Implementation and De-prescribing

  1. Clinical Guidelines. Society of Metabolic Health Practitioners. Hite et al. 
  2. Low-Carbohydrate Nutrition Approaches in Patients with Obesity, Prediabetes and Type 2 Diabetes – Low Carb Nutrition – Queen’s Units. Guidelines. 
  3. Antonia. A simple model to find patient hope for positive lifestyle changes: GRIN. British Holistic Medical Association. https://bhma.org/a-simple-model-to-find-patient-hope-for-positive-lifestyle-changes-grin/  PDF 
  4. Cucuzzella M, Riley K, Isaacs D. Adapting Medication for Type 2 Diabetes to a Low Carbohydrate Diet. Front Nutr. 2021;0. doi:10.3389/fnut.2021.688540
  5. Murdoch C, Unwin D, Cavan D, Cucuzzella M, Patel M. Adapting diabetes medication for low carbohydrate management of type 2 diabetes: a practical guide. Br J Gen Pract. 2019;69(684):360-361. doi:10.3399/bjgp19X704525 
  6. Zinn C, North S, Donovan K, Muir C, Henderson G. Low-carbohydrate, healthy-fat eating: A cost comparison with national dietary guidelines. Nutr Diet. April 2019. doi:10.1111/1747-0080.12534
  7. Kalra S, Singla R, Rosha R, Sharma S, Surana V, Kalra B. Pre ketogenic diet counselling. J Pak Med Assoc. 2019;69(4):592-594. PMID: 31000870 PDF
  8. Cucuzzella, M., Hite, A., Patterson, K., Heath, L.S.& R., 2019. A clinician’s guide to inpatient low carbohydrate diets for remission of type 2 diabetes : toward a standard of care protocol. Diabetes Management 9, 7–19. ISSN 1758-1907 PDF
  9.  Kelly T, Unwin D, Finucane F. Low-Carbohydrate Diets in the Management of Obesity and Type 2 Diabetes: A Review from Clinicians Using the Approach in Practice. International Journal of Environmental Research and Public Health. 2020;17(7):2557. doi:10.3390/ijerph17072557 (Infographics development paper – doi:10.4102/jir.v1i1.8)
  10. Unwin D, Khalid AA, Unwin J, et al. Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years. BMJ Nutrition, Prevention & Health. 2020;3(2). doi:10.1136/bmjnph-2020-000072 
  11. Griauzde DH, Standafer Lopez K, Saslow LR, Richardson CR. A Pragmatic Approach to Translating Low- and Very Low-Carbohydrate Diets Into Clinical Practice for Patients With Obesity and Type 2 Diabetes. Front Nutr. 2021;8:682137. doi:10.3389/fnut.2021.682137
  12. Cupit C, Redman E. Supporting people to implement a reduced carbohydrate diet: a qualitative study in family practice. BMJ Nutrition, Prevention & Health. Published online May 10, 2021:bmjnph. doi:10.1136/bmjnph-2021-000240
  13. Saslow LR, Moskowitz JT, Mason AE, et al. Intervention Enhancement Strategies Among Adults With Type 2 Diabetes in a Very Low–Carbohydrate Web-Based Program: Evaluating the Impact With a Randomized Trial. JMIR Diabetes. 2020;5(3):e15835. doi:10.2196/15835
  14. Tay J, Thompson CH, Luscombe-Marsh ND, et al. Nutritional adequacy of very low- and high-carbohydrate, low saturated fat diets in adults with type 2 diabetes: a secondary analysis of a 2-year randomised controlled trial. Diabetes Research and Clinical Practice. 2020;0(0). doi:10.1016/j.diabres.2020.108501
  15. Fieger EI, Fadel KM, Modarres AH, Wickham EP, Wolver SE. SUCCESSFUL REIMPLEMENTATION OF A VERY LOW CARBOHYDRATE KETOGENIC DIET AFTER SGLT2 INHIBITOR ASSOCIATED EUGLYCEMIC DIABETIC KETOACIDOSIS. AACE Clin Case Rep. 2020;6(6):e330-e333. doi:10.4158/ACCR-2020-0314
  16. Aronica L, Volek J, Poff A, D’agostino DP. Genetic variants for personalised management of very low carbohydrate ketogenic diets. BMJNPH. Published online December 12, 2020:bmjnph-2020-000167. doi:10.1136/bmjnph-2020-000167
  17. Honza. Vyjidak (2021) Beating Diabetes with Food – Abbott ebook. Neslazeno. Published January 23, 2021. 

