Category Archives: Low-Carb

Ketogenic and Very Low-Carb Diet Effective for T2 Diabetes for at Least Two Years

This Avocado Chicken soup is very low-carb. Use the search box to find the recipe.

It’s well-established that very low-carb and ketogenic diets over the short-term usually do a good job for folks with type 2 diabetes: better blood sugar levels, fewer diabetes drugs needed, improved lipids, lower blood pressure, etc. Many people—from patients to dietitians to physicians—question whether the diet and associated improvements can be sustained for more than a few months. The study at hand looked at results two years out, and found definite clinical benefit and sustainability.

First, a quick point to get out of the way. In the U.S., HgbA1c is reported as a percentage. But other countries often report HgbA1c in mmol/mol. It’s not easy to convert one to the other accurately, so when you see values in mmol/mol below, be aware they’re only my approximations, not the researchers’.

Here’s how the researchers did their study, published in the summer of 2019.

Scientific Method

262 adults with type 2 diabetes (average age 54) were enrolled in the intervention group, called CCI (digitally-monitored continuous care intervention via a web-based app). 87 were assigned to “usual care.” For all participants at baseline, body mass index averaged 37-40, HgbA1c averaged 7.6% (60 mmol/mol), and they had diabetes for an average of eight years. The CCI group monitored beta-hydroxybutyrate (a ketone) levels, glucoses, body weight, etc, and uploaded results via the web-based app. The app also facilitated an online peer community for social support. For those who preferred in-person education (about half of the total), clinic-based group meetings were held weekly for 12 weeks, bi-weekly for 12 weeks, monthly for six months, and then quarterly in the second year. Continuous Care Intervention included individual support with telemedicine, customized nutritional guidance (emphasis on sustained nutritional ketosis), and health coaching.

The 87 Usual Care folks were recruited from the same geographic area and healthcare system. The received care from their primary care physician or endocrinologist and were counseled by a dietitian (ADA recommendations) as part of their diabetes education. Medical care was not modified for the study. This group had less intense clinical measurements than the CCI cohort.

Of the 262 participants who started with the CCI group, 218 remained after one year. So 44 drop-outs. Of these 262 pioneers, 194 remained for the entire second year (so 24 more drop-outs). If those drop-out numbers seem high to you, be aware that they are NOT. Even the Usual Care group of 87 had 19 drop-outs over the two years.

So what happened?

Reductions from baseline to two years in the CCI group included: fasting insulin, weight (down about 10% or 11.9 kg), blood pressure (systolic and diastolic), HgbA1c, and triglycerides. Those are all going in the right direction.

Other findings for the CCI group: HDL-cholesterol (“good cholesterol”) went up. Excluding metformin, the use of diabetes control drugs in the CCI group dropped from 56% of participants to 27%. Some dietitians fear the ketogenic diets are bad for bones, causing calcium to leak out of bones, weakening them since calcium is the main mineral in bones. But spine bone mineral density in the CCI group was unchanged over the two years.

The “usual care” group had no changes in those measurements or diabetes medication use.

Now, to understand some of the investigators results, you need to know their definitions. Diabetes remission = glycemic control without medication use. Partial remission is “sub-diabetic hyperglycemia of at least 1 year duration, HgbA1c level between 5.7-6.5% (39 to 48 mmol/mol), without any medications (two HbgA1c measurements).” Complete remission is “normoglycemia of at least 1 year duration, HgbA1c below 5.7% [39 mmol/mol], without any medications (two HgbA1c measurements).” Diabetes reversal per Supplementary Table 2: Sub-diabetic hyperglycemia and normoglycemia (HgbA1c below 6.5% or 48 mmol/mol), without medications except metformin.

The CCI group had resolution of diabetes (partial or complete remission in 18%, reversal in 53%), which was not seen in the usual care group. Complete remission was achieved in 17 (6.7%) of the CCI group. HgbA1c in the CCI group at two years dropped from average of 7.6% (60 mmol/mol)  to 6.7% (50 mmol/mol).

Conquer Diabetes and Prediabetes

Metformin is the most-recommended drug for type 2 diabetes

“CCI diabetes reversal exceeds remission as prescriptions for metformin were usually continued given its role in preventing disease progression, preserving beta-cell function and in the treatment of pre-diabetes per guidelines.”

The average dose of insulin in CCI folks who were using insulin at baseline decreased by 81% at two years. (Have you noticed the price of insulin lately?)

