How Low Can You Go?Evidence Update For LowCarb EatingWilliam S. Yancy, Jr, MD MHS FTOSDirector, Duke Diet and Fitness CenterAssociate Professor of MedicineDuke UniversityDisclosures Consultant for dietdoctor.com Consultant for Guideline CentralLearning Objectives Describe the low-carbohydrate eatingpattern and the rationale behind it Summarize weight loss effects of lowcarbohydrate eating plans Describe potential mechanisms of weightloss during low-carbohydrate eating Describe the effects of low-carbohydrateeating on health and risk factors
Client SB67 yo WM with diabetes, high cholesterol, hypertensionInsulin Units per ContinueMetforminDecreaseatorvastatin0Week 0WeightGlucoseWeek 1Week 2252Week 3236Week 4231190-30084-110TG28468HDL3442LDL533610.58.4Hb A1cOutline Background on low-carbohydrate eatingpattern Weight loss effects How weight loss occurs Health effects5Nutritional Therapy for ObesityE nergy consum ption intended to cause negative calorie balance and lossof fat m assLow -calorie diets:1,200-1,800 kcal/dayR estricted fat dietLow-fat diet:V ery low -calorie diets:Less than 800 kcal/dayP hysiciansupervisionrecom m endedR estrictedcarbohydrate dietLow-glycemic diet:R ecom m endedfor shorterdurationsLow-carbohydratediet50-150 grams/dayFull m ealreplacem entprogram s 30% fat caloriesVery low-fat diet: 10% fat caloriesVery lowcarbohydrate diet 50 grams/day(with or withoutnutritional ketosis)Reference/s:       Obesity Algorithm . 2015-2016 Obesity Medicine Association.6
Diets, Carbohydrates, and Calories300Carbohydrate (g/day)Typical U.S. DietLow Glycemic DASHIndex DietDiet200Mediterranean DietRice Diet10050200VLCD(Ketonuria)Duke MCD Zone DietSo. Beach Phase 2Atkins MaintenanceProtein Power, Paleo,So. Beach Phase 1, Duke LCDAtkins Induction, Keto10002000Calories/dayLow Carbohydrate Ketogenic Diet(LCKD) Initially, 20 g of carbohydrates per day––––Unrestricted amounts of meat and eggsFour oz. hard cheeseTwo cups salad vegetablesOne cup low-carbohydrate vegetables Calories not restricted Carbohydrate intake slowly increased asweight goal approached Daily multivitamin, copious liquids, broth
Low Carb / High Fat Diet Rationale:The Role of Insulin Dietary carbohydrate (sugar or starch) raisesserum glucose and insulin A carbohydrate restricted (high fat) diet reducesthe diet contribution to serum glucose, which thenlowers insulin levels Insulin is a potent stimulator of lipogenesis (fatstorage) and a potent inhibitor of lipolysis (fatburning) Lowering insulin levels leads to burning of storedbody fat, raising serum ketones and loweringbody weightHow Low Can You Go?(Or Are Carbohydrates Essential in Humans?)What is known: Humans can endogenously synthesizecarbohydrates Humans do not show signs of deficiency in theabsence of dietary carbohydrates No reports of micronutrient deficiency syndromesin clinical trials of low carbohydrate ketogenic diets RDA for carbohydrates is 130g /day to ensuresufficient glucose for the brain– However, when intake is 130g /day, the body meetsenergy needs of brain with endogenously producedglucose and ketonesTondt J, Nutr Res Rev, In Press.Outpatient Low Carb Trials: Weight LossNDuration(mo)Low-fat(kg)Brehm 2003 †426-3.9-8.5*Yancy 2004‡1196-6.5-12.0*Samaha 2003 †ReferenceLow-carb(kg)1326-1.9-5.8*Foster 2003†636-5.3-9.7*Foster 2003†6312-4.5-7.3Stern 2004 ‡13212-3.1-5.1Dansinger 2005 §16012-3.0-2.1Gardner 2007 §31112-1.6-4.7** p 0.05 for between-groups comparison.For Gardner, comparison was the Zone diet.
