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Treating metabolic syndrome, type 2 diabetes, and obesity with therapeutic carbohydrate restriction
2
MODULE 1: Background and definitions
MODULE 2: Physiological and metabolic effects of carbohydrate-restricted diets
MODULE 3: Initiating the intervention
MODULE 4: Administering TCR
MODULE 5: Follow-up care
1.1 Introduction: Outline of course
Therapeutic Carbohydrate Restriction CME
3
MODULE 1: Background and definitions
Therapeutic Carbohydrate Restriction CME
35%+
30 - 34.9%
25 - 29.9%
20 - 24.9%
15 - 19.9%
10 - 14.9%
0 - 9.9%
Obesity rates increase over the last 3 decades
Therapeutic Carbohydrate Restriction CME 41.1.1 Background and general principles
Obesity 2017Obesity 1990
31.9%
22.6%25.1%
37.3%
25.7%
Historical uses of TCR
51.1.2 History
https://archive.org/details/diabeticcookeryr00oppeiala
Therapeutic Carbohydrate Restriction CME
EASD and ADA Guidelines
61.1.2 History Therapeutic Carbohydrate Restriction CME
ADA Guidelines Statement
71.1.2 History
“Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences (Evert et al., 2019).”
Therapeutic Carbohydrate Restriction CME
Time
Blo
od s
ugar
Fasting blood sugar
Carbohydrate
Nutrients and their impact on blood glucose
81.2 Nutrition physiology and adequacyTherapeutic Carbohydrate Restriction CME
Nutrients and their impact on blood glucose
91.2 Nutrition physiology and adequacy
Protein
Time
Blo
od s
ugar
Fasting blood sugar
Carbohydrate
Therapeutic Carbohydrate Restriction CME
Nutrients and their impact on blood glucose
101.2 Nutrition physiology and adequacy
Fat
Protein
Carbohydrate
Time
Blo
od s
ugar
Fasting blood sugar
Therapeutic Carbohydrate Restriction CME
111.2.1 Protein
Recommended protein intake:
RDA
Therapeutic carbohydrate restriction
0.8 g of protein per kg reference body weight
1.2 - 1.7 g of protein per kg reference body weight
Therapeutic Carbohydrate Restriction CME
100 grams of protein
121.2 Nutrition physiology and adequacy
3 eggs 60 g (2 oz) cheese
30 g
150 g (5 oz) salmon
30g
140 g (5 oz) chicken
40 g+ + = 100
Breakfast Lunch Dinner
Therapeutic Carbohydrate Restriction CME
Olive oil
Salmon
Whole fats are a mixture of fatty acids
131.2.2 Fat and saturated fat
Beef
Therapeutic Carbohydrate Restriction CME
141.2.2 Fat and saturated fat
Why is saturated fat allowed on a carbohydrate-restricted diet?
Absolute grams of fat may not increase on TCR.
(Hite et al., 2010)
Higher dietary saturated fat does not always increase serum saturated fat.
(Volek et al., 2009)
Within the context of TCR, it is unclear what effect saturated fats have on health.
(Forouhi, Krauss, Taubes & Willett, 2018)
Therapeutic Carbohydrate Restriction CME
151.2.3 Micronutrients Therapeutic Carbohydrate Restriction CME
TCR includes a variety of whole foods
The liver stores glucose as glycogen
glycogenolysis
glucose
Getting energy without dietary carbohydrates: glycogenolysis
161.2.4 Carbohydrate Therapeutic Carbohydrate Restriction CME
Getting energy without dietary carbohydrates: gluconeogenesis
171.2.4 Carbohydrate Therapeutic Carbohydrate Restriction CME
Active skeletal muscle
gluconeogenesis
glucose
Burn fatfor fuel
ketones
body fat
dietary fat
Getting energy without dietary carbohydrates: ketones from fatty acids
181.2.4 Carbohydrate Therapeutic Carbohydrate Restriction CME
Glycemic index and glycemic load
191.2.5 Glycemic index and glycemic loadTherapeutic Carbohydrate Restriction CME
Above-ground vegetables: high fiber, low starch
201.2.6 Fiber Therapeutic Carbohydrate Restriction CME
Net carbs per 100 grams of vegetable
211.2.7 Total vs. net carbohydrateTherapeutic Carbohydrate Restriction CME
221.3.1 Defining TCR Therapeutic Carbohydrate Restriction CME
Moderate LiberalUnder 20 grams of net carbs per day
This meal has 6 grams of net carbs.
Under 50 grams of net carbs per day
This meal has 16 grams of net carbs.
Under 100 grams of net carbs per day
This meal has 37 grams of net carbs.
Ketogenic
231.3.2 Calories
“Calories still count, but we don’t have to count them.”
Therapeutic Carbohydrate Restriction CME
Personal 53 years old, female
Low-fat, moderate-carbohydrate diet, focusing on low-glycemic-index foods
Patient believes fat has definitely been proven to cause heart disease and cancer.
• GLP-1 agonist (exenatide)• Insulin• Metformin• SGLT-2 inhibitor (empagliflozin)
Health history
Clinical
Diet history
Medications
Tests
Social/other
Type 2 diabetes
Ultrasound
HbA1c Creatinine ALT 86 U/L9.3%
(12.2 mmol/L)1.6 mg/dL
(141.5 µmol/L)
Evidence of fatty liver
5’2” (157 cm)
186 lbs (84 kg)
146/90 mmHg
Height
Lab Value Lab Value Lab Value
Weight
Blood pressure
241.4 Module 1 case studies
Module 1, Patient 1
Therapeutic Carbohydrate Restriction CME
251.4 Module 1 case studies
How do you respond to her concern that eating fat
definitively causes heart disease and cancer?
