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Home / List of Low Fat High Carbohydrate Diets

List of Low Fat High Carbohydrate Diets

Continuing Education Activity

Low carbohydrate (low-carb) diets are a strategy for weight loss. Today, there continues to be an interest in low-carb approaches. While all low carbohydrate approaches reduce the overall intake of carbohydrates, there is no clear consensus on what defines a low-carb diet. This activity will review the evidence and effectiveness of low-carb approaches in clinical medicine by an interprofessional team.

Objectives:

  • Outline low carbohydrate diets in terms of percent of macronutrient content and total carbohydrate load.

  • Review the evidence behind low carbohydrate diets.

  • Describe the potential concerns of low carbohydrate diets.

  • Explain the importance of collaboration and communication among the interprofessional team to ensure the appropriate selection of candidates for low carbohydrate diets and educate patients to provide the best possible outcome.

Access free multiple choice questions on this topic.

Introduction

Since 1860, and more recently, in 1972, low carbohydrate (low-carb) diets have been a strategy for weight loss. Today, there continues to be an interest in low-carb approaches. While all low carbohydrate approaches reduce the overall intake of carbohydrates, there is no clear consensus on what defines a low-carb diet. There are three macronutrients—carbohydrates (4 kcal/gm), fat (9 kcal/gm), and protein (4 kcal/gm) found in food. Therefore, studies have defined low carbohydrate as a percent of daily macronutrient intake or total daily carbohydrate load. We will define it here as:

  1. Very low-carbohydrate (less than 10% carbohydrates) or 20-50 gm/day

  2. Low-carbohydrate (less than 26% carbohydrates) or less than 130 gm/day

  3. Moderate-carbohydrate (26%-44%)

  4. High-carbohydrate (45% or greater)

For reference, the institute of medicine proposes Americans obtain 45%-65% of calories from carbohydrates.[1] This article will review the evidence and effectiveness of low-carb approaches in clinical medicine.

Function

Low-carb approaches stem primarily from the hypothesis that lowering insulin, a critical hormone that produces an anabolic, fat-storing state, improves cardiometabolic function, and induces weight loss.[2] This approach has been recently called the carbohydrate-insulin model.[3] Studies have shown low-carb approaches to be superior to other dietary approaches in producing rapid weight loss for the first 6-12 months.[4][5][6] While diets inducing weight loss produce a caloric deficit, the mechanism of low-carb diets remains in debate. When lowering carbohydrates from the diet, the macronutrient intake of fat and protein generally increases to compensate for the reduction of carbohydrates. One hypothesis of why low-carb approaches produce rapid weight loss compared to other diets is that fats and protein increase satiety and produce less concomitant hypoglycemia. This increase in satiety and less rebound hypoglycemia then reduces hunger and overall food intake and produces a caloric deficit. Additionally, another hypothesis contends that low-carb diets can produce a higher metabolic burn than high-carb diets. In recent studies, there appears to be a metabolic advantage of approximately 200 to 300 more calories burned compared to an iso-caloric high-carb diet.[2][7] However, these theories remain controversial.[8]

The ketogenic (keto) diet, a specific version of low-carb, deserves mention. Keto diets restrict carbohydrate to induce nutritional ketosis and typically limits carbs to 20-50 gms daily. Restricting carbs to under 50 gms induces glycogen depletion and ketone production from the mobilization of fat stored in adipose tissue. Nutritional ketosis produces ketone bodies (acetoacetate, acetone, and beta-hydroxybutyrate) and is measurable as serum or urinary ketones. Nutritional ketosis generally increases serum ketones to 1 mmol/L to 7 mmol/L but does not produce metabolic acidosis. Diabetic ketoacidosis, by definition, includes metabolic acidosis, hyperglycemia, and serum ketones (generally over 20 mmol/L).[9]

Despite the debate, it is clear from numerous systematic reviews that low-carb diets are as effective, if not more effective for weight loss compared to other diets. The evidence for benefits and concerns for low-carb will be further delineated below.

Issues of Concern

There are several hypothetical concerns of the long-term safety of low-carb diets that deserve mention. Safety concerns of low-carb diets relate to ketosis, long-term cardiovascular safety, lipid, and renal effects.