RCTs 12 months: Low Carb vs Low Fat-0.91 kg (-1.65, -0.17)Bueno NB, Br J Nutr, 2013.2-Year Low Carbohydrate Diet StudiesFoster G, Ann Intern Med, 2010.Shai I, NEJM, 2008.How Weight Loss Occurs:Calories, Calories, Calories!Bas el ine DietStud y DietMean Calories per day25002000150010005000Low Carb ParticipantsLow Fat ParticipantsYancy WS, Arch Intern Med, 2010.
Calories are Reduced b/c Hunger is LessGibson AA, Obes Rev, 2015.How Weight Loss Occurs: A Little Bit ofWater LossLow Carb (n 59)43Low Fat (n 60)4241-2.4 kg†40-1.8 kg†3924k20Wkk16W12kWkWW8106kWWk42kWkWk038WMean Total Body Water, kg44Duration of Intervention† p 0.05, for comparison between diet groups.Yancy WS, Ann Intern Med, 2004.How Weight Loss Occurs:What About Metabolism?Low carb dietModerate carb dietHigh carb dietEbbeling CB, BMJ, 2018.
Health Effects: Symptomatic EffectsLow fatSymptom(n 60)Constipation35%Headache40%Bad breath8%Muscle cramps 7%Diarrhea7%Weakness8%Rash0%Low carb(n 59)68%60%38%35%23%25%13%P value .001.03 .001 .001.02.01.006Yancy WS, Ann Intern Med, 2004.Comparison of Participant CompletionRates of Low-Fat vs Low-Carb Diet StudiesEach pointrepresents acomparisonfrom one of19 studies.Feinman RD,Nutrition, 2015.Meta-Analysis: Low Carb vs Low FatNo. ofTrialsNet DifferenceLow Carb – Low Fat95% CIWeight, kg22-1.0 2.2, 0.2Systolic BP, mmHg18-1.0 3.5, 1.5Diastolic BP,mmHg18-0.7 1.6, 0.2HDL-C, mg/dL193.3*1.9, 4.7LDL-C, mg/dL193.7*1.0, 6.4TG, mg/dL20-14.0* 19.4, 8.7Variable*p 0.05 for net change.Hu T, Am J Epidemiol, 2012.
DIRECT (PI-Iris Shai) Study – 6 yearsSchwarzfuchs D,N Engl J Med,2012.Glucose and Insulin Response to 300kcal Meal After 10 days on DietHigh-carb dietIntermediate-carb dietLow-carb diet(n 6)*Glucose AUC lowest for low-carbdiet (p .001).*Insulin AUC different for eachdiet (p .001)Bisschop, J ClinEndocrinol Metab, 2003.Network Meta-analysis Comparing DietEffects on Glycemia in Type 2 DM 56 trials enrolling 4937 participantscomparing 9 diets:– Low-fat, Vegetarian, Mediterranean, high-protein,moderate-carbohydrate, low-carbohydrate,control, low GI/GL, Paleolithic “For reducing HbA1c, the low-carbohydratediet was ranked as the best dietary approach(SUCRA: 84%), followed by theMediterranean diet (80%) and Paleolithic diet(76%) compared to a control diet.”Schwingshackl L, Eur J Epidemiol, 2018.
Other Benefits in Patients with DiabetesRCT using group medical visits (GMVs)– Low-carbohydrate weight loss program vs medicationintensification to improve glycemia Both improved HbA1c by 1% Additionally, low-carbohydrate program led to:– Greater weight loss by 3.7 kg– Reduction in diabetes medication vs increase incomparison arm– Transient greater improvement (during greatestweight differences) in diabetes-related distress– 50% reduction in hypoglycemia eventsYancy WS Jr, JAMA Intern Med, 2019.Client RJT64 yo WF with sleep apnea, diabetes, fatty liver,hypertension, mild 201320162018Weight200199182151144138BP rilCarvedilolLisinoprilLisinoprilDM acinFish oilsPitavastatinFish oilsFish oilsFish oilsHb 56984CRP1.341.081.040.42Low Carb Take Home Points Low carbohydrate intake leads to spontaneousreduction in calorie intake and lower insulin levels Body fat breaks down into ketonesà used for energy Early diuresis requires adequate intake of fluid and salt Weight loss mildly better on average than comparison If carbohydrate is added back, do it gradually Blood pressure and triglycerides decrease, HDLincreases LDL does not typically increase BUT it does at times Blood sugar decreases profoundly--reduce medicationsat diet start!
