Carbo Ingles

Treating metabolic
syndrome, type 2 diabetes,

and obesity with therapeutic
carbohydrate restriction
1.1 Introduction: Outline of course
MODULE 1: Background and definitions
MODULE 2: Physiological and metabolic effects of carbohydrate-restricted diets
MODULE 3: Initiating the intervention
MODULE 4: Administering TCR
MODULE 5: Follow-up care
Therapeutic Carbohydrate Restriction CME 2

MODULE 1:
Background and definitions

Obesity rates increase over the last 3 decades
25.7%
31.9%
22.6%
25.1%
37.3%
35%+
30 - 34.9%
25 - 29.9%
Obesity 1990 20 - 24.9%

Obesity 2017
15 - 19.9%
10 - 14.9%
0 - 9.9%
Therapeutic Carbohydrate Restriction CME 1.1.1 Background and general principles 4

Historical uses of TCR
https://archive.org/details/diabeticcookeryr00oppeiala
Therapeutic Carbohydrate Restriction CME 1.1.2 History 5

EASD and ADA Guidelines

ADA Guidelines Statement
“Reducing overall carbohydrate intake for individuals with diabetes has

demonstrated the most evidence for improving glycemia and may be
applied in a variety of eating patterns that meet individual needs and
preferences (Evert et al., 2019).”

Nutrients and their impact on blood glucose
Carbohydrate
Blood sugar
Fasting
blood sugar Time
Therapeutic Carbohydrate Restriction CME 1.2 Nutrition physiology and adequacy 8

Carbohydrate
Blood sugar
Protein
Fasting
blood sugar Time

Carbohydrate
Blood sugar
Protein
Fat
Fasting
blood sugar Time

Recommended protein intake:
RDA 0.8 g of protein per kg reference body weight
Therapeutic carbohydrate
1.2 - 1.7 g of protein per kg reference body weight
restriction
Therapeutic Carbohydrate Restriction CME 1.2.1 Protein 11

100 grams of protein
Breakfast Lunch Dinner

3 eggs
60 g (2 oz) cheese 150 g (5 oz) salmon 140 g (5 oz) chicken
30 g + 30g + 40 g = 100
Whole fats are a mixture of fatty acids
Salmon
Beef
Olive oil
Therapeutic Carbohydrate Restriction CME 1.2.2 Fat and saturated fat 13

Why is saturated fat allowed on
a carbohydrate-restricted diet?
Absolute grams of fat may not increase on TCR.

(Hite et al., 2010)
Higher dietary saturated fat does not always increase serum saturated fat.
(Volek et al., 2009)
Within the context of TCR, it is unclear what effect saturated fats have
on health.
(Forouhi, Krauss, Taubes & Willett, 2018)
Therapeutic Carbohydrate Restriction CME 1.2.2 Fat and saturated fat 14

TCR includes a variety of whole foods
Therapeutic Carbohydrate Restriction CME 1.2.3 Micronutrients 15

Getting energy without dietary carbohydrates:
glycogenolysis
The liver stores

glucose as
glycogen
glucose
glycogenolysis
Therapeutic Carbohydrate Restriction CME 1.2.4 Carbohydrate 16

Getting energy without dietary carbohydrates:
gluconeogenesis
Active skeletal
muscle
glucose
gluconeogenesis

Getting energy without
dietary carbohydrates:
ketones from fatty acids Burn fat
for fuel dietary fat
ketones
body fat

Glycemic index and glycemic load
Therapeutic Carbohydrate Restriction CME 1.2.5 Glycemic index and glycemic load 19
Above-ground vegetables: high fiber, low starch
Therapeutic Carbohydrate Restriction CME 1.2.6 Fiber 20

Net carbs per 100 grams of vegetable
Therapeutic Carbohydrate Restriction CME 1.2.7 Total vs. net carbohydrate 21

Ketogenic Moderate Liberal
Under 20 grams of Under 50 grams of Under 100 grams of
net carbs per day net carbs per day net carbs per day
This meal has This meal has This meal has

6 grams of net carbs. 16 grams of net carbs. 37 grams of net carbs.
Therapeutic Carbohydrate Restriction CME 1.3.1 Defining TCR 22

“Calories still count, but we don’t have to count them.”
Therapeutic Carbohydrate Restriction CME 1.3.2 Calories 23

Module 1, Patient 1 Personal 53 years old, female
Health history Type 2 diabetes

Height 5’2” (157 cm)
Clinical Weight 186 lbs (84 kg)
Blood pressure 146/90 mmHg
Low-fat, moderate-carbohydrate diet, focusing on
Diet history
low-glycemic-index foods
• GLP-1 agonist (exenatide)

• Insulin
Medications
• Metformin
• SGLT-2 inhibitor (empagliflozin)
Tests Ultrasound Evidence of fatty liver

Patient believes fat has definitely been proven to
Social/other cause heart disease and cancer.
Lab Value Lab Value Lab Value
9.3% 1.6 mg/dL

HbA1c Creatinine ALT 86 U/L
(12.2 mmol/L) (141.5 µmol/L)
Therapeutic Carbohydrate Restriction CME 1.4 Module 1 case studies 24

Q1: How do you respond to her concern that eating fat
definitively causes heart disease and cancer?

