1. Ketogenic Diet for Type 2 Diabetes
Dr. Sarah Hallberg DO, MS

2. Purpose
Examine the current treatment limitations for patients with type 2 diabetes
Research on carb restriction for diabetes
Discuss a ketogenic diet
Ongoing study at Indiana University Health

3. 2012 The Problem 14.3% of all adults had diabetes
38% have pre-diabetes
Now OVER 50% (52.3%) have diabetes or pre-diabetes
JAMA. 2015;314(10): doi: /jama

4. The problem

6. The Solution……

9. Medical Nutrition Therapy Goals
Promote Healthy eating patterns
achieve and maintain body weight goals
attain individualized glycemic, blood pressure, and lipid goals
delay or prevent the complications of diabetes
Address individual nutrition needs
personal and cultural preferences
health literacy
access
willingness

10. Medical Nutrition Therapy Goals
3. Maintain pleasure of eating
4. To provide an individual with diabetes the practical
tools for developing healthy eating patterns rather
than focusing on individual macronutrients, micronutrients,
or single foods.

11. ADA Nutrition Guidelines 2017
There is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total calorie and metabolic goals in mind.

12. About those Macronutrients…….

13. Carbohydrates

14. ADA 2017 Guidelines Carbohydrates will cause blood sugar to rise.
“Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake for people and considering the blood glucose response to dietary carbohydrates are key for improving postprandial glucose control. “
“Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management”
Carbohydrates will cause blood sugar to rise.

15. “Monitor Carbohydrate Intake”

16. Take away this
glass and then
“monitor”
this child

17. “Couple insulin administration with carbohydrate intake”
ADA 2017 Guidelines
“Couple insulin administration with carbohydrate intake”
ok….

18. This does not This “couples” with a lot of insulin
Am J Clin Nutr March 2002 vol. 75 no

19. Nutrition Therapy Recommendations for the Management of Adults with Diabetes
“total amount of carbohydrate eaten is the primary predictor of glycemic response.”
Diabetes Care Jan 2014, 37 (Supplement 1) S120-S143; DOI: /dc14-S120

20. ADA 2017 Guidelines Complex??? Eat carbs. Blood sugar rises.
“For people whose meal schedules or carbohydrate consumption is variable, regular counseling to help them understand the complex relationship between carbohydrate intake and insulin needs is important”
Complex???
Eat carbs.
Blood sugar rises.
Insulin needs go up.
Simple.

21. The carbohydrate:protein:fat ratio of the control diet was 55:15:30
The test diet ratio was 20:30:50

22. ADA 2017 Guidelines This makes sense. It still causes glucose to rise.
“Whole grain consumption was not associated with improvements in glycemic control in the 2 diabetes”
This makes
sense. It
still causes
glucose to
rise.
Katri S Juntunen et al. Am J Clin Nutr 2002;75:

23. Proteins

24. ADA 2017 Guidelines
Some research has found successful management of type 2 diabetes with meal plans including slightly higher levels of protein ( %, which may contribute to increased satiety.

25. Fats

26. ADA 2017 Guidelines
“The ideal amount of dietary fat for individual with diabetes is controversial. The IOM has defined an acceptable macronutrient distribution for total fat for ALL adults to be % of energy.”
“Lowering total fat intake infrequently improved glycemic control or CVD risk factors in clinical trials involving patients with diabetes”
In fact, 1 of 7 studies it did not improve. In the 1 study where it did was a very small decrease and calorie restricted in obese patients who had uncontrolled diabetes.

27. Mediterranean/MUFA 2017 Standards of Care
5 studies cited that show a Mediterranean diet can improve A1c.
1 did not have glycemic control as primary endpoint
2 did not show a difference in glycemic control
1 showed low carb did better
Meta-analysis looked at developing diabetes only
In fact, 1 of 7 studies it did not improve. In the 1 study where it did was a very small decrease and calorie restricted in obese patients who had uncontrolled diabetes.

