Issue #76 February 2021

Table of Contents
Interview: Lauren Bruzzone, PhD, JD
We chat with CrossFitter Lauren Bruzzone about how she's stayed fit throughout her life.

Deep Dive: A heartbreaking story of EPA, DHA, and CVD

A major study looking at how pharmaceutical-grade fish oil affects CVD risk came up
empty-handed. We cover that trial here and discuss its possible ramifications.

Deep Dive: Cutting carbs may help reverse diabetes, but dietary adherence remains a
challenge
Low-carb diets can reverse diabetes for some people, but they can be challenging to stick
to, and longer-term efficacy remains uncertain.

Curcumin reduces DOMS, with some caveats

A recent meta-analysis suggests a modest effect of curcumin on delayed-onset muscle
soreness, but the quality of evidence ain't great.

Deep Dive: Keto, carbs, and calories

A tightly-controlled experiment found that short-term keto led to more ad libitum food intake
than a higher-carb diet, raising further doubts about the carbohydrate-insulin model of
obesity.

Safety spotlight: Sex, drugs, and weight loss supplements

We give the lowdown on a recent FDA crackdown on sexual enhancement and weight loss
supplements.

Evaluating the efficacy of vitamin D, omega-3, and strength training in older adults
This large and meticulously designed trial explored whether supplementation or strength
training improved the mental or physical health of people over 70. It came up empty-
handed. The question is: why?

Deep Dive: Zinc and immunity

One big reason people take zinc is to boost immunity. This meta-analysis looked at the
details of how supplementation impacted specific immune and inflammation markers.

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 From the Editor
While I like every issue of NERD we publish, I think this issue stands out for three reasons.

The first is that we cover some higher-than-average quality studies in this issue. The study that
looked at how a high-fat ketogenic diet affected caloric intake compared to a higher-carb diet stood
out to me for its tight control, which is both a boon and a bane. While a strong control is useful for
determining causality, the conditions don’t necessarily reflect real-world diet patterns. But since the
point of the study was to evaluate the carbohydrate-insulin theory of obesity, it was well-suited to its
specific task.

While tightly controlled nutrition research is nice to see, it isn’t all that rare to see in NERD
compared to landmark trials—studies that have a big sample size, last a long time, and are very
well designed. In this issue, we cover two such trials.

These trials are usually named with contrived acronyms. These names, while awkward, make them
easier to refer to. The two landmark trials covered in this issue are the DO-HEALTH (Vitamin
D3-Omega-3-Home Exercise-Healthy Aging and Longevity Trial) and STRENGTH (Statin Residual
Risk Reduction With Epanova in High CV Risk Patients With Hypertriglyceridemia) trials. Those
acronyms are so tortured that they probably violate the Geneva Conventions!

DO-HEALTH was designed to examine how either a home strength training regimen or
supplementation with omega-3s or vitamin D affected several measures of mental and physical
health in older people. STRENGTH examined how a specific brand of pharmaceutical-grade fish oil
(Epanova, a mix of EPA and DHA) affected cardiovascular disease risk in people at high risk who
were already taking statins.

This brings me to the third reason why this issue stands out: both STRENGTH and DO-HEALTH
came up mostly empty-handed. While I think it’s super important to cover trials with null results, we
usually cover those trials quickly in NERD. But when major trials are published and don’t find much
of an effect, I think it’s worth emphasizing this null in a full review. It’s worth the space to lay out
why the researchers came up with zilch and how those results compare to the broader literature.

I hope you find these null results as interesting as I do.

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Gregory Lopez, MA, PharmD
Editor-in-chief, Nutrition Examination Research Digest

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Interview: Lauren Bruzzone, PhD, JD
 Tags: NERD Interview

 Read this article online at Examine.com

Lauren Bruzzone is a 74-year-old CrossFitter who was born and raised in New York City whose
fitness regimen has been covered by outlets including Women’s Health and Good Morning
America. She received a PhD in Mathematics from NYU and then went to work with IBM as a
systems engineer. In 1989, she went back to law school part-time. After getting her law degree,
she continued to work at IBM in their intellectual property law department. In addition to exercise,
she loves reading (science fiction, fantasy, murder mysteries) and laughing with her friends.

Q. You’re very committed to your fitness and physical

health. When did that start? Has this been a lifelong
pursuit or something that you started recently?
I always enjoyed some kind of physical activity, although I was never an “athlete”—I was the kid
who was chosen last for the team. I did basic gym classes for years, but about eight years ago I
started CrossFit, and then two years ago I met Wesley James (who trains me) and that really took
it up a notch.

Q. We’ve seen you doing CrossFit-style workouts on

social media. Is this your preferred type of exercise?

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What other types of exercise do you enjoy?
Actually, what you are seeing are more bodyweight exercises. I like CrossFit because those
workouts make it easy to measure your progression. I like the body workouts because they
challenge what I think I can physically do. I wish I could say I enjoy running: I keep starting
beginner programs. Let’s just say that’s a work in progress.

Q. With respect to the workouts themselves, what sort

of goals do you have? Are they specific (e.g., improving
strength with barbells, doing more pushups,
completing workouts faster) or are they more about
just showing up and getting after it?
It's a two-step process: goal 1—get out of bed and get there; goal 2—lift just a bit more weight or
get that balance on the exercise ball. I would really like to do a pull-up. I got it a while ago and then
lost it. Another work in progress.

Q. Outside of the workouts, what types of outcomes are

you trying to achieve? For example, are you trying to
improve mental clarity and flexibility, increase strength
in daily life, or something else?
I have always said my ultimate goal is to get to the bathroom by myself when I am 90. Having said
that, I feel SOOOO much better when I exercise.

Q. What sort of dietary/nutritional practices do you

have? Do you follow a certain diet or any guiding
principles? (No pressure if you don’t, by the way! We
are big nutrition nerds, but we understand not
everyone is!)
I watch my weight and if it goes above a certain level, I cut back on sugar and carbs. I try to limit

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alcohol, chocolate, cake, and ice cream to the weekends. If quarantine makes me stress eat, I eat
air-popped popcorn. It provides a lot of chewing for very few calories.

Q. On a similar note, what else do you do to support

your health goals? Do you take supplements, meditate,
get massages, etc.?
I teach math at UConn. If that doesn’t keep my brain active, nothing will. I also audit other courses
there.

Q. If someone reached out and said “I want to be just

like you,” what advice would you give them? Would
that advice change based on their age?
First, start small and start slow. If you have never exercised, walk around the block and see how
you do. Then, the next day, walk around the block twice. DON’T GIVE UP!!! Try keeping a journal
of what you are doing so you can track your progress. Would this advice change based on age?
Absolutely not. We can all do something. If you are older, it just takes a bit longer to reach certain
goals.

Q. Do you have any closing remarks? Is there anything

important I forgot to ask you about?
Yes. If you are starting an exercise program, have fun! You will feel so much better.

The views and opinions expressed by interviewees are their own,

and do not necessarily reflect those of Examine.

^ Go back to table of contents

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Deep Dive: A heartbreaking story of EPA,
DHA, and CVD
 Tags: CVD, EPA, DHA, Supplementation, Cardiovascular Disease, Omega 3, Fish Oil

 Study under review: Effect of High-Dose Omega-3 Fatty Acids vs Corn Oil on Major
Adverse Cardiovascular Events in Patients at High Cardiovascular Risk: The STRENGTH
Randomized Clinical Trial

 Read this article online at Examine.com

Quick Takes
• What was the question? Does a pharmaceutical-grade
carboxylic acid form of EPA plus DHA reduce the risk of
negative cardiovascular outcomes?
• How was it answered? Researchers conducted a large-
scale, long-duration randomized controlled trial.
• Who was studied? This study included over 13,000
participants at high risk for CVD and high triglycerides whose
LDL cholesterol was well controlled due to statin treatment.
• What was the intervention? Participants took 4 grams of
pharmaceutical-grade carboxylated EPA plus DHA daily, or a
corn oil placebo, for over three years.
• What’s the main takeaway? The trial was stopped early due
to the low probability of seeing any cardiovascular benefit
from EPA plus DHA. There was no clear benefit for the

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 primary cardiovascular composite outcome, nor for any
secondary outcome. However, there was an increased risk of
atrial fibrillation in the treatment group.
• Any caveats? These results may not carry over to
populations at lower risk of CVD. Also the individual
contributions of EPA and DHA are open to question since
researchers administered them at a fixed ratio.

Introduction
An estimated 25% of adults in the U.S[1] have elevated triglyceride (TG) levels (at least 150 mg/dL).
This condition, also called hypertriglyceridemia[2], has long been known to be associated with
cardiovascular disease (CVD)[3] as an independent risk factor increasing relative risk by 14% in
men and 37% in women. Hypertriglyceridemia can be divided into moderate (TG levels of
150–1000 mg/dL) and severe (TG levels of more than 1000 mg/mL) forms. According to the
American Heart Association’s recent guidelines, people with severe hypertriglyceridemia are at
very high risk of CVD and require effective lipid-lowering treatment[4]. Even though a putative
causal role[5] between triglycerides and heart disease is heavily debated, CVD prevention and
treatment[6] in high-risk populations generally includes lowering TG levels. The two most effective
ways to lower TG levels are medications and lifestyle modifications such as weight loss, cessation
of alcohol consumption, and tighter blood sugar control. The former option usually involves the
treatment with statins[7], which are low-density lipoprotein (LDL) lowering drugs that effectively
reduce CVD risk[8]. Their effects on triglyceride levels[9] are limited, though, and high-risk people
often benefit from additional treatment approaches[10] to prevent adverse events such as heart
attack and stroke.

Omega-3 fatty acids[11] (O3FAs) have attracted considerable interest for their cardioprotective
benefits[12]. These long-chain, polyunsaturated fatty acids play an essential role in the human diet
and human physiology.[13] The two main O3FAs are eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA). Observational[14] studies[15] found that the frequent consumption of
fatty fish is associated with lower CVD risk. Furthermore, mechanistic studies identified EPA and
DHA as the critical bioactive components[16] that convey the protective effects of O3FAs, and

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increased circulating levels of EPA and DHA are associated with a decreased CVD risk[17]. There’s
also evidence that O3FA supplementation exerts a favorable impact on various risk factors[16]
implicated in CVD, such as abnormal inflammatory, oxidative, thrombotic, and vascular blood
markers.

Many mechanisms have been proposed concerning O3FA and lipid metabolism[18], yet research is
still ongoing. What is known with reasonable certainty is that the liver, the hub of fatty acid
synthesis and lipid circulation[19], seems to be the primary site of action where O3FAs may
positively affect lipid metabolism. Mechanistic studies have found three possible pathways where
O3FAs could positively impact lipid metabolism, summarized in Figure 1: synthesis, secretion, and
clearance of certain kinds of lipids. First, O3FAs may attenuate the hepatic synthesis of
triglycerides. Studies show that O3FAs reduce triglyceride synthesis by inhibiting the major hepatic
triglyceride-synthesizing enzyme[20] called diacylglycerol acyltransferase. Second, O3FAs inhibit
the secretion of triglyceride-rich lipoproteins. This mechanism is based on the findings that O3FAs
induce the intracellular degradation of apoprotein-B[21], the primary organizing protein of many lipid
particles such as LDL. In other words, O3FAs deplete the cell of the “package proteins” that
transport these kinds of lipids out of the cell into blood circulation. The third potential mechanism is
the increased clearance of blood triglycerides. To achieve this, O3FAs may upregulate lipoprotein
lipase[22], which breaks down triglycerides and is involved in the cellular uptake of certain lipids
from circulation. Overall, the putative mechanisms of action combined with the clinical evidence of
the triglyceride-lowering benefits of O3FAs make a compelling case to use O3FA to prevent CVD.

Figure 1: Possible influences of O3FA on triglyceride

metabolism

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Reference: Skulas-Ray et al. Circulation. 2019 Sep.[18]

Here is the enigma: Even though the biological rationale for O3FA use for CVD prevention is clear,
the clinical evidence is still inconsistent. Three[23] meta[24]-analyses[25] from 2008–2009 have
shown modest reductions in the rates of cardiovascular events. In contrast, a recent meta-analysis
of double-blinded RCTs from 2018 found no effect of low doses (less than 1–1.5 grams daily) of
the O3FA agents EPA/DHA on cardiovascular outcomes. In contrast, a recent trial[26] used higher
O3FA doses (more than 1.5–2 grams daily) and found significant cardiovascular benefits. This
study, called the REDUCE-IT[26] trial, showed a significantly reduced relative risk reduction of 25%
of adverse events in statin-treated participants taking about 3.8 grams of EPA daily, compared with
placebo. However, the mineral oil placebo used in this trial has been criticized[27] for having
adverse effects[28] on the control group, making the treatment group look more positive. Yet, a
review by the US Food and Drug Administration (FDA) concluded that the harmful effects of the
mineral oil could only explain a small fraction of the risk reduction. Nevertheless, this problem with
oil placebos, and also supplement type and quality, will also become pivotal points when
discussing the present study results in the “Bigger Picture” section below.

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Why do all these trials show such inconsistent outcomes? There are various potential reasons:
Most notably, the doses of O3FAs[27] may have been too low in some trials. Also, different studies
use different EPA/DHA ratios and products. Some O3FAs products contain a mixture of both EPA
and DHA. Other products only contain EPA, as some studies suggest that EPA is more potent[29]
for cardiovascular benefits. Since 2019, the REDUCE-IT[26] trial is often quoted as further evidence
for this claim. Another reason to explain the inconsistent outcomes is that O3FA products use
different formulations[30]. The main ones used in pharmaceutical-grade products are usually ethyl
EPA (E-EPA), also called icosapent ethyl, and carboxylic acid (CA-EPA), while those in
supplements tend to be triglyceride or phospholipid forms among others, as shown in Figure 2.
Even though all prescription formulations reduce TG levels effectively[30], head-to-head clinical
trials directly comparing different O3FA products are lacking. Overall, it remains unclear as to what
formulation and dosage of omega-3 is most efficacious (if any), and what the concrete benefits and
risks are, especially for high-risk patients. However, answering this question is of paramount
importance to optimize the treatment regime for optimal clinical outcomes.

Figure 2: The different forms of EPA and DHA

The present study[31] was designed to shed more light on this question. The trial carries the proud
name STRENGTH, which stands for the less-catchy “Long-Term Outcomes Study to Assess Statin
Residual Risk with Epanova in High Cardiovascular Risk Patients with Hypertriglyceridemia.” In this

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double-blind, multicenter randomized controlled trial, the researchers used a mixture of carboxylic
acid EPA plus DHA. The rationale of using a carboxylic acid formulation is that it has a potentially
higher bioavailability due to improved intestinal absorption. Two previous trials[32][33] already
showed beneficial effects of the carboxylic acid formulation to lower blood triglycerides. Here, the
researchers wanted to investigate cardiovascular outcomes.

The omega-3 fatty acids DHA and EPA have potential

cardiovascular benefits which are thought to arise partly due to
their triglyceride-lowering effects. This effect could be beneficial for
statin-treated patients who are still at high risk of adverse
cardiovascular events due to high triglyceride levels. Yet, the
current body of evidence does not provide a clear picture of
whether O3FAs improve clinical outcomes in people at high CVD
risk. The present study investigated the effects of a
pharmaceutical-grade omega-3 product using a carboxylic acid
EPA plus DHA formulation in high cardiovascular risk participants.

What was studied?

The STRENGTH trial was a preregistered, double-blind, randomized controlled trial (RCT)
performed at multiple centers (675 hospitals in 22 countries) from October 2014 to January 2020.
In total, 13,089 statin-treated participants (65% men and 35% women) with high CVD risk, high
triglycerides (180–500 mg/dL), and low HDL cholesterol (less than 42 mg/dL) levels were recruited.
The participants were, on average, 62 years old, and about 70% had diabetes. The study excluded
participants who had an adverse cardiovascular event 30 days before the trial started or who were
already consuming O3FA supplements. The intervention group (n = 6,539) received a daily EPA/
DHA mixture of 4 grams, while the control group (n = 6,539) received corn oil. Hint: Keep the corn
oil in mind when reading about the Bigger Picture, as this will be an essential detail to interpret the
findings of this study.

Both groups further received their usual baseline therapies, including statins. The primary outcome
was the first occurrence of any of the following coronary adverse events: cardiovascular death,

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nonfatal myocardial infarction, nonfatal stroke, emergent/elective coronary revascularization, and
hospitalization for unstable angina. This list of primary outcomes is referred to as “MACE” in the
rest of this article. There was also a long list of secondary end points, mostly involving other
composite outcomes, along with CVD-related death and death by any cause in both the entire
study population as well as participants who had CVD when the study started.

Before the study, the researchers defined a 15% reduction in relative CV risk as a minimally
significant difference to be clinically relevant. Further, the researchers measured blood lipids and
C-reactive protein.

The present study is a large, multicenter RCT investigating the

potentially beneficial effects of omega-3 CA supplementation in
13,089 statin-treated participants with high CV risk. Corn oil was
given to the control group as a comparator. The primary outcome
was a composite of several CVD outcomes.

What were the findings?

The trial was terminated early in January 2020 due to a low probability of finding a clinical benefit of
omega-3 CA compared with corn oil. Due to the coronavirus pandemic, the researchers performed
end-of-treatment visits by telephone rather than through in-person check-ups. The researchers
state that this change in methodology was necessary to complete the trial in a timely and orderly
manner, with the least possible effect on study integrity. However, even with the early stoppage,
96.6% of the participants completed the trial.

