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and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data

Diabetes remission in newly diagnosed type 2 diabetes mellitus through short-term continuous subcutaneous insulin infusion intensive therapy combined with low-carbohydrate diet treatment

AIM/INTRODUCTION

To evaluate the therapeutic efficacy short-term continuous subcutaneous insulin infusion (CSII) intensive therapy combined with a low-carbohydrate diet (LCD) for diabetes remission in patients with newly diagnosed type 2 diabetes mellitus.

MATERIALS AND METHODS

This study included patients newly diagnosed with type 2 diabetes mellitus, who were randomly divided into two groups: conventional (conventional CSII + traditional lifestyle guidance); and intensive (intensive CSII + LCD lifestyle guidance). CSII was used for blood glucose control, with continuous glucose monitoring (CGM) used to monitor blood glucose levels. The primary outcome measure was hemoglobin A1c (HbA1c) level; secondary outcomes included body weight, body mass index (BMI), waist circumference, glycemic control, and biochemical indices.

RESULTS

The time in range (TIR) in the intensive treatment group was greater than that in the conventional treatment group (P < 0.05). There was no significant difference in the incidence of hypoglycemia between the two groups (P > 0.05). Compared with the conventional treatment group, diabetes remission rates were significantly greater in the intensive treatment group (P < 0.05). In the intensive treatment group, fasting plasma glucose (FPG), HbA1c, Homeostasis Model assessment of Insulin Resistance (HOMA-IR), triglycerides (TG), low-density lipoprotein cholesterol (LDL-c), and changes in body weight, BMI, visceral fat area (VFA), and subcutaneous fat area (SFA) decreased significantly (P < 0.05). FPG, HOMA-IR, TG, LDL-c, and changes in body weight, BMI, waist circumference, and VFA were significantly correlated with HbA1c levels (P < 0.05).

CONCLUSIONS

The combination of intensive CSII and LCD lifestyle guidance had been improved the remission rate in patients with newly diagnosed type 2 diabetes mellitus.

Efficacy and safety of 11 sodium-glucose cotransporter-2 inhibitors at different dosages in type 2 diabetes mellitus patients inadequately controlled with metformin: a Bayesian network meta-analysis

OBJECTIVES

Assess the efficacy and safety profiles of different sodium-glucose cotransporter-2 inhibitors (SGLT2is) as an add-on to metformin in type 2 diabetes mellitus (T2DM) patients.

DESIGN

Bayesian network meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov were searched before 18 December 2024.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) evaluating T2DM patients taking one of 12 SGLT2is as add-on therapy to metformin. Efficacy outcomes focused on glycated haemoglobin (HbA1c) reduction, fasting plasma glucose (FPG) reduction and weight loss (WL). Safety outcomes included adverse events (AEs), serious AEs (SAEs), hypoglycaemia, urinary tract infections (UTI) and genital infections (GI).

DATA EXTRACTION AND SYNTHESIS

Two investigators independently extracted data. The quality of the included studies was assessed using the Cochrane Risk of Bias Tool (V.2.0) for RCTs.

RESULTS

23 RCTs involving 9144 patients and 11 SGLT2is were included. Compared with placebo, most SGLT2is reduced HbA1c (mean difference (MD), -0.45~-0.80%), FPG (MD, -0.78~-2.02 mmol/L) and body weight (MD, -0.88~-2.67 kg). Only 10 mg of henagliflozin increased the incidence of AEs, and none of the included interventions increased the risks of SAEs or UTIs. 50 mg of empagliflozin exhibited higher risks of hypoglycaemia. Only 10 mg of empagliflozin increased the risk of GI. According to the surface under the cumulative ranking values, SGLT2is with optimal efficacy and safety were 15 mg of ertugliflozin in HbA1c reduction, 300 mg of canagliflozin in FPG reduction, WL and hypoglycaemia, 400 mg of sotagliflozin in total AEs, 10 mg of ertugliflozin and 150 mg of ipragliflozin in SAEs, 12.5 mg of ipragliflozin in UTI and 1 mg of ertugliflozin in GI.

CONCLUSIONS

As add-on therapy, SGLT2is demonstrated favourable antidiabetic efficacy and acceptable safety. 300 mg of canagliflozin was the best option among the included interventions considering favourable glucose control and WL. Some novel SGLT2is (eg, henagliflozin) exhibited promising efficacy and safety profiles, but more research is needed to validate the findings.

Overcoming dietary complexity in type 2 diabetes: influencing factors and coping strategies

BACKGROUND

Adherence to dietary guidelines is a fundamental aspect of diabetes management; however, it poses a significant challenge for patients with diabetes. Our research aims to assess the level of dietary compliance among individuals with type 2 diabetes (T2DM) and to identify the factors that influence their adherence to dietary advice.

METHODS

This study was a cross-sectional survey. The patients with T2DM undergoing treatment at our hospital from March, 2023, to June, 2024 were included. Compliance with dietary recommendations was assessed using the validated dietary compliance scale for type 2 diabetes mellitus patients (DCS-T2DM). Spearman correlation and logistic regression analyses were conducted to evaluate the factors influencing dietary compliance in patients with T2DM.

RESULTS

A total of 308 T2DM patients were included in our study. The results revealed that 46.10% of the participants had suboptimal dietary compliance. There were significant correlations between dietary compliance and several demographic and clinical factors, including age (r = 0.501), gender (r = 0.447), education level (r = 0.610), average monthly household per capita income (r = 0.627), and the duration, since T2DM diagnosis (r = 0.552), all of which were statistically significant (p < 0.05). Logistic regression identified age (OR = 1.705, 95%CI 1.262 ~ 1.987), gender (OR = 2.401, 95%CI 1.909 ~ 3.134), education level (OR = 3.083, 95%CI 2.434 ~ 3.957), average monthly household per capita income (OR = 3.721, 95%CI 2.553 ~ 4.405), and the time since T2DM diagnosis (OR = 2.470, 95%CI 1.755 ~ 3.262) as significant predictors of dietary compliance.

CONCLUSIONS

46.10% of patients with T2DM exhibited suboptimal dietary adherence, with age, gender, education, income, and diabetes duration significantly predicting compliance. It is imperative for healthcare providers to devise individualized intervention strategies that incorporate these pivotal factors to enhance dietary adherence in patients with T2DM.

Effectiveness of Calorie Restriction for Weight Loss in Type 2 Diabetes Mellitus: A Systematic Review

The effectiveness of calorie restriction (CR) for weight loss in type 2 diabetes mellitus (T2DM) has not been thoroughly studied. This review aims to evaluate CR's short- and long-term effectiveness for weight loss and its impact on cardiometabolic parameters in T2DM. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, Medline Complete, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched to identify studies up to June 7, 2024. Furthermore, a reference search was conducted. Randomized controlled trials involving adults with T2DM examining CR and reporting weight changes were included. The revised Cochrane risk-of-bias tool was used to assess the study's quality. A narrative synthesis was used to analyze the findings. Eleven studies, with 1,554 participants, were included; all had a low risk of bias. The intervention group participants' mean baseline weight and Body Mass Index were 93.3 kg and 32.7 kg/m², respectively. Interventions used included total diet replacement (TDR) and very low- and low-calorie diets lasting 12 weeks to two years. CR with TDR resulted in >12% weight loss. Additionally, CR improved cardiometabolic parameters; glycated hemoglobin (HbA1c) decreased to ≤6.5%; diabetes remission was achieved in 19% to 83%; high-density lipoprotein significantly increased; and triglyceride, systolic, and diastolic blood pressure significantly decreased. In conclusion, CR effectively reduces weight and improves cardiometabolic markers in T2DM. However, large long-term studies addressing CR in T2DM are lacking, which challenges drawing firm conclusions. This highlights the need for further research to address this gap. This review is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42024573505.

Impact of Probiotics on Triglyceride Level After Bariatric Surgery: A Trial Sequential Analysis

This meta-analysis and trial sequential analysis (TSA) investigated the effects of probiotic supplementation on triglyceride levels in patients after bariatric surgery. A comprehensive literature search identified seven randomized controlled trials involving 411 participants. The meta-analysis revealed a significant reduction in triglyceride levels favoring probiotic supplementation (mean difference =  - 18.46 mg/dL, 95% confidence interval [- 29.73, - 7.2], p = 0.001) with no heterogeneity (I2 = 0%). The observed reduction in triglycerides (18.46 mg/dL) exceeds the reported minimal clinically important difference (MCID) threshold for triglycerides (i.e., 7.97 mg/dL), suggesting clinically meaningful improvements. TSA confirmed that sufficient evidence has been accumulated to support the effect of probiotics on triglycerides, with the cumulative Z-curve crossing the required information size of 313 participants. These findings suggest that probiotic supplementation could be a valuable adjunct therapy for managing lipid profiles in patients undergoing bariatric surgery. Future research should focus on optimizing probiotic interventions, including identifying the most effective strains, dosages, and duration of supplementation.

Replacing dietary carbohydrate with protein and fat improves lipoprotein subclass profile and liver fat in type 2 diabetes independent of body weight: evidence from 2 randomized controlled trials

BACKGROUND

Dyslipidemia with elevated concentrations of triacylglycerol-rich lipoproteins (TRLs), small-dense LDL, and reduced HDL is linked to hepatic steatosis and promotes atherogenesis in type 2 diabetes (T2D).

OBJECTIVES

We aimed to analyze whether moderate carbohydrate restriction reduces liver fat in T2D independent of changes in body weight and whether this is accompanied by parallel improvements in plasma lipoprotein subclasses.

