Testosterone Enhancement Pills

Testosterone Enhancement Pills

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Testosterone is the primary sex hormone in males, but it also has important functions in the female body. If a person has a testosterone deficiency, they may wish to take testosterone supplements or adopt certain lifestyle changes.

In this article, we explain more about testosterone, including its role in males and females and how a person can increase their levels of this hormone.

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Some of the best testosterone supplements may include vitamin D and ashwagandha.

Testosterone is a key male sex hormone. During puberty, testosterone is responsible for the deepening of the voice, the growth of the male sexual organs, and the development of pubic hair. It also plays an important role in sperm production.

Although people often associate testosterone with males, this hormone has several functions in both males and females. These include:

• regulating sex drive
• increasing bone mass
• fat distribution and storage
• muscle growth
• red blood cell production
• sperm production

The key difference is that males tend to have higher testosterone levels than females, while females have higher levels of a different sex hormone: estrogen. Testosterone levels can fluctuate throughout the female and male life cycle.

If a person is transitioning, they may choose to increase their testosterone levels to make certain aspects of their body — those that society understands as masculine — more apparent.

In this situation, a person may consider testosterone therapy. A person should discuss the potential benefits and risks of hormone therapy with their doctor.

Testosterone supplements may be useful for people who have a testosterone deficiency. In males, a testosterone deficiency may cause the following symptoms:

• reduced sex drive
• erectile dysfunction
• reduced facial hair growth
• loss of lean muscle mass
• fatigue

Females with a testosterone deficiency may present with:

• fatigue
• difficulty sleeping
• reduction in sex drive
• weight gain
• irregular menstrual cycles
• vaginal dryness

Learn more about low testosterone in women.

Taking testosterone supplements in these circumstances may help alleviate these symptoms. However, a person may need to discuss this with a doctor.

A 2014 study highlights that when older and younger males with preexisting heart conditions took testosterone supplements, this led to an increase in the risk of having a heart attack.

In another study, scientists gave testosterone supplements to rats and noted that this led to an increase in prostate tumors. More research is necessary to assess whether the same happens in humans.

This section examines supplements that may help increase testosterone levels.

Vitamin D

A recent study featuring in the Journal of Steroid Biochemistry and Molecular Biology notes an association between vitamin D levels and testosterone. Men with a vitamin D deficiency had lower testosterone levels than those without a deficiency.

This research implies that an increase in vitamin D may help raise testosterone levels. Vitamin D supplements come in the form of capsules or a spray.

People can purchase Vitamin D supplements online.

Ashwagandha

Ashwagandha is an evergreen shrub. The roots and fruit of this plant have medicinal properties.

A 2019 study examined the effects of ashwagandha on hormone levels in males aged 40–70 years with overweight and mild fatigue. One group received a placebo while the others received ashwagandha.

The researchers found that the testosterone levels of the participants taking ashwagandha increased by 14.7% more than they did among the placebo group.

Ashwagandha supplements are available to purchase online.

D-aspartic acid

This amino acid plays a role in testosterone production and release.

In an older study, researchers gave 23 men a daily dose of D-aspartate for 12 days, which led to an increase in their testosterone. More research is necessary to determine whether similar results will occur in females.

People can purchase D-aspartic acid supplements online.

Fenugreek

Fenugreek is a plant belonging to the Fabaceae family.

A meta-analysis of trials investigating the effect of a fenugreek extract supplement on testosterone levels in males suggests that it has a significant effect.

Research has produced similar results in females. In a 2015 study, researchers gave 80 females aged 20–49 years 600 milligrams of fenugreek seed extract or a placebo each day for 8 weeks. The extract led to a significant increase in testosterone levels and sexual desire compared with the placebo.

Fenugreek supplements are available to purchase online.

DHEA

Dehydroepiandrosterone (DHEA) is a hormone that humans naturally make in their adrenal glands.

A study examining the effect of DHEA and whole-body vibrations on mice found that this combination decreased testosterone levels. However, DHEA alone led to an increase in testosterone levels.

More research is necessary to explore the effects of DHEA on testosterone in humans.

It is possible to purchase DHEA supplements online.

Some people may prefer not to take supplements but to rely on natural ways of boosting testosterone. Alternatively, people may wish to combine supplements with natural boosters. Some examples of ways to increase testosterone naturally include:

Sleep

An older study looking at the effects of sleep restriction in young men found that their morning testosterone levels were lower after they had less sleep. This finding implies that an association exists between more sleep and higher testosterone levels.

Weight loss

Males with obesity tend to have lower testosterone levels. Losing weight healthfully may help these individuals increase their testosterone levels.

Diet

Research suggests that males who consume low fat diets have lower levels of testosterone, regardless of body mass index (BMI) and physical activity levels.

Sunlight

Older research indicates that exposure to sunlight may help increase testosterone levels, as this is the source of most of the body's vitamin D.

Learn more about boosting testosterone naturally.

Testosterone is a key male sex hormone, but it also facilitates important functions in females.

If a person is experiencing a testosterone deficiency, they may consider taking testosterone supplements to help increase their levels of this hormone.

If a person prefers to increase testosterone naturally by making lifestyle changes, they can try safely exposing themselves to more sunlight and getting more sleep.

Testosterone Enhancement Pills

Source: https://www.medicalnewstoday.com/articles/best-testosterone-supplements

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Carb Amount For Low Carb Diet

Carb Amount For Low Carb Diet

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Low-carb diet and meal plan

Eating a low-carb diet means cutting down on the amount of carbohydrates (carbs) you eat to less than 130g a day. But low-carb eating shouldn't be no-carb eating.

Some carbohydrate foods contain essential vitamins, minerals and fibre, which form an important part of a healthy diet.

Here we'll explain what we mean by low-carb, what the benefits are of low-carb eating when you have diabetes, and share a low-carb meal plan to help you get started if this is the diet for you. We'll also explain how to get support to manage any potential risks, especially if you manage your diabetes with medications which put you at risk of hypos.

If you or someone you know is self-isolating, find out how to eat healthily whilst staying at home.

What's a low-carb diet?

But how low is low-carb? There are different types of low-carb diets. Generally, low-carb eating is when you reduce the total amount of carbs you consume in a day to less than 130g.

To put this into context, a medium-sized slice of bread is about 15 to 20g of carbs, which is about the same as a regular apple. On the other hand, a large jacket potato could have as much as 90g of carbs, as does one litre of orange juice.

A low-carb diet isn't for everyone. The evidence shows they can be safe and effective in helping people with type 2 diabetes manage their weight, blood glucose (sugar) levels and risk of heart disease in the short term.

But the evidence also shows they can affect growth in children, and so should not be recommended for them. And there is little evidence to show the benefits of this type of diet in people with type 1.

If you do decide to follow a low-carb diet, it's important to know all the potential benefits and how to manage any potential risks.

Low-carb meal plan

Our low-carb meal plan aims to help you maintain a healthy balance while reducing the amount of carbs you eat. Varying amounts of carbohydrate are shown each day to help you choose which works best for you.

It's nutritionally balanced, we've counted the calories for you, and it contains at least five portions of fruit and veg per day.

We've included the values of fibre and protein too to help you make sure you are meeting your nutritional requirements. We know lots of people in the UK aren't eating enough fibre, so it's important to try and include good sources in your diet every day.

Please note that the nutritional information and exact specifications for all meals and snacks is available in the linked recipes and the low carb meal plan (PDF 84KB).

Before you begin this meal plan

Before starting any healthy eating programme, please read how to choose your meal plan to make sure you follow the plan that's right for you.

Please speak to your diabetes health care team before making significant changes to your diet.

This is especially important if you treat your condition with insulin and diabetes medications that increase the risk of hypos (low blood sugar levels). Reducing your carbohydrate intake and changes to your body weight may mean your insulin and diabetes medication needs to be adjusted.

Important points about this meal plan

1. This meal plan has taken nutritional information from our recipes and the sixth edition of Carbs and Cals, unless otherwise stated.
2. A mix of whole milk and semi-skimmed milk has been used, but please use whichever you prefer. Any dairy alternative should be unsweetened and fortified with calcium.
3. These meal plans meet your recommended amount of fibre across the week.
4. This meal plan outlines daily food intake for one person, but it's still important to remember to drink regular fluids. This includes plain water, plain milk, and tea or coffee without added sugar.

Disclaimer: every effort has been taken to make these meal plans as accurate as possible, but there will be some variation in nutritional values. Speak to a dietitian or your diabetes healthcare team if you have questions about your individual dietary needs.