Overall, participants treated with omega-3 CA showed the expected increases in circulating EPA
and DHA levels, indicating sufficient absorption of the carboxylic acid O3FA formulation.
Participants in the O3FA group also had a greater reduction in triglycerides than those in the corn
oil group (-19% vs. -0.9%) and reduced C-reactive protein levels (-20% vs. -6.3%). However,
administration of O3FA did not change the clinical outcomes: The primary endpoint occurred in 785
participants (12.0%) treated with omega-3 CA and 795 (12.2%) treated with corn oil. The difference
between the intervention and control group is not statistically significant. Similarly, the secondary
outcomes also did not show any beneficial effects: participants treated with omega-3 CA did not
show any statistically relevant decreases in the occurrences of stroke compared with control (8.3%

14
vs. 7.9%) or any other of the adverse CV events (8.5% vs. 9.4%). However, there was a small yet
significant risk reduction (about -15%) for coronary events in participants with established CVD at
baseline taking O3FAs (11.5%) compared to the control (13.4%). The hazard ratios of some of the
outcomes along with their 95% confidence intervals are shown in Figure 3.

Figure 3: Select results from the study (plus 95%

confidence intervals)

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16
Overall, CA-O3FA was less well tolerated than corn oil, as evidenced by three findings. First, drug-
related adverse events occurred almost twice as frequently in the omega-3 CA group than in the
corn oil comparator group (22.2% vs. 12.9%, respectively). Second, participants taking omega-3
CA were almost twice as likely to experience atrial fibrillation, characterized by irregular and often
rapid heart beats stemming from problems in the upper heart chambers (2.2% vs. 1.3%). Notably,
atrial fibrillation is the most common cardiac arrhythmia and is associated with an increased risk for
stroke or heart attack[34]. Third, gastrointestinal (GI) adverse events were also higher in the
omega-3 CA treatment group (24.7% vs. 14.7%). As a consequence of experiencing such
complications with the O3FA agent, about every ninth participant (10.8%) had discontinued the
trial, compared to only every 13th (8.0%) in the control group.

Omega-3 CA supplementation had no clear positive impact on

CVD risk on almost all of the CVD-related outcomes measured
compared to a corn oil placebo. However, the omega-3 CA
treatment group had a higher risk of experiencing drug-related
adverse events such as atrial fibrillation and GI problems.

The bigger picture

The present study’s findings prompt a major question: Why did the STRENGTH study find no effect
of O3FA supplementation while other trials found a positive effect? To attempt to answer this
question, it’s helpful to dive deeper into the relevant clinical trials, especially the REDUCE-IT trial,
since this recent trial was also large and long, but found a sizable reduction in CVD risk. There are
four comparisons to the REDUCE trial worth diving deeper into in order to shed light on the matter.

First, there is a qualitative difference in the omega-3 products used. The REDUCE-IT trial used
highly purified ethyl EPA (E-EPA, Vascepa[35]). In contrast, the present trial used a mixture of
carboxylic acid O3FA agents (CA-DHA/EPA, Epanova). So, what’s the difference, and why does
this even matter? Besides the presence of CA-DHA in the mixture, CA-EPA differs from E-EPA
because it does not require hydrolysis by pancreatic lipase during intestinal absorption due to its
chemical structure (see Figure 2). This characteristic may eliminate the need for consumption with
a high-fat meal, resulting in greater bioavailability. However, the putative improvement in
bioavailability has not been proven so far, but provides an attractive biological rationale to conduct
clinical trials. Two previous trials[32][33] already showed that CA-EPA effectively reduced plasma

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triglyceride levels. The study under review also found similar results concerning triglyceride, yet it
failed to find evidence of an effect on CVD outcomes. So perhaps the CA-DHA/EPA doesn’t affect
clinical endpoints, but E-EPA may. Interestingly, some[36] case[37] studies[38] report that statin-
treated patients who switched from ethyl O3FA to a high-dose EPA monotherapy showed improved
lipid profiles, which is consistent with E-EPA perhaps being better, though this is very weak
evidence on its own.

This leads into the second point: there are two quantitative differences between the two trials. For
one, EPA doses differed. Even though both studies used high doses of 4 grams per day, the total
amount of EPA was almost double in the REDUCE-IT trial (4 grams of E-EPA is about 3.8 grams of
EPA per day), compared to the STRENGTH trial (about 2 grams of EPA per day). This effect is
directly measurable. The increase in EPA blood levels relative to baseline was higher in the
REDUCE-IT trial (+400%) than the STRENGTH trial (+270%). Yet, both trials show a very similar
triglyceride-lowering effect: after a one-year follow-up, the STRENGTH trial showed a -19.0% and
the REDUCE-IT trial a -18.5% reduction in triglyceride blood levels, compared to baseline. This
raises the question of whether higher EPA blood levels have other metabolic effects besides
reducing triglyceride levels. In fact, the observed cardiovascular benefits in the REDUCE-IT trial
were similar across baseline levels and irrespective of the attained triglyceride levels, indicating
that also other mechanisms may be at work here. Second, DHA doses differed. The REDUCE-IT
trial administered an EPA monotherapy, while the present study used a mixture of EPA (about 2
grams per day) and DHA (about 1 gram per day). This difference in outcomes raises two questions:
Are EPA/DHA mixtures less efficacious than EPA alone? And did DHA attenuate the beneficial
effects of EPA? Here, the evidence is also unclear: On the one hand, a recent systematic review
from 2019[39] praises DHA as a useful bioactive compound for heart, cardiovascular, and brain
function. On the other hand, three previous trials[40][41][42] also found no clinical benefits of mixed
omega-3 products to reduce CVD risk. Also, a meta-analysis from 2011[43] found that DHA
increased LDL, while EPA did not. This can also be observed in the present study where the
treatment group showed a small but significant (+1%) increase in LDL. Factors like this have led
some[28] researchers[27] to speculate that DHA might have offset the effects of the EPA in the
present study. Overall, the current evidence raises the possibility that mixed EPA/DHA formulations
may not effectively prevent CVD in high-risk patients.

Third, as previously hinted at, the choice of placebo could have impacted the outcomes. While the
REDUCE-IT trial used mineral oil, the STRENGTH study used corn oil. It turns out this difference
matters a lot more than expected: Participants taking mineral oil in the REDUCE-IT trial showed
moderately increased blood markers of proven CV risk factors, namely HsCRP, apoB, and LDL-C.
The newer STRENGTH study, using the corn oil placebo, didn’t detect corresponding changes in
the control arm. Could the negative effects of the mineral oil[27] on the control make the omega-3
intervention group look more positive? A review by the U.S. Food and Drug Administration (FDA)

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concluded that the mineral oil’s putative negative effects on blood markers of cardiovascular risk
could explain some, but not all, of the differences in outcomes. Other studies[44][45] also suggest
that mineral oil is a safe placebo and did not meaningfully influence the trial’s outcomes. Further, a
meta-analysis assessing the safety and use of mineral oil as a placebo[44] concluded that mineral
oil does not appear to effect clinical outcomes when used in such low doses. Hence, the evidence
suggests that the most likely interpretation is that E-EPA treatment in the REDUCE-IT trial was
beneficial. Yet, only a new clinical trial of E-EPA using corn oil instead of mineral oil as a control
comparator could fully answer this question. However, this would be both very expensive and take
quite a long time even, assuming this hypothetical study even received funding. Accordingly, the
current evidence must suffice for now.

Fourth, it’s always worth evaluating the potential risks associated with any drug treatment. The
possible side effects of taking O3FA include allergic reactions, diarrhea, upset stomach, abdominal
pain, and burping. Both trials found an increased risk of experiencing adverse events, especially GI
problems and atrial fibrillation, the latter being associated with an increased risk of stroke[46].
Further, the REDUCE-IT trial also found higher rates of serious bleeding events. It thus remains
uncertain if the potential benefits of these omega-3 products outweigh the potential risks of
suffering one or many of the mentioned above side effects for people with high cardiovascular risk.
Based on the present trial, the evidence suggests that—at least for mixed EPA/DHA
products—supplementation may not be worth it, as there were more downsides in the form of side
effects than benefits, which were pretty much nil. However, this may be different for EPA
monotherapy, as evidenced by the REDUCE-IT trial. Notably, it’s important to mention, once again,
that comparing two independent RCTs is difficult—the possible explanations given here need to be
viewed with caution.

While these four domains cover many of the possible explanations for the differences between the
two trials, another difference is worth mentioning briefly. The treatment groups differed regarding
baseline triglyceride levels. While the present study included only participants with TG levels of
180–500 mg/dL, about 10% of enrolled participants in the REDUCE-IT trial had TG levels lower
than 150 mg/dL. Hence, the beneficial effects of omega-3 fatty acids may vary depending on the
intervention group.

Finally, it’s worth mentioning some individual strengths and weaknesses of the present study.
There are a lot of strengths to STRENGTH. First, it is one of the largest, longest clinical trials
investigating the effects of a pharma-grade omega-3 product on CVD outcomes to date. The
researchers enrolled over 13,000 participants in multiple centers (675 hospitals) worldwide in 22
countries. Given its size and expense, the study had to be well designed from the get-go: it had a
single clear, primary outcome along with several secondary outcomes that measured clear,
important clinical endpoints. While this study is of much higher quality than the usual studies
covered in NERD, it still has a couple of limitations. First, a fixed proportion of EPA and DHA was

19
administered. Since no CV benefits were observed, it remains an open question whether other
proportions (e.g., with higher EPA share) would have shown a positive effect. Also, there are no
large clinical trials available that tested the effect of DHA monotherapy. This would be helpful to
disentangle the effects of the mixed EPA/DHA product.

In contrast to the REDUCE-IT trial, the present study did not show
any beneficial effects of the carboxylic acid EPA/DHA for
participants with a high risk of CVD. There are three plausible
explanations for this difference: The trials used different omega-3
formulations, the administered doses of EPA were higher in
REDUCE-IT, or REDUCE-IT’s placebo choice could have
exaggerated the apparent efficacy of E-EPA. However, both trials
have one disturbing point in common: both found an increased risk
for adverse events such as GI problems and atrial fibrillation after
supplementation.

Frequently asked questions

Q. The STRENGTH participants were all at high risk for CVD. What’s the evidence for the
efficacy of O3FAs in lower-risk people?

The current evidence suggests that the answer to this question depends on O3FA intake from the
diet. The VITAL trial[47] was a recent large landmark trial covered previously in NERD. It
investigated the effects of a 1 gram daily dose of an EPA plus DHA mixture on about 25,800
individuals ages 50 and older and found that omega-3 supplements likely won’t benefit people who
eat at least 1–2 servings of fatty fish per week, though supplementation helped reduce
cardiovascular events in people who didn’t take in much marine O3FAs from their diets.

The VITAL trial outcomes agree with a recent meta-analysis[15] suggesting that fish consumption is
associated with a lower risk of not only CVD but also depression and mortality. However, the
benefits expected may differ for types of fish consumed and different methods of cooking fish.
Furthermore, some people don’t eat fish for moral reasons[48], environmental protection[49], and/or
other health-related factors such as fish allergy[50]. For these groups, O3FA supplementation

20
seems like a safe and effective way to still gain cardiovascular benefits.

Q. The present study used a highly purified pharma-grade omega-3 product. Are the
omega-3 supplements I am taking of sufficient quality?

Maybe, but maybe not. A recent study[51] found that three top-selling fish oil supplements in the
U.S. contain undesired saturated fat species and up to 4,000% more oxidized fats than prescription
fish oil. NERD has also covered other similar issues with fish oil products sold in New Zealand. The
saturated fats and oxidized O3FAs may interfere with their intended/potential biological benefits.
Hence, the predictive power of high-quality RCTs using pharma-grade omega-3 products may not
be applicable to these over-the-counter products. Overall, the potential benefits of over the counter
omega-3 supplements remains controversial.

What should I know?

The present study, called the STRENGTH trial, is one of the largest and longest clinical trials
investigating the effect of omega-3 supplementation on older individuals with a high risk for CVD-
related adverse events. Despite its biological rationale (putatively improved bioavailability of
carboxylic acid omega-3), the present study provides no evidence that mixed omega-3 products
have much of a positive effect on CVD outcomes. This lack of any beneficial cardioprotective
outcome is in contrast to other previous trials, most prominently the REDUCE-IT trial, in which high
doses of the EPA significantly reduced the risk for adverse CV events. While there are some
plausible reasons why these results may have differed, it’s not absolutely clear why there was a
discrepancy.

While this study found little benefit for omega-3s, it did find some evidence of harm: participants
taking omega-3 CA had higher risks for adverse events such as GI problems and atrial fibrillation.

What do you think explains the discrepancy between these results

and previous studies like REDUCE-IT? Have your say and see
what other readers are saying over at the NERD forum.

^ Go back to table of contents

21
 References
1. ^ Wenjun Fan, et al. Prevalence of US Adults with Triglycerides ≥ 150 mg/dl:
NHANES 2007-2014. Cardiol Ther. (2020)
2. ^ Casey Elkins, Debra Friedrich. Hypertriglyceridemia: A review of the evidence.
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3. ^ M A Austin, J E Hokanson, K L Edwards. Hypertriglyceridemia as a cardiovascular
risk factor. Am J Cardiol. (1998)
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still a hypothesis?. Arterioscler Thromb Vasc Biol. (2011)
6. ^ Klaus G Parhofer, Ulrich Laufs. The Diagnosis and Treatment of
Hypertriglyceridemia. Dtsch Arztebl Int. (2019)
7. ^ Katarzyna Rygiel. Hypertriglyceridemia - Common Causes, Prevention and
Treatment Strategies. Curr Cardiol Rev. (2018)
8. ^ Dhruv S Kazi, Joanne M Penko, Kirsten Bibbins-Domingo. Statins for Primary
Prevention of Cardiovascular Disease: Review of Evidence and Recommendations for
Clinical Practice. Med Clin North Am. (2017)
9. ^ Björn W Karlson, et al. A VOYAGER Meta-Analysis of the Impact of Statin Therapy
on Low-Density Lipoprotein Cholesterol and Triglyceride Levels in Patients With
Hypertriglyceridemia. Am J Cardiol. (2016)
10. ^ Lars Berglund, et al. Evaluation and treatment of hypertriglyceridemia: an
Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. (2012)
11. ^ Shahidi F, Ambigaipalan P. Omega-3 Polyunsaturated Fatty Acids and Their Health
Benefits. Annu Rev Food Sci Technol. (2018)
12. ^ Jin Endo, Makoto Arita. Cardioprotective mechanism of omega-3 polyunsaturated
fatty acids. J Cardiol. (2016)
13. ^ Ondrej Kuda, Martin Rossmeisl, Jan Kopecky. Omega-3 fatty acids and adipose
tissue biology. Mol Aspects Med. (2018)
14. ^ Liana C Del Gobbo, et al. ω-3 Polyunsaturated Fatty Acid Biomarkers and
Coronary Heart Disease: Pooling Project of 19 Cohort Studies. JAMA Intern Med.
(2016)

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15. ^ a b Ahmad Jayedi, Sakineh Shab-Bidar. Fish Consumption and the Risk of Chronic
Disease: An Umbrella Review of Meta-Analyses of Prospective Cohort Studies. Adv
Nutr. (2020)
16. ^ a b Mozaffarian D, Wu JH. Omega-3 fatty acids and cardiovascular disease: effects
on risk factors, molecular pathways, and clinical events. J Am Coll Cardiol. (2011)
17. ^ Dariush Mozaffarian, et al. Plasma phospholipid long-chain ω-3 fatty acids and total
and cause-specific mortality in older adults: a cohort study. Ann Intern Med. (2013)
18. ^ a b Ann C Skulas-Ray, et al. Omega-3 Fatty Acids for the Management of
Hypertriglyceridemia: A Science Advisory From the American Heart Association.
Circulation. (2019)
19. ^ P Nguyen, et al. Liver lipid metabolism. J Anim Physiol Anim Nutr (Berl). (2008)
20. ^ William S Harris, Deepti Bulchandani. Why do omega-3 fatty acids lower serum
triglycerides?. Curr Opin Lipidol. (2006)
21. ^ Meihui Pan, et al. Presecretory oxidation, aggregation, and autophagic destruction
of apoprotein-B: a pathway for late-stage quality control. Proc Natl Acad Sci U S A.
(2008)
22. ^ Gregory C Shearer, Olga V Savinova, William S Harris. Fish oil -- how does it
reduce plasma triglycerides?. Biochim Biophys Acta. (2012)
23. ^ Yun-Tao Zhao, et al. Prevention of sudden cardiac death with omega-3 fatty acids
in patients with coronary heart disease: a meta-analysis of randomized controlled
trials. Ann Med. (2009)
24. ^ Paul E Marik, Joseph Varon. Omega-3 dietary supplements and the risk of
cardiovascular events: a systematic review. Clin Cardiol. (2009)
25. ^ Hernando León, et al. Effect of fish oil on arrhythmias and mortality: systematic
review. BMJ. (2008)
26. ^ a b c Bhatt DL, et al. Cardiovascular Risk Reduction with Icosapent Ethyl for
Hypertriglyceridemia. N Engl J Med. (2019)
27. ^ a b c d Gregory Curfman. Do Omega-3 Fatty Acids Benefit Health?. JAMA. (2020)
28. ^ a b Garima Sharma, Seth S Martin, Roger S Blumenthal. Effects of Omega-3 Fatty
Acids on Major Adverse Cardiovascular Events: What Matters Most: the Drug, the
Dose, or the Placebo?. JAMA. (2020)
29. ^ Sarabjeet Singh, et al. Eicosapentaenoic Acid Versus Docosahexaenoic Acid as
Options for Vascular Risk Prevention: A Fish Story. Am J Ther. (May-Jun)
30. ^ a b Ito MK. A Comparative Overview of Prescription Omega-3 Fatty Acid Products.
P T. (2015)
31. ^ Stephen J Nicholls, et al. Effect of High-Dose Omega-3 Fatty Acids vs Corn Oil on
Major Adverse Cardiovascular Events in Patients at High Cardiovascular Risk: The

