This article presents the position of the Society of Metabolic Health Practitioners (SMHP) regarding therapeutic carbohydrate reduction (TCR) nutrition interventions for type 1 diabetes mellitus (T1DM). A modified Delphi methodology was used to arrive at a consensus consisting of several focus groups, multiple rounds, and an anonymous survey. The field of endocrinology has seen many new advances for the treatment of T1DM including hybrid closed-loop insulin delivery systems and continuous glucose monitors for better glycaemic control, monoclonal antibodies to delay the onset of disease and increased access to paediatric endocrinologists, among many other noteworthy achievements. Despite these advancements, standard of care approaches to T1DM result in higher than acceptable morbidity and mortality, with a high prevalence of microvascular and macrovascular complications. Insulin resistance in type 1 diabetes is an independent risk factor for adverse outcomes even in well controlled type 1 diabetes. In 2021, only 21% of adults with T1DM in the United States achieved the American Diabetes Association’s (ADA’s) target haemoglobin A1C goal of 7.0%, while data in the paediatric and adolescent population have demonstrated worse glycaemic control. Supported by observational and interventional evidence, the SMHP advocates for the reevaluation of the prevailing nutritional therapy for T1DM with more broad consideration for TCR. The SMHP recommends open access and clinical support for TCR nutrition interventions for individuals with T1DM of all ages and calls upon the medical community to help foster more attention and research on TCR for T1DM.

There is a substantial body of clinical evidence supporting the beneficial effects of lower-carbohydrate dietary patterns on multiple established risk factors associated with insulin resistance and cardiovascular diseases in adult populations. Nutrition and health researchers, clinical practitioners, and stakeholders gathered for, “The Scientific Forum on Nutrition, Wellness, and Lower-Carbohydrate Diets: An Evidence- and Equity-Based Approach to Dietary Guidance” to discuss the evidence base around lower-carbohydrate diets, health outcomes, and dietary guidance. Consensus statements were agreed upon to identify current areas of scientific agreement and spotlight gaps in research, education, and practice to help define and prioritize future pathways. Given the evidence base and considering that most American adults are living with at least one nutrition-related chronic disease, there was consensus that including a lower-carbohydrate dietary pattern as one part of the Dietary Guidelines for Americans could help promote health equity among the general population.

PURPOSE OF REVIEW:Pediatric obesity and comorbidities related to insulin resistance continue to be a growing public health crisis. If lifestyle measures are unsuccessful, pharmacological and surgical interventions are offered. In this paper, we describe the driving force of the obesity crisis: hyperinsulinemia and the development of insulin resistance. We give historical background of key policy issues which have contributed to this pandemic as well as the physiologic mechanisms of insulin resistance. The prevalence of obesity will continue to rise unless the root cause of hyperinsulinemia is addressed. RECENT FINDINGS:Current research on insulin resistance demonstrates that a decreased consumption of carbohydrates is an effective first-line dietary intervention for the treatment of obesity and related metabolic diseases. Evidence shows it is safe and beneficial. A low-carbohydrate eating pattern can be helpful to address pediatric obesity. However, there must be policy guardrails in place to ensure that this is a sustainable and viable option for children and their families. There must be a change in the nutritional environment to help individuals battle the chronic disease of obesity.

PURPOSE OF REVIEW:Pediatric obesity and comorbidities related to insulin resistance continue to be a growing public health crisis. If lifestyle measures are unsuccessful, pharmacological and surgical interventions are offered. In this paper, we describe the driving force of the obesity crisis: hyperinsulinemia and the development of insulin resistance. We give historical background of key policy issues which have contributed to this pandemic as well as the physiologic mechanisms of insulin resistance. The prevalence of obesity will continue to rise unless the root cause of hyperinsulinemia is addressed.RECENT FINDINGS:Current research on insulin resistance demonstrates that a decreased consumption of carbohydrates is an effective first-line dietary intervention for the treatment of obesity and related metabolic diseases. Evidence shows it is safe and beneficial. A low-carbohydrate eating pattern can be helpful to address pediatric obesity. However, there must be policy guardrails in place to ensure that this is a sustainable and viable option for children and their families. There must be a change in the nutritional environment to help individuals battle the chronic disease of obesity.

