few diet pills that can help you get over your weight loss hump.

Best Overall: Phentermine

Photo Courtesy: WebMD

Phentermine is a prescription diet pill consistently proven to help its users lose weight. Users report that phentermine boosts their energy levels, making it easier for them to increase their daily activity and exercise more. Most users also experience appetite reduction that makes it less arduous to eat less. However, phentermine users also find that the drug is less effective the longer you take it.

Best Value: Nature Craft's Natural Raw Green Coffee Bean Extract

Photo Courtesy: Amazon

Prefer something OTC? Nature Craft's Natural Raw Green Coffee Bean Extract contains caffeine to boost your metabolism, plus chlorogenic acid to slow the absorption of carbohydrates (aka everything delicious). Users find that they're less likely to overindulge when taking this diet pill, and report high energy levels with no jittery feelings or "crash." More than 900 reviewers have weighed in, giving it a solid 4.5 star average rating.

Best Diet Pill for a Low-Fat Diet: Alli Orlistat

Photo Courtesy: Target

Alli Orlistat is a diet pill that blocks 25 percent of the fat from the foods you consume, creating a reduction in the amount of calories you absorb. Orlistat users experience the best results when they combine the diet pill with the suggested, healthy eating plan—seriously, you do not want to over-indulge. Users report that it's essential to adhere to a low-fat diet when taking Alli; otherwise, you risk digestive distress, stool leakage, and flatulence.

Best Diet Pill for Men: Prime Labs Prime Test Testosterone Booster

Photo Courtesy: Amazon

Prime Labs Prime Test testosterone booster is a popular diet pill with men who want to lose a few pounds and increase their testosterone levels. Users find that they have more energy and have better performance in the gym and weight room. Is there's a six-pack under your pudge? Fans also report that this diet pill helps eradicate stubborn belly fat. It has over 25,000 Amazon reviews and a 4.5 rating.

Best Diet Pill for a Ketogenic Diet: Keto BHB

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If you want to try a ketogenic diet or prefer to eat low-carb foods, Purley Optimal's Keto BHB Supplement is an excellent diet pill to assist with your weight loss efforts and help you reach ketosis (the prized metabolic state where fat, not glucose, is used as fuel) as quickly as possible. Users report that Keto BHB helps combat the low energy levels that can accompany a low-carb diet, and boosts mental clarity to help prevent keto-related brain fog.

Best Diet Pill for Women: Nobi Nutrition Premium Women's Fat Burner

Photo Courtesy: Amazon

Nobi Nutrition Premium Women's Fat Burner is formulated specifically to assist with the often frustrating female weight loss journey. Fans of this diet pill find that it gives them more energy and suppresses the appetite without making them feel jittery. They also report feeling less hungry between meals and having more self control around foods that typically trigger them to overeat.

Best Night Time Diet Pill: Dr. Emil Bedtime Burn

Photo Courtesy: Amazon

Tackle your weight loss goals at night with Dr. Emil Bedtime Burn. This stimulant-free diet pill raises your metabolism while you sleep and contains ingredients to promote a better night's sleep—bonus! Bedtime Burn fans find that it helps reduce their cravings and raises their metabolism. It also aids them with falling asleep quicker and staying asleep so that they have ample energy to conquer their workouts.

Best Diet Pill for Overhauling Your Brain's Hunger System: CONTRAVE

Photo courtesy: Medscape

The brain's bitty hypothalamus, which is responsible for controlling the body's appetite and energy expenditure, can have an outsized effect on a person's weight. CONTRAVE is a prescription diet pill that reduces hunger and cravings by impacting how the brain's hypothalamus functions. While users of CONTRAVE report significant weight loss, this weight loss comes at a price. CONTRAVE can cost anywhere from $100 to $400 if it isn't covered by your insurance. Some users report side effects including headaches and constipation.

Best Multitasking Diet Pill: Native Nutrition Apple Cider Vinegar+

Photo Courtesy: Amazon

Apple cider vinegar is associated with a slew of health benefits, like controlling blood sugar levels, easing indigestion, and lowering cholesterol levels. Native Nutrition Apple Cider Vinegar+ encourages weight loss and features all the qualities conventionally associated with this supplement—except the taste. Fans of this diet pill find it a far more pleasant alternative to drinking apple cider vinegar, and report that it's effective at reducing bloat and assisting with appetite control.

Best Diet Pill for Reducing Bloat: NutriRise 15-Day Colon Cleanse

Photo Courtesy: Amazon

Bloated from overeating or consuming high sodium foods? Your body may be retaining water, which can conceal your weight loss. It's also incredibly uncomfortable. NutriRise 15-Day Colon Cleanse is an excellent way to jumpstart your lifestyle change and eliminate stomach-distending bloat. Users like that this cleanse eliminates that too-full feeling and encourages a loss in pesky water weight without causing significant digestive distress.

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Simple Low Carb Diet Plan For Weight Loss

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Diabetes Uk Low Carb Diet

Diabetes Uk Low Carb Diet

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Low-carb diet and meal plan

Eating a low-carb diet means cutting down on the amount of carbohydrates (carbs) you eat to less than 130g a day. But low-carb eating shouldn't be no-carb eating.

Some carbohydrate foods contain essential vitamins, minerals and fibre, which form an important part of a healthy diet.

Here we'll explain what we mean by low-carb, what the benefits are of low-carb eating when you have diabetes, and share a low-carb meal plan to help you get started if this is the diet for you. We'll also explain how to get support to manage any potential risks, especially if you manage your diabetes with medications which put you at risk of hypos.

If you or someone you know is self-isolating, find out how to eat healthily whilst staying at home.

What's a low-carb diet?

But how low is low-carb? There are different types of low-carb diets. Generally, low-carb eating is when you reduce the total amount of carbs you consume in a day to less than 130g.

To put this into context, a medium-sized slice of bread is about 15 to 20g of carbs, which is about the same as a regular apple. On the other hand, a large jacket potato could have as much as 90g of carbs, as does one litre of orange juice.

A low-carb diet isn't for everyone. The evidence shows they can be safe and effective in helping people with type 2 diabetes manage their weight, blood glucose (sugar) levels and risk of heart disease in the short term.

But the evidence also shows they can affect growth in children, and so should not be recommended for them. And there is little evidence to show the benefits of this type of diet in people with type 1.

If you do decide to follow a low-carb diet, it's important to know all the potential benefits and how to manage any potential risks.

Low-carb meal plan

Our low-carb meal plan aims to help you maintain a healthy balance while reducing the amount of carbs you eat. Varying amounts of carbohydrate are shown each day to help you choose which works best for you.

It's nutritionally balanced, we've counted the calories for you, and it contains at least five portions of fruit and veg per day.

We've included the values of fibre and protein too to help you make sure you are meeting your nutritional requirements. We know lots of people in the UK aren't eating enough fibre, so it's important to try and include good sources in your diet every day.

Please note that the nutritional information and exact specifications for all meals and snacks is available in the linked recipes and the low carb meal plan (PDF 84KB).

Before you begin this meal plan

Before starting any healthy eating programme, please read how to choose your meal plan to make sure you follow the plan that's right for you.

Please speak to your diabetes health care team before making significant changes to your diet.

This is especially important if you treat your condition with insulin and diabetes medications that increase the risk of hypos (low blood sugar levels). Reducing your carbohydrate intake and changes to your body weight may mean your insulin and diabetes medication needs to be adjusted.

Important points about this meal plan

1. This meal plan has taken nutritional information from our recipes and the sixth edition of Carbs and Cals, unless otherwise stated.
2. A mix of whole milk and semi-skimmed milk has been used, but please use whichever you prefer. Any dairy alternative should be unsweetened and fortified with calcium.
3. These meal plans meet your recommended amount of fibre across the week.
4. This meal plan outlines daily food intake for one person, but it's still important to remember to drink regular fluids. This includes plain water, plain milk, and tea or coffee without added sugar.

Disclaimer: every effort has been taken to make these meal plans as accurate as possible, but there will be some variation in nutritional values. Speak to a dietitian or your diabetes healthcare team if you have questions about your individual dietary needs.

