Oh Robert C, Murphy Kendrick C, Jenks Cory M, Lopez Kathleen B, Patel Mahendra A, Scotland Emily E, Khanna Monu
Veterans Affairs Palo Alto Health Care System, California.
Western North Carolina Veterans Affairs Health Care System, Asheville.
Fed Pract. 2024 Jan;41(1):6-15. doi: 10.12788/fp.0429. Epub 2024 Jan 20.
Type 2 diabetes mellitus (T2DM) has been traditionally considered a chronic, progressive disease. Since 2017, guidelines from the US Department of Veterans Affairs and US Department of Defense have included low-carbohydrate (LC) dietary patterns in managing T2DM. Recently, carbohydrate reduction, including ketogenic diets, has gained renewed interest in the management and remission of T2DM.
This narrative review examines the evidence behind carbohydrate reduction in T2DM and a practical guide for clinicians starting patients on therapeutic LC diets. We present an illustrative case and provide practical approaches to prescribing a very LC ketogenic (< 50 g), LC (50-100 g), or a moderate LC (101-150 g) dietary plan and discuss adverse effects and management of LC diets. We provide a medication management and deprescription approach and discuss strategies to consider in conjunction with LC diets. As patients adopt LC diets, glycemia improves, and medications are deprescribed, hemoglobin A levels and fasting glucose may drop below the diagnostic threshold for T2DM. Remission of T2DM may occur with LC diets (hemoglobin A < 6.5% for ≥ 3 months without T2DM medications). Finally, we describe barriers and limitations to applying therapeutic carbohydrate reduction in a federal health care system.
The effective use of LC diets with close and intensive lifestyle counseling and a safe approach to medication management and deprescribing can improve glycemic control, reduce the overall need for insulin and medication and provide sustained weight loss. The efficacy and continuation of therapeutic carbohydrate reduction for patients with T2DM appears promising. Further research on LC diets, emerging strategies, and long-term effects on cardiometabolic risk factors, morbidity, and mortality will continue to inform practice.
2型糖尿病（T2DM）传统上被认为是一种慢性进行性疾病。自2017年以来，美国退伍军人事务部和国防部的指南已将低碳水化合物（LC）饮食模式纳入T2DM的管理中。最近，包括生酮饮食在内的碳水化合物减少法在T2DM的管理和缓解方面重新引起了人们的兴趣。
本叙述性综述探讨了T2DM中碳水化合物减少背后的证据，以及为开始采用治疗性LC饮食的患者的临床医生提供的实用指南。我们展示了一个示例病例，并提供了开具极低碳水化合物生酮（<50克）、低碳水化合物（50-100克）或中等低碳水化合物（101-150克）饮食计划的实用方法，并讨论了LC饮食的不良反应及管理。我们提供了药物管理和减药方法，并讨论了与LC饮食联合使用时应考虑的策略。随着患者采用LC饮食，血糖得到改善，药物被减用，糖化血红蛋白水平和空腹血糖可能降至T2DM的诊断阈值以下。采用LC饮食（糖化血红蛋白<6.5%，持续≥3个月且未使用T2DM药物）可能实现T2DM的缓解。最后，我们描述了在联邦医疗保健系统中应用治疗性碳水化合物减少法的障碍和局限性。
有效使用LC饮食，同时进行密切和强化的生活方式咨询，以及采用安全的药物管理和减药方法，可以改善血糖控制，减少胰岛素和药物的总体需求，并实现持续减重。T2DM患者采用治疗性碳水化合物减少法的疗效和持续性似乎很有前景。对LC饮食、新出现的策略以及对心血管代谢危险因素、发病率和死亡率的长期影响的进一步研究将继续为实践提供信息。
