Journal of Metabolic Health

ISSN: (Online) 2960-0391

Page 1 of 7 Clinical Audit

Use of a very low carbohydrate diet for prediabetes

and type 2 diabetes: An audit

Authors: Background: Type 2 diabetes (T2D) is viewed as a progressive chronic condition, yet recent
Mariela Glandt1
research has raised hopes for reversal of this trajectory through innovative approaches.
Nir Y. Ailon2
Slava Berger1 Aim: This audit assessed the impact of a very low carbohydrate ketogenic diet (VLCKD) on
David Unwin3,4
glucose control, weight and medication usage in T2D and prediabetes patients. The Glandt
Affiliations: Center for Diabetes Care, in Tel Aviv, Israel, from 2015 to 2022.
1
Glandt Center for Diabetes
Care, Diabetes Center, Setting: The Glandt Center for Diabetes Care, in Tel Aviv, Israel, from 2015 to 2022.
Tel Aviv, Israel
Methods: A cohort of 344 T2D or prediabetes patients following a VLCKD diet for 6 months at
2
Al Ailon Consulting, Tel Aviv, a specialised diabetes centre was analysed. Patient records were reviewed for glucose control,
Israel weight, blood pressure, lipid profile, liver function and medication usage, with paired t-tests
used for analysis.
3
Norwood Surgery,
Southport, United Kingdom Results: Patients (mean age: 62 years; T2D duration: 12.3 years) showed significant improvements.
Among patients with diabetes (N = 244), median HbA1c dropped from 59 mmol/mol (7.6%) to
4
NNEdPro Global Centre for
45 mmol/mol (6.3%), with 96.3% showing improvement. Prediabetes patients (N = 100)
Nutrition and Health, St.
John’s Innovation Centre, experienced a drop from 42 mmol/mol (6%) to 38.7 mmol/mol (5.7%), with 84% improving.
Cambridge, United Kingdom Weight loss occurred in both groups (median changes: −6.5 kg and −5.7 kg). Blood pressure,
triglycerides and liver enzymes also improved. Initially, 78 patients were on insulin, reduced to
Corresponding author:
Mariela Glandt,
16 patients at 6 months, with average dose of those remaining on insulin reduced by 72%.
mglandt@gmail.com
Conclusion: Very low carbohydrate ketogenic diet is effective in enhancing glucose control,
Dates: weight loss and cardiovascular risk factors in T2D. Most patients achieved insulin independence,
Received: 13 July 2023 with others significantly reducing insulin dosage. The study underscores the potential of
Accepted: 29 Oct. 2023 integrating a VLCKD with medication management in comprehensive T2D treatment.
Published: 04 Jan. 2024
Contribution: The audit shows the application of a KD in patients with long-standing diabetes.
How to cite this article:
Glandt M, Ailon NY, Berger S, Keywords: obesity; metabolic syndrome; type 2 diabetes; ketogenic diet; low carb diet.
Unwin D. Use of a very low
carbohydrate diet for
prediabetes and type 2
diabetes: An audit. J. metab. Introduction
health. 2024;7(1), a87.
According to the current standard of care, type 2 diabetes (T2D) is a chronic progressive disease,
https://doi.org/10.4102/jmh.
v7i1.87 a depressing prospect for the people involved. However, over the last few years, there has been a
surge in more optimistic publications that show drug-free remission of T2D.1,2,3,4 In our diabetes
Copyright: centre, based on our own clinical experience and lessons learned from the many randomised
© 2024. The Authors.
controlled trials published over the last 20 years,5,6,7,8,9,10,11,12,13,14,15,16,17 we have implemented a
Licensee: AOSIS. This work
is licensed under the comprehensive very low carbohydrate programme to treat our patients with T2D.
Creative Commons
Attribution License. Our setting is a specialised clinic based on treatment by a consultant endocrinologist. In this audit
of service provision, we looked at a selected cohort of patients with prediabetes or T2D who
followed the diet for 6 months. We were interested to quantify what was possible in terms of
improvement in glucose control, weight and use of medications and reflect on lessons learned
over the 7 years of offering this approach.