Ketosis

Nutritional ketosis can be induced in the keto diet, the induction phase, and any time where carb load is limited to less than 10% of macronutrient intake or 20 to 50 gm/day of carbohydrates. However, there is no evidence that very low-carb intake produces metabolic ketoacidosis and remains safe in patients, even with type 2 diabetes.[9][10] While there have been cases of diabetic ketoacidosis (DKA) with concomitant SGLT2 inhibitors in patients with type 2 diabetes, it is unclear if the very low carb approach can put the increased risk of DKA with SGLT2 use. However, the recommendation is for caution with the use of ketogenic diets with concomitant use of SGLT-2 inhibitors.[11]

Mortality and Cardiovascular Safety

There have been several studies linking low-carb diets to increased mortality. Epidemiological studies and meta-analyses have shown an increased risk of mortality with a carbohydrate intake of less than 40%.[12][13] However, the recent prospective urban rural epidemiology (PURE) study, a large prospective nutrition study involving over 135,000 participants across the globe, found a relationship between increased mortality and higher carbohydrate intake, and lower mortality associated with higher fat intake.[14] Until long-term, randomized studies can be undertaken, the long-term effect is unclear.

Lipid Response

Incorporating more fat and protein in response to the reduction of dietary carbs has led to concerns on the effect of low-carb dieting on lipids; specifically, LDL cholesterol. Recent systematic reviews of low-carb diets on lipids demonstrate a neutral to a small increase in LDL but a favorable triglycerides reduction and an increase in HDL cholesterol, particularly those assigned to the very low-carb intervention.[15][16] Although not formally studied, there may be a subset of lean individuals who have a hyper LDL response with ketogenic diets, a term coined lean mass hyper-responders. Due to the varied and individualized response, recommendations are for baseline fasting lipid profile, periodic testing, and shared decision making.

Renal Function

With a potentially higher protein intake on low-carb diets, some have expressed concerns about renal function. However, depending on specific goals, athletes should ingest protein loads to optimize muscle protein synthesis (1.6 gm/kg) or endurance sports (0.8 gm/kg).[17][18] Encouraging higher protein loads to support physical activity can also help with improving body composition and metabolic adaptations. In general, there are no data to associate high protein load with worsening kidney function in those with normal kidneys.[19] For those with chronic kidney disease, a low or very-low-protein diet (0.2-0.8 gm/kg/day) may be recommended to prevent further renal deterioration.[20]

Clinical Significance

The study of low-carb diets has centered on weight loss in obese and overweight people as well as patients with or at risk for cardiometabolic diseases such as type 2 diabetes and nonalcoholic fatty liver disease. Ketogenic diets have also been used for seizure disorders and, more recently, have found use in the athletic population as an alternative fuel for performance and health.

Weight Loss

By far, most research in low-carb approaches has shown that low-carb diet, and specifically ketogenic approaches, induces rapid induction of weight loss. Initial weight loss is due partly to water loss, but fat loss occurs with adherence to the low carb approach. With all dietary interventions, as adherence to the diet wanes, the weight loss effect becomes similar to other dietary approaches after one year.[21] It is notable that most of the low-carb studies generally use an ad-libitumapproach of caloric intake (limiting carbs instead), while most comparison diets are calorie-restricted. In general, shared decision-making is a valid and person-centered approach in determining nutritional approaches to weight loss.

Type 2 Diabetes

Before medications, carbohydrate control has been the cornerstone of glycemic control in both type 1 and type 2 diabetes. Dietary carbohydrates increase insulin needs, and reduction of carbohydrate intake can improve glycemic control.[22] A recent study demonstrated a significant reduction of insulin and oral medications and hemoglobin A1c reduction with ketogenic approaches while demonstrating a high adherence to the intervention at 12 months.[23][24] Also, markers of cardiometabolic risk factors improved.[25] Approaches to nutritional lifestyle and approaches to diabetes (medical nutrition therapy) have included low carb as an option in recent guidelines.[26][27] Recent prospective and randomized controlled trials have demonstrated a consistent benefit in glycemic control, weight loss, and sustained medication reduction using a very low carb approach (less than 14% of energy from carbohydrates).[28][29][30]