Q1:
Therapeutic Carbohydrate Restriction CME
261.4 Module 1 case studies
Module 1, Patient 2
Personal
Health history
Diet history
34 years old, female
Metabolic Syndrome
Vegetarian
Therapeutic Carbohydrate Restriction CME
Can she successfully start TCR as a vegetarian and
still achieve adequate nutrition goals?
Q1:
271.4 Module 1 case studiesTherapeutic Carbohydrate Restriction CME
What is her target daily protein range and how do you
explain the difference between plant and animal proteins?
Q2:
281.4 Module 1 case studiesTherapeutic Carbohydrate Restriction CME
MODULE 2: Physiological and metabolic effects of carbohydrate-restricted diets
29Therapeutic Carbohydrate Restriction CME
Shift from “glucocentric” to “adipocentric”
302.1 Glucose, insulin, and ketones Therapeutic Carbohydrate Restriction CME
“Glucocentric” Fuel = glucose
“Adipocentric”Fuel = fatty acids & ketones
Foods that digest down into glucose
312.1.1 GlucoseTherapeutic Carbohydrate Restriction CME
Fat
Insulin
Insulin prevents fat from leaving cell
322.1.2 InsulinTherapeutic Carbohydrate Restriction CME
ketones
body fat
dietary fat
Beta-hydroxybutyrate (BHB)
Acetoacetate
Acetone
332.1.3 KetonesTherapeutic Carbohydrate Restriction CME
Blood ketones in mmol/L
Op
tim
al f
uel f
low
for
bra
in a
nd m
uscl
es
0 0.5 1.0 1.5 2.0 2.5 3.0
Nutritionalketosis begins
Optimalketonezone
342.2.1 Nutritional ketosisTherapeutic Carbohydrate Restriction CME
352.2.1 Nutritional ketosisTherapeutic Carbohydrate Restriction CME
Blood ketones in mmol/L
Op
tim
al f
uel f
low
for
bra
in a
nd m
uscl
es
0 0.5 1.0 1.5 2.0 2.5 3.0 5.0 10+
Nutritionalketosis begins
Optimalketonezone
Post-exerciseketosis
Starvationketosis
Ketoacidosis
Adapted from: Phinney & Volek
May occur with SGLT-2 inhibitors, combined with TCR.
Patient has normal blood glucose levels.
Patient has metabolic acidosis.
Patient is typically symptomatic: fatigue, confusion, dehydration, and more.
Requires immediate treatment.
Euglycemic ketoacidosis
362.2.2 KetoacidosisTherapeutic Carbohydrate Restriction CME
≥ Systolic 130 mmHg
≥ Diastolic 85 mmHg
Receiving treatment for hypertensionBlood pressure
≥ 150 mg/dL (1.7 mmol/L)
Receiving treatment for elevated triglyceridesTriglycerides
< 40 mg/dL in men (1.0 mmol/L)
< 50 mg/dL in women (1.3 mmol/L)
Receiving treatment for low HDL-cholesterolHDL-cholesterol
≥ 100 mg/dL (5.6 mmol/L)
Receiving treatment for type 2 diabetesFasting
glucose level
> 40 inches for men (102 cm)
> 35 inches for women (89 cm)
Waist circumference
372.3.1 Definition of metabolic syndromeTherapeutic Carbohydrate Restriction CME
Metabolic syndrome is defined by the presence of 3 of the 5 criteria:
Central nervous system: Increased sympathetic nervous system activity
Blood vessels: Proliferation of smooth muscle Diminished release of nitric oxide from the endotheliumIncreased secretion of endothelin-1, a potent vasoconstrictor
Kidneys: Increased sodium retention
382.3.2 HypertensionTherapeutic Carbohydrate Restriction CME
How does insulin increase blood pressure?
392.3.2 HypertensionTherapeutic Carbohydrate Restriction CME
402.3.3 DyslipidemiaTherapeutic Carbohydrate Restriction CME
Summary of different measures of cholesterol
Name
LDL-C
LDL-P
ApoB
Description
Low-density lipoprotein cholesterol Total concentration of cholesterol contained in LDL particles
Low-density lipoprotein particles Total number of LDL particles in circulation
Apolipoprotein B-100 Serves as a proxy measure for all potentially atherogenic lipid particles, including LDL, IDL, and VLDL
Unit
mg/dL
nmol/L
mg/dL
412.3.3 DyslipidemiaTherapeutic Carbohydrate Restriction CME
Increased triglycerides
Decreased HDL
Increased atherogenic, small LDL particles
Hyperinsulinemia is associated with changes in serum lipids:
422.3.3 DyslipidemiaTherapeutic Carbohydrate Restriction CME
Fasting blood sugar ≥ 100 mg/dL (5.6 mmol/L)
HbA1c > 5.7% (6.3 mmol/L)
Impaired glucose tolerance or prediabetes
432.3.4 Hyperglycemia and type 2 diabetesTherapeutic Carbohydrate Restriction CME
The insidious cycleWeight gain and insulin
resistance actually form a closed circle of cause and effect,
leading to diabetes and all its complications.