Beta-hydroxybutyrate is a ketone, and at a certain level in the blood, indicates the presence of ketosis on a ketogenic diet. “The 2 year beta-hydroxybutryate (BHB) increase above baseline demonstrated sustained dietary modification.”  “…the encouraged range of nutritional ketosis (> or = 0.5 mM) was observed in only a minority (14.1%) of participants at 2 years. On average, patient-measured BHB was > or = 0.5mM for 32.8% of measurement over the 2 years.”

Bottom Line

In summary, the CCI group—eating ketogenic and/or very low-carb—showed sustained beneficial effects even two years after start of the study. I suspect the Virta app, clinic-based group meetings, and individual support and coaching contributed significantly to the participants’ success.

Steve Parker, M.D.

PS: By the way, many of the study authors are affiliated with Virta Health Corp., which I assume is a for-profit company. Virta provided funding for the study. Could that funding have unduly influenced the results? It’s always possible but I have no evidence that it did. If not already available, I expect a commercial version of the program will be within 12–24 months.

Reference: Athinarayanan, S.J., et al (including Sarah Hallberg, Jeff Volek, and Stephen Phinney). Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 2-year Non-randomized Clinical Trial. Frontiers in Endocrinology, Vol. 10, article 348, June 19, 2019.

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Can You Avoid Muscle Loss on Low-Calorie Diets?

Greek salad with canned salmon

The parts of your body that aren’t fat tissue are collectively called fat-free mass or lean mass. Fat-free mass includes muscle, organs, bones, water, connective tissue, etc. Reduced-calorie diets are often linked to reduction of body components—like muscle—other than the desired loss of excess fat.

One proven effective way to preserve muscle mass on a reduced-calorie diet is to consume adequate protein. Judicious exercise also helps.

I haven’t read the full article below, and probably won’t. For what it’s worth, the authors say fat-free mass can be preserved during a very low-carb ketogenic diet via adequate intake of vitamin D, leucine, and whey protein. Do you think maybe they’re selling a particular supplement?

The abstract isn’t very well written. Or is it the title that’s misleading?

Abstract

The loss of fat free mass (FFM) that occurs during a weight loss secondary to low-calorie diet can lead to numerous and deleterious consequences. We performed a review in order to evaluate the till-now evidence regarding the optimum treatment for maintaining FFM during low-calorie diet. This review included eligible studies. In order to maintain FFM during a low-calorie diet, there are various diet strategies: adopt a very-low carbohydrates ketogenic diets (VLCKD) and take an adequate amount of specific nutrients (vitamin D, leucine, whey protein). As regard the numerous and various low-calorie diet proposals for achieving weight loss, the comparison of VLCKD with prudent low-calorie diet demonstrated that FFM was practically unaffected by VLCKD. This is possible for numerous mechanisms, involving insulin and insulin like grow factor-I – growth hormone (IGF-I-GH) axis, and which acts by stimulating protein synthesis. Considering protein and amino acids intake, an adequate daily intake of leucine (4 grams/day), and whey protein (20 grams/day) is recommended.

Regarding vitamin D, if the blood vitamin D has low values (<30 ng/ml), it is mandatory that an adequate supplementation is provided, specifically calcifediol because in the obese subject, this form is recommended to avoid seizure in the adipose tissue: 3–4 drops/day or 20–30 drops/week of calcifediol are generally adequate to restore normal 25(OH)D plasma levels in obese subjects.

Source: Current Opinion On Dietary Advice In Order To Preserve Fat Free Mass During A Low-Calorie Diet – ScienceDirect

I had never heard of that obesity-calcifidiol connection.

Steve Parker, M.D.

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Why Can’t You Score a Great Hemoglobin A1c?

Is this device from 20 years ago?

The good folks over at Diabetes Daily conducted a survey of people with diabetes to find out what they were doing to get good HgbA1c levels. HgbA1c is a measure of average blood sugar levels over the prior three months. Lower HgbA1c levels, generally speaking, are linked to fewer diabetes complications. Prevention is always better than treatment. If you run across someone succeeding at anything, wouldn’t you want to know how they do it, assuming it’s a goal you share?  I recommend the entire report to you. An excerpt:

Type 2 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to:

  • Eat a very low-carbohydrate diet (<40 g per day): 32% vs. 13%
  • Eat a ketogenic diet (<20 g per day): 13% vs. 0%
  • Not vary their daily carbohydrate intake: 16% vs. 29%
  • Eat a low-carbohydrate lunch (<20 g) on a regular basis: 50% vs. 28%
  • Use an insulin pump: 10% vs. 3%
  • Vary the timing of their meal-time insulin: 53% vs. 40%
  • Exercise: Daily: 14% vs 8%. Exercise 4-6 times per week: 20% vs 8%.Exercise less than once per week: 51% vs 73%
  • Feel very confident about their diabetes management skills: 69% vs. 26%
  • Feel very optimistic about their long-term health: 58% vs. 30%
  • Feel that diabetes doesn’t greatly interfere with their daily life: 56% vs. 19%
  • Report a high degree of socioemotional support related to diabetes: 59% vs. 46%