Remote Care (Covid-19 experience, Zoom and Health App based)

  1. Walker L, Smith N, Delon C. Weight loss, hypertension and mental well-being improvements during COVID-19 with a multicomponent health promotion programme on Zoom: a service evaluation in primary care. BMJ Nutrition, Prevention & Health. Published online February 13, 2021:bmjnph. doi:10.1136/bmjnph-2020-000219   PDF
  2. Summers C, Tobin S, Unwin D. Evaluation of the Low Carb Program Digital Intervention for the Self-Management of Type 2 Diabetes and Prediabetes in an NHS England General Practice: Single-Arm Prospective Study. JMIR Diabetes. 2021;6(3):e25751. doi:10.2196/25751
  3. Hanson P, Summers C, Panesar A, et al. Low Carb Program health app within a hospital-based obesity setting: cluster randomised service evaluation. JMIR Form Res. Published online August 1, 2021. doi:10.2196/29110
  4. Kossoff EH, Turner Z, Adams J, et al. Ketogenic diet therapy provision in the COVID-19 pandemic: Dual-center experience and recommendations. Epilepsy Behav. 2020;111:107181. doi:10.1016/j.yebeh.2020.107181
  5. Semprino M, Fasulo L, Fortini S, et al. Telemedicine, drug-resistant epilepsy, and ketogenic dietary therapies: A patient survey of a pediatric remote-care program during the COVID-19 pandemic. Epilepsy & Behavior. 2020;112:107493. doi:10.1016/j.yebeh.2020.107493

Consensus Statements

  1. Association AD (American Diabetes Association). 5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020;43(Supplement 1):S48-S65. doi:10.2337/dc20-S005 (Introduction statement doi:10.2337/dc20-Sint )
  2. Diabetes Canada Position Statement on Low Carbohydrate Diets for Adults with Diabetes: A Rapid Review. Canadian Journal of Diabetes. 2020;0(0). doi:10.1016/j.jcjd.2020.04.001 PDF
  3. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019;42(5):731-754. doi:10.2337/dci19-0014 (American Diabetes Association)
  4. Position Statements – Diabetes Australia. 2018. https://www.diabetesaustralia.com.au/research-advocacy/position-statements/
  5. Hallberg SJ, Dockter NE, Kushner JA, Athinarayanan SJ. Improving the scientific rigour of nutritional recommendations for adults with type 2 diabetes: A comprehensive review of the American Diabetes Association guideline-recommended eating patterns. Diabetes, Obesity and Metabolism. 2019;21(8):1769-1779. doi:10.1111/dom.1373
  6. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. Circulation. 2014;129(25 Suppl 2):S102-S138. doi:10.1161/01.cir.0000437739.71477.ee (Section 3.3. CQ3)
  7. Virani SS, Morris PB, Agarwala A, et al. 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia. Journal of the American College of Cardiology. 0(0). doi:10.1016/j.jacc.2021.06.011 (section 6.1)
  8. Riddle MC, Cefalu WT, Evans PH, et al. Consensus report: definition and interpretation of remission in type 2 diabetes. Diabetologia. Published online August 30, 2021. doi:10.1007/s00125-021-05542-z

Possible Complications

NB Common side effects on initiation and interactions with medications are not included here – see Implementation and De-prescribing

  1. Scientific evidence underlying contraindications to the ketogenic diet: An update – Watanabe – – Obesity Reviews https://onlinelibrary.wiley.com/doi/full/10.1111/obr.13053 

There are some examples of complications in the literature. These are rare and there is a paucity of articles which exist mostly in the form of case studies.