Weight gain in a person with family history and predisposing genes to diabetes mellitus type 2
Increased need for glucose
β-cells in the pancreas secrete more insulin
Insulin resistancedevelpos in the liver, muscles and fat
Even more insulin is secreted
β-cells become exhausted
Diabetes mellitus type 2
Hypertension
442.3.4 Hyperglycemia and type 2 diabetesTherapeutic Carbohydrate Restriction CME
Insulin resistance
452.3.4 Hyperglycemia and type 2 diabetesTherapeutic Carbohydrate Restriction CME
Adapted from: King & Blom, 2017
Insulin resistance
Fasting blood glucose
Time:YearsDecreasing post-mealglucose control
Loss of !-cell mass
Pre-diabetes Diabetes
Insulin production
High insulin keeps glucose low — until insulin production fails
Food Item
Basmati rice 69 150 10.1
9.1
7.5
6.6
4.0
1.3
5.7
2.3
3.0
0.2
0
150
150
180
80
80
120
120
30
80
60
96
64
39
60
51
62
39
74
15
0
French friesbaked
Spaghetti whiteboiled
Sweet cornboiled
Frozen peas,boiled
Banana
Apple
Wholemealsmall slice
Broccoli
Eggs
Potato, white,boiled
Glycaemicindex
Servesize g
How does each food affect blood glucose compared with one 4g teaspoon of table sugar?
462.3.4 Hyperglycemia and type 2 diabetesTherapeutic Carbohydrate Restriction CME
All carbohydrate foods are not the same
Adapted from: Unwin, Haslam & Livesey, 2016
Other foods in the very low glycemic range would be chicken, oily fish, almonds, mushrooms, cheese
472.3.4 Hyperglycemia and type 2 diabetesTherapeutic Carbohydrate Restriction CME
482.3.4 Hyperglycemia and type 2 diabetesTherapeutic Carbohydrate Restriction CME
Open-label, 2-year, non-randomized study of TCR (n= 262) showed, compared to control:
Elimination of all diabetes medications (except metformin) for most participants
Reduced: HbA1c, fasting glucose, fasting insulin, body weight, blood pressure, triglycerides
See: Athinarayanan et al., 2019
492.3.5 Obesity and abdominal obesityTherapeutic Carbohydrate Restriction CME
Why people might be less hungry during TCR:
Ketosis (Gibson et al., 2015; Paoli et al., 2015)
Protein & fiber-filled foods (Blundell & Stubbs, 1999; Veldhorst et al., 2008) Satiety
without stimulating brain food-reward centers (Alonso-Alonso et al., 2015)
Subcutaneous fat
502.3.5 Obesity and abdominal obesityTherapeutic Carbohydrate Restriction CME
Visceral fat linked to metabolic impairment
Visceral fat
512.4 Module 2 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 3
Personal
Health history
Social/other
Female
Obesity (BMI 43)
BHB level, post-exercise, home test: 4.5 mmol/L
522.4 Module 2 case studiesTherapeutic Carbohydrate Restriction CME
Does a BHB level this high suggest she may be
at risk for ketoacidosis? Q1:
532.4 Module 2 case studiesTherapeutic Carbohydrate Restriction CME
Blood ketones in mmol/L
Op
tim
al f
uel f
low
for
bra
in a
nd m
uscl
es
0 0.5 1.0 1.5 2.0 2.5 3.0 5.0 10+
Nutritionalketosis begins
Optimalketonezone
Post-exerciseketosis
Starvationketosis
Ketoacidosis
Personal 62 years old, male
• Aspirin, 81 mg daily• Lisinopril, 10 mg daily•Metformin, 1000 mg twice daily
Health history
Clinical
Medications
Type 2 diabetes; coronary artery disease; stent placed 18 months prior
HbA1c LDL
HDL
TG 265 mg/dL(3 mmol/L)
7.2%(8.9 mmol/L)
165 mg/dL(4.3 mmol/L)
31. mg/dL(0.8 mmol/L)
5’10” (178 cm)
234 lbs (106 kg)
126/72 mmHg
Height
Lab Value Lab Value Lab Value
Weight
Blood pressure
542.4 Module 2 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 4
552.4 Module 2 case studiesTherapeutic Carbohydrate Restriction CME
Given his history of coronary disease and elevated
LDL is he a good candidate for TCR?
Why or why not?
Q1:
562.4 Module 2 case studiesTherapeutic Carbohydrate Restriction CME
How would you address his elevated LDL? Q2:
572.4 Module 2 case studiesTherapeutic Carbohydrate Restriction CME
Would you check an advanced or nuclear magnetic
resonance (NMR) lipid profile?
How would you expect his lipid panel to change
with statin therapy and TCR initiation?