Monday

Breakfast: Baked eggs with two slices of rye bread

Lunch: Chilli bean soup with avocado salsa

Dinner: Mackerel tomatoes served with leeks and broccoli

Pudding: Apple strudel

Snacks: Greek yogurt, two satsumas, plain almonds, one apple

Milk: 225ml semi-skimmed milk

Tuesday

Breakfast: Porridge made with 30g porridge oats, 200ml almond milk, 40g blueberries and 10g pumpkin seeds

Lunch: Bang bang chicken salad

Dinner: Minced beef and vegetable filo pie

Pudding: 80g strawberries

Snacks: Avocado, brazil nuts, celery and peanut butter

Milk: 225ml semi-skimmed milk

Wednesday

Breakfast: Mushroom and spring onion omelette

Lunch: Butterbean paté with carrots, tomatoes and mini wholemeal pitta bread

Dinner: Aubergine and courgette parmesan bake with rocket, tomato and tinned kidney beans

Pudding: 80g melon

Snacks: One apple and peanut butter, one pear with almonds, natural yogurt and pumpkin seeds

Milk: 225ml semi-skimmed milk

Thursday

Breakfast: Summerberry smoothie

Lunch: Chickpea and tuna salad

Dinner: Chicken tikka masala and cauliflower pilaf

Pudding: Summer berry posset

Snacks: Greek yogurt, two satsumas, one orange, almonds, two oatcakes topped with smooth peanut butter

Milk: 225ml semi-skimmed milk

Friday

Breakfast: Baked eggs with two slices of rye bread

Lunch: Two slices of medium wholemeal bread with grated cheddar, vegetable oil-based spread, tomato and cucumber

Dinner: Grilled salmon steak with baked sweet potato, broccoli and cabbage

Pudding: Sugar-free jelly

Snacks: raspberries, melon, avocado, plain almonds

Milk: 225ml semi-skimmed milk

Saturday

Breakfast: Welsh leek rarebit

Lunch: Cauliflower and leek soup with 25g cheddar

Dinner: Butternut squash and borlotti bean stew

Pudding: Tinned peaches in juice

Snacks: One apple, 30g almonds, Greek yogurt, small pear and almonds, 60g pistachios with shells

Milk: 225ml semi-skimmed milk

Sunday

Breakfast: Omelette made with two eggs and milk along with 80g spinach, 80g mushrooms, 1tsp of vegetable oil, 25g grated cheddar. Pair with a slice of rye bread with 1tsp of unsaturated margarine

Lunch: Smoked mackerel on granary toast with 1sp of veg spread, rocket, tomato and cucumber.

Dinner: Greek homestyle chicken with broccoli and leeks

Pudding: 80g raspberries and 80g melon

Snacks: Low-fat Greek yogurt with almonds and pumpkin seeds, spicy roasted chickpeas, one small pear

Milk: 225ml semi-skimmed milk

Benefits of following a low-carb diet

One of the main benefits of following a low-carb diet is weight loss. For people with type 2 diabetes, this helps to reduce HbA1c and blood fats such as triglycerides and cholesterol. For people who don't have diabetes, losing weight can reduce your risk of developing type 2 diabetes, and a low-carb diet is one option to help you do this.

For people with type 1 diabetes

If you have type 1, the strongest evidence suggests that carb counting is the best way to manage your blood sugar levels. This means matching how much insulin you take to the amount of carbs in your meal, snack or drink.

There is no strong evidence that following a low-carb diet is safe or beneficial, which is why we don't recommend this diet for people with type 1 diabetes.

It is really important that you speak to your healthcare team for support to manage your insulin if you're considering a low-carb diet.

For people with type 2 diabetes

We know losing 15kg within three to five months will give people with type 2 the best chance of putting their diabetes into remission. Evidence tells us this is more likely if you are able to lose weight within 6 years of your diagnosis.

Finding a way to lose weight can also help you improve the way you manage your condition and reduce your risk of diabetes complications. There are different ways to lose weight, such as a low-carb diet - but there's no one-size-fits-all approach.

Find out more about weight loss and diabetes.

"I changed to a high-fat, low-carb diet and cut out sweet stuff altogether. Diabetes UK's website and an app for my phone really helped.

I lost around 12lbs (5.5kg) in my first week. When I returned to see the nurse after three months, my HbA1c was down to 42mmol/mol – it had been 51mmol/mol when I was diagnosed. The nurse thought she was seeing things.

I've now lost around seven-and-a-half stone (46.8kg) and my HbA1c level is 37mmol/mol."

- Paul's type 2 diabetes is now in remission.

However, there's no evidence that following a low-carb diet is any more beneficial in managing diabetes than other approaches in the long term, including a healthy, balanced diet.

Research suggests that the best type of diet is one that you can maintain in the long term, so it's important to talk to your healthcare professional about what you think will work for you. Another option is the Mediterranean diet, which is also linked to reducing the risk of heart diseases and stroke.

What to consider before following a low-carb diet

If you treat your diabetes with insulin or any other diabetes medication that puts you at risk of hypos, following a low-carb diet may increase this risk. Speak to your healthcare team about this so they can help you adjust your medications to reduce your risk of hypos. Your team may also support you to check your blood sugar levels more often.

"I make sure I balance out my diet with what suits my insulin, but with a bit of tweaking, most things can be persuaded to suit my insulin!

I won't eat a load of pasta with a side of garlic bread and not much else, because the carb load would be difficult to bolus for. But neither would I eat a completely carb free meal. It's all a question of balance, and a healthy diet is good for all of us, diabetic or not."

- Online forum user living with type 1.

Depending on the approach, following a low-carb diet may also lead to other side effects, such as constipation or bad breath.

Although these can be unpleasant, they are usually temporary and shouldn't be harmful in the long term. Speak to your healthcare professional if you're concerned about any of these.

It's really important to first reduce your carb intake from unhealthy sources such as sugary drinks, pizzas, cakes, biscuits, chips, white bread, fruit juices and smoothies.

And it is a good idea to get your limited carbs from healthy high-fibre carb foods, such as pulses, nuts, vegetables, whole fruits and whole grains. You can help make sure you're getting the calcium you need by including unsweetened milk and yoghurt in your diet too.

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Diabetes Uk Low Carb Diet

Source: https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/meal-plans/low-carb

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Are Quest Bars Good For Low Carb Diets

Are Quest Bars Good For Low Carb Diets

Are quest bars keto

Yes, sort of. Quest bars are protein bars, and protein bars are simply candy bars with more protein and a great marketing strategy. While Quest products replace sugar with oligosaccharides - sugar alcohols made from fermented fruit peels - there are still a lot of problematic and high-carb things going on here. You can fit them into your keto diet, but there are better alternatives and you need to be selective about how often and when you eat Quest bars on keto.

Keto rating: Okay

Quest bars are flavored with natural ingredients and oligosaccharides are reasonable in small quantities on keto, but the bars are filled out with a lot of fiber. Most of this is in the form of prebiotic corn starch fiber, which is both good and bad. Indigestible fiber is great for your gut microbiome, but corn and wheat products are sketchy at best on keto. Our bodiesdon't react well to themand our gut bacteria like fiber from non-starchy vegetables best.

Still, in a pinch, you can sneak a Quest bar in here and there and still maintain ketosis. Let's take an in-depth look at Quest bars on keto.

[keto-cookies-1]

Examining Quest bars for keto dieters

Quest bars come in a huge range of flavors now - just about 8 years ago when the company started, they only had a few and while they were fine, they were pretty basic. The bars themselves are very chewy, though that has improved as well in the last 8 years. With the improved texture came a variety of flavor options, including:

• Cinnamon Roll
• Vanilla Almond
• Blueberry Muffin
• Mocha
• Double Chocolate Chip
• Cookie Dough
• Birthday Cake
• Peanut Butter Fudge
• Fudge Brownie

There are plenty more than that and they release seasonal ones as well, like Pumpkin Pie. But with all these flavors, are they really keto-friendly? Most Quest bars boast around 25 total carbs, and more than half are usually from fiber. After that, there are the sugar alcohols, which make up around half of the remaining total carbs, leaving around 4-5 net carbs per bar.

Understanding "low carb" versus "keto"

While many keto adherents advocate a very strict policy of no additives, no wheat or corn, and often no sugar alcohols, this doesn't necessarily mean these things aren't "keto". Truth be told, ketosis is a state of your metabolism, caused by a low enough dietary carbohydrate intake. You could, through fasting and other carb restriction, probably enter ketosis even if you were eating a Snickers bar every day.

Low carb is different, seeking to keep your carb intake under 50-100g a day. This also has health benefits including weight loss, but is less restrictive, although the speed of weight loss is slower and the health benefits are lessened. The point is that Quest bars fit both keto and low carb lifestyles, if they fit into your macros, but you need to take care when using them with an intention of maintaining ketosis.

One good way to see if they fit into your diet is to allow yourself to eat them and see if your weight loss stalls. If so, they probably aren't for you.

Quest bars  nutritional facts

There are currently 19 flavors of Quest bars, along with Hero bars (which are more like candy bars), and snack bars which are more nut-based. Let's look at a few and get a feel for their nutritional facts.