Duke Diet and Fitness Center28Extra Slides29Active Learning Question #1Compared with low-fat eating patterns, lowcarbohydrate eating patterns typically lead towhich of the following changes in serum lipidprofiles?A. Lower HDL cholesterol levelB. Higher HDL cholesterol levelC. Lower LDL cholesterol levelD. Higher triglyceride levelE. Higher triglyceride: HDL ratio30
Active Learning Question #1Compared with low-fat eating patterns, low-carbohydrate eatingpatterns typically lead to which of the following changes in serum lipidprofiles?A. Lower HDL cholesterol levelB. Higher HDL cholesterol levelC. Lower LDL cholesterol levelD. Higher triglyceride levelE. Higher triglyceride: HDL ratioRationale: Multiple randomized clinical trials in various populations andmeta-analyses of these trials have shown that low-carbohydrate eatingpatterns lead to higher HDL cholesterol and lower serum triglycerideswhereas low-fat eating patterns lead to lower LDL cholesterol.Ref: Hu T et al. Am J Epidemiol. 2012;176 Suppl 7:S44-54.31Active Learning Question #2There are data to support that weight lossfrom a low-carbohydrate eating pattern isrelated to which of the following?A. Water loss from use of glycogen storesB. Water loss related to lower insulin levelsC. Reduced calorie intakeD. Increased energy expenditureE. All of the above32Active Learning Question #2There are data to support that weight loss from a low-carbohydrate eating pattern is related to which ofthe following?A.Water loss from use of glycogen storesB.Water loss related to lower insulin levelsC.Reduced calorie intakeD.Increased energy expenditureE.All of the aboveRationale: Water loss occurs particularly in the early phase of a low-carbohydrate eating pattern and isthought to be due to a combination of water release that occurs as glycogen stores are used andchanges that occur in the kidney when insulin levels are lower resulting in greater release of sodiumand water. Multiple studies have shown that low-carbohydrate eating leads to reduced appetite andcalorie intake. Studies by Ebbeling show increased energy expenditure measured by doubly labelledwater occurs on a low-carbohydrate eating plan.Ref:Yancy W S JR et al. Ann Intern Med 2004;140(10):769-77.Yancy W S JR et al. Arch Intern Med 2010;170(2):136-145.Ebbeling CB et al. BMJ. 2018;363.33
Current Treatment Options for ObesitySurgery(In order of lowest risk/costand potency):LAGB VSG RNYVery Low Calorie DietPotency*Lifestyle MedicationIncludes lifestyle, and antiobesity medicationsLifestyleIncludes nutrition, physicalactivity, and behavioralprogramsRisk/Cost*Potency includes many factors, such as the amount, rate, and sustainability of weight loss, and the long-term resolution of adiposopathy and fat mass disease.Potency varies greatly for each individual (i.e., long-term adherence to a lifestyle program can be as potent as gastric bypass surgery).Obesity Algorithm . 2015-2016 Obesity Medicine Association.34The Role of Ketones Ketone bodies: molecules that deliver energy Ketones can be used by all cells excepterythrocytes, cornea, lens, retina Ketone levels increase when dieting–––––Fed stateOvernight fastLow-carb diet—induction 20 days fastingDiabetic ketoacidosis0.1 mmol/L0.3 mmol/L1–3 mmol/L10 mmol/L25 mmol/L Serum pH did not decrease below 7.37 in astudy performing arterial blood gas analysesMeckling KA, Can J Physiol Pharmacol, 2002; Coleman MD,J Am Diet Assoc, 2005; Yancy WS, Eur J Clin Nutr, 2007.Are Carbohydrates Essential in Humans?Definitions: Physiological essentiality- substance that is indispensablefor life (eg, cholesterol) Nutritional essentiality- substance that is indispensable inthe diet (eg, leucine, linoleic acid, vitamin A, calcium, copper)– required in the diet for growth, health, and survival– inadequate intake results in characteristic signs of a deficiencydisease– signs of deficiency are prevented only by the nutrient or aspecific precursor of it, not by other substances– substance is not synthesized in the body and is thereforerequired to be obtained from the diet Nutrients that can be removed from the diet without causinggrowth failure or disease are classified as nonessentialTondt J, Nutr Res Rev, In Press,