METHODS

We determined the density profile of circulating lipoproteins in patients with T2D from 2 previous randomized controlled trials. In the isoenergetic study, 30 participants were allocated in a crossover design to 6 + 6 wk of an isocaloric carbohydrate-reduced high-protein (CRHP, C/P/F = 30/30/40 E%) or conventional diabetes (CD, C/P/F = 50/17/33 E%) diet aimed at weight maintenance. In the hypoenergetic study, 72 participants were allocated in a parallel-group design to 6 wk of a hypocaloric CRHP or CD diet aimed at matched ∼6% weight loss. Both studies provided all meals from a metabolic kitchen to maximize adherence.

RESULTS

In the isoenergetic study, the CRHP diet reduced TRL (mean: -33%; 95% CI: -48%, -14%) and LDL5 (mean: -16%; 95% CI: -26%, -4%) and increased HDL2/HDL3 (mean: 10%; 95% CI: 0%, 22%) compared with the CD diet. In the hypoenergetic study, weight loss induced by CRHP diet tended to reduce TRL (mean: -16%; 95% CI: -30%, 1%), reduced LDL5 (mean: -13%; 95% CI: -22%, -3%), and increased HDL2/HDL3 (mean: 11%; 95% CI: 1%, 22%) compared with an equivalent weight loss induced by CD diet. The CRHP diet decreased intrahepatic triacylglycerol (IHTG) more than the CD diet (isoenergetic: -55%; 95% CI: -74%, -22%; hypoenergetic: -26%; 95% CI: -45%, 0%), and changes in IHTG correlated directly with changes in TRL and LDL5 (r = 0.36-0.55; P < 0.01 for all) in both studies.

CONCLUSIONS

Replacing dietary carbohydrate with protein and fat improves dyslipidemia in T2D independently of changes in body weight, by inducing an atheroprotective shift in the lipoprotein particle profile possibly facilitated by reduced IHTG accumulation. These trials were registered at clinicaltrials.gov as NCT02764021 (https://clinicaltrials.gov/study/NCT02764021?term=NCT02764021&rank=1) and NCT03814694 (https://clinicaltrials.gov/study/NCT03814694?term=NCT03814694&rank=1).

Ketogenic diet combined with intermittent fasting: an option for type 2 diabetes remission?

With increasing attention to diabetes remission, various special dietary patterns have been found to be effective in achieving diabetes remission. The effect of a single dietary pattern on lowering blood glucose is clear, but studies on the synergistic effects of different dietary patterns are limited. This article describes the types of intermittent fasting and ketogenic diets, potential mechanisms, contraindications of combination diets, recommendations for combination diets, and their health outcomes. This paper aims to illustrate the evidence for intermittent fasting combined with a ketogenic diet on outcomes of diabetes remission and effect on blood glucose control. Knowledge of these findings can help doctors and patients determine dietary patterns for achieving diabetes remission and understanding their application.

A whole-food, plant-based intensive lifestyle intervention improves glycaemic control and reduces medications in individuals with type 2 diabetes: a randomised controlled trial

AIMS/HYPOTHESIS

We conducted the largest and longest clinical trial comparing a whole-food, plant-based intervention with standard medical care (SMC) in individuals with type 2 diabetes.

METHODS

We randomised (parallel-arm; computerised 1:1 randomisation ratio) 169 adults aged 18-75 years with type 2 diabetes in the Marshall Islands to an intensive whole-food, plant-based intervention with moderate exercise (PB+Ex) or SMC for 24 weeks. The PB+Ex intervention included 12 weeks of meals, exercise sessions and group classes. Primary outcomes were glycaemic control (HbA1c, glucose, insulin and HOMA-IR) and glucose-lowering medication use. Secondary outcomes included lipids, blood pressure, heart rate and C-reactive protein. Only lab analysts were blinded.

RESULTS

Compared with SMC (n=90 randomised; n=70 analysed), the PB+Ex (n=79 randomised; n=66 analysed) intervention decreased HbA1c by an additional 14 mmol/mol (1.3%) at week 12 (-22 vs -7 mmol/mol [-2.0% vs -0.7%]; p<0.0001) and 8 mmol/mol (0.7%) at week 24 (-16 vs -8 mmol/mol [-1.4% vs -0.7%]; p=0.01). Concomitantly, 63% of medicated PB+Ex participants reduced their glucose-lowering medications (vs 24%; p=0.006), and 23% of PB+Ex participants with a baseline HbA1c <75 mmol/mol (<9%) achieved remission. Additionally, the PB+Ex intervention reduced weight (-2.7 kg; p<0.0001), C-reactive protein (-11 nmol/l; p=0.005) and cardiovascular medication use compared with SMC. At intermediate timepoints, it improved glucose, insulin, HOMA-IR, cholesterol, triglycerides and heart rate, but not at week 24.

CONCLUSIONS/INTERPRETATION

A whole-food, plant-based lifestyle intervention was more effective for improving glycaemic control than SMC. It also reduced the need for diabetes and cardiovascular medications and induced diabetes remission in some participants. Therefore, it is an effective, evidence-based lifestyle option for individuals with type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03862963 FUNDING: This research was funded by the Department of the Army (W81XWH-05-1-0547). CJH received support through a National Institutes of Health Predoctoral T32 Obesity Fellowship (T32 HL105349).

Study protocol, menu design, and rationale for a study testing the effects of a whole fruit-rich diet on glycemic control, liver fat, pancreatic fat, and cardiovascular health in adults with type 2 diabetes

Dietary interventions such as very-low-calorie diets and low-carbohydrate diets can improve glycemic control and even induce type 2 diabetes (T2D) remission. However, less is known about the effects of carbohydrate-rich whole foods, such as whole fruit, in people with T2D. Therefore, the aim of this pilot study is to investigate the effects of a whole fruit-rich diet on glycemic control, ectopic fat, and cardiovascular risk factors in adults with T2D. In this pilot study, sixteen adults aged 20 to 70 years with insulin-independent T2D for ≤6 years will complete a 12-week controlled-feeding intervention while maintaining their weight. During the ramp-up phase (weeks 1-4), participants progressively consume more whole fruit. During weeks 5 to 12, participants eat a fruit-rich Mediterranean diet providing 50% of calories as whole fruit (∼16.4 servings/day). All outcomes are measured at weeks 0, 4, and 12. The primary outcome is glycemic control, assessed hierarchically by whether participants achieve nondiabetic glucose concentrations without antihyperglycemic medications; the total dose of antihyperglycemic medications; mean glucose during a three-hour oral glucose tolerance test; and mean 24-hour glucose from continuous glucose monitoring. Secondary outcomes include intrahepatic lipid, pancreatic fat, blood pressure, heart rate, and serum lipids. We hypothesize that a fruit-rich diet will improve glycemic control, reduce the need for antihyperglycemic medications, decrease ectopic fat, and improve cardiovascular risk factors. This novel study will help determine the effects of a whole fruit-rich diet on glycemic control and liver fat and whether diabetes remission may be possible without losing weight. This study was registered at ClinicalTrials.gov (NCT03758742).

Types of dietary sugars and carbohydrates, cardiometabolic risk factors, and risk of diabetes: a cohort study from the general Danish population

BACKGROUND

The role of carbohydrates in diabetes risk is of particular interest due to conflicting results. This study aims to examine the prospective association between types of dietary carbohydrates (fiber, starch, total sugar, glucose, fructose, lactose, maltose, and added sugar) and the risk of diabetes. Further, this study examines the cross-sectional associations between these nutrients and cardiometabolic risk factors.

METHODS

Danish Health Examination Survey (2007-2008) investigated 76,484 Danes in a representative sample using online questionnaires. Dietary information using a food frequency questionnaire was obtained from 42,836 participants. Information on incident cases of diabetes was obtained from the Danish National Diabetes Register. Cox proportional hazard models were used to estimate Hazard Ratios (95% CI). Multiple linear regression analyses were used to assess the associations between carbohydrate types and cardiometabolic risk factors measured in a subsample of 12,977 participants.

RESULTS

During a median follow-up of 4.9 years, 970 participants developed diabetes. A higher consumption of fructose, but a lower consumption of glucose was associated with a lower risk of diabetes. In subgroup analyses, these associations were only significant among individuals with other risk factors, such as older age, obesity, low fiber consumption, sedentary behavior, smoking status, and hypertension. Participants with a higher intake of fiber tend to have a lower risk of diabetes and healthier anthropometric parameters compared to those with a lower intake.

CONCLUSIONS

Our findings suggest that a higher intake of dietary fiber and fructose is associated with a lower risk of diabetes and healthier metabolic status, while higher glucose intake is associated with a higher diabetes risk.

A data-driven machine learning algorithm to predict the effectiveness of inulin intervention against type II diabetes

Introduction

The incidence of type 2 diabetes mellitus (T2DM) has increased in recent years. Alongside traditional pharmacological treatments, nutritional therapy has emerged as a crucial aspect of T2DM management. Inulin, a fructan-type soluble fiber that promotes the growth of probiotic species like Bifidobacterium and Lactobacillus, is commonly used in nutritional interventions for T2DM. However, it remains unclear which type of T2DM patients are suitable for inulin intervention. The aim of this study was to predict the effectiveness of inulin treatment for T2DM using a machine learning model.

Methods

Original data were obtained from a previous study. After screening T2DM patients, feature election was conducted using LASSO regression, and a machine learning model was developed using XGBoost. The model's performance was evaluated based on accuracy, specificity, positive predictive value, negative predictive value and further analyzed using receiver operating curves, calibration curves, and decision curves.

Results

Out of the 758 T2DM patients included, 477 had their glycated hemoglobin (HbA1c) levels reduced to less than 6.5% after inulin intervention, resulting in an incidence rate of 62.93%. LASSO regression identified six key factors in patients prior to inulin treatment. The SHAP values for interpretation ranked the characteristic variables in descending order of importance: HbA1c, difference between fasting and 2 h-postprandial glucose levels, fasting blood glucose, high-density lipoprotein, age, and body mass index. The XGBoost prediction model demonstrated a training set accuracy of 0.819, specificity of 0.913, positive predictive value of 0.818, and negative predictive value of 0.820. The testing set showed an accuracy of 0.709, specificity of 0.909, positive predictive value of 0.705, and negative predictive value of 0.710.