23
 STRENGTH Randomized Clinical Trial. JAMA. (2020)
32. ^ a b Kevin C Maki, et al. A highly bioavailable omega-3 free fatty acid formulation
improves the cardiovascular risk profile in high-risk, statin-treated patients with
residual hypertriglyceridemia (the ESPRIT trial). Clin Ther. (2013)
33. ^ a b John J P Kastelein, et al. Omega-3 free fatty acids for the treatment of severe
hypertriglyceridemia: the EpanoVa fOr Lowering Very high triglyceridEs (EVOLVE)
trial. J Clin Lipidol. (Jan-Feb)
34. ^ Peter Zimetbaum. Atrial Fibrillation. Ann Intern Med. (2017)
35. ^ Budoff M, et al. Effect of Vascepa (icosapent ethyl) on progression of coronary
atherosclerosis in patients with elevated triglycerides (200-499 mg/dL) on statin
therapy: Rationale and design of the EVAPORATE study. Clin Cardiol. (2018)
36. ^ Anurag W Kedia, Erin Lynch. Effects of switching from omega-3-acid ethyl esters to
icosapent ethyl in a statin-treated patient with elevated triglycerides. Postgrad Med.
(2015)
37. ^ James R Crandell, Christina Tartaglia, Joseph Tartaglia. Lipid effects of switching
from prescription EPA+DHA (omega-3-acid ethyl esters) to prescription EPA only
(icosapent ethyl) in dyslipidemic patients. Postgrad Med. (2016)
38. ^ James R Crandell. Switching from EPA + DHA (Omega-3-acid Ethyl Esters) to
High-Purity EPA (Icosapent Ethyl) in a Statin-Treated Patient with Persistent
Dyslipidemia and High Cardiovascular Risk: A Case Study. Clin Med Insights Cardiol.
(2016)
39. ^ Samaneh Ghasemi Fard, et al. How does high DHA fish oil affect health? A
systematic review of evidence. Crit Rev Food Sci Nutr. (2019)
40. ^ ASCEND Study Collaborative Group, et al. Effects of n-3 Fatty Acid Supplements
in Diabetes Mellitus. N Engl J Med. (2018)
41. ^ Manson JE, et al. Marine n-3 Fatty Acids and Prevention of Cardiovascular
Disease and Cancer. N Engl J Med. (2019)
42. ^ ORIGIN Trial Investigators, et al. n-3 fatty acids and cardiovascular outcomes in
patients with dysglycemia. N Engl J Med. (2012)
43. ^ Wei MY, Jacobson TA. Effects of eicosapentaenoic acid versus docosahexaenoic
acid on serum lipids: a systematic review and meta-analysis. Curr Atheroscler Rep.
(2011)
44. ^ a b Brian Olshansky, et al. Mineral oil: safety and use as placebo in REDUCE-IT
and other clinical studies. Eur Heart J Suppl. (2020)
45. ^ Suvasini Lakshmanan, et al. Comparison of mineral oil and non-mineral oil placebo
on coronary plaque progression by coronary computed tomography angiography.
Cardiovasc Res. (2020)
46. ^ Jeff S Healey, Guy Amit, Thalia S Field. Atrial fibrillation and stroke: how much

24
 atrial fibrillation is enough to cause a stroke?. Curr Opin Neurol. (2020)
47. ^ JoAnn E Manson, et al. Principal results of the VITamin D and OmegA-3 TriaL
(VITAL) and updated meta-analyses of relevant vitamin D trials. J Steroid Biochem
Mol Biol. (2020)
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concern. Dis Aquat Organ. (2007)
49. ^ Carlos M Duarte, et al. Rebuilding marine life. Nature. (2020)
50. ^ Michael F Sharp, Andreas L Lopata. Fish allergy: in review. Clin Rev Allergy
Immunol. (2014)
51. ^ R Preston Mason, Samuel C R Sherratt. Omega-3 fatty acid fish oil dietary
supplements contain saturated fats and oxidized lipids that may interfere with their
intended biological benefits. Biochem Biophys Res Commun. (2017)

25
Deep Dive: Cutting carbs may help reverse
diabetes, but dietary adherence remains a
challenge
 Tags: Low-Carb, Diabetes, Diet, Meta-analysis

 Study under review: Efficacy and safety of low and very low carbohydrate diets for type
2 diabetes remission: systematic review and meta-analysis of published and unpublished
randomized trial data

 Read this article online at Examine.com

Quick Takes
• What was the question? Can low and very low
carbohydrate diets reverse type 2 diabetes?
• How was it answered? Researchers conducted a meta-
analysis of randomized controlled trials.
• Who was studied? The participant population was made up
of adults 40–70 years old with type 2 diabetes.
• What was the intervention? Participants followed either low
carbohydrate (under 130 grams daily or under 26% of daily
energy intake) or very low carbohydrate (under 10% of daily
calories from carbs) diets lasting at least 12 weeks.
• What's the main takeaway? Low carbohydrate diets put
diabetes into remission twice as often as control diets at 6
months, but not at 12 months. Other beneficial effects, like

26
 weight loss and lower triglyceride levels, were also observed
at 6 months, with reduced efficacy at 12 months.
• Any caveats? The data at 12 months was sparse and thus
more uncertain. Also, very low carbohydrate diets tended to
do worse than low carbohydrate diets, but this
underperformance was mostly accounted for by lower
adherence rates. Finally, the evidence is of low to moderate
certainty. More evidence would be useful, especially over
longer time frames.

Introduction
Type 2 diabetes has been a constant challenge for researchers and clinicians for more than a
century, if not longer[1]. Throughout its history, a cornerstone of treatment has been based on
nutrition. Before the discovery of insulin 100 years ago in 1921, nutritional fasting was the only
treatment available, but as pharmacotherapies (insulin, sulfonylureas, biguanides, etc.) have been
developed, treatment has tended to emphasize these new technologies, pushing research on
nutritional management to the side.

Perhaps due to an excessive focus on the available medical treatments, diabetes remission was
considered impossible for decades. In the 1990s and 2000s, mention of diabetes remission in
PubMed was limited to animal models, bariatric surgery, and experimental treatments like islet cell
transplantation. Little attention was paid to the few extant human diet studies, and these studies
focused on delaying diabetes progression[2], not putting the disease into remission entirely. Only
recently have scientific[3], medical[4], and public health communities recognized the possibility of
putting the disease in remission with diet and lifestyle changes.

As methodological rigor in nutritional studies has improved, so too has the confidence placed in
nutrition therapies by professional organizations increased. For instance, the American College of
Lifestyle Medicine[5], American Diabetes Association[6], Diabetes Canada[7], Diabetes UK,
European Association for the Study of Diabetes[8], and other organizations now consider the
evidence for low carbohydrate diet equally, if not more, compelling as the long standing low-to-

27
moderate fat and consistent-carbohydrate diets recommended by government and other
organizations like the American Academy of Nutrition and Dietetics[9].

Diet and lifestyle changes are promoted as a key feature of diabetes management plans because
they induce[10] weight[9] loss[2]. Weight loss may decrease insulin resistance and could restore
beta-cell function, the purported mechanisms of type 2 diabetes[11] pathophysiology[12]. Dietary
macronutrient manipulation can also substantially affect metabolic function and energy substrate,
suggesting a possible role for macronutrient modified diets. Moderate fat restriction has been
associated with weight loss and lower LDL cholesterol, despite also lowering HDL cholesterol and
raising triglycerides[13]. Moderate carbohydrate restriction can induce some positive effects on
insulin signaling and blood lipids, but more severe carbohydrate restriction can induce ketogenesis,
the metabolic changes of which may positively affect insulin resistance and sensitivity seen in type
2 diabetes metabolism[14], but these effects are likely attributed to the weight loss often associated
with stringent carbohydrate restriction. Studies measuring insulin sensitivity in weight stable people
with the gold-standard hyperinsulinemic-euglycemic clamp show that moderate carbohydrate
restriction has no effect on insulin sensitivity, and very low carbohydrate ketogenic diets may
actually reduce insulin sensitivity. Most studies that estimate insulin sensitivity using the
homeostatic model assessment of insulin resistance (HOMA-IR) suggest carbohydrate-restriction
can increase insulin sensitivity, but this is misleading in the context of low carb diets because they
reduce insulin secretion independently of insulin sensitivity[15]. In fact, one study[16] comparing a
high-carbohydrate diet to a very-low carbohydrate diet in the context of weight loss showed that
carbohydrate-restriction resulted in greater reduction in insulin resistance measured by HOMA-IR,
but no differences between diets were observed when insulin sensitivity was measured with the
hyperinsulinemic-euglycemic clamp.

A chronic issue in previous cohort studies[17] and meta-analyses[18] on carbohydrate-restricted

diets is that the definitions of low carbohydrate diets and very low carbohydrate diets are quite
inconsistent. Less stringent definitions of “low carb” applied in research can result in conclusions
that may not line up with the real results of people following very low or low carbohydrate diets
defined more stringently. The authors use a common definition[19] of very low carbohydrate diets
(less than 10% of calories, or 20–50 grams from carbohydrate per day) and low carbohydrate diets
(less than 26% or 130 grams per day), but ultimately these thresholds are estimates, not
standardized, and may be arbitrary in light of the individualized response to carb cutting.

In addition to the diverse definitions of different tiers of carbohydrate restriction, the physiological
response to tiered carbohydrate restriction is not linear. The data[20] suggest that[21] as the
proportion of calories from carbohydrates decreases, ketone body concentration increases
exponentially, while fasting blood glucose decreases slightly in a linear fashion[21] in healthy
individuals. In light of this suggested non-linear relationship between carbohydrate intake and
circulating ketone bodies, previous studies that combine the results of very low carbohydrate diets

28
and moderate carbohydrate diets may be missing effects that only appear with very low
carbohydrate restriction. For reference, the previously cited trials that suggested increased
mortality with low carb diets defined “low carbohydrate” as 39%[18] to 40%[17] of calories, quite far
from the meager 10% or less often necessary for ketosis.

Figure 1: The nonlinear increase in ketone production

References: Johnston et al. Am J Clin Nutr. 2006 May.[21]

Puchalska et al. Cell Metab. 2017 Feb.[20]
Harvey et al. Nutr X. 2019 Jun. DOI: 10.1016/j.nutx.2019.100005.

Other systematic reviews and meta-analyses[22][23][24][25][26] (the last of which was covered in
NERD #72) have tried to answer the question: how does low carb stack up against other diets for
diabetes treatment? Lack of consensus on the definition of diabetes remission, the extent and
definition of carbohydrate restriction, and the length of time during which people may expect to
experience positive effects have all contributed to divergent results. This systematic review and
meta-analysis aims to address some of the inconsistencies left by previous meta-analyses: the

29
issues of what constitutes a “low carbohydrate” diet, and what constitutes diabetes reversal.

A number of randomized controlled trials comparing carbohydrate

restriction with other diets for diabetes management have provided
suggestive evidence that low carb diets may help to not just
manage type 2 diabetes, but to actually send it into remission, as
opposed to previous strategies that have aimed to slow the
progression of the disease. This has been documented by a
number of meta-analyses, and reflected by the revision of a
number of professional organization position statements.
Differences in study methodologies have so far made it difficult to
compare the effects of different tiers of carbohydrate intake.

What was studied?

This systematic review and meta-analysis of randomized controlled trials examined the
effectiveness and safety of low carbohydrate diets in adult participants with type 2 diabetes. The
authors included 23 studies with 1,357 adult participants (mean age: 47–67 years) in their analysis.
Only 12 of the 23 studies were designed to restrict carbohydrates to the very low carbohydrate diet
threshold of 10% of total calories, only 4 of these very low carbohydrate diet interventions had low
levels (less than 20%) of missing participant outcome data, and 18 of the 23 used a low fat diet as
the control. Diet adherence and missing data were common with most studies. Intervention diets
ranged from 20 to 130 grams or fewer carbohydrates per day, and dietary protein was not
measured.

Studies were included regardless of additional exercise or lifestyle recommendations, presence of

participant cardiovascular comorbidities, medication use, glucose concentration, and glycated
hemoglobin A1C (HbA1C) level. Primary outcomes included remission of diabetes defined by HbA1C
of less than 6.5% with diabetes medication or fasting glucose of less than 7.0mmol/L without it,
weight loss, HbA1C, fasting glucose, and the occurrence of adverse events. Secondary outcomes
were quality of life, reduction of medication, and blood lipids including total cholesterol, low density
lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), and triglycerides; as well

30
as assessments of insulin resistance (HOMA-IR), and inflammation (C-reactive protein).

The study protocol was preregistered and publicly available on PROSPERO. The authors’
secondary subgroup analyses were based on plausible arguments and predetermined before the
study was conducted. Statistically significant interaction effects of these subgroups were subject to
a credibility checklist[27]. The researchers also evaluated risk of bias, publication bias, certainty of
results, and heterogeneity. Clinical significance of effect sizes were reported using standard
“minimal clinically important differences,” and statistical significance was reported in the form of
confidence intervals, a more clinically relevant interpretation of statistical significance than[28] p-
values[29], due to its inclusion of effect size, the uncertainty of that effect size, and ease of
interpretation[30]. To top it off, the authors even solicited researchers for unpublished raw outcome
data: they successfully acquired data from five additional studies!

This rigorous systematic review and meta-analysis included 23

randomized controlled trials with a total of 1,357 adult participants.
Just over half of the studies used a very low carbohydrate diet
(less than 10% calories from carbohydrate, or 20–50 grams of
carbohydrate per day), and just over 75% used a low fat diet as
the control. Unlike any previous meta-analysis, remission was
defined dichotomously as HbA1C of less than 6.5% or fasting
glucose of less than 7.0mmol/L with and without diabetes
medication. Reduced-carbohydrate diets not meeting the 130 gram
threshold were excluded.

What were the findings?

Some of the primary outcomes at 6 months are summarized in Figure 2. As shown there, low
carbohydrate diets affected diabetes remission, glucose control, and weight at 6 months, with
moderate to high certainty. However, no significant effects were found at 12 months. Note that a
couple were borderline, namely HbA1C at 12 months (-0.23%, 95% CI: -0.46% to 0%) and
remission at 12 months (27% relative chance, 95% CI: -1% to 64%). Also note that remission was
achieved in the control diets, too. For control diets, 78% of which were low fat, 31 of 100

31
participants experienced remission of diabetes defined as HbA1C below 6.5%, and 13 of 100
achieved an HbA1C below 6.5% in addition to their cessation of diabetes medications.

Figure 2: Select primary outcomes at 6 months

Effect Effect Size Certainty
(via
GRADE)

Remission (as defined as HbA1C 28 out of every 100 people on a low Moderate
under 6.5%) at 6 months carb diet compared to control

Remission (as defined as HbA1C 3 out of every 100 people on a low carb Low
under 6.5% and no diabetes meds diet compared to control (not
needed) at 6 months statistically significant)

HbA1C at 6 months 0.47% lower compared to control High

Fasting glucose at 6 months 13.1 mg/dL lower compared to control Moderate

Weight loss at 6 months 3.5 kg (7.6 lbs) lower compared to Moderate

control

The preregistered secondary analyses revealed some additional interesting results, depicted in
Figure 3. Weight loss was more pronounced in studies with a lower risk of bias. Remission with low
carb diets was lower in studies that included participants using insulin compared to studies with
participants not using insulin, which may suggest that continued insulin use and lower remission
rates may be associated, an effect suggested previously among participants with type 2 diabetes
managed via gastric bypass surgery[31]. In studies that excluded participants using insulin,
remission defined as HbA1C below 6.5% was about 1.5 times higher than the pooled results (i.e., 1
of 2 people would likely see remission, compared to 1 of 3), and 4 times higher for remission
defined as HbA1C below 6.5% and cessation of diabetes medication (i.e. 1 in 5, compared to 1 in
20).

Figure 3: Some interesting results from the secondary

analyses
32
At six months, less restrictive low carb diets (10–26% of calories from carbs, 50–130 grams per
day) led to 5.2 kg of weight loss, whereas it appears that very low carbohydrate diets (less than
10% of calories from carbs, 20–50 grams per day) only led to a little more than 1 kg of weight loss.
Poor adherence to the stricter diet explained this observation, as this effect was not observed when
trials with high dropouts were excluded and only highly-adherent participants were analyzed.
Participants more adherent to a very low carbohydrate diet experienced almost 4 kg (about 8.5 lb)
greater weight loss than participants less adherent to a very low carb diet.

Peer reviewers requested that another subgroup analysis be conducted on the effect of using the
nutriGRADE[32] score, as opposed to the GRADE[33] score that the authors used. Some experts
consider the GRADE criteria, originally developed to assess certainty of evidence in biomedical
research, inappropriately stringent for use with nutrition studies due to the high level of variability in
measurement, adherence, and response of dietary interventions[32], though this position is not
without criticism[34]. This post-hoc sensitivity analysis suggested an increased confidence for most
of the secondary analyses, but the confidence in most primary results stayed the same.

Low carbohydrate diets can improve type 2 diabetes or put it into

remission in some people, as indicated by decreased HbA1C
levels, fasting glucose, weight, and medication use. The only
clinically relevant negative effects (reduced quality of life and
increased LDL cholesterol) were not statistically significant.
Generally, most effects seen at 6 months were no longer evident

33
 at 12 months.

The bigger picture

These findings are in line with the increasing awareness that diet composition, energy balance, and
lifestyle are effective tools for type 2 diabetes management. Moreover, this systematic review and
meta-analysis is one of the most rigorous investigations of carbohydrate restriction for
management and reversal of type two diabetes to date. The results suggest that low carbohydrate
and very low carbohydrate diets reduce HbA1C, blood glucose, insulin, and weight, and put type 2
diabetes into remission more often than a low fat diet. The study suggests that the response of
some of these parameters is dependent on the degree of carbohydrate restriction, potentially
explaining divergence in findings from studies that do not differentiate “low carb” diets (less than
26% calories from carbs) from “moderate carb” diets (less than 45% calories from carbs).

Even with the rigorous methods applied in this systematic review and meta analysis, it is not
without limitations. First, the way researchers measured diet composition and adherence was
unique to every study. As with any meta-analysis, comparing different diet and lifestyle
interventions can be fraught, if not downright inappropriate. In this case, a strict less-than-20- gram
carb restriction[35] lumped together with an initial 30 daily grams restriction[35], followed by a graded
carbohydrate increase, leaves room for ambiguity. An unlimited “Paleolithic[35]” diet is a distant
cousin to a modified Atkins[36] diet, but both are relatively higher in protein than low carb high fat[37]
diets.