Ketoacidosis

In the case of diet/starvation ketoacidosis, there are usually other factors involved such as illness or breastfeeding (or both) which create additional physiological challenges. For a prudent interpretation of the literature regarding breastfeeding, the link below to Dr. Andreas Eenfeldt – Diet Doctor, may be helpful – Breastfeeding on a low-carb diet – is it dangerous? Diet Doctor. 

  1. Iwata H, Tsuzuki S, Iwata M, Terasawa T. Ketoacidosis due to a Low-carbohydrate Diet in an Elderly Woman with Dementia and Abnormal Eating Behaviour. Intern Med. 2017;56(19):2671-2675. doi:10.2169/internalmedicine.8689-16   
  2. Larroumet A, Camoin M, Foussard N, et al. Euglycemic ketoacidosis induced by therapeutic fasting in a non-diabetic patient. Nutrition. 2019;72:110668. doi:10.1016/j.nut.2019.110668 ABSTRACT
  3. Freeman TF, Willis B, Krywko DM. Acute intractable vomiting and severe ketoacidosis secondary to the Dukan Diet©. J Emerg Med. 2014;47(4):e109-112. doi:10.1016/j.jemermed.2014.06.020 ABSTRACT  

Lactation Ketoacidosis

  1. Alawi AMA, Falhammar H. Lactation ketoacidosis: case presentation and literature review. Case Reports. 2018;2018:bcr-2017-223494. doi:10.1136/bcr-2017-223494 ABSTRACT   
  2. Gleeson S, Mulroy E, Clarke DE. Lactation Ketoacidosis: An Unusual Entity and a Review of the Literature. Perm J. 2016;20(2):71-73. doi:10.7812/TPP/15-097  
  3. Nnodum B, Oduah E, Albert D, Pettus M. Ketogenic Diet-induced Severe Ketoacidosis in a Lactating Woman: A Case Report and Review of the Literature (FS17-01-19). Curr Dev Nutr. 2019;3(Supplement_1). doi:10.1093/cdn/nzz035.FS17-01-19 
  4. von Geijer L, Ekelund M. Ketoacidosis associated with low-carbohydrate diet in a non-diabetic lactating woman: a case report. J Med Case Rep. 2015;9. doi:10.1186/s13256-015-0709-2  
  5. Sloan G, Ali A, Webster J. A rare cause of metabolic acidosis: ketoacidosis in a non-diabetic lactating woman. Endocrinol Diabetes Metab Case Rep. 2017;2017. doi:10.1530/EDM-17-0073 

Prurigo Pigmentosa

This may also be referred to as ‘keto rash’ in mainstream media articles. A helpful summary can be found on the Dr. Andreas Eenfeldt – Diet Doctor website: Keto Rash – Why You May Itch on Low Carb, and What to Do About It. Diet Doctor. 

  1. Mufti A, Mirali S, Abduelmula A, et al. Clinical manifestations and treatment outcomes in prurigo pigmentosa (Nagashima disease): A systematic review of the literature. JAAD Int. 2021;3:79-87. doi:10.1016/j.jdin.2021.03.00
  2.  Goh S, Adawiyah J, Md Nor N, Yap F, Ch’ng P, Chang C. Skin eruption induced by dieting – an underdiagnosed skin disease in Malaysia. Malays Fam Physician. 2019;14(1):42-46. PMID: 31289632
  3. MACO MW, Lee E, Wu Y, Lee R. Treatment of Prurigo Pigmentosa with Diet Modification: A Medical Case Study. Hawaii J Med Public Health. 2018;77(5):114-117. PMID: 29761029
  4. Almaani N, Al-Tarawneh AH, Msallam H. Prurigo Pigmentosa: A Clinicopathological Report of Three Middle Eastern Patients. Case Reports in Dermatological Medicine. 2018 doi:10.1155/2018/9406797
  5. Oh YJ, Lee M-H. Prurigo pigmentosa: a clinicopathologic study of 16 cases. Journal of the European Academy of Dermatology and Venereology. 2012;26(9):1149-1153. doi:10.1111/j.1468-3083.2011.04263.x ABSTRACT
  6. Onaygil E, Songur A, Kutlubay Z, Demirkesen C. Early stage prurigo pigmentosa: a case report. TJPATH. 2015. doi:10.5146/tjpath.2015.01333
  7. Alshaya MA, Turkmani MG, Alissa AM. Prurigo pigmentosa following ketogenic diet and bariatric surgery: A growing association. JAAD Case Reports. 2019;5(6):504-507. doi:10.1016/j.jdcr.2019.03.011
  8. Abbass M, Abiad F, Abbas O. Prurigo Pigmentosa After Bariatric Surgery. JAMA Dermatol. 2015;151(7):796-797. doi:10.1001/jamadermatol.2015.0247 
  9. Al-Dawsari NA, Al-Essa A, Shahab R, Raslan W. Prurigo pigmentosa following laparoscopic gastric sleeve. Dermatology Online Journal. 2019;25(5). https://escholarship.org/uc/item/2b20c2w8