Conclusion

The XGBoost-SHAP framework for predicting the impact of inulin intervention in T2DM treatment proves to be effective. It allows for the comparison of prediction effect based on different features of an individual, assessment of prediction abilities for different individuals given their features, and establishes a connection between machine learning and nutritional intervention in T2DM treatment. This offers valuable insights for researchers in this field.

The effects of low-carbohydrate diet on glucose and lipid metabolism in overweight or obese patients with T2DM: a meta-analysis of randomized controlled trials

Background

The dual burden of Type 2 Diabetes Mellitus (T2DM) and obesity is a critical public health issue. Low-carbohydrate diets have emerged as a potential intervention, yet clinical evidence remains inconclusive.

Purpose

This meta-analysis assesses the impact of low-carbohydrate diets on metabolic profiles in overweight or obese T2DM patients, aiming to guide clinical practice.

Methods

A systematic review identified randomized clinical trials (RCTs) comparing low-carbohydrate diets to control diets in T2DM patients from PubMed, Embase, and the Cochrane Library databases up to April 2023.

Results

Seventeen RCTs, encompassing 1,197 participants, demonstrated that low-carbohydrate diets significantly improved HbA1c levels and fasting plasma glucose (mean difference [MD] = -0.36, 95% CI -0.44 to -0.29, p < 0.00001; MD = -10.71, 95% CI -14.39 to -7.03, p < 0.00001). They also reduced triglycerides and increased HDL cholesterol (MD = -19.91, 95% CI -28.83 to -10.99, p < 0.00001; MD = 2.49, 95% CI 1.07-3.91, p = 0.0006), without affecting LDL and total cholesterol. Weight loss, reduced BMI, lower diastolic blood pressure, and decreased waist circumference were additional benefits.

Conclusion

Low-carbohydrate diets may enhance glycemic control and lipid profiles in overweight or obese T2DM patients, warranting consideration in T2DM management. However, the variability in diet definitions and methodologies underscores the necessity for further research to standardize dietary guidelines and evaluate long-term effects.

Assessing the impact of intermittent fasting and a low-carbohydrate-high-protein diet on metabolic health and pancreatic histopathology in type 2 diabetic rat model

Objective

The current study was conducted to investigate the effect of intermittent fasting (IF) with a low-carbohydrate-high-protein (LCHP) diet on blood glucose control in streptozotocin (STZ)-nicotinamide-induced type 2 diabetic rats (DR).

Methods

Thirty male Wistar rats were divided into six groups (n = 5) including a group of normal rats (NR) that received a control diet (CD) (50% carbohydrates, 17% protein, and 33% fat) with ad libitum (AL) feeding. The remaining 5 groups were DR injected with STZ and fed on CD or LCHP diet (40% carbohydrates, 30% protein, and 30% fat) for 6 weeks, either AL or IF (with a time-restricted feeding of 16 h followed by 8 h feeding period). There was a standard control group treated with metformin and fed on CD with AL feeding. A random blood glucose was measured. Changes in body weight and feed intake (FI) were monitored weekly.

Results

Feeding rats on LCHP and IF and their combination significantly reduced FI, body weight gain, blood glucose (P < 0.001), and improved insulin resistance (P < 0.05) with no effect on the insulin levels (P > 0.05). LCHP and IF decreased the levels of triglycerides and very-low-density lipoprotein and showed a possible protection against atherosclerosis by reducing the atherogenic index (P < 0.01). Furthermore, LCHP+IF greatly alleviates the pancreatic histopathological changes induced by STZ and showed the normal histological structure of the Langerhans islets.

Conclusion

IF with a LCHP diet could be effectively used in improving the indicators of glucose control, and reversing pancreatic histopathological alterations in type 2 diabetes.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Low-carbohydrate diets in East Asians with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIMS

Despite the reported success of low-carbohydrate diets in improving glycemic control in the Western countries, no studies have investigated the effects of such diets in Asians. We aimed to conduct a systematic review and meta-analysis of randomized controlled trials to examine the effects of low-carbohydrate diets on glycemic control in East Asian adults.

MATERIALS AND METHODS

We systematically searched the PubMed, Cochrane Library, and Embase databases from inception to June 28, 2023, to identify randomized controlled trials examining the efficacy of low-carbohydrate diets in patients with type 2 diabetes (PROSPERO number CRD 42023453007). The primary outcome was the difference in glycated hemoglobin levels between the low-carbohydrate diet and control groups. The secondary outcome was the difference in body mass index, fasting blood glucose level, blood pressure, and lipid profile.

RESULTS

Six randomized controlled trials met the eligibility criteria. The study duration ranged from 3 to 18 months, with five studies conducted within 6 months. The results showed that low-carbohydrate diets were more beneficial in lowering glycated hemoglobin levels and body mass index than control diets. The risk of bias for the six studies was minimal for two and moderate for four. The heterogeneity among the studies was low.

CONCLUSIONS

Low-carbohydrate diets improved glycated hemoglobin levels and body mass index in East Asians compared with control diets. Therefore, carbohydrate restriction may be effective for glycemic management in East Asians with type 2 diabetes for at least 6 months.

The effect of probiotics on gestational diabetes mellitus: an umbrella meta-analysis

BACKGROUND

Prior studies indicated the positive effects of probiotics on glycemic regulation in patients with gestational diabetes mellitus (GDM). Nonetheless, the results remain inconclusive. To address this, we conducted an umbrella meta-analysis to evaluate the impact of probiotics on glycemic indicators in GDM.

METHODS

A comprehensive search was conducted on the PubMed and Scopus databases to identify all relevant meta-analyses of randomized clinical trials published until July 2024. The outcomes included serum hemoglobin A1C (HbA1c), fasting blood insulin (FBI), fasting blood sugar (FBS), homeostatic model assessment for insulin resistance (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), homeostatic model assessment of beta cell function (HOMA-B), C-peptide, and oral glucose tolerance test (OGTT). Standardized mean difference (SMD) was used to test the effects.

RESULTS

In total, 27 studies, comprising 33,378 participants, were included in the analysis. Probiotics resulted in a significant decrease in FBS (SMD: -0.39, 95% CI: -0.56 to -0.23), especially when administered for ≤ 7 weeks. Significant reductions were also observed in FBI (SMD: -1.99, 95% CI: -2.41 to -1.58), HOMA-IR (SMD: -0.61, 95% CI: -0.72 to -0.50), and HOMA-B (SMD: -24.58, 95% CI: -30.59 to -18.56). Moreover, supplementation with probiotics significantly improved QUICKI (SMD: 0.007, 95% CI: 0.004 to 0.01). There was significant evidence of heterogeneity and publication bias. No significant effects were observed on 1-h OGTT, 2-h OGTT, HbA1c, and C-peptide. No dose-specific effect was observed.

CONCLUSIONS

Supplementation with probiotics could improve glycemic control in women with GDM. The effects of probiotics on HOMA-IR, HOMA-B, and fasting insulin were clinically important, while, their effect on FBS was not clinically important.

Personalized nutrition in type 2 diabetes remission: application of digital twin technology for predictive glycemic control

Background

Type 2 Diabetes (T2D) is a complex condition marked by insulin resistance and beta-cell dysfunction. Traditional dietary interventions, such as low-calorie or low-carbohydrate diets, typically overlook individual variability in postprandial glycemic responses (PPGRs), which can lead to suboptimal management of the disease. Recent advancements suggest that personalized nutrition, tailored to individual metabolic profiles, may enhance the effectiveness of T2D management.

Objective

This study aims to present the development and application of a Digital Twin (DT) technology-a machine learning (ML)-powered platform designed to predict and modulate PPGRs in T2D patients. By integrating continuous glucose monitoring (CGM), dietary data, and other physiological inputs, the DT provides individualized dietary recommendations to improve insulin sensitivity, reduce hyperinsulinemia, and support the remission of T2D.

Methods

We developed a sophisticated DT platform that synthesizes real-time data from CGM, dietary logs, and other biometric inputs to create personalized metabolic models for T2D patients. The intervention is delivered via a mobile application, which dynamically adjusts dietary recommendations based on predicted PPGRs. This methodology is validated through a randomized controlled trial (RCT) assessing its impact on various metabolic markers, including HbA1c, metabolic-associated fatty liver disease (MAFLD), blood pressure, body weight, ASCVD risk, albuminuria, and diabetic retinopathy.

Results

Preliminary data from the ongoing RCT and real-world study demonstrate the DT's capacity to generate significant improvements in glycemic control and metabolic health. The DT-driven personalized nutrition plan has been associated with reductions in HbA1c, enhanced beta-cell function, and normalization of hyperinsulinemia, supporting sustained T2D remission. Additionally, the DT's predictions have contributed to improvements in MAFLD markers, blood pressure, and cardiovascular risk factors, highlighting its potential as a comprehensive management tool.

Conclusion

The DT technology represents a novel and scalable approach to personalized nutrition in T2D management. By addressing individual variability in PPGRs, this method offers a promising alternative to conventional dietary interventions, with the potential to improve long-term outcomes and reduce the global burden of T2D.

Acupuncture as an Adjunct to Lifestyle Interventions for Weight Loss in Simple Obesity: A Systematic Review and Meta-Analysis

Objective

This study aims to evaluate the efficacy of acupuncture as an adjunct to lifestyle interventions on weight loss in simple obesity.

Methods

Potentially eligible studies that assessed anthropometric outcomes as well as glucose and lipid metabolism following acupuncture combined with lifestyle interventions in simple obesity patients were searched from eight databases from inception to October 2023. All analyses were performed using the Review Manager software v5.4 and Stata software v17.0.