Type 1 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to:

  • Eat a very low-carbohydrate diet (<40 g per day): 22% vs. 7%
  • Not vary their daily carbohydrate intake: 9% vs. 28%
  • Use an insulin pump: 71% vs. 53%
  • Wear a continuous glucose monitor (CGM): 76% vs. 60%
  • Have lower “high glucose alert” setting on their CGM
  • Have lower “low glucose alert” settings on their CGM
  • Not vary the timing of their meal-time insulin: 43% vs. 59%
  • Incorporate the protein content of their meal in determining their bolus insulin dose: 44% vs. 23
  • Eat similar food every day, at similar times, AND limit eating out at restaurants: 20% vs. 7%
  • Exercise: Daily: 21% vs 11%. Exercise 4-6 times per week: 24% vs 8%. Exercise less than once per week: 40% vs 66%
  • Feel very confident about their diabetes management skills: 82% vs. 39
  • Feel very optimistic about their long-term health: 59% vs. 42el that diabetes doesn’t greatly interfere with their daily life: 35% vs. 21%
  • Report a high degree of socioemotional support related to diabetes: 68% vs. 56%

Source: Habits of a Great A1c Survey Data Report – Diabetes Daily

Lead researcher was Maria Muccioli, PhD.

Steve Parker, M.D.

PS: The Paleobetic Diet provides 40–80 g of digestible carbs daily. For 20–40 g/day, check out my Low-Carb Diabetic Mediterranean Diet.

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Low-Carb Eating for Diabetes Is Taking Off in the U.K.: Dr David Unwin Explains

 

diabetic diet, Paleobetic diet, diabetes,

Sunny’s Super Salad

The Diet Doctor website posted a video interview of Dr David Unwin (in the U.K.) discussing his experience with low-card diets in folks with diabetes (type 2, I assume). If  you’re short on time, just read the transcript. Thanks, Diet Doctor!

I took note of Dr Unwin’s transformation from a run-of-the mill follow-the-herd practitioner to a low-carb advocate. This happened around 2012 when Dr Unwin was 55 years old and on the threshold of retirement. Here it is:

Dr David Unwin speaking: ….There was one particular case I’ve talked about before where there was a patient who – so in 25 years I’d never seen a single person put their [type 2] diabetes into remission, I had not seen it once. I didn’t even really know it was possible.

Dr Bret Scher speaking:  We were not [taught] that it’s possible.

Dr Unwin:  No, my model was that the people with diabetes… It was a chronic deteriorating condition and I could expect that they would deteriorate and I would add drugs and that’s what would be normally going to happen. And then one particular patient wasn’t taking her drugs and she actually went on the low-carb diet and put her diabetes into remission.

But she confronted me with, you know, “Dr. Unwin, surely you know that actually sugar is not a good thing for diabetes.” “Yes, I do.” But then she said, “But you’ve never once in all the years mentioned that really bread was sugar, did you.” And, you know, I never did. I don’t know what my excuse was. So this this lady had done this wonderful thing and she’d also changed her husband’s life as well.

She’d sorted his diabetes out and she’d done it with a low-carb diet and that really made me think I didn’t know much about it. I didn’t know much about it. So I found out what she’d been on… on the low-carb forum of diabetes.co.uk and to my amazement there was 40,000 people on there, all doing this amazing thing. And I was blown away but then I was very sad because the stories of the people online were full of doctors who are critical of these people’s achievements.

***

Dr Unwin: And that original case that showed me you could put into remission; if you could repeat that, how wonderful for people… And when I now – because I think we’ve done 60 patients who put their type 2 diabetes into remission. So I’m able to say with confidence to people, you know, you stand a good chance. In fact I can say that of my patients who take up low-carb, about 45% of them will put their diabetes into remission which is amazing.

At no point does the transcript indicate they’re talking about type 2 diabetes rather than type 1, but that must be the case. Nor does it mention the amount of required carbohydrate restriction. I figure it’s between 20 and 100 grams/day of digestible carbohydrate, depending on one’s metabolic health and how many years of diabetes.

I’ve mentioned Dr Unwin before.

Source: Diet Doctor Podcast #33 – Dr. David Unwin – Diet Doctor

Steve Parker, M.D.

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Is a Very Low-Carb Diet Reasonable for Type 1 Diabetes?

Exercise was natural when we were kids

Bottom line: A very low-carb diet worked well for children and adults with type 1 diabetes in this relatively small study.