Monday

Breakfast: Baked eggs with two slices of rye bread

Lunch: Chilli bean soup with avocado salsa

Dinner: Mackerel tomatoes served with leeks and broccoli

Pudding: Apple strudel

Snacks: Greek yogurt, two satsumas, plain almonds, one apple

Milk: 225ml semi-skimmed milk

Tuesday

Breakfast: Porridge made with 30g porridge oats, 200ml almond milk, 40g blueberries and 10g pumpkin seeds

Lunch: Bang bang chicken salad

Dinner: Minced beef and vegetable filo pie

Pudding: 80g strawberries

Snacks: Avocado, brazil nuts, celery and peanut butter

Milk: 225ml semi-skimmed milk

Wednesday

Breakfast: Mushroom and spring onion omelette

Lunch: Butterbean paté with carrots, tomatoes and mini wholemeal pitta bread

Dinner: Aubergine and courgette parmesan bake with rocket, tomato and tinned kidney beans

Pudding: 80g melon

Snacks: One apple and peanut butter, one pear with almonds, natural yogurt and pumpkin seeds

Milk: 225ml semi-skimmed milk

Thursday

Breakfast: Summerberry smoothie

Lunch: Chickpea and tuna salad

Dinner: Chicken tikka masala and cauliflower pilaf

Pudding: Summer berry posset

Snacks: Greek yogurt, two satsumas, one orange, almonds, two oatcakes topped with smooth peanut butter

Milk: 225ml semi-skimmed milk

Friday

Breakfast: Baked eggs with two slices of rye bread

Lunch: Two slices of medium wholemeal bread with grated cheddar, vegetable oil-based spread, tomato and cucumber

Dinner: Grilled salmon steak with baked sweet potato, broccoli and cabbage

Pudding: Sugar-free jelly

Snacks: raspberries, melon, avocado, plain almonds

Milk: 225ml semi-skimmed milk

Saturday

Breakfast: Welsh leek rarebit

Lunch: Cauliflower and leek soup with 25g cheddar

Dinner: Butternut squash and borlotti bean stew

Pudding: Tinned peaches in juice

Snacks: One apple, 30g almonds, Greek yogurt, small pear and almonds, 60g pistachios with shells

Milk: 225ml semi-skimmed milk

Sunday

Breakfast: Omelette made with two eggs and milk along with 80g spinach, 80g mushrooms, 1tsp of vegetable oil, 25g grated cheddar. Pair with a slice of rye bread with 1tsp of unsaturated margarine

Lunch: Smoked mackerel on granary toast with 1sp of veg spread, rocket, tomato and cucumber.

Dinner: Greek homestyle chicken with broccoli and leeks

Pudding: 80g raspberries and 80g melon

Snacks: Low-fat Greek yogurt with almonds and pumpkin seeds, spicy roasted chickpeas, one small pear

Milk: 225ml semi-skimmed milk

Benefits of following a low-carb diet

One of the main benefits of following a low-carb diet is weight loss. For people with type 2 diabetes, this helps to reduce HbA1c and blood fats such as triglycerides and cholesterol. For people who don't have diabetes, losing weight can reduce your risk of developing type 2 diabetes, and a low-carb diet is one option to help you do this.

For people with type 1 diabetes

If you have type 1, the strongest evidence suggests that carb counting is the best way to manage your blood sugar levels. This means matching how much insulin you take to the amount of carbs in your meal, snack or drink.

There is no strong evidence that following a low-carb diet is safe or beneficial, which is why we don't recommend this diet for people with type 1 diabetes.

It is really important that you speak to your healthcare team for support to manage your insulin if you're considering a low-carb diet.

For people with type 2 diabetes

We know losing 15kg within three to five months will give people with type 2 the best chance of putting their diabetes into remission. Evidence tells us this is more likely if you are able to lose weight within 6 years of your diagnosis.

Finding a way to lose weight can also help you improve the way you manage your condition and reduce your risk of diabetes complications. There are different ways to lose weight, such as a low-carb diet - but there's no one-size-fits-all approach.

Find out more about weight loss and diabetes.

"I changed to a high-fat, low-carb diet and cut out sweet stuff altogether. Diabetes UK's website and an app for my phone really helped.

I lost around 12lbs (5.5kg) in my first week. When I returned to see the nurse after three months, my HbA1c was down to 42mmol/mol – it had been 51mmol/mol when I was diagnosed. The nurse thought she was seeing things.

I've now lost around seven-and-a-half stone (46.8kg) and my HbA1c level is 37mmol/mol."

- Paul's type 2 diabetes is now in remission.

However, there's no evidence that following a low-carb diet is any more beneficial in managing diabetes than other approaches in the long term, including a healthy, balanced diet.

Research suggests that the best type of diet is one that you can maintain in the long term, so it's important to talk to your healthcare professional about what you think will work for you. Another option is the Mediterranean diet, which is also linked to reducing the risk of heart diseases and stroke.

What to consider before following a low-carb diet

If you treat your diabetes with insulin or any other diabetes medication that puts you at risk of hypos, following a low-carb diet may increase this risk. Speak to your healthcare team about this so they can help you adjust your medications to reduce your risk of hypos. Your team may also support you to check your blood sugar levels more often.

"I make sure I balance out my diet with what suits my insulin, but with a bit of tweaking, most things can be persuaded to suit my insulin!

I won't eat a load of pasta with a side of garlic bread and not much else, because the carb load would be difficult to bolus for. But neither would I eat a completely carb free meal. It's all a question of balance, and a healthy diet is good for all of us, diabetic or not."

- Online forum user living with type 1.

Depending on the approach, following a low-carb diet may also lead to other side effects, such as constipation or bad breath.

Although these can be unpleasant, they are usually temporary and shouldn't be harmful in the long term. Speak to your healthcare professional if you're concerned about any of these.

It's really important to first reduce your carb intake from unhealthy sources such as sugary drinks, pizzas, cakes, biscuits, chips, white bread, fruit juices and smoothies.

And it is a good idea to get your limited carbs from healthy high-fibre carb foods, such as pulses, nuts, vegetables, whole fruits and whole grains. You can help make sure you're getting the calcium you need by including unsweetened milk and yoghurt in your diet too.

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Carb Amount For Low Carb Diet

Source: https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/meal-plans/low-carb

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3 Week Low Carb Diet Results

3 Week Low Carb Diet Results

I've tried my fair share of weird weight-loss strategies, none of which I wind up maintaining long-term because of the crazy restrictions. But in the summer of 2015, my parents started their own journey on the low-carb diet, and after seeing each of them successfully shed some pounds, I decided to give the diet a try for myself and see what kind of low-carb diet results I'd get.

Diets that minimize carbs go by many names. Chances are you've heard people refer to the Atkins, South Beach, or Keto (short for "ketogenic") diets. For the purposes of this experiment, I followed the rules laid out by Susan Kleiner, Ph.D, R.D, author of Power Eating, in this article. Since I work out moderately at least three times a week, I planned to consume 100 grams of carbohydrates per day on the plan—and that was the only rule. Considering cheese is naturally low in carbs (and was the hardest thing to give up during my bouts of Paleo and Whole30), I figured I'd finally met my perfect weight-loss match. So, armed with no further restrictions than capping my carb count, I kicked off two full weeks on the diet. Here's what I learned and what my low-carb diet results looked like.

1. You might want to start a food journal

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I've heard people preach about the wonders of food journals and how helpful they can be, but I always found the idea of writing down every last bite of food I consumed to be overkill. After all, I'm pretty aware of what I'm putting in my body, thankyouverymuch. But during my first day of counting carbs, I realized how helpful it really was to keep track of what I was eating. I kept my daily journal on a Google doc and updated it throughout my day. Not only did it help me keep a daily tally of how many carbs I'd eaten, but it was also a great reference for looking up the number of carbs in foods I eat regularly.

2. Meal prep is helpful, but not totally necessary

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Anyone who knows me knows I'm a huge advocate of meal prepping. And planning my low-carb meals ahead of time made sense since I wanted to reduce temptation. However, when I got tired of my meals by day three and checked out the menus of a few restaurants online, I was pleasantly surprised to find it's easy to eat out on the low-carb diet. As a rule of thumb, I stuck to grabbing food from places I could accurately record the nutrition of my meal. And if that wasn't available, I'd use my best judgement to order as low-carb as possible. (Read: No bun or fries with my burger, please.)

Related: 7 Foods I Prep Each Week to Make Sure I Eat as Healthy as Possible

3. Booze is allowed

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Just as not all diets are created equal, neither are your favorite happy hour drinks. I quickly got into the habit of looking up the carbs per serving of foods online before (and sometimes after) I consumed them, and when doing a quick search for drinks I learned that most red wine and spirits are actually safe options. I got into the habit of ordering a glass of Pinot Noir (3.4 grams of carbs for five ounces) or a gin and soda (no carbs!), which was a totally welcome change from Paleo, which discourages all alcohol. (These are the best wines to drink if you're trying to lose weight.)