28. Mediterranean/MUFA
Nutrition Therapy Recommendations for the Management of Adults with Diabetes 2014
6 RCT that included people with diabetes reported improved glycemic control
2 showed no difference
1 looked at only new diagnosis improvements
1 did not have glycemic control as a primary endpoint
1 showed that the low carb mediterranean is superior to both traditional mediterranean and ADA standard
1 showed low carb had better A1c improvements than Mediterranean and low fat.
In fact, 1 of 7 studies it did not improve. In the 1 study where it did was a very small decrease and calorie restricted in obese patients who had uncontrolled diabetes.

29. WHAT IS A MEDITERRANEAN DIETARY PATTERN?

30. Dietary Patterns

31. A variety of eating patterns are acceptable:
Mediterranean
DASH
references of which neither looked at glycemic control.
Only 1 small study reviewed
Plant-based
review showed that plant based is just as good as standard treatment, not consistently better.
“did not consistently improve glycemic control or CVD risk factors”

32. The 2014 Nutrition review did look at low carb as an eating pattern
11 studies reviewed
7 showed clear advantage for low carb
4 did not show a difference
2 showed greater med reduction in LC “These limited data suggest that changes in medication may have masked a potential in the lo- carb dietary advice group to have m a more positive impact on glycemic control”
1 study was on its with and without diabetes and there was a statistically significant advantage within the patients with diabetes
1 was tried to do low fat and low carb

33. AACE

34. AACE

35. American Association of Diabetes Educators Healthy Eating Patters
My Plate
DASH
Mediterranean
Vegetarian or Vegan

36. Common Thread
LOW FAT

38. Carbs – must be high(er)
Macronutrients
Fat – low
Protein - ??
Carbs – must be high(er)

39. “total amount of carbohydrate
eaten is the primary predictor
of glycemic response.”

40. From ADA Website 3/3017
How Much Carbohydrate?
How much carbohydrate you eat is very individual. Finding the right amount of carbohydrate depends on many things including how active you are and what, if any, medicines you take. Some people are active and can eat more carbohydrate. Others may need to have less carbohydrate to keepHow Much Carbohydrate?
How much carbohydrate you eat is very individual. Finding the right amount of carbohydrate depends on many things including how active you are and what, if any, medicines you take. Some people are active and can eat more carbohydrate. Others may need to have less carbohydrate to keep their blood glucose in control.
Finding the balance for yourself is important so you can feel your best, do the things you enjoy, and lower your risk of diabetes complications.
A place to start is at about grams of carbohydrate at a meal. You may need more or less carbohydrate at meals depending on how you manage your diabetes.
You and your health care team can figure out the right amount for you. Once you know how much carb to eat at a meal, choose your food and the portion size to match.

42. The way it used to be

43. The origin of low carb for diabetes
The eighth patient described in his ledger had special significance for Elliott Joslin: it was his mother, Sara Proctor Joslin, diagnosed with diabetes in The disease was considered uniformly fatal, but Sara Joslin lived an astonishing 13 years after her diagnosis. She followed her son's instructions to eat a low-carbohydrate, high-fat diet.

44. “The discovery of insulin was a
severe setback to the advancement
of the science and art of
nutrition” Louis Newburgh 1936

45. OOPS IS RIGHT

46. The nutrition advice given to most diabetics might be killing them
By Dara Mayers
July 2003
U.S. News Health & Medicine
The Bible says “make starches the star.” That’s the Diabetes Food and Nutrition Bible, published by the American Diabetes Association. “Grains, beans, and starchy vegetables form the foundation of the Diabetes Food Pyramid. The message is to eat more of these foods than of any of the other food groups.” For 17 million Americans with diabetes, diet is a crucial part of treatment, And what the ADA bible preaches, many doctors, nutritionists, and patients believe.
But what if the ADA’s high-starch diet–another way of saying high-carbohydrate–is not healthy for people with diabetes but harmful to them instead?