Abstract

OBJECTIVES:

To evaluate glycemic control among children and adults with type 1 diabetes mellitus (T1DM) who consume a very low-carbohydrate diet (VLCD).

METHODS:

We conducted an online survey of an international social media group for people with T1DM who follow a VLCD. Respondents included adults and parents of children with T1DM. We assessed current hemoglobin A1c (HbA1c) (primary measure), change in HbA1c after the self-reported beginning of the VLCD, total daily insulin dose, and adverse events. We obtained confirmatory data from diabetes care providers and medical records.

RESULTS:

Of 316 respondents, 131 (42%) were parents of children with T1DM, and 57% were of female sex. Suggestive evidence of T1DM (based on a 3-tier scoring system in which researchers took into consideration age and weight at diagnosis, pancreatic autoimmunity, insulin requirement, and clinical presentation) was obtained for 273 (86%) respondents. The mean age at diagnosis was 16 ± 14 years, the duration of diabetes was 11 ± 13 years, and the time following a VLCD was 2.2 ± 3.9 years. Participants had a mean daily carbohydrate intake of 36 ± 15 g. Reported mean HbA1c was 5.67% ± 0.66%. Only 7 (2%) respondents reported diabetes-related hospitalizations in the past year, including 4 (1%) for ketoacidosis and 2 (1%) for hypoglycemia.

CONCLUSIONS:

Exceptional glycemic control of T1DM with low rates of adverse events was reported by a community of children and adults who consume a VLCD. The generalizability of these findings requires further studies, including high-quality randomized controlled trials.

Source: Management of Type 1 Diabetes With a Very Low-Carbohydrate Diet. – PubMed – NCBI

Steve Parker, M.D.

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Management of T1 Diabetes With a Very Low-Carb Diet

diabetic diet, low-carb mediterranean diet

Long-term diabetes management begins in the kitchen

From the medical journal Pediatrics:

“Abstract

OBJECTIVES: To evaluate glycemic control among children and adults with type 1 diabetes mellitus (T1DM) who consume a very low–carbohydrate diet (VLCD).

METHODS: We conducted an online survey of an international social media group for people with T1DM who follow a VLCD. Respondents included adults and parents of children with T1DM. We assessed current hemoglobin A1c (HbA1c) (primary measure), change in HbA1c after the self-reported beginning of the VLCD, total daily insulin dose, and adverse events. We obtained confirmatory data from diabetes care providers and medical records.

RESULTS: Of 316 respondents, 131 (42%) were parents of children with T1DM, and 57% were of female sex. Suggestive evidence of T1DM (based on a 3-tier scoring system in which researchers took into consideration age and weight at diagnosis, pancreatic autoimmunity, insulin requirement, and clinical presentation) was obtained for 273 (86%) respondents. The mean age at diagnosis was 16 ± 14 years, the duration of diabetes was 11 ± 13 years, and the time following a VLCD was 2.2 ± 3.9 years. Participants had a mean daily carbohydrate intake of 36 ± 15 g. Reported mean HbA1c was 5.67% ± 0.66%. Only 7 (2%) respondents reported diabetes-related hospitalizations in the past year, including 4 (1%) for ketoacidosis and 2 (1%) for hypoglycemia.

CONCLUSIONS: Exceptional glycemic control of T1DM with low rates of adverse events was reported by a community of children and adults who consume a VLCD. The generalizability of these findings requires further studies, including high-quality randomized controlled trials.”

Source: Management of Type 1 Diabetes With a Very Low–Carbohydrate Diet | Articles | Pediatrics

Low-Carb Diet for Diabetes

This Avocado Chicken soup is low-carb. Use the search box to find the recipe.

Over at Diabetes Daily, Dr Maria Muccioli wrote about recent low-carb diet research as applied to diabetes, as discussed at a recent meeting of the American Diabetes Association. A couple excerpts to whet your appetite:

Dr. Tay stated that a very low carbohydrate diet offers a considerable advantage over a high carbohydrate approach for patients with type 2 diabetes.She noted that reducing medication use is not only cost-effective but can also safeguard from the considerable side effects of some second-line medications. She also explained that achieving less glycemic variability, which may be an independent risk factor for the development of diabetes-associated complications, is “of great clinical importance.”“It is a good diet to have if you have diabetes, and the data support that,” she concluded.

  *   *   *

What about VLC diet for children with type 1 diabetes?

Dr. de Bock does not deny that a VLCD for children with type 1 diabetes can help to achieve exceptional glycemic control, as recently demonstrated in a study showing normal average A1c levels in a large cohort of patients. The speaker remarked that the patients in that study had very low glycemic variability.

