Guide for low-carb dietitians

For decades, doctors specializing in diabetes and obesity management have recommended low-carb diets to their patients, typically with excellent results. However, dietetic associations and many dietitians traditionally hold negative views of carb-restricted diets, often criticizing them as being unbalanced, unsafe, and unsustainable.

As a registered dietitian and certified diabetes educator who has followed and recommended a low-carb lifestyle for more than six years, I respectfully disagree. Moreover, I feel that dietitians should be aware of the mounting evidence supporting carbohydrate restriction and learn how to successfully work with patients and clients using this approach.

First steps for practicing low carb as a registered dietitian

  1. Familiarize yourself with the diet by reading one or more of the following books: The Art and Science of Low Carbohydrate Living by Steve Phinney, MD, and Jeff Volek, PhD, RD, The Art and Science of Low Carbohydrate Performance by Steve Phinney, MD, and Jeff Volek, PhD, RD and Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet by Steve Parker, MD.
  2. Consider following a low-carb or ketogenic diet yourself for at least a month, if you haven’t already done so.
  3. Carry liability insurance before you begin counseling or coaching clients. Although I’m not aware of any dietitians who have used it in connection with practicing low carb, having liability insurance is always recommended when providing dietary advice to patients or clients.

Here is a list of US companies that offer liability insurance for registered dietitians.

Recommending low-carb diets in practice vs. a medical office

Being in private practice allows you to individualize low-carb recommendations with your clients based on your own clinical judgement and experience. However, you may find it difficult to go out on your own right away. I recommend easing into private practice while continuing to learn as much as possible about carb restriction.

You may be able to practice low carb with patients in a medical office setting if the doctors or health care providers you work with believe in a low-carb approach. For instance, registered dietitian Valerie Goldstein provided exclusively low-carb guidance to all patients while working with Dr. Atkins in the early 2000’s. Today, I continue to hear from a growing number of physicians and specialists that they are eager to have their patients work with experienced low-carb dietitians. For instance, Virta Health — an organization committed to reversing diabetes via carb restriction — has hired several dietitians as part of its growing clinical team.

On the other hand, if you’re employed by general practitioners or specialists who are skeptical about low-carb diets, it’s best to introduce the idea gradually by providing recent high-quality studies supporting their benefits.

Below are 10 of the best studies on low-carb and very-low-carb ketogenic diets, including their safety and sustainability.

Top 10 studies supporting low carb and keto diets

  1. Dietary carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base
  2. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials
  3. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet.
  4. Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women
  5. Long-Term Effects of a Very Low Carbohydrate Compared With a High Carbohydrate Diet on Renal Function in Individuals With Type 2 Diabetes: A Randomized Trial.
  6. Do ketogenic diets really suppress appetite? A systematic review and meta-analysis.
  7. Long-term effects of a very-low-carbohydrate weight-loss diet and an isocaloric low-fat diet on bone health in obese adults
  8. The Effects of a Low-Carbohydrate Diet vs.a Low-Fat Diet on Novel Cardiovascular Risk Factors: A Randomized Controlled Trial
  9. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets
  10. A randomised trial of the feasibility of a low carbohydrate diet vs standard carbohydrate counting in adults with type 1 diabetes taking body weight into account

Read more: The science of low carb

American Diabetes Association: moving toward low-carb acceptance

Back in 2011, based on the results of several studies, The American Diabetes Association included the following statement in their Standards of Medical Care in Diabetes:

“For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short term (up to 2 years).”

Then in 2012, at the request of editors at the ADA journal Diabetes Spectrum, I wrote an article about carbohydrate restriction: A Low-Carbohydrate, Whole-Foods Approach to Managing Diabetes and Prediabetes. The article included a sample menu containing 80 grams of net carbs and 55% of calories from fat – definitely well outside of standard recommendations.

Two years later, the ADA published Nutrition Therapy Recommendations for the Management of Adults With Diabetes, which includes the following statements:

  • Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes.”
  • A variety of eating patterns have been shown modestly effective in managing diabetes, including Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH) style, plant-based (vegan or vegetarian), lower-fat, and lower-carbohydrate patterns.”
  • “A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences and metabolic goals should be considered when recommending one eating pattern over another.

I believe these statements allow dietitians to use critical thinking and clinical judgement when making dietary recommendations for diabetic and prediabetic individuals – the great majority of whom would benefit from a carb-restricted diet.

Potential consequences of practicing low carb

One thing to be aware of is the potential backlash by dietitians who hold negative views about low-carb diets. In recent years, some dietitians report having been censured or fired as a result of practicing carb restriction with clients or patients.

The most notable case is that of Jennifer Elliott from New South Wales, Australia. After working as a dietitian for more than 30 years, Jennifer received notice of a formal complaint from another dietitian for recommending low-carb diets to her patients with diabetes and metabolic syndrome. She was eventually deregistered by the Dietitians Association of Australia, which led to her loss of employment. You can read more about Jennifer’s story here.

To my knowledge, there aren’t any other cases of dietitians having lost their credentials for practicing low carb outside of Australia.