Check out these moves that can help you reach your weight loss goal faster.

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4. Always calculate your own nutrition information

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Sure, you can trust nutrition labels on foods you buy at the grocery store, but if you're cooking from a recipe you found online (or even if you're relying on MyFitnessPal), it's best to double check how many carbs are in your ingredients. I found when I was grocery shopping that different brands of certain products (i.e. marinara sauce) can have insanely different carb counts per serving. During my first week of prep, I followed a blogger's low-carb recipe for a veggie lasagna and found that my version actually had more carbs per serving than hers (thanks to the sauce).

Related: Is Weight Loss Really 80 Percent Diet and 20 Percent Exercise?

5. This diet is very dairy friendly.

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Listen up, cheese lovers, because this diet could potentially be a good fix for you. I know how hard it is to part ways with cheese and cream, but since dairy is naturally low in carbs it's actually a great source of healthy fats (which you'll consume a lot of on this plan). Since the whole point of a low-carb diet is to train your body to burn fat and not sugar as a source of energy, full-fat dairy is encouraged. Score! (Hit the reset button—and burn fat like crazy with The Body Clock Diet!)

6. You probably won't get crazy cravings.

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My parents are in the super-serious Atkins induction phase, which only allows them 20 grams of carbs per day (about the amount in a small apple). My mom constantly preached to me about keeping snacks handy for when my body suddenly goes into ketosis, but I actually never felt any symptoms of weakness or deprivation. In fact, since I was filling up on protein and healthy fats, I was able to consistently stay full. Sorry, mom!

Related: The Changes One Trainer Made to Lose Weight After Years of Diet and Exercise

7. You'll start seeing results quickly.

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Even though I was only committed to this diet for two weeks, I couldn't help but weigh myself after my first week. I wasn't feeling hungry or deprived, so I worried that I was doing something wrong. Despite my concerns I'd dropped 1.8 pounds after one week on the diet. After my second week, I'd lost 3.4 pounds and started to notice my frame thin out a bit. So yes, I did get to eat dairy, drink wine, and drop a few pounds. Needless to say, I think this is a plan I could happily stick with. But first I need a slice of pizza.

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3 Week Low Carb Diet Results

Source: https://www.womenshealthmag.com/weight-loss/a19968209/low-carb-diet-results/

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Does Low Carb Diet Help Lose Weight

Does Low Carb Diet Help Lose Weight

10 Diet Pills to Kickstart Your Weight Loss Efforts

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If you're struggling to lose weight, a diet pill can give you the boost you need to reach your goals. Some are available over-the-counter (OTC), while others require a prescription from your doctor. Either way, for the best results, combine any weight loss pill with lifestyle changes (like exercising more or eating a healthier diet). Here are a few diet pills that can help you get over your weight loss hump.

Best Overall: Phentermine

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Phentermine is a prescription diet pill consistently proven to help its users lose weight. Users report that phentermine boosts their energy levels, making it easier for them to increase their daily activity and exercise more. Most users also experience appetite reduction that makes it less arduous to eat less. However, phentermine users also find that the drug is less effective the longer you take it.

Best Value: Nature Craft's Natural Raw Green Coffee Bean Extract

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Prefer something OTC? Nature Craft's Natural Raw Green Coffee Bean Extract contains caffeine to boost your metabolism, plus chlorogenic acid to slow the absorption of carbohydrates (aka everything delicious). Users find that they're less likely to overindulge when taking this diet pill, and report high energy levels with no jittery feelings or "crash." More than 900 reviewers have weighed in, giving it a solid 4.5 star average rating.

Best Diet Pill for a Low-Fat Diet: Alli Orlistat

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Alli Orlistat is a diet pill that blocks 25 percent of the fat from the foods you consume, creating a reduction in the amount of calories you absorb. Orlistat users experience the best results when they combine the diet pill with the suggested, healthy eating plan—seriously, you do not want to over-indulge. Users report that it's essential to adhere to a low-fat diet when taking Alli; otherwise, you risk digestive distress, stool leakage, and flatulence.

Best Diet Pill for Men: Prime Labs Prime Test Testosterone Booster

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Prime Labs Prime Test testosterone booster is a popular diet pill with men who want to lose a few pounds and increase their testosterone levels. Users find that they have more energy and have better performance in the gym and weight room. Is there's a six-pack under your pudge? Fans also report that this diet pill helps eradicate stubborn belly fat. It has over 25,000 Amazon reviews and a 4.5 rating.

Best Diet Pill for a Ketogenic Diet: Keto BHB

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If you want to try a ketogenic diet or prefer to eat low-carb foods, Purley Optimal's Keto BHB Supplement is an excellent diet pill to assist with your weight loss efforts and help you reach ketosis (the prized metabolic state where fat, not glucose, is used as fuel) as quickly as possible. Users report that Keto BHB helps combat the low energy levels that can accompany a low-carb diet, and boosts mental clarity to help prevent keto-related brain fog.

Best Diet Pill for Women: Nobi Nutrition Premium Women's Fat Burner

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Nobi Nutrition Premium Women's Fat Burner is formulated specifically to assist with the often frustrating female weight loss journey. Fans of this diet pill find that it gives them more energy and suppresses the appetite without making them feel jittery. They also report feeling less hungry between meals and having more self control around foods that typically trigger them to overeat.

Best Night Time Diet Pill: Dr. Emil Bedtime Burn

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Tackle your weight loss goals at night with Dr. Emil Bedtime Burn. This stimulant-free diet pill raises your metabolism while you sleep and contains ingredients to promote a better night's sleep—bonus! Bedtime Burn fans find that it helps reduce their cravings and raises their metabolism. It also aids them with falling asleep quicker and staying asleep so that they have ample energy to conquer their workouts.

Best Diet Pill for Overhauling Your Brain's Hunger System: CONTRAVE

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The brain's bitty hypothalamus, which is responsible for controlling the body's appetite and energy expenditure, can have an outsized effect on a person's weight. CONTRAVE is a prescription diet pill that reduces hunger and cravings by impacting how the brain's hypothalamus functions. While users of CONTRAVE report significant weight loss, this weight loss comes at a price. CONTRAVE can cost anywhere from $100 to $400 if it isn't covered by your insurance. Some users report side effects including headaches and constipation.

Best Multitasking Diet Pill: Native Nutrition Apple Cider Vinegar+

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Apple cider vinegar is associated with a slew of health benefits, like controlling blood sugar levels, easing indigestion, and lowering cholesterol levels. Native Nutrition Apple Cider Vinegar+ encourages weight loss and features all the qualities conventionally associated with this supplement—except the taste. Fans of this diet pill find it a far more pleasant alternative to drinking apple cider vinegar, and report that it's effective at reducing bloat and assisting with appetite control.

Best Diet Pill for Reducing Bloat: NutriRise 15-Day Colon Cleanse

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Bloated from overeating or consuming high sodium foods? Your body may be retaining water, which can conceal your weight loss. It's also incredibly uncomfortable. NutriRise 15-Day Colon Cleanse is an excellent way to jumpstart your lifestyle change and eliminate stomach-distending bloat. Users like that this cleanse eliminates that too-full feeling and encourages a loss in pesky water weight without causing significant digestive distress.

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Does Low Carb Diet Help Lose Weight

Source: https://www.consumersearch.com/health-beauty/best-diet-pills?utm_content=params%3Ao%3D740007%26ad%3DdirN%26qo%3DserpIndex

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Best Alcoholic Drinks Low Carb Diet

Best Alcoholic Drinks Low Carb Diet

Whether you're out at a bar or fixing yourself a drink at home, there are plenty of options to stay true to your low carb or keto lifestyle—especially if you have the added versatility of a flexible ketogenic diet like Atkins20^® or Atkins40^®*. When consumed in moderation, alcohol can be enjoyed as part of your keto lifestyle. Keep in mind that while many of these choices are low in carbs, alcohol still provides calories and the body needs to burn off those alcohol calories before it can get back into fat burning mode. If you notice that your weight-loss has stalled, you may need to cut back on alcohol. Read on to discover which keto friendly alcohol and drinks to stick to and which to avoid.

What Alcohol Can I Drink On Keto?

• Pure Spirits. Hard alcohol like vodka, rum, tequila, whiskey, and gin all contain zero carbs and are the most keto friendly alcohol choise.
• Hard seltzer. White Claw started the hard seltzer craze with their 2g carb per can beverages, plus more options like Truly and Bon & Viv make it easy to find your favorite.
• Some wines. Not all wines are ideal keto alcohol drinks; depending on the type, carbs range from 0-4 grams a glass. Look for dry varieties—like brut champagne for sparkling; Sauvignon Blanc or Pinot Grigio for white; and Cabernet Sauvignon or Merlot for red—to stay on the lower end of the spectrum. Additionally, a higher alcohol content in the wine also indicates that it will have fewer carbs. Stick with wines that are greater than 12% alcohol.