Arrhythmias

There is only one study referring to Incident Atrial Fibrillation currently, and some controversy over the methodology. The carbohydrate content exceeds what would be clinically described as low carb; only two Food Frequency Questionnaires (known to be problematic) were used over the study duration (~22yrs); presence of confounders.

A commentary on these issues can be found on the Dr. Andreas Eenfeldt – Diet Doctor website: Inaccurate news stories suggest low carb causes atrial fibrillation. Diet Doctor

  1. Zhang Shaozhao, Zhuang Xiaodong, Lin Xiaoyu, et al. Low‐Carbohydrate Diets and Risk of Incident Atrial Fibrillation: A Prospective Cohort Study. Journal of the American Heart Association. 2019;8(9):e011955. doi:10.1161/JAHA.119.011955

In the following case study authors concluded that the implementation of a ketogenic diet triggered an increased number of arrhythmia events in a patient with congenital Long QT syndrome (LQTS) 

  1. Sudhakaran S, Yazdani L, Wheelan KR, Rao PK. The ketogenic diet and the QT interval. Proc (Bayl Univ Med Cent). 2019;33(1):77-79. doi:10.1080/08998280.2019.1664220

Children

In this case report two children are presented with growth failure using carbohydrate restriction in type 1 diabetes. In both cases they present as hypocaloric with no details apart from macronutrient percentage. These cases highlight the necessity of a well formulated diet in children along with sufficient monitoring and diet adjustments as required.

  1. Franceschi R, Rizzardi C, Cauvin V, Berchielli F, Liguori A, Soffiati M. Carbohydrate Restriction and Growth Failure in Two Children with Type 1 Diabetes: A Case Report. DDE. Published online October 6, 2020:1-5. doi:10.1159/000510819

Studies in children with epilepsy constitute the majority of the data on this subject. Of note is that the medical ketogenic diet for epilepsy may be lower in protein due to high ketones being of therapeutic importance for seizure control (often 4:1 or 3:1 ratios). 

In the following paper, appropriate growth was maintained in the ketogenic diet group consisting of participants less than 2 years old, which is a critical period for growth.

  1. Liu Y, Wan J, Gao Z, Xu L, Kong L. Ketogenic diet and growth in Chinese infants with refractory epilepsy. Asia Pac J Clin Nutr. 2021;30(1):113-121. doi:10.6133/apjcn.202103_30(1).0014

This study of older children with epilepsy or GLUT1-DS found the majority of participants (80%) maintained or improved their weight at one year follow-up.

  1. Ferraris C, Guglielmetti M, Pasca L, et al. Impact of the Ketogenic Diet on Linear Growth in Children: A Single-Center Retrospective Analysis of 34 Cases. Nutrients. 2019;11(7). doi:10.3390/nu11071442

Optic Neuropathy

For completeness the following articles are included. In both these cases a thiamine deficiency was found and recovery of optic nerve function occurred with appropriate treatment.