Module 1, Patient 2
Personal 34 years old, female
Health history Metabolic Syndrome
Diet history Vegetarian

Q1: Can she successfully start TCR as a vegetarian and
still achieve adequate nutrition goals?

Q2: What is her target daily protein range and how do you
explain the difference between plant and animal proteins?

MODULE 2:
Physiological and metabolic effects of
carbohydrate-restricted diets

Shift from “glucocentric” to “adipocentric”
“Glucocentric” “Adipocentric”
Fuel = glucose Fuel = fatty acids & ketones
Therapeutic Carbohydrate Restriction CME 2.1 Glucose, insulin, and ketones 30

Foods that digest down into glucose
Therapeutic Carbohydrate Restriction CME 2.1.1 Glucose 31

Insulin prevents fat
from leaving cell
In
su
lin
Fat
Therapeutic Carbohydrate Restriction CME 2.1.2 Insulin 32

Beta-hydroxybutyrate (BHB)
Acetoacetate
Acetone dietary fat
ketones
body fat
Therapeutic Carbohydrate Restriction CME 2.1.3 Ketones 33

Optimal fuel flow for brain and muscles
Optimal
ketone
zone
Nutritional
ketosis begins
0 0.5 1.0 1.5 2.0 2.5 3.0
Blood ketones in mmol/L
Therapeutic Carbohydrate Restriction CME 2.2.1 Nutritional ketosis 34

Optimal
ketone
zone
Post-exercise
ketosis
Nutritional Starvation
ketosis begins ketosis
Ketoacidosis
0 0.5 1.0 1.5 2.0 2.5 3.0 5.0 10+
Adapted from: Phinney & Volek Blood ketones in mmol/L
Therapeutic Carbohydrate Restriction CME 2.2.1 Nutritional ketosis 35

Euglycemic ketoacidosis
May occur with SGLT-2 inhibitors, combined with TCR.
Patient has normal blood glucose levels.
Patient has metabolic acidosis.

Patient is typically symptomatic: fatigue, confusion, dehydration, and more.
Requires immediate treatment.
Therapeutic Carbohydrate Restriction CME 2.2.2 Ketoacidosis 36

Metabolic syndrome is defined by the presence of 3 of the 5 criteria:
≥ Systolic 130 mmHg

Fasting ≥ 100 mg/dL (5.6 mmol/L)
Blood pressure ≥ Diastolic 85 mmHg
glucose level Receiving treatment for type 2 diabetes
Receiving treatment for hypertension
< 40 mg/dL in men (1.0 mmol/L)

< 50 mg/dL in women (1.3 mmol/L)
Waist > 40 inches for men (102 cm)
HDL-cholesterol circumference > 35 inches for women (89 cm)
Receiving treatment for low HDL-cholesterol
≥ 150 mg/dL (1.7 mmol/L)

Triglycerides
Receiving treatment for elevated triglycerides
Therapeutic Carbohydrate Restriction CME 2.3.1 Definition of metabolic syndrome 37

How does insulin increase
blood pressure?
Central nervous system:
Increased sympathetic nervous
system activity
Blood vessels:
Proliferation of smooth muscle
Diminished release of nitric oxide
from the endothelium
Increased secretion of endothelin-1,
a potent vasoconstrictor
Kidneys:
Increased sodium retention
Therapeutic Carbohydrate Restriction CME 2.3.2 Hypertension 38

Therapeutic Carbohydrate Restriction CME 2.3.2 Hypertension 39
Summary of different measures of cholesterol
Name Description Unit
Low-density lipoprotein cholesterol

LDL-C mg/dL
Total concentration of cholesterol contained in LDL particles
Low-density lipoprotein particles

LDL-P nmol/L
Total number of LDL particles in circulation
Apolipoprotein B-100
ApoB Serves as a proxy measure for all potentially atherogenic lipid particles, including mg/dL
LDL, IDL, and VLDL
Therapeutic Carbohydrate Restriction CME 2.3.3 Dyslipidemia 40

Hyperinsulinemia is associated with
changes in serum lipids:
Increased triglycerides
Decreased HDL
Increased atherogenic, small LDL particles

Impaired glucose tolerance or prediabetes
Fasting blood sugar ≥ 100 mg/dL (5.6 mmol/L)
HbA1c > 5.7% (6.3 mmol/L)
Therapeutic Carbohydrate Restriction CME 2.3.4 Hyperglycemia and type 2 diabetes 43

