Low-Carbohydrate Diets in the Management of Obesity and Type 2 Diabetes: A Review from Clinicians Using the Approach in Practice

Ketosis Suppression and Ageing (KetoSAge) Part 2: The Effect of Suppressing Ketosis on Biomarkers Associated with Ageing, HOMA-IR, Leptin, Osteocalcin, and GLP-1, in Healthy Females

Metabolic dysfunctions are among the best documented hallmarks of ageing. Cardiovascular disease, Alzheimer's disease, cancer, type 2 diabetes mellitus, metabolic-dysfunction-associated steatosis liver disease, and fragility fractures are diseases of hyperinsulinaemia that reduce life and healthspan. We studied the effect of suppressing ketosis in 10 lean (BMI 20.5 kg/m2 ± 1.4), metabolically healthy, pre-menopausal women (age 32.3 ± 8.9 years) maintaining nutritional ketosis (NK) for an average of 3.9 years (± 2.3) who underwent three 21-day phases: nutritional ketosis (NK; P1), suppressed ketosis (SuK; P2), and returned to NK (P3). Ketosis suppression significantly increased insulin, 1.83-fold (p = 0.0006); glucose, 1.17-fold (p = 0.0088); homeostasis model assessment for insulin resistance (HOMA-IR), 2.13-fold (p = 0.0008); leptin, 3.35-fold (p = 0.0010); total osteocalcin, 1.63-fold (p = 0.0138); and uncarboxylated osteocalcin, 1.98-fold (p = 0.0417) and significantly decreased beta-hydroxybutyrate, 13.50-fold (p = 0.0012) and glucagon-like peptide-1 (GLP-1), 2.40-fold (p = 0.0209). Sustained NK showed no adverse health effects and may mitigate hyperinsulinemia. All biomarkers returned to basal P1 levels after removing the intervention for SuK, indicating that metabolic flexibility was maintained with long-term euketonaemia.

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.

Type 2 Diabetes Mellitus and Cardiometabolic Prospects: A Rapid Narrative Review

Cardiometabolic syndrome (CMS), type 2 diabetes mellitus (T2DM), and cardiovascular diseases are among the major altruists to the international liability of disease. The lifestyle and dietary changes attributable to economic growth have resulted in an epidemiological transition towards non-communicable diseases (NCDs) as the leading causes of death. Low- and middle-income countries (LMICs) bear a more substantial disease burden due to limited healthcare sector capacities to address the rapidly growing number of chronic disease patients. The purpose of this narrative review paper was to explore the interrelationships between CMS, T2DM, and cardiovascular impairments in the context of NCDs, as well as major preventative and control interventions. The role of insulin resistance, hyperglycemia, and dyslipidemia in the pathogenesis of T2DM and the development of severe cardiovascular impairments was highlighted. This paper elaborated on the pivotal role of lifestyle modifications, such as healthy diets and physical activity, as cornerstones of addressing the epidemics of metabolic diseases. Foods high in calories, refined sugar, red meat, and processed and ready-to-eat meals were associated with an amplified risk of CMS and T2DM. In contrast, diets based on fruits, legumes, vegetables, and whole grain, home-cooked foods demonstrated protective effects against metabolic diseases. Additionally, the role of a psychological and behavioral approach in addressing metabolic diseases was highlighted, especially regarding its impact on patient empowerment and the patient-centered approach to preventative and therapeutic interventions.

Weight Loss Programs: Why Do They Fail? A Multidimensional Approach for Obesity Management

PURPOSE OF REVIEW

Despite the prevalence of weight loss programs, their success rates remain discouraging, with around half of individuals regaining lost weight within two years. The primary objective of this review is to explore the factors contributing to the failure of weight loss programs and to provide insights into effective weight management strategies.

RECENT FINDINGS

Factors contributing to the failure of weight loss programs include the impracticality of restrictive diets, potential metabolic impacts, limited focus on lifestyle changes, genetic predispositions, psychological influences, socioeconomic status, and medical conditions. A holistic approach considering these factors is crucial for safe and sustainable weight loss. Key findings indicate the importance of holistic approaches to weight management, including lifestyle modifications, medical interventions, and behavioral and psychological strategies. Effective weight loss strategies emphasize low-calorie, nutrient-rich diets, regular physical activity, and interventions tailored to individual needs. Combining multiple approaches offers the best chance of successful weight management and improved health outcomes. This review provides insights into the complexities of obesity management and the factors contributing to the failure of weight loss programs. It highlights the necessity of adopting a holistic approach that addresses dietary habits, physical activity, genetic factors, psychological well-being, and socioeconomic influences. Recommendations include implementing lifestyle modifications, medical interventions when necessary, and integrating behavioral and psychological support to achieve sustainable weight loss and mitigate the global health challenge posed by obesity.

Addressing uncertainty about the role of structured lifestyle modification for metabolic surgery patients

There is good evidence that structured lifestyle modification programmes improve health in patients with metabolic and cardiovascular disorders, but there is no specific evidence that they improve outcomes in patients undergoing metabolic or obesity surgery. Despite expert consensus guidelines stating this fact, some healthcare systems still compel patients to participate in a structured lifestyle modification programme prior to metabolic or obesity surgery. There is a well-established need for individualised multidisciplinary dietetic and physical activity care for metabolic and obesity surgery patients, and the benefits of intentional weight loss prior to surgery are well proven, but these are distinct from potentially harmful requirements for patients to undertake compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery and reinforce obesity stigma. A critical step in rejuvenating metabolic surgery is to reframe patient participation in structured lifestyle modification programmes as an opportunity for education and empowerment, not as an indicator of motivation or suitability for metabolic surgery. Large, well-designed and adequately powered clinical trials are needed to address uncertainties in the evidence base for these programmes. Given genuine equipoise, they will need to determine whether "surgery plus lifestyle" is superior to "surgery plus placebo". Moreover, they will need to determine the cost-effectiveness of these programmes and identify some of the factors giving rise to the substantial heterogeneity in responses to structured lifestyle modification.

Gut microbiota changes associated with low-carbohydrate diet intervention for obesity

Low-carbohydrate diets (LCDs) are frequently recommended for alleviating obesity, and the gut microbiota plays key roles in energy metabolism and weight loss. However, there is limited in-human research on how LCD changes gut microbiota. In this before-after study, 43 participants were assigned to the LCD intervention for 4 weeks. The main objective was to investigate the specific changes that occur in the participants' microbiome in response to the LCD. Changes in gut microbiota were analyzed using 16s rRNA sequencing. Body composition was measured using InBody 770. Remarkably, 35 participants (79.07%) lost more than 5% of their body weight; levels of BMI, body fat, and total cholesterol were significantly decreased, indicating the effectiveness of the LCD intervention. The richness of microbiota significantly increased after the intervention. By taking the intersection of ANOVA and linear discriminant analysis effect size (LEfSe) analysis results, we identified three phyla, three classes, four orders, five families, and six genera that were differentially enriched between baseline and week-4 time points. Among the three phyla, relative abundances of Firmicutes and Actinobacteriota decreased significantly, while Bacteroidetes increased significantly. At the genus level, Ruminococcus, Agathobacter, Streptococcus, and Bifidobacterium showed a significant reduction in relative abundances, whereas Parabacteroides and Bacteroides increased steadily. Our results demonstrate that LCD can effectively alleviate obesity and modify certain taxa of gut microbiota, providing potential insights for personalized dietary interventions against obesity.

