An Online Intervention Comparing a Very Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate Method Diet in Overweight Individuals With Type 2 Diabetes: A Randomized Controlled Trial

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.

Effects of ketogenic and low-carbohydrate diets on the body composition of adults with overweight or obesity: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND AND AIMS

More than one-third of individuals are overweight and obese in the world. Their risks of chronic health conditions are increased, which places additional burden on their family, caregivers, and healthcare system. Dietary modification is widely used for overweight and obese individuals. We investigated the effects of ketogenic diet (KD) and low-carbohydrate diet (LCD) in improving body weight (BW), body mass index (BMI), fat mass (FM), and body fat percentage (BFP) in overweight or obese individuals.

METHODS

A three-step approach was adopted for searching relevant randomised controlled trials (RCTs) across five electronic databases. Two reviewers conducted the screening, review, and quality appraisal independently. A random-effects model was used because of variations in intervention and participant characteristics. Sensitivity and subgroup analyses were conducted to assess heterogeneity and variations in the results, respectively.

RESULTS

Thirty-three RCTs involving 2821 individuals were included. Overall meta-analysis results indicated that KD/LCD significantly reduced BW, BMI, and BFP, but not FM, in individuals with a carbohydrate intake of ≤100 g/d. Subgroup analyses revealed significant improvements in BW, BMI, and FM in individuals on KD/LCD for ≥1 month and in all parameters for those with a carbohydrate intake of ≤50 g/d. High statistical heterogeneity was noted because of variations in interventions and participant characteristics.

CONCLUSION

Adults with overweight or obesity should consume KD/LCD for ≥1 month and limit carbohydrate intake to ≤50 g/d. Further multicentre or multicountry RCTs are needed to improve the generalisability of our findings. We recommend integrating text messaging and evidence-based information to support interventions and ensuring stringent medical supervision throughout the intervention.

PROSPERO REGISTRATION NUMBER

CRD42022353074.

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.

Insight into the post-translational modifications in pregnancy and related complications

Successful pregnancy is dependent on a number of essential events, including embryo implantation, decidualization and placentation. Failure of the above process may lead to pregnancy-related complications, including preeclampsia (PE), gestational diabetes mellitus (GDM), preterm birth, fetal growth restriction (FGR), etc., may affect 15% of pregnancies, and lead to increased mortality and morbidity of pregnant women and perinatal infants, as well as the occurrence of short-term and long-term diseases. These complications have distinct etiology and pathogenesis, and the present comprehension is still lacking. Post-translational modifications (PTMs) are important events in epigenetics, altering the properties of proteins through protein hydrolysis or the addition of modification groups to one or more amino acids, with different modification states regulating subcellular localization, protein degradation, protein-protein interaction, signal transduction and gene transcription. In this review, we focus on the impact of various PTMs on the progress of embryo and placenta development and pregnancy-related complications, which will provide important experimental bases for exploring new insights into the physiology of pregnancy and pathogenesis associated with pregnancy complications.

Ketogenic diet in clinical populations-a narrative review

Ketogenic diet (KD) is a high-fat, low-carbohydrate (CHO) diet, designed to induce a metabolic state of ketosis in which the body metabolizes primarily lipids for energy production. Various forms of KD are being promoted as promising treatments for numerous health conditions from chronic headaches to weight-loss and even different forms of cancer and are becoming increasingly more popular. KD appears to be an efficacious approach for weight-loss, and maintenance, improved glycemia, cognitive function and cancer prognosis. However, there is a controversy regarding the safety of KD, and the potential health risks that might be associated with long-term exposure to KD. There is a gap between the acceptance and utilization of KD in individuals with health conditions and the criticism and negative attitudes toward KD by some clinicians. Many individuals choose to follow KD and are encouraged by the positive results they experience. Although the medical establishment does not endorse KD as a first line of treatment, clinicians need to be informed about KD, and offer support and medical supervision for patients who self-select to follow KD. This can ensure that within the boundaries of KD, patients will make good and healthy dietary choices and prevent clinical disengagement in extreme cases. To that end, there is an urgent need for good quality research to address the issues of long-term safety of KD in different clinical populations and for standardization of KD both in research and in the clinic.

Neuropathy of diabetes following initiation of a low-carbohydrate diet: Case report

Introduction

This case study portrays an unusual case of treatment-induced neuropathy of diabetes (TIND) in a patient with uncontrolled type 2 diabetes (T2D) who achieved rapid improvement in glucose control primarily with dietary intervention. Initial presentation was 50-year-old white male with a long-standing history of obesity and a family history of T2D with a screening glucose level >500mg/dL by glucometer, HbA1c of 14.9%, and initial weight 213 lbs.

Methods

The initial intervention included a low-carbohydrate diet, metformin, and a continuous glucose monitor (CGM). Semaglutide was added after seven days.

Results

His glycemia was within the target range within three weeks. Four weeks after initiation of therapy, he developed TIND symptoms consisting of burning, tightness, and numbness of bilateral feet along with 10/10 pain. At three months, his HbA1c dropped to 6.9% and his weight to 195 lbs. Treatment of his TIND reduced his pain from 10/10 to 2/10.

Conclusion

Whereas TIND is commonly associated with the use of insulin or sulfonylureas, this study adds evidence to the paucity of literature regarding TIND precipitated by dietary intervention.

Alterations in Vagal Tone Are Associated with Changes in the Gut Microbiota of Adults with Anxiety and Depression Symptoms: Analysis of Fecal Metabolite Profiles

Accumulating evidence suggests that interactions between the brain and gut microbiota significantly impact brain function and mental health. In the present study, we aimed to investigate whether young, healthy adults without psychiatric diagnoses exhibit differences in metabolic stool and microbiota profiles based on depression/anxiety scores and heart rate variability (HRV) parameters. Untargeted nuclear magnetic resonance-based metabolomics was used to identify fecal metabolic profiles. Results were subjected to multivariate analysis through principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA), and the metabolites were identified through VIP score. Metabolites separating asymptomatic and symptomatic groups were acetate, valine, and glutamate, followed by sugar regions, glutamine, acetone, valerate, and acetoacetate. The main metabolites identified in high vagal tone (HVT) and low vagal tone (LVT) groups were acetate, valerate, and glutamate, followed by propionate and butyrate. In addition to the metabolites identified by the PLS-DA test, significant differences in aspartate, sarcosine, malate, and methionine were observed between the groups. Levels of acetoacetate were higher in both symptomatic and LVT groups. Valerate levels were significantly increased in the symptomatic group, while isovalerate, propionate, glutamate, and acetone levels were significantly increased in the LVT group. Furthermore, distinct abundance between groups was only confirmed for the Firmicutes phylum. Differences between participants with high and low vagal tone suggest that certain metabolites are involved in communication between the vagus nerve and the brain.

Ketogenic Diet and Its Potential Role in Preventing Type 2 Diabetes Mellitus and Its Complications: A Narrative Review of Randomized Controlled Trials

Diabetes mellitus is a global health crisis affecting millions. Nutrition plays a vital role in its management and prevention. While carbohydrate reduction is beneficial for glycemic control, various dietary approaches exist. The ketogenic diet, characterized by very low carbohydrate intake, has shown promise in weight management and blood sugar control. However, its potential for preventing type 2 diabetes mellitus (T2DM) remains largely unexplored. To evaluate the ketogenic diet's potential in preventing T2DM, this review searched the PubMed database for studies published between 2013 and 2023. Findings suggest that the diet can effectively aid weight loss and improve blood glucose levels. Some evidence indicates reduced reliance on diabetes medications. However, effects on cholesterol levels are inconsistent, and long-term adherence challenges exist. Additionally, potential micronutrient deficiencies and safety concerns require careful consideration. While the ketogenic diet offers potential benefits, further research is needed to establish its efficacy and safety as a long-term prevention strategy for T2DM. However, the results of the present study indicate the need for further research in this area, utilizing rigorous methodology.

Feasibility and acceptability of an online multicomponent very low-carbohydrate intervention in young adult women with obesity: a pilot study

BACKGROUND

Approximately one-third of US young adults (18-25 years) have obesity, and there are calls to help young adults lose weight to prevent weight-related chronic conditions. This pilot trial tested the feasibility and acceptability of a very low-carbohydrate (VLC) eating pattern, with supportive positive affect and mindful eating skills, for weight management among young females with obesity.