Pediatric obesity and comorbidities related to insulin resistance continue to be a growing public health crisis. If lifestyle measures are unsuccessful, pharmacological and surgical interventions are offered. In this paper, we describe the driving force of the obesity crisis: hyperinsulinemia and the development of insulin resistance. We give historical background of key policy issues which have contributed to this pandemic as well as the physiologic mechanisms of insulin resistance. The prevalence of obesity will continue to rise unless the root cause of hyperinsulinemia is addressed. Current research on insulin resistance demonstrates that a decreased consumption of carbohydrates is an effective first-line dietary intervention for the treatment of obesity and related metabolic diseases. Evidence shows it is safe and beneficial. A low-carbohydrate eating pattern can be helpful to address pediatric obesity. However, there must be policy guardrails in place to ensure that this is a sustainable and viable option for children and their families. There must be a change in the nutritional environment to help individuals battle the chronic disease of obesity.

Recent reviews of using therapeutic carbohydrate reduction to treat metabolic disease in paediatric patients have consistently made errors in the form of bias against recommending this nutrient-dense eating pattern despite strong evidence for its use in adults and emerging evidence in paediatric patients. The purpose of this perspective is to review these errors, which include conflating 4:1 ketogenic diets with well-formulated ketogenic diets and the needless medicalisation of using therapeutic carbohydrate reduction in paediatric populations.

Background: Diabetic retinopathy (DR) remains the leading cause of legal blindness in 18- to 74-year-old Americans and in most developed nations. Screening for DR has increased minimally over four decades.Aim: Primary care physicians are critical to improve both visual and systemic outcomes in patients with diabetes. Diabetic retinopathy screening affords clinicians the opportunity to discuss type 2 diabetes (T2D) remission with patients. Primary care is well positioned to manage, and lower risks, of the systemic-associated diseases predicted by DR. The goal of this review was to assess the current literature on DR, new technology to enhance primary care-based screening, and the science and practical application of diabetes remission. A two-pronged strategy, bringing attention to ophthalmologists the potential of diabetes remission, and family physicians, the importance of retinopathy screening, may reduce the prevalence of blindness in patients with diabetes.Methods: Embase, PubMed, Google Scholar, AMED, and MEDLINE databases were searched using keywords ‘diabetic retinopathy; diabetic retinopathy screening, diabetes remission, diabetes reversal, and AI and diabetic retinopathy’.Results: Robust literature now exists on diabetes remission and international consensus panels are aligning on the strategies and the definition.Conclusion: Diabetic retinopathy remains the leading cause of legal blindness. Novel primary care friendly imaging would benefit nearly half of Americans from earlier detection and treatment of DR still not receiving such care. The most powerful way a primary care clinician could impact DR would be assisting in making the T2D go into remission. Prevention or slowing of progression of DR would greatly improve both visual and systemic outcomes patients with diabetes.Contribution: This article highlights the importance of addressing DR and metabolic health to reduce not only the eye effects of T2D but the multisystem complications.

