HomeResourcesResearch Papers

The Western diet: a blind spot of eating disorder research?—a narrative review and recommendations for treatment and research

Authors: Agnes Ayton, Ali Ibrahim

Over the last 50 years, in parallel with the obesity epidemic, the prevalence of eating disorders has increased and presentations have changed. In this narrative review, we consider recent research exploring the implications of changing patterns of food consumption on metabolic and neurobiological pathways, a hitherto neglected area in eating disorder research. One of the major changes over this time has been the introduction of ultra-processed (NOVA-4) foods, which are gradually replacing unprocessed and minimally processed foods. This has resulted in the increased intake of various sugars and food additives worldwide, which has important metabolic consequences: triggering insulin and glucose response, stimulating appetite, and affecting multiple endocrine and neurobiological pathways, as well as the microbiome. A paradigm shift is needed in the conceptual framework by which the vulnerability to, and maintenance of, different eating disorders may be understood, by integrating recent knowledge of the individual metabolic responses to modern highly processed foods into existing psychological models. This could stimulate research and improve treatment outcomes.

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A simple model to find patient hope for positive lifestyle changes: GRIN

Authors: Jen Unwin, David Unwin

We work together in a GP practice to bring psychology into the GP realm.We realised that psychological theory can seem complex and time consuming to translate into general practice. However, a large proportion of consultations are for physical and mental health conditions exacerbated by behavioural/lifestyle factors such as smoking, alcohol consumption, inactivity and poor nutrition. Doctors often lack the confidence and competence to address these issues in clinic, assuming a lack of patient motivation or fearing opening a can of worms in an all-too-short consultation.The result can be worsening wellbeing, repeat consulting and poly-pharmacy. We have devised a simple four-step plan that we have been using in 10-minute GP appointments for more than 15 years. It enhances the hope that people have for achieving their personal goals and hence their ability to make significant and lasting positive changes in their wellbeing and health. Specifically it is part of an approach that has helped us achieve drug-free remission for 57 people with type 2 diabetes, along with significant practice drug budget savings (Unwin and Unwin, 2014).

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Hyperinsulinemia in Obesity, Inflammation, and Cancer

Authors: Anni M.Y. Zhang, Elizabeth A. Wellberg, Janel L. Kopp, James D. Johnson

The relative insufficiency of insulin secretion and/or insulin action causes diabetes. However, obesity and type 2 diabetes mellitus can be associated with an absolute increase in circulating insulin, a state known as hyperinsulinemia. Studies are beginning to elucidate the cause-effect relationships between hyperinsulinemia and numerous consequences of metabolic dysfunctions. Here, we review recent evidence demonstrating that hyperinsulinemia may play a role in inflammation, aging and development of cancers. In this review, we will focus on the consequences and mechanisms of excess insulin production and action, placing recent findings that have challenged dogma in the context of the existing body of literature. Where relevant, we elaborate on the role of specific signal transduction components in the actions of insulin and consequences of chronic hyperinsulinemia. By discussing the involvement of hyperinsulinemia in various metabolic and other chronic diseases, we may identify more effective therapeutics or lifestyle interventions for preventing or treating obesity, diabetes and cancer. We also seek to identify pertinent questions that are ripe for future investigation.

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Insulin Resistance and Coronary Heart Disease in Nondiabetic Individuals

Authors: Gerald Reavan

The goal of this review was to summarize evidence supporting the view that insulin resistance/compensatory hyperinsulinemia play an important role in the pathogenesis of coronary heart disease (CHD) in nondiabetic individuals. Results of case–control and epidemiological studies in nondiabetic individuals will be reviewed to examine the link between insulin resistance/compensatory hyperinsulinemia, associated abnormalities, and CHD. The primary focus of the review will be on the central role that dyslipidemia plays in the link between insulin resistance/compensatory hyperinsulinemia and CHD. Additional issues to be addressed include the following: (1) the relationship among obesity, insulin resistance, and CHD; (2) a listing of other abnormalities that contribute to risk of CHD in insulin-resistant individuals; and (3) discussion of the importance of differential tissue insulin sensitivity in the development of abnormalities that increase CHD risk in insulin-resistant, nondiabetic individuals. The information will reflect the author’s decision as to what issues are believed to be of particular relevance or less well appreciated concerning the complex relationship between insulin resistance and CHD. Resistance to insulin-mediated glucose disposal and hyperinsulinemia is a common finding in apparently healthy individuals and is associated with a number of abnormalities that greatly increase risk of CHD.

