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Athinarayanan SJ, Roberts CGP, Vangala C, Shetty GK, McKenzie AL, Weimbs T, Volek JS. The case for a ketogenic diet in the management of kidney disease. BMJ Open Diabetes Res Care 2024; 12:e004101. [PMID: 38677719 DOI: 10.1136/bmjdrc-2024-004101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024] Open
Abstract
Ketogenic diets have been widely used for weight loss and are increasingly used in the management of type 2 diabetes. Despite evidence that ketones have multiple positive effects on kidney function, common misconceptions about ketogenic diets, such as high protein content and acid load, have prevented their widespread use in individuals with impaired kidney function. Clinical trial evidence focusing on major adverse kidney events is sparse. The aim of this review is to explore the effects of a ketogenic diet, with an emphasis on the pleiotropic actions of ketones, on kidney health. Given the minimal concerns in relation to the potential renoprotective effects of a ketogenic diet, future studies should evaluate the safety and efficacy of ketogenic interventions in kidney disease.
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Affiliation(s)
| | | | | | | | | | - Thomas Weimbs
- Department of Molecular Cellular & Developmental Biology, University of California Santa Barbara, Santa Barbara, California, USA
| | - Jeff S Volek
- Department of Human Sciences, The Ohio State University, Columbus, Ohio, USA
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McKenzie AL, Athinarayanan SJ. Impact of Glucagon-Like Peptide 1 Agonist Deprescription in Type 2 Diabetes in a Real-World Setting: A Propensity Score Matched Cohort Study. Diabetes Ther 2024; 15:843-853. [PMID: 38421559 PMCID: PMC10951146 DOI: 10.1007/s13300-024-01547-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Glucagon-like peptide 1 receptor agonists (GLP-1) elicit substantial reductions in glycemia and body weight in people with type 2 diabetes (T2D) and obesity, but existing data suggest the therapy must be continued indefinitely to maintain clinical improvements. Given the high cost and poor real-world persistence of GLP-1, an effective therapy that enables deprescription with sustained clinical improvements would be beneficial. Thus, the purpose of this real-world study was to assess the effect of GLP-1 deprescription on glycemia and body weight following co-therapy with carbohydrate restricted nutrition therapy (CRNT) supported via telemedicine in a continuous remote care model. METHODS A retrospective, propensity score matched cohort study among patients with T2D at a telemedicine clinic was conducted. Patients in whom GLP-1 were deprescribed (DeRx; n = 154) were matched 1:1 with patients in whom GLP-1 were continued (Rx). HbA1c and body weight at enrollment in clinic (pre-CRNT), at date of deprescription or index date (derx/ID), and at 6 and 12 months (m) post-derx/ID were utilized in this study. RESULTS No regression in weight was observed following deprescription with > 70% maintaining ≥ 5% weight loss 12 m post-derx/ID. HbA1c rose 6 m and 12 m post-derx/ID in both DeRx and Rx cohorts, but most patients maintained HbA1c < 6.5%. HbA1c and body weight measured 6 m and 12 m following derx/ID did not significantly differ between cohorts and were improved at derx/ID and at follow-up intervals compared to pre-CRNT. CONCLUSION These results demonstrate the potential for an alternate therapy, such as CRNT supported via telemedicine, to enable maintenance of weight loss and glycemia below therapeutic targets following discontinuation of GLP-1 therapy.
