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• W4380680921 abstract "More rigorous studies are needed to obtain robust and consistent results to provide helpful and feasible dietary recommendations for patients with type 2 diabetes and nonalcoholic fatty liver disease The rate of carbohydrate consumption in the world has gradually increased in recent years. The United States National Health and Nutrition Examination Surveys (NHANES) show that carbohydrate consumption in the United States increased from 42–45% in 1971–1974 to 49–52% in 1999–2000. The average American diet is about 49% carbohydrates1. In addition to the increased consumption of carbohydrates, the increased intake of sugar-sweetened beverages by young people has led to an increase in obesity, type 2 diabetes, and nonalcoholic fatty liver disease (NAFLD) worldwide. Type 2 diabetes and NAFLD share a common pathogenic mechanism of insulin resistance. Approximately 55–70% of patients with type 2 diabetes have NAFLD, and type 2 diabetes exacerbates the inflammation of NAFLD2. A study by Hansen et al.2 provided useful insights into the effects of calorie-unrestricted low-carbohydrate, high-fat diet vs high-carbohydrate, low-fat diet in patients with type 2 diabetes and nonalcoholic fatty liver disease. Before and after the invention of insulin, doctors prescribed a low-carbohydrate diet to help people with diabetes lower their blood glucose levels1, 3. With the availability of effective antidiabetic drugs, people gradually stopped using low-carbohydrate diets to control blood sugar levels3. Currently, the definitions for different forms of carbohydrate diets are (1) very-low-carbohydrate ketogenic diet (VLCKD): carbohydrate, 20–50 g/day or <10% of the 2000 kcal/day, (2) low-carbohydrate diet: <130 g/day or <26% total energy, (3) moderate carbohydrate diet: 26–45% total energy, (4) high-carbohydrate diet: >45% total energy1, 3, 4. Each medical association recommends lifestyle modification as the first step of type 2 diabetes management, but their recommendations for medical nutrition therapy for type 2 diabetes include an energy intake of 45–60% carbohydrate, 10–20% protein, and 20–35% fat1. Systematic reviews have shown that a low-carbohydrate diet can significantly lower hemoglobin A1c1, 3, 4. Hansen et al.2 conducted a 6 month randomized trial of calorie-unrestricted low-carbohydrate, high-fat [LCHF: carbohydrate <20 energy percent (E%), fat 50–60 E%, and protein 25–30 E%] vs high-carbohydrate, low-fat (HCLF: carbohydrate 50–60 E%, fat 20–30 E%, and protein 20–25 E%) diet in patients with type 2 diabetes and nonalcoholic fatty liver disease. During the 6th month of dietary intervention, the LCHF and HCLF groups consumed a mean total energy of 1702 and 1618 kcal/day, with 15.0% and 45.7% of carbohydrate, 59.4% and 28.3% of fat, respectively; they showed weight loss of 5.5 and 1.7 kg, blood glucose of 25.4 and 10.63 mg/dL, and hemoglobin A1c of 0.88% and 0.29%, respectively. The LCHF diet significantly reduced body weight [−3.8 (−1.4 to −6.2) kg], insulin resistance (using homeostatic model assessment for insulin resistance) [HOMA-IR: −2.13 (−3.84 to −0.42)], blood glucose [−14.77 (−22.70 to −6.85) mg/dL], and hemoglobin A1c [−0.59% (−0.30 to −0.87%)] compared with the HCLF diet. Since there were no striking differences in the reduced daily energy intake (LCHF:HCLF = 111:202 kcal/day) and mean physical activity (LCHF:HCLF = 410:379 count/min per day) between the LCHF and HCLF groups, the striking effect on reducing hemoglobin A1c (0.88%, a similar effect to an oral antidiabetic medication) and body weight (5.5 kg, 5.6% of mean weight) could be due to a lower carbohydrate intake (13–15%) in the LCHF group, which was close to the very-low-carbohydrate ketogenic diet (<10% total energy). Studies have also shown that low-carbohydrate and high-fat diets can increase satiety and decrease appetite to reduce body weight1, 3. Although a lower percentage of a low-carbohydrate diet is more effective in lowering blood glucose, it also has more side effects and is less likely to be maintained over time2. In this study, 3 months after the end of the study (month 9), the difference in blood glucose lowering and body weight between the LCHF and HCLF groups was insignificant. Since