METHODS

In a single-arm trial, women (N = 17), aged 19-23, with obesity participated in a 4-month diet and lifestyle intervention. Participants were taught how to follow a VLC eating pattern with the help of a coach and 16 weekly web-based sessions. We assessed feasibility and acceptability through session participation, outcome collection, intervention satisfaction, and adverse events.

RESULTS

Seventeen participants enrolled and 14 (82%) reported body weight at 4 months. Fifteen participants (94% of those beginning the intervention) viewed at least one session, and 8/15 (53%) of these participants were active in the intervention, viewing at least half of the sessions. Among the nine participants who provided 4-month self-report information, intervention satisfaction was high (mean 5.89/7, 95% CI 4.59 to 7.19). Among participants with a 4-month body weight, 7/14 (50%) lost ≥ 5% of their body weight, and of those who were also active in the intervention, 6/7 (86%) lost ≥ 5% of their body weight. There were no serious adverse events.

CONCLUSIONS

The results of this pilot study suggest that a VLC eating pattern may be a feasible and acceptable approach for weight loss in some young women with obesity.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov on August 18, 2021. The trial number is NCT05010083.

Impact of very low carbohydrate ketogenic diets on cardiovascular risk factors among patients with type 2 diabetes; GRADE-assessed systematic review and meta-analysis of clinical trials

OBJECTIVE

This study was designed to evaluate the impact of VLCKD on cardiovascular risk factors in patients with T2DM.

METHODS

Until March 2024, extensive searches were conducted on PubMed, Scopus, Web of Science, Embase, and other relevant databases. The purpose was to identify clinical trials examining the impact of VLCKD on glycemic control, lipid profile, and blood pressure. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) method was used to assess the evidence's degree of certainty.

RESULTS

Our initial search found a total of 2568 records and finally 29 trials were included in final analysis. Our results showed that adherence from VLCKD led to significant reduction in fasting blood sugar (WMD= -11.68 mg/dl; 95% CI: -18.79, -4.56; P = 0.001), HbA1c (WMD= -0.29; 95% CI: -0.44, -0.14; P < 0.001), HOMA-IR(WMD= -0.71; 95% CI: -1.14, -0.29; P = 0.001), insulin (WMD= -1.45; 95% CI: -2.54, -0.36; P = 0.009), triglyceride (WMD= -17.95; 95% CI: -26.82, -9.07; P < 0.001), systolic blood pressure (WMD= -2.85, 95% CI: -4.99, -0.71; P = 0.009) and diastolic blood pressure (WMD= -1.40; 95% CI: -2.66, -0.13; P = 0.03). We also found a significant increase in high-density lipoprotein (HDL) level after adherence from VLCKD diet (WMD = 3.93, 95% CI: 2.03, 5.84; P = 0.000). We couldn't find any significant differences between groups in term of LDL and total cholesterol levels.

CONCLUSION

People following a VLCKD experience a more significant improvement in cardiovascular risk factors when compared to individuals on control diets.

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.

Metagenomic and metabolomic analysis showing the adverse risk-benefit trade-off of the ketogenic diet

BACKGROUND

Ketogenic diets are increasingly popular for addressing obesity, but their impacts on the gut microbiota and metabolome remain unclear. This paper aimed to investigate how a ketogenic diet affects intestinal microorganisms and metabolites in obesity.

METHODS

Male mice were provided with one of the following dietary regimens: normal chow, high-fat diet, ketogenic diet, or high-fat diet converted to ketogenic diet. Body weight and fat mass were measured weekly using high-precision electronic balances and minispec body composition analyzers. Metagenomics and non-targeted metabolomics data were used to analyze differences in intestinal contents.

RESULTS

Obese mice on the ketogenic diet exhibited notable improvements in weight and body fat. However, these were accompanied by a significant decrease in intestinal microbial diversity, as well as an increase in Firmicutes abundance and a 247% increase in the Firmicutes/Bacteroidetes ratio. The ketogenic diet also altered multiple metabolic pathways in the gut, including glucose, lipid, energy, carbohydrate, amino acid, ketone body, butanoate, and methane pathways, as well as bacterial secretion and colonization pathways. These changes were associated with increased intestinal inflammation and dysbiosis in obese mice. Furthermore, the ketogenic diet enhanced the secretion of bile and the synthesis of aminoglycoside antibiotics in obese mice, which may impair the gut microbiota and be associated with intestinal inflammation and immunity.

CONCLUSIONS

The study suggest that the ketogenic diet had an unfavorable risk-benefit trade-off and may compromise metabolic homeostasis in obese mice.

A long journey to treat epilepsy with the gut microbiota

Epilepsy is a common neurological disorder that affects approximately 10.5 million children worldwide. Approximately 33% of affected patients exhibit resistance to all available antiseizure medications, but the underlying mechanisms are unknown and there is no effective treatment. Increasing evidence has shown that an abnormal gut microbiota may be associated with epilepsy. The gut microbiota can influence the function of the brain through multiple pathways, including the neuroendocrine, neuroimmune, and autonomic nervous systems. This review discusses the interactions between the central nervous system and the gastrointestinal tract (the brain-gut axis) and the role of the gut microbiota in the pathogenesis of epilepsy. However, the exact gut microbiota involved in epileptogenesis is unknown, and no consistent results have been obtained based on current research. Moreover, the target that should be further explored to identify a novel antiseizure drug is unclear. The role of the gut microbiota in epilepsy will most likely be uncovered with the development of genomics technology.

Ketogenic Diet Plus Resistance Training Applied to Physio-Pathological Conditions: A Brief Review

The ketogenic diet (KD) is a nutritional strategy characterized by a reduced intake of carbohydrates (between 30 and 45 g per day or ≈5% of one’s total calories from this macronutrient). The regimen induces physiological ketosis in which serum levels of ketone bodies increase from 0.5 to 3.0 mM, becoming an essential contributor to energy production. The popularity of using the KD to lose weight and its application in specific physio-pathological conditions, such as epilepsy, lipedema, and polycystic ovary syndrome, which is maintained over extended periods, gave us the impulse to write this brief review. In these types of physio-pathological conditions, subjects can achieve favorable training outcomes even if adhering to a KD. Therefore, performing resistance training under the KD to enhance muscle status and quality of life could be possible. It is important to note that, while some statements here suggest potential future directions, they are hypotheses that require experimental validation, even if they are supported by the independent benefits reported from the KD and resistance training and represent a promising area for future research.

Ketogenic Diet Intervention on Metabolic and Psychiatric Health in Bipolar and Schizophrenia: A Pilot Trial

The ketogenic diet (KD, also known as metabolic therapy) has been successful in the treatment of obesity, type 2 diabetes, and epilepsy. More recently, this treatment has shown promise in the treatment of psychiatric illness. We conducted a 4-month pilot study to investigate the effects of a KD on individuals with schizophrenia or bipolar disorder with existing metabolic abnormalities. Twenty-three participants were enrolled in a single-arm trial. Results showcased improvements in metabolic health, with no participants meeting metabolic syndrome criteria by study conclusion. Adherent individuals experienced significant reduction in weight (12 %), BMI (12 %), waist circumference (13 %), and visceral adipose tissue (36 %). Observed biomarker enhancements in this population include a 27 % decrease in HOMA-IR, and a 25 % drop in triglyceride levels. In psychiatric measurements, participants with schizophrenia showed a 32 % reduction in Brief Psychiatric Rating Scale scores. Overall Clinical Global Impression (CGI) severity improved by an average of 31 %, and the proportion of participants that started with elevated symptomatology improved at least 1-point on CGI (79 %). Psychiatric outcomes across the cohort encompassed increased life satisfaction (17 %) and enhanced sleep quality (19 %). This pilot trial underscores the potential advantages of adjunctive ketogenic dietary treatment in individuals grappling with serious mental illness.

Nutrition counsellors' recommended eating patterns for individuals with type 2 diabetes in the USA

Introduction

Multiple eating patterns can promote glycaemic control and weight loss among patients with type 2 diabetes mellitus (T2D). Clinical practice guidelines for T2D management encourage health professionals to guide patients' selection of a patient-centred eating pattern. This study aims to characterise beliefs about and recommendations for and against practice guideline-concordant eating patterns among registered dietitians (RDs) and other healthcare professionals who provide nutrition counselling to patients with T2D.

Methods

This was a cross-sectional online survey. We invited 82 RDs affiliated with an academic health system in the midwestern USA to participate. We also invited health professionals who provide nutrition counselling to patients with T2D and are affiliated with 264 primary care practices within the Michigan Collaborative for Type 2 Diabetes. Participants were asked to select the eating pattern(s) that they commonly recommend or avoid for patients with T2D and why.