Insulin resistance Weight gain in a person with
family history and predisposing
genes to diabetes mellitus type 2
Hypertension
Even more insulin

is secreted
The insidious cycle Increased need
for glucose
Weight gain and insulin
β-cells become resistance actually form a closed
exhausted circle of cause and effect,
leading to diabetes and all its
complications.
β-cells in the pancreas

Diabetes mellitus type 2 secrete more insulin
Insulin resistance
develpos in the liver,
muscles and fat

High insulin keeps glucose
low — until insulin Insulin resistance
production fails
Insulin production
Fasting blood glucose

Time:Years
Decreasing post-meal Loss of !-cell mass
glucose control
Adapted from: King & Blom, 2017 Pre-diabetes Diabetes

All carbohydrate foods are not the same
Food Item Glycaemic Serve How does each food affect blood glucose compared with one 4g teaspoon of table sugar?
index size g
Basmati rice 69 150 10.1
Potato, white,
96 150 9.1
boiled
French fries
64 150 7.5
baked
Spaghetti white
39 180 6.6
boiled
Sweet corn
60 80 4.0
boiled
Frozen peas,
51 80 1.3
boiled
Banana 62 120 5.7
Apple 39 120 2.3
Wholemeal
74 30 3.0
small slice
Other foods in the very low
Broccoli 15 80 0.2 glycemic range would be
Eggs 0 60 0
chicken, oily fish, almonds,
mushrooms, cheese
Adapted from: Unwin, Haslam & Livesey, 2016

Open-label, 2-year, non-randomized study of TCR
(n= 262) showed, compared to control:
Elimination of all diabetes medications (except metformin) for most participants
Reduced: HbA1c, fasting glucose, fasting insulin, body weight, blood pressure, triglycerides
See: Athinarayanan et al., 2019

Why people might be less hungry during TCR:
Ketosis (Gibson et al., 2015; Paoli et al., 2015)
Protein & fiber-filled foods (Blundell & Stubbs, 1999; Veldhorst et al., 2008) Satiety
without stimulating brain food-reward centers (Alonso-Alonso et al., 2015)
Therapeutic Carbohydrate Restriction CME 2.3.5 Obesity and abdominal obesity 49

Visceral fat linked to
metabolic impairment
Subcutaneous fat
Visceral fat
Therapeutic Carbohydrate Restriction CME 2.3.5 Obesity and abdominal obesity 50

Case study:
Patient 3
Personal Female
Health history Obesity (BMI 43)
BHB level, post-exercise, home test:

Social/other 4.5 mmol/L

Q1: Does a BHB level this high suggest she may be
at risk for ketoacidosis?

Optimal
ketone
zone
Post-exercise
ketosis
Nutritional Starvation
ketosis begins ketosis
Ketoacidosis
0 0.5 1.0 1.5 2.0 2.5 3.0 5.0 10+
Blood ketones in mmol/L

Case study: Personal 62 years old, male
Patient 4 Health history Type 2 diabetes; coronary artery disease; stent placed 18 months prior
Height 5’10” (178 cm)
• Aspirin, 81 mg daily
Medications • Lisinopril, 10 mg daily
•Metformin, 1000 mg twice daily
165 mg/dL
LDL
HbA1c 7.2% (4.3 mmol/L) TG 265 mg/dL
(8.9 mmol/L) (3 mmol/L)
31. mg/dL
HDL (0.8 mmol/L)

Q1: Given his history of coronary disease and elevated
LDL is he a good candidate for TCR?
Why or why not?

Q2: How would you address his elevated LDL?

Q3: Would you check an advanced or nuclear magnetic
resonance (NMR) lipid profile?
How would you expect his lipid panel to change
with statin therapy and TCR initiation?

MODULE 3:
Initiating the intervention

Therapeutic carbohydrate restriction is
not appropriate for patients with:
Advanced renal insufficiency not on hemodialysis
Therapeutic Carbohydrate Restriction CME 3.1.1 Exclusion criteria 59


Carnitine palmitoyltransferase (CPT) deficiency
Short-chain, medium-chain or long-chain acyl dehydrogenase
deficiency (SCAD,MCAD or LCAD)
Pyruvate carboxylase deficiency


Hyperchylomicronemia


Hyperchylomicronemia
Acute, decompensated medical condition

Conditions that require caution:
Type 2 diabetes Decreased kidney function
Hypertension Kidney stones
Type 1 diabetes Gout
Gallbladder removal Pregnancy & breastfeeding
Therapeutic Carbohydrate Restriction CME 3.1.2 Need for caution 63

Baseline measurements
Height
Weight
Lean body mass / body fat %
Blood pressure
Therapeutic Carbohydrate Restriction CME 3.2 Baseline assessments 64

Fasting insulin*
µIU/mL or mIU/L pmol/L Risk for insulin Reference

resistance
≥ 25 ≥ 174 High Johnson, Duick, Chui & Aldasouqi, 2010
>12 > 83 Moderate McAuley et al., 2001
≤8 Low Johnson, Duick, Chui & Aldasouqi, 2010
* These definitions have not been