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Volk BM, Roberts CGP, VanTieghem M, George MP, Adams RN, Athinarayanan SJ, McKenzie AL. Reduced COVID-19 severity elicited by weight loss from a medically supervised ketogenic diet in a geographically diverse ambulatory population with type 2 diabetes and obesity. BMJ Nutr Prev Health 2022; 5:154-158. [PMID: 36619341 PMCID: PMC9813610 DOI: 10.1136/bmjnph-2022-000444] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/20/2022] [Indexed: 01/11/2023] Open
Abstract
Objective To investigate factors associated with COVID-19 severity in ambulatory individuals with type 2 diabetes mellitus (T2DM) and obesity treated with a medically supervised ketogenic diet (MSKD). Research design and methods In this real-world, retrospective, exploratory analysis, multivariate modelling was used to assess clinical factors associated with hospitalisation for COVID-19 in a geographically diverse outpatient population with T2DM treated virtually. Results Leading up to COVID-19 onset, non-hospitalised patients had higher average ketones (0.64 vs 0.52 mmol/L; p=0.016) and greater weight loss (6.8% vs 4.2%; p=0.009) compared with those hospitalised. Greater weight loss was significantly associated with lower likelihood of hospitalisation (adjusted OR=0.91, p=0.005), controlling for enrolment demographics and medical characteristics. Conclusions Therapies such as MSKD, which elicit rapid, significant weight loss, may favourably impact COVID-19 hospitalisation rate and severity in individuals with T2DM and obesity.
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Affiliation(s)
| | | | | | - M Patricia George
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Rebecca N Adams
- Clinical Research, Virta Health, San Francisco, California, USA
| | | | - Amy L McKenzie
- Clinical Research, Virta Health, San Francisco, California, USA
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Athinarayanan SJ, Adams RN, VanTieghem M, McKenzie AL, Volk BM, Ratner RE, Phinney SD. Impact of the COVID-19 Pandemic on the Effectiveness of a Metabolic Health Telemedicine Intervention for Weight Loss: A Propensity Score Matching Analysis. Front Public Health 2022; 10:897099. [PMID: 35784202 PMCID: PMC9246258 DOI: 10.3389/fpubh.2022.897099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCoronavirus disease 2019 (COVID-19) pandemic public health measures such as stay-at-home and mandatory work-from-home orders have been associated with obesogenic lifestyle changes, increased risk of weight gain, and their metabolic sequelae. We sought to assess the impact of this pandemic on weight loss from a telemedicine-delivered very-low-carbohydrate intervention targeting nutritional ketosis (NKI).MethodsA total of 746 patients with a BMI ≥25kg/m2, enrolled between January and March 2020 and treated for at least 1 year with the NKI, were classified as pandemic cohort (PC). A separate cohort of 699 patients who received 1 year of the NKI in the preceding years, enrolled between January and March 2018, were identified as pre-pandemic cohort (Pre-PC). Demographic and clinical data were obtained from medical records to compare the cohorts and assess the outcomes. Using propensity score matching (PSM), balanced and matched groups of 407 patients in the Pre-PC and 407 patients in the PC were generated. Longitudinal change in absolute weight and percentage weight change from baseline to 1 year were assessed.ResultsWeight significantly decreased in both PC and Pre-PC at 3, 6, 9, and 12 months. The weight loss trajectory was similar in both PC and Pre-PC with no significant weight differences between the two cohorts at 3, 6, 9, and 12 months. On an average, the PC lost 7.5% body weight while the Pre-PC lost 7.9% over 1 year, and the percent weight loss did not differ between the two cohorts (p = 0.50).ConclusionA very-low-carbohydrate telemedicine intervention delivered comparable and medically significant weight loss independent of pandemic stress and lifestyle limitations.