Cardiovascular Risk Factors

As mentioned above, the effect of low-carb diets on cardiovascular risk factors continues to be controversial. While a few studies have demonstrated an increase in LDL cholesterol with low-carb diets, others showed negligible changes. However, other metabolic markers, such as lowering triglycerides, increases in HDL, have been demonstrated with low-carb diets.[4][25][16]

Other Issues

Ketogenic diets have been used successfully since 1920 before the existence of medications for epilepsy.[9][31] Recent studies have shown that acne, cancer, non-alcoholic fatty liver disease, polycystic ovary syndrome, and Alzheimer disease may improve with ketogenic diets.[9][32] Recently use of keto diets to provide sustained, and steady fuel for endurance sports in athletic individuals and the optimization of body composition in high-intensity training for the recreational population have also undergone testing.[33][34]

Enhancing Healthcare Team Outcomes

Initiation of a Low-Carb Lifestyle

After a shared decision-making process with the patient, there are numerous ways to start a patient on a low-carb diet. Low-carb nutrition may be advisable for those who desire healthy or athletic performance, weight loss, improvement of glycemic control for type 1 or 2 diabetes, or for a seizure disorder.

  • First, an understanding of what macronutrients are and their relation to food is a critical part of the counseling.

  • Secondly, determine the patient's desire for either small steps or a rapid induction phase through motivational interviewing and S.M.A.R.T goal setting.

  • Limitation of added sugar (sucrose) and refined carbohydrates is critical in the overall improvement of food quality and will generally reach a moderate carbohydrate (less than 45% carbohydrates) level.

  • A way to initiate low-carb is through a rapid induction phase of 2 to 4 weeks, with 20 to 50 gms of carbohydrates to induce nutritional ketosis.Ad libitumvegetables that grow above the ground and are lower in carbohydrate content are encouraged. Additionally, carbs should be limited to those found in whole, unprocessed food.

  • Finally, after the induction phase, depending on goals, patients can remain in the keto phase or slowly add healthy carbohydrates from whole, unprocessed vegetables, and low-glycemic, high fiber fruit (i.e., berries).

Maintenance of a Low-Carb Lifestyle

If limited initially or during the induction phase, full-fat dairy, legumes, and whole grains can also be added during this maintenance phase as long as goals are maintained and tolerated without any hypersensitivity or an adverse response. The lifelong maintenance phase can then continue in accordance with patient preference. Periodic monitoring of cardiovascular risk markers and control of cardiometabolic disease should also be a priority. Those with type 2 diabetes require close monitoring for hypoglycemia, and reduction of insulin or hypoglycemic medications are prudent with rapid reductions in fasting glucose. [Level 4]

Review Questions

References

1.

Trumbo P, Schlicker S, Yates AA, Poos M., Food and Nutrition Board of the Institute of Medicine, The National Academies. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. J Am Diet Assoc. 2002 Nov;102(11):1621-30. [PubMed: 12449285]

2.

Ebbeling CB, Feldman HA, Klein GL, Wong JMW, Bielak L, Steltz SK, Luoto PK, Wolfe RR, Wong WW, Ludwig DS. Effects of a low carbohydrate diet on energy expenditure during weight loss maintenance: randomized trial. BMJ. 2018 Nov 14;363:k4583. [PMC free article: PMC6233655] [PubMed: 30429127]

3.

Ludwig DS, Ebbeling CB. The Carbohydrate-Insulin Model of Obesity: Beyond "Calories In, Calories Out". JAMA Intern Med. 2018 Aug 01;178(8):1098-1103. [PMC free article: PMC6082688] [PubMed: 29971406]

4.

Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy WS, Brehm BJ, Bucher HC. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med. 2006 Feb 13;166(3):285-93. [PubMed: 16476868]

5.

Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr. 2013 Oct;110(7):1178-87. [PubMed: 23651522]

6.

Tobias DK, Chen M, Manson JE, Ludwig DS, Willett W, Hu FB. Effect of low-fat diet interventions versus other diet interventions on long-term weight change in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2015 Dec;3(12):968-79. [PMC free article: PMC4667723] [PubMed: 26527511]

7.

Ebbeling CB, Swain JF, Feldman HA, Wong WW, Hachey DL, Garcia-Lago E, Ludwig DS. Effects of dietary composition on energy expenditure during weight-loss maintenance. JAMA. 2012 Jun 27;307(24):2627-34. [PMC free article: PMC3564212] [PubMed: 22735432]

8.

