Diets restricting carbohydrate consumption
Low-carbohydrate diets or carbohydrate-restricted diets (CRDs) are diets that restrict carbohydrate consumption relative to the average diet. Foods high in carbohydrates (e.g., sugar, bread, pasta) are limited, and replaced with foods containing a higher percentage of fat and protein (e.g., meat, poultry, fish, shellfish, eggs, cheese, nuts, and seeds), as well as low carbohydrate foods (e.g. spinach, kale, chard, collards, and other fibrous vegetables).
There is a lack of standardization of how much carbohydrate low-carbohydrate diets must have, and this has complicated research. One definition, from the American Academy of Family Physicians, specifies low-carbohydrate diets as having less than 20% carbohydrate content.
There is no good evidence that low-carbohydrate dieting confers any particular health benefits apart from weight loss, where low-carbohydrate diets achieve outcomes similar to other diets, as weight loss is mainly determined by calorie restriction and adherence.
An extreme form of low-carbohydrate diet – the ketogenic diet – is established as a medical diet for treating epilepsy. Through celebrity endorsement it has become a popular weight-loss fad diet, but there is no evidence of any distinctive benefit for this purpose, and it may have a number of initial side effects. The British Dietetic Association named it one of the “top 5 worst celeb diets to avoid in 2018”.
Definition and classification
The macronutrient ratios of low-carbohydrate diets are not standardized. As of 2018[update] the conflicting definitions of “low-carbohydrate” diets have complicated research into the subject.
The American Academy of Family Physicians defines low-carbohydrate diets as diets that restrict carbohydrate intake to 20 to 60 grams (g) per day, typically less than 20% of caloric intake. A 2016 review of low-carbohydrate diets classified diets with 50g of carbohydrate per day (less than 10% of total calories) as “very low” and diets with 40% of calories from carbohydrates as “mild” low-carbohydrate diets. The UK National Health Service recommend that “carbohydrates should be the body’s main source of energy in a healthy, balanced diet.”
There is evidence that the quality, rather than the quantity, of carbohydrate in a diet is important for health, and that high-fiber slow-digesting carbohydrate-rich foods are healthful while highly-refined and sugary foods are less so. People choosing diet for health conditions should have their diet tailored to their individual requirements. For people with metabolic conditions, a diet with approximately 40-50% carbohydrate is recommended.
Most vegetables are low- or moderate-carbohydrate foods (in some low-carbohydrate diets, fiber is excluded because it is not a nutritive carbohydrate). Some vegetables, such as potatoes, carrots, maize (corn) and rice are high in starch. Most low-carbohydrate diet plans accommodate vegetables such as broccoli, spinach, kale, lettuce, cucumbers, cauliflower, peppers and most green-leafy vegetables.
Adoption and advocacy
The National Academy of Medicine recommends a daily average of 130 g of carbohydrates per day. The FAO and WHO similarly recommend that the majority of dietary energy come from carbohydrates. Low-carbohydrate diets are not an option recommended in the 2015-2020 edition of Dietary Guidelines for Americans, which instead recommends a low fat diet.
Carbohydrate has been wrongly accused of being a uniquely “fattening” macronutrient, misleading many dieters into compromising the nutritiousness of their diet by eliminating carbohydrate-rich food. Low-carbohydrate diet proponents emphasize research saying that low-carbohydrate diets can initially cause slightly greater weight loss than a balanced diet, but any such advantage does not persist. In the long-term successful weight maintenance is determined by calorie intake, and not by macronutrient ratios.
The public has become confused by the way in which some diets, such as the Zone diet and the South Beach diet are promoted as “low-carbohydrate” when in fact they would more properly be termed “medium” carbohydrate diets.
Low-carbohydrate diet advocates including Gary Taubes and David Ludwig have proposed a “carbohydrate-insulin hypothesis” in which carbohydrates are said to be uniquely fattening because they raise insulin levels and cause fat to accumulate unduly. The hypothesis appears to run counter to known human biology whereby there is no good evidence of any such association between the actions of insulin, fat accumulation, and obesity. The hypothesis predicted that low-carbohydrate dieting would offer a “metabolic advantage” of increased energy expenditure equivalent to 400-600 kcal(kilocalorie)/day, in accord with the promise of the Atkin’s diet: a “high calorie way to stay thin forever.”
With funding from the Laura and John Arnold Foundation, in 2012 Taubes co-founded the Nutrition Science Initiative (NuSI), with the aim of raising over $200 million to undertake a “Manhattan Project For Nutrition” and validate the hypothesis. Intermediate results, published in the American Journal of Clinical Nutrition did not provide convincing evidence of any advantage to a low-carbohydrate diet as compared to diets of other composition – ultimately a very low-calorie, ketogenic diet (of 5% carbohydrate) “was not associated with significant loss of fat mass” compared to a non-specialized diet with the same calories; there was no useful “metabolic advantage.” In 2017 Kevin Hall, a NIH (National Institutes of Health) researcher hired to assist with the project, wrote that the carbohydrate-insulin hypothesis had been falsified by experiment. Hall wrote “the rise in obesity prevalence may be primarily due to increased consumption of refined carbohydrates, but the mechanisms are likely to be quite different from those proposed by the carbohydrate–insulin model.”