As we reopen society and search for medicines and vaccines that could improve coronavirus outcomes, we should not miss the opportunity to talk about the conditions that have increased our vulnerability to this pandemic in the first place: America's poor state of health. Some 60% of us has one or more diet-related, chronic disease and the cost of this is a staggering contribution to the 3.5 trillion dollar annual US health care expenditure. These diseases have accompanied a large majority of severe cases in the United States, according to the Centers for Disease Control and Prevention (CDC) with the 2 most common underlying health conditions being cardiovascular disease (32%) and diabetes (30%).1 Hospitalizations were 6 times higher and deaths 12 times higher among those with reported underlying conditions compared with those with none reported.1 In a large study in the New York City of 5700 patients hospitalized with COVID-19%, 57%, 42%, and 34% had hypertension, obesity, and diabetes, respectively.2 Obesity is clearly emerging as a dominant factor greatly increasing the risk of hospitalization and death.3–6 In one of the most recent studies on comorbidities to date, conducted in France, only 1 in every 10 people who ended up in intensive care with Covid-19 were in a range of healthy weight. Researchers led by Francois Pattou, the head of Lille University Hospital's general and endocrine surgery department in France, presented data at a conference showing that about half of the 124 intensive-care patients with Covid-19 in a sample they studied were obese, and most of the remaining ones were overweight.7 Thus, to build resilience to this and future viruses, we need to talk about better nutrition. In the United Kingdom, the National Health Service reports that over a quarter of fatalities from Covid are accompanied by diabetes.8 Prime Minister Boris Johnson became convinced that his own obesity contributed to his hospital stay, prompting him to declare, on launching a probe into the link between obesity and worsened Covid outcomes, “I have changed my mind on this [obesity]. We need to be much more interventionist.” COVID, COMORBIDITY, AND ETHNICITY—A DEADLY COMBINATION? Early on, experts attributed the high mortality rates from the virus to air pollution, smoking, and advanced age; yet over the past months, the significant risk of metabolic illness has emerged. This is even more pronounced in our minority populations. Minorities who have higher rates of comorbidities and diet-related illness are being affected at higher rates.9–11 Indeed, a recent report found that per-capita death rates from Covid-19 have increased dramatically over the summer for Black and Brown Americans. Although fatalities also increased for White Americans, yet the impact on this group has been notably less severe. The latest figures record that in the 2 weeks from 4 to 18 August the death rate of African Americans shot up from 80 to 88 per 100 000 population—an increase of 8 per 100 000. By contrast, the White population suffered half that increase, from 36 to 40 per 100 000, an increase of 4 per 100 000. For Latino Americans, the increase was even more stark, rising from 46 to 54 per 100 000—an increase of 9 per 100 000 when rounded.9 The most recent US CDC data reveal almost 5 times the hospitalization rates for Blacks and Latinos versus Whites.12 INSULIN RESISTANCE AS A ROOT CAUSE Almost all of these comorbidities—hypertension, diabetes, coronary artery disease, and obesity—have a common root cause, called insulin resistance,13 which is diagnosed when a person has a spectrum of symptoms, including abdominal obesity, low High Density Lipoprotein-cholesterol, high triglycerides, high blood pressure, and high blood sugars. According to one recent estimate based on government data, no less than 88% of Americans may currently have insulin resistance. This means that only 12% of our population is metabolically well. Given that chronic diseases are strongly implicated in poor outcomes for coronavirus, we need to take insulin resistance far more seriously.14 CAUSES OF INSULIN RESISTANCE Insulin resistance has been called a “metabolic storm” in the body, where normal function breaks down. The principal malfunction is related to the body's inability to process sugars in the blood. Whereas a healthy body reacts to sugar consumption by stimulating the pancreas to secrete insulin, which then shunts the sugar off to be stored in the liver, muscles, or fat tissues, at some point, this insulin mechanism is overwhelmed. An overabundance of sugar in the blood stream, throughout the day and after many months, erodes the body's ability to respond to insulin, a state known as insulin resistance. Levels of circulating insulin rise. This ultimately leads to any number of conditions, from type 2 diabetes and obesity to nonalcoholic fatty liver disease and heart disease.Figure 1.: WHO message on Covid and sugar reduction. The primary driver of this excess sugar in the blood stream is the food we eat. The reality is that not only do simple sugars such as candy convert to blood sugar, but so do more “complex” carbohydrates, such as bread, pasta, crackers, and even sweet fruits. These all become sugar—glucose—as soon as they are digested. Thus, to avoid high blood sugar, the logical solution is to cut down on eating them. Easier said than done, of course, but there are now some 100 clinical trials showing, altogether, that carbohydrate restriction is safe and effective for sustainably reversing a diagnosis of type 2 diabetes, bringing down blood pressure, improving most cardiovascular risk factors, and helping people to lose weight. POSSIBLE MECHANISMS FOR WORSE COVID-19 OUTCOMES WITH METABOLIC DISEASES Based on the emerging data, obesity and other chronic diseases might contribute to more acute Covid outcomes through the following possible mechanisms. The ACE-2 Receptor A virus works by gaining access to the cells of its host and hijacking a receptor on that cell. In the case of Covid, access is obtained by the ACE-2 receptor, which explains why the virus gains access so readily through the lungs and small intestine—because these tissues have ample ACE-2 receptors. There is some logic to the idea that metabolically ill people, because they tend to have higher ACE-2 expression, are therefore more vulnerable to the virus. Endocrine and Metabolic Link A recent paper in Nature15 discusses how the Coronavirus might exacerbate, or even cause, diabetes by seriously damaging the pancreas. Specifically, it attacks pancreatic islets, where insulin is formed. People with diabetes are at a heightened risk for the virus, because these impaired pancreatic cells, combined with Covid-induced pneumonia, may in fact form a vicious circle, amplifying the negative effects of the virus. More recently, we have been witnessing unusual cases of clotting and strokes. A 2006 paper in Diabetes suggests that people who are more insulin resistant are less likely to have clots dissolve and are “especially susceptible to thrombotic events by a concurrent insulin-driven impairment of fibrinolysis and a glucose-driven activation of coagulation.”16 Immune Dysregulation People with insulin resistance are likely also vulnerable to the virus because of their weakened immune system.17The immune system exists in 2 parts: an innate, first responder and a more delayed, adaptive second responder which provides additional immunity. Both of these arms combine to reflect one's overall health, and both of these immune system arms are negatively impacted by obesity and metabolic syndrome. In 2017, biologist Catherine Anderson explored this topic,18 and in 2019, researchers added to the discourse in Nature,19 stating:“…during respiratory viral infections, insulin-resistant participants respond differently than insulin-sensitive participants. Third, global coassociation analyses among the thousands of profiled molecules reveal specific host–microbe interactions that differ between insulin-resistant and insulin-sensitive individuals.” (Emphases added) Importantly the article explains how the more delayed and robust cytokine release in insulin-resistant patients may contribute to the “cytokine storm.” Moreover, visceral adipose tissue itself contributes to the cytokine storm.20,21 High Blood Sugar Persistently high blood sugar clearly hinders immune responses, according to a 1972 paper,22 which states, “hyperglycemia [high blood sugar] negatively affects white blood cell defense against infection. High glucose impairs these cells in the innate immune response to invading organisms.” More recently, high blood sugar was found, in an analysis of more than 7000 Chinese Covid patients to be the single-most important determinant of outcomes for hospitalized patients.23 Researchers found that mainly because of high-blood sugar, subjects with type 2 diabetes required more medical interventions and had a significantly higher mortality (7.8% vs 2.7%) and multiple organ injury compared with nondiabetic individuals. FOR SAFER RE-ENTRY—EAT REAL FOOD AND LIMIT SUGAR CONSUMPTION Recently, the World Health Organization launched a Stay Healthy At Home Campaign, urging adults to limit their sugar consumption to less than 6 teaspoons a day—the amount of sugar in one small carton of chocolate milk served to school children. The reality is that we are partially responsible for our fragility to the coronavirus. Now, we are hoping for a vaccine and medications to pull us out of this pandemic. But the current crisis reveals how truly vulnerable we are. We have often blamed the victim for having obesity or other diet-related diseases, but these illnesses now affect up to 80% of the world's population.24 Our current Covid-19 approach has focused on hiding from the virus and now hoping immunization will set us free. We believe the best idea going forward instead is to strengthen our resistance to Covid and future viruses, with a healthy immune system—which means a healthy lifestyle. Reducing sugar and refined carbohydrates, which together fuel insulin resistance, is an ideal first step. Eating to keep blood sugar low and stable will clearly reduce risk. Anyone can purchase a continuous glucose monitor to know exactly how foods are affecting blood sugar levels. Junk food is the obvious enemy, even if it can be every quarantiner's best friend. Yet even these comforting foods can be resisted when replaced by whole, natural foods including filling fats and proteins. It is also critical to focus the diet on foods that are nutrient dense: meats, eggs, seafood, dairy, vegetables, and low-sugar fruits. Many people who aim to achieve good health aim to do so through natural means, such as better nutrition and other lifestyle changes. So instead of managing their conditions with pills, they seek to reverse chronic disease through more natural approaches. This strategy, such as a vaccine, should provide protection now and for many years to come, and that is essential, since Covid-19 will not be like a blizzard (hitting hard and quickly passing over) but rather like a long hard winter. We all can get healthier, and this applies especially to those with metabolic illness. Each comorbidity you have decreases your physiological reserve. We should be doing a better job in maintaining our health for times when we are under stress. We hope to see a new world where people have the tools to recover their good health and become stronger to fight pandemics such as this one. We are probably in mile 4 now of the 26 mile Covid marathon, and even as the coronavirus abates, the ongoing obesity, diabetes, and metabolic disease pandemics will continue to take their toll on our society. It is time to take back our health, our own resilience—and that of our nation.

