Low carb & keto
Something is clearly wrong. While our medical knowledge improves every year, and while the world gets richer and healthier every year, wiping out infectious diseases and perfecting our treatment of acute trauma… one thing moves in the opposite direction.
The word-wide epidemic of obesity keeps getting worse, and the epidemic of type 2 diabetes follows. Soon half a BILLION people will have type 2 diabetes, and every second American born today is predicted to get it too. What follows is complications like heart disease, increased cancer risk, kidney disease, blindness, amputations, dementia and more.
Somehow this new epidemic is considered more or less incurable and progressive. Perhaps only major surgery can slow it down, a surgery where we partially remove healthy organs. When we consider amputating healthy organs the only treatment that works, it’s clear that we lack understanding of the disease.
Something is clearly wrong. While medical science and progress continue to eradicate older diseases and improve treatments, this single epidemic threatens to wipe out all medical progress, in all other areas. Already there are signs that the younger generation will live shorter lives than their parents, to a large extent because of complications and disease due to obesity, type 2 diabetes and metabolic syndrome.
Something is deeply wrong, and the resulting suffering and disease is unacceptable, especially if it’s the result of a mistake. Fortunately more and more smart doctors and researchers have figured out the mistake we’ve made.
This epidemic started in the 80s, at the same time as well-meaning American politicians started to push low-fat diet advice to every man, woman and child in the nation. This was based on unproven theories about the health effects of natural fats, that have since been disproven. But by then these theories had become dogma and official policy, not just in the US but around the world.
Less fat in food means less taste and less satiety. The food industry quickly added cheap and addictive sugar and other processed carbs instead… carbs that become blood sugar as soon as they are digested, raising blood glucose and blood levels of the fat-storing hormone insulin. That’s how he obesity epidemic started, that’s how the type 2 diabetes epidemic started.
As doctors, we can’t fix this problem with a drug, or a surgery. We can’t cure a dietary disease with a drug, and we shouldn’t surgically remove healthy organs in the majority of the population. It’s not a solution, because it simply does not work.
A better way
Something else is desperately needed. A treatment that works. A simple way that doctors can help their patients, empowering them to revolutionize their health. Not with lifelong drug treatments to mask some of the symptoms, but with lifestyle interventions that work, to reverse the disease and remove the need of medications. To return the patients to health and wellbeing.
Dozens of randomized controlled trials – the gold standard of nutrition science – now demonstrate that a lower-carb diet is more effective for losing excess weight, reversing type 2 diabetes and improving metabolic risk factors.
The problem is that a low-carb diet is still hard to do for patients, and it’s hard and time-consuming for doctors to learn and implement it with their patients.
On this page we want to solve this problem. At zero cost to you as a doctor, and at zero cost to your patients, we aim to make low carb simple. We’ll provide everything, all the resources you need to safely, quickly and effectively treat your patients with obesity, type 2 diabetes and other metabolic disease.
Diet Doctor is founded and led by a medical doctor, and we’re working with some of the top low-carb doctors and researchers in the world to provide this service. We show no ads, sell no products and take no industry money. We’re 100% owned by the people who work here, and completely funded by the people, via an optional membership.
Our only obligation is to the people we aim to empower, doctors like you and people struggling to improve their health. Thus, we can look objectively at the science, to provide the best possible lifestyle advice that works.
How low carb can improve your effectiveness and happiness as a doctor
Are you frustrated with managing risk factors and increasing daily medications for chronic disease every year? Would you like to empower your patients to instead make themselves healthier long-term, allowing you to remove medications instead of adding it? Plus get the satisfaction and happiness that comes from doing the successful medicine that you were always meant to do?
- Dozens of studies show that low carb is a powerful weight loss tool
- Many studies demonstrates its effectiveness in reversing type 2 diabetes or pre-diabetes
- Many studies show how it helps lower blood pressure
- Several studies show how it helps manage epilepsy
- A few studies show how it can reverse PCOS
2. Patients’ stories
3. Doctors’ storiesPerhaps you’d like to benefit from the experiences and insights of fellow doctors, who’ve already become confident at using low carb to benefit their patients?