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Metabolic Syndrome and Skin Diseases

Authors: Yu Hu, Yun Zhu, Ni Lian, Min Chen, Andrzej Bartke, Rong Yuan

The increasing prevalence of Metabolic syndrome (MetS) is a worldwide health problem, and the association between MetS and skin diseases has recently attracted growing attention. In this review, we summarize the associations between MetS and skin diseases, such as psoriasis, acne vulgaris, hidradenitis suppurativa, androgenetic alopecia, acanthosis nigricans, and atopic dermatitis. To discuss the potential common mechanisms underlying MetS and skin diseases, we focus on insulin signaling and insulin resistance, as well as chronic inflammation including adipokines and proinflammatory cytokines related to molecular mechanisms. A better understanding of the relationship between MetS and skin diseases contributes to early diagnosis and prevention, as well as providing clues for developing novel therapeutic strategies.

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Metabolic syndrome is associated with an increased risk of psoriasis: A nationwide population-based study

Authors: Ha-Na Kim, Kyungdo Han, Yong-Gyu Park, Ji Hyun Lee

Psoriasis is a chronic inflammatory skin disease characterized by an abnormal T-cell-mediated immune response, and is associated with metabolic syndrome (MetS) and components thereof. However, few prospective studies have investigated the associations between MetS and its components, on the one hand, and the risk of psoriasis, on the other. Therefore, we investigated the association between the presence of MetS and its components and the prospective risk of psoriasis development.

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The “discordant doppelganger dilemma”: SGLT2i mimics therapeutic carbohydrate restriction - food choice first over pharma?

Authors: Scott W. Murray, Sean McKelvey, Thomas D. Heseltine, George Henderson, Jagdeep Singh, David Unwin, Adrian J. B. Brady

Conclusions and recommendations: Where the Discordant Doppelganger Dilemma occurs in clinical practice is when the SGLT2i drugs are always chosen as first line, as per the latest ESC guidance. We then may potentially lose the chance to leverage diet and lifestyle changes first (TCR and VLED). The possible risk of hypoglycaemia or euglycaemic ketoacidosis exists when combining significant dietary change with SGLT2i. The physiology has been described as far as we know it earlier here and is constant and reproducible. The drugs work in highly controlled clinical trials but can have side effects and the lifestyle changes work in observational trials and specialist centres, but could be hard to maintain for everyone. So how can we get the drug-like outcomes, without financing or taking the drug? What is the right way to move forward when both can produce “mirror-like” results but they cannot therefore be combined? In a way we are lucky to have new options to improve the outlook for these patients but there remains a pertinent analogy: If we found out tomorrow that cancer could be prevented in 50% of people (or put into drug-free “remission”) by avoiding the ingestion of known substances, but at the same time an expensive drug could eliminate those substances from the body, what would be the best course of action for everybody? Taking this from a philosophical, moral, ethical, economic and human perspective? Should one avoid the known substances or keep ingesting the substances whilst concurrently eliminating them with the new “wonder” drug? Tight physiological glycaemic homoeostasis should be a human right but it has been somewhat hijacked by our need for food “rewards” and the vested interests of the processed food industrial complex. The sooner we return the power to individuals, in the form of continuous glucose monitoring and education on sensible dietary advice for a healthy life, the sooner we may stem the tsunami of morbidity and mortality associated with preventable cardiovascular disease.

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Triglycerides and Cardiovascular Disease. A Scientific Statement From the American Heart Association

Authors: Michael Miller, Neil J. Stone, Christie Ballantyne, Vera Bittner, Michael H. Criqui, Henry N. Ginsberg, Anne Carol Goldberg, William James Howard, Marc S. Jacobson, Penny M. Kris-Etherton, Terry A. Lennie, Moshe Levi, Theodore Mazzone, Subramanian Pennathur

Introduction: A long-standing association exists between elevated triglyceride levels and cardiovascular disease* (CVD).1,2 However, the extent to which triglycerides directly promote CVD or represent a biomarker of risk has been debated for 3 decades.3 To this end, 2 National Institutes of Health consensus conferences evaluated the evidentiary role of triglycerides in cardiovascular risk assessment and provided therapeutic recommendations for hypertriglyceridemic states.4,5 Since 1993, additional insights have been made vis-à-vis the atherogenicity of triglyceride-rich lipoproteins (TRLs; ie, chylomicrons and very low-density lipoproteins), genetic and metabolic regulators of triglyceride metabolism, and classification and treatment of hypertriglyceridemia. It is especially disconcerting that in the United States, mean triglyceride levels have risen since 1976, in concert with the growing epidemic of obesity, insulin resistance (IR), and type 2 diabetes mellitus (T2DM).6,7 In contrast, mean low-density lipoprotein cholesterol (LDL-C) levels have receded.7 Therefore, the purpose of this scientific statement is to update clinicians on the increasingly crucial role of triglycerides in the evaluation and management of CVD risk and highlight approaches aimed at minimizing the adverse public health–related consequences associated with hypertriglyceridemic states. This statement will complement recent American Heart Association scientific statements on childhood and adolescent obesity8 and dietary sugar intake9 by emphasizing effective lifestyle strategies designed to lower triglyceride levels and improve overall cardiometabolic health. It is not intended to serve as a specific guideline but will be of value to the Adult Treatment Panel IV (ATP IV) of the National Cholesterol Education Program, from which evidence-based guidelines will ensue. Topics to be addressed include epidemiology and CVD risk, ethnic and racial differences, metabolic determinants, genetic and family determinants, risk factor correlates, and effects related to nutrition, physical activity, and lipid medications.