What Alcohol Should I Avoid on Keto?

• Beer. At an average of 17g carbs per serving, there's a reason beer is sometimes called liquid bread! If you simply must have beer, look for the lightest beers, which can be as low as 2g of carb per serving. But still, beer should be consumed sparingly.
• Some wines. As above, some wines are more keto friendly than others. In general, sweeter varieties of wines like Moscato and Riesling will have a greater carb count. Also, avoid dessert wines like ports and sherries, as these contain quite a few more carbs.
• Wine coolers & malt beverages. While these colorful, fruity beverages can have a lower ABV per serving, they're loaded with sugar and a super-high carb count.

What Cocktails Can I Drink on Keto?

Knowing that most pure spirits, or "hard alcohol," can fit into your low carb lifestyle is the first half of the battle. If you prefer a mixed drink, you'll have to be sure to choose your mixers carefully to avoid sugary juices, sodas, and store-bought cocktail mixes.

For example, if you're a fan of tonic water, make sure to choose diet tonic, as regular tonic water has upwards of 25 grams of sugar per serving. You could also choose to drink your keto friendly alcoholic straight or on the rocks to keep things simple and free from additional carbs. But, for those looking for a cocktail to sip, here are a few keto alcohol drinks ideas to get you started:

• Vodka soda. This cocktail is the king of keto vodka drinks, made simply with vodka, club soda and a lemon or lime wedge. Easy, refreshing, and zero carbs; what's not to love?
• Old Fashioned. Traditionally made with whiskey, a dash of orange bitters, and a sugar cube, this cocktail can be made even lower carb with your favorite low carb sweetener.
• Sangria. Depending on the keto friendly fruit involved, a red or white sangria can be a refreshing, low carb beverage to enjoy on a patio or porch.
• And more! Check out cocktails in our New Year's article, and browse our Recipes page to find even more adult beverages that can fit into your low carb and keto lifestyle

Learn More About Low Carb Articles & Research

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There's no one set of rules for the Mediterranean diet; the term refers to planning your meals based on the traditional eating styles of the countries bordering the Mediterranean Sea.

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Best Alcoholic Drinks Low Carb Diet

Source: https://www.atkins.com/how-it-works/library/articles/low-carb-and-keto-alcohol-drinks-what-to-order

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Type 1 Diabetes Low Carb Diet Ketones

Type 1 Diabetes Low Carb Diet Ketones

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If you've recently been diagnosed with Type 2 diabetes, you might've heard that your diet plays a vital role in how well you treat and manage this condition. All people who have Type 2 diabetes should adhere to a strict diet plan that focuses on several healthy food groups. What you may not know is that the diet recommended for people with Type 2 diabetes is one of the healthiest diets for anyone, whether or not they've been diagnosed with diabetes. If you're interested in adapting your lifestyle to include a healthier diet in an effort to manage your diabetes effectively, here's what you need to know to get started.

For people with diabetes, a diet plan is a critical part of their overall treatment plan. That's because the foods they choose can help to better control their blood sugar. The recommended diet plan for diabetics has been developed as medical nutrition therapy (MNT). This means an evidence-based medical approach is used to create a nutrition plan tailored to meet the needs of people who have one or more chronic health conditions.

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Diets developed using the principles of MNT typically exclude foods that people's bodies can't process efficiently because of their health conditions. For Type 2 diabetics, these foods include simple sugars and carbohydrates that are metabolized into sugar during digestion. Type 2 diabetics frequently develop secondary health conditions such as elevated levels of triglycerides and low-density lipoprotein (or "bad") cholesterol. A healthy diet plan is essential for managing blood sugar. An appropriate diet may also help someone with diabetes achieve and maintain a healthy weight, which can be difficult after a Type 2 diagnosis.

When someone with Type 2 diabetes consumes excess fat, carbohydrates and calories, their body can respond with a dangerous spike in blood sugar levels. As this happens repeatedly over time, it can lead to chronic health problems, including nerve, kidney and heart damage. According to the American Diabetes Association, diabetes and its complications contribute to as many as 270,000 deaths each year in the United States alone. Maintaining a healthy diet may help to prevent some of the most serious outcomes of this chronic condition.

Here are a few important factors to consider when creating a Type 2 diabetes diet plan:

• Current body composition: Weight and body mass index (BMI) can help to determine whether someone with Type 2 diabetes needs to lose weight. Up to 90% of people with Type 2 diabetes are overweight. Weight loss can result in significant improvements for diabetics. As such, body composition plays a major role in formulating a diabetic diet.
• Activity level: Active people need to consume more calories and nutrients than those who are less active.
• Special dietary needs: Diabetics who have health conditions, such as food allergies, have special dietary needs that need to be incorporated into their individual diet plans.

When creating a food plan, a dietician will request a diabetic's complete medical history to ensure the diet meets all nutritional and health-related needs. The main goal of the diet is to help control Type 2 diabetes.

What to Include on a Type 2 Diabetes Diet

Some foods are almost always healthy and will play a prominent role in most diabetic diet plans. The principles of MNT include the fact that the quality of what you eat is just as important as the quantity. Among the components in a diet plan for Type 2 diabetes are:

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• Fiber: Fiber is a critical factor in any diet, as it helps your body eliminate excess cholesterol from your cardiovascular system. It absorbs water from your digestive tract and ensures proper bowel function. It's also an indigestible complex carbohydrate that your body can't absorb and break down into sugars. As such, it doesn't cause large glucose spikes in your bloodstream.
• Healthy carbohydrates: Carbohydrates come in many forms. Sugars are simple carbohydrates, whereas starches are complex carbohydrates. Although all carbohydrates are ultimately broken down into glucose, the simpler carbohydrates, such as white sugar, generate glucose rapidly and can cause a quick increase in blood glucose levels. The healthiest carbohydrates are those that are the least processed and contain fiber; these include the carbohydrates found in vegetables, whole grains and legumes.
• Heart-healthy protein: Two good sources of animal-based protein are chicken and fish. These sources are low in saturated fat and cholesterol. Chicken should be served without skin and baked, broiled or grilled to avoid excess fat. Fish is a rich source of omega-3 fatty acids that can promote heart health by lowering triglyceride levels. Salmon, mackerel and herring are among the fish highest in omega-3 fatty acid content.
• Heart-healthy fat: Heart-healthy or "good" fats are those that help to lower cholesterol. They include monounsaturated and polyunsaturated fats. Foods that supply these fats include avocados, nuts, olives and certain oils. People with diabetes should limit their intake of fat because it's high in calories.

Foods to Avoid on a Type 2 Diabetes Diet

Because diabetes increases the risk for cardiovascular disease, people with diabetes should watch their intake of the following:

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• Cholesterol: Sources of cholesterol include high-fat dairy products, red meat, organ meats, eggs and shellfish. Eat these foods sparingly.
• Saturated fats: Saturated fats are found in high-fat dairy products, beef, processed meats and pork products. You should also consume these foods sparingly.
• Trans-unsaturated fats: These fats are typically found in processed foods, shortening and margarine. Avoid them completely.
• Sodium: Sodium balance is critical. But consuming too much sodium (usually in the form of salt) can exacerbate health problems that occur frequently in people with Type 2 diabetes, including hypertension, congestive heart failure, liver and kidney problems, heart attack and stroke. Processed foods are high in sodium and should be consumed sparingly.

Putting It All Together

With the help of a dietician, you can find an approach to healthy eating that works for you. It's also essential to take the time to read food labels, as careful monitoring of the nutrients you're consuming is a critical factor in successful dietary management.

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Rather than counting calories, it may be easier to count net daily carbohydrates ("net carbs"). To calculate net carbs, subtract the amount of fiber and sugar alcohols (found in some diet products) from the total grams of carbohydrates in the foods you eat. This value may provide a more accurate idea of the impact of various foods on your blood glucose levels. Many net-carb calculators are available online to help you figure out these numbers.

Some people with Type 2 diabetes find it easier to use the "exchange" system to manage their diets. In this way of eating, food groups with similar values are used to select meals. This system can be difficult for some because it's quite a different way to think about foods in comparison to the traditional food groups that we learn as children.

Some people use the "glycemic index" system, which assigns a number value to individual foods based on their potential to affect blood sugar levels. While this method can make it easier to select foods, some foods with a low glycemic index aren't necessarily the healthiest for people with Type 2 diabetes. Foods that are high in fat, for example, have a low glycemic index but should still be avoided because they're generally high in calories.

Maintaining a healthy diet is important for everyone. People who are concerned about their health or their weight can also consult with a dietitian and create a diet plan tailored to their individual needs and preferences. The improved health that can follow is worth the effort.