Quest White Chocolate Raspberry

Per 1 bar serving:

• Calories: 200
• Fat: 8g
• Protein: 20g
• Carbs: 22g
• Sugar: 1g
• Dietary Fiber: 15g
• Sugar Alcohols: 2g

Quest Maple Waffle Bars

Per 1 bar serving:

• Calories: 190
• Fat: 6g
• Protein: 20g
• Carbs: 24g
• Sugar: 1g
• Dietary Fiber: 16g
• Sugar Alcohols: 3g

Quest Double Chocolate Chunk

Per 1 bar serving:

• Calories: 180
• Fat: 7g
• Protein: 20g
• Carbs: 24g
• Sugar: 0g
• Dietary Fiber: 14g
• Sugar Alcohols: 6g

Keto alternatives to Quest Bars

There are tons of truly ketogenic snack bars out there now if you know where to look. In a market saturated with brands looking to imitate the success of Quest brand products, it's refreshing to find some companies looking to make keto-friendly bars that taste great, are gluten free and aren't filled with junk.

Keto Bars

With several flavor options, Keto Bars are, well, the original keto bar! Their bars are high fat (21+ grams) and low carb (~3g net carbs). They boast they are  vegan, gluten free, soy free, and contain no fiber syrups. Their flavor options include mint chocolate, chocolate strawberry, dark chocolate coconut almond, & chocolate peanut butter.

Per 1 bar serving (1.65oz or 47g):

• Calories: 220
• Fat: 19g
• Protein: 6g
• Carbs: 15g
• Sugar: 0g
• Dietary Fiber: 7g
• Sugar Alcohols: 5g (Erythritol)
• Net Carbs: ~3g

Atlas Bars

Made without corn or wheat - opting instead for tapioca as a binder and fiber-fill - Atlas bars add extra fats from healthy sources, like almond butter. They're delicious, with a low-key sweetness, unlike the sometimes cloyingly sweet flavor of Quest bars. You can find them on Amazon or on their website.

Per 1 bar serving:

• Calories: 210
• Fat: 11g
• Protein: 14g
• Carbs: 22g
• Sugar: 0g
• Dietary Fiber: 11g
• Sugar Alcohols: 6g (from vegetable glycerin)

Love Good Fats bars

These bars are a keto dieter's dream. They're sweetened with chicory, made with healthy fats like palm and coconut oil, as well as almond butter, and they taste incredible. With a variety of novel flavors, it's hard to beat Good Fat bars for nutrition, taste, and quality of ingredients. You'll also note that the protein is much lower here, and that's because these bars are specifically formulated for keto macros.

Per 1 bar serving:

• Calories: 190
• Fat: 14g
• Protein: 7g
• Carbs: 14g
• Sugar: 2g
• Dietary Fiber: 9g
• Sugar Alcohols: 0g

Perfect Keto snacks

This brand really aims to hit the keto crowd with something specific to their macros and delicious. More than any of these other products, Perfect Keto hammers home the fat and keeps the carbs and protein low, perfect for on-the-go keto snacking.

Per 1 bar serving:

• Calories: 240
• Fat: 18g
• Protein: 13g
• Carbs: 10g
• Sugar: 1g
• Dietary Fiber: 2g
• Sugar Alcohols: 0g

Quest bars for keto are okay, in moderation

While Quest bars are readily available - you can find them at most Walgreens and even gas stations - they're not something you should eat daily. If they don't interfere with your weight loss, there are certainly worse things you could eat, but for keto, there are better bars. Whole foods are always going to be the best option, but in a pinch, Quest bars are delicious, and if they fit your macros, can be a useful tool to keep you on track with your keto weight loss goals.

Interested in keto snack ideas? We've listed 120+ options!

Published: January 11, 2021
Author: Tony Lozzi
Tony Lozzi is a keto adherent who lost over 200 pounds cutting carbs and lifting weights. He has researched low carb  eating for over 10 years and runs www.fit2father.com, a keto blog dedicated to helping others lose weight with keto. He lives in the US with his wife, kids, and various cats.

Written by Tony Lozzi

Published: January 11, 2021

Are Quest Bars Good For Low Carb Diets

Source: https://www.superfat.com/blogs/keto/are-quest-bars-keto

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Indian Vegetarian Low Carb Diet Meal Plan

Indian Vegetarian Low Carb Diet Meal Plan

Photo Courtesy: alvarez/E+/Getty Images

In the United States, the average person consumes only about 10-15 grams of fiber per day. And that's not even half of the official recommendation. Along with protein, carbohydrates, and essential fats, fiber is an integral part of a healthy diet. So, what makes it essential?

Unlike other food components, fiber is indigestible. Although it is not absorbed by the body, fiber provides many health benefits, from maintaining bowel health to controlling blood sugar levels. With this in mind, developing a high-fiber diet plan is a great idea for folks with particular health needs. Here, we'll review which foods to eat and how to incorporate the right amount of fiber into your diet while avoiding the common pitfalls associated with high-fiber regimens.

As you may know, there are two types of dietary fiber — insoluble and soluble. The difference is simple: soluble fiber partially dissolves in water, while insoluble doesn't. While neither type of fiber is digestible, soluble fiber does undergo some changes as it travels through one's digestive tract.

Photo Courtesy: fcafotodigital/E+/Getty Images

To make the most of a high-fiber diet, one should incorporate both types of fiber into their plan, namely because they provide different health benefits. For instance, diverticulitis is a common disease that causes the colon to develop small pouches, which become painful and inflamed. According to the Harvard School of Public Health, eating a diet high in insoluble fiber is believed to lower the risk of diverticulitis by about 40 percent.

Benefits of a High Fiber Diet

Most people have heard that fiber should be incorporated into their diet, but its benefits may still surprise many folks. For example, eating foods high in soluble fiber can help lower cholesterol levels and, as a result, the risk of experiencing heart disease.

Moreover, a diet high in both insoluble and soluble fiber is vital for people who have, or are at high risk of developing, diabetes. According to the Mayo Clinic, increasing soluble fiber in one's diet can help control blood sugar levels by slowing down the absorption of sugar. The chances of developing type 2 diabetes also decrease in people who eat a diet high in insoluble fiber.

Although most people will experience an occasional bout of constipation, elderly folks may encounter it more frequently, so a high-fiber diet may be beneficial as it can decrease the chances of constipation. Another benefit? A high-fiber diet may help with weight loss since eating fiber-rich foods can help dieters feel full faster and, therefore, eat less.

Tips for Crafting a Successful High-Fiber Diet

When creating a high fiber diet plan, several tips can help make the change easier and reduce the likelihood of common pitfalls. First, it is crucial to know how much dietary fiber to consume. According to the University of Maryland Medical Center, most adults should eat a minimum of 25 to 40 grams of fiber each day.

Selecting Good Sources of Fiber

First up: insoluble fiber. Great sources of insoluble fiber include various fruits, like apples and raspberries, as well as vegetables, like broccoli and carrots. When choosing your daily fruit and vegetables, keep in mind that the highest fiber content will be located in the skin and pulp of vegetables. Root vegetables and leafy greens — carrots, potatoes, kale and spinach — are all solid high-fiber choices.

So, what about soluble fiber? Foods made from whole grains, such as bread, pasta, and oats, are good choices when it comes to crafting a daily high-fiber diet plan, namely because wheat bran, which is part of the grain, has a very high fiber content. Other foods high in soluble fiber include barley and legumes, such as peas, lentils, and beans.

Another way to add more fiber to one's diet? Trade your morning glass of fruit juice for a piece of whole fruit — skin and all. You'll not only get more fiber, but you'll likely consume less calories.

Common Pitfalls Associated With High-Fiber Diets

Even when eating healthy, too much of a good thing can have negative consequences. Since fiber is not digested, overeating it — or eating too much of it quickly — can lead to bloating and gas. Some people may also develop diarrhea if they overeat fiber. To mitigate this side effect, fiber intake should be increased gradually over the course of six weeks. This will allow one's body time to adjust.

Another reason to increase your fiber intake slowly? A sudden increase in fiber may lead to stomach cramps and other intestinal discomforts. When making the gradual transition to a high-fiber diet, remember that even small dietary changes can add up. For instance, swap processed white bread for whole-grain loaves of bread made from oat or wheat bran.

Although it may decrease constipation in some people, increased fiber can also have the opposite effect and lead to constipation or irregular bowel movements. Therefore, it's important to drink plenty of water when one increases their fiber intake.