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Lyman KS, Athinarayanan SJ, McKenzie AL, Pearson CL, Adams RN, Hallberg SJ, McCarter JP, Volek JS, Phinney SD, Andrawis JP. Continuous care intervention with carbohydrate restriction improves physical function of the knees among patients with type 2 diabetes: a non-randomized study. BMC Musculoskelet Disord 2022; 23:297. [PMID: 35351093 PMCID: PMC8961996 DOI: 10.1186/s12891-022-05258-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 03/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background In a previous study, we assessed a novel, remotely monitored carbohydrate restricted diet regimen including nutritional ketosis in patients with type 2 diabetes and reported significant improvements in weight, glycemic control, abdominal fat and inflammation from baseline to 2 years. Knee outcome measures were collected as a secondary outcome in the trial. This study aims to assess the effect of this intervention on knee functional scores and to identify if changes in weight, central abdominal fat (CAF), glycemic status and high sensitivity C-reactive protein (hsCRP) were associated with its improvement. Methods This prospective analysis included continuous care intervention (CCI, n = 173) and usual care (UC, n = 69) trial participants with type 2 diabetes that reported knee pain at baseline. Knee outcome measures included the Knee injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, activities of daily living (ADL), sports and recreation function, and knee-related quality of life subscales, and total KOOS score were assessed from baseline to 2 years. Missing data at each time point were replaced with multiple imputation under the assumption of missing at random. To assess if the primary analysis of the knee scores changed under plausible missing not at random assumptions, sensitivity analysis was also performed using pattern mixture models. In CCI, we also assessed factors associated with the improvement of knee scores. Results In the primary analysis, CCI participants demonstrated a statistically significant improvement in total KOOS and all KOOS individual subscale scores at 1 year and maintained through 2 years as opposed to UC patients who showed no significant changes from baseline to 2 years. The significant improvement in total KOOS and its individual subscale scores from baseline to 2 years remained relatively stable in CCI in the sensitivity analysis under different missing not at random scenarios confirming the robustness of the findings from the primary analysis. Approximately 46% of the CCI participants met the 10 points minimal clinically important change at 2 years. A reduction in CAF was associated with improvement in total KOOS and KOOS ADL, while a decrease in hsCRP was associated with improvement in KOOS symptoms scores. Conclusion A very low carbohydrate intervention including nutritional ketosis resulted in significant improvements in knee pain and function among patients with T2D. The improvements in knee function were likely secondary to a reduction in central adiposity and inflammation. Future research on the applicability of this intervention in radiographically confirmed OA patients is important. Trial registration Clinical trial registration: NCT02519309 (10/08/2015). Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05258-0.
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Adams RN, Athinarayanan SJ, McKenzie AL, Hallberg SJ, McCarter JP, Phinney SD, Gonzalez JS. Depressive symptoms improve over 2 years of type 2 diabetes treatment via a digital continuous remote care intervention focused on carbohydrate restriction. J Behav Med 2022; 45:416-427. [PMID: 35084637 PMCID: PMC9160138 DOI: 10.1007/s10865-021-00272-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 12/13/2021] [Indexed: 01/02/2023]
Abstract
Depressive symptoms are prevalent among people with type 2 diabetes (T2D) and, even at low severity levels, are associated with worse diabetes outcomes. Carbohydrate restriction is an effective treatment for T2D but its long-term impacts on depressive symptoms are unclear. In the current study we explored changes in depressive symptoms over 2 years among 262 primarily non-depressed T2D patients participating in a continuous remote care intervention emphasizing carbohydrate restriction. Subclinical depressive symptoms decreased over the first 10 weeks and reductions were maintained out to 2 years. Increased frequency of blood ketone levels indicative of adherence to low carbohydrate eating predicted decreases in depressive symptoms. Concerns have been raised with recommending restrictive diets due to potential negative impacts on quality-of-life factors such as mood; however, results of the current study support positive rather than negative long-term impacts of closely monitored carbohydrate restriction on depressive symptoms.
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Affiliation(s)
- Rebecca N Adams
- Virta Health Corp, 501 Folsom Street, San Francisco, CA, 94105, USA.