Methods
Study Population
Read online:
This cohort consists of 344 patients with T2D (N = 244) or prediabetes (N = 100) who followed a
Scan this QR
code with your very low carbohydrate diet for 6 months while treated at the Glandt Center for Diabetes Care, in
smart phone or
mobile device Tel Aviv, Israel, from 2015 to 2022. Specifically, it is a very low carbohydrate ketogenic diet
to read online.
Note: Additional supporting information may be found in the online version of this article as Online Appendix 1.

http://www.journalofmetabolichealth.org Open Access

 Page 2 of 7 Clinical Audit

(VLCKD) defined as carbohydrate content between 20 g/day underestimation of HbA1c. Patients who had undergone
and 50 g/day or < 10% of the 2000 kcal/day diet, whether or renal transplants but who had creatinine under 3 were
not ketosis occurs.18 included, leaving a total of 499 in the cohort. Although
patients had a visit at time 0 and time 6, they did not always
We arrived at this cohort in the following way (Figure 1): have a corresponding HbA1c at both times. In order to have
3235 patients have been seen by the staff of the Glandt a consistent cuffoff, 59 patients who did not have Hb A1c at
Center for Diabetes Care since 2015. Of these, 600 patients the time baseline and 6 months (± 1 month) were excluded,
were not recorded in our current medical record system and leaving a cohort of 441 patients. Of these 441 patients, 44 of
hence were excluded. In our electronic medical record them were never explained or offered the diet and were
(EMR), 2635 people had some visit notes recorded. Of these treated only with medications (the majority of these were in
patients, we excluded 171 patients who had type 1 diabetes, the years 2015 and 2016). The remaining 397 patients were
MODY or latent autoimmune diabetes in adults (LADA) as offered a VLCKD defined by 20 g – 50 g of net carbohydrates
their diagnosis. We looked at patients who had a note in the per day. Of these 397 patients, 344 (87%) made the lifestyle
chart at the 6-month mark after the initial visit, which change and adopted the diet, as stated in the follow-up clinic
excluded 1777 patients, leaving a cohort of 687 patients. notes and/or the presence of ketone levels of more than
0.3 mmol/L in their clinic notes.
Because we decided to focus on T2D and prediabetes, of
these 687, we excluded 184 patients who had come to the All the patients in the cohort had an appointment with an
clinic to treat metabolic disease other than hyperglycaemia, endocrinologist who presented the idea of using a very low
meaning that they had a HbA1c below 39 mmol/mol (5.7%) carb diet as the main therapy for T2D. The diet was also
at the baseline visit (using the ADA definition of prediabetes,19 offered to concomitantly treat other symptoms of metabolic
with 503 patients remaining in the cohort). We also excluded syndrome such as obesity, high blood pressure, high blood
a woman with T2D who became pregnant in the 6-month triglycerides and low high-density lipoproteins (HDL).
observation period and three patients with creatinine greater Educational material (see Online Appendix 1) was provided.
than 3.5 mg/dL because fluid retention leads to overestimation When the patient agreed to start the dietary intervention,
of weight, and anaemia of kidney disease leads to medications were adjusted as necessary, similar to
the protocol delineated in Cucuzzella et al.20 Insulin
administration was adjusted accordingly to individual needs
Total patients treated by
the clinic stuff n = 3,235
to avoid hypoglycaemia. All sulfonylurea and meglitinide
medications were stopped from the first visit. SGLT-2
n = 600 excluded because their inhibitors were stopped or adjusted at the beginning of
medical records are in an old EMR treatment in order to decrease the risk of euglycemic diabetic
ketoacidosis (DKA).21 If SGLT-2 inhibitors were continued,
Patients had medical patients were told to take half the dose every other day and
notes recorded n = 2,635
to check ketones. Blood pressure medications were also
adjusted, as blood pressure can decrease as lifestyle changes
Excluded because had Type
1 Diabetes, MODY, LADA n = 171 are implemented.22 Patients had blood pressure and weight
measured at this visit and after 6 months.
Eligible patients
n = 2,464
Lifestyle or dietary treatment
Excluded because didn’t Within the first week of the baseline meeting with the
have a chart note at either time
0 andor 6 months n = 1,777 endocrinologist, the patient met with a dietician who
Patients with notes at provided an individualised dietary treatment plan, which
times 0 and 6 months in all cases consisted of a maximum of 20 g – 50 g net
n = 687 Excluded for medical reasons:
carbohydrates per day. A brochure with the dietary
• No prediabetes or diabetes (HbA1c
< 38.8 mmolmol, < 5.7% at time 0) guidelines was given to the patients (see Supplementary
(n = 184) files). Patients then met with the dietician and/or physician
• Pregnancy (n = 1)
on average every 2 months before the 6-month visit.
• Creatinine > 3.5 (n = 3) n = 188
Patients eligible for
medical reasons n = 499
Excluded for other reasons: Blood laboratory analysis
• No HbA1c record at time 0 andor
6 months (n = 59) Patients had blood tests that included serum glucose,
• Not offered the diet (n = 44) haemoglobin A1c (HbA1c), triglycerides, total cholesterol,
• Did not want to follow the diet low-density lipoprotein (LDL)-cholesterol, HDL-cholesterol,
(n = 53) n = 155
Patients included in the creatinine, alanine transaminase (ALT), creatinine before the
study n = 344
first visit and at 6 months again. Every patient had to have at
FIGURE 1: Flowchart showing the recruitment process of the total number of
least a baseline and 6-month HbA1c to be included in the
patients observed in the Glandt Center for Diabetes Care. cohort of the audit.