Dietary interventions improve diabetic kidney disease, but not peripheral neuropathy, in a db/db mouse model of type 2 diabetes

Patients with type 2 diabetes often develop the microvascular complications of diabetic kidney disease (DKD) and diabetic peripheral neuropathy (DPN), which decrease quality of life and increase mortality. Unfortunately, treatment options for DKD and DPN are limited. Lifestyle interventions, such as changes to diet, have been proposed as non-pharmacological treatment options for preventing or improving DKD and DPN. However, there are no reported studies simultaneously evaluating the therapeutic efficacy of varying dietary interventions in a type 2 diabetes mouse model of both DKD and DPN. Therefore, we compared the efficacy of a 12-week regimen of three dietary interventions, low carbohydrate, caloric restriction, and alternate day fasting, for preventing complications in a db/db type 2 diabetes mouse model by performing metabolic, DKD, and DPN phenotyping. All three dietary interventions promoted weight loss, ameliorated glycemic status, and improved DKD, but did not impact percent fat mass and DPN. Multiple regression analysis identified a negative correlation between fat mass and motor nerve conduction velocity. Collectively, our data indicate that these three dietary interventions improved weight and glycemic status and alleviated DKD but not DPN. Moreover, diets that decrease fat mass may be a promising non-pharmacological approach to improve DPN in type 2 diabetes given the negative correlation between fat mass and motor nerve conduction velocity.

Obesity-related parameters in carriers of some BDNF genetic variants may depend on daily dietary macronutrients intake

Some common single-nucleotide polymorphisms of the brain-derived neurotrophic factor (BDNF) gene have been associated not only with the neurodegenerative diseases but also with some eating disorders. The aim of this study was to assess the possible differences in the obesity-related and glucose metabolism parameters between some BDNF genotypes', that may depend on the daily energy and macronutrients intake. In 484 adult participants we performed the anthropometric measurements, body composition analysis, and body fat distribution. The daily dietary intake was assessed using the 3-day food intake diaries. Blood glucose and insulin concentrations were measured at fasting and during oral glucose tolerance tests. Moreover, the visceral adipose tissue/subcutaneous adipose tissue (VAT/SAT) ratio and homeostatic model assessment of insulin resistance were calculated. We noted that participants carrying the GG genotype had lower skeletal muscle mass and fat free mass (FFM) when carbohydrate intake was > 48%, whereas they presented higher fat-free mass (FFM), and surprisingly higher total cholesterol and LDL-C concentrations when daily fiber intake was > 18 g. Moreover, in these subjects we noted higher waist circumference, BMI, and fasting glucose and insulin concentrations, when > 18% of total daily energy intake was delivered from proteins, and higher VAT content and HDL-C concentrations when > 30% of energy intake was derived from dietary fat. Our results suggest that glucose homeostasis and obesity-related parameters in carriers of some common variants of BDNF gene, especially in the GG (rs10835211) genotype carriers, may differ dependently on daily energy, dietary macronutrients and fiber intake.

Low-Carbohydrate Diet Scores and Mortality Among Adults With Incident Type 2 Diabetes

OBJECTIVE

The current study aims to prospectively examine the association between postdiagnosis low-carbohydrate diet (LCD) patterns and mortality among individuals with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

Among participants with incident diabetes identified in the Nurses' Health Study and Health Professionals Follow-up Study, an overall total LCD score (TLCDS) was calculated based on the percentage of energy as total carbohydrates. In addition, vegetable (VLCDS), animal (ALCDS), healthy (HLCDS), and unhealthy (ULCDS) LCDS were further derived that emphasized different sources and quality of macronutrients. Multivariable-adjusted Cox models were used to assess the association between the LCDS and mortality.

RESULTS

Among 10,101 incident T2D cases contributing 139,407 person-years during follow-up, we documented 4,595 deaths of which 1,389 cases were attributed to cardiovascular disease (CVD) and 881 to cancer. The pooled multivariable-adjusted hazard ratios (HRs, 95% CIs) of total mortality per 10-point increment of postdiagnosis LCDS were 0.87 (0.82, 0.92) for TLCDS, 0.76 (0.71, 0.82) for VLCDS, and 0.78 (0.73, 0.84) for HLCDS. Both VLCDS and HLCDS were also associated with significantly lower CVD and cancer mortality. Each 10-point increase of TLCDS, VLCDS, and HLCDS from prediagnosis to postdiagnosis period was associated with 12% (7%, 17%), 25% (19%, 30%), and 25% (19%, 30%) lower total mortality, respectively. No significant associations were observed for ALCDS and ULCDS.

CONCLUSIONS

Among people with T2D, greater adherence to LCD patterns that emphasize high-quality sources of macronutrients was significantly associated with lower total, cardiovascular, and cancer mortality.

Metabolic surgery versus usual care effects on diabetes remission: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery is superior to usual care for diabetes remission. Previous meta-analyses were limited by pooling observational and randomized trials, using various definitions of diabetes remission, and not controlling for various diabetes medications. The current meta-analysis aimed to compare bariatric surgery and usual care regarding the same.

METHODS

We searched PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Library for relevant articles from the date of the first inception up to February 2023. The keywords diabetes remission, Bariatric surgery, metabolic surgery, lifestyles, usual care, GLIP-1 agonists, insulin use, gastric banding, biliopancreatic diversion, sleeve gastrectomy, and Roux-en-Y gastric bypass, were used. A datasheet was used to extract the relevant data.

RESULTS

Diabetes remission (complete and prolonged) was higher among bariatric surgeries compared to usual care, odd ratio, 0.06, 95 CI, 0.02-0.25 and 0.12, 95 CI, 0.02-0.72, respectively. bariatric surgery patients were younger, had higher HbA1c, odd ratio, - 3.13, 95 CI, - 3.71 to 2.54, and 0.25, 95 CI, 0.02-0.48, respectively, insulin use was higher, and glucagon-like peptide agonists use was lower among bariatric surgery patients, odd ratio, 0.49, 95% CI, 0.24-0.97, and 3.06, 95% CI, 1.44-6.53, respectively.

CONCLUSION

Bariatric surgery was better than usual care in diabetes remission. Bariatric surgery patients were younger, had higher HbA1c, and received more insulin and lower GLP-1 agonists. No differences were evident regarding body mass index and the duration of diabetes. Further trials comparing the new anti-diabetic medications and different forms of bariatric surgery and controlling for the level of exercise and diet are recommended.

Protein-Balanced Dietary Habits Benefit Cognitive Function in Japanese Older Adults

Since daily dietary habits can affect cognitive function, dietary patterns such as the Mediterranean-DASH Intervention for Neurodegenerative Delay diet have been proposed as interventions to slow cognitive decline. However, because dietary habits vary widely among different food cultures, it is necessary to establish dietary pattern intervention methods that are appropriate for each population. Therefore, in this study, the dietary patterns of elderly Japanese individuals were classified using cluster analysis, and their relationship with cognitive function was investigated. We then modeled the dietary patterns and applied them to another cohort of elderly Japanese individuals to determine whether differences in dietary patterns could predict cognitive decline. One hundred and fifty older adults ≥ 65 years of age in the community were recruited. Their daily food intake and cognitive function were measured using the brief-type self-administered diet history questionnaire and Montreal Cognitive Assessment, respectively. K-means cluster analysis identified a high-carbohydrate (HC) dietary pattern with high cereal intake and a protein-balanced (PB) dietary pattern with high intake of legumes, vegetables, seafood, meat, and eggs. Cognitive function was significantly higher in the PB group than in the HC group. Furthermore, to classify the new data into HC and PB patterns, a classification model was created by discriminant analysis using food groups with significantly different intakes among dietary patterns. Next, we recruited 267 new older adults ≥ 65 years of age and measured food intake and cognitive function assessed using the memory performance index score. Individuals with cognitive decline were identified and their detailed cognitive functions were assessed using the neurocognitive index score. Cognitive function was significantly impaired in the HC pattern in both the general elderly and cognitively impaired cohorts. These findings suggest that a dietary pattern of low carbohydrate and high protein intake is associated with good cognitive function in elderly Japanese individuals. Classification by these dietary patterns can predict cognitive reservation in community-dwelling older adults.

Pattern of weight gain in pregnant women in slum areas of Hamadan using multilevel ordinal regression

BACKGROUND

Adequate gestational weight gain (GWG) is an important factor for maternal and fetal health. This is especially important in low-income and slum areas due to limited access to health services and malnutrition. Thus, the purpose of this study is to evaluate the pattern of GWG changes in the slum areas of Hamadan in Iran.