Type 2 diabetes (T2D) is a growing epidemic in the United States, and metabolic control has not been improved over the last 10 years. Glycemic excursion minimization (GEM) is an alternative lifestyle treatment option focused on reducing postnutrient glucose excursions rather than reducing weight. GEM has been proven to be superior to routine care when delivered face to face, and equivalent or superior to conventional weight loss therapy, but it has not been evaluated among patients newly diagnosed with T2D or in a self-administered format. This pilot study evaluated the feasibility of a self-administered version of GEM, augmented with continuous glucose monitoring (CGM), to improve metabolic control (hemoglobin A1c [HbA1c]) while diminishing or delaying the need for diabetes medications in adults recently diagnosed with T2D. These primary objectives were hypothesized to be achieved by reducing carbohydrate intake and increasing physical activity to diminish CGM glucose excursions, leading to the secondary benefits of an increase in diabetes empowerment and reduced diabetes distress, depressive symptoms, and BMI. GEM was self-administered by 17 adults recently diagnosed with T2D (mean age 52 years, SD 11.6 years; mean T2D duration 3.9 months, SD 2.5 months; mean HbA1c levels 8.0%, SD 1.6%; 40% female; 33.3% non-White), with the aid of a 4-chapter pocket guide and diary, automated motivational text messaging, and feedback from an activity monitor, along with CGM and supplies for the 6-week intervention and the 3-month follow-up. Treatment was initiated with one telephone call reviewing the use of the technology and 3 days later with a second call reviewing the use of the GEM pocket guide and intervention. At 3-month follow-up, 67% of the participants’ diabetes was in remission (HbA1c levels <6.5%), and only one participant started taking diabetes medication. Participants demonstrated a significant reduction in HbA1c levels (–1.8%; P<.001). Participants also experienced significant reductions in high-glycemic-load carbohydrates routinely consumed, CGM readings that were >140 mg/dL, diabetes distress, depressive symptoms, and BMI. Participants felt that use of the CGM was the most significant single element of the intervention. GEM augmented with CGM feedback may be an effective initial intervention for adults newly diagnosed with T2D. A self-administered version of GEM may provide primary care physicians and patients with a new tool to help people recently diagnosed with T2D achieve remission independent of medication and without weight loss as the primary focus. Future research is needed with a larger and more diverse sample.