Hall KD, Bemis T, Brychta R, Chen KY, Courville A, Crayner EJ, Goodwin S, Guo J, Howard L, Knuth ND, Miller BV, Prado CM, Siervo M, Skarulis MC, Walter M, Walter PJ, Yannai L. Calorie for Calorie, Dietary Fat Restriction Results in More Body Fat Loss than Carbohydrate Restriction in People with Obesity. Cell Metab. 2015 Sep 01;22(3):427-36. [PMC free article: PMC4603544] [PubMed: 26278052]

9.

Paoli A, Rubini A, Volek JS, Grimaldi KA. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2013 Aug;67(8):789-96. [PMC free article: PMC3826507] [PubMed: 23801097]

10.

Noakes TD, Windt J. Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review. Br J Sports Med. 2017 Jan;51(2):133-139. [PubMed: 28053201]

11.

Rosenstock J, Ferrannini E. Euglycemic Diabetic Ketoacidosis: A Predictable, Detectable, and Preventable Safety Concern With SGLT2 Inhibitors. Diabetes Care. 2015 Sep;38(9):1638-42. [PubMed: 26294774]

12.

Noto H, Goto A, Tsujimoto T, Noda M. Low-carbohydrate diets and all-cause mortality: a systematic review and meta-analysis of observational studies. PLoS One. 2013;8(1):e55030. [PMC free article: PMC3555979] [PubMed: 23372809]

13.

Seidelmann SB, Claggett B, Cheng S, Henglin M, Shah A, Steffen LM, Folsom AR, Rimm EB, Willett WC, Solomon SD. Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. Lancet Public Health. 2018 Sep;3(9):e419-e428. [PMC free article: PMC6339822] [PubMed: 30122560]

14.

Dehghan M, Mente A, Zhang X, Swaminathan S, Li W, Mohan V, Iqbal R, Kumar R, Wentzel-Viljoen E, Rosengren A, Amma LI, Avezum A, Chifamba J, Diaz R, Khatib R, Lear S, Lopez-Jaramillo P, Liu X, Gupta R, Mohammadifard N, Gao N, Oguz A, Ramli AS, Seron P, Sun Y, Szuba A, Tsolekile L, Wielgosz A, Yusuf R, Hussein Yusufali A, Teo KK, Rangarajan S, Dagenais G, Bangdiwala SI, Islam S, Anand SS, Yusuf S., Prospective Urban Rural Epidemiology (PURE) study investigators. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 04;390(10107):2050-2062. [PubMed: 28864332]

15.

Gjuladin-Hellon T, Davies IG, Penson P, Amiri Baghbadorani R. Effects of carbohydrate-restricted diets on low-density lipoprotein cholesterol levels in overweight and obese adults: a systematic review and meta-analysis. Nutr Rev. 2019 Mar 01;77(3):161-180. [PubMed: 30544168]

16.

Lu M, Wan Y, Yang B, Huggins CE, Li D. Effects of low-fat compared with high-fat diet on cardiometabolic indicators in people with overweight and obesity without overt metabolic disturbance: a systematic review and meta-analysis of randomised controlled trials. Br J Nutr. 2018 Jan;119(1):96-108. [PubMed: 29212558]

17.

Morton RW, Murphy KT, McKellar SR, Schoenfeld BJ, Henselmans M, Helms E, Aragon AA, Devries MC, Banfield L, Krieger JW, Phillips SM. A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. Br J Sports Med. 2018 Mar;52(6):376-384. [PMC free article: PMC5867436] [PubMed: 28698222]

18.

Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance. Med Sci Sports Exerc. 2016 Mar;48(3):543-68. [PubMed: 26891166]

19.

Martin WF, Armstrong LE, Rodriguez NR. Dietary protein intake and renal function. Nutr Metab (Lond). 2005 Sep 20;2:25. [PMC free article: PMC1262767] [PubMed: 16174292]

20.

Hahn D, Hodson EM, Fouque D. Low protein diets for non-diabetic adults with chronic kidney disease. Cochrane Database Syst Rev. 2018 Oct 04;10:CD001892. [PMC free article: PMC6517211] [PubMed: 30284724]

21.

Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, Kraemer HC, King AC. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007 Mar 07;297(9):969-77. [PubMed: 17341711]

22.

Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ, Westman EC, Accurso A, Frassetto L, Gower BA, McFarlane SI, Nielsen JV, Krarup T, Saslow L, Roth KS, Vernon MC, Volek JS, Wilshire GB, Dahlqvist A, Sundberg R, Childers A, Morrison K, Manninen AH, Dashti HM, Wood RJ, Wortman J, Worm N. Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. Nutrition. 2015 Jan;31(1):1-13. [PubMed: 25287761]

23.

McKenzie AL, Hallberg SJ, Creighton BC, Volk BM, Link TM, Abner MK, Glon RM, McCarter JP, Volek JS, Phinney SD. A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes. JMIR Diabetes. 2017 Mar 07;2(1):e5. [PMC free article: PMC6238887] [PubMed: 30291062]

24.

Hallberg SJ, McKenzie AL, Williams PT, Bhanpuri NH, Peters AL, Campbell WW, Hazbun TL, Volk BM, McCarter JP, Phinney SD, Volek JS. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Ther. 2018 Apr;9(2):583-612. [PMC free article: PMC6104272] [PubMed: 29417495]

25.

Bhanpuri NH, Hallberg SJ, Williams PT, McKenzie AL, Ballard KD, Campbell WW, McCarter JP, Phinney SD, Volek JS. Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study. Cardiovasc Diabetol. 2018 May 01;17(1):56. [PMC free article: PMC5928595] [PubMed: 29712560]

26.

Davies MJ, D'Alessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, Rossing P, Tsapas A, Wexler DJ, Buse JB. Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2018 Dec;41(12):2669-2701. [PMC free article: PMC6245208] [PubMed: 30291106]

27.

American Diabetes Association. 5. Lifestyle Management: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019 Jan;42(Suppl 1):S46-S60. [PubMed: 30559231]

28.

Tay J, Thompson CH, Luscombe-Marsh ND, Wycherley TP, Noakes M, Buckley JD, Wittert GA, Yancy WS, Brinkworth GD. Effects of an energy-restricted low-carbohydrate, high unsaturated fat/low saturated fat diet versus a high-carbohydrate, low-fat diet in type 2 diabetes: A 2-year randomized clinical trial. Diabetes Obes Metab. 2018 Apr;20(4):858-871. [PubMed: 29178536]

29.

Tay J, Luscombe-Marsh ND, Thompson CH, Noakes M, Buckley JD, Wittert GA, Yancy WS, Brinkworth GD. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. Am J Clin Nutr. 2015 Oct;102(4):780-90. [PubMed: 26224300]

30.

Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013 Mar;97(3):505-16. [PubMed: 23364002]

31.

Martin-McGill KJ, Jackson CF, Bresnahan R, Levy RG, Cooper PN. Ketogenic diets for drug-resistant epilepsy. Cochrane Database Syst Rev. 2018 Nov 07;11:CD001903. [PMC free article: PMC6517043] [PubMed: 30403286]

32.

Broom GM, Shaw IC, Rucklidge JJ. The ketogenic diet as a potential treatment and prevention strategy for Alzheimer's disease. Nutrition. 2019 Apr;60:118-121. [PubMed: 30554068]

33.

Volek JS, Freidenreich DJ, Saenz C, Kunces LJ, Creighton BC, Bartley JM, Davitt PM, Munoz CX, Anderson JM, Maresh CM, Lee EC, Schuenke MD, Aerni G, Kraemer WJ, Phinney SD. Metabolic characteristics of keto-adapted ultra-endurance runners. Metabolism. 2016 Mar;65(3):100-10. [PubMed: 26892521]

34.

Kephart WC, Pledge CD, Roberson PA, Mumford PW, Romero MA, Mobley CB, Martin JS, Young KC, Lowery RP, Wilson JM, Huggins KW, Roberts MD. The Three-Month Effects of a Ketogenic Diet on Body Composition, Blood Parameters, and Performance Metrics in CrossFit Trainees: A Pilot Study. Sports (Basel). 2018 Jan 09;6(1) [PMC free article: PMC5969192] [PubMed: 29910305]

List of Low Fat High Carbohydrate Diets

Source: https://www.ncbi.nlm.nih.gov/books/NBK537084/