METHODS

In this longitudinal study, the study sample consisted of 509 pregnant women who referred to nine health care clinics in the slum areas of Hamadan. Women's weight gain based on the recommended GWG by U.S. Institute of Medicine (IOM) was divided into three categories: Inadequate weight gain, Adequate weight gain, and Excessive weight gain. In order to evaluate the trend of GWG, a multi-level ordinal model was used.

RESULTS

According to pre-pregnancy BMI, a little more than half people (56.6%) were overweight or obese. 85.4% women in the first trimester and 49.1% in the second trimester did not have adequate GWG, but in the third trimester (38.9%) had adequate GWG. Based on multivariate analysis, pre- pregnancy BMI has a significant effect on the odds of inadequate GWG (P-value = 0.021); with one unit increase in pre-pregnancy BMI, the odds of inadequate GWG grows by 1.07 times compared to adequate and excessive GWG.

CONCLUSIONS

In general, women did not have adequate weight gain in the first and second trimesters.Thus, designing appropriate interventions to achieve optimal GWG seems to be necessary in slums.

Statin therapy is not warranted for a person with high LDL-cholesterol on a low-carbohydrate diet

PURPOSE OF REVIEW

Although there is an extensive literature on the efficacy of the low carbohydrate diet (LCD) for weight loss and in the management of type 2 diabetes, concerns have been raised that the LCD may increase cardiovascular disease (CVD) risk by increasing the level of low-density lipoprotein cholesterol (LDL-C). We have assessed the value of LDL-C as a CVD risk factor, as well as effects of the LCD on other CVD risk factors. We have also reviewed findings that provide guidance as to whether statin therapy would be beneficial for individuals with high LDL-C on an LCD.

RECENT FINDINGS

Multiple longitudinal trials have demonstrated the safety and effectiveness of the LCD, while also providing evidence of improvements in the most reliable CVD risk factors. Recent findings have also confirmed how ineffective LDL-C is in predicting CVD risk.

SUMMARY

Extensive research has demonstrated the efficacy of the LCD to improve the most robust CVD risk factors, such as hyperglycemia, hypertension, and atherogenic dyslipidemia. Our review of the literature indicates that statin therapy for both primary and secondary prevention of CVD is not warranted for individuals on an LCD with elevated LDL-C who have achieved a low triglyceride/HDL ratio.

The effects of consuming a Mediterranean style diet on associated COVID-19 severity biomarkers in obese/overweight adults: A systematic review

Background

COVID-19 severity is strongly associated with high Body Mass Index (BMI) (≥25kg/m²) amongst adults and elevated inflammatory markers have enabled prediction of disease progression. The composition of a Mediterranean diet provides favourable outcomes on weight reduction and inflammatory markers.

Aim

This systematic review aimed to investigate the effects of consuming a Mediterranean diet on BMI and inflammatory markers of obese/overweight adults (≥18 years) at risk of developing severe COVID-19 outcomes.

Methods

PubMed Central, Cochrane Library and MEDLINE databases were searched to identify randomised controlled trials published between January 2010 to August 2021 evaluating the impact of Mediterranean diet on BMI and inflammatory markers in overweight/obese adults. The review followed the PRISMA checklist, used Cochrane Collaboration search strategies, and is PROSPERO registered (CRD42021277070). Two authors independently screened and evaluated studies for methodological quality. Papers were extracted and included based eligibility, despite risk of bias scores.

Results

Of 65 extracted records, six studies met the eligibility criteria and were included. Reductions in BMI, TNF-α, IL-6 and hs-CRP were reported amongst most findings, the majority of which were significant.

Conclusion

The main findings indicate a hypocaloric, fibre dense Mediterranean diet is a short-term (<4 months) mitigation strategy to significantly reduce BMI and inflammatory markers amongst overweight/obese adults at risk of developing severe COVID-19 outcomes. Further research is now needed to examine the role of Mediterranean diet in COVID-19 prevalence, severity, morbidity and mortality.

Investigating the experiences of low-carbohydrate diets for people living with Type 2 Diabetes: A thematic analysis

Low-Carbohydrate Diets (LCDs) are becoming increasingly popular to manage Type 2 diabetes mellitus (T2DM). However, there is a need to identify people with T2DM’s understanding of LCDs, their reasons for engaging in such a diet, how they sustain it and any challenges they face. This study aimed to assess the experience of adhering to a LCD within a sample of individuals with T2DM. Ten participants with T2DM were recruited using a self-selecting sampling method from an online diabetes community that promotes LCDs. Participants completed one-to-one digitally recorded semi-structured interviews, which were later transcribed verbatim and data subjected to Thematic Analysis. Five core themes and twelve subthemes were developed during the analysis: (1) Lack of professional guidance; (2) Fear of complications & long-term medication use; (3) Dietary control as motivation; (4) Positive health outcomes; and (5) Social support. The findings are discussed with reference to a psychological model of behaviour, COM-B. Participants reported gaining knowledge and skills to increase their Capability to engage in LCDs, Motivation to manage diabetes outcomes influenced adherence. However, challenges were reported with the Opportunity to engage in behaviour, mainly influenced by social support. Health professionals and significant others may benefit from resources to help build knowledge and understanding and assist with maintaining a LCD long-term.

Therapeutic Benefits and Dietary Restrictions of Fiber Intake: A State of the Art Review

Throughout history, malnutrition and deficiency diseases have been a problem for our planet’s population. A balanced diet significantly influences everyone’s health, and fiber intake appears to play a more important role than previously thought. The natural dietary fibers are a category of carbohydrates in the constitution of plants that are not completely digested in the human intestine. High-fiber foods, such as fruits, vegetables and whole grains, have consistently been highly beneficial to health and effectively reduced the risk of disease. Although the mode of action of dietary fiber in the consumer body is not fully understood, nutritionists and health professionals unanimously recognize the therapeutic benefits. This paper presents the fiber consumption in different countries, the metabolism of fiber and the range of health benefits associated with fiber intake. In addition, the influence of fiber intake on the intestinal microbiome, metabolic diseases (obesity and diabetes), neurological aspects, cardiovascular diseases, autoimmune diseases and cancer prevention are discussed. Finally, dietary restrictions and excess fiber are addressed, which can cause episodes of diarrhea and dehydration and increase the likelihood of bloating and flatulence or even bowel obstruction. However, extensive studies are needed regarding the composition and required amount of fiber in relation to the metabolism of saprotrophic microorganisms from the enteral level and the benefits of the various pathologies with which they can be correlated.

Nutritional components as mitigators of cellular senescence in organismal aging: a comprehensive review

The process of cellular senescence is rapidly emerging as a modulator of organismal aging and disease. Targeting the development and removal of senescent cells is considered a viable approach to achieving improved organismal healthspan and lifespan. Nutrition and health are intimately linked and an appropriate dietary regimen can greatly impact organismal response to stress and diseases including during aging. With a renewed focus on cellular senescence, emerging studies demonstrate that both primary and secondary nutritional elements such as carbohydrates, proteins, fatty acids, vitamins, minerals, polyphenols, and probiotics can influence multiple aspects of cellular senescence. The present review describes the recent molecular aspects of cellular senescence-mediated understanding of aging and then studies available evidence of the cellular senescence modulatory attributes of major and minor dietary elements. Underlying pathways and future research directions are deliberated to promote a nutrition-centric approach for targeting cellular senescence and thus improving human health and longevity.