BACKGROUND Type 2 diabetes (T2D) is a growing epidemic in the United States, and new treatments are needed. Glycemic Excursion Minimization (GEM) is an alternative lifestyle treatment option focused on reducing post-nutrient blood glucose (BG) excursions. GEM has been proven to be superior to routine care when delivered face-to-face, and equivalent or superior to conventional weight loss therapy, but it has not been evaluated among patients newly diagnosed with T2D or in a self-administered format. OBJECTIVE This study aimed to evaluate whether a self-administered version of GEM, augmented with continuous glucose monitoring (CGM), would improve metabolic control while diminishing or delaying the need for diabetes medications in adults recently diagnosed with T2D. METHODS GEM was self-administered by 17 adults recently diagnosed with T2D, with the aid of a 4-chapter pocket guide and diary, automated motivational text messaging, and feedback from an activity monitor, and CGM and supplies for the 6-week intervention and the 3-month follow-up. The protocol was supplemented with one telephone call reviewing the use of the technology and one call reviewing the use of the GEM pocket guide and intervention in general. RESULTS At follow-up, 67% of the participants’ diabetes was in remission (HbA1c < 6.5%) and only one participant subsequently initiated diabetes medication. Participants demonstrated a significant reduction of HbA1c (from 8.0% to 6.2%, P < .001). Participants also experienced significant reductions in high glycemic load carbohydrates routinely consumed, CGM readings >140mg/dl, body mass index, diabetes distress, and depressive symptoms. Participants felt that use of the CGM was the most significant single element of the intervention. CONCLUSIONS GEM augmented with CGM feedback may be an effective initial intervention for adults newly diagnosed with T2D. A self-administered version of GEM may provide primary care physicians and clinicians with a new tool to help people recently diagnosed with T2D achieve remission independent of medication and without weight loss as the primary focus. Future research is needed with a larger and more diverse sample.