Particularly interesting for adherence are issues of confounding due to co-interventions. One study
[38] with intensive behavioral support achieved a 53% follow-up rate, whereas another trial[39] that

included intensive behavioral support alongside an even more strict carbohydrate allowance held
onto 89% of participants, while an online intervention[40] managed to acquire outcomes from 76%
of the participants. Outside factors having to do with the population, place, and time of the studies
may very well be driving these differences. To make matters worse, that last study only allowed
participants who were willing to cut out baked goods, grains, and sugary fruit, essentially picking
out the participants who would do best on a low carb diet and then randomizing them. Compare
that approach to another study[41] with far less dramatic results, in which the researchers ensured
that participants would not go into ketosis and even permitted occasional consumption of sweets,
and the limitations of analyzing these studies together become clear. The differences between
these studies compromise the ability to extrapolate the results of this analysis to real-world
settings.

34
The most significant confounder to the conclusions the authors reached is the issue of calorie
balance, since weight[9] loss[2] has been previously consistently associated with diabetes control
and remission[10]. In light of the fact that the carbohydrate-restricted groups achieved greater
weight loss in this study at 6 months (3.5 kg difference), followed by a reversal of weight loss (0.3
kg difference) and an associated trend for reversal of favorable diabetes outcomes at 12 months, it
is no stretch to imagine that weight loss, not macronutrient composition, is driving most of the
positive effects in this case. Although the authors specified they conducted a subgroup analysis on
iso-energetic studies vs. non-calorie-matched studies, these results were not reported in the text.
Another meta-analysis[24] has looked into this at length. This meta-analysis[24] found almost no
statistically significant results when comparing diets only if the intervention and the control diets
were approximately matched for calories. In the absence of a difference in caloric composition, the
results of this systematic review and meta-analysis suggest that macronutrient composition has
little effect on weight or other risk factors for diabetes and cardiovascular disease, with the major
caveat being that the adherence in these studies was moderate to poor. The previous issue of
NERD (article: Do Low-Carb Diets Stoke the Metabolic Fire?) covered a meta-analysis that
suggested restricting dietary fat may induce greater weight loss, calorie per calorie, than restricting
dietary carbohydrates in the short term (less than 2.5 weeks), but this effect may be reversed in the
long term. Regardless, this study reaffirms that comparator diets (typically low fat) can induce
significant weight loss and induce diabetes remission.

This study also adds some credibility to the idea suggested in previous research that insulin dose
should be adjusted accordingly for successful diabetes management. The authors found that the
effect of carbohydrate restriction was substantially increased in studies in which insulin changes
were permitted. However, this finding was the product of secondary analyses, and could easily be
explained by the observation that people with more severe disease progression are both more
likely to be on insulin and more likely to have difficulty managing their disease. Reverse causality
and temporal confounding cannot be ruled out, as well, so this conclusion should be evaluated
cautiously.

Taking a more moderate approach to carbohydrate restriction, defined as choosing a level of

carbohydrate restriction that a person can stick to, rather than a level of carbohydrate restriction too
aggressive to maintain, may be the key for successful outcomes. Illustrating this is the result that,
on average, participants aiming to maintain a low carbohydrate diet achieved more than 4 kg (9 lb)
greater weight loss compared to participants trying to stick to a very low carbohydrate diet. When
stratified by level of adherence, this result was attenuated, and participants most adherent to a very
low carbohydrate diet experience more benefits (4.47 kg weight loss) than those less adherent to a
very low carbohydrate diet (0.55 kg weight loss), but still not as great of a benefit as those adhering
to a low carb diet (5.22 kg weight loss, not stratified by adherence). Additionally, at 6 months, LDL
cholesterol was no different between diets, yet by 12 months the participants following the low carb

35
intervention had a higher LDL. This could suggest dietary drift or potentially an effect of the diet
unmasked by weight stabilization (ie. low carb can increase LDL cholesterol but weight loss can
lower LDL cholesterol). This effect, combined with the associated detriments to quality of life,
suggest that adherence emerges time and again as the number one determinant of weight loss
success in the real world.

This is nothing new. One illustration of this comes from the A-to-Z trial[42], in which participants
were allowed to self-select their optimal level of adherence after starting their assigned diet (Atkins,
Ornish, Weight Watchers, and Zone). This translated into 75% of the participants adhering to their
assigned diet 50% or less of the time, a 42% dropout rate, and merely 10% of all participants
maintaining 10% or greater weight loss at one year. In subgroup analyses, diet adherence was
associated with successful weight loss, and inversely associated with restrictiveness of the diet[43].
A similar example from the DIRECT trial[44] (not to be confused with the DiRECT[10] trial, which
evaluated weight loss and diabetes remission) shows that carbohydrate restriction is probably more
difficult than a Mediterranean diet or a low fat diet, and that initial weight loss is the primary
determinant of long-term weight loss success.

Even though this latest meta-analysis seems to confirm that carbohydrate-restricted diets may be a
more effective option for type 2 diabetes management, on average, the results also maintain that
dietary fat restriction can be a viable option for some people. On low carb diets, 59 out of 100
people saw their HbA1C levels drop lower than 6.5%, but 31 out of 100 people still achieved
remission on control diets, which were typically low fat. This is especially important considering the
variability of weight loss seen with healthy low fat and healthy low carb diets[45]. It seems that
tailoring the right diet for the person is what makes a diet successful, or not.

Pooled findings of 23 randomized controlled trials suggest that

major carbohydrate restriction can result in substantial advantages
in management and even remission of type 2 diabetes. Further
research will reveal the long-term safety and efficacy of low carb
diets, as well as what participant characteristics predict success
with one diet or another. Many of the advantages fade as
adherence drops, so finding ways to make carbohydrate-restriction
sustainable will be a major component of successful treatment for
people with type 2 diabetes and their caregivers to tackle in the

36
 future.

Frequently asked questions

Q. Why do low carb diets stop being as effective after six months?

Why do any diets lose their initially superior efficacy after six months? Is it all due to adherence?
After all, the authors showed that there was a credible difference in positive outcomes between
participants who adhered most strictly to a very low carbohydrate diet and participants who fell off
their diet after a window of six months. In a high carb world, low carbohydrate diets are pretty
difficult to stick to without additional support, as evidenced by the decreased quality of life seen in
this study, as well as increased LDL cholesterol at 12 months, a possible secondary indicator of
poor adherence. Some mixed intervention programs, like dietary changes plus lifestyle and
nutritional counseling, maintain promising results at two years[46], but methodological limitations
lower confidence in these results. Other possible issues contributing to unexpected long-term
effects include the potential for inadequate micronutrient intake (particularly magnesium, calcium,
iron, phosphorus, potassium, and many water-soluble vitamins, according to one study[47] on a
ketogenic diet; and thiamine, folic acid, and vitamin C according to another[48] study on a similar
modified Atkins diet), long-term resistance to metabolic adaptation[49], and other metabolic effects
not adequately studied[50]. Adherence is the most straightforward explanation for the reduction in
effectiveness typically observed over time, but current evidence can’t rule out other contributors.
The diet that works is the one you can stick to!

Q. How many carbs are too many carbs for a very low carbohydrate diet?

One method many studies use to optimize adherence is carbohydrate titration. Initially,
carbohydrates are severely restricted at 20–50 grams per day, followed by a period of
macronutrient titration aimed at providing the most generous carbohydrate allowance while still
staying below the threshold level required for that individual to[35] maintain[40] ketosis[51]. Higher
carbohydrate allowance might be considered with successful weight loss or with increased
exercise. With heavy exercise, protein allowance may go from less than 1 gram of protein per
kilogram of bodyweight to 1.5 g/kg[52] or even more.

Q. Are low carbohydrate diets and very low carbohydrate diets safe for your heart?

There have not been any randomized controlled trials designed to measure the effects of low
carbohydrate diets on cardiovascular events like heart attacks, so all conclusions on this topic are

37
based on indirect evidence like changes in cardiovascular biomarkers. The interactions between
diet and heart disease are too complex to review comprehensively here, but the results from this
study showed a number of improvements in cardiovascular risk factors, including decreased
weight, increased HDL cholesterol, and decreased triglycerides. C-reactive protein, a general
marker of inflammation, did not change. With HDL and triglycerides being strong predictors of heart
[53] disease[54], this is good news for low-carbers, but there still remains the issue of increased LDL

cholesterol, which was found to be increased to a clinically relevant extent, though the result was
not statistically significant in this study. Even though elevated LDL cholesterol is a mechanistic
underpinning of heart disease, LDL itself is a rather crude measure. Marginally increased LDL
cholesterol may not be meaningful in this context, since particle density[55], ApoB concentration[56],
REDOX status of lipid particles[57], and an individual’s genetics (ie. apolipoprotein var epsilon ApoE
gene polymorphism[58]), among other variables, all play a role in LDL cholesterol’s effects, none of
which were measured in this study. Additionally, other research suggests that dietary saturated fat
does not act alone, it interacts with carbohydrate intake to determine LDL[59] level[60]. It is not just
the quality and type of fat that you eat, but also the quality of dietary carbohydrates that affect
biomarkers of disease. The authors of the study under review suggest that low carbohydrate diets
might be considered for short term improvements, followed by something closer to a more habitual
diet, if increased LDL cholesterol is a concern.

In this study, total adverse events and serious adverse events did not differ between diets and did
not pose a clinically relevant risk, though the confidence intervals are so wide the finding is
uninformative. That said, 70% of the studies in this analysis either did not permit adjustments in
medication or they did not have adequate reporting of medication use, limiting extrapolation to real-
world settings. To prevent the likelihood of severe adverse events like hypoglycemic fainting,
participants making such a dramatic change as a carbohydrate-restricted diet need to work with
their doctor to adjust insulin and other medications appropriately.

What should I know?

The meta-analysis seems to confirm that low carbohydrate diets may be more effective for
managing and putting into remission type 2 diabetes than the often recommended low fat diets.
However, it’s important to consider what a sustainable level of carb-cutting is for each individual.
More restriction may not necessarily be better, and a conventional low fat diet can be effective for
some people, too. Successful lifestyle management of diabetes may necessitate adjustments in
diabetes medication. This systematic review and meta-analysis is one of the most rigorous
investigations of the topic to date, and the promising conclusions drawn can be asserted with a
level of certainty higher than that of previous meta-analyses. Unanswered questions still exist,

38
including whether an optimal protein level exists, what the relationship between exogenous insulin
and diabetes remission is, and whether the effects of low carb diets are due to the diet itself or
secondary to the weight loss they may cause.

Crazy about carb cutting? Still consider high fat a fad? Let the
discussion commence in the private NERD Facebook forum!

^ Go back to table of contents

39
 References
1. ^ Kristina Blaslov, et al. Treatment approach to type 2 diabetes: Past, present and
future. World J Diabetes. (2018)
2. ^ a b c Diabetes Prevention Program (DPP) Research Group. The Diabetes
Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. (2002)
3. ^ Chia-Wei Cheng, et al. Fasting-Mimicking Diet Promotes Ngn3-Driven β-Cell
Regeneration to Reverse Diabetes. Cell. (2017)
4. ^ Roy Taylor. Type 2 diabetes: etiology and reversibility. Diabetes Care. (2013)
5. ^ John Kelly, Micaela Karlsen, Gregory Steinke. Type 2 Diabetes Remission and
Lifestyle Medicine: A Position Statement From the American College of Lifestyle
Medicine. Am J Lifestyle Med. (2020)
6. ^ Evert AB, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A
Consensus Report. Diabetes Care. (2019)
7. ^ . Diabetes Canada Position Statement on Low-Carbohydrate Diets for Adults With
Diabetes: A Rapid Review. Can J Diabetes. (2020)
8. ^ Melanie J Davies, et al. Management of Hyperglycemia in Type 2 Diabetes, 2018.
A Consensus Report by the American Diabetes Association (ADA) and the European
Association for the Study of Diabetes (EASD). Diabetes Care. (2018)
9. ^ a b c Janice MacLeod, et al. Academy of Nutrition and Dietetics Nutrition Practice
Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition Intervention Evidence
Reviews and Recommendations. J Acad Nutr Diet. (2017)
10. ^ a b c Lean ME, et al. Primary care-led weight management for remission of type 2
diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. (2018)
11. ^ Roy Taylor, et al. Remission of Human Type 2 Diabetes Requires Decrease in
Liver and Pancreas Fat Content but Is Dependent upon Capacity for β Cell Recovery.
Cell Metab. (2018)
12. ^ Michael G White, James A M Shaw, Roy Taylor. Type 2 Diabetes: The Pathologic
Basis of Reversible β-Cell Dysfunction. Diabetes Care. (2016)
13. ^ Lu M, et al. Effects of low-fat compared with high-fat diet on cardiometabolic
indicators in people with overweight and obesity without overt metabolic disturbance:
a systematic review and meta-analysis of randomised controlled trials. Br J Nutr.
(2018)
14. ^ Judith Farrés, et al. Revealing the molecular relationship between type 2 diabetes
and the metabolic changes induced by a very-low-carbohydrate low-fat ketogenic diet.

40
 Nutr Metab (Lond). (2010)
15. ^ Hall KD, et al. Energy expenditure and body composition changes after an
isocaloric ketogenic diet in overweight and obese men. Am J Clin Nutr. (2016)
16. ^ Kirk E, et al. Dietary fat and carbohydrates differentially alter insulin sensitivity
during caloric restriction. Gastroenterology. (2009)
17. ^ a b Sara B Seidelmann, et al. Dietary carbohydrate intake and mortality: a
prospective cohort study and meta-analysis. Lancet Public Health. (2018)
18. ^ a b Mohsen Mazidi, et al. Lower carbohydrate diets and all-cause and cause-
specific mortality: a population-based cohort study and pooling of prospective studies.
Eur Heart J. (2019)
19. ^ Robert Oh, Brian Gilani, Kalyan R. Uppaluri. Low Carbohydrate Diet.
20. ^ a b Puchalska P, Crawford PA. Multi-dimensional Roles of Ketone Bodies in Fuel
Metabolism, Signaling, and Therapeutics. Cell Metab. (2017)
21. ^ a b c Johnston CS, et al. Ketogenic low-carbohydrate diets have no metabolic
advantage over nonketogenic low-carbohydrate diets. Am J Clin Nutr. (2006)
22. ^ Snorgaard O, et al. Systematic review and meta-analysis of dietary carbohydrate
restriction in patients with type 2 diabetes. BMJ Open Diabetes Res Care. (2017)
23. ^ Olubukola Ajala, Patrick English, Jonathan Pinkney. Systematic review and meta-
analysis of different dietary approaches to the management of type 2 diabetes. Am J
Clin Nutr. (2013)
24. ^ a b c Naude CE, et al. Low carbohydrate versus isoenergetic balanced diets for
reducing weight and cardiovascular risk: a systematic review and meta-analysis.
PLoS One. (2014)
25. ^ Emma Sainsbury, et al. Effect of dietary carbohydrate restriction on glycemic
control in adults with diabetes: A systematic review and meta-analysis. Diabetes Res
Clin Pract. (2018)
26. ^ G A Silverii, et al. Low-carbohydrate diets and type 2 diabetes treatment: a meta-
analysis of randomized controlled trials. Acta Diabetol. (2020)
27. ^ Xin Sun, et al. How to use a subgroup analysis: users' guide to the medical
literature. JAMA. (2014)
28. ^ Greenland S, et al. Statistical tests, P values, confidence intervals, and power: a
guide to misinterpretations. Eur J Epidemiol. (2016)
29. ^ Kristian Thorlund, et al. Pooling health-related quality of life outcomes in meta-
analysis-a tutorial and review of methods for enhancing interpretability. Res Synth
Methods. (2011)
30. ^ Chun Wah Michael Tam, et al. How doctors conceptualise P values: A mixed
methods study. Aust J Gen Pract. (2018)

41
31. ^ Guo-Feng Wang, et al. Predictive factors of type 2 diabetes mellitus remission
following bariatric surgery: a meta-analysis. Obes Surg. (2015)
32. ^ a b Lukas Schwingshackl, et al. Perspective: NutriGrade: A Scoring System to
Assess and Judge the Meta-Evidence of Randomized Controlled Trials and Cohort
Studies in Nutrition Research. Adv Nutr. (2016)
33. ^ Guyatt GH, et al. GRADE: an emerging consensus on rating quality of evidence
and strength of recommendations. BMJ. (2008)
34. ^ Joerg J Meerpohl, et al. Comment on "Perspective: NutriGrade: A Scoring System
to Assess and Judge the Meta-Evidence of Randomized Controlled Trials and Cohort
Studies in Nutrition Research". Adv Nutr. (2017)
35. ^ a b c d Shai I, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat
diet. N Engl J Med. (2008)
36. ^ Nichola J Davis, et al. Comparative study of the effects of a 1-year dietary
intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic
control in type 2 diabetes. Diabetes Care. (2009)
37. ^ Laura R Saslow, et al. A randomized pilot trial of a moderate carbohydrate diet
compared to a very low carbohydrate diet in overweight or obese individuals with type
2 diabetes mellitus or prediabetes. PLoS One. (2014)
38. ^ Nayyar Iqbal, et al. Effects of a low-intensity intervention that prescribed a low-
carbohydrate vs. a low-fat diet in obese, diabetic participants. Obesity (Silver Spring).
(2010)
39. ^ Yancy WS Jr, et al. A randomized trial of a low-carbohydrate diet vs orlistat plus a
low-fat diet for weight loss. Arch Intern Med. (2010)
40. ^ a b Laura R Saslow, et al. An Online Intervention Comparing a Very Low-
Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate Method
Diet in Overweight Individuals With Type 2 Diabetes: A Randomized Controlled Trial.
J Med Internet Res. (2017)
41. ^ Yoshifumi Yamada, et al. A non-calorie-restricted low-carbohydrate diet is effective
as an alternative therapy for patients with type 2 diabetes. Intern Med. (2014)
42. ^ Dansinger ML, et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone
diets for weight loss and heart disease risk reduction: a randomized trial. JAMA.
(2005)
43. ^ S Alhassan, et al. Dietary adherence and weight loss success among overweight
women: results from the A TO Z weight loss study. Int J Obes (Lond). (2008)
44. ^ Greenberg I, et al. Adherence and success in long-term weight loss diets: the
dietary intervention randomized controlled trial (DIRECT). J Am Coll Nutr. (2009)
45. ^ Gardner CD, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month
Weight Loss in Overweight Adults and the Association With Genotype Pattern or