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 Page 3 of 7 Clinical Audit

Statistical analysis Eighty-seven (35.7%) patients were females. The baseline

median (IQR) HbA1c was 59.5 mmol/mol (51.9, 72.7) (7.6%)
The results of our analysis are reported as median with an
interquartile range (IQR). Tests for significant differences and decreased to 45.3 mmol/mol (39.8, 42.1) (6.3%) after
between the patients at time 0 and after 6 months were 6 months, p < 0.001. The majority of patients, 96.3%, had an
performed using paired two-tailed student’s t-test. Statistical improvement in their HbA1c (Figure 2).
analysis was performed using Python with NumPy and
SciPy libraries. Data are expressed as mean ± standard error In the T2D group median (IQR), weight was reduced from
of the mean (SEM). P < 0.05 was considered statistically 89.5 (78.2, 102.1) kg to 83 (72.1, 93.5) kg. Median (IQR) systolic
significant. BP decreased from 142 mm Hg (131, 150) to 129 mm Hg
(121, 137), p < 0.001 and diastolic blood pressure decreased
Ethical considerations from 80 mm Hg (73, 90) to 75.5 mm Hg (71, 82). Median (IQR)
triglycerides decreased from 170 mg/dL (113, 243) to
This article reports an internal audit, rather than a study, and
120 mg/dL (88, 159), p < 0.001. Median (IQR) HDL increased
hence it does not require an ethics committee review.
from 42 mg/dL (35, 50) to 47.5 mg/dL (41, 54), p < 0.001.

Results a b
Prediabetes Type 2 diabetes
Our cohort included a total of 344 patients (Table 1). The
14 p < 0.001 14 p < 0.001
average age for the whole group was 62 and the average time
13 13
with T2D or prediabetes was 12.3 years. Of these, 244 had 12 12
T2D, that is, HbA1c was 48 mmol/mol (6.5%) or above, and HbA1c (%) 11 11

HbA1c (%)
100 patients had prediabetes with an HbA1c ranging from 10 10
9 9
39 mmol/mol (5.7%) to 47 mmol/mol (6.4%). 8 8
7 7
In the entire cohort, 78 patients (22.6%) had a history of a 6 6
5 5
cardiac event and 48 patients (14%) reported symptoms of 4 4
diabetic peripheral neuropathy. Baseline 6-months Baseline 6-months

FIGURE 2: Baseline and 6-month follow-up haemoglobin A1c (HbA1c) in patients

For the T2D group of 244 patients, the median age was with (a) prediabetes (5.7% < HbA1c > 6.5%) and (b) type 2 diabetes (HbA1c >
64 years, with a median duration of diabetes of 12 years. 6.5%). Data are presented in Whisker plots.