Resource Links:

• "High Fiber Diet" via National Center for Biotechnology Information (NCBI), U.S. National Library of Medicine
• "Diet and Health: Implications for Reducing Chronic Disease Risk" via Diet and Health, National Center for Biotechnology Information (NCBI), U.S. National Library of Medicine
• "Health benefits and practical aspects of high-fiber diets" via The American Journal of Clinical Nutrition
• "The Health Benefits of Dietary Fiber" via Nutrients, National Center for Biotechnology Information (NCBI), U.S. National Library of Medicine
• "Dietary fibre in foods: a review" via J. Food Science Tech., National Center for Biotechnology Information (NCBI), U.S. National Library of Medicine

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Indian Vegetarian Low Carb Diet Meal Plan

Source: https://www.symptomfind.com/health/high-fiber-diet-plan-tips?utm_content=params%3Ao%3D740013%26ad%3DdirN%26qo%3DserpIndex

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Grapefruit And Low Carb Diet

Grapefruit And Low Carb Diet

Grapefruit is a citrus fruit that is a cross between an orange and a pomelo. There are several color varieties of grapefruit including white, pink, yellow, and red, but they are primarily pink or red on the inside. Grapefruit has a sour taste and is not as traditionally sweet as most fruit . Since they are more sour than sweet, some assume they are lower in sugar. Does that mean they are low carb? Is grapefruit keto?

Grapefruit Nutrition Facts

One small grapefruit weighs approximately 200 grams. A 123g serving size (1/2 a grapefruit) contains 37 calories, 9.22g of carbs, 1.35g of fiber, 0.1g of fat, and 0.676g of protein. ^[1]

Health Benefits of Grapefruit

Grapefruit is often considered a healthy food because it is low in calories and high in nutrients. Because of this, grapefruit is often seen as a weight-loss food. Since grapefruit is low in calories, contains a lot of water, and has a very sour taste, many find that it is a helpful snack when trying to lose weight.

One study found that consuming grapefruit may benefit insulin resistance. This 12-week study found that individuals consuming one grapefruit a day lost 3.5 lbs, whereas the individuals not consuming grapefruit lost <1 pound. ^[2]

Grapefruit packs a substantial amount of vitamin C (37mg per 1/2 grapefruit serving). It also provides vitamin A, potassium, and calcium. ^[1]

Some research also suggests that consuming grapefruit may be beneficial for heart health. One study found that consuming grapefruit may help improve blood pressure and reduce the risk for heart disease. ^[3]

Is Grapefruit Keto?

1 whole small grapefruit contains about 20g of carbohydrates, 3g of dietary fiber, and 17g of net carbs. Since the average ketogenic dieter consumes less than 20 grams of carbs a day, grapefruit are not traditionally considered keto-friendly. Grapefruit is also low in fat and the ketogenic diet is a high-fat diet.

That being said, some individuals are able to eat up to around 50 grams of carbs a day on the ketogenic diet. Grapefruit is not considered a low-carb fruit ; however, if portioned, it could be consumed in moderation. For example, 1/4 of a grapefruit has about 4g of net carbs.

When consuming grapefruit on low-carb diets, it's important to eat only in moderation and to closely monitor the carb count so that you do not exceed your total daily carbs.

It should also be noted that grapefruit juice should be avoided, for the most part. Grapefruit juice tends to have added sugar and less fiber.

Do You Eat Grapefruit on the Keto Diet?

Comment below and share your thoughts with the community ! Is grapefruit keto? Or do you avoid it?

References

Grapefruit And Low Carb Diet

Source: https://ketogenic.com/is-grapefruit-keto-should-you-avoid-citrus-on-keto/

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How Does A Low Carb Diet Make You Lose Weight

How Does A Low Carb Diet Make You Lose Weight

Photo Courtesy: [Phil Fisk/Cultura/Getty Images]

Carbs may be delicious, but, depending on your health status and any conditions you may have, they may not be the most nourishing (or healthy) macronutrients for you to eat. However, that doesn't mean you can't enjoy your favorite typically higher-carb foods — it just means you need a bit of creativity and a few tips and tricks for making modifications. That's especially true when it comes to a classic breakfast favorite: quiche.

Traditional quiche begins with a pie crust as its base, which isn't ideal if you're limiting carbs. But, by removing the crust — or using some delicious, low-carb substitutes — you can still enjoy the delicate egg and zesty ingredient combinations that make this dish so versatile. Start diversifying your low-carb breakfast menu (or even your evening meals) with these easy crustless quiche recipes.

Crustless Vegetable Quiche

Photo Courtesy: [EasyBuy4u/Getty Images]

Starting the day with an array of healthy vegetables — plus the protein from eggs — on your plate is never a bad idea. That's why this crustless vegetable quiche is such a nice option: You get great flavors and all the nutritional benefits of whatever veggies you add. Plus, it's vegetarian friendly. Even if you're not fully vegetarian, there are some great reasons to try this quiche; forgoing meat once in a while and upping your consumption of fresh produce can improve your cholesterol levels, for one.

This recipe from Food.com calls for broccoli, red pepper and zucchini, though you can swap them out for other vegetables if you prefer. Mushrooms, asparagus and tomatoes are tasty options as well. All are great sources of different vitamins, minerals and fiber. Add the cheese of your choice and some salt and pepper or other spices for an easy way to change up the flavor profile.

Crustless Quiche Lorraine

 Photo Courtesy: [jaker5000/Getty Images]

Quiche Lorraine might be one of the most classic (and best-known) recipes for this dish — and it's just as delicious without the crust. If you're looking for a keto-friendly breakfast dish that helps you reach your daily protein goals, this crustless quiche Lorraine, also from Food.com, is a top option.

Generally, people who follow the ketogenic diet get about 75% of their daily calories from fat, 20-30% from protein and around 5% from carbs. This recipe gets its fat and protein from the eggs, bacon and Swiss cheese you'll use. If you want to add a vegetable for extra flavor and nutrients, try spinach; it's relatively low in carbs but packed with healthy vitamins A and K.

Bacon Cheeseburger Keto Breakfast Quiche

 Photo Courtesy: [John Rizzo/Getty Images]

Looking for more crustless quiche options that work just as well for dinners as they do your morning meals? You'll want to try this bacon cheeseburger keto quiche from Kalyn's Kitchen. It satisfies keto fat and protein requirements thanks to its ground beef, bacon, eggs and the cheese of your choice (we recommend sharp cheddar). For a little bit of low-carb veggie crunch, add a handful of green onions and pickles into the mix too — yes, pickles in crustless quiche. They really do elevate this dish with their crunch and zesty tang.

Spicy Southwest Crustless Quiche

 Photo Courtesy: [yipengge/Getty Images]

For those on the keto diet who also like a little kick to their meals, this spicy Southwest crustless quiche from the folks at Wisconsin Cheese will definitely satisfy any flavor cravings. It's packed full of fat and protein thanks to its eggs, heavy whipping cream, milk and pork sausage. Add some jalapenos, green peppers and pepper jack cheese to crank up the spice level.

As with most of the quiche dishes in this list, you'll cook this in a greased pie dish at 350 degrees Fahrenheit until the edges are golden brown and the center of the quiche no longer looks runny or jiggly. It may take about 45 minutes to achieve the right cooked consistency, and you can also tell the quiche is done — as with many baked treats — when a knife inserted into the center comes out clean. Let the quiche stand for about 10 minutes to fully firm up before slicing into it.

Vegan Crustless Quiche

 Photo Courtesy: [Cavan Images/Getty Images]

This one is a bit of a surprise — a unique and flavorful surprise. You already know quiche is an egg dish, and eggs aren't vegan. So you might also be wondering how a vegan version could exist. In showcasing some true culinary creativity, this vegan crustless quiche from The Spruce Eats utilizes tofu, dairy-free crumbled cheese, soy or almond milk, nutritional yeast, ground cashews and dairy-free cream cheese.

The result is a smooth, authentic crustless quiche that's perfect for people who eat a plant-based diet or those who are allergic to eggs. In addition to its healthful egg-free base, it's got asparagus, garlic and turmeric to spice things up just right. You can always add or substitute your preference for other veggies as well; consider using what's in season to enjoy them at their peak of freshness.

Kale and Feta Crustless Quiche

 Photo Courtesy: [Kale and Feta Crustless Quiche/Eating Bird Food]

Eating Bird Food's kale and feta crustless quiche recipe is an easy yet flavorful low-carb meal that makes for not only a delicious breakfast but also an ideal main course for lunch or dinner. Simply pair a slice with a cup of soup or a salad to create a well-rounded meal. As an added bonus, this recipe is a little different from other basic crustless quiches, which can keep your taste buds on their toes while giving you a nutrient boost at the same time.

Aside from the kale, feta and eggs — its star ingredients — this recipe uses coconut oil, almond milk, mushrooms, garlic, nutmeg and parsley. And here's an interesting tidbit of information about kale: It's a superfood that's chock-full of vitamins and minerals — but that's also low in calories and carbs.