Resource Links:

https://www.niddk.nih.gov/health-information/diabetes

https://www.nhlbi.nih.gov/health/educational/lose_wt/eat/fd_exch.htm

http://www.thecmafoundation.org/projects/pdfs/excercise%20on%20glycemic%20control%20and%20bmi.pdf

http://www.mayoclinic.com/health/diabetes-diet/DA00027

http://www.diabetes.org/food-and-fitness/food/planning-meals/diabetes-meal-plans-and-a-healthy-diet.html

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Type 1 Diabetes Low Carb Diet Ketones

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Low Carb Diet For Diabetics

Low Carb Diet For Diabetics

1. Research
2. Efficacy and safety of...
3. Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data

Research

Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.m4743 (Published 13 January 2021) Cite this as: BMJ 2021;372:m4743

Linked Fast Facts

Low and very low carbohydrate diets for diabetes remission

1. Joshua Z Goldenberg , research investigator1 2,
2. Andrew Day , physician3,
3. Grant D Brinkworth , professor4,
4. Junko Sato , professor5,
5. Satoru Yamada , professor6,
6. Tommy Jönsson , professor7,
7. Jennifer Beardsley , research librarian8,
8. Jeffrey A Johnson , professor9,
9. Lehana Thabane , professor, director10 11,
10. Bradley C Johnston , associate professor, methodologist1 10

1. ¹Department of Nutrition, Texas A&M University, College Station, TX, USA
2. ²Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
3. ³Day Family Medicine, Poulsbo, WA, USA
4. ⁴Commonwealth Scientific and Industrial Research Organisation (CSIRO) - Health and Biosecurity, Sydney, NSW, Australia
5. ⁵Department of Metabolism and Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
6. ⁶Diabetes Center, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
7. ⁷Center for Primary Health Care Research, Lund University/Region Skåne, Skåne University Hospital, Malmö, Sweden
8. ⁸Independent research librarian, Seattle, WA, USA
9. ⁹School of Public Health, University of Alberta, Edmonton, AB, Canada
10. ¹⁰Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
11. ¹¹Biostatistics Unit, St Joseph's Healthcare, Hamilton, ON, Canada

1. Correspondence to: B C Johnston bradley.johnston{at}tamu.edu (or @methodsnerd on Twitter)

• Accepted 30 October 2020

Abstract

Objective To determine the efficacy and safety of low carbohydrate diets (LCDs) and very low carbohydrate diets (VLCDs) for people with type 2 diabetes.

Design Systematic review and meta-analysis.

Data sources Searches of CENTRAL, Medline, Embase, CINAHL, CAB, and grey literature sources from inception to 25 August 2020.

Study selection Randomized clinical trials evaluating LCDs (<130 g/day or <26% of a 2000 kcal/day diet) and VLCDs (<10% calories from carbohydrates) for at least 12 weeks in adults with type 2 diabetes were eligible.

Data extraction Primary outcomes were remission of diabetes (HbA_1c <6.5% or fasting glucose <7.0 mmol/L, with or without the use of diabetes medication), weight loss, HbA_1c, fasting glucose, and adverse events. Secondary outcomes included health related quality of life and biochemical laboratory data. All articles and outcomes were independently screened, extracted, and assessed for risk of bias and GRADE certainty of evidence at six and 12 month follow-up. Risk estimates and 95% confidence intervals were calculated using random effects meta-analysis. Outcomes were assessed according to a priori determined minimal important differences to determine clinical importance, and heterogeneity was investigated on the basis of risk of bias and seven a priori subgroups. Any subgroup effects with a statistically significant test of interaction were subjected to a five point credibility checklist.

Results Searches identified 14 759 citations yielding 23 trials (1357 participants), and 40.6% of outcomes were judged to be at low risk of bias. At six months, compared with control diets, LCDs achieved higher rates of diabetes remission (defined as HbA_1c <6.5%) (76/133 (57%) v 41/131 (31%); risk difference 0.32, 95% confidence interval 0.17 to 0.47; 8 studies, n=264, I²=58%). Conversely, smaller, non-significant effect sizes occurred when a remission definition of HbA_1c <6.5% without medication was used. Subgroup assessments determined as meeting credibility criteria indicated that remission with LCDs markedly decreased in studies that included patients using insulin. At 12 months, data on remission were sparse, ranging from a small effect to a trivial increased risk of diabetes. Large clinically important improvements were seen in weight loss, triglycerides, and insulin sensitivity at six months, which diminished at 12 months. On the basis of subgroup assessments deemed credible, VLCDs were less effective than less restrictive LCDs for weight loss at six months. However, this effect was explained by diet adherence. That is, among highly adherent patients on VLCDs, a clinically important reduction in weight was seen compared with studies with less adherent patients on VLCDs. Participants experienced no significant difference in quality of life at six months but did experience clinically important, but not statistically significant, worsening of quality of life and low density lipoprotein cholesterol at 12 months. Otherwise, no significant or clinically important between group differences were found in terms of adverse events or blood lipids at six and 12 months.

Conclusions On the basis of moderate to low certainty evidence, patients adhering to an LCD for six months may experience remission of diabetes without adverse consequences. Limitations include continued debate around what constitutes remission of diabetes, as well as the efficacy, safety, and dietary satisfaction of longer term LCDs.

Systematic review registration PROSPERO CRD42020161795.

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Introduction

Diabetes is a common, deadly, and expensive medical condition. It is estimated that 1 in 11 adults worldwide have diabetes and that it is responsible for 11% of deaths annually, costing $760bn (£570bn; €626bn) in direct costs alone.1 Type 2 diabetes is the most common form of diabetes, accounting for 90-95% of cases, and for decades has been a rapidly growing international concern.2 Type 2 diabetes is characterized by insulin resistance driven by chronic hyperglycemia and is commonly diagnosed by measures of glycemia such as fasting blood glucose concentrations of 7.0 mmol/L or above or glycated hemoglobin (HbA_1c) values of 6.5% (48 mmol/mol) or above.3 It is associated with several risk factors including genetics and lifestyle influences, but by far the most common risk factor is obesity.1

Structured dietary interventions are commonly recommended for patients with diabetes, with varied recommendations from authoritative organizations.4 Before the discovery of insulin, diets emphasizing carbohydrate restriction had been used extensively in the management of diabetes, but more recently they have fallen out of favor.5 Because a key underlying mechanism of type 2 diabetes is insulin resistance driven in part by chronic hyperglycemia, lowering dietary intake of carbohydrate, most of which is absorbed as glucose or fructose, has been suggested to improve blood glucose control and outcomes of type 2 diabetes.6 Structured diets with carbohydrate restriction have been variably described in the research literature but have been commonly grouped into three categories: 20-50 g/day carbohydrates or less than 10% of the 2000 kcal/day diet that is generally sufficient to induce ketosis; less than 130 g/day or less than 26% of the 2000 kcal/day diet; and less than 45% of the 2000 kcal/day diet.78 For the purposes of this review, we refer to diets with less than 130 g/day or less than 26% of calories from carbohydrates based on 2000 kcal/day as a low carbohydrate diet (LCD).

Type 2 diabetes remains a significant and worsening problem worldwide, despite many pharmaceutical developments and a global emphasis on glycemic control.9 Structured diets are recognized as an essential component of treating diabetes,10 but confusion remains about which diet to choose.11 Systematic reviews and meta-analyses to date have attempted to pool carbohydrate restricted diets for diabetic populations, reporting mixed results.121314 Among the limitations, as a whole, the systematic reviews and meta-analyses have included interventions with moderate carbohydrate intake that may dilute the effect of LCDs. Other limitations include an exclusive focus on surrogate outcomes (for example, blood lipids), with the largest systematic reviews and meta-analysis to date identifying only 10 trials that meet strict eligibility criteria of LCDs three months or more in length, limiting the certainty and precision in effect estimates.15 Furthermore, no review to date has attempted to report the effect of LCDs on rates of remission of diabetes,16 and no review has presented effect estimates with consideration of minimal important difference thresholds, thresholds that will assist patients and clinicians with interpreting the magnitude of treatment effects.1718 We aimed to systematically assess the efficacy, safety, and certainty of estimates for both surrogate outcomes and outcomes important to patients of strict LCDs for people with type 2 diabetes.

Methods

Search strategy and selection criteria

On the basis of an a priori and publicly available protocol (PROSPERO CRD42020161795), we did a systematic review with meta-analysis of randomized controlled trials assessing the efficacy and safety of LCDs among adult patients with a diagnosis of type 2 diabetes. We included people with or without cardiovascular conditions regardless of medication use or glucose concentration and HbA_1c level.

We included trials comparing LCDs with any wait list controls or any active controls including competing dietary programs higher in carbohydrates (≥26%), with or without exercise, lifestyle, and behavioral recommendations. No language, date, or publication restrictions were applied. We sought unpublished data from investigators of published and unpublished trials.