a low-carbohydrate diet can effectively decrease blood glucose, why do the medical associations not recommend a low-carbohydrate diet for patients with type 2 diabetes? Perhaps because there are not many rigorous, long-term studies on medical nutrition therapy (similar to the study by Hansen et al.2) with robust and consistent results. Moreover, dietary habits and staple foods of people with type 2 diabetes vary from place to place, and such a low-carbohydrate diet may not be acceptable to many people. Associations generally recommend exercise and a low-calorie, low-fat diet for weight loss in patients with nonalcoholic fatty liver disease5. Some people think that the excessive intake of carbohydrates, especially fructose, can cause obesity and fatty liver, and the effect of carbohydrates on fatty liver may be no less than that of fat. Studies have compared the effects of low-carbohydrate, high-fat vs high-carbohydrate, low-fat diets on fatty liver (Table 1)2, 3, 5. Hansen et al.2 used liver biopsy (the gold standard) to calculate NAFLD activity scores [NAS, steatosis (0–3), inflammation (0–3), and hepatocyte ballooning (0–2)] and compared the percentage of a ≥2 point improvement in NAS between the LCHF and HCLF groups. They showed that more people in the LCHF group had an improvement of 1 or more points in NAS (mainly due to reduced steatosis and lobular inflammation) than in the HCLF group. Moreover, fewer people in the LCHF group worsened than in the HCLF group. After 6 months, 17% in the LCHF group and 13% in the HCLF group showed improved NAS scores by 2 or more points. However, the differences were statistically insignificant. Hansen et al.2 used the NAS for a more precise assessment of fatty liver inflammation than measuring intrahepatocellular triglyceride (IHTG) content. These studies in Table 1 suggest that hypoenergetic LCHF and HCLF diets are more likely to reduce body weight, insulin resistance, and liver fat, while isoenergetic HCLF diets are more likely to reduce liver fat, whereas hyperenergetic LCHF and HCLF diets may increase body weight and liver fat content. Only Hansen's study showed that the isoenergetic LCHF diet could improve NAS, and the LCHF diet had a non-significant increase of ≧2 points improvement in NAS than the HCLF diet. The improvement in the NAFLD activity score in Hansen's LCHF intervention could be because their low-carbohydrate diet resembles a very-low-carbohydrate diet, and their high-fat diet consists mainly of monounsaturated fats (e.g., olive oil, avocado, almonds), some polyunsaturated fats (e.g., from fish, seeds, and sunflower oil) with a minimum of saturated fats. Studies have shown that saturated fatty acids are more likely to increase the liver fat content than monounsaturated and polyunsaturated fatty acids5. In conclusion, a rigorous, long-term study on medical nutrition therapy by Hansen et al.2 showed that a calorie-unrestricted low-carbohydrate, high-fat diet was more effective than a high-carbohydrate, low-fat diet in reducing body weight, improving insulin resistance, lowering blood glucose, and lowering hemoglobin A1c; however, the effect was not sustained after 3 months of stopping the intervention. It is unclear whether the significant reduction in hemoglobin A1c in the LCHF group in this study was due to the low-carbohydrate, high-fat diet or the active weight loss among participants in the LCHF group. More rigorous studies are needed to obtain robust and consistent results to provide helpful and feasible dietary recommendations for patients with type 2 diabetes and nonalcoholic fatty liver disease. This work was supported by grants from the Taipei Veterans General Hospital (V105C-204, V110C-175) and the Ministry of Science and Technology, R.O.C (MOST 110-2314-B-075-027-MY3). The authors declare no conflict of interest. Approval of the research protocol: N/A. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A." @default.
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• W4380680921 date "2023-06-14" @default.
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• W4380680921 title "Is a low‐carbohydrate, high‐fat diet feasible for people with type 2 diabetes and nonalcoholic fatty liver disease?" @default.
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