TABLE 1: Statistical analysis of demographic and cardiometabolic variables measured at baseline and after 6 months follow-up.
Measurements N % Baseline IQR 6 months IQR P
Patients with type 2 diabetes (244)
Age (years) 244 100 64 56, 70 - - -
Gender (females/males) 87/157 36/64 - - - - -
Years of diabetes, median 244 100 12 5, 20 - - -
Weight (Kg) 227 93 89.5 78.2, 102.1 83 72.1, 93.5 < 0.001
Haemoglobin A1c (HbA1c) (mmol/mol) 244 100 59.5 51.9, 72.7 45.3 39.8, 42.1 < 0.001
Blood pressure (systolic) (mm Hg) 145 59.4 142 131, 150 129 121, 137 < 0.001
Blood pressure (diastolic) (mm Hg) 144 59 80 73, 90 75.5 71, 82 < 0.001
Low-density lipoproteins (LDL) (mg/dL) 114 47 87 66.5, 120.5 94 69, 127 < 0.05
High-density lipoproteins (HDL) (mg/dL) 136 56 42 35, 50 47.5 41, 54 < 0.05
Triglycerides (TG) (mg/dL) 136 56 170 113, 243 120 88, 159 < 0.001
TG/HDL 136 56 3.8 2.2.6.4 2.5 1.6, 3.9 < 0.001
Creatinine (mg/dL) 123 50 0.9 0.7, 1.0 0.8 0.7, 1.0 0.079
Alanine transaminase (ALT) (U/L) 61 25 28 20, 40 20 16, 27 < 0.001
Patients with prediabetes (100)
Age (years) 100 100 63.5 55, 70 - - -
Gender (females/males) 53/47 53/47 - - - - -
Years of prediabetes, median 100 100 5.5 3, 13.5 - - -
Weight (Kg) 90 90 87.1 75.7, 97.7 81.4 71.3, 91.7 < 0.001
Haemoglobin A1c HbA1c (mmol/mol) 100 100 42 41, 44.2 38.7 36.6, 42 < 0.001
Blood pressure (systolic) (mm Hg) 53 53 139 126, 147 128 120, 135 < 0.001
Blood pressure (diastolic) (mm Hg) 53 53 83 76, 88 78 72, 84 < 0.001
Low-density lipoproteins (LDL) (mg/dL) 53 53 101 81, 133 116 84, 145 0.089
High-density lipoproteins (HDL) (mg/dL) 57 57 47 37, 55 52 43, 59 < 0.001
Triglycerides (TG) (mg/dL) 57 57 123 93, 197 97 74, 146 < 0.001
TG/HDL 57 57 2.7 1.8, 4.4 1.8 1.3, 2.9 < 0.001
Creatinine (mg/dL) 51 51 0.8 0.7, 0.9 0.7 0.7, 0.9 < 0.05
Alanine transaminase (ALT) (U/L) 32 32 25 18.5, 38 20 16, 25 < 0.05
The results are shown as median (IQR) unless otherwise stated.