RCTs Comparing LC vs LF DietsPublic Health CollaborationFind out more at: www.PHCuk.org/RCTsMeta-Analysis: Before/After Low Carb EffectsNo. ofReportsNet Change95% CIWeight, kg28-7.0*-7.2, -6.9Systolic BP,mmHg22-4.8*-5.3, -4.3Diastolic BP,mmHg22-3.1*-3.5, -2.7HDL-C, mg/dL221.7*1.4, 2.0LDL-C, mg/dL22-0.5-1.5, 0.6TG, mg/dL19-29.7*-32.0, -27.4Variable*p 0.05 for net change.Santos FL, Obes Rev, 2013.Variability of Change in WeightOrlistat Low Fat DietLow Carbohydrate DietYancy WS Jr, Arch Intern Med, 2010.
Heart Disease Risk for Types of Fat% Change in CHD10080Trans(p 0.001)6040200-20-40Saturated(p 0.1)1%E2%E3%E4%E5%EMonounsaturated(p 0.05)Polyunsaturated(p 0.003)Risk for replacement of X% of energy from carbohydrate by fat.Hu et al. NEJM, 1997. (Nurses’ Health Study)Meta-analysis:Associationof SaturatedFat with HeartDisease andStrokeSiri-Tarino PW,Amer J ClinNutr2009Meta-analyses: Saturated Fat Intake and Heart DiseaseSkeaff CM, Ann Nutr Metab, 2009 (Cohort studies: 28 studies, N 280,000, f/u 4-25y) Total fat intake and CHD mortality 0.94 (95% CI 0.74 to 1.18) Saturated fat intake and CHD mortality RR 1.14 (95% CI 0.82 to 1.60)Schwingshackl L, BMJ Open, 2014 (RCTs of secondary prevention: 12 trials, N 7150) Reduced fat or modified fat diets did not reduce all-cause mortality, CHD mortality, or CV eventsSiri-Tarino, Amer J Clin Nutr, 2010 (Prospective cohort studies: 16 studies, N 347,747) Saturated fat and CHD RR 1.07 (95% CI 0.96 to 1.19)Chowdhury R, Ann Intern Med, 2014 (Prospective cohort studies: 32 studies, N 530,525) Saturated fat and CHD RR 1.02 (95% CI 0.97 to 1.07)de Souza, BMJ, 2015 (Prospective cohort studies: 12 studies, N 339,090) Saturated fat and all cause mortality RR 0.99 (95% CI 0.91 to 1.09)Saturated fat and CVD mortality RR 0.97 (95% CI 0.84 to 1.12) Saturated fat and ischemic stroke RR 1.02 (95% CI 0.90 to 1.15) Saturated fat and type 2 diabetes RR 0.95 (95% CI 0.88 to 1.03)Hooper L, Cochrane, 2015 (RCTs of primary or secondary prevention: 12 trials: N 54,000 ) Saturated fat and all-cause mortality RR 0.97 (95% CI 0.90 to 1.05)Saturated fat and CV mortality RR 0.95 (95% CI 0.80 to 1.12)Harcombe Z, Open Heart, 2016 (RCTs of primary or secondary prevention: 10 trials, N 62,421, mean f/u 5.4y) Mean serum total cholesterol lowered Total/saturated fat and all-cause mortality RR 0.99 (95% CI 0.94 to 1.05)Total/saturated fat and CHD mortality RR 0.98 (95% CI 0.88 to 1.08)Harcombe Z, Br J Sports Med, 2017 (Cohorts 7 studies; N 89,801; mean f/u 11.9y) Total fat intake and CHD mortality RR 1.04 (95% CI 0.98 to 1.10) Saturated fat intake and CHD mortality RR 1.08 (95% CI 0.94 to 1.25)
Predicted Changes in Blood Cholesterolbasedon Types of Fat Intake8Saturated fat6Mono unsaturated fatPol yunsaturated fat4% Change20-2-4-6-8-10H DL-CLDL-CLDL-C /HD L-CTGBased on replacement of 5% of energy as carbohydrate with fatty acid.Mensink RP, Arterioscler Thromb, 1992; Hu FB, Willet WC. JAMA 2002.SystematicReviewOf Diabetes% change in HbA1c by% dietary carbohydrate13 trials metcriteria: 45%carbohydrate 2 to 26 weekdurationKirk JK, JADA, 2008.Network Meta-analysis Comparing DietEffects on Glycemia in Type 2 DM Size of nodes:proportionalto total Nallocated toeach diet Thickness oflines:proportionalto number ofstudies ofeach directcomparisonSchwingshackl L, Eur J Epidemiol, 2018.
