Clinical Experience of a Carbohydrate-Restricted Diet: Effect on Diabetes Mellitus MARY C. VERNON, M.D., 1 JOHN MAVROPOULOS, M.P.H., 1 MELISSA TRANSUE, R.N., B.S.N., 1 WILLIAM S. YANCY, Jr., M.D. M.H.S., 2 and ERIC C. WESTMAN, M.D., M.H.S. 2 233 METABOLIC SYNDROME AND RELATED DISORDERS Volume 1, Number 3, 2003 © Mary Ann Liebert, Inc. Brief Report 1 Private Bariatric and Family Practice, and Clinical Faculty, University of Kansas School of Medicine, Lawrence, Kansas. 2 Division of General Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina. INTRODUCTION O UR OBJECTIVE was to assess the effect of a carbohydrate-restricted dietary approach on diabetes mellitus. The rationale for using a carbohydrate-restricted diet for diabetes melli- tus derives from the known effect of dietary carbohydrate on insulin secretion. 1 For type 1 diabetes, less dietary carbohydrate will lead to a lower requirement for insulin to control post- prandial blood glucoses. For type 2 diabetes, less dietary carbohydrate will lead to lower in- sulin levels and less insulin resistance—if in- sulin resistance is an adaptive response to high insulin levels. Less insulin resistance will then lead to improved glycemic control. MATERIALS AND METHODS Design This case series was a retrospective chart re- view of an outpatient weight and metabolism management program utilizing a carbohydrate- restricted diet in Lawrence, Kansas (M.C.V.). Patients were self-referred or referred by other physicians for weight loss or risk factor man- agement (abnormal lipids or diabetes). Patients were included if they were diagnosed with di- abetes mellitus, and had at least baseline and 2-month follow-up weight measurements and laboratory values. After a complete medical history, physical examination, and laboratory evaluation, pa- tients were individually counseled to reduce their dietary intake of carbohydrate to fewer than 20 g per day detected with the goal of pro- ducing detectable urinary ketones. 2,3 The diet was based on animal foods (meat, chicken, turkey, other fowl, fish, shellfish), hard cheese, eggs, and limited amounts (1–2 cups per day) of salad or low-carbohydrate vegetables (let- tuce, broccoli, cauliflower, kale, spinach, cabbage or asparagus). Patients were advised not to re- strict salt or water intake, but instead, to drink fluids as needed if thirsty. Patients were in- structed to take a daily multivitamin (Atkins Nutritionals Basic #3 or Solaray multivitamin with minerals) and essential fatty acid formula (Atkins Nutritionals Essential Oils Formula or omega-3 fatty acid supplement). At return clinic visits, a urine sample for ketones was measured using Chemstrips or Bayer Multistix to monitor adherence to the carbohydrate-restricted diet. Once glycemic control was achieved, an addi- tional 5 g of daily carbohydrate was added to the diet each week until no further ketones were detectable in the urine. This final level of car- bohydrate intake was recommended as the pa- tient’s daily maintenance diet. Medical monitoring was necessary to ad- just diabetic and anti-hypertensive medications. Follow-up clinic visits occurred at one-week intervals, or more frequently if needed. Oral hypoglycemic agents were discontinued at the