Resource Links:

https://nutritiondata.self.com/facts/vegetables-and-vegetable-products/2626/2

https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/the-many-types-and-health-benefits-of-kale

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How Does A Low Carb Diet Make You Lose Weight

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Low Carb Diet And Diabetes

Low Carb Diet And Diabetes

1. Research
2. Efficacy and safety of...
3. Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data

Research

Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.m4743 (Published 13 January 2021) Cite this as: BMJ 2021;372:m4743

Linked Fast Facts

Low and very low carbohydrate diets for diabetes remission

1. Joshua Z Goldenberg , research investigator1 2,
2. Andrew Day , physician3,
3. Grant D Brinkworth , professor4,
4. Junko Sato , professor5,
5. Satoru Yamada , professor6,
6. Tommy Jönsson , professor7,
7. Jennifer Beardsley , research librarian8,
8. Jeffrey A Johnson , professor9,
9. Lehana Thabane , professor, director10 11,
10. Bradley C Johnston , associate professor, methodologist1 10

1. ¹Department of Nutrition, Texas A&M University, College Station, TX, USA
2. ²Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
3. ³Day Family Medicine, Poulsbo, WA, USA
4. ⁴Commonwealth Scientific and Industrial Research Organisation (CSIRO) - Health and Biosecurity, Sydney, NSW, Australia
5. ⁵Department of Metabolism and Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
6. ⁶Diabetes Center, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
7. ⁷Center for Primary Health Care Research, Lund University/Region Skåne, Skåne University Hospital, Malmö, Sweden
8. ⁸Independent research librarian, Seattle, WA, USA
9. ⁹School of Public Health, University of Alberta, Edmonton, AB, Canada
10. ¹⁰Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
11. ¹¹Biostatistics Unit, St Joseph's Healthcare, Hamilton, ON, Canada

1. Correspondence to: B C Johnston bradley.johnston{at}tamu.edu (or @methodsnerd on Twitter)

• Accepted 30 October 2020

Abstract

Objective To determine the efficacy and safety of low carbohydrate diets (LCDs) and very low carbohydrate diets (VLCDs) for people with type 2 diabetes.

Design Systematic review and meta-analysis.

Data sources Searches of CENTRAL, Medline, Embase, CINAHL, CAB, and grey literature sources from inception to 25 August 2020.

Study selection Randomized clinical trials evaluating LCDs (<130 g/day or <26% of a 2000 kcal/day diet) and VLCDs (<10% calories from carbohydrates) for at least 12 weeks in adults with type 2 diabetes were eligible.

Data extraction Primary outcomes were remission of diabetes (HbA_1c <6.5% or fasting glucose <7.0 mmol/L, with or without the use of diabetes medication), weight loss, HbA_1c, fasting glucose, and adverse events. Secondary outcomes included health related quality of life and biochemical laboratory data. All articles and outcomes were independently screened, extracted, and assessed for risk of bias and GRADE certainty of evidence at six and 12 month follow-up. Risk estimates and 95% confidence intervals were calculated using random effects meta-analysis. Outcomes were assessed according to a priori determined minimal important differences to determine clinical importance, and heterogeneity was investigated on the basis of risk of bias and seven a priori subgroups. Any subgroup effects with a statistically significant test of interaction were subjected to a five point credibility checklist.

Results Searches identified 14 759 citations yielding 23 trials (1357 participants), and 40.6% of outcomes were judged to be at low risk of bias. At six months, compared with control diets, LCDs achieved higher rates of diabetes remission (defined as HbA_1c <6.5%) (76/133 (57%) v 41/131 (31%); risk difference 0.32, 95% confidence interval 0.17 to 0.47; 8 studies, n=264, I²=58%). Conversely, smaller, non-significant effect sizes occurred when a remission definition of HbA_1c <6.5% without medication was used. Subgroup assessments determined as meeting credibility criteria indicated that remission with LCDs markedly decreased in studies that included patients using insulin. At 12 months, data on remission were sparse, ranging from a small effect to a trivial increased risk of diabetes. Large clinically important improvements were seen in weight loss, triglycerides, and insulin sensitivity at six months, which diminished at 12 months. On the basis of subgroup assessments deemed credible, VLCDs were less effective than less restrictive LCDs for weight loss at six months. However, this effect was explained by diet adherence. That is, among highly adherent patients on VLCDs, a clinically important reduction in weight was seen compared with studies with less adherent patients on VLCDs. Participants experienced no significant difference in quality of life at six months but did experience clinically important, but not statistically significant, worsening of quality of life and low density lipoprotein cholesterol at 12 months. Otherwise, no significant or clinically important between group differences were found in terms of adverse events or blood lipids at six and 12 months.

Conclusions On the basis of moderate to low certainty evidence, patients adhering to an LCD for six months may experience remission of diabetes without adverse consequences. Limitations include continued debate around what constitutes remission of diabetes, as well as the efficacy, safety, and dietary satisfaction of longer term LCDs.

Systematic review registration PROSPERO CRD42020161795.

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Introduction

Diabetes is a common, deadly, and expensive medical condition. It is estimated that 1 in 11 adults worldwide have diabetes and that it is responsible for 11% of deaths annually, costing $760bn (£570bn; €626bn) in direct costs alone.1 Type 2 diabetes is the most common form of diabetes, accounting for 90-95% of cases, and for decades has been a rapidly growing international concern.2 Type 2 diabetes is characterized by insulin resistance driven by chronic hyperglycemia and is commonly diagnosed by measures of glycemia such as fasting blood glucose concentrations of 7.0 mmol/L or above or glycated hemoglobin (HbA_1c) values of 6.5% (48 mmol/mol) or above.3 It is associated with several risk factors including genetics and lifestyle influences, but by far the most common risk factor is obesity.1

Structured dietary interventions are commonly recommended for patients with diabetes, with varied recommendations from authoritative organizations.4 Before the discovery of insulin, diets emphasizing carbohydrate restriction had been used extensively in the management of diabetes, but more recently they have fallen out of favor.5 Because a key underlying mechanism of type 2 diabetes is insulin resistance driven in part by chronic hyperglycemia, lowering dietary intake of carbohydrate, most of which is absorbed as glucose or fructose, has been suggested to improve blood glucose control and outcomes of type 2 diabetes.6 Structured diets with carbohydrate restriction have been variably described in the research literature but have been commonly grouped into three categories: 20-50 g/day carbohydrates or less than 10% of the 2000 kcal/day diet that is generally sufficient to induce ketosis; less than 130 g/day or less than 26% of the 2000 kcal/day diet; and less than 45% of the 2000 kcal/day diet.78 For the purposes of this review, we refer to diets with less than 130 g/day or less than 26% of calories from carbohydrates based on 2000 kcal/day as a low carbohydrate diet (LCD).

Type 2 diabetes remains a significant and worsening problem worldwide, despite many pharmaceutical developments and a global emphasis on glycemic control.9 Structured diets are recognized as an essential component of treating diabetes,10 but confusion remains about which diet to choose.11 Systematic reviews and meta-analyses to date have attempted to pool carbohydrate restricted diets for diabetic populations, reporting mixed results.121314 Among the limitations, as a whole, the systematic reviews and meta-analyses have included interventions with moderate carbohydrate intake that may dilute the effect of LCDs. Other limitations include an exclusive focus on surrogate outcomes (for example, blood lipids), with the largest systematic reviews and meta-analysis to date identifying only 10 trials that meet strict eligibility criteria of LCDs three months or more in length, limiting the certainty and precision in effect estimates.15 Furthermore, no review to date has attempted to report the effect of LCDs on rates of remission of diabetes,16 and no review has presented effect estimates with consideration of minimal important difference thresholds, thresholds that will assist patients and clinicians with interpreting the magnitude of treatment effects.1718 We aimed to systematically assess the efficacy, safety, and certainty of estimates for both surrogate outcomes and outcomes important to patients of strict LCDs for people with type 2 diabetes.

Methods

Search strategy and selection criteria

On the basis of an a priori and publicly available protocol (PROSPERO CRD42020161795), we did a systematic review with meta-analysis of randomized controlled trials assessing the efficacy and safety of LCDs among adult patients with a diagnosis of type 2 diabetes. We included people with or without cardiovascular conditions regardless of medication use or glucose concentration and HbA_1c level.

We included trials comparing LCDs with any wait list controls or any active controls including competing dietary programs higher in carbohydrates (≥26%), with or without exercise, lifestyle, and behavioral recommendations. No language, date, or publication restrictions were applied. We sought unpublished data from investigators of published and unpublished trials.