Here are several such stories:
4. Misconceptions to break free of
Isn’t fat dangerous, after all? Isn’t weight loss only about calories? And isn’t low carb or keto just another fad diet? Here we answer those misconceptions and more.
The calorie dogma
We’ve all heard it. A calorie is a calorie. It does not matter what you eat as long as you burn it off. It’s Coca Cola’s favorite argument, taking all the blame from the producers of junk food, and blaming the victims.
Unfortunately it’s not true. An avocado is not the same thing as a soft drink for your body, no matter what the calorie count says. The hormonal effects are quite different, and let’s not even mention the vast difference in nutrient levels.
Furthermore, you can’t outrun a bad diet.
While calories do count, most patients do not have to count them. On a low-carb diet appetite is reduced and the ability to burn body fat is vastly increased, reducing hunger and eliminating the need to eat every three hours. People spontaneously eat fewer calories when they stop eating sugar and other bad carbs, and according to some studies they may even burn more calories.
The proof is in the pudding. Low-carb diets without calorie counting, recommending ad libitum food intake, regularly outperform low-fat diets with calorie restriction.
Saturated fats, cholesterol, heart disease etc.
The foundation of the low-fat hysteria was the unproven theory that natural saturated fats increased the risk of heart disease, via its effect on cholesterol levels.
We now know that this has been a mistake. Multiple RCTs and meta-analyses conducted over the last decades have shown no relationship between intake of saturated fats and heart disease.
What can explain this is that cholesterol levels are in some ways consistently improved on a low-carb, high-fat diet, with higher level of the ”good” HDL cholesterol, and lower levels of triglycerides (both of these correlate with a lower risk of heart disease).
One randomized trial even demonstrated a hard endpoint, reduced signs of atherosclerosis in blood vessels after two years of advice to eat a strict low-carb, high fat diet.
It’s clear that the fear of natural fat in real foods has been a mistake, and it’s now high time to let it go.
Isn’t low carb just a fad diet?
The true fad is the last 30-40 years of low-fat hysteria, that has been disproven by modern scientific studies, and now remain as dogma and belief, despite the lack of evidence or effectiveness.
Low carb has been popular for at least 150 years, and it’s backed up by modern science. That’s not a fad, it’s simply something that works.
But don’t take our word for it. Check the scientific studies and then perhaps try it yourself for a week or two. You’ll quickly notice the results. Then you may want to learn some more and try it on your patients with weight issues and type 2 diabetes. Once you try it there’ll be no going back. Because it’s so much more fun to be a doctor when your patients actually get better.
5. Video course
10,995 viewsOur video course for doctors features Dr. David Unwin, a family physician in England, who’s involved in educating doctors and has been treating patients with low-carb diets since 2012.
The course covers very practical tips for doctors, like how to effectively discuss the low-carb lifestyle with patients, how to handle medications, safety, patient motivation and much more.
We hope this will encourage even more doctors to learn how to use low carb in a simple, safe and effective way to empower their patients. For Dr. Unwin it not only helped his patients and saved money for his clinic, it made being a doctor feel rewarding and meaningful again.
- Who are the best patients
- Low carb in other situations
- Is there scientific evidence for low carb?
- Polite intros to discuss obesity
- Explaining low carb in a simple way
- The glycemic index and the teaspoon equivalent
- How to motivate patients
- Baseline tests and screening
- Blood-pressure medications
- Diabetes medications
- Side effects and how to handle them
- What about cholesterol?
- Convincing colleagues
- Common problems and troubleshooting
- Summary and conclusion
- BONUS: Motivating patients to change their lives 1
For more on how to use low carb as a doctor, use the resources below.
6. New patients
Every week new research is published demonstrating the potential benefits of low-carbohydrate diets on many of the chronic diseases that modern medicine is struggling to manage. So how do you select the right patients? Keep reading.
Who can benefit?