Low-carbohydrate, high-fat diet and running exercise influence bone parameters in old mice

We examined the effects and interactions of a low-carbohydrate, high-fat (LCHF) diet and voluntary running exercise on bone in older mice. Male 19-month-old mice were divided into four groups by diet (control vs. LCHF) and exercise (sedentary vs. voluntary running). The control diet was 55% carbohydrate, 23% protein, and 22% fat, and the LCHF diet was 10% carbohydrate, 33% protein, and 57% fat as percentages of calories. The experiment ended when the mice reached 24 months old. Statistical analysis was conducted using two-way analysis of variance with diet and exercise. The LCHF diet decreased bone mineral content (BMC), bone mineral density, bone volume fraction, and trabecular number. There was no significant interaction between diet and exercise on many bone parameters. However, there were significant diet and exercise interactions on lumbar BMC and tibial trabecular total tissue volume and average cortical thickness. The LCHF diet attenuated the benefit of running exercise on lumbar BMC and caused running to have a negative effect on tibial trabecular total tissue volume. Our study suggests that the LCHF diet impairs bone mass and some trabecular microstructure and reduces the benefit of exercise on lumbar BMC in old mice.

Body weight, diabetes incidence vascular events and survival 15 years after very low calorie diet in community medical clinics in the UK

Objective

To assess weight loss maintenance, diabetes status, mortality and morbidity 15 years after a very low calorie diet programme (VLCD) in patients with obesity.

Design

General practice data bases were interrogated for subjects coded for group therapy with VLCD in the 1990s. Causes of death, occurrence of vascular disease and remission or development of diabetes were ascertained from patient records and national stroke and cardiovascular disease data bases.

Results

325 subjects engaged in the programme and had sufficient data for analysis. Baseline characteristics were: age 47.8±12. 8 years; body mass index (BMI) 36.1±6.8 kg/m²; 79.1% female/20.9% male; 13.5% had type 2 diabetes. After 15±4 years weight had changed from 97.9±19 kg at baseline to 100±20.8 kg. 10 with diabetes at baseline were in remission at 3 months, but only two remained in remission at 5 years. 50 new cases of type 2 diabetes and 11 of impaired fasting glucose developed during follow-up. Only 5.9% who remained healthy at follow-up had maintained >10% body weight reduction. Neither diabetes incidence nor diabetes free survival were related to percentage body weight lost during VLCD. Only baseline BMI was related to development of new impaired fasting glucose or diabetes by 15 years (p=0.007). 37 subjects had a cardiovascular event. Age (p=0.000002) and degree of weight loss after VLCD (p=0.03) were significantly associated with subsequent vascular events.

Conclusion

Long-term maintenance of weight loss after VLCD was rare in this single centre retrospective study 15 years later. Glucose intolerance developed in 21.4%. Lasting remission of type 2 diabetes or prevention of later glucose intolerance were not achieved. Vascular events were more frequent in those who lost most weight. Risk management during weight regain should be studied in future to assess potential for reduction in adverse cardiovascular outcomes.

Randomised controlled trial of a web-based low carbohydrate diet intervention for adults with type 2 diabetes: the T2Diet study protocol

INTRODUCTION

Type 2 diabetes (T2D) management frequently involves a multidisciplinary care team. However, standard care for patients with T2D is the central role of the general practice physician, and consists of routine appointments to monitor glycaemic status and overall health. Dietary modification is an essential component of T2D management. Evidence suggests that a low carbohydrate diet (LCD) provides better clinical outcomes for people with T2D compared with other diets. However, providing dietary support in face-to-face settings is challenged by issues of availability and accessibility. Provided in conjunction with standard care, digital interventions can help bridge this gap. The objective of this paper is to describe the protocol of a randomised controlled trial (RCT) of a web-based intervention that will evaluate the effectiveness of standard care plus web-based LCD intervention when compared with standard care only.

METHODS AND ANALYSIS

In a two-arm parallel RCT, 100 adults with non-insulin-dependent T2D aged between 40 and 89 years will be randomised to either a theoretically informed 16-week automated web-based LCD intervention plus standard care or standard care only. LCD recommendations emphasise consuming nutrient-dense whole foods and encourage a daily carbohydrate goal of 50-100 g, with an objective of achieving 10% to <26% carbohydrates from total energy intake. Assessments will take place at baseline and 16 weeks. The primary outcome will be haemoglobin A1c. Additional data collected will include dietary intake, self-efficacy, weight and height, anti-diabetes medication and dosages, and diabetes-related comorbidities. Process evaluation will consist of a mixed-methods assessment of website engagement metrics, user experience and participants' perspectives.

ETHICS AND DISSEMINATION

All study procedures have been approved by the Deakin University Human Research Ethics Committee (2020-349). Study findings will be disseminated widely through public, professional and academic presentation and publication.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621000096853).

Effectiveness of Workplace Mediterranean Diet Interventions on Cardiometabolic Risk Factors: A Systematic Review

BACKGROUND

There are numerous health benefits related to high adherence to the Mediterranean diet (MedDiet), providing a protective effect against cardiometabolic diseases, but there are very few MedDiet studies conducted in the workplace. Therefore, the purpose of this systematic review is to analyze the effectiveness of MedDiet workplace interventions on cardiovascular risk factors.

METHODS

Studies were identified in four databases: PubMed, Scopus, Web of Science, and CINAHL, published from the earliest time point until 15 May 2021. The inclusion criteria were (a) adults aged 18 to 70 years; (b) MedDiet intervention only; (c) intervention was conducted in a workplace; and (d) the outcomes included measurement of cardiometabolic biomarkers. Exclusion criteria were (a) abstract not in English; (b) full-text non-available; and (c) review articles. Ninety-five studies were retrieved and assessed for inclusion by two independent reviewers, who also used the Cochrane Collaboration Tool to assess study quality and risk of bias.

RESULTS

Five high-quality studies were included (n = 436, 89% male). MedDiet interventions carried out within the workplace were effective in improving cardiovascular risk factors such as lipid profile and insulin sensitivity compared with a low-fat diet, especially among obese participants. Blood pressure and inflammatory markers were not improved after the MedDiet interventions.

CONCLUSIONS

Worksite occupational health teams should consider promoting MedDiet by conducting regular nutritional sessions and providing tailored menus in workplace cafeterias. However, more high-quality studies are necessary to bring more evidence to this topic.

Effects of a Very Low-Carbohydrate High-Fat Diet and High-Intensity Interval Training on Visceral Fat Deposition and Cardiorespiratory Fitness in Overfat Individuals: A Randomized Controlled Clinical Trial

Purpose: This randomized controlled parallel-group study examined the effects of a very low-carbohydrate high-fat (VLCHF) diet and high-intensity interval training (HIIT) program over 12 weeks on visceral adipose tissue (VAT) and cardiorespiratory fitness (CRF) level in overfat individuals. Methods: Ninety-one participants were randomly allocated to the HIIT (N = 22), VLCHF (N = 25), VLCHF+HIIT (N = 25), or control (N = 19) groups for 12 weeks. Body composition and CRF were analyzed before the experimental period and after 4, 8, and 12 weeks. Dual-energy X-ray absorptiometry (DXA) and graded exercise test (GXT) to volitional exhaustion were used for the body composition and CRF assessments, respectively. Results: There were significant between-group differences in the VAT mass and body composition outcome changes. VAT mass decreased after 12 weeks only in the VLCHF and VLCHF+HIIT groups (p < 0.001, median [95% CI]: VLCHF: -142.0 [-187.0; -109.5] g; VLCHF+HIIT: -104.0 [-135.0; -71.0] g). Similarly, changes in body mass, total body fat, trunk fat mass, waist and hip circumferences were distinctly decreased in the VLCHF and VLCHF+HIIT groups, when compared to HIIT and Control groups. Total lean mass significantly decreased in the VLCHF and VLCHF+HIIT groups (-2.1 [-3.0; -1.6] kg and -2.5 [-3.6; -1.8] kg, respectively) after 12 weeks. While the HIIT program significantly increased total time to exhaustion in the GXT, peak oxygen uptake was unchanged. Conclusions: A VLCHF diet, either in isolation or in combination with HIIT, was shown to induce a significant reduction in VAT mass and body composition variables. HIIT alone did not cause such effects on body composition, but improved exercise capacity. Our findings indicate that the VLCHF diet and exercise training provoked different and isolated effects on body composition and CRF. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03934476, identifier: NCT03934476.