He believes that more research needs to be conducted to evaluate the relevance of the potential concerns that he outlined. Until then, he advises parents of children who follow a VLCD to work closely with their medical care providers to monitor growth, cardiac, nutritional, and mental/emotional parameters.

Source: Very Low Carbohydrate Diets for Diabetes (ADA 2018)

Research Supports Very Low-Carb Diet for BOTH Adults and Children With T1 Diabetes

Hamburger-Avocado Salad with tomatoes, cucumbers, lettuce, salt/pepper, and olive oil vinaigrette. Yes, it’s very low-carb.

MedPage Today has a brief report that may interest you. A new study indicates that a very low-carb diet (VLCD) is beneficial to both adults and children with type 1 diabetes. No surprise to me, although I admit this was not an ideal study.

Among people with type 1 diabetes, following a very low-carbohydrate diet (VLCD) can aid in achieving glycemic control, researchers suggested.

Responses from an online survey of people with type 1 diabetes found that those who followed a VLCD reported very good glycemic control – a mean HbA1c of 5.67% ± 0.66%, according to the study by Belinda Lennerz, MD, PhD, of Boston Children’s Hospital, and colleagues. Overall, 97% of these participants achieved the recommended glycemic targets of the American Diabetes Association.

The average blood glucose levels among the subset of patients who reported these values were 104 ± 16 mg/dL, the researchers reported in Pediatrics.

Followers of this diet also noted very few adverse events, with only 2% of the total respondents reporting a diabetes-related hospitalization within the past year – 1% for ketoacidosis and 1% for hypoglycemia.

The survey included 316 responses from both adults with type 1 diabetes and the parents of children with type 1 diabetes. These individuals belonged to a Facebook group of people living with type 1 diabetes who adhere to a VLCD. While a VLCD is usually defined as ≤20 to 50 g per day of carbohydrates or ≤5% to 10% of daily caloric intake, the mean carbohydrate intake of these respondents was 36 ± 15 grams per day.

Source: Carb-Light Diet Helps T1D Patients Achieve Glycemic Control | Medpage Today

Click for the scientific citation.

Here’s more info from Maria Muccioli, Ph.D.

Steve Parker, M.D.

Julianne Taylor Has a Great Post on Amylase Gene Copy Number and Predisposition to Obesity and Carbohydrate Intolerance

“Before I knew anything about the effect of diet on my health and hunger, I did notice that an hour or 2 after eating refined starch foods I suffered low blood sugar and was ravenously hungry.

Back in the day (1995) as I’ve written about previously, I discovered The Zone Diet, it was literally life changing for me.

Through following this eating plan I discovered that refined carbohydrates, particularly those from grains and sugars played havoc with my blood sugar regulation. The Zone diet reduces carbohydrates, for me it was down to around 70 – 100 grams a day, divided to around 20 – 30 grams per meal.  Vegetable and low glycemic index (GI) carbohydrates are encouraged over refined grains and high GI carbs.

I’ve followed this principal for 20 years now, and found limiting carbohydrates, and adding animal protein to each meal is critical for both my well-being and appetite regulation. I’ve since found that 50 to 100 grams of carbs per day works well for me, and carbohydrate quality is important. This works out to 1 to 2 grams per kg body weight per day.I’ve often wondered why I seem to be so sensitive to carbohydrates, while others don’t suffer the dysregulated blood sugars and reactive hypoglycemia and consequent carbohydrate cravings that I do.The answer may be in my genes. I recently had a gene test to find out how many copies of the AMY1 gene I have, this a gene that codes for salivary amylase.”

Source: Your carbohydrate tolerance – is it written in your genes? AMY1 copy numbers | Julianne’s Paleo & Zone Nutrition

Hmmm: Spend $26,000 on Weight-Loss Surgery, Or Just Cut Carb Consumption?

Dr. Sarah Hallberg got some well-deserved publicity from the New York Times:

“Once a fad diet, the safety and efficacy of the low-carb diet have now been verified in more than 40 clinical trials on thousands of subjects. Given that the government projects that one in three Americans (and one in two of those of Hispanic origin) will be given a diagnosis of diabetes by 2050, it’s time to give this diet a closer look.

When someone has diabetes, he can no longer produce sufficient insulin to process glucose (sugar) in the blood. To lower glucose levels, diabetics need to increase insulin, either by taking medication that increases their own endogenous production or by injecting insulin directly. A patient with diabetes can be on four or five different medications to control blood glucose, with an annual price tag of thousands of dollars.”

Source: Before You Spend $26,000 on Weight-Loss Surgery, Do This – The New York Times