Results

Herein, 25 randomized controlled trials (RCTs) involving 2018 patients were included. Generally, acupuncture combined with lifestyle interventions outperformed lifestyle interventions alone in terms of body weight (MD = -4.73, 95% CI [-6.32, -3.13], p < 0.00001), body mass index (BMI) (MD = -2.11, 95% CI [-2.75, -1.48], p < 0.00001), waist circumference (WC) (MD = -4.96, 95% CI [-6.89, -3.03], p < 0.00001), body fat percentage (BF %) (MD = -2.61, 95% CI [-4,51, -0.71], p = 0.007), fasting plasma glucose (FPG) (SMD = -0.66, 95% CI [-1.02, -0.31], p = 0.0002), fasting serum insulin (FINS) (SMD = -1.12, 95% CI [-1.44, -0.81], p < 0.00001), homeostasis model assessment-insulin resistance (HOMA-IR) (MD = -1.22, 95% CI [-1.50, -0.94], p < 0.00001), total cholesterol (TC) (SMD = -1.14, 95% CI [-1.83, -0.45], p = 0.001), triglyceride (TG) (SMD = -1.31, 95% CI [-2.07, -0.56], p = 0.0006), and low-density lipoprotein cholesterol (LDL-C) (SMD = -1.81, 95% CI [-3.11, -0.51], p = 0.006). Subgroup analysis based on three subgroup variables (types of acupuncture and lifestyle interventions as well as treatment durations) could partially explain the heterogeneity of the results.

Conclusion

Acupuncture demonstrated an enhancing effect on the benefits of lifestyle interventions for weight loss in patients with simple obesity, including reducing body weight and improving glucose and lipid metabolism. This finding suggests its potential value as a complementary therapy alongside lifestyle interventions in a clinical setting. However, further validation with rigorously designed and high-quality RCTs is still needed in the future.

Added Value of Medical Subject Headings Terms in Search Strategies of Systematic Reviews: Comparative Study

BACKGROUND

The massive increase in the number of published scientific articles enhances knowledge but makes it more complicated to summarize results. The Medical Subject Headings (MeSH) thesaurus was created in the mid-20th century with the aim of systematizing article indexing and facilitating their retrieval. Despite the advent of search engines, few studies have questioned the relevance of the MeSH thesaurus, and none have done so systematically.

OBJECTIVE

The objective of this study was to estimate the added value of using MeSH terms in PubMed queries for systematic reviews (SRs).

METHODS

SRs published in 4 high-impact medical journals in general medicine over the past 10 years were selected. Only SRs for which a PubMed query was provided were included. Each query was transformed to obtain 3 versions: the original query (V1), the query with free-text terms only (V2), and the query with MeSH terms only (V3). These 3 queries were compared with each other based on their sensitivity and positive predictive values.

RESULTS

In total, 59 SRs were included. The suppression of MeSH terms had an impact on the number of relevant articles retrieved for 24 (41%) out of 59 SRs. The median (IQR) sensitivities of queries V1 and V2 were 77.8% (62.1%-95.2%) and 71.4% (42.6%-90%), respectively. V1 queries provided an average of 2.62 additional relevant papers per SR compared with V2 queries. However, an additional 820.29 papers had to be screened. The cost of screening an additional collected paper was therefore 313.09, which was slightly more than triple the mean reading cost associated with V2 queries (88.67).

CONCLUSIONS

Our results revealed that removing MeSH terms from a query decreases sensitivity while slightly increasing the positive predictive value. Queries containing both MeSH and free-text terms yielded more relevant articles but required screening many additional papers. Despite this additional workload, MeSH terms remain indispensable for SRs.

Differential Efficacy of Weight Loss Interventions in Patients with Versus Without Diabetes

Obesity is both a major risk factor for diabetes and a serious comorbidity of the condition. The twin epidemics of obesity and diabetes have spread globally over the past few decades. Treatment of obesity in patients with diabetes provides a host of clinical benefits that encompass virtually all body systems. Despite this, multiple lines of evidence suggest that the efficacy of most therapies for weight loss is significantly reduced among patients with diabetes. With this background, we summarize the evidence of a differential effect of lifestyle, pharmacological, and surgical treatments for obesity in patients with existing diabetes, and explore the potential mechanisms involved in this phenomenon. This information is then used to formulate strategies to improve weight loss outcomes for patients with diabetes.

Short-term high-fat and high-carb diet effects on glucose metabolism and hedonic regulation in young healthy men

Background

Daily dietary intake of macronutrients and energy is closely associated with long-term metabolic health outcomes, but whether 24-h nutritional intervention under isocaloric conditions leads to changes in metabolism remains unclear. Moreover, the short-term effect of diets with different macronutrient composition on hedonic appetite regulation is less clear.

Methods

This study examined the impact of an acute high-fat (F+) and high-carbohydrate (C+) diet on glucose metabolism and hedonic regulation of food intake in young healthy men under controlled conditions. Using a cross-over design, 19 male participants received a one-day isocaloric diet with different macronutrient composition (F+ = 11% carbohydrates, 74% fat; C+ = 79% carbohydrates, 6% fat) compared to a control diet (CON = 55% carbohydrates, 30% fat). Protein content was set at 15% of energy in all diets. The feeling of hunger, as well as "liking" and "wanting" for foods, was assessed through visual analog scales, and blood samples for glucose, insulin, and cortisol levels were assessed repeatedly during the experimental day. An intravenous glucose tolerance test was conducted the next morning.

Results

Postprandial glucose and insulin levels were lowest in F+ over the 24 h. Except for dinner, the CON diet showed the highest mean values in glucose. F+ diet improved insulin resistance, lowering Homeostatis Model Assessment Insulin Resistance (HOMA-IR) values. Changes in hedonic regulation of food intake were not observed during the intervention between the diets, except for higher feelings of satiety under the CON diet.

Conclusion

An acute, isocaloric, high-fat diet improved insulin resistance even in healthy individuals but did not affect hedonic food intake regulation. Macronutrient composition modulate glucose metabolism even under short-term (24-h) and isocaloric diets, which should be considered for personalized preventive dietary treatments.

One-year outcomes of a digital twin intervention for type 2 diabetes: a retrospective real-world study

This retrospective observational study, building on prior research that demonstrated the efficacy of the Digital Twin (DT) Precision Treatment Program over shorter follow-up periods​​, aimed to examine glycemic control and reduced anti-diabetic medication use after one-year in a DT commercial program. T2D patients enrolled had adequate hepatic and renal function and no recent cardiovascular events. DT intervention powered by artificial intelligence utilizes precision nutrition, activity, sleep, and deep breathing exercises. Outcome measures included HbA1c change, medication reduction, anthropometrics, insulin markers, and continuous glucose monitoring (CGM) metrics. Of 1985 enrollees, 132 (6.6%) were lost to follow-up, leaving 1853 participants who completed one-year. At one-year, participants exhibited significant reductions in HbA1c [mean change: -1.8% (SD 1.7%), p < 0.001], with 1650 (89.0%) achieving HbA1c below 7%. At baseline, participants were on mean 1.9 (SD 1.4) anti-diabetic medications, which decreased to 0.5 (SD 0.7) at one-year [change: -1.5 (SD 1.3), p < 0.001]. Significant reductions in weight [mean change: -4.8 kg (SD 6.0 kg), p < 0.001], insulin resistance [HOMA2-IR: -0.1 (SD 1.2), p < 0.001], and improvements in β-cell function [HOMA2-B: +21.6 (SD 47.7), p < 0.001] were observed, along with better CGM metrics. These findings suggest that DT intervention could play a vital role in the future of T2D care.

Ketogenic Diet: A Review of Composition Diversity, Mechanism of Action and Clinical Application

The ketogenic diet (KD) is a special high-fat, very low-carbohydrate diet with the amount of protein adjusted to one's requirements. By lowering the supply of carbohydrates, this diet induces a considerable change in metabolism (of protein and fat) and increases the production of ketone bodies. The purpose of this article is to review the diversity of composition, mechanism of action, clinical application and risk associated with the KD. In the last decade, more and more results of the diet's effects on obesity, diabetes and neurological disorders, among other examples have appeared. The beneficial effects of the KD on neurological diseases are related to the reconstruction of myelin sheaths of neurons, reduction of neuron inflammation, decreased production of reactive oxygen species, support of dopamine production, repair of damaged mitochondria and formation of new ones. Minimizing the intake of carbohydrates results in the reduced absorption of simple sugars, thereby decreasing blood glucose levels and fluctuations of glycaemia in diabetes. Studies on obesity indicate an advantage of the KD over other diets in terms of weight loss. This may be due to the upregulation of the biological activity of appetite-controlling hormones, or to decreased lipogenesis, intensified lipolysis and increased metabolic costs of gluconeogenesis. However, it is important to be aware of the side effects of the KD. These include disorders of the digestive system as well as headaches, irritability, fatigue, the occurrence of vitamin and mineral deficiencies and worsened lipid profile. Further studies aimed to determine long-term effects of the KD are required.

Mapping the evolution and impact of ketogenic diet research on diabetes management: a comprehensive bibliometric analysis from 2005 to 2024

Objective

The ketogenic diet (KD) has been explored for diabetes management; however, a quantitative synthesis of its specific effects on diabetes has not yet been conducted. This study aims to examine the current status and research hotspots of KD in diabetes management from 2005 to 2024, providing a reference for future research.

Methods

We retrieved articles published between 2005 and 2024 from the Web of Science database and analyzed them using R software, VOSviewer, and CiteSpace.