Zone Diet Typical U.S. Diet Rice Diet) Duke MCD 20 0 50 100 200 300 Calories/day 1000 (Ketonuria) Low Glycemic Index Diet Mediterranean Diet Protein Power, Paleo, So. Beach Phase 1, Duke LCD Atkins Induction, Keto So. Beach Phase 2 Atkins Maintenance DASH Diet VLCD Low Carbohydrate Ketogenic Diet
Low gross-Judy Nicoletti, 166. Low net-Laurie Maesano, 141. Men’s senior flight overall champions: Low gross-Chris Christie, 158. Low net-Don Capretta, 132. Flight 1 Low gross-Jim Creighton, 162. Low net-Don Moore, 139. Flight 2 Low gross-Bobby Bryce, 170 Low net-Bill Snyder, 141. Fligh
Details: 53 healthy but obese females were randomized to either a low-fat diet, or a low-carb diet. Low-fat group was calorie restricted. The study went on for 6 months. Weight Loss: The women in the low-carb group lost an average og 8.5 kg (18.7 lbs), while the low-fat group lost an average of 3.9 kg (8.6 lbs).
3516B 2250 2250 2000 1750 Low Fuel Consumption, Low Emissions 3516B-HD 2500 2500 2275 2000 Low Fuel Consumption, Low Emissions 3516C-HD 2750 2750 2500 — Low Fuel Consumption, Low Emissions PROVEN PERFORMANCE RELIABLE POWER FLEXIBLE CONFIGURATIONS DISCOVER A GENERATOR SET – MADE TO TAKE IT ON. THE CAT 3500 SERIES LINEUP YOU DECIDE THE DETAILS.
51 Chapter six: Low pay and in-work benefits Key points 51 Context 52 Low-paid residents 53 Low-paid jobs 55 Families receiving in-work benefits57 59 Chapter seven: Ethnicity, low income and work Key points 59 Context 60 Low income and ethnicity 61 Work, ethnicity and country of birth 62 The link between work and low income for different ethnic groups 66 67 Chapter eight: Ill health
Pavement Performance, yrs. Ohio High/Low Asphalt 16 Low Composite 11 High Composite 7 North Carolina ---- Concrete 6 –10 Ontario High Asphalt 8 Illinois Low Asphalt 7 –10 New York ---- Asphalt 5 –8 Indiana Low Asphalt 9 –11 Austria High/Low Asphalt 10 High Concrete 8 Georgia Low Asphalt 10
CONTENTS ACKNOWLEDGMENTS v INTRODUCTION 1 1 Low-Carb Comfort Food Cooking Guidelines 5 2 Bread and Other Delicious Low-Carb Baked Goods 19 3 Low-Carb Comfort Food Breakfasts, Brunches, and Light Meals 41 4 Low-Carb Comfort Food Appetizers, Soups, Salads, and Light Lunches 67 5 Low-Carb Comfort Foo
Dipropylene glycol diacrylate Low volatility, good dilution power, low viscosity TPGDA Tripropylene glycol diacrylate Low volatility, low viscosity, good dilution power PPG400DA Polypropylene glycol 400 diacrylate Good flexibilty, low shrinkage, low skin irritation File Size: 486KB
Average Nutrition Herbalife AMOUNTS AMOUNTS High SALT Low High FAT Low High SUGAR Low High CALORIES Low Low NUTRITION High Low FIBER High . 5 Many of us think we are eating well, but are we? Average Kiwi and Aussie diet contains approximately .