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 Insulin Secretion: The DIETFITS Randomized Clinical Trial. JAMA. (2018)
46. ^ Athinarayanan SJ, et al. 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)
47. ^ J M Bourre. Effects of nutrients (in food) on the structure and function of the
nervous system: update on dietary requirements for brain. Part 1: micronutrients. J
Nutr Health Aging. (Sep-Oct)
48. ^ Christopher D Gardner, et al. Micronutrient quality of weight-loss diets that focus on
macronutrients: results from the A TO Z study. Am J Clin Nutr. (2010)
49. ^ F L Greenway. Physiological adaptations to weight loss and factors favouring
weight regain. Int J Obes (Lond). (2015)
50. ^ Louise M Burke, et al. Adaptation to a low carbohydrate high fat diet is rapid but
impairs endurance exercise metabolism and performance despite enhanced glycogen
availability. J Physiol. (2021)
51. ^ Elizabeth Morris, et al. A food-based, low-energy, low-carbohydrate diet for people
with type 2 diabetes in primary care: A randomized controlled feasibility trial. Diabetes
Obes Metab. (2020)
52. ^ Wajeed Masood, Pavan Annamaraju, Kalyan R. Uppaluri. Ketogenic Diet.
53. ^ W P Castelli, et al. Lipids and risk of coronary heart disease. The Framingham
Study. Ann Epidemiol. (Jan-Mar)
54. ^ Benoit J Arsenault, et al. Beyond low-density lipoprotein cholesterol: respective
contributions of non-high-density lipoprotein cholesterol levels, triglycerides, and the
total cholesterol/high-density lipoprotein cholesterol ratio to coronary heart disease
risk in apparently healthy men and women. J Am Coll Cardiol. (2009)
55. ^ Hoogeveen RC, et al. Small dense low-density lipoprotein-cholesterol
concentrations predict risk for coronary heart disease: the Atherosclerosis Risk In
Communities (ARIC) study. Arterioscler Thromb Vasc Biol. (2014)
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measurements to cardiovascular risk assessment. Diabetes Obes Metab. (2008)
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cardiovascular diseases. Free Radic Biol Med. (2019)
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a HuGE review. Am J Epidemiol. (2002)
59. ^ Cassandra E Forsythe, et al. Limited effect of dietary saturated fat on plasma
saturated fat in the context of a low carbohydrate diet. Lipids. (2010)
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circulating saturated Fatty acids and palmitoleic Acid in adults with metabolic
syndrome. PLoS One. (2014)

43
Curcumin reduces DOMS, with some
caveats
 Tags: Meta-analysis, Curcumin, Supplementation, Muscle Soreness

 Study under review: The effect of curcumin supplementation on recovery following

exercise-induced muscle damage and delayed-onset muscle soreness: A systematic review
and meta-analysis of randomized controlled trials

 Read this article online at Examine.com

Quick Takes
• What was the question? How does curcumin
supplementation affect exercise-induced muscle damage and
post-exercise muscle soreness?
• How was it answered? Researchers conducted a meta-
analysis of randomized controlled trials.
• Who was studied? The participant population was made up
of 220 people, mostly male, under 40 years old. Studies
involving both trained and untrained participants engaging in
both aerobic and resistance exercise were included.
• What was the intervention? Researchers provided a variety
of curcumin formulations with a median daily dose of 400 mg
for a maximum duration of 56 days.
• What’s the main takeaway? Supplementation had modest
beneficial effects on muscle damage and soreness. These

44
 effects were mostly seen in untrained participants undergoing
resistance exercise.
• Any caveats? The study characteristics were quite different
from each other, raising questions about whether they should
be combined. Furthermore, many of the studies were at
moderate or high risk of bias, meaning that higher quality
evidence could sway these results in the future.

What was the question?

What is the effect of curcumin supplementation on exercise-induced muscle damage and delayed
onset muscle soreness (DOMS)?

Why was the question worth asking?

Exercise, especially when it involves eccentric or unaccustomed[1] loading, may result in muscle
pain that typically appears[2] 12–24 hours after the physical challenge, peaks between 24 and 72
hours, and progressively subsides within 5–7 days after exercise. This pain is referred to as
delayed onset muscle soreness, or DOMS. While it’s not entirely clear how exercise causes
DOMS, several mechanisms may contribute[3], including mechanical damage to the muscle fibers
and connective tissues, and increased levels of inflammation and oxidative stress.

Figure 1: The typical time course of DOMS

45
Adapted from: Szymanski. Strength Con J. 2001 Aug. DOI: 10.1519/00126548-200108000-00001.

Since exercise-induced muscle damage and DOMS may hinder training performance, there’s a
need for strategies that can help speed up recovery and reduce DOMS. One proposed strategy is
the use of antioxidant and anti-inflammatory compounds, such as curcumin.

Curcumin is a yellow polyphenolic pigment that, potentially due to its anti-inflammatory and
antioxidant properties[4], may reduce exercise-induced muscle soreness and creatine kinase levels,
a marker of muscle damage. However, while several trials have examined these potential effects,
their results have been inconsistent. As such, the goal of the study under review was to conduct a
meta-analysis of the effects of curcumin supplementation on exercise-induced muscle soreness
and creatine kinase levels in healthy adults.

While curcumin supplementation may reduce exercise-induced

muscle damage and soreness, clinical trials examining these

46
 potential effects have produced inconsistent results. The study
under review is a meta-analysis that investigated the effects of
curcumin supplementation on exercise-induced muscle soreness
and creatine kinase levels, a marker of muscle damage, in healthy
adults.

How was the question answered?

The authors conducted meta-analyses of randomized controlled trials that looked at the effects of
curcumin supplementation on exercise-induced muscle soreness and markers of muscle damage
in healthy adults.

Ultimately, nine studies were included in the meta-analyses. Of these, seven studies (220
participants) looked at the effects of curcumin on creatine kinase (a marker of muscle damage),
and six studies (159 participants) looked at the effects of curcumin on DOMS, as measured by
visual analogue scale. The study participants were young (ages 19–36 years), and the majority of
them were men. In five studies, the participants were trained, and in the remaining four studies they
were untrained. The curcumin formulations used in the studies varied. There were a total of seven
different formulations. CurcuWIN® and Theracurmin® were the most common. The dose of
curcumin supplementation ranged from 150–6,000 grams per day, and the duration of the
interventions ranged from 1–56 days, with most interventions being 4–7 days long.

In addition to the main analyses, the researchers also conducted subgroup analyses based on the
time point of the outcomes assessment (less than 24 hours, and 24, 48, 72, and 96 hours),
curcumin dose (no more than 180 vs. more than 180 grams per day), trial duration (less than one
week vs. at least one week), training status (trained vs. untrained), and study design (crossover vs.
parallel). Additionally, the researchers conducted a subgroup analysis for DOMS based on exercise
type (aerobic vs. resistance exercise).

The researchers assessed the risk of bias of the included trials with the Cochrane Collaboration’s
risk of bias assessment tool for RCTs. Bias was assessed as high, low, or unclear over seven
domains: random sequence generation, allocation concealment, blinding of participants and
personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and
other. Publication bias was assessed using funnel plots. The meta analysis followed PRISMA

47
guidelines, but was not preregistered. Outcome data were pooled using a random-effects model,
and heterogeneity was tested using the I2 statistic.

In this study, researchers conducted meta-analyses to assess the

effects of curcumin supplementation on exercise-induced muscle
soreness and creatine kinase, a marker of muscle damage. In
addition to the main analyses, researchers also conducted
subgroup analyses to explore potential sources of heterogeneity,
such as dosing, duration, and training status.

What was the answer?

In the overall analyses, curcumin supplementation improved creatine kinase levels, with an
average difference relative to placebo of -49 units/liter (95% CI: -81, -16), and high levels of
heterogeneity detected. Curcumin supplementation also improved muscle soreness, with a
reported mean difference relative to placebo of -0.48 (95% CI: -0.75, -0.20), and high levels of
heterogeneity detected. The term ‘reported’ in the previous sentence is used intentionally, as
centimeter units would be expected in the context of a weighted mean difference for a visual
analog scale. However, the authors didn’t report units, so they may actually be reporting a
standardized mean difference (SMD), which doesn’t have units. The NERD editors reached out to
the authors for clarification, but no reply was received as of publication time. Thus, for the rest of
this review, assume soreness is being reported as an SMD. If that’s true, the reduction in soreness
can be considered small to moderate.

In the subgroup analyses for muscle damage, curcumin improved creatine kinase only at 48 hours
post-exercise, with a curcumin dose of more than 180 grams per day, in intervention durations of
less than one week, in untrained participants, and in parallel trial designs. In the subgroup analyses
for muscle soreness, curcumin improved DOMS at 72 and 96 hours post-exercise, in intervention
durations of both less than one week and at least one week, in untrained participants, in both
parallel and crossover trial designs, and only when resistance exercise was performed. As shown
in Figure 2, there was a possible trend for better outcomes a few days after exercise, although
there’s also a lot of error. There were moderate or high levels of heterogeneity in most of the
subgroup analyses.

48
 Figure 2: Time course of curcumin’s effect on muscle
soreness (with 95% confidence intervals)

According to the risk of bias assessment, more than 75% of the trials had an unclear or high risk of
bias in four out of the seven domains of the Cochrane Collaboration’s risk of bias assessment tool:
random sequence generation, allocation concealment, and two blinding domains. The researchers
did not detect any publication bias.

The findings of the study under review indicate that curcumin

supplementation improves exercise-induced muscle soreness and
reduces creatine kinase in parallel design trials, and that these
effects may be more pronounced in untrained populations
performing resistance exercise.

49
How much should you trust the answer?
While meta-analyses generate useful quantitative data that can be used to provide information
about the current state of the science on a given topic, this information is only as good as the
studies included in the related meta-analysis. In this case, while the results indicate a positive
effect of curcumin on exercise-induced muscle soreness and damage, more than 75% of the
studies included in the meta-analysis were assessed as being of an unclear or high risk of bias in
four out of the seven domains of the risk of bias assessment. This reduces confidence in the
results, especially since supplementation interventions like this are easier to blind and standardize,
compared to whole-diet interventions, in which it’s harder to blind and control factors. Hopefully,
future trials looking at curcumin’s effects on soreness will have stronger study designs, so more
solid conclusions can be made.

Another issue with the meta-analyses relates to the variability of the included studies in terms of
their design. For example, some studies used trained participants, while others used untrained
participants. Also, the studies varied widely in treatment duration, supplement dose, and the
curcumin formulation used. The latter may be an especially important issue, as different types and
formulations of curcumin may greatly influence its bioavailability[5] and, thereby, moderate its
potential effects. For example, the relative bioavailability[6] of CurcuWIN® is almost 10 times higher
than that of Theracurmin®. Relative bioavailability compares how much more of a compound gets
absorbed compared to a reference (usually plain curcumin), adjusted for dose.

Another source of variability was study length. Recall that duration ranged from a few days to close
to two months. However, most of the studies were under a week long. Thus, the results of this
meta-analysis mostly speak to short-term effects.

The variability between studies in these parameters was also reflected in the high levels of
heterogeneity observed in the overall analyses. Although the researchers tried to explore the
potential sources of heterogeneity by conducting subgroup analyses, there were still moderate to
high levels of heterogeneity in most of the subgroups. Moreover, out of the subgroup analyses that
returned statistically significant findings, all but one had moderate/high levels of heterogeneity. This
suggests that it may not have been appropriate to meta-analyze the data from these studies to
begin with, and “cleaner” combinations of studies, in terms of low levels of heterogeneity, tended to
result in less evidence for curcumin’s efficacy.

It’s also worth keeping in mind that the creatine kinase response to exercise can vary considerably
between individuals. For example, in a 2007 trial[7], the peak creatine kinase levels in response to
the same full body resistance training workout varied between participants from around 2,000 up to
a little over 50,000 units/liter. Such high levels of interindividual variability suggest that it’s likely
inappropriate to use parallel trials to assess this marker, and that crossover trials, in which each

50
participant serves as their own control, are the way to go. With this in mind, it makes sense that in
the subgroup analyses according to study design (crossover vs. parallel), curcumin was found to
be effective in parallel, but not in crossover, trials.

Finally, considering that creatine kinase levels may typically reach around 2,000 units/liter after
resistance training, but can also reach, or even surpass, 10,000 units/liter, curcumin’s observed
effects in the overall analysis on creatine kinase (-49 units/liter) are likely too small to be practically
relevant. Assuming that the mean difference of -0.48 relative to control is the standardized mean
difference, this effect size is small to medium in terms of alleviating DOMS.

Overall, considering the limitations of the meta-analysis, it’s prudent to interpret the results
cautiously. Even when the results are taken at face value, the magnitude of curcumin’s effect on
creatine kinase is likely too small to practically matter, while its effect on soreness itself is moderate
at best.

While the results of this meta-analysis suggest that curcumin

supplementation improves exercise-induced muscle damage and
soreness to a statistically significant but modest degree, these
results are based on heterogeneous studies with an unclear or
high risk of selection, performance, and detection bias.

What’s the take-home?

This meta-analysis suggests that curcumin supplementation has a positive effect on exercise-
induced muscle damage that is likely too small to be of practical relevance, and a small to medium
positive effect on DOMS, primarily in untrained populations after resistance exercise. That said,
due to the considerable levels of heterogeneity detected in most of the analyses, and because
most of the studies included in the analyses were assessed as having an unclear or high risk of
bias in four out of the seven domains of the risk of bias assessment, the results of the study under
review should be interpreted cautiously.

Do you find the evidence of curcumin’s effects on muscle damage

51
and soreness compelling? Let us know in the private NERD
Facebook forum!

^ Go back to table of contents

52
 References
1. ^ Stéphanie Hody, et al. Eccentric Muscle Contractions: Risks and Benefits. Front
Physiol. (2019)
2. ^ W C Byrnes, P M Clarkson. Delayed onset muscle soreness and training. Clin
Sports Med. (1986)
3. ^ Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness : treatment
strategies and performance factors. Sports Med. (2003)
4. ^ Betül Kocaadam, Nevin Şanlier. Curcumin, an active component of turmeric
(Curcuma longa), and its effects on health. Crit Rev Food Sci Nutr. (2017)
5. ^ Michele Dei Cas, Riccardo Ghidoni. Dietary Curcumin: Correlation between
Bioavailability and Health Potential. Nutrients. (2019)
6. ^ Jamwal R. Bioavailable curcumin formulations: A review of pharmacokinetic studies
in healthy volunteers. J Integr Med. (2018)
7. ^ Jonas Pettersson, et al. Muscular exercise can cause highly pathological liver
function tests in healthy men. Br J Clin Pharmacol. (2008)

53
Deep Dive: Keto, carbs, and calories
 Tags: Keto, Carbohydrate, Keto Diet, High Carb

 Study under review: Effect of a plant-based, low-fat diet versus an animal-based,

ketogenic diet on ad libitum energy intake

 Read this article online at Examine.com

Quick Takes
• What was the question? How does a ketogenic diet affect
energy intake compared to a high-carbohydrate diet?
• How was it answered? Researchers conducted a
randomized crossover trial in a metabolic ward.
• Who was studied?Researchers recruited 20 men and
women under 40 with no serious chronic diseases and BMIs
ranging from normal to obese.
• What was the intervention? Participants followed either a
high-fat animal-based ketogenic diet (10% energy from
carbs) or a high-carbohydrate plant-based diet (75% energy
from carbs) for two weeks per diet. The participants could
consume as much as they wanted for each of three meals
during a one-hour time period. Both diets were matched for
non-starchy vegetables and protein (about 15% of total
calories).
• What’s the main takeaway? Participants on the high-fat

54
 keto diet consumed 689 more calories per day on average.
• Any caveats? The tight dietary control is both a strength and
weakness, since these results may not extend to free-living
conditions in which dietary adherence would be more of an
issue. Also, given the relatively short study length, it could
have missed longer term effects.

Introduction
According to U.S. News, the most searched diet in 2020 was the ketogenic diet. The ketogenic diet
is a high-fat (HF), low-carbohydrate diet that was first developed in the 1920s to treat children with
epilepsy[1]. Since then, the evidence has been growing for other therapeutic uses[2] of the keto diet
for pathologies, including obesity, diabetes, and cardiovascular disease, while some studies even
suggest a potential for neurological diseases, cancer, and more. However, as with most diets,
identifying the mechanism behind any associated benefits is rather difficult because food is
complex and has intricate interactions with behavior and physiology that cannot completely be
accounted for with general macronutrient restrictions.

One of the debated benefits of a ketogenic diet is that it may improve appetite control. This is
supported by the carbohydrate-insulin model[3] of obesity, which suggests that elevations in
postprandial insulin from intake of high-glycemic carbohydrates and decreases in circulating levels
of metabolic fuel promote increased body fat mass, and subsequently increase hunger and energy
intake. A systematic review and meta-analysis reported decreased hunger[4] and desire to eat in
participants following a ketogenic diet. However, only three studies were included. Of these three
studies, only one reported energy intake and verified a state of ketosis, which is thought to
suppress appetite[5]. Moreover, there is evidence to suggest that high-fat foods actually promote
overconsumption[6] and excess energy intake, which is attributed to their weak effect on satiety and
reduction in food hedonics[7] (food wanting and liking) after consumption, as well as their higher
energy density. However, these types of findings have generally not been reported in the context of
carbohydrate restriction, and advocates of very low-carbohydrate diets might suggest that the
levels of carbohydrate may not be low enough to invoke the positive benefits.