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 Page 4 of 7 Clinical Audit

Median (IQR) LDL increased from 87 mg/dL (66.5, 120.5) to The number of patients taking metformin increased from 203
94 mg/dL (69, 127), p < 0.018. Median (IQR) ALT was 28 mg/ (59%) to 223 (64.8%). The number of patients on GLP-1
dL (20, 40), and it decreased to 20 (16, 27), p < 0.001. Median agonists treatment increased from 79 patients (23%) at the
(IQR) creatinine was 0.9 mg/dL (0.7, 1.0) and decreased to beginning of the treatment to 122 patients (35.4%) after
0.8 mg/dL (0.7, 1.0), p = 0.079. 6 months. The number of patients on SGLT-2 inhibitors
decreased from 77 (22.3%) to 45 (13.1%). The number of
For the prediabetes group of 100 patients, the median age patients who were taking DPP-4 inhibitors decreased from
was 63.5 years, with an average duration of 5.5 years. Fifty- 76 (22%) to 64 (18.6%). The number of patients taking
three (53%) were female. The baseline median (IQR) HbA1c thiazolidinediones increased from 14 (4.1%) to 18 (5.2%). All
was 42 mmol/mol (41, 44.2) (6%) and decreased to 37 patients who were taking sulfonylureas or meglitinides
38.7 mmol/mol (36.6, 42) (5.7%) after 6 months, p < 0.001 stopped taking these medications (Table 2).
(Figure 2). Eighty-four percent of patients had an
improvement in their HbA1c. Fifty-three percent of patients were taking statins at the
beginning of treatment. Three patients had statins added to
their medication regimen, while two patients stopped taking
In the prediabetes group, median (IQR) weight was
statins during the 6-month observation period.
reduced from 87.1 (75.7, 97.7) kg to 81.4 (71.3, 91.7) kg.
Median (IQR) systolic BP decreased from 139 mm Hg (126,
147) to 128 mm Hg (120, 135), p < 0.001, and diastolic blood Discussion
pressure decreased from 83 mm Hg (76, 88) to 78 mm Hg This article presents real-world data from a cohort of 344
(72, 84). Median (IQR) triglycerides decreased from patients who adhered to a very low carbohydrate programme
123 mg/dL (93, 197) to 97 mg/dL (74, 146), p < 0.001. for 6 months under the guidance of a treating endocrinologist
Median (IQR) HDL increased from 47 mg/dL (37, 55) to in a specialty clinic. The total cohort comprised patients who
52 mg/dL (43, 59), p < 0.001. Median (IQR) LDL increased had T2D or prediabetes for an average of 12 years. In this type
from 101 mg/dL (81, 133) to 116 mg/dL (84, 145), p < 0.089. of population, diabetes is considered a progressive disease,
Median (IQR) ALT was 25 mg/dL (18.5, 38) and it and medications are usually added to prevent its deterioration.23
decreased to 20 mg/dL (16, 25), p = 0.004. Median (IQR)
creatinine was 0.8 mg/dL (0.7, 0.9) and decreased to The analysis of this cohort demonstrated that both patients
0.7 mg/dL (0.7, 0.9), p = 0.047. with T2D and prediabetes significantly improved glucose

Seventy-eight patients were taking insulin at the beginning TABLE 2: Breakdown of the medication regimen for all patients at baseline and
after 6-month follow-up.
of the treatment. Of these, only 16 patients were taking Meds for the entire cohort Baseline 6-months
insulin by 6 months, that is, 79% of patients were able to stop Metformin 203 223
insulin. Of these 16 patients who were still on insulin at SGLT2 inhibitors 77 45
6 months, the average insulin dose decreased from 55 to Insulin 78 16
15 units per day, a decrease of 72% (Figure 3). The patients GLP-1 79 122

who were not able to get off insulin had on average a longer DPP4 inhibitors 76 64
Thiazolidinediones 14 18
duration of diabetes (24.9 years) versus those who were able
Sulfonylureas 20 0
to stop insulin (19.9 years). Of the 78 patients that were able
Metiglinides 17 0
to stop injecting insulin, 20 patients had a GLP-1 agonist
SGLT2, Sodium-glucose co-transporter-2; GLP-1, glucagon-like peptide-1; DPP4, dipeptidyl
medication added to their treatment. peptidase IV.

Baseline a 6-months b

Insulin 7% 160
(16 patients) p < 0.001
140

120
Insulin 32% 100
Insulin (U)

(78 patients)
80

60

40
No insulin 93%
No insulin 68% 20
(228 patients)
(166 patients)
0
Baseline 6-months

FIGURE 3: (a) Type 2 diabetes pie chart; baseline and 6-month follow-up percentage of patients taking insulin. (b) Insulin dosage in patients who continued taking insulin
after 6 months was significantly lower.