Results

This study includes 432 relevant publications. From 2005 to 2024, the volume of literature in this field has shown a steady upward trend, with a notable increase from 2017 to 2021, and a slight decline observed from 2021 to 2023. The United States is the leading country in terms of the number of publications, followed by China, Australia, and Canada. The United States not only leads in publication volume but also maintains a broader international collaboration network. Nutrients and the American Journal of Clinical Nutrition are the most frequently published and cited journals. Current research hotspots primarily focus on the impact of KD on blood glucose control, insulin resistance, and lipid metabolism in diabetic patients. Mechanistic studies on KD in diabetes management concentrate on aspects such as the "regulation of genes by β-hydroxybutyrate," "anti-inflammatory effects," and "oxidative stress." The role of the gut microbiome is also emerging as an important research area. Currently, exploring the application of KD in managing different age groups and types of diabetes has become a significant research trend.

Conclusion

As an emerging dietary intervention, KD is gradually attracting widespread attention from researchers around the world and is expected to become a major research focus in the future for diabetes management and control. This paper provides a systematic review and analysis of the current research status and hotspots of KD in diabetes management, offering important references and insights for future research in related fields.

Type 2 diabetes mellitus in adults: pathogenesis, prevention and therapy

Type 2 diabetes (T2D) is a disease characterized by heterogeneously progressive loss of islet β cell insulin secretion usually occurring after the presence of insulin resistance (IR) and it is one component of metabolic syndrome (MS), and we named it metabolic dysfunction syndrome (MDS). The pathogenesis of T2D is not fully understood, with IR and β cell dysfunction playing central roles in its pathophysiology. Dyslipidemia, hyperglycemia, along with other metabolic disorders, results in IR and/or islet β cell dysfunction via some shared pathways, such as inflammation, endoplasmic reticulum stress (ERS), oxidative stress, and ectopic lipid deposition. There is currently no cure for T2D, but it can be prevented or in remission by lifestyle intervention and/or some medication. If prevention fails, holistic and personalized management should be taken as soon as possible through timely detection and diagnosis, considering target organ protection, comorbidities, treatment goals, and other factors in reality. T2D is often accompanied by other components of MDS, such as preobesity/obesity, metabolic dysfunction associated steatotic liver disease, dyslipidemia, which usually occurs before it, and they are considered as the upstream diseases of T2D. It is more appropriate to call "diabetic complications" as "MDS-related target organ damage (TOD)", since their development involves not only hyperglycemia but also other metabolic disorders of MDS, promoting an up-to-date management philosophy. In this review, we aim to summarize the underlying mechanism, screening, diagnosis, prevention, and treatment of T2D, especially regarding the personalized selection of hypoglycemic agents and holistic management based on the concept of "MDS-related TOD".

The effects of curcumin supplementation on biomarkers of inflammation, oxidative stress, and endothelial function: A meta-analysis of meta-analyses

Numerous interventional studies have revealed the beneficial impact of curcumin supplementation on inflammation, oxidative stress, and endothelial function biomarkers, but the findings are still inconsistent. Thus, this study was conducted to investigate the effects of curcumin supplementation on inflammation, oxidative stress, and endothelial function biomarkers. A meta-analyses of randomized clinical trials was performed by searching PubMed, Embase, Scopus, and Web of Science up to March 31, 2024. Pooled estimates of 21 meta-analyses revealed that curcumin significantly reduced CRP (weighted mean difference (WMD) = -0.87; 95 % CI: - 1.14, - 0.59, P< 0.001), tumor-necrosis factor-alpha (TNF-α) (WMD = -2.72; 95 % CI: -4.05, -1.38; P< 0.001), interleukin-6 (IL-6) (WMD = -0.97, 95 % CI: -1.40, -0.54; P< 0.001), malondialdehyde (MDA) (Effect size (ES) = -0.81; 95 % CI: -1.39, -0.23, P = 0.006) and pulse wave velocity (PWV) (WMD = -45.60; 95 % CI: -88.16, -3.04, P = 0.036), and increased flow-mediated dilation (FMD) (WMD = 1.64, 95 % CI: 1.06, 2.22, P < 0.001), catalase (CAT) (WMD = 10.26; 95 % CI: 0.92, 19.61, P= 0.03), glutathione peroxidase (GPx) (WMD = 8.90; 95 % CI: 6.62, 11.19, P <0.001), and superoxide dismutase (SOD) levels (WMD = 20.51; 95 % CI: 7.35, 33.67, P= 0.002 and SMD = 0.82; 95 % CI: 0.27, 1.38, P= 0.004). However, curcumin did not significantly change total antioxidant capacity (TAC) (ES = 0.29; 95 % CI: -0.09, 0.66, P= 0.059). These results suggest that curcumin has a beneficial effect on CRP, IL-6, TNF-α, SOD, GPx, CAT, MDA, PWV, and FMD levels and may be an effective adjunctive therapy for improving inflammation, oxidative stress, and endothelial function. Registration number: PROSPERO, CRD42024539018.

Association patterns of ketone bodies with the risk of adverse outcomes according to diabetes status

AIM

To investigate the associations between ketone bodies (KB) and multiple adverse outcomes including cardiovascular disease (CVD), chronic kidney disease (CKD) and all-cause mortality according to diabetes status.

METHODS

This prospective study included 222 824 participants free from CVD and CKD at baseline from the UK Biobank. Total KB including β-hydroxybutyrate, acetoacetate and acetone were measured by nuclear magnetic resonance. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between KB and adverse outcomes among participants with normoglycaemia, prediabetes and type 2 diabetes, respectively.

RESULTS

During a mean follow-up of 14.1 years, 24 088 incident CVD events (including 17 303 coronary heart disease events, 5172 stroke events and 5881 heart failure [HF] events), 8605 CKD events and 15 813 deaths, were documented. Higher total KB significantly increased the risk of HF among participants with normoglycaemia (HR, 1.32 [95% CI, 1.17-1.49], per 10-fold increase in total KB) and prediabetes (1.35 [1.04-1.76]), and increased the risk of CKD among those with normoglycaemia (1.20 [1.09-1.33]). Elevated KB levels were associated with an increased risk of all-cause mortality across the glycaemic spectrum (1.32 [1.23-1.42] for normoglycaemia, 1.45 [1.24-1.71] for prediabetes and 1.47 [1.11-1.94] for diabetes). Moreover, a significant additive interaction between KB and diabetes status was observed on the risk of death (P = .009), with 4.9% of deaths attributed to the interactive effects.

CONCLUSIONS

Our study underscored the variation in association patterns between KB and adverse outcomes according to diabetes status and suggested that KB could interact with diabetes status in an additive manner to increase the risk of mortality.

Low-Carbohydrate Dietary Interventions for Metabolic Control in Individuals With Type 2 Diabetes Mellitus: An Overview of Systematic Reviews

CONTEXT

Dietary interventions providing different amounts of carbohydrates have been proposed as a means of achieving glycemic control and weight loss in type 2 diabetes mellitus (T2DM); however, the supporting evidence is heterogeneous, making this recommendation difficult to apply in nutritional clinical practice.

OBJECTIVE

The aim was to assess the quality of evidence from meta-analyses on low-carbohydrate (LC) dietary interventions for glycemic control, weight loss, and lipid profile in individuals with T2DM.

DATA SOURCES

The MEDLINE, Web of Science, and Scopus databases were searched until September 2023.

DATA EXTRACTION

A systematic review was conducted. Systematic reviews with meta-analysis of randomized clinical trials designed to assess glycated hemoglobin (HbA1c) reductions in individuals with T2DM were eligible. The AMSTAR-2 critical appraisal tool was used to evaluate the methodological aspects of all included studies. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to assess the certainty of the evidence.

DATA ANALYSIS

The LC interventions were associated with a reduction in HbA1c (%) of -0.42 (-1.45 to -0.09; high certainty of evidence) without considering follow-up time; at up to 3 months of follow-up of -0.28 (-0.13 to -0.43); at up to 6 months of follow-up of -0.40 (-0.61 to -0.09); at 6 to 12 months of follow-up of -0.32 (-0.49 to 0.11); and at >12 months of follow-up time of -0.31 (-0.14 to -0.65) compared with control diets.

CONCLUSION

LC diets can help reduce HbA1c in individuals with T2DM in the short term (up to 3 months). However, dietary recommendations must always be individualized, as the studies reviewed herein analyzed different populations and used different definitions of what constitutes an LC diet.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO no. CRD42023404197.

A Cross-Sectional Study Investigating Associations between Personality Traits, Glycemic Control, and BMI in Persons with Diabetes: Lolland-Falster Health Study, Denmark

There is a growing focus on person-centered care, emphasizing the importance of respecting inter-individual differences and implementing individualized treatment initiatives. Prior research has established an association between personality traits, body mass index, and health-related behaviors. The aim of this study was to explore the potential of personality trait assessments in identifying individuals at risk of glycemic dysregulation and increasing BMI. This cross-sectional study used a dataset comprising 140 participants with diabetes who completed the Big Five personality trait questionnaire from the Lolland-Falster Health Study. Logistic regression was used to investigate associations between personality traits, glycemic control, and BMI ≥ 25. No significant associations between personality traits and glycemic control were found. There was a significant association between agreeableness and lower odds of BMI ≥ 25 in the unadjusted analysis (OR 0.54 (0.34-0.86)), which persisted after adjusting for sex, age, and education (OR 0.54 (0.33-0.89)). No significant association between glycemic control and personality traits was observed in this small sample study. However, higher levels of agreeableness were associated with a lower likelihood of having a BMI of ≥25. This preliminary study suggests that integrating personality assessments could help identify individuals at risk of increasing BMI. These findings highlight the potential of using personality traits to guide targeted interventions, offering a direction for future research.