It’s interesting that whether participants follow an HF ketogenic diet or a low-fat high-carbohydrate

55
(HC) diet, studies either fail[8] to show long term weight loss beyond a few pounds, or find stronger
efficacy but little difference between HF and HC diets. Lack of efficacy could be explained by a
decreased diet adherence due to increased appetite[9] that is proportional to bodyweight loss,
along with inadequate behavioral and lifestyle adaptation to the diet. Thus, an understanding of
which aspects of dietary modification influence adherence and appetite[10] could be key to
developing better strategies for weight loss management. Even when provided with the food,
outpatient study participants often do not adhere[11] to prescribed diets, while inpatient studies (that
adequately control and monitor diet adherence) have not investigated HF versus HC diets that are
sufficiently low in the macronutrient of interest to reveal the claimed health benefits.

Since no studies have compared the effects of high-fat versus high-carbohydrate diets on energy
intake (as an objective indicator of appetite) in a highly controlled manner (to ensure adequate
adherence), researchers from the National Institute of Diabetes and Digestive and Kidney Diseases
in Bethesda, Maryland conducted an inpatient crossover randomized controlled trial comparing ad
libitum energy intake on a ketogenic diet versus a low-fat HC diet.

Despite being an increasingly popular diet, understanding of the

high-fat ketogenic diet and its supposed health benefits is limited.
One of the most debated benefits of high-fat (HF) versus high-
carbohydrate (HC) diets is appetite control, with evidence
supporting either side limited by inadequate adherence, diet
prescription, and control. To determine whether a HF or HC diet
induces greater energy intake, the researchers of the study under
review conducted an inpatient crossover randomized controlled
trial comparing ad libitum energy intake on an HF ketogenic diet
versus an HC diet.

What was studied?

This was a preregistered, single-blind, crossover, randomized controlled trial involving 20 healthy
adults (11 male, 9 female, average age of 30) that compared the effects of a high-carbohydrate
(HC) diet to a high fat (HF) diet on ad libitum energy intake. Participants were weight stable (less

56
than ± 5% over the past six months), had an average BMI of 28, and exercised vigorously for less
than two hours per week. Participants were excluded if they had dietary restrictions due to allergies
or were following a diet that significantly limited their food choices, suffered from any diseases
(e.g., cardiovascular, diabetes, cancer) or took any medication that may influence metabolism, or
experienced psychiatric conditions like depression or bipolar disorder.

Participants were admitted to the Metabolic Clinical Research Unit at the National Institutes of
Health Clinical Center allowing for complete oversight and observation by nursing and/or research
staff for the full four-week duration of the study. They were randomized to consume three HF or HC
meals per day for a two-week duration and immediately switched to the alternate diet for the latter
two weeks. Participants were instructed to consume as much or as little of the provided meals as
desired at standardized times and within one-hour eating windows. Diet-compliant snacks and
bottled water were always available. To calculate the amount of each food consumed, remaining
food and beverages from each meal were identified and weighed and nutrient and energy intake
was estimated according to nutrient values derived from USDA food and nutrient databases.

Meals rotated on a seven-day schedule and were matched for total energy, protein (about 15%
energy), and nonstarchy vegetables. The diets differed in animal food content, energy density, and
percentage of energy from carbohydrate versus fat. The HF diet primarily consisted of animal-
based foods (82%) with an energy density of about 2 kcal/g and 10% energy from carbohydrates
and 75% energy from fat. The HC diet consisted of vegan plant-based foods with an energy
density of about 1 kcal/g and 75% energy from carbohydrate and 10% from fat. Some notable
nutrient details along with some example meals are shown in Figure 1.

Figure 1: Some facts about the test meals

57
58
The primary outcomes were energy intake (kcal per day) over the entire two-week diet period and
over the second week of each diet period. Secondary outcomes included changes in weight and
body composition, oral glucose tolerance (OGTT), energy expenditure and substrate metabolism
(measured using indirect calorimetry), circulating metabolites, and 24-hour urinary excretion. The
study was powered to detect a 125–150 kilocalorie difference per day in energy intake with a
probability of 80%.

This was a single-blind, crossover, randomized controlled trial

involving 20 healthy, weight-stable adults. The effects of two
weeks on an animal-based HF diet were compared to the effects
of a plant-based HC diet. Meals were matched for total energy,
protein (about 15% energy), and nonstarchy vegetables, and were
provided on a seven-day rotating menu. The diets differed in
animal food content, energy density, and percentage of energy
from carbohydrate versus fat (about 75% energy of the targeted
macronutrient). The primary outcome was energy intake.

What were the findings?

Mean energy intake was 689 kcal per day lower during the HC diet when compared to the HF diet
over the two-week intervention period. This lower energy intake was observed at breakfast, lunch,
and dinner. When comparing only the final week of each diet, the HC diet was 544 kcal/d lower
than the HF diet. Interestingly, energy intake during the second week of the HF diet was 312 kcal/d
lower than the first week, but no changes were observed for the HC diet.

Consumed macronutrient composition was similar to that which was presented, only differing in
protein intake by -1.5% for the HC diet, as well as energy density. Actual dietary fiber was three-
fold greater on the HC diet, while actual sodium intake was almost doubled on the HF diet. HC
meals were eaten more quickly, but the higher energy density of the HF diet resulted in a higher
energy intake rate. Meals were generally consumed within about 20 minutes.

As you can see in Figure 2, bodyweight decreased during both diets by more than 1 kg. The HF
diet demonstrated a rapid loss of fat-free mass during the first week, while the HC diet did not lose

59
a significant amount of fat-free mass over the entire two-week period. The HC diet led to a
significant loss of 1.5 lbs (0.67 kg) of fat mass over the two-week period, while the HF diet led to a
small, nonsignificant loss of fat mass (0.4 lbs; 0.2 kg). Total urinary nitrogen excretion was higher
during the HF diet, indicating a greater net loss of body protein despite slightly higher dietary
protein intake.

Figure 2: Energy intake and body composition

outcomes over time

Daily energy expenditure was about 150 kcal/d lower on the HC diet, including lower sedentary and
sleeping energy expenditure, potentially partially compensating for the reduced ad libitum energy
intake. Physical activity expenditure was not different between diet groups. The daily respiratory

60
quotient was greater during the HC diet, indicating greater carbohydrate oxidation, while it was
lower during the HF diet, indicating greater fat oxidation. Urinary ketones and capillary β-
hydroxybutyrate (indicators of ketosis) increased and were greater during the HF diet (2.01 mM,
which is around what is expected[12] during ketosis) in comparison to the HC diet (0.125 mM).

The HF diet demonstrated a relative impairment of glucose tolerance and slightly increased blood
pressure and pulse rate when compared to the HC diet. However, no difference in insulin sensitivity
was noted. The HC diet resulted in greater post-prandial glucose and insulin concentrations, as
shown in Figure 3. Fasting free fatty acids increased on both diets, but the HF diet demonstrated
significantly higher levels than the HC diet, while triglycerides trended toward a significant decrease
on the HF diet and increased on the HC diet. A rapid and transient postprandial increase in
triglycerides and decrease in free fatty acids was shown on the HF and HC diet, respectively. No
differences in pleasantness, satisfaction, hunger, or fullness were found.

Figure 3: Post-prandial blood levels after a test meal

61
 Participants consumed almost 689 kcal/d more during the HF diet
compared to the HC diet. Total energy expenditure was 150 kcal/d
lower, dietary fiber was three times higher, and sodium was 50%
lower on the HC diet. Participants lost more than 1 kg of total
weight on either diet, driven mostly by loss of fat mass on the HC
diet and loss of fat-free mass on the HF diet. HC meals were eaten
faster, but the higher energy density of the HF diet resulted in
higher energy intake rates. No differences in pleasantness,
satisfaction, hunger, or fullness were found.

The bigger picture

This study demonstrates that a protein-matched HC diet reduces ad libitum energy intake up to 689
kcal/d and body fat mass when compared to a HF diet over a two-week period, without influencing
subjective measures of appetite. Two previous[13] studies[14] comparing low-fat diets (15–20% total
energy from fat) to diets higher in fat demonstrated similar reductions in energy intake on the low-
fat diets, but the comparison “HF” diets still contained about 30–40% of total energy from
carbohydrate that may have been too high to increase ketones and decrease insulin. Ketones[15]
and insulin[16] are known to impact appetitive measures, although one could speculate that they
may affect insulin-sensitive people differently. People with obesity have demonstrated lower[17]
satiety-inducing[18] glucagon-like-peptide 1 levels when compared to lean individuals, while still
exhibiting higher serum insulin levels that are inversely associated with energy intake.

The novel aspect of the study under review is that the HF diet was sufficiently low in carbohydrate
to induce ketogenic diet adaptations, including: an increase and stabilization of ketones, impaired
glucose tolerance, and a respiratory quotient closer to 0.70 (indicating fat oxidation as the preferred
method of energy metabolism). While longer studies are needed to confirm whether the decrease
in energy intake on the second week of the HF diet would continue and potentially eliminate or
reverse the difference in energy intake between diets, some evidence suggests this would not be
expected. A recent study[19] demonstrated reduced satiety ratings in participants who had adapted
to a HF diet (about 20% CHO, about 60% fat) for 10–15 weeks when compared to a HC diet (about
20% fat, about 60% CHO). Moreover, once fasting blood ketones stabilize[20], as they did within the

62
first week of the HF diet in the study under review, further increases in ketones or other indicators
of ketogenic diet adaptation would not be expected unless the macronutrient composition of the
diet were to change.

Whether these differences in energy intake would remain and lead to lasting changes in
bodyweight is also uncertain. Some evidence suggests that a HF diet results in greater weight loss
[21] over three to six months when compared to a HC diet, although this HC diet had 30% of

calories from fat, which could have accounted for the difference in weight loss. The faster weight
loss after the first week on the HF diet in the study under review may be attributed to differences in
body water, glycogen, protein, and gastrointestinal contents, since greater energy density means
less overall mass of food consumed.

Despite these possibilities and slightly lower dietary protein intake, fat-free mass was relatively
preserved on the HC diet. Accordingly, decreases in body fat accounted for most of the weight lost
on the HC diet. Interestingly, this occurred following a slightly lower protein intake and lower energy
intake. It is worth noting that these anthropometric measurements were conducted using dual x-ray
absorptiometry which accurately detects[22] body fluid changes as fat-free mass without affecting
body fat mass measurements.

With no significant fat loss or gain on the HF diet, it can be assumed that energy intake was similar
to energy expenditure. How then to explain the difference in energy intake between diets? The
average loss of 35 grams more fat mass per day on the HC vs. HF diet accounts for 315 kcal/d (fat
holds 9 kcal/g) extra consumed on the HF diet out of the 689 kcal/d difference between diets.
Energy expenditure measured in the respiratory chambers was 153 kcal/d greater on the HF diet,
leaving 221 kcal/d unaccounted for. This is interesting because the uncertainty of the estimate is
about 150 kcal/d, suggesting that these calculations may be at the limits of their precision for a
short term study such as this one, or unmeasured aspects of energy excretion or expenditure may
be contributing.

The higher energy intake from the HF diet group may have to do with its two-fold greater energy
density and 66% lower dietary fiber content. Fiber is known to enhance satiety[23] following
increased mastication, bulk of a meal, retention time in the stomach, and gut microbial metabolism
and metabolite activity. It is not yet clear if these four effects translate to consistent decreases[24] in
energy intake. What is known, however, is that diets lower in energy density[25] lead to lower
energy intake[26] despite a greater overall intake of food. Nonetheless, the authors of the study
under review note that one of their previous studies[27] (reviewed in NERD #57), which compared
ultra-processed diets to unprocessed diets under very similar study design and control settings,
demonstrated less body fat loss on the unprocessed diet when compared to the HC diet in the
current study, despite both having a high fiber content and being matched for energy density. While
this is a relatively imperfect cross-study comparison, it raises the possibility that energy intake

63
regulation is more complex than currently understood, especially when combined with the factors
described above.

Two possible aspects of metabolism that may be related to energy regulation are the gut
microbiome and phytochemicals from plant foods, although researchers are only beginning to
understand some aspects of each and observe how they might interact. They are relatively poorly
understood because of their tremendous amounts and the intricate differences between species
and molecules. Beyond its possible impact on appetite[28], the gut microbiome is seemingly
implicated in several[29] aspects[30] of metabolism, such as improving energy extraction from the
diet by fermenting dietary fibers or regulating gut hormone release[31]. Phytochemicals are
secondary plant metabolites that serve as the core of traditional medicine, with some studies
suggesting their role in appetite-suppression[32], but a recent systematic review[33] of different
green tea, coffee, and pepper extracts reports inconclusive evidence for their role in appetite
regulation. An even bigger question is whether interactions between phytochemicals and the gut
microbiome that have been observed[34] might ultimately influence energy intake regulation.
Although there is much left to understand regarding the gut microbiome, phytochemicals, and their
interactions with each other, the host, and metabolism, it is intriguing to think that these variables
may account for added complexities involved in energy intake regulation that have yet to be
understood.

The main limitation of a study as tightly controlled and monitored as this one is that it is difficult to
translate the (quasi-)lab results to real-life situations in which most of the factors are prone to much
more variability. After all, these diets are rather restrictive and adherence is often transient[10].
Moreover, there was no diet break to allow for normalization before crossover to the comparison
diet, which may influence participant response to the intervention. There was also no mention of
potential differences, or lack thereof. Also, a definitive statement on the contribution of food origins
(animal vs. plant food) cannot be made based on the study at hand due to non-inert micronutrient
differences between the two study arms.

Some evidence suggests that low-fat diets lead to lower energy

intake when compared to higher fat diets, while greater weight loss
has been observed on very low-carbohydrate diets after three to
six months. This suggests there is a factor that isn’t captured in the
existing literature. Although ketones may reduce appetite, the
higher energy density of high-fat diets and other physiological

64
 adaptations may keep energy intake higher overall. With the
several aspects of nutrition involved in energy intake regulation,
including dietary fiber, energy density, food processing, and more,
the process is seemingly more complex than is currently
understood and will require more research, including investigation
of the emerging connection with the gut microbiome, to explain.

Frequently asked questions

Q. What are ketones?

Ketones[35], or ketone bodies, are the alternative energy source leveraged by the brain for fuel
when glucose is not available, such as during long durations of fasting, nutrient deprivation,
starvation, or even insulin deficiency. The two main[36] ketones are acetoacetate and beta-
hydroxybutyrate, while acetone is considered a third and is a spontaneous breakdown product of
acetoacetate. Beyond serving as the “emergency” fuel source, ketones have demonstrated roles in
signaling, protein post-translational modification, and inflammation and oxidative stress.

What should I know?

This trial was designed to determine whether a HF or HC diet induces greater energy intake.
Researchers compared the impact of two weeks on a HF ketogenic diet to a HC diet. Energy intake
was 689 kcal/d greater when participants consumed the HF diet. Both diets led to similar weight
loss, but the HC diet led to fat loss while the HF diet did not. While factors related to energy density
and fiber may be involved, the study was not designed to determine the cause of the
difference.The heavy control of study parameters increases confidence in the causal link between
fat and energy intake, but it reduces the applicability of the results to a real-world setting in which
such strict dietary patterns are difficult to adhere to. Moreover, the study hints at complexities of
energy intake regulation that may not be fully understood.