Homeostatic model assessment for insulin resistance (HOMA-IR)** standardized. These are “working” ranges
until more studies are done to standardize
values for predicting insulin resistance.
HOMA-IR score = fasting insulin (mIU/L) x fasting glucose (mg/dL) / 405 (Matthews et al., 1985) Following the trend in an individual patient
over time is likely more helpful than an
absolute value when monitoring patients on
therapeutic carbohydrate restriction.
Score Risk for insulin resistance Reference
** A calculator for HOMA-IR can be found at:
< 1.6 Low Shashaj & Luciano, 2015 mdcalc.com/homa-ir-homeostatic-model-ass
essment-insulin-resistance
Therapeutic Carbohydrate Restriction CME 3.2.1 Recommended lab tests 65

Baseline fasting labs
CMP: liver, kidney, electrolytes, glucose CBC
HbA1c Insulin (with glucose, can calculate HOMA-IR)
Lipids (NMR or advanced analysis if possible) For select individuals: Uric acid, TSH
Therapeutic Carbohydrate Restriction CME 3.2.1 Recommended lab tests 66

Potential benefits of therapeutic
Improved blood pressure control

Improved overall lipid profile
Improved glucose control
Diabetes & blood pressure medication reduction
Weight loss, especially reduced waist circumference
Therapeutic Carbohydrate Restriction CME 3.3 Pre-diet evaluation and counseling 67

Case study: Personal 54 years old, female
Health history Metabolic syndrome; gallstones; cholecystectomy 4 years prior
Patient 5 Height 5’2” (155 cm)
Waist circumference 38 inches (96.5 cm)
Diet history Low-fat, high-carbohydrate diet
• Lisinopril, 10 mg daily
Medications • Metformin, 500 mg twice daily
Social/other 15 minutes of walking per day

6.3% 92 mg/dL 210 mg/dL
HbA1c LDL TG
(7.5 mmol/L) (2.4 mmol/L) (2.37 mmol/L)
118 mg/dL 41 mg/dL
FBG HDL ALT 78 U/L
(6.6 mmol/L) (1.07 mmol/L)

Case study: Current diet
Patient 5
(cont.) 7:00 am Oatmeal with raisins, brown sugar, and fruit
9:30 am Protein bar
12:00 pm Turkey sandwich with chips and diet soda
3:00 pm Apple, orange, or grapes
Chicken with rice, potatoes, or broccoli; pasta with

7:00 pm
marinara sauce; occasionally pizza
8:30 pm Usually ice cream, popcorn, or fruit salad
Walks 15 minutes on lunch break, with no other regular exercise.

Q1: Is she a good candidate for TCR? Why or why not?

Q2: What are your initial dietary recommendations for her?

Q3: Are there special considerations for her initiation?

Q4: What baseline assessments would you check
and follow?

Case study:
Patient 6
Personal 14 years old, male
Health history Type 1 diabetes; frequent hypoglycemia; 3 hospital admissions for DKA
Medications Insulin
Social/other Depression
Lab Value Lab Value
10.2% 210 mg/dL

HbA1c FBG
(13.6 mmol/L) (11.6 mmol/L)

Q1: Is he a good candidate for TCR? Why or why not?

MODULE 4:
Administering therapeutic

Support your patient’s dietary changes
Discuss current diet, diet history, and health goals

Assess patient’s knowledge about carbohydrate restriction
Address concerns about carbohydrate restriction
Create a personalized dietary plan
Provide ongoing support
Therapeutic Carbohydrate Restriction CME 4.1 Supporting behavior change 77

Patient education resources for therapeutic
Sample menu
Shopping list
Recipes
Meal-planning tips
Replacement options for favorite foods
Therapeutic Carbohydrate Restriction CME 4.1 Supporting behavior change 78

Therapeutic carbohydrate restriction: Easy as 1-2-3!
1 Limit carbohydrates.
2 Aim for adequate protein.
3 Adjust fat as needed for fullness and flavor.
Therapeutic Carbohydrate Restriction CME 4.2 Patient education 79

Foods to choose for TCR

Foods to avoid on any diet

Limit carbohydrate foods

Above ground
Below ground

High-fiber, low-glycemic berries

Aim for 75 -100 g of protein (or more) per day
Breakfast Lunch Dinner

3 eggs
60 g (2 oz) cheese 150 g (5 oz) salmon 140 g (5 oz) chicken
30 g 30g 40 g
Biological value of
protein sources What does 25 grams of protein look like?
Amount Calories Protein
Quinoa 3 cups (700 ml) 666 25 g
Peanut butter 6.25 tablespoons (92 ml) 587 25 g
Black beans 1 ⅔ cups (378 ml) 385 25 g
Edamame 1 ⅓ cup (307 ml) 251 25 g
Beef 3 ounces (85 grams) 210 25 g

Adjust the amount of fat as needed
Olive oil 0
Cheese 2
Cold cuts 2 Olives 3
Butter 0
Avocado 2
Coconut oil 0 Heavy cream 3 Eggs 1
Therapeutic Carbohydrate Restriction CME 4.2.3 Fat 87

Choose alcohol wisely
Therapeutic Carbohydrate Restriction CME 4.2.4 Beverages 88

“Getting started” tips for patients
Eat when you’re

Two-steps to a Keep cooking Find substitutes
hungry; stop when
TCR kitchen: simple: for favorite foods.
you’re full.
Make “deliberate” leftovers.

