Which one is better for losing weight, lowering blood sugar, regulating lipids and protecting the liver?

Most patients with type 2 diabetes and those with excess weight have comorbidities, such as hypertension, atherosclerotic dyslipidemia, and nonalcoholic fatty liver disease, leading to increased disability and mortality
.

Weight loss improves glycemic control and improves lipid metabolism, which may reduce the risk of microvascular complications and CVD, respectively, and may lead to remission in type 2 diabetes

Traditionally, an energy-reduced diet rich in fiber, rich in low-glycemic index carbohydrates, and limited in fat (allowing 10-20% of total energy intake from protein) has been the recommended dietary approach in the treatment of type 2 diabetes
.

Recently, the ADA concluded in a consensus statement that a carbohydrate-restricted dietary regimen may provide a viable therapeutic strategy for the management of type 2 diabetes

Recent studies have demonstrated that a 6-week, reduced carbohydrate high protein (CRHP) diet improves glucose and lipid metabolism and reduces liver fat content compared to a conventional diabetic diet (CD)
.

However, the clinical utility of low-carbohydrate diets outside of weight loss remains elusive, and these diets are often prone to weight loss

However, the clinical utility of low-carbohydrate diets outside of weight loss remains elusive, and these diets are often prone to weight loss

This open-label parallel RCT included adults with type 2 diabetes, HbA1c 48-97 mmol/mol (6.
5-11%), B BMI >25 kg/m , eGFR < 30 ml min-1 [1.
73 m]-2 and only Hypoglycemic therapy limited to metformin or dipeptidyl peptidase-4 (DPP-4) inhibitors
.

Participants were randomly assigned to a 6-week energy-restricted low-carbohydrate high-protein diet (CRHP, percent of total energy intake [E %]: CH30/E/F40) or a traditional diabetic diet (CD, E %: CH50 /P17/F33)

This open-label parallel RCT included adults with type 2 diabetes, HbA1c 48-97 mmol/mol (6.

In the end, 72 subjects were included in the study (Figure 1)
.

Baseline characteristics were well balanced between groups (Table 1 ), except that participants assigned to the CRHP diet were more likely to be male and to receive DPP-4 inhibitor treatment compared with the CD diet group

In the end, 72 subjects were included in the study (Figure 1)

1.
Weight, Anthropometric Measurements, and Body Composition

Both interventions resulted in a weight loss of 5.
8 kg (Table 2)
.

Waist circumference, body fat percentage, fat mass, and fat-free mass decreased significantly in both groups, but there were no significant differences between diets

Waist circumference, body fat percentage, fat mass, and fat-free mass decreased significantly in both groups, but there were no significant differences between diets

2.
Ectopic fat deposition

Following CD and CRHP diets, liver fat content was significantly reduced by 51% and 64% , respectively, with the difference between groups reaching borderline significance ( −26[−45,0]%, p = 0.
051) (Table 2)
.
Pancreatic fat was decreased in both diets, but was significantly lower in the CRHP diet compared to the CD diet (33 [7, 65]%, p = 0.
010), and despite weight loss, the two diets were significantly lower.
Muscle fat fraction did not change in either diet
.
The volumes of VAT and SAT were significantly reduced and similar in both diet groups
.

51% 64% −26[−45,0]%, p = 0.
051) (Table 2)
.
Significant reduction in the volume of VAT and SAT

3.
Glycemic control and metabolic variables

Glycated hemoglobin decreased after weight loss in both groups, and the reduction rate of glycated hemoglobin in the CRHP group was significantly higher than that in the CD group (−1.
9 [−3.
5, −0.
3] mmol/mol (−0.
18 [−0.
32, −0.
03]%), p =0.
018) (Table 3, Figure 2b)
.
Fasting blood glucose (Fig.
2c), insulin (Fig.
2d), c-peptide and homa-ir decreased to the same extent in both groups
.

Glycated hemoglobin decreased after weight loss in both groups, and the reduction rate of glycated hemoglobin in the CRHP group was significantly higher than that in the CD group (−1.
9 [−3.
5, −0.
3] mmol/mol (−0.
18 [−0.
32, −0.
03]%), p =0.
018) (Table 3, Figure 2b)
.
Fasting blood glucose (Fig.
2c), insulin (Fig.
2d), c-peptide and homa-ir decreased to the same extent in both groups
.