Advances and counterpoints in type 2 diabetes. What is ready for translation into real-world practice, ahead of the guidelines

This review seeks to address major gaps and delays between our rapidly evolving body of knowledge on type 2 diabetes and its translation into real-world practice. Through updated and improved best practices informed by recent evidence and described herein, we stand to better attain A1c targets, help preserve beta cell integrity and moderate glycemic variability, minimize treatment-emergent hypoglycemia, circumvent prescribing to "treatment failure," and prevent long-term complications. The first topic addressed in this review concerns updates in the 2023 and 2024 diabetes treatment guidelines for which further elaboration can help facilitate integration into routine care. The second concerns advances in diabetes research that have not yet found their way into guidelines, though they are endorsed by strong evidence and are ready for real-world use in appropriate patients. The final theme addresses lingering misconceptions about the underpinnings of type 2 diabetes-fundamental fallacies that continue to be asserted in the textbooks and continuing medical education upon which physicians build their approaches. A corrected and up-to-date understanding of the disease state is essential for practitioners to both conceptually and translationally manage initial onset through late-stage type 2 diabetes.

Effectiveness and safety of Liriope Tuber (Liriopis seu Ophiopogonis Tuber, Maidong) included traditional herbal medicine for patients with paroxysmal atrial fibrillation: A systematic review, meta-analysis, and network analysis

Background

Conventional medicine (CM) for paroxysmal atrial fibrillation (PAF) have limitations and side effects. Integrative approaches, including traditional herbal medicines like Liriope Tuber, are being explored for potential benefits, although evidence remains limited.

Methods

In April 2023, a literature search was conducted across nine databases, focusing on randomized controlled trials assessing the effects of Liriope Tuber in traditional herbal medicine (LTHM) on PAF. The risk of bias was evaluated using Version 2 of the Cochrane risk-of-bias tool for randomized trials. A random-effects model was employed for the meta-analysis.

Results

A total of 43 studies with 3,743 participants were included. The meta-analysis indicated that adding LTHM to CM reduced PAF frequency (SMD = -0.99, 95 % CI = -1.40 to -0.57, I² = 88 %, N = 16, n = 1266), left atrium diameter (LAD) (MD = -2.39 mm, 95 % CI = -3.09 to -1.68), P-wave dispersion (Pd) (MD = -6.41 ms, 95 % CI = -8.44 to -4.37), high sensitive C-Reactive Protein (hs-CRP) (MD = -1.10 mg/l, 95 % CI = -1.73 to -0.47), and improved left ventricular ejection fraction (LVEF) (MD = 4.71 %, 95 % CI = 3.17 to 6.25). Thirty-four studies raised concerns about bias, with eight showing high risk. Certainty of evidence was rated as "low" for PAF frequency, LAD, Pd, hs-CRP, and LVEF.

Conclusion

LTHM combined with CM may reduce PAF frequency. However, due to the complexity of interventions, with Liriope Tuber being only one component of the regimen, high risk of bias, substantial heterogeneity, and indirectness, interpretations should be cautious.

Study registration

PROSPERO (ID: CRD42023477926).

Association between low-carbohydrate-diet score, glycemia and cardiovascular risk factors in adults with type 1 diabetes

BACKGROUND AND AIMS

Low-carbohydrate-diets (LCDs) are gaining popularity in individuals with type 1 diabetes (T1D). However, the impact of such diets on glycemia and cardiovascular risk factors is debated. This study aims to evaluate associations between low-carbohydrate intakes using LCD score with glycemia and cardiovascular risk factors (lipid profile) in adults with T1D or LADA in Québec, Canada.

METHODS AND RESULTS

This is a cross-sectional study using data collected in the BETTER registry (02/2019 and 04/2021) including self-reported 24-h dietary recalls to calculate LCD scores, waist circumference, level-2 and level-3 hypoglycemic episodes and measured biochemical data (HbA1c, LDL-cholesterol and non-HDL-cholesterol). Participants were divided into quartiles (Q) based on LCD scores. Two hundred eighty-five adults (aged 48.2 ± 15.0 years; T1D duration 25.9 ± 16.2 years) were included. Categorical variables underwent Chi-squared/Fisher's Exact tests, while continuous variables underwent ANOVA tests. Mean carbohydrate intake ranged from 31.2 ± 6.9% (Q1) to 56.5 ± 6.8% (Q4) of total daily energy. Compared to Q4, more people in Q1 reported HbA1c ≤ 7% [≤53.0 mmol/mol] (Q1: 53.4% vs. Q4: 29.4%; P = 0.011). The same results were found in the models adjusted for age, sex and T1D duration. A greater proportion of participants in Q1 never experienced level-3 hypoglycemia compared to Q3 (Q1: 60.0% vs. Q3: 31.0%; P = 0.004). There were no differences across quartiles for frequency of level-2 hypoglycemia events and lipid profile (LDL-cholesterol and non-HDL-cholesterol).

CONCLUSIONS

Low-carbohydrate intakes are associated with higher probabilities of reaching HbA1c target and of never having experienced level-3 hypoglycemia. No associations with level-2 hypoglycemia frequency, nor cardiovascular risk factors were observed.

Advances in small-molecule insulin secretagogues for diabetes treatment

Diabetes, a metabolic disease caused by abnormally high levels of blood glucose, has a high prevalence rate worldwide and causes a series of complications, including coronary heart disease, stroke, peripheral vascular disease, end-stage renal disease, and retinopathy. Small-molecule compounds have been developed as drugs for the treatment of diabetes because of their oral advantages. Insulin secretagogues are a class of small-molecule drugs used to treat diabetes, and include sulfonylureas, non-sulfonylureas, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase 4 inhibitors, and other novel small-molecule insulin secretagogues. However, many small-molecule compounds cause different side effects, posing huge challenges to drug monotherapy and drug selection. Therefore, the use of different small-molecule drugs must be improved. This article reviews the mechanism, advantages, limitations, and potential risks of small-molecule insulin secretagogues to provide future research directions on small-molecule drugs for the treatment of diabetes.

Nutritional Considerations During Major Weight Loss Therapy: Focus on Optimal Protein and a Low-Carbohydrate Dietary Pattern

PURPOSE OF REVIEW

Considering the high prevalence of obesity and related metabolic impairments in the population, the unique role nutrition has in weight loss, reversing metabolic disorders, and maintaining health cannot be overstated. Normal weight and well-being are compatible with varying dietary patterns, but for the last half century there has been a strong emphasis on low-fat, low-saturated fat, high-carbohydrate based approaches. Whereas low-fat dietary patterns can be effective for a subset of individuals, we now have a population where the vast majority of adults have excess adiposity and some degree of metabolic impairment. We are also entering a new era with greater access to bariatric surgery and approval of anti-obesity medications (glucagon-like peptide-1 analogues) that produce substantial weight loss for many people, but there are concerns about disproportionate loss of lean mass and nutritional deficiencies.

RECENT FINDINGS

No matter the approach used to achieve major weight loss, careful attention to nutritional considerations is necessary. Here, we examine the recent findings regarding the importance of adequate protein to maintain lean mass, the rationale and evidence supporting low-carbohydrate and ketogenic dietary patterns, and the potential benefits of including exercise training in the context of major weight loss. While losing and sustaining weight loss has proven challenging, we are optimistic that application of emerging nutrition science, particularly personalized well-formulated low-carbohydrate dietary patterns that contain adequate protein (1.2 to 2.0 g per kilogram reference weight) and achieve the beneficial metabolic state of euketonemia (circulating ketones 0.5 to 5 mM), is a promising path for many individuals with excess adiposity.

Nutrient analysis of three low-carbohydrate diets differing in carbohydrate content

Introduction

Low-carbohydrate diets are increasing in popularity. Despite clinical evidence demonstrating their safety and efficacy, concerns regarding the nutrient adequacy of low-carbohydrate diets persist. The aims of this study were to assess the nutrient adequacy of three 7-day meal plans that delivered 20 (VLCD20), 40 (VLCD40), and 100 (LCD100) grams of net carbohydrate per day respectively.

Methods

Nutrient analyses were conducted using USDA Food Data Central.

Results

All three low-carbohydrate meal plans exceeded recommendations for vitamins A, C, D, E, K, thiamin, riboflavin, niacin, B6, folate and B12 in males and females 31-70 years and exceeded calcium recommendations for adults 31-50 years but remained below the Tolerable Upper Intake Level. VLCD40 and LCD100 met or exceeded fiber recommendations for females ages 31-70 years and were adequate for males 51-70 years. None of the meal plans contributed meaningful amounts of added sugar. The plans exceeded the Recommended Dietary Allowance for protein for adults ages 31-70 years of age but were within the Acceptable Macronutrient Distribution Range of 10-35% of energy. The plans slightly exceeded recommendations for saturated fat and sodium but were lower in these nutrients than the average American diet and had more favorable omega-6 to omega-3 and sodium to potassium ratios than is typical. All three meals plans met or exceeded the Estimated Average Requirement for micronutrients in females ages 31-50 years, the population group most likely to consume low-carbohydrate diets.

Discussion

Well-constructed low-carbohydrate meal plans can be nutritionally adequate in adults.

Nutrition Users' Guides: RCTs Part 2 - structured guide for interpreting and applying study results from randomised controlled trials on therapy or prevention questions

This article continues from a prior commentary on evaluating the risk of bias in randomised controlled trials addressing nutritional interventions. Having provided a synopsis of the risk of bias issues, we now address how to understand trial results, including the interpretation of best estimates of effect and the corresponding precision (eg, 95% CIs), as well as the applicability of the evidence to patients based on their unique circumstances (eg, patients' values and preferences when trading off potential desirable and undesirable health outcomes and indicators (eg, cholesterol), and the potential burden and cost of an intervention). Authors can express the estimates of effect for health outcomes and indicators in relative terms (relative risks, relative risk reductions, OR or HRs)-measures that are generally consistent across populations-and absolute terms (risk differences)-measures that are more intuitive to clinicians and patients. CIs, the range in which the true effect plausibly lies, capture the precision of estimates. To apply results to patients, clinicians should consider the extent to which the study participants were similar to their patients, the extent to which the interventions evaluated in the study are applicable to their patients and if all patient-important outcomes of potential benefit and harm were reported. Subsequently, clinicians should consider the values and preferences of their patients with respect to the balance of the benefits, harms and burdens (and possibly the costs) when making decisions about dietary interventions.