Q3:
MODULE 3: Initiating the intervention
58Therapeutic Carbohydrate Restriction CME
593.1.1 Exclusion criteriaTherapeutic Carbohydrate Restriction CME
Advanced renal insufficiency not on hemodialysis
Therapeutic carbohydrate restriction is not appropriate for patients with:
603.1.1 Exclusion criteriaTherapeutic Carbohydrate Restriction CME
Advanced renal insufficiency not on hemodialysis
Pyruvate carboxylase deficiency
Carnitine palmitoyltransferase (CPT) deficiency
Short-chain, medium-chain or long-chain acyl dehydrogenase deficiency (SCAD,MCAD or LCAD)
Therapeutic carbohydrate restriction is not appropriate for patients with:
613.1.1 Exclusion criteriaTherapeutic Carbohydrate Restriction CME
Advanced renal insufficiency not on hemodialysis
Pyruvate carboxylase deficiency
Hyperchylomicronemia
Carnitine palmitoyltransferase (CPT) deficiency
Short-chain, medium-chain or long-chain acyl dehydrogenase deficiency (SCAD,MCAD or LCAD)
Therapeutic carbohydrate restriction is not appropriate for patients with:
Advanced renal insufficiency not on hemodialysis
Pyruvate carboxylase deficiency
Hyperchylomicronemia
Acute, decompensated medical condition
Carnitine palmitoyltransferase (CPT) deficiency
Short-chain, medium-chain or long-chain acyl dehydrogenase deficiency (SCAD,MCAD or LCAD)
Therapeutic carbohydrate restriction is not appropriate for patients with:
623.1.1 Exclusion criteriaTherapeutic Carbohydrate Restriction CME
633.1.2 Need for cautionTherapeutic Carbohydrate Restriction CME
Type 2 diabetes
Hypertension
Type 1 diabetes
Gallbladder removal
Decreased kidney function
Kidney stones
Gout
Pregnancy & breastfeeding
Conditions that require caution:
643.2 Baseline assessmentsTherapeutic Carbohydrate Restriction CME
Height
Weight
Lean body mass / body fat %
Blood pressure
Baseline measurements
653.2.1 Recommended lab testsTherapeutic Carbohydrate Restriction CME
Fasting insulin*
µIU/mL or mIU/L pmol/L Reference
High Johnson, Duick, Chui & Aldasouqi, 2010
McAuley et al., 2001
Johnson, Duick, Chui & Aldasouqi, 2010
Moderate
Low
≥ 25 ≥ 174
> 83 >12
≤ 8
Risk for insulin resistance
Homeostatic model assessment for insulin resistance (HOMA-IR)**
Score Risk for insulin resistance Reference
< 1.6 Low Shashaj & Luciano, 2015
HOMA-IR score = fasting insulin (mIU/L) x fasting glucose (mg/dL) / 405 (Matthews et al., 1985)
* These definitions have not been standardized. These are “working” ranges until more studies are done to standardize values for predicting insulin resistance. Following the trend in an individual patient over time is likely more helpful than an absolute value when monitoring patients on therapeutic carbohydrate restriction.
** A calculator for HOMA-IR can be found at: mdcalc.com/homa-ir-homeostatic-model-assessment-insulin-resistance
663.2.1 Recommended lab testsTherapeutic Carbohydrate Restriction CME
Baseline fasting labs
CMP: liver, kidney, electrolytes, glucose CBC
HbA1c
Lipids (NMR or advanced analysis if possible)
Insulin (with glucose, can calculate HOMA-IR)
For select individuals: Uric acid, TSH
Improved blood pressure control
Improved overall lipid profile
Improved glucose control
Diabetes & blood pressure medication reduction
Weight loss, especially reduced waist circumference
Potential benefits of therapeutic carbohydrate restriction
673.3 Pre-diet evaluation and counseling Therapeutic Carbohydrate Restriction CME
683.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
Case study: Patient 5
Personal 54 years old, female
Low-fat, high-carbohydrate diet
15 minutes of walking per day
• Lisinopril, 10 mg daily
• Metformin, 500 mg twice daily
Health history
Clinical
Diet history
Medications
Tests
Social/other
Metabolic syndrome; gallstones; cholecystectomy 4 years prior
Ultrasound
HbA1c LDL TG 210 mg/dL(2.37 mmol/L)
6.3%(7.5 mmol/L)
92 mg/dL(2.4 mmol/L)
FBG HDL ALT 78 U/L118 mg/dL(6.6 mmol/L)
41 mg/dL(1.07 mmol/L)
Evidence of fatty liver
5’2” (155 cm)
172 lbs (78 kg)
38 inches (96.5 cm)
142/88 mmHg
Height
Lab Value Lab Value Lab Value
Weight
Waist circumference
Blood pressure
693.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
Case study: Patient 5 (cont.)
Current diet
Oatmeal with raisins, brown sugar, and fruit7:00 am
9:30 am
12:00 pm
3:00 pm
7:00 pm
8:30 pm
Protein bar
Turkey sandwich with chips and diet soda
Apple, orange, or grapes
Chicken with rice, potatoes, or broccoli; pasta with marinara sauce; occasionally pizza
Usually ice cream, popcorn, or fruit salad
Walks 15 minutes on lunch break, with no other regular exercise.
703.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
Is she a good candidate for TCR? Why or why not?Q1:
713.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
What are your initial dietary recommendations for her?Q2:
723.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
Are there special considerations for her initiation?Q3:
733.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
What baseline assessments would you check
and follow?
