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Nutrition  Volume 31, Issue 1, January 2015, Pages 1–13


Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base

  Richard D. FeinmanPh.D.a, , 

  Wendy K. PogozelskiPh.D.b

  Arne AstrupM.D.c

  Richard K. BernsteinM.D.d

  Eugene J. FineM.S., M.D.e

  Eric C. WestmanM.D., M.H.S.f,


•We present major evidence for low-carbohydrate diets as first approach for diabetes.

•Such diets reliably reduce high blood glucose, the most salient feature of diabetes.

•Benefits do not require weight loss although nothing is better for weight reduction.

•Carbohydrate-restricted diets reduce or eliminate need for medication.

•There are no side effects comparable with those seen in intensive pharmacologic treatment.


The inability of current recommendations to control the epidemic of diabetes, the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk, or general health and the persistent reports of some serious side effects of commonly prescribed diabetic medications, in combination with the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects, point to the need for a reappraisal of dietary guidelines. The benefits of carbohydrate restriction in diabetes are immediate and well documented. Concerns about the efficacy and safety are long term and conjectural rather than data driven. Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss (although is still best for weight loss), and leads to the reduction or elimination of medication. It has never shown side effects comparable with those seen in many drugs. Here we present 12 points of evidence supporting the use of low-carbohydrate diets as the first approach to treating type 2 diabetes and as the most effective adjunct to pharmacology in type 1. They represent the best-documented, least controversial results. The insistence on long-term randomized controlled trials as the only kind of data that will be accepted is without precedent in science. The seriousness of diabetes requires that we evaluate all of the evidence that is available. The 12 points are sufficiently compelling that we feel that the burden of proof rests with those who are opposed.


Point 1. Hyperglycemia is the most salient feature of diabetes. Dietary carbohydrate restriction has the greatest effect on decreasing blood glucose levels

Both type 1 and type 2 diabetes are defects in the response to food, particularly to carbohydrates. The associated hyperglycemia is both the most characteristic symptom and the cause of downstream sequelae including insulin effects and generation of advanced glycation end products (AGEs). The most obvious glycation product, hemoglobin A1c (HbA1c) is widely taken as diagnostic. Glycemic control remains the primary target of therapy in patients with type 1 and type 2 diabetes. It is universally accepted that dietary carbohydrate is the main dietary determinant of blood glucose [7] and restriction shows the greatest reduction in postprandial and overall glucose concentrations as well as HbA1c[3][6][8][9][10][11][12][13] and [14]. Whereas defects in repression of gluconeogenesis and glycogenolysis are the major causes of hyperglycemia [8] and [15], carbohydrate is by far the greatest dietary contributor to blood sugar rises and, as expected, dietary carbohydrate restriction reliably reduces glucose profile.

Hussain et al. [14], for example, compared a VLCKD with a low-calorie diet over a 24-wk period in 102 diabetic and 261 nondiabetic individuals. As shown in Figure 1, blood glucose dropped more dramatically in the VLCKD group than in those given the low-calorie diet. In the patients with type 2 diabetes, however, after 24 wk, the average blood glucose level was approximately 1 mM lower than in the low-calorie diet group. More significantly, the VLCKD group approached normal blood sugar levels after 24 wk, whereas the low-calorie group's blood glucose concentration leveled out at 16 wk and remained elevated. In the normal patients, blood glucose was already at normal levels, and the VLCKD produced only a small effect. [Confounding variable is that on a low calorie diet, dieters typically cut back on the high sugar items of drinks, deserts, beer, fruits, and candies; thus improving their HbA1c through reduction sugars). 

[Note:P  because glycation damages Hemoglobin A through glycation, it damages all other proteins and by extension other compounds in the body.  The lower the diet in carbs the lower the damage.] 


Point 2. During the epidemics of obesity and type 2 diabetes, caloric increases have been due almost entirely to increased carbohydrates

Data from the National Health and Nutrition Examination Surveys (NHANES) [16] indicate a large increase in carbohydrates as the major contributor to caloric excess in the United States from 1974 to 2000 

Point 3. Benefits of dietary carbohydrate restriction do not require weight loss.

Given the difficulties that most people have losing weight, this factor alone provides an obvious advantage to low-carbohydrate diets.

Point 4. Although weight loss is not required for benefit, no dietary intervention is better than carbohydrate restriction for weight loss

Point 5. Adherence to low-carbohydrate diets in people with type 2 diabetes is at least as good as adherence to any other dietary interventions and is frequently significantly better.

Point 6. Replacement of carbohydrate with protein is generally beneficial

Point 7. Dietary total and saturated fat do not correlate with risk for cardiovascular disease

Point 8. Plasma saturated fatty acids are controlled by dietary carbohydrate more than by dietary lipids

Point 9. The best predictor of microvascular and, to a lesser extent, macrovascular complications in patients with type 2 diabetes, is glycemic control (HbA1c)

Point 10. Dietary carbohydrate restriction is the most effective method (other than starvation [fasting]) of reducing serum TGs and increasing high-density lipoprotein

Point 11. Patients with type 2 diabetes on carbohydrate-restricted diets reduce and frequently eliminate medication. People with type 1 usually require lower insulin

Point 12. Intensive glucose lowering by dietary carbohydrate restriction has no side effects comparable to the effects of intensive pharmacologic treatment

The ACCORD (Action to Control Cardiovascular Disease in Diabetes) trial was halted because of deaths from CVD [85]. After 3.5 y of follow-up, there were 257 deaths in the intensive-therapy group compared with 203 in the standard-therapy group (hazard ratio, 1.22; 95% CI, 1.01–1.46; P = 0.04). Hypoglycemia requiring assistance and weight gain >10 kg were more frequent in the intensive-therapy group (P < 0.001). The results were interpreted as showing “a previously unrecognized harm of intensive glucose lowering in high-risk patients with type 2 diabetes.” Results were reported as such in the popular media. Logically, however, it is not the target but the method of trying to attain it. Intensive use of medications in high-risk patients is a more reasonable explanation. There are numerous concerns about diabetes medications [85].

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