47. Another solution

48. Ketogenic Diet
Low Carbohydrate (under 50gr of total carbs often under 30gr)
Adequate Protein – NOT high
High Fat including saturated fat but also high MUFA

49. Carb Sources Non-starchy Vegetables Nuts and Seeds Limited Berry Fruit
Dairy
NO Grains, potatoes or sugar

51. A Day in the Low Carb Life
Snacks
2 oz mixed nuts, broth
2 oz soft cheese with
6 oz celery
Dinner
8 oz tomato bisque
8 oz steak
4 oz buttered green beans
4 oz sauteed mushrooms
4 oz maple walnut ice cream
(made w/ sucralose/xylitol)
Breakfast
black coffee
4 sausages
Lunch
2 cups mixed greens
6 oz water pack tuna
10 black olives
½ cup blue cheese dressing (yogurt, olive oil)
Total: kcal fat, 600 protein, 150 carbs (74% fat, 5% carb, 21% protein)

52. We can use ketones for fuel

53. And the science says…..

54. Weight Loss with a low-carbohydrate, Mediterranean, or low-fat diet
2 year RCT with 322 moderately obese subjects
Adherence was 84.6% at 2 years
Subgroups of met with dietitians
1, 2, 5, 7 weeks and ten 6 week intervals for 18 sessions of 90 min each
N Engl J Med 2008; 359:

55. Weight Loss with a low-carbohydrate, Mediterranean, or low-fat diet
AHA Guidelines calorie restricted 30% fat
Low Carb
No calorie restriction
20g carbs per day for 2 months
Then increased to max of 120gr for maintenance
Mediterranean
Calorie restricted<35%fat
Rich in veggies and low in red meat
N Engl J Med 2008; 359:

56. Weight Loss with a low-carbohydrate, Mediterranean, or low-fat diet
36 patients had diabetes
Fasting glucose decreased only in Mediterranean group
Glucose went UP in the low fat group
HOMA-IR decreased in low carb and Mediterranean – more in Mediterranean
At 24 months changes in A1c was only significant in the low carb group %
N Engl J Med 2008; 359:

57. 10 Obese patients with Type 2 Diabetes Hospitalized for testing period
Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes
10 Obese patients with Type 2 Diabetes
Hospitalized for testing period
Day 1 – 7 Usual diet
Day 8 – 21 Low-Carbohydrate Diet 21 g/day with ad lib fat and protein
Ann Intern Med 2005;142:

58. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes
Figure 1
Glucose and Insulin response for patients with type 2 diabetes on low carbohydrate diet vs. control. Data (means ± SE) are for 9 patients with type 2 diabetes after seven days on their usual high-carbohydrate diet (control) and after 2 weeks) on a low-carbohydrate diet. Medication was reduced in 4 patients and discontinued in one during the low-carbohydrate diet. Figure redrawn from Boden, et al. [8].
Ann Intern Med 2005;142:

59. RCT 34 patients with type 2 diabetes or prediabetes
A randomized pilot trial of a moderate carbohydrate diet compared to a very low carbohydrate diet in overweight or obese individuals with type 2 diabetes mellitus or prediabetes
RCT 34 patients with type 2 diabetes or prediabetes
ADA low fat diet calorie-restricted
Low Carb High Fat Diet – 20 – 50 total grams carbs – no calorie restriction
Each group only lost 1 participant
All attended 13 – 2 hour classes
. PLoS ONE 9(4): e91027

60. Figure 2. Change in HbA1c by diet group.
PLoS ONE 9(4): e91027.

61. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus
RCT 84 Patients with type 2 Diabetes and Obesity
Very Low Carb <20 total gram per day – NO calorie restriction
Low GI diet 55% carbs and 500kcal reduction from baseline intake
Twenty of 21 (95.2%) LCKD group participants had an elimination or reduction in medication, compared with 18 of 29 (62.1%) LGID group participants (p < 0.01).
From baseline to 24 weeks, the reduction of mean ± SD hemoglobin A1c was greater for the LCKD group
LCKD ± 1.8% to 7.3 ± 1.5%, p = 0.009, within group change, n = 21
LGID group ± 1.9% to 7.8 ± 2.1% p = NS, within group change, n = 29
between groups comparison p = 0.03
Westman, Eric C et al. “The Effect of a Low-Carbohydrate, Ketogenic Diet versus a Low-Glycemic Index Diet on Glycemic Control in Type 2 Diabetes Mellitus.”Nutrition & Metabolism 5 (2008): 36. PMC. Web. 29 Apr