| | | | - Amy L McKenzie
- Virta Health Corp, 501 Folsom Street, San Francisco, CA, 94105, USA
| | - Sarah J Hallberg
- Virta Health Corp, 501 Folsom Street, San Francisco, CA, 94105, USA
- Indiana University Health Arnett, Lafayette, IN, USA
| | - James P McCarter
- Abbott Diabetes Care, Alameda, CA, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Jeffrey S Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
- Departments of Medicine (Endocrinology) and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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McKenzie AL, Athinarayanan SJ, McCue JJ, Adams RN, Keyes M, McCarter JP, Volek JS, Phinney SD, Hallberg SJ. Type 2 Diabetes Prevention Focused on Normalization of Glycemia: A Two-Year Pilot Study. Nutrients 2021; 13:749. [PMID: 33652715 PMCID: PMC7996820 DOI: 10.3390/nu13030749] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/09/2021] [Accepted: 02/19/2021] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study is to assess the effects of an alternative approach to type 2 diabetes prevention. Ninety-six patients with prediabetes (age 52 (10) years; 80% female; BMI 39.2 (7.1) kg/m2) received a continuous remote care intervention focused on reducing hyperglycemia through carbohydrate restricted nutrition therapy for two years in a single arm, prospective, longitudinal pilot study. Two-year retention was 75% (72 of 96 participants). Fifty-one percent of participants (49 of 96) met carbohydrate restriction goals as assessed by blood beta-hydroxybutyrate concentrations for more than one-third of reported measurements. Estimated cumulative incidence of normoglycemia (HbA1c <5.7% without medication) and type 2 diabetes (HbA1c ≥6.5% or <6.5% with medication other than metformin) at two years were 52.3% and 3%, respectively. Prevalence of metabolic syndrome, class II or greater obesity, and suspected hepatic steatosis significantly decreased at two years. These results demonstrate the potential utility of an alternate approach to type 2 diabetes prevention, carbohydrate restricted nutrition therapy delivered through a continuous remote care model, for normalization of glycemia and improvement in related comorbidities.
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Affiliation(s)
- Amy L McKenzie
- Virta Health, San Francisco, CA 94105, USA; (S.J.A.); (R.N.A.); (J.S.V.); (S.D.P.); (S.J.H.)
| | | | - Jackson J McCue
- University of Washington School of Medicine Wyoming WWAMI, Laramie, WY 82071, USA;
| | - Rebecca N Adams
- Virta Health, San Francisco, CA 94105, USA; (S.J.A.); (R.N.A.); (J.S.V.); (S.D.P.); (S.J.H.)
| | - Monica Keyes
- Department of Bariatric and Medical Weight Loss, Indiana University Health-Arnett, Lafayette, IN 47905, USA;
| | - James P McCarter
- Department of Genetics, Washington University School of Medicine, St. Louis, MO 63110, USA;
- Abbott Diabetes Care, Inc., Alameda, CA 94502, USA
| | - Jeff S Volek
- Virta Health, San Francisco, CA 94105, USA; (S.J.A.); (R.N.A.); (J.S.V.); (S.D.P.); (S.J.H.)
- Department of Human Sciences, The Ohio State University, Columbus, OH 43210, USA
| | - Stephen D Phinney
- Virta Health, San Francisco, CA 94105, USA; (S.J.A.); (R.N.A.); (J.S.V.); (S.D.P.); (S.J.H.)
| | - Sarah J Hallberg
- Virta Health, San Francisco, CA 94105, USA; (S.J.A.); (R.N.A.); (J.S.V.); (S.D.P.); (S.J.H.)
- Department of Bariatric and Medical Weight Loss, Indiana University Health-Arnett, Lafayette, IN 47905, USA;
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Athinarayanan SJ, Hallberg SJ, McKenzie AL, Lechner K, King S, McCarter JP, Volek JS, Phinney SD, Krauss RM. Correction to: Impact of a 2‑year trial of nutritional ketosis on indices of cardiovascular disease risk in patients with type 2 diabetes. Cardiovasc Diabetol 2021; 20:37. [PMID: 33546666 PMCID: PMC7866435 DOI: 10.1186/s12933-021-01214-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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Affiliation(s)
| | - Sarah J Hallberg
- Virta Health, 501 Folsom Street, San Francisco, CA, 94105, USA.,Indiana University Health Arnett, Lafayette, IN, USA.,School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Amy L McKenzie
- Virta Health, 501 Folsom Street, San Francisco, CA, 94105, USA
| | - Katharina Lechner
- Department of Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Partner Site Munich, Munich, Germany
| | - Sarah King
- School of Medicine, University of California, San Francisco, CA, 94143, USA
| | - James P McCarter
- Abbott Diabetes Care, Alameda, CA, 94502, USA.,Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeff S Volek
- Virta Health, 501 Folsom Street, San Francisco, CA, 94105, USA.,Department of Human Sciences, The Ohio State University, Columbus, OH, USA
| | | | - Ronald M Krauss
- School of Medicine, University of California, San Francisco, CA, 94143, USA.