  1. Hoyt CS, Billson FA. Optic neuropathy in ketogenic diet. British Journal of Ophthalmology. 1979;63(3):191-194. doi:10.1136/bjo.63.3.191 PDF
  2. Hoyt CS, Billson FA. Low-carbohydrate diet optic neuropathy. Med J Aust. 1977;1(3):65-66. PMID: 840092

Books

There are many books which may be useful in guiding our low carb journey, both as clinicians and patients. The list below is a sample and by no means exhaustive. 

  1. Bernstein, R. (2003) Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars Revised & Updated. Little, Brown and Company; Revised, Subsequent edition
  2. Bikman B, Fung J. Why We Get Sick: The Hidden Epidemic at the Root of Most Chronic Disease―and How to Fight It. BenBella Books; 2020.
  3. Cummins, I., Gerber J. (2018) Eat Rich, Live Long: Mastering the Low-Carb & Keto Spectrum for Weight Loss and Longevity. Victory Belt Publishing
  4. Feinman DRD. Nutrition in Crisis: Flawed Studies, Misleading Advice, and the Real Science of Human Metabolism. Illustrated edition. Chelsea Green Publishing; 2019.
  5. Fung, J. (2016). The Obesity Code: Unlocking the Secrets of Weight Loss. Melbourne, Australia: Scribe Publications
  6. Fung, J., Moore, J. (2016). The Complete Guide to Fasting: Heal Your Body Through Intermittent, Alternate-Day, and Extended Fasting. Las Vegas, Nevada: Victory Belt Publishing
  7. Harcombe, Z. (2010). The Obesity Epidemic: What caused it? How can we stop it? Cwmbran, United Kingdom: Columbus Publishing Ltd
  8. Herschede AM. Grit Pregnancies: How to Have a Healthy Pregnancy and Normal Blood Sugars with Type 1 Diabetes. Allison Herschede; 2021. 
  9. Kraft, J. (2008). Diabetes Epidemic & You. Victoria, Canada: Trafford Publishing. 
  10. Lustig, R. (2013) Fat Chance: The bitter truth about sugar. Fourth Estate
  11. Malhotra, A., O’Neil, D. (2017)The Pioppi Diet: A 21-Day Lifestyle Plan. Penguin Books Ltd
  12. Nichols, L (2018) Real Food for Pregnancy: The Science and Wisdom of Optimal Prenatal Nutrition: 9780986295041: Amazon.com: Books. 
  13. Nichols L. (2015) Real Food for Gestational Diabetes: An Effective Alternative to the Conventional Nutrition Approach. 0986295000
  14. Noakes, T. (2018). Lore of Nutrition: Challenging conventional dietary beliefs. Cape Town, South Africa: Penguin Random House South Africa
  15. Noakes, T. & Proudfoot, J. (2015). The Real Meal Revolution. London, United Kingdom: Little Brown
  16. Rockermeier J, Seyfried DT, D’Agostino DD. Summary of: Cancer as a Metabolic Disease by Dr. Thomas Seyfried. On the Origin, Management, and Prevention of Cancer.: Including Texts by Dominic D’Agostino and Travis Christofferson. Independently published; 2020.
  17. Seyfried T. Cancer as a Metabolic Disease: On the Origin, Management, and Prevention of Cancer. 1st edition. Wiley; 2012.
  18. Taubes, G. (2010). Why We Get Fat. New York City, New York: Alfred A. Knopf
  19. Teicholtz, N. (2014). The Big Fat Surprise: Why Butter, Meat & Cheese Belong in a Healthy Diet. New York City, New York: Simon & Schuster
  20. Volek, J.S., Phinney, S.D. (2011). The Art and Science of Low Carbohydrate Living: An Expert Guide to Making the Life-Saving Benefits of Carbohydrate Restriction Sustainable and Enjoyable. Miami, Florida: Beyond Obesity LLC
  21. Volek, J.S., Phinney, S.D. (2012) The Art and Science of Low Carbohydrate Performance. Beyond Obesity LLC
  22. Westman, E.C., Volek, J.S., Phinney, S.D. (2010). New Atkins for a New You. Touchstone

Updated 01 October 2021