Results

Survey respondents (n=81) most commonly recommend low-carbohydrate (77.8%); Mediterranean-style (52.8%) and energy-modified/calorie-restricted (36.1%) eating patterns. Survey respondents most commonly recommend avoiding very low-carbohydrate (51.0%) and very low-calorie (49.0%) eating patterns. Respondents who did not recommend very low-carbohydrate were most concerned about the eating pattern being too restrictive (93.0%).

Conclusions

Survey respondents recommend a range of guideline-adherent eating patterns to patients with T2D but tend to recommend against very low-carbohydrate and very low-calorie eating patterns. Additional strategies are needed to increase patient-centred use of these evidence-based options in clinical practice settings.

Clinical effectiveness and cost-impact after 2 years of a ketogenic diet and virtual coaching intervention for patients with diabetes

AIM

We previously evaluated the impacts at 5 months of a digitally delivered coaching intervention in which participants are instructed to adhere to a very low carbohydrate, ketogenic diet. With extended follow-up (24 months), we assessed the longer-term effects of this intervention on changes in clinical outcomes, health care utilization and costs associated with outpatient, inpatient and emergency department use in the Veterans Health Administration.

MATERIALS AND METHODS

We employed a difference-in-differences model with a waiting list control group to estimate the 24-month change in glycated haemoglobin, body mass index, blood pressure, prescription medication use, health care utilization rates and associated costs. The analysis included 550 people with type 2 diabetes who were overweight or obese and enrolled in the Veterans Health Administration for health care. Data were obtained from electronic health records from 2018 to 2021.

RESULTS

The virtual coaching and ketogenic diet intervention was associated with significant reductions in body mass index [-1.56 (SE 0.390)] and total monthly diabetes medication usage [-0.35 (SE 0.054)]. No statistically significant differences in glycated haemoglobin, blood pressure, outpatient visits, inpatient visits, or emergency department visits were observed. The intervention was associated with reductions in per-patient, per-month outpatient spending [-USD286.80 (SE 97.175)] and prescription drug costs (-USD105.40 (SE 30.332)].

CONCLUSIONS

A virtual coaching intervention with a ketogenic diet component offered modest effects on clinical and cost parameters in people with type 2 diabetes and with obesity or overweight. Health care systems should develop methods to assess participant progress and engagement over time if they adopt such interventions, to ensure continued patient engagement and goal achievement.

The impact of ketogenic diet on some metabolic and non-metabolic diseases: Evidence from human and animal model experiments

The ketogenic diet (KD) is recognized as minimum carbohydrate and maximum fat intakes, which leads to ketosis stimulation, a state that is thought to metabolize fat more than carbohydrates for energy supply. KD has gained more interest in recent years and is for many purposes, including weight loss and managing serious diseases like type 2 diabetes. On the other hand, many believe that KD has safety issues and are uncertain about the health drawbacks. Thus, the outcomes of the effect of KD on metabolic and non-metabolic disease remain disputable. The current narrative review aims to evaluate the effect of KD on several diseases concerning the human health. To our best knowledge, the first report aims to investigate the efficacy of KD on multiple human health issues including type 2 diabetes and weight loss, cardiovascular disease, kidney failure and hypertension, non-alcoholic fatty liver, mental problem, oral health, libido, and osteoporosis. The literature searches were performed in Databases, PubMed, Scopus, and web of Science looking for both animal and human model designs. The results heterogeneity seems to be explained by differences in diet composition and duration. Also, the available findings may show that proper control of carbohydrates, a significant reduction in glycemic control and glycated hemoglobin, and weight loss by KD can be an approach to improve diabetes and obesity, hypertension, non-alcoholic fatty liver, PCOS, libido, oral health, and mental problem if isocaloric is considered. However, for some other diseases like cardiovascular disease and osteoporosis, more robust data are needed. Therefore, there is robust data to support the notion that KD can be effective for some metabolic and non-metabolic diseases but not for all of them. So they have to be followed cautiously and under the supervision of health professionals.

Label-free analysis of the β-hydroxybutyricacid drug on mitochondrial redox states repairment in type 2 diabetic mice by resonance raman scattering

BACKGROUND

Mitochondrial redox imbalance underlies the pathophysiology of type2 diabetes mellitus (T2DM), and is closely related to tissue damage and dysfunction. Studies have shown the beneficial effects of dietary strategies that elevate β-hydroxybutyrate (BHB) levels in alleviating T2DM. Nevertheless, the role of BHB has not been clearly elucidated.

METHODS

We performed a spectral study to visualize the preventive effects of BHB on blood and multiorgan mitochondrial redox imbalance in T2DM mice via using label-free resonance Raman spectroscopy (RRS), and further explored the impact of BHB therapy on the pathology of T2DM mice by histological and biochemical analyses.

FINDINGS

Our data revealed that RRS-based mitochondrial redox states assay enabled clear and reliable identification of the improvement of mitochondrial redox imbalance by BHB, evidenced by the reduction of Raman peak intensity at 750 cm-1, 1128 cm-1 and 1585 cm-1 in blood, tissue as well as purified mitochondria of db/db mice and the increase of tissue mitochondrial succinic dehydrogenase (SDH) staining after BHB treatment. Exogenous supplementation of BHB was also found to attenuate T2DM pathology related to mitochondrial redox states, involving organ injury, blood glucose control, insulin resistance and systemic inflammation.

INTERPRETATION

Our findings provide strong evidence for BHB as a potential therapeutic strategy targeting mitochondria for T2DM.

Does a Ketogenic Diet Have a Place Within Diabetes Clinical Practice? Review of Current Evidence and Controversies

Carbohydrate restriction has gained increasing popularity as an adjunctive nutritional therapy for diabetes management. However, controversy remains regarding the long-term suitability, safety, efficacy and potential superiority of a very low carbohydrate, ketogenic diet compared to current recommended nutritional approaches for diabetes management. Recommendations with respect to a ketogenic diet in clinical practice are often hindered by the lack of established definition, which prevents its capacity to be most appropriately prescribed as a therapeutic option for diabetes. Furthermore, with conflicted evidence, this has led to uncertainty amongst clinicians on how best to support and advise their patients. This review will explore whether a ketogenic diet has a place within clinical practice by reviewing current evidence and controversies.

The effects of the ketogenic diet for the management of type 2 diabetes mellitus: A systematic review and meta-analysis of recent studies

OBJECTIVE

To systematically review the effects of the ketogenic diet on glycaemic control, body weight, cardiovascular risk factors, and liver and kidney function in patients with type 2 diabetes.

METHODS

PubMed, MEDLINE, Embase, Cochrane Library and CINAHL were searched for randomised controlled trials published between 2001 and 2021 that compared the ketogenic diet to a control diet for effects on glycaemic control, body weight, cardiovascular risk factors, liver and renal function markers in adults with type 2 diabetes for >14 days. Meta-analyses using fixed or random effects models were conducted.

RESULTS

Nineteen reports from 11 randomised controlled trials were included. Compared to the control, the ketogenic diet showed no significant difference in changes in glycaemic control or body weight, but greater increases in HDL (standardised mean difference 0.19; 95%CI 0.02-0.37; I2 = 0 %; moderate-quality evidence) and greater reductions in triglycerides (standardised mean difference -0.41; 95%CI -0.64 to -0.18; I2 = 0 %; low-quality evidence).

CONCLUSIONS

The ketogenic diet may improve lipid profiles but showed no additional benefits for glycaemic control or weight loss compared to control diets in type 2 diabetes patients over two years.