Q4:
743.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
Case study: Patient 6
Personal 14 years old, male
Insulin
Health history
Medications
DepressionSocial/other
Type 1 diabetes; frequent hypoglycemia; 3 hospital admissions for DKA
HbA1c FBG10.2%(13.6 mmol/L)
210 mg/dL(11.6 mmol/L)
Lab Value Lab Value
753.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME
Is he a good candidate for TCR? Why or why not? Q1:
MODULE 4: Administering therapeutic carbohydrate restriction
76Therapeutic Carbohydrate Restriction CME
774.1 Supporting behavior changeTherapeutic Carbohydrate Restriction CME
Discuss current diet, diet history, and health goals
Address concerns about carbohydrate restriction
Create a personalized dietary plan
Provide ongoing support
Assess patient’s knowledge about carbohydrate restriction
Support your patient’s dietary changes
784.1 Supporting behavior changeTherapeutic Carbohydrate Restriction CME
Sample menu
Recipes
Meal-planning tips
Replacement options for favorite foods
Shopping list
Patient education resources for therapeutic carbohydrate restriction
794.2 Patient educationTherapeutic Carbohydrate Restriction CME
Therapeutic carbohydrate restriction: Easy as 1-2-3!
Limit carbohydrates.
Aim for adequate protein.
Adjust fat as needed for fullness and flavor.
1
2
3
804.2 Patient educationTherapeutic Carbohydrate Restriction CME
Foods to choose for TCR
814.2 Patient educationTherapeutic Carbohydrate Restriction CME
Foods to avoid on any diet
824.2.1 CarbohydrateTherapeutic Carbohydrate Restriction CME
Limit carbohydrate foods
834.2.1 CarbohydrateTherapeutic Carbohydrate Restriction CME
Above ground
Below ground
844.2.1 CarbohydrateTherapeutic Carbohydrate Restriction CME
High-fiber, low-glycemic berries
854.2.2 ProteinTherapeutic Carbohydrate Restriction CME
Aim for 75 -100 g of protein (or more) per day
3 eggs 60 g (2 oz) cheese
30 g150 g (5 oz) salmon
30g 140 g (5 oz) chicken
40 g
Breakfast Lunch Dinner
What does 25 grams of protein look like?
Quinoa
Amount Calories Protein
Peanut butter
Black beans
Edamame
Beef
25 g3 cups (700 ml)
6.25 tablespoons (92 ml)
1 ⅔ cups (378 ml)
1 ⅓ cup (307 ml)
3 ounces (85 grams)
25 g
25 g
25 g
25 g210
251
385
587
666
864.2.2 ProteinTherapeutic Carbohydrate Restriction CME
Biological value of protein sources
874.2.3 FatTherapeutic Carbohydrate Restriction CME
Adjust the amount of fat as needed
Butter 0
Coconut oil 0 Heavy cream 3
Cold cuts 2
Olive oil 0
Olives 3
Eggs 1 Avocado 2
Cheese 2
884.2.4 BeveragesTherapeutic Carbohydrate Restriction CME
Choose alcohol wisely
“Getting started” tips for patients
Two-steps to a TCR kitchen:
Toss or give away foods not on TCR list.
Use list to restockthe kitchen.
Keep cooking simple:
Find substitutes for favorite foods.
Make “deliberate” leftovers.
Plan no-cook meals.
Repeat quick & easy favorite meals.
Eat when you’re hungry; stop when you’re full.
1
2
894.2.6 “Getting started” tips for patientsTherapeutic Carbohydrate Restriction CME
904.3.1 Diabetes medicationsTherapeutic Carbohydrate Restriction CME
Initial adjustments for diabetes medications
Insulin
If post-prandial glucose is <200 mg/dL (11 mmol/L), stop short-acting insulin.
Reduce long-acting insulin by 33-50%.
Stop mixed insulin; transition to long-acting insulin only.
A history of diabetic ketoacidosis (DKA)
A history of hospitalizations for severe hyperglycemia
Think “possible latent autoimmune diabetes of adults (LADA)” if a patient has:
914.3.1 Diabetes medicationsTherapeutic Carbohydrate Restriction CME
924.3.1 Diabetes medicationsTherapeutic Carbohydrate Restriction CME
Initial adjustments for diabetes medications
InsulinIf post-prandial glucose is <200 mg/dL (11 mmol/L), stop short-acting insulin.
Reduce long-acting insulin by 33-50%.
Sulfonylureas Stop sulfonylureas, unless fasting glucose is > 200 mg/dL (11 mmol/L).
Stop mixed insulin; transition to long-acting insulin only.
Metformin
DPP-4 inhibitors and GLP-1 agonists
May safely be continued.
May be continued until glucose levels are well controlled.
SGLT-2 inhibitors
Stop all SGLT-2 inhibitors before TCR is initiated.
SGLT-2 inhibitors + TCR = increased risk of DKA.
Educate patients about symptoms of low BP
Have patients monitor BP at home & communicate results to healthcare team
If BP is consistently < 110/70, consider stopping or reducing meds
If patient develops symptomatic hypotension, stop or reduce meds to relieve symptoms
Initial adjustments for anti-hypertensive medication
934.3.2 Anti-hypertensive medicationTherapeutic Carbohydrate Restriction CME
Electrolyte imbalance
Side effects related to diuresis and natriuresis and how to treat
4-7 grams of sodium/day (2-3 teaspoons or 10-15 mL of salt)
Constipation magnesium oxide 400 mg per day or supplemental fiber
Muscle cramps
400 mg/day magnesium citrate or magnesium oxide
If GI side effects, use magnesium glycinate or transdermal
944.4 Side effects, adverse outcomes, and treatmentTherapeutic Carbohydrate Restriction CME
954.4 Side effects, adverse outcomes, and treatmentTherapeutic Carbohydrate Restriction CME
400 mg/day magnesium citrate or magnesium oxideIf GI side effects, use magnesium glycinate or transdermal
4 -7 grams of sodium (2-3 teaspoons or 10-15 mL of salt)
Muscle cramps
Stop TCR.