The list of potential benefits is growing. Here is a list of the most common conditions that low-carb eating is known to help with, where there is good scientific support for the positive effects:
- Type 2 diabetes
- Polycystic ovarian syndrome (PCOS)
- Non-alcoholic fatty liver disease (NAFLD)
- Type 1 diabetes
- Irritable bowel syndrome (IBS)
Anecdotal or preliminary evidence
There are many other disorders that people often report improvements in, but where there’s still a very limited amount or an absence of reliable science to prove an effect. Whether these commonly reported improvements are mostly due to weight loss or hormonal factors is hard to say. Some of these potential benefits include:
- Sugar cravings and food addiction
- Sleep apnea
- Chronic pain disorders (fibromyalgia, chronic inflammation, etc.)
- Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)
- Potentially some cancers, e.g. brain cancer
- Alzheimer’s disease (possibly prevent or slow down progression, some improvement might occur)
- Mental health (depression, anxiety, etc.)
- Reduced symptoms of ADHD
When is the perfect time to suggest a low-carb diet?
The ideal patients to talk to about low-carb diets are those who are struggling with controlling their weight and who want to do something about it, or have some degree of metabolic syndrome, especially type 2 diabetes.
There are a few key instances where it might be easier to engage your metabolic patient because they’re frustrated with the status of their health. They may then be more motivated to try something new. Some of these situations include:
- Recent lab results diagnose borderline diabetes or development of type 2 diabetes.
- A patient that have gained weight since their last appointment despite their best efforts to try to lose weight following a more conventional calories in, calories out model, and they are disappointed with the outcome.
- Their blood pressure has become elevated and you may want to start them on an antihypertensive medication, increase the dosage of their current medication(s), or add another medication to their regimen.
- Their glucose levels are so high that you want to start them on antihyperglycemic medication(s), increase the dosage of any current hyperglycemic medication(s), or add another antihyperglycemic medication to their regimen, especially insulin, which is patients often believe to be too invasive.
- The patient has a diabetic wound that will not heal, perhaps despite usage of antibiotics that may be making the patient feel ill.
- They are at high risk for amputation due to their diabetes.
- They are struggling to afford their medications.
As mentioned, low-carb diets may have a role in the prevention and treatment of many medical conditions. Since many of these conditions are quite common it appears that many people in the Western World could benefit from some degree of carbohydrate reduction from their daily diets.
Some of your healthier patients may benefit from adopting some variation of a low-carb diet for disease prevention. Patients you might want to approach are those who:
- Have a passion for cooking and has the physical ability to cook for oneself.
- Demonstrates a desire to live a healthy lifestyle and maintain their good health.
- Easy access to good quality low-carb, high-fat foods.
- Has a spouse or partner living with them who wishes to be more conscious about their diets.
How strictly does the patient need to follow a low-carb diet?
Not every patient needs to adhere to a strict low-carb diet to achieve their desired results. However, the lower carb intake patients can achieve, the more powerful the effects tend to be. Especially people with a significant metabolic syndrome (e.g. type 2 diabetes) may do best on a very low-carb diet with below 20 grams of carbs per day.
Doctors who practice low-carb often find often their patients do best by jumping in with both feet and reducing their carbohydrates immediately. Most patients do not find this to be very difficult. Patients often report that they immediately feel better (perhaps after a few days of transitional side effects) and notice results, which makes them want to continue to stick with their new diet.
What to do if a patient is not ready for a strict low-carb diet?
That said, some patients are not ready to do a strict low-carb diet. In these cases, when it’s judged that carbohydrate restriction may be helpful, you may want to encourage your patient to instead make small, gradual changes to build results. A little improvement may then motivate these patients to make more significant changes in the long run. The protocol below can help you gradually introduce low-carbohydrate eating to an initially reluctant patient:
Start by reducing their intake of refined carbohydrates by 10%
Small changes reap significant results at the start. Simply eliminating soft drinks and sugar from coffee and tea and have quite an impact. Once a patient experiences a mild degree of success, they are likely to going to want to build upon that success. This will inspire them to make more significant changes to their diet.
Once the patient sees the incredible effect reducing their intake of refined sugar by as little as 10% has on their blood sugar levels, waistline and blood pressure, then they are likely going to be willing to make more significant changes.