Healthcare professionals in the primary care setting need to be competent to safely adapt diabetes medications when patients with Type 2 Diabetes (T2D) alter their diet. Safe prescribing practice is supported through an understanding of the clinical evidence, basic science, and pharmacology of medications. This review article supports clinicians in the practical application of this knowledge to achieve safe practice. Traditional medical training and clinical practice for chronic disease has long revolved around the teaching of intensifying therapy and evidenced based prescribing, a crucial skill when chronic disease progresses. Now that we are witnessing remission of Type 2 Diabetes through nutritional interventions specifically low carbohydrate diets (LCD) we must apply the same effort and thought to de-prescribing as the underlying metabolic condition improves. There is minimal guidance in the literature on how to actively de-prescribe. The American Diabetes Association in theirStandards of Medical Care in Diabetes–2021acknowledges low carbohydrate nutritional therapy (LCD) as a viable option in the management of Type 2 Diabetes (T2D). Thus, the goal of our paper is to help close the gap between the clinical evidence, basic science, and pharmacology of T2D medications to the practical application and teamwork needed to facilitate safe medication reduction in the primary care setting when applied to a LCD. The LCD is an increasingly popular and effective option for managing T2D and can lead to an improvement in the condition, reduced medication burden, and contribute to significant weight loss. Safe initiation of a LCD in patients on medications requires significant monitoring and medication adjustments to decrease and eliminate the risk of hypoglycemia and hypotension. The health care team including clinicians in primary care, nursing, pharmacy and nutrition need to be competent in adjusting diabetes and antihypertensive medications to achieve safe and effective care. The most immediate and important adjustments are to insulin, sulfonylureas, SGLT2 inhibitors, blood pressure medications and diuretics. Interdisciplinary care teams can individualize therapy while following the guidance, which includes monitoring blood glucose and blood pressure closely, decreasing medications that can cause hypoglycaemia and hypotension, evaluating blood glucose and blood pressure data responses regularly, and open access communication with the team. The article is an international consensus document on de-prescribing that was put together by a multidisciplinary team of clinicians.

The pathological changes associated with type 2 diabetes (T2D) can be reversed through lifestyle measures, in some cases leading to remission.1 The low carbohydrate diet (LCD) is recognised as an effective option that is clinically inexpensive with few side effects.2 Many patients are achieving significant improvements in glycaemic control, with associated reduction in drug costs from cessation of hypoglycaemic agents.3 Digital-technology behaviour change solutions for T2D remission are being delivered at scale.4 Primary care clinicians need to be competent to adjust diabetes medications appropriately in individuals who follow an LCD. An LCD comprises <130 g of digestible carbohydrates per day.5 Digestible carbohydrate refers to sugars and complex carbohydrates such as starch, which is digested to glucose. Aligned with national guidance, carbohydrate choices in an LCD will typically be higher fibre and low glycaemic index (GI).6 Reduced total carbohydrate ingestion and low GI choices give the LCD a low glycaemic load (GL). In T2D the GI and GL of food consumed is a determinant of blood glucose level and thus the requirement for hypoglycaemic medication. Blood glucose levels typically fall substantially when an individual adopts an LCD. This article discusses key considerations regarding hypoglycaemic medications for an LCD and provides practical suggestions to prescribers. The recommendations are developed from the experience of the authors, discussion with …

Type 2 diabetes (T2DM) is most often treated as a chronic progressive condition. However, both clinical experience and scientific studies have shown that remission indicated by a normalizing of blood glucose levels and safe medication reduction through lifestyle change should be considered an achievable clinical outcome for patients with T2DM. Dietary interventions that include therapeutic levels of carbohydrate reduction can be used by clinicians to help patients reach this goal, as evidenced by clinical experience and clinical trials; however, many clinicians and allied healthcare providers have not been trained in how to administer these therapies. This article demonstrates the successful implementation of therapeutic carbohydrate reduction for T2DM in an inpatient setting through the institutional example of a small, rural hospital in the U.S. It provides definitions for therapeutic carbohydrate reduction and a rationale for its use in an inpatient setting in patients who present with T2DM. The article outlines a seven-stage protocol developed from practice-based evidence to be used in an inpatient setting to minimize the requirement for insulin or other hypoglycemic medications and to normalize markers of T2DM in patients with this condition. The protocol consists of: 1) patient selection; 2) pre-diet evaluation and counseling; 3) patient education; 4) initiating the dietary intervention; 5) managing medication changes; 6) addressing any side effects; and 7) follow-up. This protocol serves as an initial framework for developing clinical practice guidelines and a standard of care for using carbohydrate reduction as an intervention for T2DM and related conditions in an inpatient setting. It also indicates the potential for providing clinicians with the opportunity to help patients put T2DM into remission, rather than just manage its progression. A Clinician’s Guide to Inpatient Low-Carbohydrate Diets for Remission of Type 2 Diabetes: Toward a Standard of Care Protocol.