62. Beneficial Effects of Ketogenic Diet in Obese Diabetic Subjects
Demographics:
Non-diabetic and diabetic obese subjects
BMI > 30
Two Groups:
Fasting BG > 6.1 mmol/l (Group I; n = 31)
Normal fasting BG (Group II; n = 33)
Age: 46.4 ± 9.4 (Group I); 40.0 ± 11.4 (Group II)
Method:
Outpatient; 56 weeks
Ate 20 g of carbs and 80–100g protein for 12 weeks, then 40g carbs for weeks
Results as %∆ for Total (Group I, Group II):
Fasting BG: –31.0% ± 25.0 (–50.9% ± 12.5; –7.4% ± 11.9)
Triglycerides: –59.0% ± 32.0 (–40.8% ± 38.0; –40.8% ± 38.0)
LDL: –28.2% ± 20.1 (–33.0% ± 20.4; –22.9% ± 18.7)
HDL: 52.3% ± 43.8(63.4% ± 51.1; 39.8% ± 30.0
Weight: –25.8% ± 6.4 (–24.4% ± 6.7; –27.2% ± 6.0)
Source: Beneficial effects of ketogenic diet in obese diabetic subjects; Dashti HM et al.; Mol Cell Biochem (2007) Aug; 302(1-2):249-56

63. Beneficial Effects of Ketogenic Diet in Obese Diabetic Subjects
Source: Beneficial effects of ketogenic diet in obese diabetic subjects; Dashti HM et al.; Mol Cell Biochem (2007) Aug; 302(1-2):249-56

64. Beneficial Effects of Ketogenic Diet in Obese Diabetic Subjects
Source: Beneficial effects of ketogenic diet in obese diabetic subjects; Dashti HM et al.; Mol Cell Biochem (2007) Aug; 302(1-2):249-56

65. A Very Low-Carbohydrate, Low–Saturated Fat Diet for
Type 2 Diabetes Management: A Randomized Trial
115 obese adults with T2DM
Randomized to low-carbohydrate or high carbohydrate diet
Both diets hypo-caloric
Both diets <10% saturated fat
Low carb = 14% carbs (<50gr), 28% protein
High carb 53% carbohydrate 17% protein
24 weeks
included structured exercise
Diabetes Care Nov 2014, 37 (11) ; DOI: /dc

66. A Very Low-Carbohydrate, Low–Saturated Fat Diet for
Type 2 Diabetes Management: A Randomized Trial
Diabetes Care Nov 2014, 37 (11) ; DOI: /dc

67. A Very Low-Carbohydrate, Low–Saturated Fat Diet for
Type 2 Diabetes Management: A Randomized Trial
LC reduced HbA1c to a greater extent among participants with baseline HbA1c >7.8
No diet effect in participants with baseline HbA1c < 7.8
Med reduction different
Percentage weight loss was not different between the groups with baseline HbA1c >7.8
Diabetes Care Nov 2014, 37 (11) ; DOI: /dc

68. A Very Low-Carbohydrate, Low–Saturated Fat Diet for
Type 2 Diabetes Management: A Randomized Trial
LC participants were 85% more likely to spend higher proportions of time in the euglycemic range
LC participants were 56% less likely to spend higher proportions of time in the hyperglycemic ranges
LC participants were 16% less likely to spend more time in the hypoglycemic range
Diabetes Care Nov 2014, 37 (11) ; DOI: /dc

69. An Online Intervention Comparing a Very Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate Method Diet in Overweight Individuals With Type 2 Diabetes: A Randomized Controlled Trial
25 patients randomized to
Create Your Plate from ADA
Ketogenic diet ( gr total carbs per day)
32 weeks
online intervention in both groups
drop out rate for intervention 0% and 39% in control group
twice the A1c reduction in the intervention group
J Med Internet Res 2017;19(2):e36

70. J Med Internet Res 2017;19(2):e36

71. Carbohydrate Restriction has a More Favorable Impact on the Metabolic Syndrome than a Low Fat Diet
Demographics:
40 overweight subjects with atherogenic dyslipidemia
Age: 18 – 55 years
BMI > 25 kg/m2
Method:
Outpatient; 12 weeks
Two randomly assigned groups:
Hypocaloric LCD: ~1,500 kcal; 12% carb, 59% fat, 28% protein
Hypocaloric LFD: ~1,500 kcal, 56% carb; 24% fat; 20% protein
Results as %∆ for CRD vs LFD:
Fasting BG: -12% vs -2%
Fasting Insulin: -49% vs -17%
Insulin Resistance: -55% vs -18%
TAG: -51% vs. -19%
HDL-C: 13% vs -1%
TAG/HDL-C ratio: -54% vs -20%
Weight: -12% vs. -6%
Source: Carbohydrate Restriction has a More Favorable Impact on the Metabolic Syndrome than a Low Fat Diet; Volek et al.; Lipids Apr; 44(4):