Perceptions of self-monitoring dietary intake according to a plate-based approach: A qualitative study

Dietary self-monitoring is a behaviour change technique used to help elicit and sustain dietary changes over time. Current dietary self-monitoring tools focus primarily on itemizing foods and counting calories, which can be complex, time-intensive, and dependent on health literacy. Further, there are no dietary self-monitoring tools that conform to the plate-based approach of the 2019 Canada Food Guide (CFG), wherein the recommended proportions of three food groups are visually represented on a plate without specifying daily servings or portion sizes. This paper explored the perceptions of end-users (i.e., general public) and Registered Dietitians of iCANPlateTM-a dietary self-monitoring mobile application resembling the CFG. Qualitative data were collected through virtual focus groups. Focus group questions were based on the Capability, Opportunity, Motivation-Behaviour (COM-B) theoretical framework to explore perceptions of using the CFG and currently available dietary self-monitoring tools. The prototype iCANPlateTM (version 0.1) was presented to gain feedback on perceived barriers and facilitators of its use. Focus group discussions were audio recorded and verbatim transcribed. Trained researchers used thematic analysis to code and analyze the transcripts independently. Seven focus groups were conducted with Registered Dietitians (n = 44) and nine focus groups with members from the general public (n = 52). During the focus groups, participants mainly discussed the capabilities and opportunities required to use the current iteration of iCANPlateTM. Participants liked the simplicity of the application and its capacity to foster self-awareness of dietary behaviours rather than weight control or calorie counting. However, concerns were raised regarding iCANPlateTM's potential to improve adherence to dietary self-monitoring due to specific characteristics (i.e., insufficient classifications, difficulty in conceptualizing proportions, and lack of inclusivity). Overall, participants liked the simplicity of iCANPlateTM and its ability to promote self-awareness of dietary intakes, primarily through visual representation of foods on a plate as opposed to reliance on numerical values or serving sizes, were benefits of using the app. Findings from this study will be used to further develop the app with the goal of increasing adherence to plate-based dietary approaches.

Effectiveness of Technology-Enabled, Low Carbohydrate Dietary Interventions, in the Prevention or Treatment of Type 2 Diabetes Mellitus in Adults: A Systematic Literature Review of Randomised Controlled and Non-Randomised Trials

Evidence suggests that low carbohydrate dietary (LCD) approaches can improve glycaemic control and may result in type 2 diabetes mellitus (T2DM) remission. This systematic literature review (SLR) aimed to assess the effectiveness of technology-enabled LCD interventions in the management of people with prediabetes or T2DM. Data sources included Medline, Embase, CINAHL, and Web of Science. Randomised (RCTs) or non-randomised (non-RCTs) controlled trials investigating the effect of technology-enabled LCDs (<130 g/day) or very low carbohydrate diets (VLCDs < 50 g/day) on glycosylated haemoglobin A1c (HbA1c) for at least three months and published in English between 2009 and 2023 were included. Risk of bias assessment, data extraction, and synthesis were conducted using standard tools and procedures. Six studies (two RCTs and four non-RCTs, total sample, n = 1519) were identified and included in the SLR. Two studies examining LCDs reported significant reductions in mean HbA1c (0.4% and -1.2%) and weight loss (-3.8 kg and -7.5 kg) at one year. Three studies examining VLCDs reported significant reductions in mean HbA1c (-0.8% to -1.3%) and weight loss (-12 kg to -14 kg) up to two years. Technology-enabled LCD or VLCD interventions can be a novel approach in helping people with prediabetes or T2DM self-manage their condition and possibly achieve remission. However, further research is required to determine the sustainability, effectiveness, and safety of this approach.

Physical Activity and Type 2 Diabetes: In Search of a Personalized Approach to Improving β-Cell Function

Type 2 diabetes mellitus (T2DM) is one of the most widespread diseases worldwide. Lifestyle interventions, including diet and physical activity (PA), are fundamental non-pharmacological components of T2DM therapy. Exercise interventions are strongly recommended for people with or at risk of developing or already with overt diabetes, but adherence to PA guidelines in this population is still challenging. Furthermore, the heterogeneity of T2DM patients, driven by differing residual β-cell functionality, as well as the possibility of practicing different types and intensities of PA, has led to the need to develop tailored exercise and training plans. Investigations on blood glucose variation in response to exercise could help to clarify why individuals do not respond in the same way to PA, and to guide the prescription of personalized treatments. The aim of this review is to offer an updated overview of the current evidence on the effects of different regimens and modalities of PA regarding glucose sensing and β-cell secretory dynamics in individuals with prediabetes or T2DM, with a special focus on β-cell function.

Adherence to ketogenic diet in lifestyle interventions in adults with overweight or obesity and type 2 diabetes: a scoping review

BACKGROUND/OBJECTIVES

Despite the evidence supporting the efficacy of the ketogenic diet (KD) on weight and type 2 diabetes (T2D) management, adherence to the KD is challenging. Additionally, no studies have reported changes in PA among individuals with overweight/obesity and T2D who have followed KD. We mapped out the methods used to assess adherence to the KD and level of physical activity (PA) in lifestyle interventions for weight and T2D management in individuals with overweight/obesity and T2D and compared levels of KD adherence and PA in these interventions.

METHODS

Articles published between January 2005 and March 2022 were searched in MEDLINE, CINAHL, and Scopus. Studies that included KD in lifestyle interventions for adults with T2D and overweight/obesity and measured ketone levels were included.

RESULTS

The eleven included studies comprised eight randomized controlled trials. They mainly used self-reported measures to evaluate adherence to the KD and level of PA. We found studies reported higher carbohydrate intake and lower fat intake than the KD regimen. Great inconsistencies were found among studies on the measurement and reporting of ketone and PA levels.

CONCLUSION

Our results demonstrated the need to develop intervention strategies to improve adherence to the KD, as well as the necessity of developing standardized diet and PA assessment tools to establish a stronger evidence base for including KD in lifestyle interventions for weight and T2D management among adults with overweight/obesity and T2D.

Short- and long-term effects of very low- and low-calorie ketogenic diets on metabolism and cardiometabolic risk factors: a narrative review

Worldwide obesity and cardiovascular diseases have encouraged the adoption of new and efficient dietary strategies. Among various proposed diets, ketogenic diets, both the very-low-calorie ketogenic diet (VLCKD) and the low-calorie ketogenic diet (LCKD), have been suggested in recent years as an effective nutritional approach for obesity management. The VLCKD and the LCKD are characterized by a low carbohydrate content (<50 g/day), 1-1.5 g of protein/kg of ideal body weight, less than 20-30 g of lipids, and a daily intake of about 800 calories for VLCKD and about 1200-1400 calories for LCKD. The purpose of our narrative review is to offer an overview of the most impactful studies in the scientific literature regarding VLCKD and LCKD to discuss their short- and long-term effects (less than 12 months and more than 12 months respectively) on weight loss, metabolic and cardiovascular aspects. Articles we focused on were cohort studies, case-control studies, cross-sectional studies, randomized controlled trials, and meta-analyses. Results indicate that VLCKD and LCKD could be helpful to ameliorate metabolic and cardiovascular risk factors such as weight loss, glucose, and cholesterol levels, both in the short and long term. Further research in this area may include more randomized controlled trials to gather more data.

A Qualitative Evaluation of a Plate-Method Dietary Self-Monitoring Tool in a Sample of Adults Over 50

Background

Self-monitoring is an important behavioral change technique to help users initiate and maintain dietary changes. Diet self-monitoring tools often involve the itemization of foods and recording of serving sizes. However, this traditional method of tracking does not conform to food guides using plate-based approach to nutrition education, such as the 2019 Canada's Food Guide (CFG).

Objective

To explore the acceptability, facilitators and barriers of using a plate-based dietary self-monitoring tool based on the 2019 CFG (Plate Tool) compared with a traditional Food Journal (Food Journal).

Methods

The 2 dietary self-monitoring tools were compared using a crossover study design over 2 wk. Adults over 50 (n = 47) from Montreal, Canada, were randomly assigned to use one tool over 3 d during 1 wk, then used the other tool the next week. Semistructured interviews (n = 45) were conducted after completing the second tool. A qualitative description of the interviews was conducted through an inductive determination of themes.

Results

Facilitators to using the Plate Tool were its simplicity, quick completion time compared with the Food Journal and easiness to use, increased awareness of dietary habits and accountability, with participants expressing that it could help users make informed dietary changes aligning with the CFG. However, barriers to using the Plate Tool were its lack of precision, the participants' difficulty categorizing foods into the CFG categories and recording intake of foods not present on the CFG.

Conclusions

The Plate Tool is an acceptable dietary self-monitoring tool for healthy adults over 50. Self-monitoring tools based on the plate method should take the barriers described in this study into account. Future studies should compare dietary self-monitoring methods to assess adherence and effectiveness at eliciting dietary behavior change.

Weight, insulin resistance, blood lipids, and diet quality changes associated with ketogenic and ultra low-fat dietary patterns: a secondary analysis of the DIETFITS randomized clinical trial

Background

The DIETFITS trial reported no significant difference in 12-month weight loss between a healthy low-fat and healthy low-carbohydrate diet. Participants were instructed to restrict fat or carbohydrates to levels consistent with a ketogenic or ultra low-fat diet for 2  months and to subsequently increase intakes until they achieved a comfortable maintenance level.