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 Page 5 of 7 Clinical Audit

control. Out of the 244 patients in the cohort with T2D, 93% of cholesterol.36 Both systolic and diastolic blood pressure
showed improvement, a very encouraging finding, given improved as well.
that diabetes control in the United States is declining.24 Even
more encouraging is the finding that of the 78 patients taking Often there is a fear that VLCKDs worsen kidney function
insulin, 62 patients were able to stop insulin completely by but randomised controlled trials have not shown this to be
6 months, while improving their glucose control. the case,37 and our audit also confirms its safety, as creatinine
levels were similar in the T2D group and significantly
The treatment of T2D has been glucocentric, focusing mainly decreased in the prediabetes group after 6 months, as
on treating the symptom of hyperglycaemia. We have compared to time 0.
understood that the root cause of T2D is insulin resistance,
and hence, we must treat both insulin resistance and glucose The very low carbohydrate diet has been shown to be the
levels in order to have improvements in the entire metabolic most effective means of improving fatty liver.38 As insulin
picture. Studies through the years have shown that it matters levels drop, fat is able to be used for energy. The first place
how glucose levels are lowered. If the glucose levels are where the fat is oxidised is the ectopic fat, for example, in the
lowered by increasing insulin levels, endogenously by using liver.39 We do not have specific data on fatty liver, but we do
sulfonylureas or meglitinides or exogenously with insulin show that ALT decreased significantly by 6 months, which
injections, this leads to increased insulin resistance and does correlate with an improvement in fatty liver.
inadvertently increases morbidity.25,26,27
An interesting point can be gleaned from our data. It was
On the other hand, when medications lower glucose, while estimated in a UK National Diabetes Audit that both patients
lowering insulin resistance, such as GLP-1 agonists or SGLT- with type 1 diabetes and T2D each year with a HbA1c >
2 inhibitors, then studies show a reduction in CV events and 58 mmol/mol (7.5%) lose around 100 life days.40 In our
even mortality.28,29,30 In our medical practice, the aim has been cohort, 135 patients (39.2%) had a HbA1c of more than
to both simultaneously normalise glucose and decrease 58 mmol/mol (7.5%), with an average of 74.9 mmol/mol
insulin resistance. The use of the VLCKD has demonstrated (9%). Out of these 135 patients, 117 (86.7%) were able to
its effectiveness as a powerful tool to reach this objective.1 decrease their HbA1c to below 58 mmol/mol (7.5%), to an
average of 45 mmol/mol (6.3%). This suggests that these
When necessary, particularly in patients with a long duration patients, if they persist, may see an advantage in longevity.
of diabetes, drugs such as metformin, GLP-1 agonists and
SGLT-2 inhibitors were combined with the VLCKD, as an Some patients experienced side effects, particularly flu-like
intervention that lowers glucose while lowering insulin symptoms when starting the diet. In all cases, the symptoms
resistance. were transient and were mitigated or avoided by increasing
hydration and adding salt to the diet. There were two cases
When patients presented to the clinic on a regimen that of maculopapular rashes, which resolved on their own and
included sulfonylureas or meglitinides at the beginning of one case of kidney stones in someone with a prior history of
the treatment, the medications were stopped right away kidney stones. In this cohort, there were two cases of
because they increase insulin resistance. They also increase euglycemic DKA, one in 2015 and the other in 2016, both of
the risk of hypoglycaemia and lead to increased inflammation which happened in combination with an SGLT-2 inhibitor.
in the pancreas.31,32 For those taking insulin, the dose was also One patient was treated temporarily with insulin and fluids
titrated down as tolerated because of safety concerns to avoid at home. The second patient required hospitalisation and
hypoglycaemia when starting the diet and, again, to decrease was treated with fluids and insulin. In both cases, the patients
insulin resistance and improve metabolic syndrome.20 continued with the diet, but with cessation of the SGLT-2
inhibitor. These two cases of euglycemic DKA occurred, as
This internal audit has shown that the components of the the first case reports of euglycemic DKA were published.
metabolic syndrome improved significantly. There was an
average weight loss of 7.2%, which is a good proxy for waist With increasing use of SGLT-2 inhibitors, guidance suggests
circumference.33 that they should be stopped when adopting a low
carbohydrate diet.20 In our audit, SGLT-2 inhibitors were still
The significant reduction in the circulating triglycerides prescribed in very insulin-resistant patients in combination
and significant rise in HDL led to an improved triglycerides with the diet, but only with the patient’s full awareness of the
to HDL ratio. Previous studies showed that a ratio of risks of DKA. Patients received comprehensive education
triglycerides to HDL-cholesterol (TG/HDL-c) of more than regarding the associated risks and were required to
3 is a reliable marker for insulin resistance34 and is associated acknowledge their understanding of these risks in writing
with an atherogenic lipid profile and a risk for the within their medical charts. Additionally, they were
development of coronary disease.35 In this audit, the median instructed to purchase a ketone metre for periodic monitoring
of the TG/HDL ratio decreased from 3.6 to 2.4. This suggests and in case of any adverse symptoms. In most cases, the dose
that in this cohort, the quality of LDL improved and shifted prescribed is half of the minimum standard dose, and it is to
from an atherogenic phenotype to a less dangerous type be taken every other day (e.g. empagliflozin 5 mg every other