To meet inclusion criteria, studies had to investigate allocation to an LCD (<26% calories from carbohydrates or <130 g/day) for a defined period (12 weeks or longer), with or without exercise (for example, walking, jogging, strength training) or lifestyle and behavioral recommendations (for example, cognitive therapy, group support). Primary outcomes of interest, based on our a priori protocol,16 were remission of type 2 diabetes (dichotomously defined as HbA_1c <6.5% or fasting glucose <7.0 mmol/L), with or without the use of diabetes medication. Additional primary outcomes were weight loss, HbA_1c, fasting glucose, and adverse events (total and serious adverse events). Secondary outcomes were health related quality of life, reduction of medication, and biochemical laboratory data including total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, triglycerides, homeostasis model assessment of insulin resistance (HOMA-IR), and inflammatory markers (C reactive protein).

We searched the following databases from inception to 25 August 2020 to identify studies: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Commonwealth Agricultural Bureaux (CAB) abstracts. With the assistance of an expert clinical librarian, search strategies were customized, including the use of a Cochrane recommended filter for the identification of randomized controlled trials in PubMed.19 The Medline search strategy is reported in supplementary table A. On the basis of our study protocol, we also searched three trial registries (for example, clinicaltrials.gov) and four additional grey literature sources (for example, BIOSIS Citation Index, ProQuest Dissertations & Theses Global).16

Two authors, independently and in duplicate, screened titles and abstracts and subsequently full text articles. Disagreements were resolved by consensus.

Data analysis

Data extraction was done independently and in duplicate using a pilot tested extraction form. Domains for extraction included study design factors, population, intervention, comparator, and surrogate and health outcomes (variables listed in supplementary table B). All outcomes were extracted and reported at six months (±3 months) and 12 months (±3 months). We used version 2.0 of the Cochrane Risk-of-Bias (RoB) instrument for randomized trials and assessed each of the RoB domains as "high," "low," or "some concern" using the Excel file provided by the RoB 2.0 development team.20

We used Revman software (version 5.3) and the "meta" package in R (version 3.6.1) to do meta-analyses. For dichotomous outcomes, we calculated the pooled risk difference, risk ratio, and number needed to treat for an additional beneficial outcome (NNT) with 95% confidence intervals. For continuous outcomes, we combined endpoint or change data; when both endpoint and change data were reported, we prioritized endpoint data.21 We calculated the pooled mean difference and/or standardized mean difference with corresponding 95% confidence intervals. We pooled studies that measured continuous health related quality of life with different instruments if the underlying construct was the same or similar. To improve interpretability for readers, we followed published guidance and presented effect estimates in two ways.22 Firstly, we pooled the effect estimates as standardized mean differences. Secondly, we converted scores of the different health related quality of life instruments to units of the most commonly used reference instrument and presented the mean difference.222324 Where possible, we presented the effect size on the basis of known or estimated minimal clinically important difference (MCID) thresholds for all outcomes (supplementary table C). We rated the overall certainty (quality) of evidence for each of our outcomes by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, wherein randomized trials began as high certainty evidence but could be rated down by one or more levels on the basis of five categories of limitations: risk of bias, inconsistency, indirectness, imprecision, and publication bias.2526 We assessed the RoB and GRADE independently and in duplicate, with disagreement resolved by consensus. After a request from referees, we also did a sensitivity analysis comparing the certainty of evidence using GRADE versus NutriGRADE.27

Following published guidance, we chose to use data from complete cases for our primary analysis.28 When studies had missing outcome data and reported a complete case analysis, we did sensitivity analyses and applied increasingly stringent but plausible assumptions to this data,242829 using Excel files made available from the authors of the GRADE guidance on missing outcome data.24 For assessing the effect of missing outcome data on risk of bias, we did these sensitivity assessments at the study level to best integrate with Cochrane RoB 2.0.20

We assessed and reported heterogeneity quantitatively using the I² statistic and did a χ² test for homogeneity according to guidelines from the Cochrane Handbook (for example, 50% to 90% may represent substantial heterogeneity; 75% to 100% may represent considerable heterogeneity).30

We investigated heterogeneity and the possibility of effect modification for our primary outcomes on the basis of risk of bias and seven a priori subgroups,16 with any subgroup effects with a statistically significant test of interaction subjected to a five point credibility checklist.31 Subgroups were very low carbohydrate diets (VLCD) (<10% calories from carbohydrates) versus diets with between 10% and 26% of calories from carbohydrates; trials that provided behavioral support versus those that did not; LCDs versus comparator diets (for example, low fat diets, Mediterranean diets); trials in which caloric intake did not significantly differ between groups (iso-caloric) versus those in which it did; LCD trials that used caloric restriction versus those that did not; trials that included patients who used insulin versus those that did not; trials in which the intervention group showed adequate adherence (determined by three a priori criteria: 3-β-hydroxybutyrate, measured carbohydrate intake, and author definitions16) versus those that did not. Furthermore, for each outcome, we investigated the effect on the point estimate when we restricted the analysis to studies at low risk of bias; if the risk of bias sensitivity analysis was credible,16 we focused our results on those studies at low risk.

To assess for the possibility of publication bias, we visually inspected funnel plots when 10 or more trials were included. We further assessed for publication bias by using Egger's regression test for continuous outcomes and the Harbord score for dichotomous outcomes.3233

Patient and public involvement

Given the nature of secondary data capture and analysis, patients and the public were not involved in the design or interpretation of this study.

Results

Our search yielded 14 759 records, of which 23 studies (1357 participants) met the inclusion criteria (fig 1). Table 1 shows characteristics of the clinical trials. In short, trials primarily included overweight and obese patients with type 2 diabetes, with 14/23 (61%) studies including participants using insulin. Trial size ranged from 12 to 144 participants with a mean age range of 47 to 67 years. Studies used various carbohydrate restriction thresholds with 12/23 (52%) meeting our criteria for very low carbohydrate diets (<10% daily calories from carbohydrates or <50 g/d). Trials primarily used low fat diets as control comparators (18/23; 78%). Duration of treatment ranged from three months to two years. Dropouts were common in the included studies. Eighteen (78%) of 23 studies reported missing participant outcome data, with 10 reporting more than 20% of data being missing. In studies with reported missing data, we assessed the robustness of reported effect estimates by using increasingly stringent assumptions about the missing data and incorporated this into the overall assessment for risk of bias.24 Overall, 59.4% of outcomes were rated as having some concern or high risk of bias, and 40.6% of outcomes were rated as having low risk of bias (fig 2). The randomization process was the risk of bias domain that had the poorest reporting, with just over 40% of trials having "some concerns."

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Table 1

Characteristics of included trials

Eight studies reported on remission of diabetes at six months.3435363738394041 Pooled analysis showed that when remission was defined by an HbA_1c level below 6.5% independent of medication use, LCDs increased remissions by an additional 32 per 100 patients followed (risk difference 0.32, 95% confidence interval 0.17 to 0.47; 8 studies, n=264; GRADE=moderate) (fig 3; table 2). When remission was defined by an HbA_1c level below 6.5% and the absence of diabetes medication, LCDs increased remissions at a lower rate (risk difference 0.05, –0.05 to 0.14; 5 studies, n=199; GRADE=low) (table 2). Three studies reported on remission at 12 months.353941 When remission was defined independently of medication use, LCDs increased remission (risk difference 0.10, –0.02 to 0.21; 3 studies, n=171; GRADE=moderate), but they lowered the remission rate when the definition of remission included absence of diabetes medication (risk difference –0.04, –0.16 to 0.09; 2 studies, n=126; GRADE=low) (table 2).

Table 2

Summary of findings for primary outcomes

Eighteen studies reported on weight loss at six months.343536373839404142434445464748495056 Pooled analysis showed that patients on LCDs achieved greater weight loss compared with control (mean difference –3.46, 95% confidence interval –5.25 to –1.67; n=882; GRADE=moderate) (table 2). On the basis of subgroup credibility testing, we found that in studies at low risk of bias, LCDs achieved 7.41 kg greater weight loss compared with controls (mean difference –7.41, –9.75 to –5.08; 6 studies, n=171; test for subgroup differences P<0.001) (fig 4). Seven studies reported on weight loss at 12 months,36394243445051 with our pooled analysis showing that any benefit over control diets was trivial and non-significant (mean difference 0.29 (–1.02 to 1.60) kg; n=499; GRADE=moderate) (table 2).

Seventeen studies reported on HbA_1c levels at six months.3435363738404142434445464749505256 LCDs achieved greater reductions in HbA_1c than did control diets (mean difference –0.47%, –0.60 to –0.34; n=747; GRADE=high) (table 2). At 12 months, eight studies reported on HbA_1c levels, showing that the effect size had decreased by around half (mean difference –0.23%, –0.46% to 0.00%; n=489; GRADE=moderate) (table 2).