Dietary and Lifestyle Strategies for Obesity

The prevalence of obesity globally has tripled over the last half century, and currently affects around 650 million adults and 340 million children and adolescents (ages 5-19 years). Obesity contributes towards >50 co-morbidities and premature mortality. Obesity is a highly stigmatised condition that is associated with much mental and emotional distress and dysfunction. Thus, obesity is a major contributor to healthcare expenditure globally. Traditionally, the management of obesity stratifies into three major groups that include metabolic (bariatric) surgery, pharmacotherapies, and lifestyle (primarily dietary) strategies. Although listed as a separate category, dietary strategies for obesity remain a central component of any management plan, and often complement other surgical and pharmacotherapeutic options. Indeed, the effectiveness of any management approach for obesity relies upon successful behavioural changes, particularly relating to eating behaviours. In this concise review, we explore the foundational pillars of dietary strategies for obesity: sleep, listening, routine, de-stressing and optimisation of social conditions. We then discuss the importance of balancing dietary macronutrients (including dietary fibre, carbohydrates, protein and ultra-processed foods [UPFs]) as a key dietary strategy for obesity. Although we focus on general principles, we should provide bespoke dietary strategies for our patients, tailored to their individual needs. Rather than judging the utility of a diet based simply on its associated magnitude of weight loss, we should adopt a more holistic perspective in which a dietary strategy is valued for its overall health benefits, including the nurturing of our gut microbiota, to enable them to nurture and protect us.

Effects of a carbohydrate-reduced high-protein diet delivered with meal kits to Danish people with type 2 diabetes: protocol for a 12-month randomised controlled trial

INTRODUCTION

The cornerstone in the management of type 2 diabetes (T2D) is lifestyle modification including a healthy diet, typically one in which carbohydrate provides 45%-60% of total energy intake (E%). Nevertheless, systematic reviews and meta-analyses of trials with low carbohydrate diets (which are increased in protein and/or fat) for T2D have found improved glycaemic control in the first months relative to comparator diets with higher carbohydrate content. Studies lasting ≥1 year are inconclusive, which could be due to decreased long-term dietary adherence. We hypothesise that glucometabolic benefits can be achieved following 12 months of carbohydrate-restricted dieting, by maximising dietary adherence through delivery of meal kits, containing fresh, high-quality ingredients for breakfast, dinner and snacks, combined with nutrition education and counselling.

METHODS AND ANALYSIS

This protocol describes a 12-month investigator-initiated randomised controlled, open-label, superiority trial with two parallel groups that will examine the effect of a carbohydrate-reduced high-protein (CRHP) diet compared with a conventional diabetes (CD) diet on glucometabolic control (change in glycated haemoglobin being the primary outcome) in 100 individuals with T2D and body mass index (BMI) >25 kg/m2. Participants will be randomised 1:1 to receive either the CRHP or the CD diet (comprised 30/50 E% from carbohydrate, 30/17 E% from protein and 40/33 E% from fat, respectively) for 12 months delivered as meal kits, containing foods covering more than two-thirds of the participants' estimated daily energy requirements for weight maintenance. Adherence to the allocated diets will be reinforced by monthly sessions of nutrition education and counselling from registered clinical dietitians.

ETHICS AND DISSEMINATION

The trial has been approved by the National Committee on Health Research Ethics of the Capital Region of Denmark. The trial will be conducted in accordance with the Declaration of Helsinki. Results will be submitted for publication in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05330247.

PROTOCOL VERSION

The trial protocol was approved on 9 March 2022 (study number: H-21057605). The latest version of the protocol, described in this manuscript, was approved on 23 June 2023.

Potential Add-On Benefits of Dietary Intervention in the Treatment of Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited cause of renal failure. The pathogenesis of the disease encompasses several pathways and metabolic alterations, including the hyperactivation of mTOR and suppression of AMPK signaling pathways, as well as mitochondrial dysfunction. This metabolic reprogramming makes epithelial cyst-lining cells highly dependent on glucose for energy and unable to oxidize fatty acids. Evidence suggests that high-carbohydrate diets may worsen the progression of ADPKD, providing the rationale for treating ADPKD patients with calorie restriction and, in particular, with ketogenic dietary interventions, already used for other purposes such as in overweight/obese patients or in the treatment of refractory epilepsy in children. Preclinical studies have demonstrated that calorie restriction may prevent and/or slow disease progression by inducing ketosis, particularly through increased beta-hydroxybutyrate (BHB) levels, which may modulate the metabolic signaling pathways altered in ADKPK. In these patients, although limited, ketogenic intervention studies have shown promising beneficial effects. However, larger and longer randomized controlled trials are needed to confirm their tolerability and safety in long-term maintenance and their additive role in the therapy of polycystic kidney disease.

Nutrient quality in dietary therapy for diabetes and diabetic kidney disease

Dietary therapy is crucial for diabetes care with the aim of preventing the onset and progression of diabetes and its complications. The traditional approach to dietary therapy for diabetes has primarily focused on restricting the intake of the three major nutrients and rigorously controlling blood glucose levels. However, advancements in nutritional science have shown that within the three major nutrients - carbohydrates, proteins and lipids - there exist multiple types, each with distinct impacts on type 2 diabetes and its complications, sometimes even showing conflicting effects. In light of this, the present review shifts its focus from the quantity to the quality of the three major nutrients. It aims to provide an overview of how the differences in nutrient quality can influence onset and progression of type 2 diabetes and diabetic kidney disease, highlighting the diverse effects and, at times, contradictory impacts associated with each nutrient type.

The effects of probiotic supplementation and exercise training on liver enzymes and cardiometabolic markers in patients with non-alcoholic fatty liver disease: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver ailment worldwide, in which nonpharmacological strategies have a considerable role in the treatment. Probiotic supplementation as well as physical exercise can improve cardiometabolic parameters, but further research is needed to determine the effects of combined treatment versus exercise alone in managing NAFLD-associated biomarkers, primarily liver enzymes, lipid markers, and insulin resistance.

OBJECTIVES

This systematic review and meta-analysis aimed to evaluate the effects of probiotic supplementation, combined with exercise versus exercise alone, on liver enzymes and cardiometabolic markers in patients with NAFLD.

METHODS

A systematic review and meta-analysis of randomized clinical trials was performed by searching PubMed, Scopus, and Web of Science databases up to April 2024. The search was restricted to articles published in the English language and human studies. Random effects models were used to calculate weighted mean differences (WMD).

RESULTS

Pooled estimates (9 studies, 615 patients, intervention durations ranging from 8 to 48 weeks) revealed that probiotics plus exercise decreased aspartate transaminase (AST) [WMD=-5.64 U/L, p = 0.02], gamma-glutamyl transferase (GGT) [WMD=-7.09 U/L, p = 0.004], low-density lipoprotein (LDL) [WMD=-8.98 mg/dL, p = 0.03], total cholesterol (TC) [WMD=-16.97 mg/dL, p = 0.01], and homeostatic model assessment for insulin resistance (HOMA-IR) [WMD=-0.94, p = 0.005] significantly more than exercise only. However, probiotics plus exercise did not significantly change high-density lipoprotein (HDL) [WMD = 0.07 mg/dL, p = 0.9], fasting insulin [WMD=-1.47 µIU/mL, p = 0.4] or fasting blood glucose (FBG) [WMD=-1.57 mg/dL, p = 0.3] compared with exercise only. While not statistically significant, there were clinically relevant reductions in alanine aminotransferase (ALT) [WMD=-6.78 U/L, p = 0.1], triglycerides (TG) [WMD=-21.84 mg/dL, p = 0.1], and body weight (BW) [WMD=-1.45 kg, p = 0.5] for probiotics plus exercise compared with exercise only. The included studies exhibited significant heterogeneity for AST (I2 = 78.99%, p = 0.001), GGT (I2 = 73.87%, p = 0.004), LDL (I2 = 62.78%, p = 0.02), TC (I2 = 72.41%, p = 0.003), HOMA-IR (I2 = 93.86%, p = 0.001), HDL (I2 = 0.00%, p = 0.9), FBG (I2 = 66.30%, p = 0.01), ALT (I2 = 88.08%, p = 0.001), and TG (I2 = 85.46%, p = 0.001). There was no significant heterogeneity among the included studies for BW (I2 = 0.00%, p = 0.9).

CONCLUSION

Probiotic supplementation combined with exercise training elicited better results compared to exercise alone on liver enzymes, lipid profile, and insulin resistance in patients with NAFLD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42023424290.

Digesting the complex metabolic effects of diet on the host and microbiome

The past 50 years of interdisciplinary research in humans and model organisms has delivered unprecedented insights into the mechanisms through which diet affects energy balance. However, translating these results to prevent and treat obesity and its associated diseases remains challenging. Given the vast scope of this literature, we focus this Review on recent conceptual advances in molecular nutrition targeting the management of energy balance, including emerging dietary and pharmaceutical interventions and their interactions with the human gut microbiome. Notably, multiple current dietary patterns of interest embrace moderate-to-high fat intake or prioritize the timing of eating over macronutrient intake. Furthermore, the rapid expansion of microbiome research findings has complicated multiple longstanding tenets of nutrition while also providing new opportunities for intervention. Continued progress promises more precise and reliable dietary recommendations that leverage our growing knowledge of the microbiome, the changing landscape of clinical interventions, and our molecular understanding of human biology.

The effect of a nurse-led low carbohydrate regimen on anthropometric and laboratory parameters of patients with metabolic syndrome: a quasi-experimental study

Introduction

Metabolic syndrome is a global health concern. It is a condition that includes a cluster of various risk factors for type 2 diabetes and cardiovascular disease. This quasi-experimental study investigates the effect of a nurse-led low-carbohydrate regimen on anthropometric and laboratory parameters in metabolic syndrome patients.