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Athinarayanan SJ, Hallberg SJ, McKenzie AL, Lechner K, King S, McCarter JP, Volek JS, Phinney SD, Krauss RM. Impact of a 2-year trial of nutritional ketosis on indices of cardiovascular disease risk in patients with type 2 diabetes. Cardiovasc Diabetol 2020; 19:208. [PMID: 33292205 PMCID: PMC7724865 DOI: 10.1186/s12933-020-01178-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/15/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND We have previously reported that in patients with type 2 diabetes (T2D) consumption of a very low carbohydrate diet capable of inducing nutritional ketosis over 2 years (continuous care intervention, CCI) resulted in improved body weight, glycemic control, and multiple risk factors for cardiovascular disease (CVD) with the exception of an increase in low density lipoprotein cholesterol (LDL-C). In the present study, we report the impact of this intervention on markers of risk for atherosclerotic cardiovascular disease (CVD), with a focus on lipoprotein subfraction particle concentrations as well as carotid-artery intima-media thickness (CIMT). METHODS Analyses were performed in patients with T2D who completed 2 years of this study (CCI; n = 194; usual care (UC): n = 68). Lipoprotein subfraction particle concentrations were measured by ion mobility at baseline, 1, and 2 years and CIMT was measured at baseline and 2 years. Principal component analysis (PCA) was used to assess changes in independent clusters of lipoprotein particles. RESULTS At 2 years, CCI resulted in a 23% decrease of small LDL IIIb and a 29% increase of large LDL I with no change in total LDL particle concentration or ApoB. The change in proportion of smaller and larger LDL was reflected by reversal of the small LDL subclass phenotype B in a high proportion of CCI participants (48.1%) and a shift in the principal component (PC) representing the atherogenic lipoprotein phenotype characteristic of T2D from a major to a secondary component of the total variance. The increase in LDL-C in the CCI group was mainly attributed to larger cholesterol-enriched LDL particles. CIMT showed no change in either the CCI or UC group. CONCLUSION Consumption of a very low carbohydrate diet with nutritional ketosis for 2 years in patients with type 2 diabetes lowered levels of small LDL particles that are commonly increased in diabetic dyslipidemia and are a marker for heightened CVD risk. A corresponding increase in concentrations of larger LDL particles was responsible for higher levels of plasma LDL-C. The lack of increase in total LDL particles, ApoB, and in progression of CIMT, provide supporting evidence that this dietary intervention did not adversely affect risk of CVD.
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Affiliation(s)
| | - Sarah J Hallberg
- Virta Health, 501 Folsom Street, San Francisco, CA, 94105, USA.,Indiana University Health Arnett, Lafayette, IN, USA.,Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Amy L McKenzie
- Virta Health, 501 Folsom Street, San Francisco, CA, 94105, USA
| | - Katharina Lechner
- Department of Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Sarah King
- School of Medicine, University of California, San Francisco, CA, 94143, USA
| | - James P McCarter
- Abbott Diabetes Care, Alameda, CA, 94502, USA.,Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeff S Volek
- Virta Health, 501 Folsom Street, San Francisco, CA, 94105, USA.,Department of Human Sciences, The Ohio State University, Columbus, OH, USA
| | | | - Ronald M Krauss
- School of Medicine, University of California, San Francisco, CA, 94143, USA.