Objective

To compare 3- and 12-month changes in body weight and cardiometabolic risk factors between a subsample of participants who reported 3-month fat or carbohydrates intakes consistent with either a ketogenic-like diet (KLD) or ultra low-fat diet (ULF).

Design

3-month and 12-month weight and risk factor outcomes were compared between KLD (n = 18) and ULF (n = 21) sub-groups of DIETFITS participants (selected from n = 609, healthy overweight/obese, aged 18-50  years).

Results

Less than 10% of DIETFITS participants met KLD or ULF criteria at 3-months. Both groups achieved similar weight loss and insulin resistance improvements at 3-months and maintained them at 12- months. Significant differences at 3-months included a transient ~12% increase in LDL cholesterol (LDL-C) for KLD with a concomitant greater reduction in log(TG/HDL), a measure of LDL-C's atherogenic potential. The latter was maintained at 12-months, despite substantial diet recidivism for both groups, whereas LDL-C levels were similar for ULF at baseline and 12-months. KLD participants achieved and maintained the greatest reductions in added sugars and refined grains at 3- months and 12-months, whereas ULF participants reported a 50% increase in refined grains intake from baseline to 12-months.

Conclusion

Among the ~10% of study participants that achieved the most extreme restriction of dietary fat vs. carbohydrate after 3  months, weight loss and improvement in insulin sensitivity were substantial and similar between groups. At 12  months, after considerable dietary recidivism, the few significant differences in diet quality and blood lipid parameters tended to favor KLD over ULF.

Effects of a low-carbohydrate diet in adults with type 1 diabetes management: A single arm non-randomised clinical trial

Public interest in low-carbohydrate (LC) diets for type 1 diabetes (T1D) management has increased. This study compared the effects of a healthcare professional delivered LC diet compared to habitual diets higher in carbohydrates on clinical outcomes in adults with T1D. Twenty adults (18-70 yrs) with T1D (≥6 months duration) with suboptimal glycaemic control (HbA1c>7.0% or >53 mmol/mol) participated in a 16-week single arm within-participant, controlled intervention study involving a 4-week control period following their habitual diets (>150 g/day of carbohydrates) and a 12-week intervention period following a LC diet (25-75 g/day of carbohydrates) delivered remotely by a registered dietitian. Glycated haemoglobin (HbA1c -primary outcome), time in range (blood glucose: 3.5-10.0 mmol/L), frequency of hypoglycaemia (<3.5 mmol/L), total daily insulin, and quality of life were assessed before and after the control and intervention periods. Sixteen participants completed the study. During the intervention period, there were reductions in total dietary carbohydrate intake (214 to 63 g/day; P<0.001), HbA1c (7.7 to 7.1% or 61 to 54 mmol/mol; P = 0.003) and total daily insulin use (65 to 49 U/day; P<0.001), increased time spent in range (59 to 74%; P<0.001), and improved quality of life (P = 0.015), with no significant changes observed during the control period. Frequency of hypoglycaemia episodes did not differ across timepoints, and no episodes of ketoacidosis or other adverse events were reported during the intervention period. These preliminary findings suggest that a professionally supported LC diet may lead to improvements in markers of blood glucose control and quality of life with reduced exogenous insulin requirements and no evidence of increased hypoglycaemia or ketoacidosis risk in adults with T1D. Given the potential benefits of this intervention, larger, longer-term randomised controlled trials are warranted to confirm these findings. Trial Registration: https://www.anzctr.org.au/ACTRN12621000764831.aspx.

Effectiveness of a Digitally Delivered Continuous Care Intervention (Defeat Diabetes) on Type 2 Diabetes Outcomes: A 12-Month Single-Arm, Pre-Post Intervention Study

Low-carbohydrate dietary approaches can lead to improvements in blood glucose levels and weight loss, as well as a reduction and/or cessation in medication use in people with type 2 diabetes (T2D). Recent technological advances have led to the development of health-related applications (apps), including a high proportion dedicated to the management of diabetes. The Defeat Diabetes Program is a smartphone- and web-based app that provides guidance on a low-carbohydrate dietary approach for T2D and was designed to be used in conjunction with standard care in the medical management of T2D. The primary aim of this protocol is to provide the rationale and design of a single-arm 12-month pre-post intervention clinical trial using the Defeat Diabetes Program in an Australian community-based cohort of people with T2D who were referred by their general practitioner (GP). The study seeks to engage the GP community to help demonstrate whether the results of using a low-carbohydrate dietary approach for T2D can be achieved by the Defeat Diabetes Program in their patients. This protocol describes (1) the rationale for the selection of primary and secondary outcome measures, (2) the sampling procedures and methodological steps used to identify eligible participants and collect data, and (3) the approach followed to involve and educate GPs to support the trial.

Efficacy of low carbohydrate and ketogenic diets in treating mood and anxiety disorders: systematic review and implications for clinical practice

BACKGROUND

There is mounting interest in the potential efficacy of low carbohydrate and very low carbohydrate ketogenic diets in various neurological and psychiatric disorders.

AIMS

To conduct a systematic review and narrative synthesis of low carbohydrate and ketogenic diets (LC/KD) in adults with mood and anxiety disorders.

METHOD

MEDLINE, Embase, PsycINFO and Cochrane databases were systematically searched for articles from inception to 6 September 2022. Studies that included adults with any mood or anxiety disorder treated with a low carbohydrate or ketogenic intervention, reporting effects on mood or anxiety symptoms were eligible for inclusion. PROSPERO registration CRD42019116367.

RESULTS

The search yielded 1377 articles, of which 48 were assessed for full-text eligibility. Twelve heterogeneous studies (stated as ketogenic interventions, albeit with incomplete carbohydrate reporting and measurements of ketosis; diet duration: 2 weeks to 3 years; n = 389; age range 19 to 75 years) were included in the final analysis. This included nine case reports, two cohort studies and one observational study. Data quality was variable, with no high-quality evidence identified. Efficacy, adverse effects and discontinuation rates were not systematically reported. There was some evidence for efficacy of ketogenic diets in those with bipolar disorder, schizoaffective disorder and possibly unipolar depression/anxiety. Relapse after discontinuation of the diet was reported in some individuals.

CONCLUSIONS

Although there is no high-quality evidence of LC/KD efficacy in mood or anxiety disorders, several uncontrolled studies suggest possible beneficial effects. Robust studies are now needed to demonstrate efficacy, to identify clinical groups who may benefit and whether a ketogenic diet (beyond low carbohydrate) is required and to characterise adverse effects and the risk of relapse after diet discontinuation.

Effect of calorie restriction in comparison to usual diet or usual care on remission of type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Limited evidence is available about the dose-dependent effects of calorie restriction in patients with type 2 diabetes.

OBJECTIVE

To gather available evidence on the effect of calorie restriction on management of type 2 diabetes.

METHODS

We systematically searched PubMed, Scopus, CENTRAL, Web of Science, and gray literature to November 2022 for randomized trials longer than 12 weeks looking at the effect of a pre-specified calorie-restricted diet on remission of type 2 diabetes. We performed random-effects meta-analyses to estimate the absolute effect (risk difference) at 6-month (6±3 months) and 12-month (12±3 months) follow-ups. We performed dose-response meta-analyses to estimate mean difference (MD) for the effects of calorie restriction on cardiometabolic outcomes. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to judge the certainty of evidence.

RESULTS

28 randomized trials with 6281 participants were included. Using a remission definition of glycated hemoglobin (HbA_1c) <6.5% without antidiabetic medication use, calorie-restricted diets increased remission by 38 more per 100 patients (95%CI: 9 more, 67 more; n=5 trials, GRADE=moderate) at 6-month, and by 13 more per 100 patients (95%CI: 10 more, 18 more; n=4, GRADE=moderate) at 12-month in comparison to usual diet or usual care. Using a definition of HbA_1c<6.5% after at least two months cessation of antidiabetic medications, remission increased by 34 more per 100 patients (95%CI: 15 more, 53 more; n=1, GRADE=very low) at 6-month and by 16 more per 100 patients (95%CI: 4 more, 49 more; n=2, GRADE=low) at 12-month. At 6-month, each 500 kcal/day decrease in energy intake resulted in clinically meaningful reductions in body weight (MD: -6.33 kg, 95%CI: -7.76, -4.90; n=22; GRADE=high) and HbA_1c (MD: -0.82%, 95%CI: -1.05, -0.59; n=18, GRADE=high), which attenuated remarkably at 12-month.