To meet inclusion criteria, studies had to investigate allocation to an LCD (<26% calories from carbohydrates or <130 g/day) for a defined period (12 weeks or longer), with or without exercise (for example, walking, jogging, strength training) or lifestyle and behavioral recommendations (for example, cognitive therapy, group support). Primary outcomes of interest, based on our a priori protocol,16 were remission of type 2 diabetes (dichotomously defined as HbA_1c <6.5% or fasting glucose <7.0 mmol/L), with or without the use of diabetes medication. Additional primary outcomes were weight loss, HbA_1c, fasting glucose, and adverse events (total and serious adverse events). Secondary outcomes were health related quality of life, reduction of medication, and biochemical laboratory data including total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, triglycerides, homeostasis model assessment of insulin resistance (HOMA-IR), and inflammatory markers (C reactive protein).

We searched the following databases from inception to 25 August 2020 to identify studies: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Commonwealth Agricultural Bureaux (CAB) abstracts. With the assistance of an expert clinical librarian, search strategies were customized, including the use of a Cochrane recommended filter for the identification of randomized controlled trials in PubMed.19 The Medline search strategy is reported in supplementary table A. On the basis of our study protocol, we also searched three trial registries (for example, clinicaltrials.gov) and four additional grey literature sources (for example, BIOSIS Citation Index, ProQuest Dissertations & Theses Global).16

Two authors, independently and in duplicate, screened titles and abstracts and subsequently full text articles. Disagreements were resolved by consensus.

Data analysis

Data extraction was done independently and in duplicate using a pilot tested extraction form. Domains for extraction included study design factors, population, intervention, comparator, and surrogate and health outcomes (variables listed in supplementary table B). All outcomes were extracted and reported at six months (±3 months) and 12 months (±3 months). We used version 2.0 of the Cochrane Risk-of-Bias (RoB) instrument for randomized trials and assessed each of the RoB domains as "high," "low," or "some concern" using the Excel file provided by the RoB 2.0 development team.20

We used Revman software (version 5.3) and the "meta" package in R (version 3.6.1) to do meta-analyses. For dichotomous outcomes, we calculated the pooled risk difference, risk ratio, and number needed to treat for an additional beneficial outcome (NNT) with 95% confidence intervals. For continuous outcomes, we combined endpoint or change data; when both endpoint and change data were reported, we prioritized endpoint data.21 We calculated the pooled mean difference and/or standardized mean difference with corresponding 95% confidence intervals. We pooled studies that measured continuous health related quality of life with different instruments if the underlying construct was the same or similar. To improve interpretability for readers, we followed published guidance and presented effect estimates in two ways.22 Firstly, we pooled the effect estimates as standardized mean differences. Secondly, we converted scores of the different health related quality of life instruments to units of the most commonly used reference instrument and presented the mean difference.222324 Where possible, we presented the effect size on the basis of known or estimated minimal clinically important difference (MCID) thresholds for all outcomes (supplementary table C). We rated the overall certainty (quality) of evidence for each of our outcomes by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, wherein randomized trials began as high certainty evidence but could be rated down by one or more levels on the basis of five categories of limitations: risk of bias, inconsistency, indirectness, imprecision, and publication bias.2526 We assessed the RoB and GRADE independently and in duplicate, with disagreement resolved by consensus. After a request from referees, we also did a sensitivity analysis comparing the certainty of evidence using GRADE versus NutriGRADE.27

Following published guidance, we chose to use data from complete cases for our primary analysis.28 When studies had missing outcome data and reported a complete case analysis, we did sensitivity analyses and applied increasingly stringent but plausible assumptions to this data,242829 using Excel files made available from the authors of the GRADE guidance on missing outcome data.24 For assessing the effect of missing outcome data on risk of bias, we did these sensitivity assessments at the study level to best integrate with Cochrane RoB 2.0.20

We assessed and reported heterogeneity quantitatively using the I² statistic and did a χ² test for homogeneity according to guidelines from the Cochrane Handbook (for example, 50% to 90% may represent substantial heterogeneity; 75% to 100% may represent considerable heterogeneity).30

We investigated heterogeneity and the possibility of effect modification for our primary outcomes on the basis of risk of bias and seven a priori subgroups,16 with any subgroup effects with a statistically significant test of interaction subjected to a five point credibility checklist.31 Subgroups were very low carbohydrate diets (VLCD) (<10% calories from carbohydrates) versus diets with between 10% and 26% of calories from carbohydrates; trials that provided behavioral support versus those that did not; LCDs versus comparator diets (for example, low fat diets, Mediterranean diets); trials in which caloric intake did not significantly differ between groups (iso-caloric) versus those in which it did; LCD trials that used caloric restriction versus those that did not; trials that included patients who used insulin versus those that did not; trials in which the intervention group showed adequate adherence (determined by three a priori criteria: 3-β-hydroxybutyrate, measured carbohydrate intake, and author definitions16) versus those that did not. Furthermore, for each outcome, we investigated the effect on the point estimate when we restricted the analysis to studies at low risk of bias; if the risk of bias sensitivity analysis was credible,16 we focused our results on those studies at low risk.

To assess for the possibility of publication bias, we visually inspected funnel plots when 10 or more trials were included. We further assessed for publication bias by using Egger's regression test for continuous outcomes and the Harbord score for dichotomous outcomes.3233

Patient and public involvement

Given the nature of secondary data capture and analysis, patients and the public were not involved in the design or interpretation of this study.

Results

Our search yielded 14 759 records, of which 23 studies (1357 participants) met the inclusion criteria (fig 1). Table 1 shows characteristics of the clinical trials. In short, trials primarily included overweight and obese patients with type 2 diabetes, with 14/23 (61%) studies including participants using insulin. Trial size ranged from 12 to 144 participants with a mean age range of 47 to 67 years. Studies used various carbohydrate restriction thresholds with 12/23 (52%) meeting our criteria for very low carbohydrate diets (<10% daily calories from carbohydrates or <50 g/d). Trials primarily used low fat diets as control comparators (18/23; 78%). Duration of treatment ranged from three months to two years. Dropouts were common in the included studies. Eighteen (78%) of 23 studies reported missing participant outcome data, with 10 reporting more than 20% of data being missing. In studies with reported missing data, we assessed the robustness of reported effect estimates by using increasingly stringent assumptions about the missing data and incorporated this into the overall assessment for risk of bias.24 Overall, 59.4% of outcomes were rated as having some concern or high risk of bias, and 40.6% of outcomes were rated as having low risk of bias (fig 2). The randomization process was the risk of bias domain that had the poorest reporting, with just over 40% of trials having "some concerns."

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Table 1

Characteristics of included trials

Eight studies reported on remission of diabetes at six months.3435363738394041 Pooled analysis showed that when remission was defined by an HbA_1c level below 6.5% independent of medication use, LCDs increased remissions by an additional 32 per 100 patients followed (risk difference 0.32, 95% confidence interval 0.17 to 0.47; 8 studies, n=264; GRADE=moderate) (fig 3; table 2). When remission was defined by an HbA_1c level below 6.5% and the absence of diabetes medication, LCDs increased remissions at a lower rate (risk difference 0.05, –0.05 to 0.14; 5 studies, n=199; GRADE=low) (table 2). Three studies reported on remission at 12 months.353941 When remission was defined independently of medication use, LCDs increased remission (risk difference 0.10, –0.02 to 0.21; 3 studies, n=171; GRADE=moderate), but they lowered the remission rate when the definition of remission included absence of diabetes medication (risk difference –0.04, –0.16 to 0.09; 2 studies, n=126; GRADE=low) (table 2).

Table 2

Summary of findings for primary outcomes

Eighteen studies reported on weight loss at six months.343536373839404142434445464748495056 Pooled analysis showed that patients on LCDs achieved greater weight loss compared with control (mean difference –3.46, 95% confidence interval –5.25 to –1.67; n=882; GRADE=moderate) (table 2). On the basis of subgroup credibility testing, we found that in studies at low risk of bias, LCDs achieved 7.41 kg greater weight loss compared with controls (mean difference –7.41, –9.75 to –5.08; 6 studies, n=171; test for subgroup differences P<0.001) (fig 4). Seven studies reported on weight loss at 12 months,36394243445051 with our pooled analysis showing that any benefit over control diets was trivial and non-significant (mean difference 0.29 (–1.02 to 1.60) kg; n=499; GRADE=moderate) (table 2).

Seventeen studies reported on HbA_1c levels at six months.3435363738404142434445464749505256 LCDs achieved greater reductions in HbA_1c than did control diets (mean difference –0.47%, –0.60 to –0.34; n=747; GRADE=high) (table 2). At 12 months, eight studies reported on HbA_1c levels, showing that the effect size had decreased by around half (mean difference –0.23%, –0.46% to 0.00%; n=489; GRADE=moderate) (table 2).