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 Page 6 of 7 Clinical Audit

day). Patients were also instructed on the importance of and visualisation of the data. D.U. contributed to the
maintaining hydration. conceptualisation, writing of the draft and methodology.

Audits of this nature offer various strengths, including the

Funding information
ability to assess effectiveness in a large number of people.
They also provide a reflection of real-world effectiveness, This research received no specific grant from any funding
making them more representative than tightly controlled agency in the public, commercial or not-for-profit sectors.
trials. There are, however, a number of limitations to this
work. A limitation of these data is that ketone levels are not Data availability
consistently documented during all office visits. In certain
Data may be obtained from a third party and are not publicly
instances, although the visit note indicated the patient’s diet available. The anonymised (de-identified participant data)
compliance based on clinic-conducted ketone checks, these are on an Excel Spreadsheet held by the corresponding
levels were not recorded in the patient’s chart. Conversely, in author, M.G., on behalf of the Glandt Center for Diabetes
some cases, ketone levels were not measured, and compliance Care.
was presumed based on the patient’s self-reporting. This
hinders our capacity to definitively ascertain the patient’s
adherence to the diet. Another limitation is the relatively Disclaimer
short duration of the audit. Given the powerful temptations The views and opinions expressed in this article are those of
in our environment to eat carbohydrates, this will need to be the authors and do not necessarily reflect the official policy or
tested over time. However, we have seen from previous position of any affiliated agency of the authors.
studies that a low carbohydrate diet is sustainable.1,41 How
sustainable the diet is may be in large part a function of References
how much support the patients receive from the medical
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establishment.42 continuous remote care intervention including nutritional ketosis for the
management of type 2 diabetes: A 2 year non-randomized clinical trial.
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who have an average duration of T2D for 12 years. 2. Lean MEJ, Leslie WS, Barnes AC, et al. Durability of a primary care-led weight-
management intervention for remission of type 2 diabetes: 2-year results of the
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dietary changes to our results proves challenging; however, 2019;7(5):344–355. https://doi.org/10.1016/S2213-8587(19)30068-3

we assert the diet’s significant role based on established 3. Unwin D, Khalid AA, Unwin J, et al. Insights from a general practice service
evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes
evidence of the benefits of VLCKD in T2D treatment.43 This mellitus and prediabetes: A secondary analysis of routine clinic data including
HbA1c, weight and prescribing over 6 years. BMJ Nutr Prev Health.
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control while concurrently reducing the need for diabetes 4. Riddle MC, Cefalu WT, Evans PH, et al. Consensus report: Definition and
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medications. It offers a potent tool capable of reversing the 44(10):2438–2444. https://doi.org/10.2337/dci21-0034
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The authors would like to thank the patients and the entire 2005.01760.x
staff at the Glandt Center for Diabetes Care for their dedication 7. Westman EC, Yancy Ws Jr, Mavropoulos JC, Marquart M, McDuffie JR. The effect
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