Furthermore, the CRHP diet reduced fasting triacylglycerol concentrations by 18(6, 29)% (p<0.
01) compared with the CD diet (Figure 2)
.
Changes in fasting NEFA, apoB, apoA-1, total cholesterol, LDL-C, HDL-C, and non-HDL-C concentrations were similar between diets , and all lipid variables except NEFA decreased significantly with weight loss (Table 3 and ESM Figure 1)
.

(Figure 2)
.
Fasting diet (Table 3 and ESM Figure 1)
.

3.
CGM

Compared with baseline habitual diet, both groups had improved glycemic status after weight loss (Table ​3 ) .
However, the reductions in circadian mean glucose and glucose CV following the CRHP diet were greater than those on the CD diet by −0.
8 (-1.
2, -0.
4) mmol/l (p < 0.
001) and −4.
1 (-5.
9, -2.
2)% (p < 0.
001), respectively ) .

​3

In addition, although time frames did not differ significantly between the two groups, participants randomized to the CRHP diet spent significantly more time above 10.
0 mmol/l (−3.
5 [−6.
4, −0.
6]%, p = 0.
019) less and significantly increased below 3.
9 mmol/l (8.
1 [2.
4, 13.
9]%, p < 0.
01)
.
Participants assigned to the CRHP diet were also more likely to have CGM-determined hypoglycemia (ie, a CGM reading <3.
9 mmol/l) compared to those randomly assigned to the CD diet (CD 70%, CRHP 82%), including glucose Values ​​<3.
0 mmol/l (CD 9%, CRHP 29%) (p = 0.
24 and p = 0.
06, respectively, by Fisher's Exact test)
.

p

4.
Renal function and compliance measures

in eGFR (5.
3 [2.
9, 13.
5] ml min - 1 [1.
73 m] - 2, p = 0.
21), total 24-hour albumin excretion (28[−4,69]%, p = 0.
090) or albumin/ There was no difference between the two diets in terms of creatinine ratios (19[−10,58]%, p = 0.
23) (ESM Table 6)
.
Compared with the CD diet, the CRHP diet increased daily urea excretion (184 [140, 229] mmol, p  < 0.
001), consistent with higher protein intake
.
Physical activity levels did not differ between groups (0 [−27, 37]%,  p  = 0.
99) and were consistent with baseline levels
.

in eGFR (5.
3 [2.
9, 13.
5] ml min - 1 [1.
73 m] - 2, p = 0.
21), total 24-hour albumin excretion (28[−4,69]%, p = 0.
090) or albumin/ There was no difference between the two diets in terms of creatinine ratios (19[−10,58]%, p = 0.
23) (ESM Table 6)
.
mmol, p p

5.
Adverse events

Participants were asked about any adverse events at baseline and study visits at Weeks 2, 4, 5, and 6 and were instructed to contact the investigator in the event of a serious adverse event
.
Thirteen subjects (CD 5, CRHP 8) developed symptoms of mild constipation, which were remedied by adequate fluid intake and laxatives (CD 2, CRHP 7), including one case of refractory constipation (CRHP)
.
Other symptoms are episodes of diarrhea (CD 2, CRHP 2), episodes of dizziness (CD 1, CRHP 2) and increased fatigue or lack of energy (CD 0, CRHP 2)
.
One subject (CRHP) experienced brief episodes of excessive sweating with increased plasma creatinine, although the underlying medical cause could not be identified
.
All hypoglycemic episodes were asymptomatic and no ADA-defined severe hypoglycemic episodes occurred, although the CGM-determined time was less than 3.
9 mmol/l and the number of hypoglycemic events was greater in participants on the CRHP diet
.

In conclusion, 6 weeks of moderate carbohydrate restriction moderately improved glycemic control compared with the CD diet and decreased circulating and intrahepatic triacylglycerol levels compared with the CD diet, beyond the effect of weight loss per se
.
These findings suggest that modest carbohydrate restriction and subsequent increases in protein and fat during weight loss can modestly improve metabolic health in obese and type 2 diabetic patients, at least in the short term
.
This may be relevant when designing dietary strategies for type 2 diabetes management
.

Original source:

Mads N.
Thomsen , et al.
Dietary carbohydrate restriction augments weight loss-induced improvements in glycaemic control and liver fat in individuals with type 2 diabetes: a randomised controlled trial.

Mads N.
Thomsen Diabetologia.
Diabetologia.
doi:  10.
1007/s00125-021-05628-8 10.
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