65
Are you infatuated by fat or were you clenching carbs all along?
Discuss over at the NERD Facebook forum!

^ Go back to table of contents

66
 References
1. ^ Jo Sourbron, et al. Ketogenic diet for the treatment of pediatric epilepsy: review and
meta-analysis. Childs Nerv Syst. (2020)
2. ^ Paoli A, et al. Beyond weight loss: a review of the therapeutic uses of very-low-
carbohydrate (ketogenic) diets. Eur J Clin Nutr. (2013)
3. ^ Ludwig DS, Ebbeling CB. The Carbohydrate-Insulin Model of Obesity: Beyond
"Calories In, Calories Out". JAMA Intern Med. (2018)
4. ^ Gibson AA, et al. Do ketogenic diets really suppress appetite? A systematic review
and meta-analysis. Obes Rev. (2015)
5. ^ Paoli A, et al. Ketosis, ketogenic diet and food intake control: a complex
relationship. Front Psychol. (2015)
6. ^ Blundell JE, MacDiarmid JI. Fat as a risk factor for overconsumption: satiation,
satiety, and patterns of eating. J Am Diet Assoc. (1997)
7. ^ Hopkins M, et al. Differing effects of high-fat or high-carbohydrate meals on food
hedonics in overweight and obese individuals. Br J Nutr. (2016)
8. ^ Yoni Freedhoff, Kevin D Hall. Weight loss diet studies: we need help not hype.
Lancet. (2016)
9. ^ David Polidori, et al. How Strongly Does Appetite Counter Weight Loss?
Quantification of the Feedback Control of Human Energy Intake. Obesity (Silver
Spring). (2016)
10. ^ a b Paul S MacLean, et al. NIH working group report: Innovative research to
improve maintenance of weight loss. Obesity (Silver Spring). (2015)
11. ^ Emma J Stinson, et al. Is Dietary Nonadherence Unique to Obesity and Weight
Loss? Results From a Randomized Clinical Trial. Obesity (Silver Spring). (2020)
12. ^ Paul Urbain, Hartmut Bertz. Monitoring for compliance with a ketogenic diet: what
is the best time of day to test for urinary ketosis?. Nutr Metab (Lond). (2016)
13. ^ L Lissner, et al. Dietary fat and the regulation of energy intake in human subjects.
Am J Clin Nutr. (1987)
14. ^ R J Stubbs, et al. Covert manipulation of the ratio of dietary fat to carbohydrate and
energy density: effect on food intake and energy balance in free-living men eating ad
libitum. Am J Clin Nutr. (1995)
15. ^ Sarah E Deemer, Eric P Plaisance, Catia Martins. Impact of ketosis on appetite
regulation-a review. Nutr Res. (2020)

67
16. ^ Davide Zanchi, et al. The impact of gut hormones on the neural circuit of appetite
and satiety: A systematic review. Neurosci Biobehav Rev. (2017)
17. ^ C Verdich, et al. The role of postprandial releases of insulin and incretin hormones
in meal-induced satiety--effect of obesity and weight reduction. Int J Obes Relat
Metab Disord. (2001)
18. ^ Meera Shah, Adrian Vella. Effects of GLP-1 on appetite and weight. Rev Endocr
Metab Disord. (2014)
19. ^ Kim J Shimy, et al. Effects of Dietary Carbohydrate Content on Circulating
Metabolic Fuel Availability in the Postprandial State. J Endocr Soc. (2020)
20. ^ Hall KD, et al. Energy expenditure and body composition changes after an
isocaloric ketogenic diet in overweight and obese men. Am J Clin Nutr. (2016)
21. ^ Shai I, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N
Engl J Med. (2008)
22. ^ Toomey CM, McCormack WG, Jakeman P. The effect of hydration status on the
measurement of lean tissue mass by dual-energy X-ray absorptiometry. Eur J Appl
Physiol. (2017)
23. ^ Astrid Kolderup Hervik, Birger Svihus. The Role of Fiber in Energy Balance. J Nutr
Metab. (2019)
24. ^ A J Wanders, et al. Satiety and energy intake after single and repeated exposure to
gel-forming dietary fiber: post-ingestive effects. Int J Obes (Lond). (2014)
25. ^ Jenny H Ledikwe, et al. Dietary energy density is associated with energy intake and
weight status in US adults. Am J Clin Nutr. (2006)
26. ^ J Philip Karl, Susan B Roberts. Energy density, energy intake, and body weight
regulation in adults. Adv Nutr. (2014)
27. ^ Hall KD, et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight
Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell
Metab. (2019)
28. ^ Gary Frost, et al. The short-chain fatty acid acetate reduces appetite via a central
homeostatic mechanism. Nat Commun. (2014)
29. ^ Ian Rowland, et al. Gut microbiota functions: metabolism of nutrients and other
food components. Eur J Nutr. (2018)
30. ^ Andrew J Holmes, et al. Diet-Microbiome Interactions in Health Are Controlled by
Intestinal Nitrogen Source Constraints. Cell Metab. (2017)
31. ^ Alyce M Martin, et al. The Influence of the Gut Microbiome on Host Metabolism
Through the Regulation of Gut Hormone Release. Front Physiol. (2019)
32. ^ Yoghatama Cindya Zanzer, et al. Black pepper-based beverage induced appetite-
suppressing effects without altering postprandial glycaemia, gut and thyroid hormones

68
 or gastrointestinal well-being: a randomized crossover study in healthy subjects. Food
Funct. (2018)
33. ^ Johann Stuby, et al. Appetite-Suppressing and Satiety-Increasing Bioactive
Phytochemicals: A Systematic Review. Nutrients. (2019)
34. ^ Giulia Dingeo, et al. Phytochemicals as modifiers of gut microbial communities.
Food Funct. (2020)
35. ^ Muhammad Akram. A focused review of the role of ketone bodies in health and
disease. J Med Food. (2013)
36. ^ Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of
monitoring to diabetes. Diabetes Metab Res Rev. (1999)

69
Safety spotlight: Sex, drugs, and weight loss
supplements
 Tags: Safety, Supplementation

 Read this article online at Examine.com

Rapid weight loss and enhanced sexual prowess are enticing marketing claims made by some
over-the-counter supplement manufacturers. But—buyer be safe! Recently, the FDA has reported
a concerning trend. Dangerous compounds have been found in supplements sold for sexual
enhancement and weight loss. Some of these ingredients are active compounds found in
prescription drugs. If taken in combination with prescribed medications, or by people with
preexisting medical conditions, these supplements can cause serious harm. Some sexual function
supplements contain the active ingredients found in Viagra and Cialis, which can interact with
prescription nitroglycerine, resulting in dangerously low blood pressure. Some weight loss
supplements contain sibutramine, a compound that can increase blood pressure—a risky side
effect for people with coronary artery disease.

Consumers are strongly urged to refer to the FDA website to make well-informed decisions about
the risks of taking supplements in these product classes. If you’re specifically concerned about a
specific sexual enhancement or weight loss product, you can run a search on the linked pages to
find a brand name.

However, it’s important to note that the FDA cannot test every product currently on the market, so if
a brand doesn’t appear on these pages, you shouldn’t automatically assume that it’s safe.

If you are interested in learning more about adverse event reports in various categories of
supplements, check out the Study Summaries here.

^ Go back to table of contents

70
Evaluating the efficacy of vitamin D,
omega-3, and strength training in older
adults
 Tags: Supplementation, Strength Training, Vitamin D, Older Adults, Omega 3

 Study under review: Effect of Vitamin D Supplementation, Omega-3 Fatty Acid

Supplementation, or a Strength-Training Exercise Program on Clinical Outcomes in Older
Adults: The DO-HEALTH Randomized Clinical Trial

 Read this article online at Examine.com

Quick Takes
• What was the question? What mental and physical benefits
do older adults experience after strength training and/or
supplementing with vitamin D and omega-3s?
• How was it answered? Researchers conducted a
randomized placebo-controlled trial.
• Who was studied? Over 2,000 older adults at least 70 years
old with no major cognitive or physical health problems and
with good mobility participated in the study.
• What was the intervention? Participants took 2,000 IU of
vitamin D and 1 gram of omega-3s per day, and/or
participated in strength training three times per week, alone
or in combination, over the course of about three years.
• What’s the main takeaway? None of the interventions,

71
 alone or in combination, had a clear effect on fracture or
infection risk, cognition, or blood pressure.
• Any caveats? The omega-3 dose and exercise regimen may
have been suboptimal, which could explain the lack of an
effect. This may be especially true because the participant
population was already relatively healthy and active for their
age.

What was the question?

Is there any effect of vitamin D and omega-3 supplementation, or strength training alone or in
combination, on blood pressure, nonvertebral bone fractures, physical performance, infection rate
or cognition?

Why was the question worth asking?

There is some physiological and observational evidence suggesting that supplementation with
vitamin D[1] or omega-3[2] fatty acids, as well as strength training[3], can prevent age-associated
diseases and improve the quality of life for older people. Until now, clinical trials have suggested
there is no benefit from their individual use by relatively healthy older adults. It is nevertheless
possible that they are more beneficial when combined. This study analyzed the effect of these
interventions, alone or in combination, on several health metrics in people older than 70 with no
major health issues.

How was the question answered?

This was a multi-center, randomized, double-blind, placebo-controlled trial with 2x2x2 factorial
design, having three primary treatment comparisons: 2,000 IU of vitamin D3 per day versus

72
placebo, 1 gram of omega-3 per day (330 mg of EPA and 660 mg of DHA from marine algae)
versus placebo, and strength training (30 minutes, three times per week) versus control exercise
(30 minutes, three times per week, focused on joint flexibility). This resulted in a total of eight study
groups (Figure 1). Since it’s impossible to blind people to exercise, that arm of the study was
single-blinded.

Figure 1: The treatment groups used in this trial

Adherence was assessed by serum levels of 25-hydroxyvitamin D (active metabolite) and EPA/
DHA for vitamin D and omega-3 supplementation, respectively. Pill count was also assessed.
Exercise compliance was self-reported.

There were six primary outcomes: systolic (SBP) and diastolic blood pressure (DBP), nonvertebral
fractures, Short Physical Performance Battery (SPPB), Montreal Cognitive Assessment (MoCA),
and infections. Researchers followed up over three years, and took measurements at baseline and
12, 24 and 36 months. A total of 2,157 participants (mean 75 years old, 61.7% women) were
included. The study was preregistered.

This randomized, double-blind, placebo-controlled trial tested the

effects of 2,000IU of vitamin D3 per day plus 1 gram of omega-3
per day (330 mg of EPA and 660 mg of DHA from marine algae)

73
 and strength training, alone or combined, on blood pressure,
nonvertebral fractures, physical performance, cognition and
infection rate. Participants were older than 70 with no major health
issues. Researchers followed up for three years.

What was the answer?

Neither vitamin D, omega-3, or strength training had a significant effect on any of the primary
outcomes. Exploratory analyses that were not part of the original research plan found a statistically
significant effect of omega-3 supplementation on respiratory (10% relative reduced incidence with a
99% confidence interval CI ranging from 1–19% incident reduction, p = 0.005) and urinary tract
infections (relative reduction of 62%; 99% CI 38–77%; p < 0.001). Some other interesting subgroup
results are summarized in Figure 2.

Figure 2: Select subgroup results of interest

Adherence in all groups was moderate, but stronger for the supplementation groups. Specifically,

74
serum 25-hydroxyvitamin D and EPA/DHA levels were higher in the supplementation groups,
compared to placebo. This agrees with the self-reporting data (about 70% of participants took at
least 80% of the pills at year 3). However, self-reported adherence to the strength training program
went down over the years (from 64.5% at year 1 to 47.2% at year 3). The drop-out rate was equal
for all groups, around 12%.

There was no observed effect for any intervention on the primary

outcomes, regardless of starting vitamin D or omega-3 levels.
However, there were some observed effects for secondary and
exploratory outcomes.

How much should you trust the answer?

Methodologically, this is an excellent study. The authors had clear preregistered outcomes that
were adjusted for multiple comparisons, hence the 99% confidence intervals reported above, and a
detailed, clear protocol laid out with more details than usual. The sample size was large and the
study had a long enough duration to have a good shot at observing effects from the studied
intervention. The fact that this study came up mostly empty-handed strongly suggests that vitamin
D and omega-3 were not effective at the doses used.

However, there were some hits in the secondary analyses. For example, the omega-3 infection risk
reduction effect is promising, though this result should be interpreted cautiously because these are
exploratory analyses. Theoretically, it is plausible that omega-3 might have an effect on infection,
as it is known[4] to modulate the immune system, but more research is needed before much
confidence can be placed in these results. The same goes for the possible small decrease in blood
pressure seen in men who trained or took vitamin D, as well as the possible increase in infection
risk for people over 75 in these two groups.

It is surprising that strength training didn’t produce any benefit, but that might be explained by
different factors. First, the participants followed[5] a home-based routine in which exercises were
performed with only bodyweight and resistance bands, which may have been too low of an
exercise intensity. Second, resistance exercise was compared to a mobility routine instead of no
exercise. Given the low intensity of the resistance training, these two groups may have been
roughly comparable. Third, most participants were already active at baseline, so perhaps the
modest increase in exercise didn’t result in much additional benefit. Finally, adherence was low

75
during the whole study period, so maybe no benefit was observed because the participants simply
didn’t exercise often enough. Together, these factors may explain the lack of effect seen in the
strength training group.

As with any null results, statistical power considerations come into play: null results are hard to
interpret when the researchers don’t calculate their chances of seeing effects of a certain size.
Fortunately, the authors took great pains to calculate the power for all of their primary outcomes
when designing the study. They aimed to recruit enough participants to have a 90% chance of
detecting a 6/3 mmHg difference in blood pressure, a 52% relative reduction in nonvertebral
fractures, a 15% reduction in infection risk, and clinically meaningful changes in SBPP and MoCA.
Given the null results and 90% power, it can be somewhat confidently said that none of the
interventions caused drops of these sizes. However, this study can’t rule out smaller changes.

Another caveat is that, while the dose of vitamin D was pretty large, the dose of omega-3 (1 gram
per day) might be too low for a couple of reasons. One reason is that smaller studies that found an
effect on some of the outcomes measured in the study under review, like blood pressure[6], only
found an effect at higher doses. There are also mechanistic considerations: in healthy people,
there appears to[7] be a dose-dependence effect on the incorporation of EPA and DHA after
omega-3 supplementation. In addition, incorporation of EPA and DHA into cell membranes might
be dependent on diet. For example, preliminary evidence suggests that dietary saturated fat
increases incorporation compared to a diet rich in omega-6 polyunsaturated fatty acids. Hence,
both the dose of omega-3 supplementation and the composition of participant diets are important
to determine the effects of omega-3 supplementation.

The most relevant consideration is that the study population was relatively healthy and surprisingly
active, in that participants exercised at least three times per week at a moderate or high intensity,
so it is conceivable that the interventions have minimal effects in this cohort but might have a
significant effect on less healthy participants.

The results suggest that there is no major effect of vitamin D,

omega-3, or strength training on any of the outcomes described in
the study. Exploratory analyses suggest a potential benefit of
omega-3 for infections. It is also possible that the lack of effects
from omega-3 and strength training are due to the protocols used,
specifically the relatively low dose of DHA plus EPA (1 gram), and
a hardly challenging strength training routine in already

76
 comparatively very active individuals. Participant health may also
have affected the efficacy of each of the three interventions
because they were already generally healthy.

What’s the take-home?

In this large, multi-center randomized, placebo-controlled trial with 2,157 older participants and a
follow-up of three years, researchers observed no significant effect from supplementation with
vitamin D, omega-3, or participating in strength training on blood pressure, nonvertebral fractures,
physical performance, cognition, or infection rate. Exploratory analyses suggest that there might be
a benefit of omega-3 supplementation on infection rates that is conceivable in view of existing
evidence, but more research is needed to confirm this effect. It’s important to note that the
characteristics of the strength training program, the dose of omega-3, and the health status of the
participants could explain the lack of results from these interventions.

Does this major trial make you rethink your views on vitamin D,
fish oil, or resistance training? If not, why not? Have your say and
see what your peers think at the private NERD Facebook forum.

^ Go back to table of contents

77
 References
1. ^ Paul Lips, et al. Current vitamin D status in European and Middle East countries
and strategies to prevent vitamin D deficiency: a position statement of the European
Calcified Tissue Society. Eur J Endocrinol. (2019)
2. ^ Liana C Del Gobbo, et al. ω-3 Polyunsaturated Fatty Acid Biomarkers and
Coronary Heart Disease: Pooling Project of 19 Cohort Studies. JAMA Intern Med.
(2016)
3. ^ A Kalache, A Gatti. Active ageing: a policy framework. Adv Gerontol. (2003)
4. ^ Philip C Calder. n-3 fatty acids, inflammation and immunity: new mechanisms to
explain old actions. Proc Nutr Soc. (2013)
5. ^ Heike A Bischoff-Ferrari, et al. DO-HEALTH: Vitamin D3 - Omega-3 - Home
exercise - Healthy aging and longevity trial - Design of a multinational clinical trial on
healthy aging among European seniors. Contemp Clin Trials. (2021)
6. ^ Ann C Skulas-Ray, et al. Effects of marine-derived omega-3 fatty acids on systemic
hemodynamics at rest and during stress: a dose-response study. Ann Behav Med.
(2012)
7. ^ Michael R Flock, et al. Determinants of erythrocyte omega-3 fatty acid content in
response to fish oil supplementation: a dose-response randomized controlled trial. J
Am Heart Assoc. (2013)

78
Deep Dive: Zinc and immunity
 Tags: Supplementation, Zinc, Immunity, Meta-analysis, Immune Health

 Study under review: Zinc supplementation and immune factors in adults: a systematic
review and meta-analysis of randomized clinical trials

 Read this article online at Examine.com

Quick Takes
• What was the question? What is the effect of zinc
supplementation on markers of immune function?
• How was it answered? Researchers conducted a
systematic review and meta-analysis of 35 randomized
controlled trials with a total of 1,995 participants.
• Who was studied? Participants included healthy and sick
adults 18–100 years old living in various countries.
• What was the intervention? Participants took zinc in
sulfate, gluconate, acetate, and glycine forms at doses
ranging from 5–44 milligrams per day for 1.5 to 72 weeks.
• What’s the main takeaway? Supplementation with zinc may
help boost some aspects of immunity, especially in zinc-
deficient people. It may also lower general inflammation.
• Any caveats? The studies that were included differed greatly
in terms of study duration, dosage, and zinc status, raising
questions about whether they should have been pooled for

79
 the analysis. Also, the health status and dietary patterns of
the participants were not reported in most of the studies,
making it difficult to determine exactly who these findings are
most applicable to.

Introduction
Zinc is essential for adequate development and functioning of the immune system. Inadequate
intake can lead to a compromised[1] immune response. The immunological outcomes associated
with zinc deficiency are well known. Some evidence suggests[2][3] that zinc supplementation may
help prevent or treat certain specific diseases involving the immune system. However, studies
evaluating the general immunoregulatory effect of zinc supplementation have arrived at different
results[4][5]. The variety of results plus the sheer number of immune markers which zinc can affect
makes it difficult to say what effects zinc supplementation could have on immune function. That’s
where the study under review comes in. This is a meta-analysis that combines the results of 35
studies to evaluate the effect of zinc supplementation on markers of immune system function.

As this study looked at changes in select markers of the immune response associated with zinc
supplementation, it is important to have a basic understanding of the immune system and how the
measured markers fit in. Immunity is a response our body has to foreign agents. It occurs through a
complex system of cellular mechanisms, such as through T cells and B cells, and humoral
mechanisms.

Immune mechanisms fall into two main categories: innate and adaptive. Innate immunity is the
body’s first line of defense and is activated in case of exposure to foreign agents like bacteria and
viruses. It is not specific to a particular foreign agent. The innate response involves white blood
cells (also known as leukocytes, a term that uses Greek roots to say “white cell”) called neutrophils,
basophils, eosinophils, monocytes (which turn into macrophages at the site of damage or
infection), dendritic cells, and natural killer cells. Neutrophils and macrophages engulf and destroy
foreign invaders. Eosinophils fight parasitic infections. Basophils release histamine. Dendritic cells
can be found on the skin and linings of the nose, lung and stomach. Once activated, they interact
with T and B cells. Natural killer cells limit the spread of tumor cells and infections. Innate immunity
also includes groups of chemicals that band together to destroy pathogens, called the complement
system.

