{"id":6294,"date":"2019-01-23T08:03:43","date_gmt":"2019-01-23T13:03:43","guid":{"rendered":"https:\/\/eatrightpa.org\/?p=6294"},"modified":"2021-10-30T03:37:44","modified_gmt":"2021-10-30T03:37:44","slug":"very-low-carbohydrate-diets-in-diabetes","status":"publish","type":"post","link":"http:\/\/www.eatrightpa.org\/blog\/2019\/01\/23\/very-low-carbohydrate-diets-in-diabetes\/","title":{"rendered":"Very Low Carbohydrate Diets in Diabetes"},"content":{"rendered":"

By Julie Stefanski MEd, RDN, CSSD, LDN, CDE<\/strong><\/p>\n

\u201cWhat should I eat?\u201d<\/p>\n

Hands down, this has to be the number one question people ask when faced with a diagnosis of diabetes.<\/p>\n

Over the last fifteen years, the American Diabetes Association (ADA) has recommended that diet recommendations always be individualized for each person with diabetes.\u00a0 The new 2019 diet guidelines for diabetes published by ADA are no different, \u201cEvidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes.\u201d1<\/sup><\/p>\n

A Change to Diabetes Diet Guidelines<\/h3>\n

A new statement though has been added that may surprise you.\u00a0 ADA has acknowledged that \u201c\u2026low carbohydrate eating plans may result in improved glycemia and have the potential to reduce antihyperglycemic medications for individuals with type 2 diabetes. As research studies on some low-carbohydrate eating plans generally indicate challenges with long term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach.\u201d<\/p>\n

If you\u2019re like me, you probably have a lot of people asking you about a ketogenic diet, especially for diabetes.\u00a0 The ADA has always recognized that controlling carbohydrate intake has the greatest impact on blood sugar levels.\u00a0 Previously though, the ADA recommended that individuals not decrease their carbohydrate intake lower than 130 grams per day.\u00a0 You may wonder how ADA defines the \u201clow carbohydrate eating plan\u201d mentioned.\u00a0 If we look at the studies ADA cited, the research utilized did indeed utilize a ketogenic diet plan.<\/p>\n

Research Results<\/h3>\n

Unlike the public, ADA is above being influenced simply by bacon filled Instagram posts touting keto benefits. The research cited, specifically studies conducted by Virta Health, have shown significant benefits from an extreme reduction in carbohydrate intake.\u00a0 These studies dropped carbohydrate intake to amounts needed to induce ketosis, typically less than 40 grams of carbohydrate per day.\u00a0 In one open-label, non-randomized, controlled study, participants restricted their carbohydrate intake to less than 30 grams per day.\u00a0 Protein intake was calculated at 1.5 grams per kilogram of body weight and patients received continued nutrition counseling and medical support.2<\/sup><\/p>\n

Average Beta-hydroxybutyrate (BHB) levels, a measure of the intensity and presence of ketosis, showed that subjects were mildly ketotic throughout the year of study. Participants were able to lose an average of 13.8 kg. \u00a0More importantly, medications prescribed for diabetes were reduced in response to reduced fasting insulin levels and improved insulin resistance. While both HDL and LDL cholesterol increased slightly, serum creatinine, triglyceride levels, CRP (a marker of inflammation), and liver enzymes (ALT, AST, and ALP) all declined.2<\/sup><\/p>\n

Improved Outcomes<\/h3>\n

A similar study from the same group also validated that insulin requirements decreased and blood glucose levels declined while following a ketogenic diet.\u00a0 These changes contributed to decreased fasting insulin levels and improved insulin resistance.3<\/sup>\u00a0 Improvements in insulin resistance, blunted blood sugar effects with a shift to higher fat intake, and increased feelings of satiety with the high fat diet have all been cited as benefits for a very low carb approach.<\/p>\n

Not a Good Mix<\/h3>\n

While the ADA guidelines acknowledge that this approach may be beneficial for some patients, it also echoes a paper by Kalra.\u00a0 Ketosis is not advisable for patients prescribed Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors such as canagliflozin, dapagliflozin, and empagliflozin. These meds coupled with a ketogenic diet increases the risk of euglycemic diabetic ketoacidosis.4<\/sup><\/p>\n

ADA further warns \u201cThis meal plan is not recommended at this time for women who are pregnant or lactating, people with or at risk for disordered eating, or people who have renal disease…\u201d<\/p>\n