CONCLUSIONS

Calorie-restricted diets may be effective interventions for type 2 diabetes remission, especially when coupled with an intensive lifestyle modification program.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42022300875).

Complex Association Among Diet Styles, Sleep Patterns, and Obesity in Patients with Diabetes

Background

Health risk factors (HRFs), including the adjustment of disturbed sleep patterns (including disorders and duration) and improvement of dietary intake, have become relatively novel and critical strategies to prevent the development of diabesity and treat diabetic complications.

Objective

We aimed to explore 1) whether there was an association between diet styles (including healthy and unhealthy diets) and diabesity; 2) whether sleep patterns could moderate this relationship; and 3) whether there was a complex interaction association between sleep patterns, diet styles, and diabesity.

Methods

The study was based on a national survey conducted by the China National Diabetic Chronic Complications Study Group, this study extracted data from some cities in Anhui Province and obtained basic and lifestyle information using a detailed questionnaire for analysis. The primary exposure was diet styles, and the outcomes were body mass index (BMI) and waist circumference (WC), while HbA1c and FBG and sleep patterns were moderators. Data were pooled using logistic regression and moderation analysis.

Results

The overall response rate was 92.0%. This study ultimately included 1765 participants. The mean age was 57.10 ± 10.0 years. Sociographically, participants with lower educational levels were more likely to have lower levels of WC (χ 2 = 2.73) and BMI (χ 2 = 3.47), were female (t=6.54), were more likely to have lower educational levels (F=13.78) and were older (F=23.75), were more likely to have higher detection rates of sleep disorders and were more likely to have other HRFs (walking, SSBs, HbA1c and TG). Additionally, diet styles were also significantly associated with BMI and WC. In the moderation analysis, SES (socioeconomic status) also affected the correlation between healthy diet style, sleep disorders and WC (β=0.20), neither in BMI nor unhealthy diet style in BMI and WC; the combination effect between diet styles, sleep patterns and HbA1c was associated with WC and BMI.

Conclusion

Complex associations and interactions were found between diet styles, sleep patterns, HbA1c, and diabesity. Therefore, it is necessary to understand the dietary pattern and other HRFS that cause diabesity, so as to strengthen further preventive measures. These results can provide some theoretical basis for the treatment of diabesity in the public health field.

Nutraceuticals as Supportive Therapeutic Agents in Diabetes and Pancreatic Ductal Adenocarcinoma: A Systematic Review

The correlation between pancreatic ductal adenocarcinoma (PDAC) and diabetes-related mechanisms support the hypothesis that early therapeutic strategies targeting diabetes can contribute to PDAC risk reduction and treatment improvement. A systematic review was conducted, using PubMed, Embase and Cochrane Library databases, to evaluate the current evidence from clinical studies qualitatively examining the efficacy of four natural products: Curcumin-Curcuma longa L.; Thymoquinone-Nigella sativa L.; Genistein-Glycine max L.; Ginkgo biloba L.; and a low-carbohydrate ketogenic diet in type 2 diabetes (T2D) and PDAC treatment. A total of 28 clinical studies were included, showing strong evidence of inter-study heterogeneity. Used as a monotherapy or in combination with chemo-radiotherapy, the studied substances did not significantly improve the treatment response of PDAC patients. However, pronounced therapeutic efficacy was confirmed in T2D. The natural products and low-carbohydrate ketogenic diet, combined with the standard drugs, have the potential to improve T2D treatment and thus potentially reduce the risk of cancer development and improve multiple biological parameters in PDAC patients.

Effect of the Ketogenic Diet on the Prophylaxis and Treatment of Diabetes Mellitus: A Review of the Meta-Analyses and Clinical Trials

The exponentially growing frequency of diagnosing diabetes mellitus means that a verification of the previous dietetic approach to treating the disease seems justified. The simultaneous growth of interest in the ketogenic diet and the development of knowledge in this field have contributed to the increasingly frequent application of the ketogenic diet in diabetes treatment. This paper also deals with that issue; its aim includes an extensive analysis of the influence of the ketogenic diet on the prophylaxis and treatment of diabetes. The paper has been prepared based on a wide, meticulous analysis of the available literature on the subject. Among other findings, a favorable effect of that nutrition model has been demonstrated on the values of glycated hemoglobin, glucose, insulin, or other metabolic parameters in diabetes patients. The effect of the ketogenic diet on the pharmacotherapy of type 1 and type 2 diabetes has been presented and compared with the standard nutritional management plan recommended for that disease. Further research is needed in this field, especially studies with a long follow-up period. The discussed articles report interesting therapeutic advantages to the ketogenic diet in comparison with standard diets.

Effectiveness of Non-Contact Dietary Coaching in Adults with Diabetes or Prediabetes Using a Continuous Glucose Monitoring Device: A Randomized Controlled Trial

We aimed to evaluate the effectiveness of dietary coaching and continuous glucose monitoring (CGM) in patients with diabetes or prediabetes to improve their behavioral skills and health outcomes. A randomized controlled study with pre- and post-testing was conducted. Data were collected between November 2020 and April 2021. Forty-five patients with diabetes or prediabetes who used a CGM device were enrolled and analyzed. Dietary education, individual coaching and group coaching were provided to participants in the experimental group for 4 weeks. After the intervention, the thigh circumference in men significantly differed between the two groups (z = -2.02, p = 0.044). For women, participants in the experimental group showed greater improvement in eating self-efficacy compared with those in the control group (z = -2.66, p = 0.008). Insomnia was negatively related to the change in eating self-efficacy (r = -0.35, p = 0.018) and increase in thigh circumference (r = -0.35, p = 0.017). Even if used within a short intervention period, non-contact dietary coaching programs can help enhance behavioral skills, such as eating self-efficacy and health outcomes, such as thigh circumference. Moreover, the changed variables can indirectly improve other health outcomes in patients with diabetes or prediabetes.

Low-carbohydrate diet score and the risk of stroke in older people: Guangzhou Biobank Cohort Study and meta-analysis of cohort studies

OBJECTIVES

To our knowledge, evidence regarding the association of a low-carbohydrate diet (LCD) with the risk for stroke is limited. The aim of this study was to examine the association between an LCD and stroke in a population with relatively high-carbohydrate intake and risk for stroke and use a meta-analysis to update the evidence.

METHODS

The study included 19 850 participants aged ≥50 y without stroke history at baseline in the Guangzhou Biobank Cohort Study. LCD score was calculated based on the percentage of energy from carbohydrate, protein, and fat (range 0-30 points), with a higher score indicating a lower intake of carbohydrate and a higher intake of fat and protein.

RESULTS

During an average follow-up of 13.1 y, 1661 stroke events and deaths occurred, including 1255 ischemic strokes. The second, versus the lowest quartile of animal-based LCD scores, were associated with lower risks for all stoke and ischemic stroke (hazards ratio [HR], 0.87; 95% confidence interval [CI], 0.77-0.997, and HR, 0.83; 95% CI, 0.72-0.97). Non-significant associations of plant-based or total LCD scores with the risk for stoke were found.

CONCLUSIONS

In a population consuming high levels of carbohydrates and low levels of protein and fat, a moderate level of animal-based LCD, but not plant-based LCD, was associated with a lower risk for stroke.

Very low carbohydrate (ketogenic) diets in type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIM

Very low carbohydrate/ketogenic diets (VLC/KDs) are popular but their role in managing pre-diabetes and type 2 diabetes (T2D) is uncertain. This study uses a systematic review and meta-analysis of randomized controlled trials to estimate the effect of these diets in this population.

MATERIALS AND METHODS

A systematic review identified randomized controlled trials of at least 6 months duration comparing efficacy and safety of VLC/KDs (≤50 g carbohydrate or ≤10% total energy from carbohydrate per day) with a control diet (carbohydrate above the VLC/KD threshold) in adults with pre-diabetes or T2D. The primary outcome variable was glycated haemoglobin (HbA1c) after 12 months. The meta-analysis method was inverse variance weighting of mean values for continuous variables.

RESULTS

Key word searches identified 2290 studies; 2221 were not in scope. A full text review of 69 studies identified eight meeting inclusion criteria; in total, it involved 606 participants. Six studies reported HbA1c (%) at 12 months; four as change from baseline with a fixed effects estimate (95% confidence interval): VLC/KD minus control of 0.01% (-0.22 to 0.25), p = .91; and two as change from baseline: -0.65% (-0.99; -0.31) [-7.1 mmol/mol (-10.8; -3.4)], p < .001. Serum triglycerides were lower with VLC/KD versus control: -0.28 mmol/L (-0.44 to -0.11), p < .001. High-density lipoprotein was higher with an estimate of 0.04 mmol/L (0.01 to 0.08), p = .03, in the five studies reporting 12-month summary data.