72. Nitrogen metabolic and insulin requirements in obese diabetic adults on a protein-sparing modified fast
6 obese diabetics requiring insulin were admitted as inpatients for the study
7th patients was treated as outpatient
Protein sparing modified fast (0.8 – 1.5gr/kg)
Nitrogen balance studies on 3 patients
Diabetes, 1976 vol 25, no 6;

73. Nitrogen metabolic and insulin requirements in obese diabetic adults on a protein-sparing modified fast
Nitrogen balance was obtained with at least 1.3gr/kg of IBW
Insulin stopped in all patients 0 – 19 days
5 of the 7 sustained weight loss of over 40 pounds
Hyperinsulinism will tend to establish a positive caloric balance in adipose tissue, as insulin favors glucose and triglyceride uptake while inhibiting mobilization of fat. The realization that hyperinsulinism converts adipose tissue into a sink for calories implies that weight-reducing regimens should be specifically designed to allow a sharp fall in insulin levels. Thus, the avoidance of carbohydrates assumes special importance in the fasting obese given this rend towards hyperinsulinism not only because of the anabolic effect of insulin on adipose tissue but because hyperinsulinemia per se produces insulin resistance.
Diabetes, 1976 vol 25, no 6;

74. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes
20 RCT’s
n = 3073
The low-carbohydrate, low-GI, Mediterranean, and high- protein diets all led to a greater improvement in glycemic control [glycated hemoglobin reductions of −0.12% (P = 0.04), −0.14% (P = 0.008), −0.47% (P < ), and −0.28% (P < ), respectively] compared with their respective control diets
Am J Clin Nutr March 2013 vol. 97 no

75. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes
Conclusion: Low-carbohydrate, low-GI, Mediterranean, and high-protein diets are effective in improving various markers of cardiovascular risk in people with diabetes and should be considered in the overall strategy of diabetes management.
Am J Clin Nutr March 2013 vol. 97 no

76. Forest plots that show differences in Hb A1c between low-carbohydrate and other diets (A), low-GI and other diets (B), Mediterranean and other diets (C), and high-protein and other diets (D).
Forest plots that show differences in Hb A1c between low-carbohydrate and other diets (A), low-GI and other diets (B), Mediterranean and other diets (C), and high-protein and other diets (D). A meta-analysis was done with Revman 5 software (Cochrane Information Management System). A fixed-effect inverse-variance model was used to calculate the weighted mean difference and expressed in terms of 95% CIs and level of significance. ADA, American Diabetes Association; CHO, cholesterol; GI, glycemic index; Hb A1c, glycated hemoglobin; IV, inverse variance.
Olubukola Ajala et al. Am J Clin Nutr 2013;97:
©2013 by American Society for Nutrition

77. Low-carbohydrate condition
Low-carbohydrate condition. Participants in the low- carbohydrate condition were provided with the CalorieKing Thirty grams of carbohydrate was specifically chosen as the target intake, a goal we had used in our previous study (1). Although the glycemic index was not specifically discussed, participants were encouraged to select whole grain products and foods with a high fiber content. Participants were not instructed to restrict their total fat or caloric intake, although general advice was provided on the various types of dietary fat. They were encouraged to consume healthy fats (e.g., monounsaturated and polyunsaturated) and to minimize the intake of saturated and trans fats. Urinary or plasma ketones were not measured to evaluate dietary adherence.
Iqbal, N., et al (2010), Effects of a Low-intensity Intervention That Prescribed a Low-carbohydrate vs. a Low-fat Diet in Obese, Diabetic Participants. Obesity, 18: 1733–1738. doi: /oby