Continue TCR with reduced saturated fat and increased monounsaturated fat intake.
Start a statin or other lipid-lowering drug.
Make no changes; follow coronary calcium scores and carotid intima-media thickness test (CIMT) for signs of progressive athersclerotic disease.
Continue TCR with a modestly higher carbohydrate intake.
Potential responses to LDL increase
964.4.4 LDL increaseTherapeutic Carbohydrate Restriction CME
974.5 Other lifestyle considerationsTherapeutic Carbohydrate Restriction CME
Continue ongoing program, with 25% reduction of duration and intensity
Do not start new program until TCR is established
Exercise should not increase frequency or amount of eating
Reinforce that activity is its own reward!
Exercise and initiation of TCR
Personal 47 years old, male
• Atorvastatin, 20 mg daily• Canagliflozin, 300 mg daily • Insulin glargine, long-acting, 30 units daily• Insulin aspart, dosed before meal • Metformin, 1000 mg twice daily
Health history
Clinical
Medications
Type 2 diabetes; orthopedic surgeries
HbA1c LDL TG 210 mg/dL(2.37 mmol/L)
8.2 %(10.5 mmol/L)
132 mg/dL(3.4 mmol/L)
FBG HDL
ALT 88 U/L
Creatinine 1.4 mg/dL
(123.8 µmol/L)178 mg/dL
(9.9 mmol/L)32 mg/dL
(0.84 mmol/L)
5’10” (178 cm)
288 lbs (130 kg)
43 inches (109 cm)
144/88 mmHg
Height
Lab Value Lab Value Lab Value
Weight
Waist circumference
Blood pressure
984.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 7
994.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Is he a good candidate for TCR?
Why or why not?
Q1:
1004.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Are there any special considerations when
starting him on TCR, especially regarding his
kidney function and medications?
Q2:
1014.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
After the first week of TCR with a goal net
carbohydrate intake of less than 20 grams per day, he
complains of being lightheaded, fatigued, and having
muscle cramps. What are your main considerations,
what tests, if any, would you order, and what are your
main interventions?
Q3:
1024.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Increase hydration
Drink pickle juice or bone broth
Add magnesium 200 - 400 mg daily
Increase sodium: Add salt to eggs and veggies
“Keto flu” intervention
1034.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
When would you suggest he get
his next lab draw?
Q4:
Personal 62 years old, male
• Atorvastatin, 40 mg daily• Glipizide xl, 2.5 mg daily • Liraglutide, 1.2 mg daily• Lisinopril, 10 mg daily• Metformin, 100 mg twice daily
Health history
Clinical
Medications
Type 2 diabetes; diabetic nephropathy; calcium oxalate kidney stones
HbA1c LDL Potassium 4.1 mEq/L8.2% (10.5 mmol/L)
110 mg/dL(2.9 mmol/L)
Creatine HDL1.8 mg/dL
(159.2 µmol/L)31 mg/dL
(0.81 mmol/L)
Uric acid
GFR
TG
Sodium 138 mEq/L
45 mL/min/1.73m²
Calcium9.2 mg/dL
(11.1 mmol/L)5.6 mg/dL
(0.33 mmol/L)227 mg/dL
(2.56 mmol/L)
124/76 mmHg
Lab Value Lab Value Lab Value
Blood pressure
1044.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 8
1054.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Is he a good candidate for TCR?
Why or why not?
Q1:
1064.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Are there any special considerations for
starting him on TCR?
Q2:
Personal 37 years old, female
Working on improving athletic performance
Started TCR 3 months ago; lost 15 lbs (6.8 kg)
Health history
Clinical
Diet history
Social/other
none
5’4” (162 cm)
120/70 mmHg
125 lbs (57 kg)140 lbs (63 kg)
5.9% (6.8 mmol/L)
126 mg/dL (3.3 mmol/L)
42 mg/dL (1.1 mmol/L)
127 mg/dL (1.4 mmol/L)
5.3% (5.9 mmol/L)
186 mg/dL (4.9 mmol/L)
63 mg/dL (1.66 mmol/L)
52 mg/L (0.58 mmol/L)
Height
Lab
Weight
HbA1c
LDL
HDL
TG
Baseline Current
Blood pressure
1074.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 9
1084.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Given her LDL elevation, can she continue
with TCR? Why or why not?