Fourteen studies reported on fasting glucose at six months.3536383940424445464748525356 Pooled analysis showed that LCDs achieved an average 0.73 mmol/L greater reduction in glucose concentrations compared with control diets (mean difference –0.73, –1.19 to –0.27; n=611; GRADE=moderate) (table 2). Six studies reported on fasting glucose at 12 months,394244515253 with little or no difference observed between the comparator diets (mean difference 0.06, –0.37 to 0.48; n=365; GRADE=moderate) (table 2).

Eleven studies reported total adverse events or serious adverse events at six months.3435373839414344454752 Pooled analysis suggested a trivial and non-significant increase in total adverse events among patients on LCDs (risk difference 0.04, –0.01 to 0.08; 9 studies, n=423; GRADE=very low) and similarly little or no effect on serious adverse events (risk difference 0.00, –0.03 to 0.02; 8 studies, n=448; GRADE=low) (table 2). Three studies reported on total adverse events or serious adverse events at 12 months,394344 with pooled estimates showing that LCDs were associated with a small, non-significant decrease in total adverse events (risk difference –0.05, –0.24 to 0.14; 2 studies, n=156; GRADE=very low) and a trivial, non-significant decrease in serious adverse events (risk difference –0.01, –0.06 to 0.04; 3 studies, n=217; GRADE=low) (table 2).

Table 3 shows secondary outcomes. Briefly, pooled analyses showed that LCDs led to greater reductions in diabetes medication and clinically important benefits threefold greater than the MCID estimate for triglycerides and insulin resistance (HOMA-IR) at six and 12 months. LCDs had clinically important harms on quality of life and low density lipoprotein cholesterol at 12 months, with little to no effect observed at six months. LCDs had little or no effect on total and high density lipoprotein cholesterol concentrations or C reactive protein related inflammation at six and 12 months.

Table 3

Secondary outcomes

We did subgroup assessments (level of carbohydrate restriction, behavioral support intensity, comparator diet, iso-caloric comparator, caloric restriction, inclusion of patients who used insulin, and adherence) for each of our five primary outcomes. Most subgroup observations were not deemed credible; however, three credible subgroups were identified on the basis of meeting four of five credibility criteria. Specifically, for these subgroups, statistical analysis suggested that chance could not explain the apparent subgroup effect, the effect was consistent across studies, the subgroup hypothesis was one of a small number of hypotheses developed a priori with direction specified, and strong pre-existing biological support existed (supplementary table D). Studies that included patients using insulin had fewer remissions for both definitions of remission (HbA_1c <6.5%; HbA_1c <6.5% and no diabetes medication) at six months (risk difference 0.14, 0.03 to 0.25; 0.00, –0.07 to 0.07) compared with studies that did not (risk difference 0.51, 0.36 to 0.65; 0.20, 0.03 to 0.38) (test for subgroup difference P<0.001; P=0.03). Diets with very low carbohydrates (<10% of daily calories from carbohydrates) led to smaller weight loss at six months (mean difference –1.05, –2.27 to 0.17) than did less restrictive diets (mean difference –5.22, –8.33 to –2.11) (test for subgroup difference P=0.01). However, on the basis of our third subgroup that was judged to be credible,16 this effect was explained by diet adherence. That is, among VLCDs to which the patients were highly adherent, a larger clinically important weight loss occurred (mean difference –4.47, –8.21 to –0.73) compared with patients less adherent to VLCDs (mean difference –0.55, –1.76 to 0.66) (test for subgroup difference P=0.05).

We did a post hoc sensitivity analysis comparing the certainty of evidence using GRADE versus NutriGRADE (supplementary table E). NutriGRADE analysis resulted in 16/30 (53%) outcomes with the same rating as GRADE; 10 (33%) of outcomes were upgraded compared with GRADE ratings (mainly our secondary outcomes), and 4 (13%) were downgraded.

Discussion

Among 23 studies comparing LCDs with mostly low fat control diets in patients with type 2 diabetes, on the basis of moderate to low certainty evidence, patients on LCDs achieved higher diabetes remission rates at six months (HbA_1c <6.5%: NNT=3; HbA_1c <6.5% and no diabetes medication: NNT=20). On the basis of very low to high certainty evidence, no statistically significant and clinically important detrimental effects on cardiovascular risk factors (for example, lipids, C reactive protein) or adverse events were detected with LCDs. However, we observed a trend for clinically important increases in low density lipoprotein cholesterol at 12 months. Additionally, LCDs increased weight loss, reduced medication use, and improved triglyceride concentrations at six months. In general, most benefits diminished at 12 months, a finding consistent with previous reviews.1557

Sensitivity and subgroup analyses

We did sensitivity analyses based on risk of bias for all outcomes, but only one outcome, weight loss, showed a credible subgroup effect between studies with higher and lower risk of bias. Studies with lower risk of bias showed more dramatic increases in weight loss, findings that were both statistically and clinically significant, supporting our overall findings.

Subgroup analyses, based on credibility testing,1627 suggested that patients not using insulin, compared with those that did, had increased diabetes remission rates at six months. For patients not using insulin, the NNT was 2 for remission defined as HbA_1c below 6.5% and 5 for remission defined as HbA_1c below 6.5 without diabetes medication. Furthermore, on the basis of our subgroup testing, VLCDs underperformed compared with less restrictive LCDs for weight loss at six months. However, this difference was negated when we considered patients highly adherent to VLCDs. Of note, the limited number of studies with 12 month outcome data providing differing levels of support and having highly adherent versus less adherent intervention arms precluded subgroup analyses that explicitly explored the effects of adherence at 12 months. Although improvements noted at six months diminished by 12 months, determining with any certainty whether this is related to intensity of intervention and/or dietary adherence beyond six months is difficult.

Strengths of study

Our systematic review has several important strengths. Firstly, we did a thorough literature search and contacted authors of all studies for any unpublished data on remission of diabetes. Although only three included studies previously published HbA_1c threshold criteria and medication use to determine diabetes remission, our successful contact with authors yielded trial data from five additional studies to determine remission rates,3438394058 increasing the precision and overall certainty of the effect estimates.13155759 Recent systematic reviews conducted by Sainsbury, van Zuuren, and Snorgaard have shown important reductions in mean HbA_1c values with low and very low carbohydrate diets,131559 but no previous review has summarized HbA_1c as a dichotomous outcome informed by the suggested American Diabetes Association remission definitions (for example, <6.5% HbA_1c threshold).1660 We believe that our meta-analytic summary of published and unpublished data from eight randomized controlled trials using HbA_1c thresholds, a first in the literature, will lead to more informed clinical decision making in the management of type 2 diabetes.

Secondly, on the basis of a publicly available protocol,16 we used robust evidence synthesis methods including the use of Cochrane's Risk of Bias instrument 2.0,20 missing participant outcome data sensitivity analyses,24 and subgroup credibility assessments based on a priori stated effect modifiers.31 Missing data for participants is particularly important in nutrition research in general given the often dramatic losses to follow-up in diet based clinical trials (>20% among 10/23 (43%) of trials included in this analysis) and the corresponding risk of bias due to losses to follow-up.61 Subgroup credibility assessment is of particular interest to researchers in this field given that some have advocated for subgroup elucidation when considering LCDs for treating diabetes.6263 Whereas previous reviews have focused on one or two potential modifiers—for example, Korsmo et al, who explored subgroups on length of follow-up and carbohydrate intake,57 and Naude et al, who explored calorically matched controls14—in our protocol driven approach, we explored seven actively debated potential effect modifiers by using published, explicit subgroup credibility criteria.

Thirdly, the use of GRADE for rating the certainty of evidence in systematic reviews of nutrition studies has been questioned,27 with some calling for a methodological approach specific to nutrition studies. However, we believe the logic of scientific inquiry demands consistent standards for casual inference across health claims, preferably using GRADE, a more conservative rating approach than the alternative systems suggested by the nutrition community.64656667 Nevertheless, we did a sensitivity analysis comparing GRADE ratings with NutriGRADE ratings (supplementary table E). NutriGRADE analysis resulted in 16/30 (53%) outcomes with the same rating as GRADE; 10 (33%) of outcomes were judged to be of higher certainty using NutriGRADE, and 4 (13%) were judged to be of lower certainty using NutriGRADE. Overall, the certainty of evidence using NutriGRADE indicates, on average, a higher degree of confidence in the efficacy and safety of LCDs across outcomes, particularly our primary outcomes including diabetes remission and fasting glucose, and higher certainty in the evidence for little to no short term risk of adverse events with LCDs.