Toss or give away
1
foods not on TCR list. Plan no-cook meals.
Use list to restock Repeat quick & easy

2 the kitchen.
favorite meals.
Therapeutic Carbohydrate Restriction CME 4.2.6 “Getting started” tips for patients 89
Initial adjustments for
diabetes medications
If post-prandial glucose is <200 mg/dL (11 mmol/L),

stop short-acting insulin.
Insulin Reduce long-acting insulin by 33-50%.
Stop mixed insulin; transition to long-acting insulin only.
Therapeutic Carbohydrate Restriction CME 4.3.1 Diabetes medications 90

Think “possible latent autoimmune diabetes
of adults (LADA)” if a patient has:
A history of diabetic ketoacidosis (DKA)
A history of hospitalizations for severe hyperglycemia

Initial adjustments for diabetes medications
If post-prandial glucose is <200 mg/dL (11 mmol/L), stop short-acting insulin.

Insulin Reduce long-acting insulin by 33-50%.
Stop mixed insulin; transition to long-acting insulin only.
SGLT-2 Stop all SGLT-2 inhibitors before TCR is initiated.

inhibitors SGLT-2 inhibitors + TCR = increased risk of DKA.
Sulfonylureas Stop sulfonylureas, unless fasting glucose is > 200 mg/dL (11 mmol/L).
Metformin May safely be continued.
DPP-4
inhibitors and May be continued until glucose levels are well controlled.
GLP-1 agonists

Initial adjustments for anti-hypertensive
medication
Educate patients about symptoms of low BP
Have patients monitor BP at home & communicate results to healthcare team
If BP is consistently < 110/70, consider stopping or reducing meds
If patient develops symptomatic hypotension, stop or reduce meds to

relieve symptoms
Therapeutic Carbohydrate Restriction CME 4.3.2 Anti-hypertensive medication 93

Side effects related to diuresis and natriuresis and how to treat
Electrolyte
4-7 grams of sodium/day (2-3 teaspoons or 10-15 mL of salt)
imbalance
Constipation magnesium oxide 400 mg per day or supplemental fiber
400 mg/day magnesium citrate or magnesium oxide

Muscle
cramps If GI side effects, use magnesium glycinate or transdermal
Therapeutic Carbohydrate Restriction CME 4.4 Side effects, adverse outcomes, and treatment 94
Muscle cramps
400 mg/day magnesium citrate or magnesium oxide

If GI side effects, use magnesium glycinate or transdermal
4 -7 grams of sodium (2-3 teaspoons or 10-15 mL of salt)
Therapeutic Carbohydrate Restriction CME 4.4 Side effects, adverse outcomes, and treatment 95
Potential responses to LDL increase
Stop TCR.
Continue TCR with a modestly higher carbohydrate intake.
Continue TCR with reduced saturated fat and increased

monounsaturated fat intake.
Start a statin or other lipid-lowering drug.
Make no changes; follow coronary calcium scores and carotid

intima-media thickness test (CIMT) for signs of progressive
athersclerotic disease.
Therapeutic Carbohydrate Restriction CME 4.4.4 LDL increase 96

Exercise and initiation of TCR
Continue ongoing program, with 25% reduction of duration and intensity
Do not start new program until TCR is established
Exercise should not increase frequency or amount of eating
Reinforce that activity is its own reward!
Therapeutic Carbohydrate Restriction CME 4.5 Other lifestyle considerations 97

Patient 7 Health history Type 2 diabetes; orthopedic surgeries
Height 5’10” (178 cm)
Waist circumference 43 inches (109 cm)
• Atorvastatin, 20 mg daily
Medications • Canagliflozin, 300 mg daily
• Insulin glargine, long-acting, 30 units daily
• Insulin aspart, dosed before meal
• Metformin, 1000 mg twice daily

210 mg/dL
8.2 % 132 mg/dL TG
HbA1c LDL (2.37 mmol/L)
(10.5 mmol/L) (3.4 mmol/L)
ALT 88 U/L
178 mg/dL 32 mg/dL 1.4 mg/dL
FBG HDL
(9.9 mmol/L) (0.84 mmol/L) Creatinine (123.8 µmol/L)

Q1: Is he a good candidate for TCR?
Why or why not?

Q2: Are there any special considerations when
starting him on TCR, especially regarding his
kidney function and medications?