Q1:
Personal 47 years old, female
• Atorvastatin 40 mg daily
• Empagliflozin 10 mg daily
• Metformin, 1000 twice daily
• Blood sugar average, fasting, home test: 110 mg/dL (6.1 mmol/L)
• Blood sugar average, postprandial, home test: 150 mg/dL (8.3 mmol/L)
• BHB level, home test: 11 mmol/L
Health history
Diet history
Medications
Social/other
Type 2 diabetes
Started TCR six weeks ago
1094.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 10
1104.6 Module 4 case studiesTherapeutic Carbohydrate Restriction CME
How do you respond to this information?Q1:
MODULE 5: Follow-up care
111Therapeutic Carbohydrate Restriction CME
Weight | weekly or monthly, not daily
Body fat percentage, lean body mass, waist circumference
Blood pressure | Self-check daily & communicate changes to provider
Blood glucose | Self-check daily & communicate changes to provider
Follow-up measurements
1125.1.1 Metrics to followTherapeutic Carbohydrate Restriction CME
1135.1.1 Metrics to followTherapeutic Carbohydrate Restriction CME
Follow-up labsFasting glucose
Ketones
HbA1c
Fasting lipids
Transaminases
Fasting insulin/HOMA-IR
Self-check daily if on diabetes meds; weekly otherwise
Self-check daily if on diabetes meds; weekly otherwise
Recheck at 12 weeks, then every 3-12 months
Recheck at 12 weeks, then every 3-12 months
Recheck at 12 weeks, then annually
Recheck at 12 weeks, then every 3-12 months
TSH Check only if symptoms of hypothyroidism are present
Elevated fasting glucose (100 - 125 mg/dL or 5.6 - 6.9 mmol/L)
Normal HbA1c
Normal preprandial and postprandial glucose levels
“Dawn effect”
1145.1.1 Metrics to followTherapeutic Carbohydrate Restriction CME
1155.1.1 Metrics to followTherapeutic Carbohydrate Restriction CME
100 mg/dL (5.6 mmol/L) or lowerNormal
Prediabetes
Diabetes
100 to 125 mg/dL (5.6 to 6.9 mmol/L)
126 mg/dL (7.0 mmol/L) or higher
140 mg/dL (7.8 mmol/L) or lower
141 to 199 mg/dL (7.8 to 11.0 mmol/L)
200 mg/dL (11.1 mmol/L) or higher
Fasting blood sugar 2-3 hours after eating
For perspective, review weight loss from the start.
Identify other health metrics that have improved.
Look for “non-scale victories.”
Identify time frame of “stall.”
When weight loss seems to stall:
1165.1.3 Troubleshooting weight lossTherapeutic Carbohydrate Restriction CME
1175.1.3 Troubleshooting weight lossTherapeutic Carbohydrate Restriction CME
Snacking
Troubleshooting weight loss
1
Prioritize protein!
Average of 1.2 - 1.7 g/kg of “reference body weight”
Usually equates to about 70 - 120 grams of protein per day
Patients should try to evenly distribute protein among meals
For example:
Three meals/day = 25 - 35 grams of protein/meal
Two meals/day = 45 - 50 grams of protein/meal
1185.1.3 Troubleshooting weight lossTherapeutic Carbohydrate Restriction CME
1195.1.3 Troubleshooting weight lossTherapeutic Carbohydrate Restriction CME
Snacking
Troubleshooting weight loss
1
Protein2
Carb and calorie “creep”Focus on whole foods; avoid “keto” treats; eliminate “MCT coffee”
3
1205.1.3 Troubleshooting weight lossTherapeutic Carbohydrate Restriction CME
Snacking
Troubleshooting weight loss
1
Protein2
Issues not related to diet4
Carb and calorie “creep”Focus on whole foods; avoid “keto” treats; eliminate “MCT coffee”
Activity, sleep, stress, medications, other medical issues
3
Snacking
Troubleshooting weight loss
1
Protein
Unrealistic goals
2
Issues not related to diet4
5
Carb and calorie “creep”Focus on whole foods; avoid “keto” treats; eliminate “MCT coffee”
Activity, sleep, stress, medications, other medical issues
3
1215.1.3 Troubleshooting weight lossTherapeutic Carbohydrate Restriction CME
1225.2.1 Long-term maintenanceTherapeutic Carbohydrate Restriction CME
Use individualized approach
What happens to targeted biomarkers?
What is the patient’s relationship to carbohydrate foods?
What is the patient’s physiological carbohydrate tolerance?
What, if any, dietary restrictions are needed to maintain health?
For long-term maintenance
1235.2.2 ReimbursementTherapeutic Carbohydrate Restriction CME
Medicare reimbursement for patients with BMI > 30
One face-to-face visit every week for the first month
One visit every other week for months 2 through 6
One visit per month in months 7 through 12
Intensive behavioral therapy for obesity:
Reimbursement codes:
15 minutes of one-on-one counselingCPT G0447
G0473 Groups of 2-10 people.