The next step is to eliminate their intake of refined carbohydrates as much as possible
Patients understand that refined sugar is not ideal for optimal health. It is easier to reason with them on this fact. People understand soda and candy makes them fat and isn’t good for their bodies.
Work on reducing starches and grains slowly
Reducing starches and grains is the most difficult thing to do. Start off slowly and follow the recommended protocol:
- Eliminate snacks containing starches and grains. Try to eliminate all snacks that contain starches and grains. This is quite easy because most patients know that a lot of these foods are junk foods, and there are a lot of very healthy snacks, such as nuts, seeds, olives, cheese and meats for them to substitute into their diet.
- Eliminate starches and grains from their breakfast. It is usually recommended to eliminate starches and grains from the breakfast meal first. This is the easiest meal to reason with patients for the following reasons:
- Diabetics are aware that their morning blood sugar levels are the highest levels they see throughout the day, and they understand that adding carbs makes their blood sugars worse
- “Don’t pour gasoline on a fire” – If your blood sugar levels are the highest in the morning, why eat sugar and make them go even higher? Most patients understand this reasoning.
- They usually cook breakfast at home and have more control over their food options than they do at lunch and dinner time.
- They like the idea of eating foods that have been forbidden, such as bacon, eggs and sausage – this feels less like a sacrifice and more like an indulgence
Reduce starches and grains to less than 20% of their dinner meal
Reducing starches at dinner is often easier for patients to do than reduce at lunch first, especially if they are working and eating out of the home. Most people make their dinner meals at home and have a lot more control over what they are eating. This isn’t always the case when trying to figure out what to eat at the office cafeteria or pack for your lunch. Also, it is more detrimental for patients to consume carbohydrates later in the evening when their insulin naturally rises. If they have them during the lunch hour, then they have a chance to burn them off throughout the rest of the day.
Reduce starches and grains to less than 20% of their lunch meal
This is the most challenging thing to do for patients. There often aren’t a lot of quick and easy options for low-carb lunches that are so obvious to the patient who is new to low-carb diets. Also, most cafeterias or restaurants cater to the traditional food pyramids and meal options have a significant portion of carbohydrates. This can add a lot of stress to the patient who has a very hectic workday and lacks the time to do proper meal preparation in advance. Once a patient develops stronger low-carb eating habits and has become more creative with their meal options, switching to low-carb lunch options will come naturally.
7. Adjusting medications
There are two major classes of medications that often need to be reduced on a low-carb diet: blood glucose lowering medications, and blood pressure medications. Learn more in this section.
Blood glucose lowering medications
When patients with type 2 diabetes start a low-carb diet, their blood glucose levels usually go down from day one, and they can keep dropping as weight loss continues and insulin resistance is reduced.
As this happens patients on blood-glucose lowering medications may need to reduce their medications, to avoid hypoglycemia. It’s important for their doctor to know how to handle this situation. Hypoglycemia due to overdosing of blood-glucose-lowering medications, especially insulin, is the #1 biggest risk when starting a low-carb diet.
Slightly high glucose is safer than too low
It is difficult to anticipate exactly how your patient’s blood sugar levels are going to respond to lowering their carb intake. It will usually go down immediately, from day one, and often by a lot.
Because of this uncertainty, and because low blood sugar levels are far more dangerous in the short term, it’s safer to have your patients sugars run a little bit higher than the desired range for the initial period. This is to avoid the risk of hypos.
If your patient are on insulin or sulfonylureas – with a high risk of hypos – you may want to reduce your patients medications to initially target daily blood glucose levels between 145 to 180 mg/dL (between 8.0 and 10.0 mmol/L).
This means that if your patient starts out with well-controlled blood glucose on these medications, you may want to reduce their medications before starting a low-carb diet, to avoid hypos.
Also consider that the more your patient lowers his or her intake of carbs, the larger the blood glucose lowering effect is likely to be. This means that if your patient used to eat 300 grams of carbs per day, and lowers the intake to below 20 grams per day, the effect on glucose levels is likely to be very powerful.