Q3: After the first week of TCR with a goal net
carbohydrate intake of less than 20 grams per day, he
complains of being lightheaded, fatigued, and having
muscle cramps. What are your main considerations,
what tests, if any, would you order, and what are your
main interventions?

“Keto flu” intervention
Increase hydration
Increase sodium: Add salt to eggs and veggies
Drink pickle juice or bone broth
Add magnesium 200 - 400 mg daily

Q4: When would you suggest he get
his next lab draw?

Patient 8 Health history Type 2 diabetes; diabetic nephropathy; calcium oxalate kidney stones
Clinical Blood pressure 124/76 mmHg
Medications • Glipizide xl, 2.5 mg daily
• Liraglutide, 1.2 mg daily

8.2% 110 mg/dL
HbA1c LDL Potassium 4.1 mEq/L
(10.5 mmol/L) (2.9 mmol/L)
1.8 mg/dL 31 mg/dL
Creatine (159.2 µmol/L) HDL Sodium 138 mEq/L
(0.81 mmol/L)
5.6 mg/dL 227 mg/dL 9.2 mg/dL
Uric acid (0.33 mmol/L) TG (2.56 mmol/L) Calcium (11.1 mmol/L)
GFR 45 mL/min/1.73m²

Q1: Is he a good candidate for TCR?
Why or why not?

Q2: Are there any special considerations for
starting him on TCR?

Health history none

Patient 9
Diet history Started TCR 3 months ago; lost 15 lbs (6.8 kg)
Social/other Working on improving athletic performance
Height 5’4” (162 cm)
Clinical Blood pressure 120/70 mmHg
Baseline Current
Weight 140 lbs (63 kg) 125 lbs (57 kg)
HbA1c 5.9% (6.8 mmol/L) 5.3% (5.9 mmol/L)
LDL 126 mg/dL (3.3 mmol/L) 186 mg/dL (4.9 mmol/L)

Lab
HDL 42 mg/dL (1.1 mmol/L) 63 mg/dL (1.66 mmol/L)
TG 127 mg/dL (1.4 mmol/L) 52 mg/L (0.58 mmol/L)

Q1: Given her LDL elevation, can she continue
with TCR? Why or why not?

Case study:
Patient 10 Personal 47 years old, female
Health history Type 2 diabetes
Diet history Started TCR six weeks ago
• Atorvastatin 40 mg daily
Medications
• Empagliflozin 10 mg daily
• Metformin, 1000 twice daily
• Blood sugar average, fasting, home test: 110 mg/dL (6.1 mmol/L)
Social/other
• Blood sugar average, postprandial, home test: 150 mg/dL (8.3 mmol/L)
• BHB level, home test: 11 mmol/L

Q1: How do you respond to this information?

MODULE 5:
Follow-up care

Follow-up measurements
Weight | weekly or monthly, not daily
Body fat percentage, lean body mass, waist circumference
Blood pressure | Self-check daily & communicate changes to provider
Blood glucose | Self-check daily & communicate changes to provider
Therapeutic Carbohydrate Restriction CME 5.1.1 Metrics to follow 112

Follow-up labs
Fasting glucose Self-check daily if on diabetes meds; weekly otherwise
Ketones Self-check daily if on diabetes meds; weekly otherwise
HbA1c Recheck at 12 weeks, then every 3-12 months
Fasting lipids Recheck at 12 weeks, then every 3-12 months
Transaminases Recheck at 12 weeks, then annually
Fasting insulin/HOMA-IR Recheck at 12 weeks, then every 3-12 months
TSH Check only if symptoms of hypothyroidism are present

“Dawn effect”
Elevated fasting glucose (100 - 125 mg/dL or 5.6 - 6.9 mmol/L)
Normal preprandial and postprandial glucose levels
Normal HbA1c

Fasting blood sugar 2-3 hours after eating
Normal 100 mg/dL (5.6 mmol/L) or lower 140 mg/dL (7.8 mmol/L) or lower
Prediabetes 100 to 125 mg/dL (5.6 to 6.9 mmol/L) 141 to 199 mg/dL (7.8 to 11.0 mmol/L)
Diabetes 126 mg/dL (7.0 mmol/L) or higher 200 mg/dL (11.1 mmol/L) or higher

When weight loss seems to stall:
For perspective, review weight loss from the start.
Identify time frame of “stall.”
Identify other health metrics that have improved.
Look for “non-scale victories.”
Therapeutic Carbohydrate Restriction CME 5.1.3 Troubleshooting weight loss 116

Troubleshooting weight loss
1 Snacking

Prioritize protein!
Average of 1.2 - 1.7 g/kg of “reference body weight”

Usually equates to about 70 - 120 grams of protein per day
Patients should try to evenly distribute protein among meals
For example:
Three meals/day = 25 - 35 grams of protein/meal
Two meals/day = 45 - 50 grams of protein/meal