Multi-Trajectories of Macronutrient Intake and Their Associations with Obesity among Chinese Adults from 1991 to 2018: A Prospective Study

Studies on macronutrient intake and obesity have been inconclusive. This study examined the associations between multi-trajectories of macronutrients and the risk of obesity in China. We used data from 7914 adults who participated in the China Health and Nutrition Survey at least three times from 1991 to 2018. We collected detailed dietary data by conducting three 24 h dietary recalls and weighing foods and condiments in household inventories. We identified multi-trajectories using group-based multi-trajectory models and examined their associations with the risk of obesity with multiple Cox regression models. We found four multi-trajectories in rural areas: balanced macronutrient intake (BM), moderate protein, increasing low fat, and decreasing high carbohydrate (MP&ILF&DHC); decreasing moderate protein, decreasing high fat, and increasing moderate carbohydrate (DMP&DHF&IMC); increasing moderate protein, increasing high fat, and decreasing low carbohydrate (IMP&IHF&DLC)-35.1%, 21.3%, 20.1%, and 23.5% of our rural participant population, respectively. Compared with the BM trajectory, the hazard ratios of obesity in the DMP&DHF&IMC and the IMP&IHF&DLC groups were 0.50 (95% confidence interval (CI): 0.27-0.95) and 0.48 (95% CI: 0.28-0.83), respectively, in rural participants. Relatively low carbohydrate and high fat intakes with complementary dynamic trends are associated with a lower risk of obesity in rural Chinese adults.

Optimal Type 2 Diabetes Mellitus Management and Active Ageing

Type two diabetes mellitus (T2DM) represents a chronic condition with increasing prevalence worldwide among the older population. The T2DM condition increases the risk of micro and macrovascular complications as well as the risk of geriatric syndromes such as falls, fractures and cognitive impairment. The management of T2DM in the older population represents a challenge for the clinician, and a Comprehensive Geriatric Assessment should always be prioritized, in order to tailor the glycated hemoglobin target according to functional and cognitive status comorbidities, life expectancy and type of therapy. According to the most recent guidelines, older adults with T2DM should be categorized into three groups: healthy patients with good functional status, patients with complications and reduced functionality and patients at the end of life; for each group the target for glycemic control is different, also according to the type of treatment drug. The therapeutic approach should always begin with lifestyle changes; after that, several lines of therapy are available, with different mechanisms of action and potential effects other than glucose level reduction. Particular interest is growing in sodium-glucose cotransporter-2 inhibitors, due to their effect on the cardiovascular system. In this review, we evaluate the therapeutic options available for the treatment of older diabetic patients, to ensure a correct treatment approach.

Safety and efficacy of very low carbohydrate diet in patients with diabetic kidney disease-A randomized controlled trial

Introduction

There is limited data on the effects of low carbohydrate diets on renal outcomes particularly in patients with underlying diabetic kidney disease. Therefore, this study determined the safety and effects of very low carbohydrate (VLCBD) in addition to low protein diet (LPD) on renal outcomes, anthropometric, metabolic and inflammatory parameters in patients with T2DM and underlying mild to moderate kidney disease (DKD).

Materials and methods

This was an investigator-initiated, single-center, randomized, controlled, clinical trial in patients with T2DM and DKD, comparing 12-weeks of low carbohydrate diet (<20g daily intake) versus standard low protein (0.8g/kg/day) and low salt diet. Patients in the VLCBD group underwent 2-weekly monitoring including their 3-day food diaries. In addition, Dual-energy x-ray absorptiometry (DEXA) was performed to estimate body fat percentages.

Results

The study population (n = 30) had a median age of 57 years old and a BMI of 30.68kg/m2. Both groups showed similar total calorie intake, i.e. 739.33 (IQR288.48) vs 789.92 (IQR522.4) kcal, by the end of the study. The VLCBD group showed significantly lower daily carbohydrate intake 27 (IQR25) g vs 89.33 (IQR77.4) g, p<0.001, significantly higher protein intake per day 44.08 (IQR21.98) g vs 29.63 (IQR16.35) g, p<0.05 and no difference in in daily fat intake. Both groups showed no worsening of serum creatinine at study end, with consistent declines in HbA1c (1.3(1.1) vs 0.7(1.25) %) and fasting blood glucose (1.5(3.37) vs 1.3(5.7) mmol/L). The VLCBD group showed significant reductions in total daily insulin dose (39(22) vs 0 IU, p<0.001), increased LDL-C and HDL-C, decline in IL-6 levels; with contrasting results in the control group. This was associated with significant weight reduction (-4.0(3.9) vs 0.2(4.2) kg, p = <0.001) and improvements in body fat percentages. WC was significantly reduced in the VLCBD group, even after adjustments to age, HbA1c, weight and creatinine changes. Both dietary interventions were well received with no reported adverse events.

Conclusion

This study demonstrated that dietary intervention of very low carbohydrate diet in patients with underlying diabetic kidney disease was safe and associated with significant improvements in glycemic control, anthropometric measurements including weight, abdominal adiposity and IL-6. Renal outcomes remained unchanged. These findings would strengthen the importance of this dietary intervention as part of the management of patients with diabetic kidney disease.

Which Diets Are Effective in Reducing Cardiovascular and Cancer Risk in Women with Obesity? An Integrative Review

Women are more affected by obesity than men which increases their risk of cancer and cardiovascular disease (CVD). Therefore, it is important to understand the effectiveness of different types of diet in the context of women's health. This review aims to summarize the scientific evidence on the effects of different types of diet for women with obesity and their impact on CVD and cancer risk. This review included epidemiological and clinical studies on adult women and different types of diets, such as the Mediterranean (MED) diet, the Traditional Brazilian Diet, the Dietary Approach to Stop Hypertension (DASH), intermittent fasting (IF), calorie (energy) restriction, food re-education, low-carbohydrate diet (LCD) and a very low-carbohydrate diet (VLCD). Our main findings showed that although LCDs, VLCD and IF are difficult to adhere to over an extended period, they can be good options for achieving improvements in body weight and cardiometabolic parameters. MED, DASH and the Traditional Brazilian Diet are based on natural foods and reduced processed foods. These diets have been associated with better women's health outcomes, including lower risk of CVD and cancer and the prevention and treatment of obesity.

Brief intervention of low carbohydrate dietary advice: clinic results and a review of the literature

PURPOSE OF REVIEW

The purpose of the review is to assess the efficacy of a brief intervention of low carbohydrate dietary advice for weight loss in patients with a raised body mass index (BMI) (>25 kg/m2) during routine patient appointments in primary care.

RECENT FINDINGS

Brief interventions in primary care have been shown to be a valuable tool in supporting patients to make lifestyle changes. Low carbohydrate diets have been successful in helping patients lose weight.The authors carried out a retrospective observational study based on the electronic records from a single general practitioner surgery with 7,500 patients in Essex, UK. Low carbohydrate dietary advice was given opportunistically to patients with a raised BMI, over an 18 month period, with advice and weights recorded. In total, 774 patients were given low carbohydrate dietary advice. Overall, 1103 kg of weight was lost by 339 patients, there was a median weight loss of 2.5 kg (interquartile range 0.0-6.0 kg) and a mean weight loss of 3.3 kg.

SUMMARY

There is no published literature available assessing the efficacy of brief interventions of low carbohydrate dietary advice. Our clinic results indicate that this may be an effective weight loss tool in primary care.

Evaluation of the Low Carb Program Digital Intervention for the Self-Management of Type 2 Diabetes and Prediabetes in an NHS England General Practice: Single-Arm Prospective Study

Background

Type 2 diabetes mellitus has serious health consequences, including blindness, amputation, and stroke. Researchers and clinicians are increasingly in agreement that type 2 diabetes may be effectively treated with a carbohydrate-reduced diet. Digital apps are increasingly used as an adjunct to traditional health care provisions to support remote self-management of long-term health conditions.