So what medication may you want to reduce or remove first? In summary, here’s the recommended order of deprescribing diabetes medications for patients with type 2 diabetes.
- SGLT-2 inhibitors (due to the risk of ketoacidosis, see below)
- Long-acting insulin (risk of hypos, etc.)
- Short-acting insulin (risk of hypos, etc.)
- Sulfonylureas and meglitinides (risk of hypos, etc.)
- DPP4 inhibitors
- GLP-1 agonists
- Alpha-glucosidase inhibitors
- Biguanides (metformin)
Below you’ll find more details.
It’s common within the first few months that patients’ blood glucose levels drop back down to a well-controlled range or become acceptable. Once the patient’s levels are back into the 70-130 mgl/dL range (4 to 7.0 mmol/L), it may be time to make reductions again and again target a range of 145 to 180 mg/dL (8.0 to 10.0 mmol/L).
This cycle can often repeat itself until the patient is no longer taking any diabetic medications (or is just on Metformin). After that the goal is to bring the glucose levels down to the normal range utilizing diet alone, targeting a normal A1c.
If there is not a reduction in blood glucose levels between appointments, there does not need to be an adjustment. Talk to your patient about their diet. Perhaps they could make some adjustments to speed up the process but sometimes it may just take a bit longer to see the glucose levels come down. Remind your patients of how long they have been diabetic and how long it takes to develop diabetes to put things into perspective if they are slow to respond to the low-carb diet.
Sometimes patients blood glucose levels go above 180 mg/dL (10.0 mmol/L) for various reasons, such as a vacation, relatives visiting from out of town, illness or infection, and the patient may need to temporarily increase their medication. Some patients may be resistant to this but assure them that it’s only for the short term.
Reversal of type 2 diabetes
It’s not uncommon that patients can fully reverse their type 2 diabetes on a strict low-carb diet. So what does reversal mean? A useful definition is a patient with a prior diagnosis of type 2 diabetes, who now has a normal A1c (<6,5% or 48 mmol/mol) at least two months after stopping all antidiabetes medications.
You may want to confirm the reversal with a second A1c test, unless it’s also confirmed by the patient’s own blood glucose tests being completely normal.
More about type 2 diabetes medications
|Medication||Mechanism||Pros and cons|
||Inhibit type 2 sodium-glucose cotransporter.
Elimination of glucose in the urine, as reabsorption of glucose by the kidneys is reduced.
|*** RISK OF DIABETIC KETO-ACIDOSIS *** especially on low carb, even if normal sugar levels. More reports with Invokana.
No risk of hypos.
||Forces cells to take in more glucose.||High risk of getting hypos.
Increases weight gain.
Worsens insulin resistance.
Harder to titrate than short acting.
|Intermediate and short-acting insulin
||Forces cells to take in more glucose.||High risk of getting hypos.
Increases weight gain.
Worsens insulin resistance.
Easier to titrate than long acting.
|*Insulin LA+SA Combos: split back into long acting and short acting to better titrate|
|Sulfonylureas and Meglitinides
||Stimulate insulin secretion by the pancreas.||Risk of hypos.
||Prolong the action of GLP-1.
Stimulate the secretion of insulin.
Inhibit the release of glucagon.
|No risk of hypos.
Not so useful if the patient is not eating a lot of carbs anymore.
||Increase insulin production if blood sugar levels are high.
Decreases production of glucagon.
|No risk of hypos.
Reduced appetite so useful in that matter.
||Inhibit last stage of glucose digestion.
Inhibit the transformation of starch into sugar.
Delay the absorption of certain types of carbs.
|No risk of hypos.
No weight gain.
Few patients on this drug because it causes intestinal discomfort/diarrhoea.
||Inhibit the production of glucose by the liver.
Decrease the absorption of glucose by the digestive system.
Increase the absorption of glucose in periphery.
|No risk of hypos.
No weight gain.
A note on SGLT-2 inhibitors
Some doctors choose to have patients stay on SGLT-2 inhibitors, and remove insulin and some other medications first, when possible. This is because SGLT-2 inhibitors actively remove glucose from the body, and thus reduce insulin levels. This is a very attractive benefit that may speed up weight loss and the reversal of insulin resistance, type 2 diabetes and other aspects of the metabolic syndrome, like high blood pressure.