Methods

The study used a quasi-experimental design conducted at the University of Mosul; 128 participants meeting the metabolic syndrome criteria were recruited and divided into the intervention and control groups. The intervention group received personalized counseling and support in implementing a low-carb regime, while the control group received standard advice. The study participants were assessed by anthropometry, and laboratory parameters were evaluated pre- and post-intervention. Statistical data analysis was conducted using IBM-SPSS 27, including chi-square, Fisher's exact test, t-tests, and the Mcnemar test, which were performed to compare the changes within and between groups.

Results

The mean age of the participants in the intervention and control groups was 50.72 ± 6.43 years and 49.14 ± 6.89 years, respectively. Compared to the control group, the intervention group experienced a significant positive reduction in anthropometric measures and laboratory parameters, including weight, body mass index (BMI), waist circumference, lipid profiles, and HbA1c.

Conclusion

A tangible effect of nurse-led interventions based on low-carbohydrate regimens in managing metabolic syndrome was empirically authenticated. Positive changes were observed in the intervention group regarding anthropometric measures and laboratory parameters. However, future research may require a larger sample size and a longer follow-up to confirm these effects and evaluate long-term metabolic impacts.

Effects of low-carbohydrate diets, with and without caloric restriction, on inflammatory markers in adults: a systematic review and meta-analysis of randomized clinical trials

Low-carbohydrate diets (LCDs) have gained interest due to their favorable effects on health outcomes, such as inflammation. However, further research is needed to ascertain the overall effects of LCDs on inflammatory parameters, but at the same time considering weight loss and calorie intake. Thus, a systematic review and meta-analysis of randomized clinical trials was performed to investigate the effects of LCDs compared with low-fat diets (LFDs), with and without caloric restriction, on inflammatory markers in adults. PubMed, Scopus, and Web of Science were searched through March 2022 to select intervention studies addressing LCDs vs. LFDs, in which the following circulating inflammatory markers were used: C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), and interleukin (IL-6). Analyses were conducted comparing LCDs vs. LFDs through weighted mean differences (WMD) or standardized mean differences (SMD) and 95% confidence intervals (95% CIs) using random effects models. The systematic review and meta-analysis included a total of 51 studies with a total sample of 4,164 adults, with or without other chronic diseases. Intervention durations ranged from 2-144 weeks. LCDs, compared with LFDs, significantly decreased body weight [WMD = -1.35%, p = 0.001], CRP [SMD = -0.1, p = 0.03], and IL-6 [SMD = -0.15, p = 0.09]. However, LCDs did not significantly decrease TNF-α [SMD = -0.02, p = 0.7] compared to LFDs. In conclusion, LCDs have a beneficial effect on markers of inflammation by decreasing CRP and IL-6; this effect has an association with weight loss. However, LCDs were not more effective than LFDs in decreasing TNF-α.

Krill Oil for Knee Osteoarthritis: A Randomized Clinical Trial

Importance

Knee osteoarthritis is disabling, with few effective treatments. Preliminary evidence suggested that krill oil supplementation improved knee pain, but effects on knee osteoarthritis remain unclear.

Objective

To evaluate efficacy of krill oil supplementation, compared with placebo, on knee pain in people with knee osteoarthritis who have significant knee pain and effusion-synovitis.

Design, Setting, and Participants

Multicenter, randomized, double-blind, placebo-controlled clinical trial in 5 Australian cities. Participants with clinical knee osteoarthritis, significant knee pain, and effusion-synovitis on magnetic resonance imaging were enrolled from December 2016 to June 2019; final follow-up occurred on February 7, 2020.

Interventions

Participants were randomized to 2 g/d of krill oil (n = 130) or matching placebo (n = 132) for 24 weeks.

Main Outcomes and Measures

The primary outcome was change in knee pain as assessed by visual analog scale (range, 0-100; 0 indicating least pain; minimum clinically important improvement = 15) over 24 weeks.

Results

Of 262 participants randomized (mean age, 61.6 [SD, 9.6] years; 53% women), 222 (85%) completed the trial. Krill oil did not improve knee pain compared with placebo (mean change in VAS score, -19.9 [krill oil] vs -20.2 [placebo]; between-group mean difference, -0.3; 95% CI, -6.9 to 6.4) over 24 weeks. One or more adverse events was reported by 51% in the krill oil group (67/130) and by 54% in the placebo group (71/132). The most common adverse events were musculoskeletal and connective tissue disorders, which occurred 32 times in the krill oil group and 42 times in the placebo group, including knee pain (n = 10 with krill oil; n = 9 with placebo), lower extremity pain (n = 1 with krill oil; n = 5 with placebo), and hip pain (n = 3 with krill oil; n = 2 with placebo).

Conclusions and Relevance

Among people with knee osteoarthritis who have significant knee pain and effusion-synovitis on magnetic resonance imaging, 2 g/d of daily krill oil supplementation did not improve knee pain over 24 weeks compared with placebo. These findings do not support krill oil for treating knee pain in this population.

Trial Registration

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12616000726459; Universal Trial Number: U1111-1181-7087.

Long-term ketogenic diet causes hyperlipidemia, liver dysfunction, and glucose intolerance from impaired insulin trafficking and secretion in mice

A ketogenic diet (KD) is a very low-carbohydrate, very high-fat diet proposed to treat obesity and type 2 diabetes. While KD grows in popularity, its effects on metabolic health are understudied. Here we show that, in male and female mice, while KD protects against weight gain and induces weight loss, over long-term, mice develop hyperlipidemia, hepatic steatosis, and severe glucose intolerance. Unlike high fat diet-fed mice, KD mice are not insulin resistant and have low levels of insulin. Hyperglycemic clamp and ex vivo GSIS revealed cell-autonomous and whole-body impairments in insulin secretion. Major ER/Golgi stress and disrupted ER-Golgi protein trafficking was indicated by transcriptomic profiling of KD islets and confirmed by electron micrographs showing a dilated Golgi network likely responsible for impaired insulin granule trafficking and secretion. Overall, our results suggest long-term KD leads to multiple aberrations of metabolic parameters that caution its systematic use as a health promoting dietary intervention.

Physiological and psychological determinants of long-term diet-induced type 2 diabetes (T2DM) remission: A narrative review

Type 2 diabetes mellitus (T2DM) is a highly prevalent metabolic disease, causing a heavy burden on healthcare systems worldwide, with related complications and anti-diabetes drug prescriptions. Recently, it was demonstrated that T2DM can be put into remission via significant weight loss using low-carbohydrate diets (LCDs) and very low-energy diets (VLEDs) in individuals with overweight and obesity. Clinical trials demonstrated remission rates of 25-77%, and metabolic improvements such as improved blood lipid profile and blood pressure were observed. In contrast, clinical trials showed that remission rate declines with time, concurrent with weight gain, or diminished weight loss. This review aims to discuss existing literature regarding underlying determinants of long-term remission of T2DM including metabolic adaptations to weight loss (e.g., role of gastrointestinal hormones), type of dietary intervention (i.e., LCDs or VLEDs), maintaining beta (β)-cell function, early glycemic control, and psychosocial factors. This narrative review is significant because determining the factors that are associated with challenges in maintaining long-term remission may help in designing sustainable interventions for type 2 diabetes remission.

Chinese Guidelines for Medical Nutrition Therapy for Patients with Diabetes (2022 Edition)

Medical nutrition therapy (MNT) is the foundation of the comprehensive treatment of patients with diabetes. In 2010, the Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association developed the first Chinese guideline on MNT for patients with diabetes, and it was updated in 2015. Since then, new evidence has emerged in the field of MNT and metabolic therapy in patients with diabetes. The Nutrition and Metabolic Management Branch of the China International Exchange and Promotive Association for Medical and Health Care organized a team of experts from related institutions, including the Clinical Nutrition Branch of the Chinese Nutrition Society, Chinese Diabetes Society, Chinese Society for Parenteral and Enteral Nutri-tion, and Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association. Their task was to develop the Chinese Guidelines of Medical Nutrition Therapy in Diabetes (2022 Edition) in accordance with the requirements of the Guidelines for the Formulation/Revision of Clinical Guidelines in China (2022 Edition) by combining the questions raised and evidence gathered in clinical practices in China, to guide and standardize the clinical MNT.

Role of lifestyle and glucagon-like peptide-1 receptor agonists for weight loss in obesity, type 2 diabetes and steatotic liver diseases

BACKGROUND

The current obesity pandemic has given rise to associated comorbidities and complications, including type 2 diabetes and metabolic dysfunction-associated steatotic liver disease (MASLD). During the last decade, certain glucagon-like peptide 1 receptor agonists (GLP-1RA), originally developed as antihyperglycemic drugs, also demonstrated efficacy for weight loss.

AIMS

To review shared pathophysiologic features of common metabolic diseases and compare therapeutic strategies to reduce body weight and related complications.

METHODS

We performed an extensive literature research to describe the effects of lifestyle modification, first-generation anti-obesity drugs, and GLP-1RA on weight loss in humans with obesity, type 2 diabetes and MASLD.

RESULTS

Until recently, treatment of obesity has been limited to lifestyle modification, which offer moderate degree and sustainability of weight loss. The few approved first-generation anti-obesity drugs are either limited to short term use or to certain forms of obesity. Some GLP-1RA significantly decrease caloric intake and body weight. Liraglutide and semaglutide have therefore been approved for treating people with obesity. They also lead to a reduction of hepatic fat content and inflammation in people with biopsy-confirmed MASLD. Possible limitations comprise adverse effects, treatment adherence and persistence.

CONCLUSION

Certain GLP-1RA are superior to lifestyle modification and first-generation anti-obesity drugs in inducing weight loss. They have therefore markedly changed the portfolio of obesity treatment with additional beneficial effects on steatotic liver disease.