1245.2.3 Reversal and remissionTherapeutic Carbohydrate Restriction CME
1255.2.3 Reversal and remissionTherapeutic Carbohydrate Restriction CME
Type 2 diabetes outcome Criteria and cut-offs used
HbA1c below 6.5% (7.8 mmol/L; 47.4 mmol/mol) without any diabetes medication, except metformin
Two HbA1c measurements 5.7 - 6.5% (6.5 - 7.8 mmol/L; 38.8 - 47.4 mmol/mol) Over the course of 1 year No medications
Two HbA1c measurements below 5.7% (6.5 mmol/L; 38.8 mmol/mol) Over the course of 1 year No medications
Reversal
Partial remission
Complete remission
1265.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Personal 47 years old, male
• Atorvastatin, 20 mg daily• Canagliflozin, 300 mg daily • Insulin glargine, long-acting, 30 units daily• Insulin aspart, dosed before meal • Metformin, 1000 mg twice daily
Health history
Clinical
Medications
Type 2 diabetes; orthopedic surgeries
HbA1c LDL TG 210 mg/dL(2.37 mmol/L)
8.2 %(10.5 mmol/L)
132 mg/dL(3.4 mmol/L)
FBG HDL
ALT 88 U/L
Creatinine 1.4 mg/dL
(123.8 µmol/L)178 mg/dL
(9.9 mmol/L)32 mg/dL
(0.84 mmol/L)
5’10” (178 cm)
288 lbs (130 kg)
43 inches (109 cm)
144/88 mmHg
Height
Lab Value Lab Value Lab Value
Weight
Waist circumference
Blood pressure
Case study: Patient 7
• Atorvastatin, 20 mg daily• Canagliflozin, 300 mg daily • Insulin glargine, long-acting, 30 units daily• Insulin aspart, dosed before meal • Metformin, 1000 mg twice daily
• Atorvastatin, 20 mg daily• Metformin, 500 mg twice daily
Clinical
Medications
288 lbs (130 kg)
8.2 % (10.5 mmol/L)
132 mg/dL (3.4 mmol/L)
32 mg/dL (0.84 mmol/L)
210 mg/dL (2.37 mmol/L)
88 U/L
5.4, 5.5% (6.0, 6.2 mmol/L)
97 mg/dL (2.55 mmol/L)
48 mg/dL (1.26 mmol/L)
87 mg/dL (0.98 mmol/L
28 U/L
43 inches (109 cm)
144/88 mmHg
215 lbs (97.7 kg)
36 inches (91 cm)
118/76 mmHg
Baseline
Baseline
Current
Current
Lab
Weight
Waist circumference
Blood pressure
HbA1c
LDL
HDL
TG
ALT
1275.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 7 follow-up
1285.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Does he meet criteria for reversal or remission of his diabetes?
Q1:
1295.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Type 2 diabetes outcome Criteria and cut-offs used
HbA1c below 6.5% (7.8 mmol/L; 47.4 mmol/mol) without any diabetes medication, except metformin
Two HbA1c measurements 5.7 - 6.5% (6.5 - 7.8 mmol/L; 38.8 - 47.4 mmol/mol) Over the course of 1 year No medications
Two HbA1c measurements below 5.7% (6.5 mmol/L; 38.8 mmol/mol) Over the course of 1 year No medications
Reversal
Partial remission
Complete remission
1305.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Would you stop his metformin at this time?Q2:
1315.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 5
Personal 54 years old, female
Low-fat, high-carbohydrate diet
15 minutes of walking per day
• Lisinopril, 10 mg daily
• Metformin, 500 mg twice daily
Health history
Clinical
Diet history
Medications
Tests
Social/other
Metabolic syndrome; gallstones; cholecystectomy 4 years prior
Ultrasound
HbA1c LDL TG 210 mg/dL(2.37 mmol/L)
6.3%(7.5 mmol/L)
92 mg/dL(2.4 mmol/L)
FBG HDL ALT 78 U/L118 mg/dL(6.6 mmol/L)
41 mg/dL(1.07 mmol/L)
Evidence of fatty liver
5’2” (155 cm)
172 lbs (78 kg)
38 inches (96.5 cm)
142/88 mmHg
Height
Lab Value Lab Value Lab Value
Weight
Waist circumference
Blood pressure
1325.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 5 follow-up
Personal 54 years old, female
TCR for 6 months; initially lost 24 lbs (11 kg); has started to regain weight
• Coffee with butter and MCT oil twice per day
• Snacking on keto treats once or twice per day
• Drinking 1-2 glasses of wine 3 nights per week
Health history
Diet history
Social/other
Metabolic syndrome; gallstones; cholecystectomy 4 years prior
• Lisinopril, 10 mg daily• Metformin, 500 mg twice daily • Metformin, 500 mg twice daily
Clinical
Medications
172 lbs (78 kg)
6.3% (7.5 mmol/L)
92 mg/dL (2.4 mmol/L)
41 mg/dL (1.07 mmol/L)
210 mg/dL (2.37 mmol/L)
78 U/L
5.5% (6.2 mmol/L)
106 mg/dL (2.78 mmol/L)
58 mg/dL (1.5 mmol/L)
98 mg/dL (1.1 mmol/L)
30 U/L
38 inches (96.5 cm)
142/88 mmHg
153 lbs (69.5 kg)
33 inches (84 cm)
127/66 mmHg
Baseline Current
Lab
Weight
Waist circumference
Blood pressure
HbA1c
LDL
HDL
TG
ALT
118 mg/dL (6.6 mmol/L) 97 mg/dL (5.4 mmol/L)FBG
1335.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Case study: Patient 5 follow-up
1345.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
Does she meet the criteria for a weight loss stall?Q1:
1355.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
What do you think are the three most likely factors contributing to her recent weight gain?
Q2:
1365.3 Module 5 case studiesTherapeutic Carbohydrate Restriction CME
What do you think about her weight goal of 120 pounds (54 kg)?
Q3:
5.4 Summary
137Therapeutic Carbohydrate Restriction CME
MODULE 1: Background and definitions
MODULE 2: Physiological and metabolic effects of carbohydrate-restricted diets
MODULE 3: Initiating the intervention
MODULE 4: Administering TCR
MODULE 5: Follow-up care
Please see supplemental course materials for: • clinician resources • patient resources • complete list of references included in this course • additional information on therapeutic
carbohydrate restriction