It has been repeatedly found that in the long-term, all diets with the same calorific value perform the same for weight loss, except for the one differentiating factor of how well people can faithfully follow the dietary programme. A study comparing groups taking low-fat, low-carbohydrate and Mediterranean diets found at six months the low-carbohydrate diet still had most people adhering to it, but thereafter the situation reversed: at two years the low-carbohydrate group had the highest incidence of lapses and dropouts. This may be due to the comparatively limited food choice of low-carbohydrate diets.
Studies have shown that people losing weight with a low-carbohydrate diet, compared to a low-fat diet, have very slightly more weight loss initially, equivalent to approximately 100kcal/day, but that the advantage diminishes over time and is ultimately insignificant. The Endocrine Society stated that “when calorie intake is held constant […] body-fat accumulation does not appear to be affected by even very pronounced changes in the amount of fat vs. carbohydrate in the diet.”
Much of the research comparing low-fat vs. low-carbohydrate dieting has been of poor quality and studies which reported large effects have garnered disproportionate attention in comparison to those which are methodologically sound. A 2018 review said “higher-quality meta-analyses reported little or no difference in weight loss between the two diets.” Low-quality meta-analyses have tended to report favourably on the effect of low-carbohydrate diets: a systematic review reported that 8 out of 10 meta-analyses assessed whether weight loss outcomes could have been affected by publication bias, and 7 of them concluded positively. A 2017 review concluded that a variety of diets, including low-carbohydrate diets, achieve similar weight loss outcomes, which are mainly determined by calorie restriction and adherence rather than the type of diet.
As of 2016[update] it was unclear whether low-carbohydrate dieting had any beneficial effect on cardiovascular health, though such diets can cause high LDL cholesterol levels, which carry a risk of atherosclerosis in the long term. Potential favorable changes in triglyceride and HDL cholesterol values should be weighed against potential unfavorable changes in LDL and total cholesterol values.
Some randomized control trials have shown that low-carbohydrate diets, especially very low-carbohydrate diets, perform better than low-fat diets in improving cardiometabolic risk factors in the long term, suggesting that low-carbohydrate diets are a viable option alongside low-fat diets for people at risk of cardiovascular disease.
There is only poor-quality evidence of the effect of different diets on reducing or preventing high blood pressure, but it suggests the low-carbohydrate diet is among the better-performing ones, while the DASH diet (Dietary Approaches to Stop Hypertension) performs best.
There is little evidence for the effectiveness of low-carbohydrate diets for people with type 1 diabetes. For certain individuals, it may be feasible to follow a low-carbohydrate regime combined with carefully-managed insulin dosing. This can be hard to maintain and there are concerns about potential adverse health effects caused by the diet. In general, people with type 1 diabetes are advised to follow an individualized eating plan.
The proportion of carbohydrate in a diet is not linked to the risk of type 2 diabetes, although there is some evidence that diets containing certain high-carbohydrate items – such as sugar-sweetened drinks or white rice – are associated with an increased risk. Some evidence indicates that consuming fewer carbohydrate foods may reduce biomarkers of type 2 diabetes.
A 2018 report on type 2 diabetes by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) found that a low-carbohydrate diet may not be as good as a Mediterranean diet for improving glycemic control, and that although having a healthy body weight is important, “there is no single ratio of carbohydrate, proteins, and fat intake that is optimal for every person with type 2 diabetes.” There is no good evidence that low-carbohydrate diets are better than a conventional healthy diet, in which carbohydrates typically account for more than 40% of calories consumed. Low-carbohydrate dieting has no effect on the kidney function of people who have type 2 diabetes.
Limiting carbohydrate consumption generally results in improved glucose control, although without long-term weight loss. Low-carbohydrate diets can be useful to help people with type 2 diabetes lose weight, but “no single approach has been proven to be consistently superior.” According to the ADA, people with diabetes should be “developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods.” They recommended that the carbohydrates in a diet should come from “vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains”, while highly-refined foods and sugary drinks should be avoided. The ADA also wrote that “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.” For individuals with type 2 diabetes who can’t meet the glycemic targets or where reducing anti-glycemic medications is a priority, the ADA says that low or very-low carbohydrate diets are a viable approach.
Exercise and fatigue
A low-carbohydrate diet has been found to reduce endurance capacity for intense exercise efforts, and depleted muscle glycogen following such efforts is only slowly replenished if a low-carbohydrate diet is taken. Inadequate carbohydrate intake during athletic training causes metabolic acidosis, which may be responsible for the impaired performance which has been observed.