Objective

Our objective was to evaluate the real-world 12-month outcomes of patients prescribed the Low Carb Program digital health intervention at a primary care National Health Service (NHS) site. The Low Carb Program is a nutritionally focused, 12-session, digitally delivered, educational behavior change intervention for glycemic control and weight loss for adults with prediabetes and type 2 diabetes. The program educates and supports sustainable dietary changes focused on carbohydrate restriction by utilizing behavior change techniques, including goal setting, peer support, and behavioral self-monitoring, as well as personalized downloadable resources, including recipes and meal plans tailored to ethnicity, weekly shopping budget, and dietary preferences.

Methods

This study evaluated the real-world outcomes of patients recruited to the Low Carb Program at an NHS general practice in Southport, United Kingdom. All of the NHS patients recruited to the program were diagnosed with type 2 diabetes or prediabetes and were given access to the program at no cost. A total of 45 participants, with a mean age of 54.8 years (SD 13.2), were included in the study. Women made up 42% (19/45) of the sample. The mean hemoglobin A_1c (HbA_1c) of the sample was 56.7 mmol/mol (SD 16.95) and the mean body weight was 89.4 kg (SD 13.8).

Results

Of the 45 study participants recruited to the program, all of them (100%) activated their accounts and 37 (82%) individuals reported outcomes at 12 months. All 45 (100%) patients completed at least 40% of the lessons and 32 (71%) individuals completed more than nine out of 12 core lessons of the program. Glycemic control and weight loss improved, particularly for participants who completed more than nine core lessons in the program over 12 months. The mean HbA_1c went from 58.8 mmol/mol at baseline to 54.0 mmol/mol, representing a mean reduction of 4.78 mmol/mol (SD 4.60; t₃₁=5.87; P<.001). Results showed an average total body weight reduction of 4.17%, with an average weight reduction of 3.85 kg (SD 2.49; t₃₁=9.27; P<.001) at the 12-month follow-up point.

Conclusions

A digital app prescribed to adults with type 2 diabetes and prediabetes in a primary care setting supporting a transition to a low-carbohydrate diet has been shown to be effective in improving glycemic control and enabling weight loss. Further research to understand more about factors affecting engagement with the app and further positive health implications would be valuable.

Rethinking Fragility Fractures in Type 2 Diabetes: The Link between Hyperinsulinaemia and Osteofragilitas

Patients with type 2 diabetes mellitus (T2DM) and/or cardiovascular disease (CVD), conditions of hyperinsulinaemia, have lower levels of osteocalcin and bone remodelling, and increased rates of fragility fractures. Unlike osteoporosis with lower bone mineral density (BMD), T2DM bone fragility "hyperinsulinaemia-osteofragilitas" phenotype presents with normal to increased BMD. Hyperinsulinaemia and insulin resistance positively associate with increased BMD and fragility fractures. Hyperinsulinaemia enforces glucose fuelling, which decreases NAD+-dependent antioxidant activity. This increases reactive oxygen species and mitochondrial fission, and decreases oxidative phosphorylation high-energy production capacity, required for osteoblasto/cytogenesis. Osteocytes directly mineralise and resorb bone, and inhibit mineralisation of their lacunocanalicular space via pyrophosphate. Hyperinsulinaemia decreases vitamin D availability via adipocyte sequestration, reducing dendrite connectivity, and compromising osteocyte viability. Decreased bone remodelling and micropetrosis ensues. Trapped/entombed magnesium within micropetrosis fossilisation spaces propagates magnesium deficiency (MgD), potentiating hyperinsulinaemia and decreases vitamin D transport. Vitamin D deficiency reduces osteocalcin synthesis and favours osteocyte apoptosis. Carbohydrate restriction/fasting/ketosis increases beta-oxidation, ketolysis, NAD+-dependent antioxidant activity, osteocyte viability and osteocalcin, and decreases excess insulin exposure. Osteocalcin is required for hydroxyapatite alignment, conferring bone structural integrity, decreasing fracture risk and improving metabolic/endocrine homeodynamics. Patients presenting with fracture and normal BMD should be investigated for T2DM and hyperinsulinaemia.

Benefits of Low Carbohydrate Diets: a Settled Question or Still Controversial?

PURPOSE OF REVIEW

The purpose of this review was to provide an update on the available data on the benefits of low-carbohydrate (low-carb) diets for weight management and type 2 diabetes (T2DM) and determine if low-carb diets were a settled question or still controversial.

RECENT FINDINGS

Most of the recent published literature in this area consists of reviews of past trials, with a relatively smaller number of recent trials. Low-carb is most commonly compared to low-fat, with problematically inconsistent definitions of both. There are numerous challenges in trying to draw clear conclusions about efficacy and effectiveness. Short-term vs. long-term effects can differ, which is likely impacted by adherence. Adherence is very different between metabolic chamber or feeding studies vs. free-living. Body weight alone is a crude measure that fails to capture potentially important differences in lean-mass, fat-mass, and body water. Benefits for glycemic control need to be balanced with impacts on non-glycemic outcomes such as LDL-cholesterol, the microbiome, and inflammation. It is important to differentiate between low-carb and very-low carbohydrate diets (VLCD). To date no large-scale long-term clinical trials have been conducted testing whether low-carb diets can prevent T2DM. Many issues regarding benefits and risks of low-carb diets remain controversial or unresolved, particularly for VLCD. Some of the recent, better studies highlighted in this review suggest strategies for resolving these controversies.

Low Carbohydrate Dietary Approaches for People With Type 2 Diabetes-A Narrative Review

Although carbohydrate restriction is not a new approach for the management of Type 2 diabetes, interest in its safety and efficacy has increased significantly in recent years. The purpose of the current narrative review is to summarise the key relevant research and practical considerations in this area, as well as to explore some of the common concerns expressed in relation to the use of such approaches. There is a strong physiological rationale supporting the role of carbohydrate restriction for the management of Type 2 diabetes, and available evidence suggests that low carbohydrate dietary approaches (LCDs) are as effective as, or superior to, other dietary approaches for its management. Importantly, LCDs appear to be more effective than other dietary approaches for facilitating a reduction in the requirement for certain medications, which leads to their effects on other health markers being underestimated. LCDs have also been demonstrated to be an effective method for achieving remission of Type 2 diabetes for some people. The available evidence does not support concerns that LCDs increase the risk of cardiovascular disease, that such approaches increase the risk of nutrient deficiencies, or that they are more difficult to adhere to than other dietary approaches. A growing number of organisations support the use of LCDs as a suitable choice for individuals with Type 2 diabetes.

Metabolic Phenotypes and Step by Step Evolution of Type 2 Diabetes: A New Paradigm

Unlike bolus insulin secretion mechanisms, basal insulin secretion is poorly understood. It is essential to elucidate these mechanisms in non-hyperinsulinaemia healthy persons. This establishes a baseline for investigation into pathologies where these processes are dysregulated, such as in type 2 diabetes (T2DM), cardiovascular disease (CVD), certain cancers and dementias. Chronic hyperinsulinaemia enforces glucose fueling, depleting the NAD+ dependent antioxidant activity that increases mitochondrial reactive oxygen species (mtROS). Consequently, beta-cell mitochondria increase uncoupling protein expression, which decreases the mitochondrial ATP surge generation capacity, impairing bolus mediated insulin exocytosis. Excessive ROS increases the Drp1:Mfn2 ratio, increasing mitochondrial fission, which increases mtROS; endoplasmic reticulum-stress and impaired calcium homeostasis ensues. Healthy individuals in habitual ketosis have significantly lower glucagon and insulin levels than T2DM individuals. As beta-hydroxybutyrate rises, hepatic gluconeogenesis and glycogenolysis supply extra-hepatic glucose needs, and osteocalcin synthesis/release increases. We propose insulin’s primary role is regulating beta-hydroxybutyrate synthesis, while the role of bone regulates glucose uptake sensitivity via osteocalcin. Osteocalcin regulates the alpha-cell glucagon secretory profile via glucagon-like peptide-1 and serotonin, and beta-hydroxybutyrate synthesis via regulating basal insulin levels. Establishing metabolic phenotypes aids in resolving basal insulin secretion regulation, enabling elucidation of the pathological changes that occur and progress into chronic diseases associated with ageing.