CONCLUSIONS

A VLC/KD may cause reductions in HbA1c and triglycerides in those with pre-diabetes or T2D but evidence of an advantage over other strategies is limited. More well-designed studies are required to provide certain evidence.

A Health Care Professional Delivered Low Carbohydrate Diet Program Reduces Body Weight, Haemoglobin A1c, Diabetes Medication Use and Cardiovascular Risk Markers-A Single-Arm Intervention Analysis

This study examined the effectiveness of a health care professional delivered low-carbohydrate diet program (Diversa Health Program) aiming to improve obesity/type-2-diabetes management for people living in Australia. 511 adults (Age:57.1 ± 13.7 [SD] yrs) who participated between January 2017−August 2021 for ≥30 days with pre-post data collected for ≥1 key outcome variable (body weight and HbA1c) were included in the analysis. Average participation duration was 218 ± 207 days with 5.4 ± 3.9 reported consultation visits. Body weight reduced from 92.3 ± 23.0 to 86.3 ± 21.1 kg (n = 506, p < 0.001). Weight loss was 0.9 ± 2.8 kg (1.3%), 4.5 ± 4.3 kg (5.7%) and 7.9 ± 7.2 kg (7.5%), respectively, for those with a classification of normal weight (n = 67), overweight (n = 122) and obese (n = 307) at commencement. HbA1c reduced from 6.0 ± 1.2 to 5.6 ± 0.7% (n = 212, p < 0.001). For members with a commencing HbA1c of <5.7% (n = 110), 5.7−6.4% (n = 55), and ≥6.5% (n = 48), HbA1c reduced −0.1 ± 0.2%, −0.3 ± 0.3%, and −1.4 ± 1.3%, respectively. For members with a commencing HbA1c ≥6.5%, 90% experienced a HbA1c reduction and 54% achieved a final HbA1c < 6.5%. With inclusion and exclusion of metformin, respectively, 124 and 82 diabetes medications were prescribed to 63 and 42 members that reduced to 82 and 35 medications prescribed to 51 and 26 members at final visit. A health care professional delivered low-carbohydrate diet program can facilitate weight loss and improve glycaemic control with greatest improvements and clinical relevance in individuals with worse baseline parameters.

The role of the dietary patterns in the cardiovascular disease risk prevention

Cardiovascular diseases (CVD) are a part of a wide group of diseases, which became main threat to the life and health of the population in highly developed countries. To prevent and treat CVD, in addition to implementation of pharmacological methods, there are a number of lifestyle components, including eating habits, that significantly influence the development of these diseases. The dietary patterns strongly correlate with the risk of cardiovascular disease. Modifications of the dietary habits allow to control many parameters such as: body weight, cholesterol/triglyceride levels or blood pressure. Alternative diets are frequently used to reduce the risk of developing a CVD. The main recommended dietary patterns includes Mediterranean diet (MD), the DASH diet (Dietary Approach to Stop Hypertension) and mild variants of vegetarianism. The more controversial nutritional styles includes the ketogenic or vegan diets. Due to various assumptions as well as the mechanisms of action of each diets, an attempt of its evaluation have been made. The aim of our study is to review and analyze the available data on the impact of various nutrition models regarding to cardiovascular diseases risk prevention.

Dietary Risk Factors and Eating Behaviors in Peripheral Arterial Disease (PAD)

Dietary risk factors play a fundamental role in the prevention and progression of atherosclerosis and PAD (Peripheral Arterial Disease). The impact of nutrition, however, defined as the process of taking in food and using it for growth, metabolism and repair, remains undefined with regard to PAD. This article describes the interplay between nutrition and the development/progression of PAD. We reviewed 688 articles, including key articles, narrative and systematic reviews, meta-analyses and clinical studies. We analyzed the interaction between nutrition and PAD predictors, and subsequently created four descriptive tables to summarize the relationship between PAD, dietary risk factors and outcomes. We comprehensively reviewed the role of well-studied diets (Mediterranean, vegetarian/vegan, low-carbohydrate ketogenic and intermittent fasting diet) and prevalent eating behaviors (emotional and binge eating, night eating and sleeping disorders, anorexia, bulimia, skipping meals, home cooking and fast/ultra-processed food consumption) on the traditional risk factors of PAD. Moreover, we analyzed the interplay between PAD and nutritional status, nutrients, dietary patterns and eating habits. Dietary patterns and eating disorders affect the development and progression of PAD, as well as its disabling complications including major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nutrition and dietary risk factor modification are important targets to reduce the risk of PAD as well as the subsequent development of MACE and MALE.

Ketogenic Diet Benefits to Weight Loss, Glycemic Control, and Lipid Profiles in Overweight Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trails

A ketogenic diet, characterized by low calories with high levels of fat, adequate levels of protein, and low levels of carbohydrates, has beneficial effects on body weight control in overweight patients. In the present study, a meta-analysis was conducted to investigate the role of a ketogenic diet in body weight control and glycemic management in overweight patients with type 2 diabetes mellitus (T2DM). In summary, we systematically reviewed articles from the Embase, PubMed, Web of Science and Cochrane Library databases and obtained eight randomized controlled trials for meta-analysis. The results show that a ketogenic diet had significantly beneficial effects on the loss of body weight (SMD, -5.63, p = 0.008), the reduction of waist circumference (SMD, -2.32, p = 0.04), lowering glycated hemoglobin (SMD, -0.38, p = 0.0008) and triglycerides (SMD, -0.36, p = 0.0001), and increasing high-density lipoproteins (SMD, 0.28, p = 0.003). Overall, these results suggest that a ketogenic diet may be an effective dietary intervention for body weight and glycemic control, as well as improved lipid profiles in overweight patients with T2DM. Hence, a ketogenic diet can be recommended for the therapeutic intervention of overweight patients with T2DM.

A technology assisted precision ketogenic diet intervention for cardio-renal-metabolic health in overweight or obese adults: Protocol for a randomized controlled trial

BACKGROUND

The obesity epidemic is a public health concern, as it is associated with a variety of chronic conditions. The ketogenic diet has drawn much scientific and public attention. However, implementation is challenging and its effect on cardio-renal-metabolic health is inconclusive. This study will assess the feasibility, acceptability, and preliminary efficacy of a technology-assisted ketogenic diet on cardio-renal-metabolic health.

METHODS

This is a single center, 6-month, stratified, randomized controlled trial. A total of 60 overweight/obese adults (18+ years old) will be enrolled, including 20 without type 2 diabetes (T2D) and without chronic kidney disease (CKD); 20 with T2D, but without CKD; and 20 with early-stage CKD. Participants will be stratified based on health conditions and randomized into a ketogenic diet (n = 30) or a low-fat diet group (n = 30). Health education involving diet and physical activity will be delivered both digitally and in-person. Mobile and connected health technologies will be used to track lifestyle behaviors and health indicators, as well as provide weekly feedback. The primary outcome (weight) and the secondary outcomes (e.g., blood pressure, glycemic control, renal health) will be assessed with traditional measurements and metabolomics.

DISCUSSION

Mobile and connected health technologies provide new opportunities to improve chronic condition management, health education attendance, planned lifestyle changes and engagement, and health outcomes. The advancement of bioinformatics technology offers the possibility to profile and analyze omics data which may advance our understanding of the underlying mechanisms of intervention effects on health outcomes at the molecular level for personalized and precision lifestyle interventions.

Dose-dependent effect of carbohydrate restriction for type 2 diabetes management: a systematic review and dose-response meta-analysis of randomized controlled trials

BACKGROUND

Carbohydrate restriction is effective for type 2 diabetes management.

OBJECTIVES

We aimed to evaluate the dose-dependent effect of carbohydrate restriction in patients with type 2 diabetes.

METHODS

We systematically searched PubMed, Scopus, and Web of Science to May 2021 for randomized controlled trials evaluating the effect of a carbohydrate-restricted diet (≤45% total calories) in patients with type 2 diabetes. The primary outcome was glycated hemoglobin (HbA1c). Secondary outcomes included fasting plasma glucose (FPG); body weight; serum total, LDL, and HDL cholesterol; triglyceride (TG); and systolic blood pressure (SBP). We performed random-effects dose-response meta-analyses to estimate mean differences (MDs) for a 10% decrease in carbohydrate intake.