Fourteen studies reported on fasting glucose at six months.3536383940424445464748525356 Pooled analysis showed that LCDs achieved an average 0.73 mmol/L greater reduction in glucose concentrations compared with control diets (mean difference –0.73, –1.19 to –0.27; n=611; GRADE=moderate) (table 2). Six studies reported on fasting glucose at 12 months,394244515253 with little or no difference observed between the comparator diets (mean difference 0.06, –0.37 to 0.48; n=365; GRADE=moderate) (table 2).

Eleven studies reported total adverse events or serious adverse events at six months.3435373839414344454752 Pooled analysis suggested a trivial and non-significant increase in total adverse events among patients on LCDs (risk difference 0.04, –0.01 to 0.08; 9 studies, n=423; GRADE=very low) and similarly little or no effect on serious adverse events (risk difference 0.00, –0.03 to 0.02; 8 studies, n=448; GRADE=low) (table 2). Three studies reported on total adverse events or serious adverse events at 12 months,394344 with pooled estimates showing that LCDs were associated with a small, non-significant decrease in total adverse events (risk difference –0.05, –0.24 to 0.14; 2 studies, n=156; GRADE=very low) and a trivial, non-significant decrease in serious adverse events (risk difference –0.01, –0.06 to 0.04; 3 studies, n=217; GRADE=low) (table 2).

Table 3 shows secondary outcomes. Briefly, pooled analyses showed that LCDs led to greater reductions in diabetes medication and clinically important benefits threefold greater than the MCID estimate for triglycerides and insulin resistance (HOMA-IR) at six and 12 months. LCDs had clinically important harms on quality of life and low density lipoprotein cholesterol at 12 months, with little to no effect observed at six months. LCDs had little or no effect on total and high density lipoprotein cholesterol concentrations or C reactive protein related inflammation at six and 12 months.

Table 3

Secondary outcomes

We did subgroup assessments (level of carbohydrate restriction, behavioral support intensity, comparator diet, iso-caloric comparator, caloric restriction, inclusion of patients who used insulin, and adherence) for each of our five primary outcomes. Most subgroup observations were not deemed credible; however, three credible subgroups were identified on the basis of meeting four of five credibility criteria. Specifically, for these subgroups, statistical analysis suggested that chance could not explain the apparent subgroup effect, the effect was consistent across studies, the subgroup hypothesis was one of a small number of hypotheses developed a priori with direction specified, and strong pre-existing biological support existed (supplementary table D). Studies that included patients using insulin had fewer remissions for both definitions of remission (HbA_1c <6.5%; HbA_1c <6.5% and no diabetes medication) at six months (risk difference 0.14, 0.03 to 0.25; 0.00, –0.07 to 0.07) compared with studies that did not (risk difference 0.51, 0.36 to 0.65; 0.20, 0.03 to 0.38) (test for subgroup difference P<0.001; P=0.03). Diets with very low carbohydrates (<10% of daily calories from carbohydrates) led to smaller weight loss at six months (mean difference –1.05, –2.27 to 0.17) than did less restrictive diets (mean difference –5.22, –8.33 to –2.11) (test for subgroup difference P=0.01). However, on the basis of our third subgroup that was judged to be credible,16 this effect was explained by diet adherence. That is, among VLCDs to which the patients were highly adherent, a larger clinically important weight loss occurred (mean difference –4.47, –8.21 to –0.73) compared with patients less adherent to VLCDs (mean difference –0.55, –1.76 to 0.66) (test for subgroup difference P=0.05).

We did a post hoc sensitivity analysis comparing the certainty of evidence using GRADE versus NutriGRADE (supplementary table E). NutriGRADE analysis resulted in 16/30 (53%) outcomes with the same rating as GRADE; 10 (33%) of outcomes were upgraded compared with GRADE ratings (mainly our secondary outcomes), and 4 (13%) were downgraded.

Discussion

Among 23 studies comparing LCDs with mostly low fat control diets in patients with type 2 diabetes, on the basis of moderate to low certainty evidence, patients on LCDs achieved higher diabetes remission rates at six months (HbA_1c <6.5%: NNT=3; HbA_1c <6.5% and no diabetes medication: NNT=20). On the basis of very low to high certainty evidence, no statistically significant and clinically important detrimental effects on cardiovascular risk factors (for example, lipids, C reactive protein) or adverse events were detected with LCDs. However, we observed a trend for clinically important increases in low density lipoprotein cholesterol at 12 months. Additionally, LCDs increased weight loss, reduced medication use, and improved triglyceride concentrations at six months. In general, most benefits diminished at 12 months, a finding consistent with previous reviews.1557

Sensitivity and subgroup analyses

We did sensitivity analyses based on risk of bias for all outcomes, but only one outcome, weight loss, showed a credible subgroup effect between studies with higher and lower risk of bias. Studies with lower risk of bias showed more dramatic increases in weight loss, findings that were both statistically and clinically significant, supporting our overall findings.

Subgroup analyses, based on credibility testing,1627 suggested that patients not using insulin, compared with those that did, had increased diabetes remission rates at six months. For patients not using insulin, the NNT was 2 for remission defined as HbA_1c below 6.5% and 5 for remission defined as HbA_1c below 6.5 without diabetes medication. Furthermore, on the basis of our subgroup testing, VLCDs underperformed compared with less restrictive LCDs for weight loss at six months. However, this difference was negated when we considered patients highly adherent to VLCDs. Of note, the limited number of studies with 12 month outcome data providing differing levels of support and having highly adherent versus less adherent intervention arms precluded subgroup analyses that explicitly explored the effects of adherence at 12 months. Although improvements noted at six months diminished by 12 months, determining with any certainty whether this is related to intensity of intervention and/or dietary adherence beyond six months is difficult.

Strengths of study

Our systematic review has several important strengths. Firstly, we did a thorough literature search and contacted authors of all studies for any unpublished data on remission of diabetes. Although only three included studies previously published HbA_1c threshold criteria and medication use to determine diabetes remission, our successful contact with authors yielded trial data from five additional studies to determine remission rates,3438394058 increasing the precision and overall certainty of the effect estimates.13155759 Recent systematic reviews conducted by Sainsbury, van Zuuren, and Snorgaard have shown important reductions in mean HbA_1c values with low and very low carbohydrate diets,131559 but no previous review has summarized HbA_1c as a dichotomous outcome informed by the suggested American Diabetes Association remission definitions (for example, <6.5% HbA_1c threshold).1660 We believe that our meta-analytic summary of published and unpublished data from eight randomized controlled trials using HbA_1c thresholds, a first in the literature, will lead to more informed clinical decision making in the management of type 2 diabetes.

Secondly, on the basis of a publicly available protocol,16 we used robust evidence synthesis methods including the use of Cochrane's Risk of Bias instrument 2.0,20 missing participant outcome data sensitivity analyses,24 and subgroup credibility assessments based on a priori stated effect modifiers.31 Missing data for participants is particularly important in nutrition research in general given the often dramatic losses to follow-up in diet based clinical trials (>20% among 10/23 (43%) of trials included in this analysis) and the corresponding risk of bias due to losses to follow-up.61 Subgroup credibility assessment is of particular interest to researchers in this field given that some have advocated for subgroup elucidation when considering LCDs for treating diabetes.6263 Whereas previous reviews have focused on one or two potential modifiers—for example, Korsmo et al, who explored subgroups on length of follow-up and carbohydrate intake,57 and Naude et al, who explored calorically matched controls14—in our protocol driven approach, we explored seven actively debated potential effect modifiers by using published, explicit subgroup credibility criteria.

Thirdly, the use of GRADE for rating the certainty of evidence in systematic reviews of nutrition studies has been questioned,27 with some calling for a methodological approach specific to nutrition studies. However, we believe the logic of scientific inquiry demands consistent standards for casual inference across health claims, preferably using GRADE, a more conservative rating approach than the alternative systems suggested by the nutrition community.64656667 Nevertheless, we did a sensitivity analysis comparing GRADE ratings with NutriGRADE ratings (supplementary table E). NutriGRADE analysis resulted in 16/30 (53%) outcomes with the same rating as GRADE; 10 (33%) of outcomes were judged to be of higher certainty using NutriGRADE, and 4 (13%) were judged to be of lower certainty using NutriGRADE. Overall, the certainty of evidence using NutriGRADE indicates, on average, a higher degree of confidence in the efficacy and safety of LCDs across outcomes, particularly our primary outcomes including diabetes remission and fasting glucose, and higher certainty in the evidence for little to no short term risk of adverse events with LCDs.