Effects for Type 1 Diabetes<\/h3>\n

The new ADA guidelines also advise that the ideal diet for Type 1 diabetes (T1DM) is unknown.\u00a0 Compelling evidence though is emerging regarding use of very low carb diets not only in T2DM, but also in T1DM.\u00a0 If you attended FNCE this fall, you can listen to the session The Science of Modified\u2010Carbohydrate Diets and Application in the Clinic<\/em> presented by Dr. David S. Ludwig, Professor of Nutrition, Harvard School of Public Health which reviews some of the current research on the use of very low carb diets.<\/p>\n

Dr. Ludwig was a co-author on a study published in Pediatrics<\/em> in 2018. Researchers set out to assess the impact of a very low carbohydrate diet on outcomes such as HbA1c levels, diabetes-related adverse events such as hospitalizations, ketoacidosis, and hypoglycemia in patients with T1DM.5<\/sup><\/p>\n

With an average intake less than 36 grams of carbohydrate per day and made up of about 40% children, what researchers discovered was surprising.\u00a0 This group of individuals, who support each other through a facebook group called TypeOneGrit, had excellent glycemic control and very few adverse events.\u00a0 Their reported outcomes were verified through medical records.\u00a0 Rates of hospitalization and hypoglycemia were extremely low. HbA1c was 5.67% \u00b1 0.66% among the 316 participants.<\/p>\n

From this survey group, 97% met the ADA desired glycemic targets with only 1% being hospitalized for ketoacidosis over 12 months!\u00a0 What I found particularly sad and concerning though, is that many of these individuals stated that they had to go against the medical advice of their endocrinologist or certified diabetes educators in order to implement this way of eating.<\/p>\n

How Dietitians Can Help<\/h3>\n

As dietitians we all recognize the challenges of following an extremely low carbohydrate diet.\u00a0 If not well-planned and supplemented appropriately, sources of beneficial nutrients such as vitamin C, D, folate, and minerals such as selenium and calcium along with fiber will likely be missing.\u00a0 Social, emotional, and physical health can be impacted.\u00a0 But just like any other therapeutic diet, guidance from a registered dietitian can enhance and improve the quality of the nutrition being consumed.\u00a0 As valid research continues to emerge supporting use of ketogenic diet therapies, it\u2019s important for dietitians to be knowledgeable regarding diet guidelines and pitfalls for those individuals wanting to replicate the success of this research in their own lives.<\/p>\n

\"\"Julie Stefanski MEd, RDN, CSSD, LDN, CDE<\/a> is a nutrition content expert for Relias Learning, a continuing education company, owner of Stefanski Nutrition Services and a national media spokesperson for the Academy of Nutrition & Dietetics.\u00a0 You can check out more of Julie\u2019s thoughts on ketosis in her article Ketosis and Ketoacidosis: They May Be Sisters, but They\u2019re Certainly Not Twins<\/a> in AADE in Practice<\/em>.\u00a0 You can find her on social media @foodhelp123<\/a><\/p>\n

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  1. American Diabetes Association. 5. Lifestyle management: Standards of Medical Care in Diabetes 2019. Diabetes Care.<\/em> 2019;42(Suppl. 1):S46\u2013S60<\/a><\/li>\n
  2. McKenzie AL, Hallberg SJ, Creighton BC, et al. A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes<\/a>. JMIR Diabetes.<\/em> 2017;2(1):e5. doi: 10.2196\/diabetes.6981<\/li>\n
  3. Hallberg SJ, McKenzie AL, Williams PT. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study<\/a>. Diabetes Ther.<\/em> 2018; 9(2):583-612. doi: 10.1007\/s13300-018-0373-9.<\/li>\n
  4. Kalra S, Jain A, Ved J, Unnikrishnan AG. Sodium-glucose cotransporter 2 inhibition and health benefits: The Robin Hood effect.<\/a> Indian J Endocrinol Metab.<\/em> 2016; 20:725\u20139.<\/li>\n
  5. Lennerz BS, Barton A, Bernstein RK, et al. Management of Type 1 Diabetes With a Very Low-Carbohydrate Diet.\u00a0<\/a> 2018; 141(6). pii: e20173349. doi: 10.1542\/peds.2017-3349. Epub 2018 May 7.<\/li>\n<\/ol>\n

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