The ketogenic diet is a high-fat, low-carbohydrate diet used to treat drug-resistant childhood epilepsy. In the 2010s, it became a fad diet for people wanting to lose weight. Users of the ketogenic diet may not achieve sustainable weight loss, as this requires strict carbohydrate abstinence, and maintaining the diet is difficult. Possible risks of using the ketogenic diet over the long term may include kidney stones, osteoporosis, or increased levels of uric acid, a risk factor for gout.
Ketogenic diet (low carbohydrate diet) practice for weight loss has reportedly increased mortality rate (especially from cancer and cardiovascular disease), but mortality increase was only associated with animal-based diets, whereas mortality was reduced with plant-based diets.
High and low-carbohydrate diets that are rich in animal-derived proteins and fats may be associated with increased mortality. On the contrary, with plant-derived proteins and fats, there may be a decrease of mortality.
As of 2018[update], research has paid insufficient attention to the potential adverse effects of carbohydrate restricted dieting, particularly for micronutrient sufficiency, bone health and cancer risk. One low quality meta-analysis reported that adverse effects could include “constipation, headache, halitosis, muscle cramps and general weakness.”
Ketosis induced by a low-carbohydrate diet has led to reported cases of ketoacidosis, a life-threatening condition. This has led to the suggestion that ketoacidosis should be considered a potential hazard of low-carbohydrate dieting.
In a comprehensive systematic review of 2018, Churuangsuk and colleagues reported that other case reports give rise to concerns of other potential risks of low-carbohydrate dieting including hyperosmolar coma, Wernicke’s encephalopathy, optic neuropathy from thiamine deficiency, acute coronary syndrome and anxiety disorder.
Significantly restricting the proportion of carbohydrate in diet risks causing malnutrition, and can make it difficult to get enough dietary fiber to stay healthy.
As of 2014 it appeared that with respect to the risk of death for people with cardiovascular disease, the kind of carbohydrates consumed are important; diets relatively higher in fiber and whole grains lead to reduced risk of death from cardiovascular disease compared to diets high in refined-grains.
In 1797, John Rollo reported on the results of treating two diabetic Army officers with a low-carbohydrate diet and medications. A very low-carbohydrate, ketogenic diet was the standard treatment for diabetes throughout the nineteenth century.
In 1863, William Banting, a formerly obese English undertaker and coffin maker, published “Letter on Corpulence Addressed to the Public,” in which he described a diet for weight control giving up bread, butter, milk, sugar, beer, and potatoes. His booklet was widely read, so much so that some people used the term “Banting” for the activity now called “dieting.”
In the early 1900s Frederick Madison Allen developed a highly restrictive short term regime which was described by Walter R. Steiner at the 1916 annual convention of the Connecticut State Medical Society as The Starvation Treatment of Diabetes Mellitus.:176–177 This diet was often administered in a hospital in order to better ensure compliance and safety.:179
Modern low-carbohydrate diets
Other low-carbohydrate diets in the 1960s included the Air Force diet and the Drinking Man’s Diet. In 1972, Robert Atkins published Dr. Atkins Diet Revolution, which advocated the low-carbohydrate diet he had successfully used in treating people in the 1960s. The book was a publishing success, but was widely criticized by the mainstream medical community as being dangerous and misleading, thereby limiting its appeal at the time.
The concept of the glycemic index was developed in 1981 by David Jenkins to account for variances in speed of digestion of different types of carbohydrates. This concept classifies foods according to the rapidity of their effect on blood sugar levels – with fast-digesting simple carbohydrates causing a sharper increase and slower-digesting complex carbohydrates, such as whole grains, a slower one. Jenkins’ research laid the scientific groundwork for subsequent low-carbohydrate diets.
In 1992, Atkins published an update from his 1972 book, Dr. Atkins New Diet Revolution, and other doctors began to publish books based on the same principles. During the late 1990s and early 2000s, low-carbohydrate diets became some of the most popular diets in the US. By some accounts, up to 18% of the population was using one type of low-carbohydrate diet or another at the peak of their popularity.Food manufacturers and restaurant chains noted the trend, as it affected their businesses. Parts of the mainstream medical community have denounced low-carbohydrate diets as being dangerous to health, such as the AHA in 2001, and the American Kidney Fund in 2002.[failed verification]
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Low-carbohydrate, low glycemic index, and high-protein diets, and the Dietary Approaches to Stop Hypertension (DASH) diet all improve glycemic control, but the effect of the Mediterranean eating pattern appears to be the greatest
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124th Annual Convention
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These diets are generally associated with higher intakes of total fat, saturated fat, and cholesterol because the protein is provided mainly by animal sources. … Beneficial effects on blood lipids and insulin resistance are due to the weight loss, not to the change in caloric composition. … High-protein diets may also be associated with increased risk for coronary heart disease due to intakes of saturated fat, cholesterol, and other associated dietary factors.
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