RESULTS

Fifty trials with 4291 patients were identified. At 6 months, compared with a carbohydrate intake between 55%-65% and through a maximum reduction down to 10%, each 10% reduction in carbohydrate intake reduced HbA1c (MD, -0.20%; 95% CI, -0.27% to -0.13%), FPG (MD, -0.34 mmol/L; 95% CI, -0.56 to -0.12 mmol/L), and body weight (MD, -1.44 kg; 95% CI, -1.82 to -1.06 kg). There were also reductions in total cholesterol, LDL cholesterol, TG, and SBP. Levels of HbA1c, FPG, body weight, TG, and SBP decreased linearly with the decrease in carbohydrate intake from 65% to 10%. A U-shaped effect was seen for total cholesterol and LDL cholesterol, with the greatest reduction at 40%. At 12 months, a linear reduction was seen for HbA1c and TG. A U-shaped effect was seen for body weight, with the greatest reduction at 35%.

CONCLUSIONS

Carbohydrate restriction can exert a significant and important reduction on levels of cardiometabolic risk factors in patients with type 2 diabetes. Levels of most cardiometabolic outcomes decreased linearly with the decrease in carbohydrate intake. U-shaped effects were seen for total cholesterol and LDL cholesterol at 6 months and for body weight at 12 months.

Positive effect of cognitive-behavioral intervention combined with integrated health care on patients with type 2 diabetes

OBJECTIVE

This study was designed to investigate the effects of cognitive-behavioral intervention (CBI) combined with integrated health care (IHC) on glycemic control, adverse mood, health knowledge and self-efficacy in patients with type 2 diabetes mellitus.

METHODS

The clinical data of 115 patients with type 2 diabetes mellitus were retrospectively collected and divided into two groups according to the intervention methods, with 57 patients in group A receiving conventional care and 58 patients in group B receiving CBI combined with IHC. The blood glucose, scores of Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), health knowledge, self-efficacy, quality of life, and nursing satisfaction were compared between the two groups before and after intervention.

RESULTS

Compared with group A, group B had lower glycated hemoglobin (HbAlc), 2-h postprandial glucose (2 hPG), and fasting plasma glucose (FPG) levels (P < 0.05), lower HAMD and HAMA scores (P < 0.05), higher health knowledge and self-efficacy scores (P < 0.05), and higher quality of life after intervention (P < 0.05). Group B exhibited a nursing satisfaction rate of 94.83%, higher than that of 70.18% in group A (P < 0.05).

CONCLUSION

The effects of CBI combined with IHC can effectively control blood glucose and improve dysphoria, health knowledge, self-efficacy, and quality of life in patients with type 2 diabetes.

Short Term Isocaloric Ketogenic Diet Modulates NLRP3 Inflammasome Via B-hydroxybutyrate and Fibroblast Growth Factor 21

A ketogenic diet (KD) is known to have beneficial health effects. Various types of KD interventions have been applied to manage metabolic syndrome based on modification of diet parameters such as duration of intervention, macronutrient components, and total calories. Nevertheless, the beneficial health impact of isocaloric KD is largely unknown, especially in healthy subjects. The present study investigated the acute effects of a 3-day isocaloric KD. In this non-randomized intervention study, we recruited 15 healthy volunteers aged 24-38 years (7 men and 8 women) and placed them on an isocaloric KD restricting intake of carbohydrates but not energy (75% fat, 20% protein, 5% carbohydrate) for 3 days. Biochemical profiles and laboratory measurements were performed. Peripheral blood monocular cells were cultured, and measured cell stimulated cytokines. After short-term isocaloric KD, subjects lost body weight and serum free fatty acid levels were increased. These results accompanied elevated serum β-hydroxybutyrate (BHB) concentration and fibroblast growth factor 21 (FGF21) levels and improved insulin sensitivity. Regarding the direct effect of BHB on inflammasome activation, interleukin-1β (IL-1β) and tumor necrosis factor-α secretion in response to adenosine triphosphate or palmitate stimulation in human macrophages decreased significantly after isocaloric KD. In ex-vivo experiments with macrophages, both FGF21 and BHB further reduced IL-1β secretion compared to either BHB or FGF21 alone. The inhibitory effect of FGF21 on IL-1β secretion was blunted with bafilomycin treatment, which blocked autophagy flux. In conclusion, isocaloric KD for 3 days is a promising approach to improve metabolic and inflammatory status.

Effects of technology-based interventions on dietary intake or anthropometrics among adolescents and adults in South Asia - A systematic review of intervention studies

INTRODUCTION

Mobile technology has been increasingly used as part of dietary interventions, but the effects of such interventions have not been systematically evaluated in the South Asian context. The systematic review aimed to determine the effects of technology-based interventions on dietary intake or anthropometrics among adolescents and adults in South Asia.

METHODS

Five electronic databases were searched (PubMed, Scopus, Web of Science, Global Health Library and Health Technology Assessment). Studies published in English between 1st January 2011 and 31st December 2021were included. Interventions that evaluated the effects of dietary interventions using technology on dietary outcomes and anthropometrics in adolescents or adults in the age group of 13-44 years (or a broader age group) from South Asia were eligible for inclusion. The risk of bias was assessed using the Cochrane Risk-of-bias 2 tool and ROBINS-I tool. A narrative synthesis was conducted.

RESULTS

Twenty-one studies met the inclusion criteria (20,667 participants). Eleven of the 17 randomised controlled trials (RCTs) had a high overall risk of bias. The four non-randomised intervention studies had a serious or critical overall risk of bias. When including studies with low risk or some concern for bias, the interventions had a beneficial effect on at least one dietary outcome in four of the six RCTs that measured changes in diet, and no effect on the anthropometric outcomes in the six RCTs that measured changes in anthropometric outcomes.

DISCUSSION

Technology-based dietary interventions have had some positive effects on dietary intake, but no effects on anthropometry in South Asia. More evidence is needed as the overall risk of bias was high in a majority of the studies.

Beneficial Effects of the Ketogenic Diet in Metabolic Syndrome: A Systematic Review

Metabolic syndrome (MetS) is a major societal concern due to its increasing prevalence and its high risk of cardiovascular complications. The ketogenic diet (KD), a high fat, low carbohydrate, and non-caloric restrictive diet, is a new popular weight loss intervention but its beneficial effects are controversial. This study aims to gather all of the relevant studies using KD for metabolic disease treatment to determine its beneficial effects and evaluate its safety and efficacy for patients. Following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we included 20 articles in the final review. Overall, most of the studies showed a significant effect of KD on weight loss (17/19 articles), BMI (7/7), glucose levels (9/13), insulin levels (7/9), HOMA-IR (4/5), HbA1c (7/7), total cholesterol (6/9), TG (13/15), AST (3/4), and ALT (3/5), and no major side effects. The results heterogeneity seems to be explained by a difference of diet composition and duration. In conclusion, KD is a safety diet which seems to be a promising approach for obesity and MetS treatment, even if the optimal carbohydrate proportion and diet duration must be explored to enhance the beneficial effects of KD.

The Effect of Dietary Interventions on Hypertriglyceridemia: From Public Health to Molecular Nutrition Evidence

Approximately 25–50% of the population worldwide exhibits serum triglycerides (TG) (≥150 mg/dL) which are associated with an increased level of highly atherogenic remnant-like particles, non-alcoholic fatty liver disease, and pancreatitis risk. High serum TG levels could be related to cardiovascular disease, which is the most prevalent cause of mortality in Western countries. The etiology of hypertriglyceridemia (HTG) is multifactorial and can be classified as primary and secondary causes. Among the primary causes are genetic disorders. On the other hand, secondary causes of HTG comprise lifestyle factors, medical conditions, and drugs. Among lifestyle changes, adequate diets and nutrition are the initial steps to treat and prevent serum lipid alterations. Dietary intervention for HTG is recommended in order to modify the amount of macronutrients. Macronutrient distribution changes such as fat or protein, low-carbohydrate diets, and caloric restriction seem to be effective strategies in reducing TG levels. Particularly, the Mediterranean diet is the dietary pattern with the most consistent evidence for efficacy in HTG while the use of omega-3 supplements consumption is the dietary component with the highest number of randomized clinical trials (RCT) carried out with effective results on reducing TG. The aim of this review was to provide a better comprehension between human nutrition and lipid metabolism.