1 Snacking
2 Protein
3 Carb and calorie “creep”

Focus on whole foods; avoid “keto” treats; eliminate “MCT coffee”

1 Snacking
2 Protein

4 Issues not related to diet

Activity, sleep, stress, medications, other medical issues

1 Snacking
2 Protein

4 Issues not related to diet

Activity, sleep, stress, medications, other medical issues
5 Unrealistic goals

For long-term maintenance
Use individualized approach
What happens to targeted biomarkers?
What is the patient’s relationship to carbohydrate foods?
What is the patient’s physiological carbohydrate tolerance?
What, if any, dietary restrictions are needed to maintain health?
Therapeutic Carbohydrate Restriction CME 5.2.1 Long-term maintenance 122

Medicare reimbursement for patients with BMI > 30
Intensive behavioral therapy Reimbursement codes:

for obesity:
One face-to-face visit every week for the first month CPT G0447 15 minutes of one-on-one counseling
One visit every other week for months 2 through 6
One visit per month in months 7 through 12

G0473 Groups of 2-10 people.
Therapeutic Carbohydrate Restriction CME 5.2.2 Reimbursement 123

Therapeutic Carbohydrate Restriction CME 5.2.3 Reversal and remission 124
Type 2 diabetes outcome Criteria and cut-offs used
HbA1c below 6.5% (7.8 mmol/L; 47.4 mmol/mol)

Reversal
without any diabetes medication, except metformin
Two HbA1c measurements 5.7 - 6.5%

Partial remission (6.5 - 7.8 mmol/L; 38.8 - 47.4 mmol/mol)
Over the course of 1 year
No medications
Two HbA1c measurements below 5.7% (6.5 mmol/L; 38.8 mmol/mol)

Complete remission Over the course of 1 year
No medications
Therapeutic Carbohydrate Restriction CME 5.2.3 Reversal and remission 125

Type 2 diabetes; orthopedic surgeries

Patient 7 Health history
Height 5’10” (178 cm)
Waist circumference 43 inches (109 cm)
Medications • Canagliflozin, 300 mg daily
• Insulin glargine, long-acting, 30 units daily

210 mg/dL
8.2 % 132 mg/dL TG
HbA1c LDL (2.37 mmol/L)
(10.5 mmol/L) (3.4 mmol/L)
ALT 88 U/L
178 mg/dL 32 mg/dL 1.4 mg/dL
FBG HDL
(9.9 mmol/L) (0.84 mmol/L) Creatinine (123.8 µmol/L)

Case study: Weight
Baseline
288 lbs (130 kg)

Current
215 lbs (97.7 kg)
Patient 7 Clinical Waist circumference 43 inches (109 cm) 36 inches (91 cm)
follow-up Blood pressure 144/88 mmHg 118/76 mmHg
Medications • Canagliflozin, 300 mg daily • Atorvastatin, 20 mg daily
• Insulin glargine, long-acting, 30 units daily • Metformin, 500 mg twice daily
Baseline Current
HbA1c 8.2 % (10.5 mmol/L) 5.4, 5.5% (6.0, 6.2 mmol/L)

Lab
TG 210 mg/dL (2.37 mmol/L) 87 mg/dL (0.98 mmol/L
ALT 88 U/L 28 U/L

Q1: Does he meet criteria for reversal or remission
of his diabetes?

Type 2 diabetes outcome Criteria and cut-offs used
HbA1c below 6.5% (7.8 mmol/L; 47.4 mmol/mol)

Reversal
without any diabetes medication, except metformin
Two HbA1c measurements 5.7 - 6.5%

Partial remission (6.5 - 7.8 mmol/L; 38.8 - 47.4 mmol/mol)
Over the course of 1 year
No medications
Two HbA1c measurements below 5.7% (6.5 mmol/L; 38.8 mmol/mol)

Complete remission Over the course of 1 year
No medications

Q2: Would you stop his metformin at this time?

Health history Metabolic syndrome; gallstones; cholecystectomy 4 years prior
Patient 5 Height 5’2” (155 cm)
Waist circumference 38 inches (96.5 cm)
Diet history Low-fat, high-carbohydrate diet
Social/other 15 minutes of walking per day

6.3% 92 mg/dL 210 mg/dL
HbA1c LDL TG
(7.5 mmol/L) (2.4 mmol/L) (2.37 mmol/L)
118 mg/dL 41 mg/dL
FBG HDL ALT 78 U/L
(6.6 mmol/L) (1.07 mmol/L)

Patient 5 Health history Metabolic syndrome; gallstones; cholecystectomy 4 years prior
TCR for 6 months; initially lost 24 lbs (11 kg); has started to
follow-up Diet history
regain weight
• Coffee with butter and MCT oil twice per day

Social/other • Snacking on keto treats once or twice per day
• Drinking 1-2 glasses of wine 3 nights per week

Case study: Baseline Current
Weight 172 lbs (78 kg) 153 lbs (69.5 kg)
Patient 5 Clinical Waist

circumference 38 inches (96.5 cm) 33 inches (84 cm)
follow-up Blood pressure 142/88 mmHg 127/66 mmHg
HbA1c 6.3% (7.5 mmol/L) 5.5% (6.2 mmol/L)

Lab
TG 210 mg/dL (2.37 mmol/L) 98 mg/dL (1.1 mmol/L)
ALT 78 U/L 30 U/L
FBG 118 mg/dL (6.6 mmol/L) 97 mg/dL (5.4 mmol/L)

Q1: Does she meet the criteria for a weight loss stall?