The benefits of SGLT-2 inhibitors could potentially outweigh the risk of developing diabetic ketoacidosis in selected patients.
Should you choose to continue with SGLT-2 therapy, please ask your patient to look out for the following early symptoms of ketoacidosis, and stop taking the drug and notify you immediately if they develop:
- Weakness and fatigue
In most cases however, and in the opinion of most doctors treating patients with low carb, SGLT-2 inhibitors may not be worth the risk of ketoacidosis. They should thus usually be removed first when starting a low-carb diet.
DPP4 vs. GLP-1
Discuss with your patient to see if they would prefer to reduce and discontinue their DDP4 inhibitors or GLP-1 agonists first.
- Some people prefer to discontinue the GLP1 agonist since it is an injectable and is inconvenient since needs to be refrigerated.
- However, others find that these injectables really reduce their appetite and they would prefer to reduce their DDP4 inhibitors first.
Since neither of these classes of medications put the patient at risk for hypoglycemia, it is really up to the patient’s preference. If the patient has no preference, start to reduce and discontinue the DPP4 inhibitors first, since the GLP-1 agonists may decrease hunger and cause some weightloss.
Blood pressure medications
There does not need to be an adjustment of blood pressure medications at baseline. This is something to assess during the follow-up.
Blood pressure usually takes more time to drop, if they do at all, than glucose levels. However, there are exceptions, so you may want to tell your patient to be aware of symptoms of hypotension (like dizziness, feeling tired or nausea) and contact you if they occur.
If the patient presents in clinic with low blood pressure or experiences low blood pressures at home, then their antihypertensive medications may need to be reduced.
Determining what blood pressure medication to discontinue first
- Reduce and discontinue diuretic medications first, if possible:
- Thiazide diuretics
- Thiazide-like diuretics
- Potassium-sparing diuretics
- Loop diuretics
- Reduce and discontinue any calcium channel blockers, if possible.
- Reduce and discontinue any angiotensin II receptor antagonists, if possible.
- Reduce and discontinue any ACE inhibitors.
- Reduce and discontinue any beta blockers, alpha blockers or mixed alpha + beta blockers, if possible (often this is not possible because of cardiac related complications).
More than 30 high-quality randomized controlled trials support the use of low-carb diets for treating obesity, type 2 diabetes and other symptoms of metabolic syndrome or insulin resistance.
See the link below, or the Public Health Collaboration summary of RCT evidence.
Q & A
Here are a number of short and simple Q&A videos with doctors, on the science and experience supporting low carb:
For more in-depth discussions of the science supporting low-carb interventions, see the videos below.
Most people can safely start a low-carb diet right away. But patients on certain medications, plus breastfeeding women, may require more additional preparation or adaptation:
- Is your patient on medication for diabetes, e.g. insulin? Learn more
- Is your patient on medication for high blood pressure? Learn more
- Is your patient breastfeeding? Learn more
- Is your patient on psychiatric medications? Learn more
Workshops for physicians
More resources for physicians
10. Resources for patients
Here’s a folder with basic low-carb advice, that you may want to print and hand out to patients. It can help speed up and simplify your consultations:
Other low-carb resources that you may want to share with your patients:
Below you’ll find visual guides that many doctors find useful to show to patients, during discussions about what a low-carb diet is.
Let’s start with a quick visual guide to low carb. Here are the basic food groups you can eat all you like of, until you’re satisfied. The numbers above are grams of digestible carbs per 100 grams (3½ ounces). Fiber is not counted, you can eat all the fiber you want. Detailed low-carb foods list
Above you see what you should not eat on low carb – foods full of sugar and starch. Detailed list of foods to avoid
More visual guides
What do you think about this guide? Do you have any suggestions on how to improve it? Anything you’d like added to it? Please let us know in the comments below.
This is a longer discussion with Dr. Unwin and his wife Jen Unwin, who’s a psychologist. ↩