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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 Obes Metab 2019; 21:1769-1779. [PMID: 30941880 PMCID: PMC6767093 DOI: 10.1111/dom.13736] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/26/2019] [Accepted: 03/31/2019] [Indexed: 12/15/2022]
Abstract
AIMS The global rate of type 2 diabetes (T2D) continues to rise. Guidelines that influence the worldwide treatment of this disease are central to changing this trajectory. We sought in this review to evaluate the appropriateness of sources cited in the American Diabetes Association's (ADA) guidelines on eating patterns for T2D management, identify additional relevant sources, and evaluate the evidence. MATERIALS AND METHODS We reviewed the evidence behind the ADA's recommendations on eating patterns in the 2018 and 2019 ADA Standards of Care and the 2014 ADA Nutrition Therapy Recommendations for Adults with Diabetes. Additionally, we conducted a comprehensive search to identify any additional studies not included in the cited evidence. To determine appropriateness of inclusion in the guidelines, the following criteria were applied: 1) it was a clinical trial or systematic review/meta-analysis of clinical trials; 2) it involved persons with T2D; 3) one of the study arms followed one of the eating patterns currently recommended; 4) its reported outcomes included glycaemic control; 5) outcomes were reported separately for persons with T2D. RESULTS We found a wide variation in the evidence for each eating pattern. Issues that have hampered the guideline process include: lack of a rigorous literature review, resulting in the omission of pertinent studies; an overreliance on prospective cohort studies; inconsistent standards for evidence; inclusion of studies not on persons with T2D; and bias. CONCLUSIONS The ADA Guidelines recommended eating patterns fall short of rigorous standards of scientific review according to state-of-the-art systematic review and guideline creation practices.
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Affiliation(s)
- Sarah J. Hallberg
- Medically Supervised Weight LossIndiana University Health ArnettLafayetteIndiana
- Research Virta HealthSan FranciscoCalifornia
- Department of MedicineIndiana University School of MedicineIndianapolisIndiana
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Hallberg SJ, Gershuni VM, Hazbun TL, Athinarayanan SJ. Reply to "Utility of Unrefined Carbohydrates in Type 2 Diabetes. Comment on Reversing Type 2 Diabetes: A Narrative Review of the Evidence, Nutrients, 2019, 11, 766". Nutrients 2019; 11:nu11071644. [PMID: 31323831 PMCID: PMC6683030 DOI: 10.3390/nu11071644] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sarah J Hallberg
- Virta Health, 535 Mission Street, San Francisco, CA 94105, USA.
- Indiana University Health Arnett, Lafayette, IN 47904, USA.
- Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Victoria M Gershuni
- Department of Surgery, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Tamara L Hazbun
- Indiana University Health Arnett, Lafayette, IN 47904, USA.
- Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Athinarayanan SJ, Adams RN, Hallberg SJ, McKenzie AL, Bhanpuri NH, Campbell WW, Volek JS, Phinney SD, McCarter JP. Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 2-Year Non-randomized Clinical Trial. Front Endocrinol (Lausanne) 2019; 10:348. [PMID: 31231311 PMCID: PMC6561315 DOI: 10.3389/fendo.2019.00348] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
Abstract
Purpose: Studies on long-term sustainability of low-carbohydrate approaches to treat diabetes are limited. We previously reported the effectiveness of a novel digitally-monitored continuous care intervention (CCI) including nutritional ketosis in improving weight, glycemic outcomes, lipid, and liver marker changes at 1 year. Here, we assess the effects of the CCI at 2 years. Materials and methods: An open label, non-randomized, controlled study with 262 and 87 participants with T2D were enrolled in the CCI and usual care (UC) groups, respectively. Primary outcomes were retention, glycemic control, and weight changes at 2 years. Secondary outcomes included changes in body composition, liver, cardiovascular, kidney, thyroid and inflammatory markers, diabetes medication use and disease status. Results: Reductions from baseline to 2 years in the CCI group resulting from intent-to-treat analyses included: HbA1c, fasting glucose, fasting insulin, weight, systolic blood pressure, diastolic blood pressure, triglycerides, and liver alanine transaminase, and HDL-C increased. Spine bone mineral density in the CCI group was unchanged. Use of any glycemic control medication (excluding metformin) among CCI participants declined (from 55.7 to 26.8%) including insulin (-62%) and sulfonylureas (-100%). The UC group had no changes in these parameters (except uric acid and anion gap) or diabetes medication use. There was also resolution of diabetes (reversal, 53.5%; remission, 17.6%) in the CCI group but not in UC. All the reported improvements had p < 0.00012. Conclusion: The CCI group sustained long-term beneficial effects on multiple clinical markers of diabetes and cardiometabolic health at 2 years while utilizing less medication. The intervention was also effective in the resolution of diabetes and visceral obesity with no adverse effect on bone health. Clinical Trial Registration: Clinicaltrials.gov NCT02519309.