79. The Canadian Trial of Carbohydrates in Diabetes (CCD), a 1-y controlled trial of low-glycemic-index dietary carbohydrate in type 2 diabetes: no effect on glycated hemoglobin but reduction in C-reactive protein
The high-GI, low-GI, and low-CHO diets contained, respectively, 47%, 52%, and 39% of energy as carbohydrate and 31%, 27%, and 40% of energy as fat;
For the low-CHO diet, key foods consisted of olive or canola oils or spreads, nuts, and other foods low in SFAs and high in MUFAs and known to be associated with reduced risks of diabetes and CVD (33-35) or known to reduce blood lipids (16, 36, 37). These foods replaced carbohydrate foods normally consumed and were prescribed in amounts sufficient to raise total fat intake by ≈10%.
Am J Clin Nutr January 2008 vol 87 no

80. Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, 2010
In studies reducing total carbohydrate intake, markers of glycemic control and insulin sensitivity improved, but studies were small, of short duration , and in some cases were not randomized or had high dropout rates.
Diabetes Care Feb;35(2):434-45

81. Prevention and management of type 2 diabetes: dietary components and nutritional strategies
A meta-analysis of RCTs suggested that various dietary patterns such as low-carbohydrate, low-GI, Mediterranean, and high-protein diets were effective in improving glycemic control and CVD risk factors compared to diets in diabetic patients.87 These results provide a range of dietary options for diabetes management, paying attention to overall diet quality, treatment goals, and personal and cultural food preferences.
Several low-fat vegetarian or vegan diet trials have been conducted in people with diabetes,87 but improved glycemic control or CVD risk was not consistently reported in these studies
Ley SH et al. Lancet (London, England). 2014;383(9933): doi: /S (14)

82. Ongoing study at Indiana University Health
400 treatment patients: All treated with a ketogenic diet. Blood ketones obtained initially daily then decreasing frequency.
200 patients treated “live” in the clinic with weekly group meetings for the first 3 months then decreasing frequency over 2 years
200 patients treated “virtually” with all education being done via portal. Follow ups only at 3 months, 1yr and 2yrs or as needed
100 controls
Treated by the IU Health dietitians with ADA protocol

83. Ongoing study at Indiana University Health
All treatment patients given health coach
Biomarker tracking in “app”
Medication adjustment by supervising physician based on daily blood glucose and blood pressure levels
Online support community

84. Ongoing study at Indiana University Health
Primary Outcomes
Body Weight
Metabolic Syndrome Criteria
Type 2 Diabetes Status

85. Ongoing study at Indiana University Health
Secondary Outcomes
• Carotid intima media thickness (cIMT) will be measured by ultrasound 3 times over 2 years (baseline, 12, and 24 months).
• Serum lipids analyzed by NMR to determine LDL particle size and number
• Full Body DEXA
Banked Samples

91. Time for a Paradigm Change

93. Review BHOB SGLT-2 data

94. Multiple randomized
controlled trials including patients
with type 2 diabetes have reported that
a Mediterranean-style eating pattern
(75,79–82), rich in monounsaturated
fats, can improve both glycemic control
and blood lipids.
PREDIMED which was not looking at dm control
Dietary cis-monounsaturated fatty acids and metabolic control in type 2 diabetes1,2,3,4
Brehm BJ, Lattin BL, Summer SS, et al. Oneyeacomparison of a high-monounsaturated fatdiet with a high-carbohydrate diet in type 2 diabetes.Diabetes Care 2009;32:215–220 The study showed no difference between the groups in glycemic control
shai studyBrunerova L, Smejkalova V, Potockova J,
Andel M. A comparison of the influence of high-fat diet enriched in monounsaturated fattyacids and conventional diet on weight loss and metabolic parameters in obese non-diabetic and type 2 diabet - only said that a higher fat MUFA diet had better A1c results than standard of care

95. Macronutrients
Registered dietitians (RDs) should encourage consumption
of macronutrients based on the Dietary Reference
Intakes for healthy eating as research does not support
any ideal percentage of energy from macronutrients in
meal plans for persons with diabetes.
Of the 5 studies included in the initial assessment:
3 clearly showed an advantage for low carb
1 did not test low carb
1 should not have been included in the review as it did not meet the specified inclusion criteria.
1 study was left out that should not have been