Fourthly, our interpretations of estimates for continuous outcomes were based on a priori estimates of the minimal clinically important differences (supplementary table C). To our knowledge, no previous review on this topic has attempted to present effect estimates while considering MCID thresholds, thresholds that will help clinicians and patients to better interpret the magnitude of treatment effect.30 Among 10 continuous outcomes, two showed improvements that met or surpassed the MCID at six months (triglycerides, insulin resistance) with no detrimental effects. At 12 months, two had improvements that surpassed the MCID (triglycerides, insulin resistance) and two had a clinically important worsening (quality of life, low density lipoprotein cholesterol), although neither was statistically significant (P=0.24 and P=0.05).

Limitations of study

Our study is not without limitations. Firstly, the definition of remission of diabetes is the subject of considerable debate, specifically with regards to threshold levels of HbA_1c/fasting glucose, use of diabetes medication, and the length of follow-up time meeting these criteria.60 We attempted to overcome this by using multiple a priori definitions of remission (both with and without the use of diabetes medication) at both of our predetermined endpoints (six months and 12 months).

Secondly, safety concerns have been raised with LCDs.68 Although no significant or clinically important increase in total or serious adverse events was identified, these outcomes were poorly reported among trials and the certainty of evidence for safety ranges from low to very low. By contrast, we have moderate to high certainty that surrogate markers for cardiovascular disease risk, such as blood lipids, do not worsen, whereas triglycerides significantly improved in a clinically meaningful way. One exception was low density lipoprotein cholesterol concentrations at 12 months' follow-up, which seemed to worsen, surpassing the MCID. Thirdly, 18/23 (78%) studies used low fat diets as a comparator, limiting the applicability of our results to other dietary regimens such as a Mediterranean-style diet.

Fourthly, an important concern with LCDs is the potential confounding factor of caloric restriction. Restricting carbohydrates, which tends to reduce hunger,69 would mean that whether any purported benefit was due to carbohydrate restriction or caloric restriction was unclear. For this reason, as part of our a priori planned subgroup analysis, we investigated the effect of calorically matched controls (as assessed by follow-up dietary questionnaires). On the basis of 18 studies providing adequate data, we identified no evidence of credible effect modification based on caloric matching or lack thereof. However, self-reported dietary intake data are prone to measurement error, particularly in dietary trials in which participants are not blinded.7071

Fifthly, we made a pragmatic a priori decision to assess our endpoints at six and 12 months (±3 months). Whereas trials informing our 12 month endpoint were all reported at this time point, those informing our six month endpoint varied between three months and eight months. Of the 14 trials informing our six month pooled estimates, 7/14 (50%) reported data at three to less than six months (3 months: 6 trials; 4 months: 1 trial), and 7/14 (50%) trials reported at six to nine months (6 months: 6 trials; 8 months: 1 trial). On the basis of comments from peer reviewers, we did a post hoc analysis on remission at six (±3) months. Evidence suggested larger treatment effects for LCDs in shorter term trials (3 to <6 months), suggesting that shorter term trials may be an effect modifier. For the definition of remission of HbA_1c below 6.5%, the risk difference was 0.49 (95% confidence interval 0.30 to 0.68) for trials of three to less than six months in length compared with 0.25 (0.08 to 0.42) for trials of between six and nine months. Similarly, for the definition of remission of HbA_1c below 6.5% and no diabetes medication use, the risk difference was 0.20 (0.03 to 0.38) for trials of three to less than six months compared with 0.00 (–0.07 to 0.07) for trials of between six and nine months.

Sixthly, our protocol driven results are limited to short term markers of remission of diabetes, adverse events, and related cardiometabolic outcomes.16 Future long term, well designed, calorie controlled randomized trials are needed to determine the effects of LCD on sustained weight loss and remission of diabetes, as well as cardiovascular mortality and major morbidity.

Seventhly, our review focused on studies defined by macronutrient quantity. Macronutrient quality may also be important, and, although we were unable to consider the characteristics of dietary quality given the lack of reporting in our 23 eligible trials, future trials should better document dietary quality (for example, processed versus unprocessed foods) using optimally validated questionnaires together with emerging objective biomarkers using microbiomics, metabolomics, or other high dimensional platforms.72

Finally, the limited number of trials allowing patients to reduce their medication use impeded our ability to assess remission of diabetes when defined as HbA_1c below 6.5% without diabetes medication. Only 7/23 (30%) of eligible trials permitted reduction of medication and reported usable medication data. Future trials should allow for, and adequately report on, reduction of medication while closely monitoring blood glucose concentrations.58 LCDs seem to promote important reductions in HbA_1c, potentially increasing risk for hypoglycemic episodes, including severe syncope, if the dosage of diabetes medications is not adjusted accordingly. Because blinding is not possible in these studies, these adjustments should be applied using a priori algorithms that help to guide medication management.47 Reductions in medication may blunt the effect on mean HbA_1c levels, biasing results towards the null and masking any effect; however, any improvement can still be captured if reduction of medication is included as an outcome of interest.

Conclusions

Moderate to low certainty evidence suggests that patients adhering to LCDs for six months may experience greater rates of remission of diabetes without adverse consequences compared with other diets commonly recommended for management of type 2 diabetes (for example, low fat diets). These benefits diminished at 12 months, and, although LCDs seem to improve triglycerides in a clinically meaningful way, some evidence shows clinical worsening of quality of life and low density lipoprotein cholesterol. Considering this and a recent systematic review of cohort studies suggesting that long term LCDs are associated with increased mortality,73 clinicians might consider short term LCDs for management of type 2 diabetes, while actively monitoring and adjusting diabetes medication as needed.

What is already known on this topic

• Previous systematic reviews have used broad definitions of low carbohydrate (eg, <45% of calories from carbohydrates) and have not systematically assessed remission of diabetes

• Results from reviews based on a subgroup of 10 randomized trials assessing low carbohydrate diets (LCDs) (<26-45% of daily calories from carbohydrate) have been encouraging

What this study adds

• This systematic review of the effect of LCDs on remission of type 2 diabetes included 23 trials, including unpublished HbA_1c and medication use data from five trials

• Compared with (mostly low fat) control diets, on the basis of moderate certainty evidence at six months, LCDs were associated with a large (32%) increase in remission of diabetes

• According to a priori determined minimal important difference estimates, large and clinically important improvements in weight loss, triglycerides, and insulin resistance were also seen, without adverse events

Acknowledgments

We thank Pamela Dyson for sharing unpublished data and Paria Tajallipour for her assistance with our literature search.

Footnotes

• Contributors: JZG and BCJ conceived the study. JZG, LT, and BCJ designed the study. JZG, JJ, and BCJ developed a priori estimates of the minimal clinically important difference. JB designed and executed the search. JG and AD selected the articles and extracted the data. JZG, AD, and BCJ analyzed the data. JZG and BCJ wrote the first draft of the manuscript. GB, JS, SY, and TJ provided unpublished trial data and reviewed and interpreted the data of the draft manuscript. JZG, BCJ, AD, JB, LT, GB, JS, SY, TJ, and JJ interpreted the data and contributed to the writing of the final version of the manuscript. All authors agreed with the results and conclusions of this article. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. JZG and BCJ are the guarantors.

• Funding: This study was funded in part by Texas A&M University. The university had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

• Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from Texas A&M University; BCJ receives funds from Texas A&M AgriLife Research to support investigator initiated research related to saturated and polyunsaturated fats for a separate research project, as part of his recent recruitment to Texas A&M University (support from Texas A&M AgriLife institutional funds are from interest and investment earnings, not a sponsoring organization, industry, or company); GB is author of the CSIRO Low Carb Diet Book that aims to translate clinical research outcomes of low carbohydrate diet studies for the general public in Australia, but he does not personally receive any financial royalties or funds either directly or indirectly from this publication, and any royalties received by his employment institution (CSIRO) do not contribute to his salary, nor have they been used to execute this work; no other relationships or activities that could appear to have influenced the submitted work.

• Ethical approval: Not needed. All the work was developed using aggregate level data.

• Data sharing: Further data are available on request through the corresponding author at bradley.johnston@tamu.edu.

• The lead and senior authors (manuscript's guarantors) affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

• Dissemination to participants and related patient and public communities: We plan to reach out to diabetes and obesity patient advocacy groups (eg, Obesity Canada) as well as professional medical, nutrition, and agricultural organizations (eg, Practice-based Evidence in Nutrition, Royal Australian College of General Practitioners, USDA) to help to disseminate this work. Additionally, all authors will work with their home institutions to leverage their unique dissemination platforms including social media communication and organizational websites.

• Provenance and peer review: Not commissioned; externally peer reviewed.

View Abstract

Low Carb Diet And Diabetes

Source: https://www.bmj.com/content/372/bmj.m4743

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