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Adaptive immunity happens after a period of time and is a process in which the immune system
learns to combat specific pathogens. It involves white blood cells called T lymphocytes (T cells)
and B lymphocytes (B cells). Macrophages that have been activated during the innate response act
to turn on a specific kind of T cell called T helper cells. The T helper cells activate another specific
kind of T cell called cytotoxic T cells along with B cells. The cytotoxic T cells divide to make an
army and directly attack pathogens. The B cells turn into plasma cells that make antibodies (Y-
shaped proteins that recognize foreign pathogens, also called immunoglobulins) which stick to
pathogens to take them out of commission.

Figure 1 details an index of the factors measured in this meta-analysis, what the factors indicate,
and whether the factors are part of the innate or adaptive immune response. This table can be
used as a guide to understand the methodology and outcomes of this study.

Figure 1: Factors measured in the meta-analysis

Factor Innate or Definition
Measured Adaptive

CD3 Adaptive A marker for all types of T cells.

CD4 Adaptive A marker for T helper cells. These cells help lead the fight against
infections.

CD4/CD8 Adaptive Ratio of T helper cells (CD4) to cytotoxic T cells (CD8). A normal
ratio is between 1 and 4. Outside of this range could indicate
infection or other disease.

WBC Innate White blood cells, also called leukocytes, include neutrophils,
and monocytes/macrophages, eosinophils, basophils, lymphocytes, T
adaptive cells, B cells and plasma cells. An increase in the WBC number in
the blood is used as a marker of an ongoing or recently resolved
infection.

Lymphocytes Adaptive T and B cells.

Monocytes Innate Monocytes are a type of white blood cell (leukocyte). They are the
largest type of leukocyte and can differentiate into macrophages

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 Factor Innate or Definition
Measured Adaptive

and dendritic cells. Although they are considered a part of the

innate immune system, monocytes also influence the process of
adaptive immunity.

Neutrophils Innate Type of white blood cell (leukocyte) that helps heal damaged
tissues and resolve infections. Neutrophils help prevent infections
by blocking, disabling, digesting, or warding off invading particles
and microorganisms. They also communicate with other cells to
help them repair cells and mount a proper immune response.

CRP / hs- Innate C-reactive protein (CRP) is a protein found in blood plasma.
CRP and Circulating concentrations of CRP rise in response to
adaptive inflammation. It originates in the liver and increases following
interleukin-6 (IL-6) secretion by macrophages and T cells. The
high-sensitivity C-reactive protein (hs-CRP) test is a blood test
that finds lower levels of CRP.

TNFα Innate Tumour Necrosis Factor-alpha (TNF-α), is an inflammatory

cytokine produced by macrophages/monocytes during acute
inflammation and is responsible for signaling events within cells
that lead to necrosis or apoptosis. The protein is also important
for resistance to infection and cancers.

IL-6 Innate Interleukin-6 is active in inflammation and B-cell maturation. It is

and produced in response to inflammation, usually in conjunction with
adaptive other cytokines. Cytokines are small proteins released by cells
that have a specific effect on the interactions and
communications between cells.

The association between zinc deficiency and decreased immunity

is well known. There are several studies that have evaluated the
effects of zinc supplementation on altering immune function.

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 However, outcomes have varied. Immunity is accomplished
through the innate and adaptive immune systems and each
system involves different types of cells and signaling molecules
components released from cells. These signaling molecules are
markers scientists use to indicate what the immune system is
doing. This study was designed to evaluate the non-disease-
specific effect of zinc supplementation on certain markers of
immune function.

What was studied?

The present study was a systematic review and meta-analysis examining the effects of zinc
supplementation on immune factors associated with both the innate and adaptive arms of the
immune system. The study was conducted in accordance with the Preferred Reporting Items for
Systematic Review and Meta-Analysis (PRISMA[6]) guidelines and was not preregistered.

The meta-analysis included randomized controlled trials published between 1981 and 2020 that
were conducted in participants 18–100 years old. Participants were healthy or had diseases
including cancer, AIDS, HIV, tuberculosis, sickle cell anemia, diabetes, atherosclerosis, and
polycystic ovary syndrome. There were 1,019 cases and 976 controls from 35 studies. Studies took
place in several countries, including but not limited to the U.S., Iran, India, Italy, Thailand, Turkey,
and China. Interventions durations ranged from 1.5–72 weeks. Participants took zinc in sulfate,
gluconate, acetate, and glycine forms at doses ranging from 5–44 milligrams per day (mg/d). All
studies used a parallel design, and 11 studies were not double-blinded.

Primary outcomes were the effects of supplementation on the immune system markers CD4, CD4/
CD8, IL-6, CRP, hs-CRP, lymphocytes, monocytes, and TNF-α. If the heterogeneity of the
evaluated studies was low, a fixed effect model was used. Otherwise, random effects were used to
calculate the pooled estimate of MD with a 95% confidence interval. In some cases, where there
was variation in the units of factors, the researchers used the standard mean difference (SMD).
Heterogeneity among the studies was measured by the I2 statistic, where I2 of more than 50%[7]
was assumed to represent heterogeneity among the studies. Subgroup analyses and regression
analyses were conducted to find potential reasons for the heterogeneous results.

83
The quality of the studies was assessed using the Risk of Bias 2[8] tool based on the randomization
process, deviation from the intended interventions, mission outcome data, measurement of the
outcome, and selection of the reported results. Publication bias was assessed by visually
examining funnel plots for each outcome that measured the standard error as a function of the
effect size and statistically using Egger’s regression method[9]. If there was suspected publication
bias, the researchers applied the trim and fill method[10] to adjust the effect size.

The study under review was a systematic review and meta-

analysis examining the effect of zinc supplementation on certain
immune system markers. The primary outcomes were differences
in means of select markers of innate and adaptive immunity
between the intervention and control groups. Risk of bias in
individual studies and publication bias were evaluated.
Heterogeneity was also evaluated and informed the use of linear
vs. random effect models in the main- and subgroup-analyses.

What were the findings?

The researchers selected a total of 35 studies for evaluation in the meta-analysis. The majority of
the studies (25) had a low risk of overall bias, while there was some concern regarding overall bias
in the remaining 10 studies. Most of the bias was due to unclear reporting on changes to the study
protocols, a lack of reporting of information about missing data, and inadequate information
regarding measurement of the outcome. There was a high degree of heterogeneity in studies
evaluating CD3, CD4 (before removal of a study), CD4/CD8, WBC, IL-6, CRP, and TNF-α.

Detailed results are presented in Figure 2, which shows the overall results of the meta-analysis, as
well as Figure 3, which focuses on the subgroup analysis results. The main takehome from these
tables is that many markers weren’t clearly affected by zinc supplementation, but there were a few
notable exceptions: a small decrease in neutrophils, (hs-)CRP, IL-6, and TNF-α. Supplementation
also increased the CD4/CD8 ratio in people with zinc deficiency.

84
 Figure 2: Results of the meta-analysis (significant
results bolded)
Measure Number of Effect
Intervention/Control
Participants

Serum CD3 116/85 Nonsignificant increase (SMD: 0.37)

Serum CD4 (1) 257/253 (1) Significant increase in CD4 count (SMD:
(2) 134/113 1.11)
(2) Nonsignificant increase in percentage
count in random effects model (WMD: 1.66)

Serum CD4/ 137/117 Nonsignificant increase (WMD: 0.12)

CD8

Serum white 109/108 Nonsignificant decrease (SMD: -0.70)

blood cells
(WBC)

Serum 189/161 Nonsignificant increase (SMD: 0.23)

lymphocytes

Serum 77/52 Nonsignificant increase (SMD: 0.06)

monocytes

Serum 127/101 Significant decrease (SMD: -0.46)

neutrophils

Serum IL-6 166/160 Significant decrease (WMD: -3.15 pG/mL)

Serum CRP 175/191 Significant decrease (WMD: -102.13 mg/L)

Serum hs-CRP 292/279 Significant decrease (WMD:-0.52 mg/L)

85
 Measure Number of Effect
Intervention/Control
Participants

Serum TNF-α 160/146 Nonsignificant decrease (WMD: -8.22 pG/mL)

Figure 3: Subgroup analysis results

Measure Subgroup analysis findings

Serum CD3 Significant effect with greater than 8-week duration, Asian population, gender,
more than 50 mg/d, sulfate form, both gender, syrup form, zinc deficient
participants

Serum CD4 (i) Significant effect with single-blind design, European countries, participants
with AIDS, tablet form, zinc sufficient participants. Significant effect between
dose and duration.
(ii) Zinc status was a source of heterogeneity. Significant effect with non-blind
design, less than 8-week duration, Asian population, hemodialysis patients,
less than 50 mg dose, gluconate type, capsule form, zinc deficient participants.

Serum CD4/ Significant effect with non-blind design, less than 8-week duration, zinc-
CD8 deficient, and hemodialysis.

Serum white Significant with blind design, cancer patients, less than 50 mg/day, syrup form,
blood cells tablet form, zinc deficient participants.
(WBC)

Serum No heterogeneity among studies.

lymphocytes

Serum No heterogeneity among studies.

monocytes

Serum No heterogeneity among studies. Insignificant effects from non-blind studies,

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 Measure Subgroup analysis findings

neutrophils less than 8-week duration, Asian population, cancer patients, more than 50 mg/
day, sulfate type, tablet form, zinc deficient participants.

Serum IL-6 No significance with more than 8-week duration, Australian country, both
genders, more than 50 mg/day.

Serum CRP No significant effect in studies from Australian studies. Significant effect of
dose, but not duration, in meta-regression.

Serum hs- No significant effect in studies comparing participants with atherosclerosis and
CRP premenstrual syndrome, glycine type, and pill form of zinc.

Serum TNF- No significant effect in non-blind design, greater than 8-week duration, Asian
α and Australian countries, both genders, sulfate and citrate type, participants
with cystic fibrosis and T2DM, and zinc sufficient participants. No evidence of
dose and duration response.

Zinc supplementation resulted in a significant increase in CD4 and

significant decrease in CRP, hs-CRP, neutrophils, TNF-α, and
IL-6. There was a high degree of heterogeneity in studies
evaluating CD3, CD4, CD4/CD8, WBC, IL-6, CRP, and TNF-α.
There was an overall low risk of bias.

The bigger picture

Recall that there are three types of T cells: cytotoxic, helper, and regulatory. All types of T cells
have a receptor. Receptors are proteins that are located on the surface of a cell and interact with
other proteins. Receptors act as the “locks” that recognize specific pathogen “keys.” One of these
is the CD3 surface receptor. Cytotoxic T cells have a receptor called CD8 on their surface. Helper
T cells and regulatory T cells have a receptor called CD4 on their surface. So, increases in CD3,

87
CD4, and CD8 are indicators that something is activating the immune system.

CD3 is an important marker of overall T cell count and function. Although the overall increase in
CD3 in this study was not significant, the effect was significant when the dose was more than 50
mg per day and supplementation duration was more than eight weeks in participants with zinc
deficiency and cancer. CD4 level also increased when participants who were zinc-deficient or
undergoing hemodialysis supplemented with zinc. This implies that zinc may specifically be
restoring T cell development and function in [4]zinc-deficient and[4] ill participants. The researchers
did not find a significant increase in the CD4/CD8 ratio in participants supplementing zinc. The
design and types of studies were sources of heterogeneity and subgroup analysis showed a
significant effect on CD4/CD8 ratio with a non-blind design, shorter than eight-week duration, zinc
deficiency, and participants undergoing hemodialysis. This again suggests that zinc may be
boosting this ratio due to the repletion of the immune impairment following zinc deficiency.

Zinc supplementation significantly reduced CRP, IL-6, and TNF-α. IL-6 and TNF-α induce the
synthesis of CRP, so it makes sense that CRP moved with these two other markers. A decrease in
these markers is indicative of a decrease in inflammation, which, in turn, is associated with
infection, chronic inflammatory disease, obesity, and poor metabolic health. The decrease in
inflammation associated with zinc supplementation could be considered a complement to the
elevation of the inflammatory response in zinc deficiency states. A recent meta-analysis[11] showed
that zinc supplementation led to a significant decrease in IL-6, although it did not show an effect on
TNF-α. The researchers noted that the dosage and form of the zinc supplement were key factors in
the effectiveness of zinc supplementation in modifying inflammatory responses. There are several
studies that show that zinc is effective in reducing the severity and duration in cold symptoms when
zinc is administered as a lozenge or zinc-containing syrup that temporarily “sticks” in the mouth and
throat because these forms allow zinc to make contact with the rhinovirus in those areas. Along
those same lines, meta-analyses and pooled analyses of RCTs have shown that supplementation
with oral zinc decreases the incidence rate of acute respiratory infections, shortens the duration of
symptoms associated with the flu, and helps with the rate of recovery. Doses in the meta-analyses
ranged from 20 milligrams per week to 92 mg per day.

There were notable limitations to this study. Studies included in the meta-analysis had a high
degree of heterogeneity, most importantly in regard to the duration, dose, and zinc status of the
participants. This makes it difficult to determine the optimal doses, duration of supplementation,
and forms of zinc supplementation that would provide the most benefits, as well as which
populations would benefit most from zinc supplementation. Also, the participants’ dietary patterns
and health status were not reported in many of the studies, making it difficult to determine who
these findings would best apply to.

A strength of the study was the comprehensive review of the literature completed by the

88
researchers.

Zinc supplementation improved immune system function, in that

researchers observed an increase in markers for T-cells and a
decrease in markers of inflammation. The effect of zinc
supplementation is highly dependent on baseline zinc status, with
enhanced effects in participants who were deficient in zinc or in a
disease state. Interpretation of the results of this study are
complicated by the high degree of heterogeneity associated with
the evaluation of several of the immune system markers and the
context-dependent real-world implications of their changes.

Frequently asked questions

Q. What is the recommended daily allowance (RDA) for zinc?

The RDA for adults 19 years of age and older is 11 mg per day for men and 8 mg per day for
women. The upper tolerance limit is 40 mg per day, which is based on the potential for copper
deficiency and unwanted interactions with iron metabolism with long-term use. Zinc and copper
compete for absorption[12] in the stomach, and zinc is typically the winner.

Q. What is the best type of zinc to supplement?

This answer really depends on the reason for the zinc supplementation in the first place. For the
common cold, the National Institute of Health indicates using a lozenge or syrup may help zinc
stick to the nose and mouth, where a rhinovirus would enter the body. In general, however, studies
on zinc supplementation using different study populations, dosages, formulations and duration of
treatment make it impossible to make definitive recommendations about the optimal dose,
formulation and duration of zinc supplementation.

Q. What about zinc supplementation and COVID-19?

The National Institute of Health states that “There are insufficient data to recommend either for or
against the use of zinc for the treatment of COVID-19,” and “recommends against using zinc

89
supplementation above the recommended dietary allowance for the prevention of COVID-19.”

What should I know?

It is well known that zinc deficiency adversely affects the development and function of immune cells
involved in both innate and adaptive immunity. However, the results of studies that have evaluated
the premise that supplementing zinc can affect the immune response are varied. This meta-
analysis did show overall increases in cells involved in innate and adaptive immunity, as well as
decreases in markers of inflammation, and suggests that zinc works best in people who are sick
and whose baseline zinc levels are low.

However, given the heterogeneity among the studies evaluated, it is clear that further studies are
needed to determine which populations would benefit from supplementation, the ideal conditions
(e.g., dose, duration, etc.) under which people should supplement with zinc, and the real-world
health and disease consequences in response to the observed immuno-modulatory effects of zinc.

Boost your mental immunity to nutrition falsehoods by hashing out

your views of this study in the NERD Facebook group!

^ Go back to table of contents

90
 References
1. ^ Hajo Haase, Lothar Rink. Multiple impacts of zinc on immune function. Metallomics.
(2014)
2. ^ Hajo Haase, Lothar Rink. The immune system and the impact of zinc during aging.
Immun Ageing. (2009)
3. ^ Ananda S Prasad. Impact of the discovery of human zinc deficiency on health. J
Trace Elem Med Biol. (2014)
4. ^ a b c S Sazawal, et al. Effect of zinc supplementation on cell-mediated immunity
and lymphocyte subsets in preschool children. Indian Pediatr. (1997)
5. ^ Duangjai Sangthawan, Temsak Phungrassami, Wattana Sinkitjarurnchai. Effects of
zinc sulfate supplementation on cell-mediated immune response in head and neck
cancer patients treated with radiation therapy. Nutr Cancer. (2015)
6. ^ Moher D, et al. Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. Int J Surg. (2010)
7. ^ Miranda Cumpston, et al. Updated guidance for trusted systematic reviews: a new
edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane
Database Syst Rev. (2019)
8. ^ Jonathan A C Sterne, et al. RoB 2: a revised tool for assessing risk of bias in
randomised trials. BMJ. (2019)
9. ^ Egger M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ.
(1997)
10. ^ Linyu Shi, Lifeng Lin. The trim-and-fill method for publication bias: practical
guidelines and recommendations based on a large database of meta-analyses.
Medicine (Baltimore). (2019)
11. ^ Amir Hossein Faghfouri, et al. Profiling Inflammatory Cytokines Following Zinc
Supplementation: A Systematic Review and Meta-analysis of Randomized Controlled
Trials. Br J Nutr. (2021)
12. ^ H N Hoffman 2nd, R L Phyliky, C R Fleming. Zinc-induced copper deficiency.
Gastroenterology. (1988)

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 Credits
Researchers
Antonis Damianou, MSc; Brad Dieter, PhD; Nick Milazzo, MS(c); Thomas Reichhart, MSc; Brandon
Roberts PhD, MS, CSCS; Lucas Roldos, BSc, MSc(c); Jill Ryer-Powder, PhD; Detrick Snyder,
MPH, RDN; Lucas Tafur, PhD; Nattha Wannissorn, PhD, RNH, FDN-P

Editors
Gregory Lopez, MA, PharmD

Reviewers
Stephan Guyenet, PhD & Adel Moussa, PhD

Copy Editor
Dmitri Barvinok

Infographics
Antonius Khengdro & Calla Lee

92