Background: Metabolic syndrome has become a significant problem, with the American Diabetes Association estimating the cost of diabetes and pre-diabetes in the United States alone to be $322 billion per year. Numerous clinical trials have demonstrated the efficacy of low-carbohydrate diets in reversing metabolic syndrome and its associated disorders. Aim: This study was designed to examine how voluntary adherents to a low-carbohydrate diet rate its effectiveness and sustainability using an online survey. Setting and methods: The 57-question survey was administered online and shared internationally via social media and ‘low-carb’ communities. Where appropriate, chi-squared tests and paired t-tests were used to analyse the responses. Results: There were 1580 respondents. The majority of respondents had consumed less than 100 g of carbohydrates per day for over a year, typically for reasons of weight loss or disease management. There was a reported decrease in waist circumference and weight with a simultaneous decrease in hunger and increase in energy level. Of those who provided laboratory values, the majority saw improvements in their HbA1c, blood glucose measurements, and lipid panel results. There was a reduction in usage of various medications, and 25% reported medication cost savings, with average monthly savings of $288 for those respondents. In particular, the usage of pain relievers and anti-inflammatories dropped with a simultaneous decreased rating of pain and increase in mobility. Conclusion: We conclude that low-carbohydrate diets are a sustainable method of metabolic syndrome reversal in a community setting.

BACKGROUND:Beneficial correlations are suggested between food preparation and home food preparation of healthy choices. Therefore, there is an emergence of culinary medicine (CM) programs directed at both patients and medical professionals which deliver education emphasizing skills such as shopping, food storage, and meal preparation.OBJECTIVE:The goal of this article is to provide a description of emerging CM programs and to imagine how this field can mature.METHODS:During April 2015, 10 CM programs were identified by surveying CM and lifestyle medicine leaders. Program directors completed a narrative describing their program's structure, curricula, educational design, modes of delivery, funding, and cost. Interviews were conducted in an effort to optimize data collection.RESULTS:All 10 culinary programs deliver medical education curricula educating 2654 health professionals per year. Educational goals vary within the domains of (1) provider's self-behavior, (2) nutritional knowledge and (3) prescribing nutrition. Six programs deliver patients' curricula, educating 4225 individuals per year. These programs' content varies and focuses on either specific diets or various culinary behaviors. All the programs' directors are health professionals who are also either credentialed chefs or have a strong culinary background. Nine of these programs offer culinary training in either a hands-on or visual demonstration within a teaching kitchen setting, while one delivers remote culinary tele-education. Seven programs track outcomes using various questionnaires and biometric data.CONCLUSIONS:There is currently no consensus about learning objectives, curricular domains, staffing, and facility requirements associated with CM, and there has been little research to explore its impact. A shared strategy is needed to collectively overcome these challenges.

Glycemic control in hospitalized patients who are not in intensive care remains unsatisfactory. Despite persistent expert recommendations urging its abandonment, the use of sliding-scale insulin remains pervasive in U.S. hospitals. Evidence for the effectiveness of sliding-scale insulin is lacking after more than 40 years of use. New physiologic subcutaneous insulin protocols use basal, nutritional, and correctional insulin. The initial total daily dose of subcutaneous insulin is calculated using a factor of 0.3 to 0.6 units per kg body weight, with one half given as long-acting insulin (the basal insulin dose), and the other one half divided daily over three meals as short-acting insulin doses (nutritional insulin doses). A correctional insulin dose provides a final insulin adjustment based on the preprandial glucose value. This correctional dose resembles a sliding scale, but is only a small fine-tuning of therapy, as opposed to traditional sliding-scale insulin alone. Insulin sensitivity, nutritional intake, and total daily dosing review can alter the physiologic insulin-dosing schedule. Prospective trials have demonstrated reductions in hyperglycemic measurements, hypoglycemia, and adjusted hospital length of stay when physiologic subcutaneous insulin protocols are used. Transitions in care require special considerations and attention to glycemic control medications. Changing the sliding-scale insulin culture requires a multidisciplinary effort to improve patient safety and outcomes.