Sugar Fructose Triggers Gut Dysbiosis and Metabolic Inflammation with Cardiac Arrhythmogenesis

Fructose is a main dietary sugar involved in the excess sugar intake-mediated progression of cardiovascular diseases and cardiac arrhythmias. Chronic intake of fructose has been the focus on the possible contributor to the metabolic diseases and cardiac inflammation. Recently, the small intestine was identified to be a major organ in fructose metabolism. The overconsumption of fructose induces dysbiosis of the gut microbiota, which, in turn, increases intestinal permeability and activates host inflammation. Endotoxins and metabolites of the gut microbiota, such as lipopolysaccharide, trimethylamine N-oxide, and short-chain fatty acids, also influence the host inflammation and cardiac biofunctions. Thus, high-fructose diets cause heart-gut axis disorders that promote cardiac arrhythmia. Understanding how gut microbiota dysbiosis-mediated inflammation influences the pathogenesis of cardiac arrhythmia may provide mechanisms for cardiac arrhythmogenesis. This narrative review updates our current understanding of the roles of excessive intake of fructose on the heart-gut axis and proposes potential strategies for inflammation-associated cardiac vascular diseases.

Supporting people to implement a reduced carbohydrate diet: a qualitative study in family practice

INTRODUCTION

Much of the science behind dietary guidelines for risk reduction and chronic disease management is equivocal, and there are well-accepted uncertainties and complexities relating to diet in everyday life, as well as physiological processes. Guidelines have therefore stopped short of aligning with one particular approach, instead highlighting several evidence-based options. However, reduced carbohydrate, or 'low-carb', diets have increasing traction in the media and with patients, practitioners and the general public. This qualitative study examines healthcare practitioner (HCP) experiences of implementing a reduced carbohydrate diet.

METHODS

Semistructured, qualitative interviews were conducted with 19 HCPs in the UK family practice (including general practitioners, practice nurses and non-medical practitioners), recruited through a special interest forum, and social media. Data analysis employed social science theory and methods to produce key themes.

RESULTS

All participants self-identified as 'low-carb practitioners' who, over time, had introduced a specific focus around carbohydrate reduction into their work. They reported transformations in patients' metabolic markers, patient enthusiasm for the approach and renewed job satisfaction. Key themes highlight experiences of: (1) discovering low-carb as a new 'tool-in-the-box'; (2) promoting and supporting incremental low-carb experimentation; and (3) diverging from established dietary guidelines.

CONCLUSIONS

This study provides important experience-based evidence on a topical dietary intervention. Participants strongly advocated for the use of low-carb diets. The successes described draw attention to the need for pragmatic, formative evaluation of low-carb advice and support as a 'complex intervention' (alongside physiological research), to justify, challenge and/or shape low-carb intervention in clinical practice. The findings raise important questions about the contribution of particular care practices to the apparent success of low-carb. Social science analyses can elucidate how dietary intervention is carried out across different healthcare settings (eg, dietetics, endocrinology) and patient groups, how healthcare practices intersect with people's everyday self-management and how different forms of evidence are invoked and prioritised.

Optimal Diet Strategies for Weight Loss and Weight Loss Maintenance

Obesity has become one of the most important public health problems worldwide, which suggests the need for evidence-based dietary strategies for weight loss and its maintenance. Weight management depends upon complex factors such as amount of food eaten, type of food eaten, and timing of meals. In this review, we identified evidence-based dietary strategies for weight management based on these three components. An energy deficit is the most important factor in weight loss. A low-calorie diet with a low fat or carbohydrate content has been recommended; however, in some cases, a very-low-calorie diet is required for a short period. Some macronutrient composition-based diets, such as the ketogenic diet or high-protein diet, could be considered in some cases, although the potential risks and long-term effectiveness remain unknown. Meal timing is also an important factor in weight management, and higher-calorie breakfasts in combination with overnight fasting may help to prevent obesity. Our review indicated that there is no single best strategy for weight management. Hence, strategies for weight loss and its maintenance should be individualized, and healthcare providers must choose the best strategy based on patient preferences.

Fat, Sugar or Gut Microbiota in Reducing Cardiometabolic Risk: Does Diet Type Really Matter?

The incidence of cardiometabolic diseases, such as obesity, diabetes, and cardiovascular diseases, is constantly rising. Successful lifestyle changes may limit their incidence, which is why researchers focus on the role of nutrition in this context. The outcomes of studies carried out in past decades have influenced dietary guidelines, which primarily recommend reducing saturated fat as a therapeutic approach for cardiovascular disease prevention, while limiting the role of sugar due to its harmful effects. On the other hand, a low-carbohydrate diet (LCD) as a method of treatment remains controversial. A number of studies on the effect of LCDs on patients with type 2 diabetes mellitus proved that it is a safe and effective method of dietary management. As for the risk of cardiovascular diseases, the source of carbohydrates and fats corresponds with the mortality rate and protective effect of plant-derived components. Additionally, some recent studies have focused on the gut microbiota in relation to cardiometabolic diseases and diet as one of the leading factors affecting microbiota composition. Unfortunately, there is still no precise answer to the question of which a single nutrient plays the most important role in reducing cardiometabolic risk, and this review article presents the current state of the knowledge in this field.

Weight loss, hypertension and mental well-being improvements during COVID-19 with a multicomponent health promotion programme on Zoom: a service evaluation in primary care

Background

Obesity is a risk factor for complications from SARS-CoV-2 infection, increasing the need for effective weight management measures in primary care. However, in the UK, COVID-19 restrictions have hampered primary care weight management referral and delivery, and COVID-19 related weight gain has been reported. The present study evaluated outcomes from a multicomponent weight loss and health promotion programme in UK primary care, delivered remotely due to COVID-19 restrictions.

Method

Patients with obesity, type 2 diabetes or pre-diabetes attended six 90 min sessions over 10 weeks on Zoom. The dietary component comprised a low-carbohydrate ‘real food’ approach, augmented with education on physical activity, intermittent fasting, gut health, stress management, sleep and behaviour change. Anthropometric and cardiometabolic data were self-reported. Mental well-being was assessed with the Warwick Edinburgh Mental Wellbeing Scale. Subjective outcomes and participant feedback about the programme were collected with an anonymous online survey.

Results

Twenty participants completed the programme. Weight loss and improvements in body mass index, waist circumference, systolic and diastolic blood pressure and mental well-being achieved statistical and clinical significance. Mean weight loss (5.8 kg) represented a 6.5% weight loss. Participants’ subjective outcomes included weight loss without hunger (67%) and increased confidence in their ability to improve health (83%). All participants reported the usage of Zoom to access the programme as acceptable with 83% reporting it worked well.

Conclusion

A multicomponent weight loss and health promotion programme with a low-carbohydrate dietary component, clinically and statistically significantly improved health outcomes including weight status, blood pressure and mental well-being in a group of primary care patients when delivered remotely. Further research is warranted.

Current Evidence Regarding Low-carb Diets for The Metabolic Control of Type-2 Diabetes

The management of diabetes requires a medical nutrition therapy as an essential part of this treatment. There should be no "one-size-fits-all" eating pattern for different patient´s profiles with diabetes. It is clinically complex to suggest an ideal percentage of calories from carbohydrates, protein and lipids recommended for all patients with diabetes. Among the eating patterns that have shown beneficial effects on metabolic control of patients with type 2 diabetes is the lowcarb diet, since the carbohydrate ingestion is viewed as the most important determinant of postprandial glucose and insulin response. In this context, theoretically, it could make sense to reduce the daily amount of carbohydrates ingested, to achieve lower levels of HbA1c. There could be risks associated to this approach. The adherence to a low-carb diet is here also discussed. This narrative review shows on the current evidence for answering these questions regarding low-carb diet as a possible alternative eating pattern for type 2 diabetes.