Low Vision Services: Low vision examination, low vision aids and fitting of low vision aids are reimbursable to self-employed optometrists specifically certified by the New York State Optometric Association to perform low vision examinations. (Code W0021 has been deleted. To report low vision
Field Effect Transistors Low I, Pulse Polymer Nanofibers/ Nanowires High R/Low I, 1MΩ to 1014Ω Semiconductor Nanowires Low Power, R 10MΩ, Pulse Carbon Nanotubes and Graphene Low Power, R 100kΩ Single Electron Devices/Transistors Low I, Low V Keithley instrumentation is being used in a growing list of nanotechnology research and production .
Low Carb Diet Special Report Carbohydrate Confessions: Stories (and data) from a low carb convert. precisionnutrition.com The low carb to higher carb experiment Things might have gone on like this indefinitely, with me happily eating low carb, and happily preaching to the low carb choir. But last summer my competitive itch came back. And as I .
New CGM features in Manual Mode 1. Expanded Low Limit range Your Low limit can be set as low as 50 mg/dL and up to 90 mg/dL. This is available in both Manual Mode and Auto Mode. 2. Fixed Low Alert Your system has a fixed low alert if your SG reaches or falls below 50 mg/dL. This alert cannot be changed, but the alert can be cleared.
Illumination in sunny day and low light night can vary more than 10 orders of magnitude. In low light scenes, sen-sor noise is not negligible due to the low signal-to-noise ratio (SNR). Therefore, low light image enhancement is an important task which improves the SNR and enhances the
procedures and techniques for design of variable low voltage, low power, and highly power efficient DC-DC converter with low levels of EMI (Electro-Magnetic Interference). Selection of the adequate control scheme for the DC-DC converter is the secondary objective. The result of this work can mainly be used for implementation in digital circuits
A low fiber diet is a normal diet with a reduced amount of fiber (less than 10-15g of fiber) whereas the low residue diet includes the low fiber diet and some other foods that are high residue but low fiber. For example, milk doesn't have any fiber but can leave a residue in the large intestines.1
that even the grown-ups in your life seem worried. Then what do you do? You can’t control the world. But you . can control YOU. You can be smart. You can learn the facts. You can use common sense. You can take responsibility for how you act. or face the consequences. You know what . conseq
Follow a low saturated fat, low cholesterol diet. 2. Increase omega 3 fatty acids in your diet. 3. Increase fiber sources in your diet. 4. Limit salt, alcohol ,& caffeine. 5. Exercise regularly. 6. Quit smoking. 7. Lose weight if you are overweight or obese. 1. Follow a Low Saturated Fat, Low Cholesterol Diet There are 3 main types of fat in foods.
Jaxon Tech Organizer As Low As: 10.99(C) Min.: 50 CB1012 Champion Packable Jacket As Low As: 29.99(C) Min.: 48 15808 Koozie Hot and Cold Kooler As Low As: 10.79(C) Min.: 48 36872 Pentagon Clock As Low As: 94.54(C) Min.: 6 51002 Snowflake Ornament As Low As: 6.71(C) Min.: 25 32379 High-definition Power Bank 5000 mAh
Advantages of optical networks High speed capability (theoretically possible to send 50 Terabits per second using a single fiber) Low signal attenuation Low signal distortion Low power requirement Low material usage Small space requirements Low cost Immunity to electrical interference.
ample is Koala, an ultra-low power system for reliable data retrieval. Koala uses FCP to establish reliable network paths for downloading sensor data. To achieve ultra-low duty cy-cles Koala couples FCP with Low Power Probing (LPP), a novel mechanism for waking up the network. Unlike Low Power Listening (LPL), in which receivers periodically poll the channel for long preambles from senders .