Elsevier

Nutrition

Volume 28, Issue 10, October 2012, Pages 1016-1021
Nutrition

Applied nutritional investigation
Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes

https://doi.org/10.1016/j.nut.2012.01.016Get rights and content

Abstract

Objective

Effective diabetic management requires reasonable weight control. Previous studies from our laboratory have shown the beneficial effects of a low-carbohydrate ketogenic diet (LCKD) in patients with type 2 diabetes after its long term administration. Furthermore, it favorably alters the cardiac risk factors even in hyperlipidemic obese subjects. These studies have indicated that, in addition to decreasing body weight and improving glycemia, LCKD can be effective in decreasing antidiabetic medication dosage. Similar to the LCKD, the conventional low-calorie, high nutritional value diet is also used for weight loss. The purpose of this study was to understand the beneficial effects of LCKD compared with the low-calorie diet (LCD) in improving glycemia.

Methods

Three hundred and sixty-three overweight and obese participants were recruited from the Al-Shaab Clinic for a 24-wk diet intervention trial; 102 of them had type 2 diabetes. The participants were advised to choose LCD or LDKD, depending on their preference. Body weight, body mass index, changes in waist circumference, blood glucose level, changes in hemoglobin and glycosylated hemoglobin, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, uric acid, urea and creatinine were determined before and at 4, 8, 12, 16, 20, and 24 wk after the administration of the LCD or LCKD. The initial dose of some antidiabetic medications was decreased to half and some were discontinued at the beginning of the dietary program in the LCKD group. Dietary counseling and further medication adjustment were done on a biweekly basis.

Results

The LCD and LCKD had beneficial effects on all the parameters examined. Interestingly, these changes were more significant in subjects who were on the LCKD as compared with those on the LCD. Changes in the level of creatinine were not statistically significant.

Conclusion

This study shows the beneficial effects of a ketogenic diet over the conventional LCD in obese diabetic subjects. The ketogenic diet appears to improve glycemic control. Therefore, diabetic patients on a ketogenic diet should be under strict medical supervision because the LCKD can significantly lower blood glucose levels.

Introduction

The current increase in the rate of type 2 diabetes is quite alarming. During the past three decades, the prevalence of this disease in the middle-aged has almost doubled [1]. According to reports by the World Health Organization, approximately 170 million people worldwide have diabetes and this figure is expected to reach to 366 million by 2030 [2]. A similar trend in the increase of type 2 diabetes has been observed in the Gulf region, especially in Kuwait [3], [4].

The risk of diabetes is strongly associated with obesity, and even a modest weight loss has been reported to substantially decrease the diabetic risk. According to statistics from the US Center for Disease Control and Prevention, 55% of diabetic patients are obese and 85% are overweight [5]. In several previous studies, we have shown that a low-carbohydrate ketogenic diet (LCKD) is quite effective in decreasing body weight [6], [7], [8], [9], [10], [11], [12], [13]. The LCKD has a low-carbohydrate content (20–30 g/d) that causes ketosis and mimics the physiologic state of fasting [6].

Before the advent of exogenous insulin, dietary modification was the main therapy for diabetes. However, the diet recommendations during that time were completely different from the current low-fat, high-carbohydrate dietary recommendations for patients with diabetes [14], [15]. For example, Dr. Elliot Joslin's Diabetic Diet in 1923 consisted of meats, poultry, fish, clear soups, gelatin, eggs, butter, olive oil, coffee, and tea, providing approximately 5% of energy from carbohydrates, 20% from protein, and 75% from fat [16]. During that time, a diabetic diet with a similar composition was advocated by Dr. Frederick Allen [17].

In a previous study from our laboratory, we quite convincingly showed the beneficial effects of a ketogenic diet in obese diabetic subjects [9]. Furthermore, in recent studies in an animal model of diabetes, we showed that the LCKD has a significant beneficial effect on ameliorating the diabetic state and helping to stabilize hyperglycemia [11], [13]. From the results of these studies, we recommended that the LCKD may be effective in diabetes management by improving glycemia and decreasing the need for medication.

The present study, therefore, is a continuation of our previous studies in diabetic patients and experimental diabetic animals. The main purpose of the therapeutic plan of this study was to evaluate the effects of administering a low-calorie diet (LCD) and an LCKD for 24 wk in improving glycemia and decreasing the need for diabetic medication in overweight and obese patients with type 2 diabetes.

Section snippets

Participants

In this study, the participants were recruited from the Al-Shaab Family Medicine Medical Center, Kuwait. The participants were included in this study if they were at least 18 y old, had a body mass index higher than 25 kg/m2 and a fasting serum glucose level higher than 125 mg/dL (>6.9 mmol/L). Patients with evidence of renal insufficiency, liver disease, or unstable cardiovascular disease by history, physical examination, and laboratory tests were excluded from the study. All participants

Results

Three hundred sixty-three participants were enrolled in the study and completed the 24 wk of follow-up. Adherence to the two dietary programs was discussed with the participants and recorded. Adequate food records were available to determine each participant's adherence to the dietary program (data not shown). Among the 363 participants, 86 were men (23.7%) and 277 were women (76.3%). Among the men, 28 were diabetic and 58 were non-diabetic; among the women, 74 were diabetic and 203 were

Discussion

The effect of carbohydrate restriction on type 2 diabetes was previously examined in our laboratory [9]. We found that the body weight, body mass index, and levels of blood glucose, total cholesterol, low-density lipoprotein cholesterol, triglycerides, and urea were significantly decreased from week 1 to week 56 (P < 0.0001). Conversely, the level of high-density lipoprotein cholesterol was increased significantly (P < 0.0001). These changes were more significant in subjects with a high blood

Conclusion

In summary, the LCKD had significant positive effects on body weight, waist measurement, serum triacylglycerols, and glycemic control in participants with type 2 diabetes. Most impressively, there was an improvement in HbA1c despite the small sample and short duration of follow-up, and this improvement in glycemic control occurred after the antidiabetic medications had been decreased substantially in participants using the LCKD program. Further studies are necessary to examine the optimal

Acknowledgments

The authors thank Mr. Joseph E Gomez, Department of Community Medicine, Faculty of Medicine, Kuwait University for advice and assistance in the statistical analysis of the data.

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