Q2: What do you think are the three most likely
factors contributing to her recent weight gain?

Q3: What do you think about her weight goal of
120 pounds (54 kg)?

5.4 Summary
MODULE 1: Background and definitions
MODULE 2: Physiological and metabolic effects of carbohydrate-restricted diets
MODULE 3: Initiating the intervention
MODULE 4: Administering TCR
MODULE 5: Follow-up care

Please see supplemental course materials for:
• clinician resources
• patient resources
• complete list of references included in this course
• additional information on therapeutic

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Treating metabolic

syndrome, type 2 diabetes,

MODULE 1: Background and definitions

MODULE 2: Physiological and metabolic effects of carbohydrate-restricted diets

MODULE 3: Initiating the intervention

MODULE 4: Administering TCR

MODULE 5: Follow-up care

Therapeutic Carbohydrate Restriction CME 2

Therapeutic Carbohydrate Restriction CME 3

Obesity 1990 20 - 24.9%

Therapeutic Carbohydrate Restriction CME 1.1.1 Background and general principles 4

Therapeutic Carbohydrate Restriction CME 1.1.2 History 5

Therapeutic Carbohydrate Restriction CME 1.1.2 History 6

“Reducing overall carbohydrate intake for individuals with diabetes has

Therapeutic Carbohydrate Restriction CME 1.1.2 History 7

Therapeutic Carbohydrate Restriction CME 1.2 Nutrition physiology and adequacy 8

Therapeutic Carbohydrate Restriction CME 1.2 Nutrition physiology and adequacy 9

Therapeutic Carbohydrate Restriction CME 1.2 Nutrition physiology and adequacy 10

RDA 0.8 g of protein per kg reference body weight

Therapeutic Carbohydrate Restriction CME 1.2.1 Protein 11

Breakfast Lunch Dinner

Therapeutic Carbohydrate Restriction CME 1.2.2 Fat and saturated fat 13

Absolute grams of fat may not increase on TCR.

Therapeutic Carbohydrate Restriction CME 1.2.2 Fat and saturated fat 14

Therapeutic Carbohydrate Restriction CME 1.2.3 Micronutrients 15

The liver stores

Therapeutic Carbohydrate Restriction CME 1.2.4 Carbohydrate 16

Therapeutic Carbohydrate Restriction CME 1.2.4 Carbohydrate 17

Therapeutic Carbohydrate Restriction CME 1.2.4 Carbohydrate 18

Therapeutic Carbohydrate Restriction CME 1.2.6 Fiber 20

Therapeutic Carbohydrate Restriction CME 1.2.7 Total vs. net carbohydrate 21

This meal has This meal has This meal has

Therapeutic Carbohydrate Restriction CME 1.3.1 Defining TCR 22

Therapeutic Carbohydrate Restriction CME 1.3.2 Calories 23

Health history Type 2 diabetes

• GLP-1 agonist (exenatide)

Tests Ultrasound Evidence of fatty liver

Lab Value Lab Value Lab Value

9.3% 1.6 mg/dL

Therapeutic Carbohydrate Restriction CME 1.4 Module 1 case studies 24

Therapeutic Carbohydrate Restriction CME 1.4 Module 1 case studies 25

Personal 34 years old, female

Health history Metabolic Syndrome

Diet history Vegetarian

Therapeutic Carbohydrate Restriction CME 1.4 Module 1 case studies 26

Therapeutic Carbohydrate Restriction CME 1.4 Module 1 case studies 27

Therapeutic Carbohydrate Restriction CME 1.4 Module 1 case studies 28

Therapeutic Carbohydrate Restriction CME 29

Therapeutic Carbohydrate Restriction CME 2.1 Glucose, insulin, and ketones 30

Therapeutic Carbohydrate Restriction CME 2.1.1 Glucose 31

Therapeutic Carbohydrate Restriction CME 2.1.2 Insulin 32

Therapeutic Carbohydrate Restriction CME 2.1.3 Ketones 33

0 0.5 1.0 1.5 2.0 2.5 3.0

Blood ketones in mmol/L

Therapeutic Carbohydrate Restriction CME 2.2.1 Nutritional ketosis 34

0 0.5 1.0 1.5 2.0 2.5 3.0 5.0 10+

Adapted from: Phinney & Volek Blood ketones in mmol/L