Make sure to include a disclaimer about your practice

Although including a disclaimer on your business website won’t completely protect you against complaints, it’s best to make very clear that your own dietary recommendations differ from those of major health organizations.

Here is the disclaimer that I use on my own website, which can be tailored as needed for your country of residence:

“Although I am a health care professional, I am not a physician and cannot diagnose or treat diabetes or other conditions; I can only provide nutritional advice and guidance. Some of the nutrition advice I provide is not universally accepted as evidence-based practice and is neither sponsored, approved, recommended nor endorsed by the United States Department of Agriculture (USDA), FDA (Food and Drug Administration), NIH (National Institutes of Health), American Heart Association (AHA), American Diabetes Association (ADA), or Academy of Nutrition and Dietetics (AND). Always consult with your physician prior to adopting a low-carbohydrate diet or making other dietary changes.

Network of low-carb practitioners

Here are a few resources for finding like-minded dietitians and other practitioners in different parts of the world:

FoodMed.Net:
Low-Carb Dietitians and Nutritionists
Low-Carb Doctors
Low-Carb Nurses

Facebook:
Email me at franziska@lowcarbdietitian.com if you are a registered dietitian interested in joining a private Facebook group of international low-carb dietitians.

Low-carb dietitians: a growing breed

I firmly believe that as dietitians, we can help people become healthier by providing individualized recommendations based on nutrient-dense, unprocessed low-carb plant and animal foods. Fortunately, the number of dietitians who practice low carb – or are open to doing so – is growing at a steady pace.

However, I feel we need to be diplomatic and respectful when engaging with colleagues who don’t yet share our views, both for the sake of remaining professional and protecting ourselves from being targeted. As experimental and anecdotal evidence supporting carb restriction continues to mount, I’m confident that more and more dietitians will recognize the importance of offering this option to patients and clients.

Please feel free to suggest additional information or resources that would be helpful by emailing me at franziska@lowcarbdietitian.com, or using the comments section below.


Franziska Spritzler, RD

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"A more pleasurable way to live"

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Comments

7 Comments

  1. Kris
    Thank you so much for this information. Such a great feeling to know I'm not alone!
  2. Joshua
    Can I favorite a post? Because this post deserves it. As a dietitian, I completely agree that it is our time to step up and be advocates for what science is really showing. Onward and upward.
  3. Jill
    I’ll favorite it too! We must keep moving the conversation towards low carb and embracing healthy fats. Follow the science! Thanks for writing this!!
  4. Andre Chimene
    Great work Franziska
    Congrats‼️
  5. Kenrick
    I live in France and the resistance to low carb by the establishment is really incredible ...which is ironic really when considering it was an 18th Centrury French Doctor who pioneered one of the earlier low carb diets !

    Certain foods like eating bread in France is such an ingrained cultural norm I am not sure how much evidence is offered will stop them eating it ...it will take years of determination to even begin to change cultural norms and create the paradigm shift that is needed ...

    Meanwhile like other countries the obesity rate in France is increasing constantly along with Type 2 Diabetes etc etc ...

    I despair ...but long gone is the notion of the slim middle aged women the French were much renowned for ...the greater majority of men here my age have huge over hanging bellies ...I was shocked when I first moved here from UK...

    I am 53 been a low carb follower for 5 yrs lost 5 .8 stone when I started and now have a 32 inch waist ( the same as when I was 18 ) ...my wife is the same size and weight now as she was at 16...size 8 having been size 14 prior to keto time ...so in life before Keto we were very much typical shape and size as other people our age ...

    But 90% of our friends are all either very over weight, obese all suffering from typical western diet health issues ...the biggest reaction I get from them is not “wow you look good” but “oh I guess you can eat what you want and stay slim aren’t you lucky! ” ...that then normally is my trigger to get out photos of old self and talk about how my wife and I follow a keto diet regime ...

    But the moment I mention potatoes, pasta, rice and bread then I have lost them forever ...sad ...not forgetting their horror when I mention eating saturated fats lol...

    Things will change but with ingrained behaviour and the mega billions of dollars wrapped up in gains, low fats and pharmaceuticals it’s going to be a long hard battle ...

    Ric

  6. Joe
    My A1C was at 9 had high colesterol,labs were out of control,acid reflux and was 213 lbs. and taking about 7 different meds. Took the 2 week challenge and lost 20 lbs. Kept eating Keto and in 2-1/2 months was down 40 lbs. my blood sugar was dropping a lot. My A1C is now at 5.4 all labs are at normal range,and no longer suffer from acid reflux.went from size 40 pants down to 34’S and ready to go to 32’s and best of all use no more meds for Diabetes colesterol or acid reflux. Been eating Keto since July2 2017 and feeling great. One of my Dr. told me to get off Keto because it’s wasn’t good for me,about 6 month ago.I just did full labs and went in for a physical with him and he couldn’t believe how good my labs were and how good I looked,so he asked me how I did this,and of course he didn’t remember about me being on Keto. So I said by staying on a Keto diet. He even asked me for the web site so he could tell othe ppl about it.
  7. Leslie
    I love this post!!

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