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Affiliation(s)
| | | | - Sarah J. Hallberg
- Virta Health Corp, San Francisco, CA, United States
- Indiana University Health Arnett, Lafayette, IN, United States
| | | | | | - Wayne W. Campbell
- Department of Nutrition Science, Purdue University, West Lafayette, IN, United States
| | - Jeff S. Volek
- Virta Health Corp, San Francisco, CA, United States
- Department of Human Sciences, The Ohio State University, Columbus, OH, United States
| | | | - James P. McCarter
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, United States
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Hallberg SJ, Gershuni VM, Hazbun TL, Athinarayanan SJ. Reversing Type 2 Diabetes: A Narrative Review of the Evidence. Nutrients 2019; 11:E766. [PMID: 30939855 PMCID: PMC6520897 DOI: 10.3390/nu11040766] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/22/2019] [Accepted: 03/22/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Type 2 diabetes (T2D) has long been identified as an incurable chronic disease based on traditional means of treatment. Research now exists that suggests reversal is possible through other means that have only recently been embraced in the guidelines. This narrative review examines the evidence for T2D reversal using each of the three methods, including advantages and limitations for each. METHODS A literature search was performed, and a total of 99 original articles containing information pertaining to diabetes reversal or remission were included. RESULTS Evidence exists that T2D reversal is achievable using bariatric surgery, low-calorie diets (LCD), or carbohydrate restriction (LC). Bariatric surgery has been recommended for the treatment of T2D since 2016 by an international diabetes consensus group. Both the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) now recommend a LC eating pattern and support the short-term use of LCD for weight loss. However, only T2D treatment, not reversal, is discussed in their guidelines. CONCLUSION Given the state of evidence for T2D reversal, healthcare providers need to be educated on reversal options so they can actively engage in counseling patients who may desire this approach to their disease.
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Affiliation(s)
- Sarah J Hallberg
- Virta Health, 535 Mission Street, San Francisco, CA 94105, USA.
- Indiana University Health Arnett, Lafayette, IN 47904, USA.
- Indiana University School of Medicine, Indianapolis, 46202 IN, USA.
| | - Victoria M Gershuni
- Department of Surgery, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Tamara L Hazbun
- Indiana University Health Arnett, Lafayette, IN 47904, USA.
- Indiana University School of Medicine, Indianapolis, 46202 IN, USA.
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Vilar-Gomez E, Athinarayanan SJ, Adams RN, Hallberg SJ, Bhanpuri NH, McKenzie AL, Campbell WW, McCarter JP, Phinney SD, Volek JS, Chalasani N. Post hoc analyses of surrogate markers of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis in patients with type 2 diabetes in a digitally supported continuous care intervention: an open-label, non-randomised controlled study. BMJ Open 2019; 9:e023597. [PMID: 30803948 PMCID: PMC6398805 DOI: 10.1136/bmjopen-2018-023597] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE One year of comprehensive continuous care intervention (CCI) through nutritional ketosis improves glycosylated haemoglobin(HbA1c), body weight and liver enzymes among patients with type 2 diabetes (T2D). Here, we report the effect of the CCI on surrogate scores of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis. METHODS This was a non-randomised longitudinal study, including adults with T2D who were self-enrolled to the CCI (n=262) or to receive usual care (UC, n=87) during 1 year. An NAFLD liver fat score (N-LFS) >-0.640 defined the presence of fatty liver. An NAFLD fibrosis score (NFS) of >0.675 identified subjects with advanced fibrosis. Changes in N-LFS and NFS at 1 year were the main endpoints. RESULTS At baseline, NAFLD was present in 95% of patients in the CCI and 90% of patients in the UC. At 1 year, weight loss of ≥5% was achieved in 79% of patients in the CCI versus 19% of patients in UC (p<0.001). N-LFS mean score was reduced in the CCI group (-1.95±0.22, p<0.001), whereas it was not changed in the UC (0.47±0.41, p=0.26) (CCI vs UC, p<0.001). NFS was reduced in the CCI group (-0.65±0.06, p<0.001) compared with UC (0.26±0.11, p=0.02) (p<0.001 between two groups). In the CCI group, the percentage of individuals with a low probability of advanced fibrosis increased from 18% at baseline to 33% at 1 year (p<0.001). CONCLUSIONS One year of a digitally supported CCI significantly improved surrogates of NAFLD and advanced fibrosis in patients with T2D. TRIAL REGISTRATION NUMBER NCT02519309; Results.