Dietetic management of obesity and severe obesity in children and adolescents: A scoping review of guidelines

This scoping review describes current guidelines for the dietary management of pediatric obesity and severe obesity. Guidelines were identified via electronic searches of six databases, grey literature, and reference lists and included international clinical practice guidelines (n = 21), position papers (n = 5), and scientific/consensus statements (n = 2) produced by professional bodies and/or expert panels. All recommend multicomponent lifestyle interventions including diet, physical activity, and behavior modification as first-line treatment. Most guidelines (n = 21) recommend weight loss as a treatment goal for children and adolescents with obesity and associated comorbidities or severe obesity; 15 recommend using dietary approaches. Fourteen of 28 guidelines refer to the management of severe obesity, 10 refer to dietary approaches, and seven recommend using intensive dietary approaches. Dietary approaches to weight loss focus on caloric restriction (n = 14) with some guidelines recommending very low-energy diet (n = 4), protein-sparing modified fast (n = 2), and very low-carbohydrate/ketogenic diets (n = 2). A stronger evidence base is required for dietary management of pediatric obesity and severe obesity to improve consistency in future guidelines. Guidance on the use of dietary approaches, beyond caloric restriction, and in line with the growing evidence base on novel dietary approaches is required to facilitate personalized care and optimal patient outcomes.

Reversal of diabetic tractional retinal detachment attributed to keto diet

A 40-year-old woman, known type 2 diabetes mellitus, obese (100 kg), on insulin (80 units), was under treatment for unstable proliferative diabetic retinopathy with extramacular tractional retinal detachment (TRD) in the left eye. At 1-year follow-up, she developed progression of TRD involving the macula in the left eye for which she was advised surgery. She did not follow-up for 6 months during which time she had adopted a coconut oil-rich ketogenic diet. She reported losing 25 kg body weight along with reversal of diabetes (Glycosylated Haemglobin (HbA1C) of 5.3% without insulin) in the interim. During this 2-year follow-up visit, it was found that there was complete resolution of macular detachment due to TRD in the left eye with stable vision. This was attributed to the impactful ketogenic diet.

Low carbohydrate diet: are concerns with saturated fat, lipids, and cardiovascular disease risk justified?

PURPOSE OF REVIEW

There is an extensive literature on the efficacy of the low carbohydrate diet (LCD) for weight loss, and in the improvement of markers of the insulin-resistant phenotype, including a reduction in inflammation, atherogenic dyslipidemia, hypertension, and hyperglycemia. However, critics have expressed concerns that the LCD promotes unrestricted consumption of saturated fat, which may increase low-density lipoprotein (LDL-C) levels. In theory, the diet-induced increase in LDL-C increases the risk of cardiovascular disease (CVD). The present review provides an assessment of concerns with the LCD, which have focused almost entirely on LDL-C, a poor marker of CVD risk. We discuss how critics of the LCD have ignored the literature demonstrating that the LCD improves the most reliable CVD risk factors.

RECENT FINDINGS

Multiple longitudinal clinical trials in recent years have extended the duration of observations on the safety and effectiveness of the LCD to 2-3 years, and in one study on epileptics, for 10 years.

SUMMARY

The present review integrates a historical perspective on the LCD with a critical assessment of the persistent concerns that consumption of saturated fat, in the context of an LCD, will increase risk for CVD.

The Influence of Cyclical Ketogenic Reduction Diet vs. Nutritionally Balanced Reduction Diet on Body Composition, Strength, and Endurance Performance in Healthy Young Males: A Randomized Controlled Trial

(1) Background: The influence of ketogenic diet on physical fitness remains controversial. We performed a randomized controlled trial to compare the effect of cyclical ketogenic reduction diet (CKD) vs. nutritionally balanced reduction diet (RD) on body composition, muscle strength, and endurance performance. (2) Methods: 25 healthy young males undergoing regular resistance training combined with aerobic training were randomized to CKD (n = 13) or RD (n = 12). Body composition, muscle strength and spiroergometric parameters were measured at baseline and after eight weeks of intervention. (3) Results: Both CKD and RD decreased body weight, body fat, and BMI. Lean body mass and body water decreased in CKD and did not significantly change in RD group. Muscle strength parameters were not affected in CKD while in RD group lat pull-down and leg press values increased. Similarly, endurance performance was not changed in CKD group while in RD group peak workload and peak oxygen uptake increased. (4) Conclusions: Our data show that in healthy young males undergoing resistance and aerobic training comparable weight reduction were achieved by CKD and RD. In RD group; improved muscle strength and endurance performance was noted relative to neutral effect of CKD that also slightly reduced lean body mass.

Relationships between hyperinsulinaemia, magnesium, vitamin D, thrombosis and COVID-19: rationale for clinical management

Risk factors for COVID-19 patients with poorer outcomes include pre-existing conditions: obesity, type 2 diabetes mellitus, cardiovascular disease (CVD), heart failure, hypertension, low oxygen saturation capacity, cancer, elevated: ferritin, C reactive protein (CRP) and D-dimer. A common denominator, hyperinsulinaemia, provides a plausible mechanism of action, underlying CVD, hypertension and strokes, all conditions typified with thrombi. The underlying science provides a theoretical management algorithm for the frontline practitioners.Vitamin D activation requires magnesium. Hyperinsulinaemia promotes: magnesium depletion via increased renal excretion, reduced intracellular levels, lowers vitamin D status via sequestration into adipocytes and hydroxylation activation inhibition. Hyperinsulinaemia mediates thrombi development via: fibrinolysis inhibition, anticoagulation production dysregulation, increasing reactive oxygen species, decreased antioxidant capacity via nicotinamide adenine dinucleotide depletion, haem oxidation and catabolism, producing carbon monoxide, increasing deep vein thrombosis risk and pulmonary emboli. Increased haem-synthesis demand upregulates carbon dioxide production, decreasing oxygen saturation capacity. Hyperinsulinaemia decreases cholesterol sulfurylation to cholesterol sulfate, as low vitamin D regulation due to magnesium depletion and/or vitamin D sequestration and/or diminished activation capacity decreases sulfotransferase enzyme SULT2B1b activity, consequently decreasing plasma membrane negative charge between red blood cells, platelets and endothelial cells, thus increasing agglutination and thrombosis.Patients with COVID-19 admitted with hyperglycaemia and/or hyperinsulinaemia should be placed on a restricted refined carbohydrate diet, with limited use of intravenous dextrose solutions. Degree/level of restriction is determined by serial testing of blood glucose, insulin and ketones. Supplemental magnesium, vitamin D and zinc should be administered. By implementing refined carbohydrate restriction, three primary risk factors, hyperinsulinaemia, hyperglycaemia and hypertension, that increase inflammation, coagulation and thrombosis risk are rapidly managed.

Coffee Consumption, Genetic Polymorphisms, and the Risk of Type 2 Diabetes Mellitus: A Pooled Analysis of Four Prospective Cohort Studies

The association between coffee consumption and the risk of type 2 diabetes may vary by genetic variants. Our study addresses the question of whether the incidence of type 2 diabetes is related to the consumption of coffee and whether this relationship is modified by polymorphisms related to type 2 diabetes. We performed a pooled analysis of four Korean prospective studies that included 71,527 participants; median follow-up periods ranged between 2 and 13 years. All participants had completed a validated food-frequency questionnaire (FFQ) at baseline. The odds ratios (ORs) and 95% confidence intervals (CIs) for type 2 diabetes were calculated using logistic regression models. The ORs were combined using a fixed or random effects model depending on the heterogeneity across the studies. Compared with 0 to <0.5 cups/day of coffee consumption, the OR for type 2 diabetes was 0.89 (95% CI: 0.80-0.98, p for trend = 0.01) for ≥3 cups/day of coffee consumption. We did not observe significant interactions by five single nucleotide polymorphisms (SNPs) related to type 2 diabetes (CDKAL1 rs7756992, CDKN2A/B rs10811661, KCNJ11 rs5215, KCNQ1 rs163184, and PEPD rs3786897) in the association between coffee and the risk of type 2 diabetes. We found that coffee consumption was inversely associated with the risk of type 2 diabetes.