The ongoing effect is unclear until long-term, randomized studies can be undertaken. This suggests that the quality of the food matters, not just the macronutrient itself. Another prospective cohort study found that a healthy low-carb diet and low-fat diets were associated with lower mortality, and unhealthy low-carb and low-fat diets were associated with higher mortality. However, the recent Prospective Urban Rural Epidemiology (PURE) study, a large prospective nutrition study involving over 135,000 participants across the globe, found a relationship between increased mortality and higher carbohydrate intake and lower mortality associated with higher fat intake. Epidemiological studies and meta-analyses have shown an increased mortality risk with a carbohydrate intake of less than 40%. There have been several studies linking low-carb diets to increased mortality. The recommendation is for caution with the use of ketogenic diets with the concomitant use of SGLT-2 inhibitors. While there have been cases of diabetic ketoacidosis (DKA) with concomitant SGLT2 inhibitors in patients with type 2 diabetes, it is unclear if the very low carb approach increases the risk of DKA with SGLT2 use. However, there is no evidence that very low-carb intake produces metabolic ketoacidosis and remains safe in patients, even with type 2 diabetes. Nutritional ketosis can be induced in the keto diet, the induction phase, and when carb load is limited to less than 10% of macronutrient intake or 20 to 50 gm/day of carbohydrates. Low-carb diet safety concerns relate to ketosis, long-term cardiovascular safety, lipid, and renal effects. Several theoretical concerns about the long-term safety of low-carb diets deserve mention. This can be calculated carbs by subtracting the whole amount of fiber and half the amount of sugar alcohols from the amount of total carbs. The only nutritional impact of using net carbs is it may help the patient to choose foods that are higher in fiber.ĭespite the debate, it is clear from numerous systematic reviews that low-carb diets are as effective, if not more effective, for weight loss compared to other diets. The evidence for benefits and concerns for low-carb will be further delineated below. The term net carbs refer to the total amount of fully digestible carbohydrates contained in a meal. Diabetic ketoacidosis, by definition, includes metabolic acidosis, hyperglycemia, and serum ketones (generally over 20 mmol/L). Nutritional ketosis generally increases serum ketones from 1 mmol/L to 7 mmol/L but does not produce metabolic acidosis. Nutritional ketosis produces ketone bodies (acetoacetate, acetone, and beta-hydroxybutyrate) and is measurable as serum or urinary ketones. Restricting carbs to under 50 gms induces glycogen depletion and ketone production from the mobilization of fat stored in adipose tissue. Keto diets restrict carbohydrates to induce nutritional ketosis and typically limit carbs to 20 to 50 grams daily. The ketogenic (keto) diet, a specific low-carb version, deserves mention. However, these theories remain controversial. In recent studies, there appears to be a metabolic advantage of approximately 200 to 300 more calories burned compared to an iso-caloric high-carb diet. Another hypothesis contends that low-carb diets can produce a higher metabolic burn than high-carb diets. This increase in satiety and less rebound hypoglycemia reduces hunger and overall food intake and produces a caloric deficit. One hypothesis of why low-carb approaches produce rapid weight loss compared to other diets is that fats and protein increase satiety and produce less concomitant hypoglycemia. When lowering carbohydrates from the diet, the macronutrient intake of fat and protein generally increases to compensate for the reduction of carbohydrates. While diets inducing weight loss produce a caloric deficit, the mechanism of low-carb diets remains in debate. Studies have shown low-carb approaches to be superior to other dietary methods in producing rapid weight loss for the first 6 to 12 months. This approach has been recently called the carbohydrate-insulin model. Low-carb approaches stem primarily from the hypothesis that lowering insulin, a critical hormone that produces an anabolic, fat-storing state, improves cardiometabolic function and induces weight loss.
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