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Affiliation(s)
- Eduardo Vilar-Gomez
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Sarah J Hallberg
- Virta Health, San Francisco, California, USA
- Indiana University Health Arnett, Lafayette, Indiana, USA
| | | | | | - Wayne W Campbell
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - James P McCarter
- Virta Health, San Francisco, California, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Jeff S Volek
- Virta Health, San Francisco, California, USA
- Department of Human Sciences, Ohio State University, Columbus, Ohio, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Siegmann MJ, Athinarayanan SJ, Hallberg SJ, McKenzie AL, Bhanpuri NH, Campbell WW, McCarter JP, Phinney SD, Volek JS, Van Dort CJ. Improvement in patient-reported sleep in type 2 diabetes and prediabetes participants receiving a continuous care intervention with nutritional ketosis. Sleep Med 2019; 55:92-99. [PMID: 30772699 DOI: 10.1016/j.sleep.2018.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Sleep disruption is frequently associated with type 2 diabetes (T2D) and hyperglycemia. We recently reported the effectiveness of a continuous care intervention (CCI) emphasizing nutritional ketosis for improving HbA1c, body weight and cardiovascular risk factors in T2D patients. The present study assessed the effect of this CCI approach on sleep quality using a subjective patient-reported sleep questionnaire. METHODS A non-randomized, controlled longitudinal study; 262 T2D and 116 prediabetes patients enrolled in the CCI and 87 separately recruited T2D patients continued usual care (UC) treatment. Patients completed the Pittsburgh Sleep Quality Index (PSQI) questionnaire. A PSQI score of >5 (scale 0 to 21) was used to identify poor sleepers. RESULTS Global sleep quality improved in the CCI T2D (p < 0.001) and prediabetes (p < 0.001) patients after one year of intervention. Subjective sleep quality (component 1), sleep disturbance (component 5) and daytime dysfunction (component 7), also showed improvements in the CCI T2D (p < 0.01 for sleep quality and sleep disturbance; and p < 0.001 for daytime dysfunction) and prediabetes patients (p < 0.001 for all three components); compared to the UC T2D group after one year. The proportion of patients with poor sleep quality was significantly reduced after one year of CCI (T2D; from 68.3% at baseline to 56.5% at one year, p = 0.001 and prediabetes; from 77.9% at baseline to 48.7% at one year, p < 0.001). CONCLUSION This study demonstrates improved sleep quality as assessed by PSQI in patients with T2D and prediabetes undergoing CCI including nutritional ketosis but not in T2D patients receiving UC. The dietary intervention benefited both sleep quality and the severity of T2D symptoms suggesting that nutritional ketosis improves overall health via multiple mechanisms.
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Affiliation(s)
- Morgan J Siegmann
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Sarah J Hallberg
- Virta Health, 535 Mission Street, San Francisco, CA, USA; Indiana University Health Arnett, Lafayette, IN, USA
| | - Amy L McKenzie
- Virta Health, 535 Mission Street, San Francisco, CA, USA
| | | | - Wayne W Campbell
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - James P McCarter
- Virta Health, 535 Mission Street, San Francisco, CA, USA; Department of Genetics, Washington University School of Medicine, St Louis, MO, USA
| | | | - Jeff S Volek
- Virta Health, 535 Mission Street, San Francisco, CA, USA; Department of Human Sciences, The Ohio State University, Columbus, OH, USA
| | - Christa J Van Dort
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA.
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