Fourthly, our interpretations of estimates for continuous outcomes were based on a priori estimates of the minimal clinically important differences (supplementary table C). To our knowledge, no previous review on this topic has attempted to present effect estimates while considering MCID thresholds, thresholds that will help clinicians and patients to better interpret the magnitude of treatment effect.30 Among 10 continuous outcomes, two showed improvements that met or surpassed the MCID at six months (triglycerides, insulin resistance) with no detrimental effects. At 12 months, two had improvements that surpassed the MCID (triglycerides, insulin resistance) and two had a clinically important worsening (quality of life, low density lipoprotein cholesterol), although neither was statistically significant (P=0.24 and P=0.05).

Limitations of study

Our study is not without limitations. Firstly, the definition of remission of diabetes is the subject of considerable debate, specifically with regards to threshold levels of HbA_1c/fasting glucose, use of diabetes medication, and the length of follow-up time meeting these criteria.60 We attempted to overcome this by using multiple a priori definitions of remission (both with and without the use of diabetes medication) at both of our predetermined endpoints (six months and 12 months).

Secondly, safety concerns have been raised with LCDs.68 Although no significant or clinically important increase in total or serious adverse events was identified, these outcomes were poorly reported among trials and the certainty of evidence for safety ranges from low to very low. By contrast, we have moderate to high certainty that surrogate markers for cardiovascular disease risk, such as blood lipids, do not worsen, whereas triglycerides significantly improved in a clinically meaningful way. One exception was low density lipoprotein cholesterol concentrations at 12 months' follow-up, which seemed to worsen, surpassing the MCID. Thirdly, 18/23 (78%) studies used low fat diets as a comparator, limiting the applicability of our results to other dietary regimens such as a Mediterranean-style diet.

Fourthly, an important concern with LCDs is the potential confounding factor of caloric restriction. Restricting carbohydrates, which tends to reduce hunger,69 would mean that whether any purported benefit was due to carbohydrate restriction or caloric restriction was unclear. For this reason, as part of our a priori planned subgroup analysis, we investigated the effect of calorically matched controls (as assessed by follow-up dietary questionnaires). On the basis of 18 studies providing adequate data, we identified no evidence of credible effect modification based on caloric matching or lack thereof. However, self-reported dietary intake data are prone to measurement error, particularly in dietary trials in which participants are not blinded.7071

Fifthly, we made a pragmatic a priori decision to assess our endpoints at six and 12 months (±3 months). Whereas trials informing our 12 month endpoint were all reported at this time point, those informing our six month endpoint varied between three months and eight months. Of the 14 trials informing our six month pooled estimates, 7/14 (50%) reported data at three to less than six months (3 months: 6 trials; 4 months: 1 trial), and 7/14 (50%) trials reported at six to nine months (6 months: 6 trials; 8 months: 1 trial). On the basis of comments from peer reviewers, we did a post hoc analysis on remission at six (±3) months. Evidence suggested larger treatment effects for LCDs in shorter term trials (3 to <6 months), suggesting that shorter term trials may be an effect modifier. For the definition of remission of HbA_1c below 6.5%, the risk difference was 0.49 (95% confidence interval 0.30 to 0.68) for trials of three to less than six months in length compared with 0.25 (0.08 to 0.42) for trials of between six and nine months. Similarly, for the definition of remission of HbA_1c below 6.5% and no diabetes medication use, the risk difference was 0.20 (0.03 to 0.38) for trials of three to less than six months compared with 0.00 (–0.07 to 0.07) for trials of between six and nine months.

Sixthly, our protocol driven results are limited to short term markers of remission of diabetes, adverse events, and related cardiometabolic outcomes.16 Future long term, well designed, calorie controlled randomized trials are needed to determine the effects of LCD on sustained weight loss and remission of diabetes, as well as cardiovascular mortality and major morbidity.

Seventhly, our review focused on studies defined by macronutrient quantity. Macronutrient quality may also be important, and, although we were unable to consider the characteristics of dietary quality given the lack of reporting in our 23 eligible trials, future trials should better document dietary quality (for example, processed versus unprocessed foods) using optimally validated questionnaires together with emerging objective biomarkers using microbiomics, metabolomics, or other high dimensional platforms.72

Finally, the limited number of trials allowing patients to reduce their medication use impeded our ability to assess remission of diabetes when defined as HbA_1c below 6.5% without diabetes medication. Only 7/23 (30%) of eligible trials permitted reduction of medication and reported usable medication data. Future trials should allow for, and adequately report on, reduction of medication while closely monitoring blood glucose concentrations.58 LCDs seem to promote important reductions in HbA_1c, potentially increasing risk for hypoglycemic episodes, including severe syncope, if the dosage of diabetes medications is not adjusted accordingly. Because blinding is not possible in these studies, these adjustments should be applied using a priori algorithms that help to guide medication management.47 Reductions in medication may blunt the effect on mean HbA_1c levels, biasing results towards the null and masking any effect; however, any improvement can still be captured if reduction of medication is included as an outcome of interest.

Conclusions

Moderate to low certainty evidence suggests that patients adhering to LCDs for six months may experience greater rates of remission of diabetes without adverse consequences compared with other diets commonly recommended for management of type 2 diabetes (for example, low fat diets). These benefits diminished at 12 months, and, although LCDs seem to improve triglycerides in a clinically meaningful way, some evidence shows clinical worsening of quality of life and low density lipoprotein cholesterol. Considering this and a recent systematic review of cohort studies suggesting that long term LCDs are associated with increased mortality,73 clinicians might consider short term LCDs for management of type 2 diabetes, while actively monitoring and adjusting diabetes medication as needed.

What is already known on this topic

• Previous systematic reviews have used broad definitions of low carbohydrate (eg, <45% of calories from carbohydrates) and have not systematically assessed remission of diabetes

• Results from reviews based on a subgroup of 10 randomized trials assessing low carbohydrate diets (LCDs) (<26-45% of daily calories from carbohydrate) have been encouraging

What this study adds

• This systematic review of the effect of LCDs on remission of type 2 diabetes included 23 trials, including unpublished HbA_1c and medication use data from five trials

• Compared with (mostly low fat) control diets, on the basis of moderate certainty evidence at six months, LCDs were associated with a large (32%) increase in remission of diabetes

• According to a priori determined minimal important difference estimates, large and clinically important improvements in weight loss, triglycerides, and insulin resistance were also seen, without adverse events

Acknowledgments

We thank Pamela Dyson for sharing unpublished data and Paria Tajallipour for her assistance with our literature search.

Footnotes

• Contributors: JZG and BCJ conceived the study. JZG, LT, and BCJ designed the study. JZG, JJ, and BCJ developed a priori estimates of the minimal clinically important difference. JB designed and executed the search. JG and AD selected the articles and extracted the data. JZG, AD, and BCJ analyzed the data. JZG and BCJ wrote the first draft of the manuscript. GB, JS, SY, and TJ provided unpublished trial data and reviewed and interpreted the data of the draft manuscript. JZG, BCJ, AD, JB, LT, GB, JS, SY, TJ, and JJ interpreted the data and contributed to the writing of the final version of the manuscript. All authors agreed with the results and conclusions of this article. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. JZG and BCJ are the guarantors.

• Funding: This study was funded in part by Texas A&M University. The university had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

• Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from Texas A&M University; BCJ receives funds from Texas A&M AgriLife Research to support investigator initiated research related to saturated and polyunsaturated fats for a separate research project, as part of his recent recruitment to Texas A&M University (support from Texas A&M AgriLife institutional funds are from interest and investment earnings, not a sponsoring organization, industry, or company); GB is author of the CSIRO Low Carb Diet Book that aims to translate clinical research outcomes of low carbohydrate diet studies for the general public in Australia, but he does not personally receive any financial royalties or funds either directly or indirectly from this publication, and any royalties received by his employment institution (CSIRO) do not contribute to his salary, nor have they been used to execute this work; no other relationships or activities that could appear to have influenced the submitted work.

• Ethical approval: Not needed. All the work was developed using aggregate level data.

• Data sharing: Further data are available on request through the corresponding author at bradley.johnston@tamu.edu.

• The lead and senior authors (manuscript's guarantors) affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

• Dissemination to participants and related patient and public communities: We plan to reach out to diabetes and obesity patient advocacy groups (eg, Obesity Canada) as well as professional medical, nutrition, and agricultural organizations (eg, Practice-based Evidence in Nutrition, Royal Australian College of General Practitioners, USDA) to help to disseminate this work. Additionally, all authors will work with their home institutions to leverage their unique dissemination platforms including social media communication and organizational websites.

• Provenance and peer review: Not commissioned; externally peer reviewed.

View Abstract

Low Carb Diet For Diabetics

Source: https://www.bmj.com/content/372/bmj.m4743

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