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Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement

Authors: Ian J Neeland, Robert Ross, Jean-Pierre Després, Yuji Matsuzawa, Shizuya Yamashita, Iris Shai, Jaap Seidell, Paolo Magni, Raul D Santos, Benoit Arsenault, Ada Cuevas, Frank B Hu, Bruce Griffin, Alberto Zambon, Philip Barter, Jean-Charles Fruchart, Robert H Eckel

Findings from epidemiological studies over the past 30 years have shown that visceral adipose tissue, accurately measured by CT or MRI, is an independent risk marker of cardiovascular and metabolic morbidity and mortality. Emerging evidence also suggests that ectopic fat deposition, including hepatic and epicardial fat, might contribute to increased atherosclerosis and cardiometabolic risk. This joint position statement from the International Atherosclerosis Society and the International Chair on Cardiometabolic Risk Working Group on Visceral Obesity summarises the evidence for visceral adiposity and ectopic fat as emerging risk factors for type 2 diabetes, atherosclerosis, and cardiovascular disease, with a focus on practical recommendations for health professionals and future directions for research and clinical practice. We discuss the measurement of visceral and ectopic fat, pathophysiology and contribution to adverse health outcomes, response to treatment, and lessons from a public health programme targeting visceral and ectopic fat. We identify knowledge gaps and note the need to develop simple, clinically applicable tools to be able to monitor changes in visceral and ectopic fat over time. Finally, we recognise the need for public health messaging to focus on visceral and ectopic fat in addition to excess bodyweight to better combat the growing epidemic of obesity worldwide.

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Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity

Authors: Robert Ross, Ian J. Neeland, Shizuya Yamashita, Iris Shai, Jaap Seidell, Paolo Magni, Raul D. Santos, Benoit Arsenault, Ada Cuevas, Frank B. Hu, Bruce A. Griffin, Alberto Zambon, Philip Barter, Jean-Charles Fruchart, Robert H. Eckel, Yuji Matsuzawa, Jean-Pierre Després

Despite decades of unequivocal evidence that waist circumference provides both independent and additive information to BMI for predicting morbidity and risk of death, this measurement is not routinely obtained in clinical practice. This Consensus Statement proposes that measurements of waist circumference afford practitioners with an important opportunity to improve the management and health of patients. We argue that BMI alone is not sufficient to properly assess or manage the cardiometabolic risk associated with increased adiposity in adults and provide a thorough review of the evidence that will empower health practitioners and professional societies to routinely include waist circumference in the evaluation and management of patients with overweight or obesity. We recommend that decreases in waist circumference are a critically important treatment target for reducing adverse health risks for both men and women. Moreover, we describe evidence that clinically relevant reductions in waist circumference can be achieved by routine, moderate-intensity exercise and/or dietary interventions. We identify gaps in the knowledge, including the refinement of waist circumference threshold values for a given BMI category, to optimize obesity risk stratification across age, sex and ethnicity. We recommend that health professionals are trained to properly perform this simple measurement and consider it as an important ‘vital sign’ in clinical practice.

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Waist-to-Height Ratio Is More Predictive of Years of Life Lost than Body Mass Index

Authors: Margaret Ashwell, Les Mayhew, Jon Richardson, Ben Rickayzen

Conclusion: This study supports the simple message “Keep your waist circumference to less than half your height”. The use of WHtR in public health screening, with appropriate action, could help add years to life.

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UK Chief Medical Officers' Physical Activity Guidelines

Authors: A collaborative research paper

"In 2010, we were among the first Nations in the world to set out the evidence for how much and what kinds of physical activity we need to do to keep ourselves healthy. Since then, the evidence has become more compelling and the message is clear: "If physical activity were a drug, we would refer to it as a miracle cure, due to the great many illnesses it can prevent and help treat.” Physical activity is not just a health issue. It brings people together to enjoy shared activities and contributes to building strong communities whilst supporting the economy to grow. These physical activity guidelines update the 2011 guidelines across all age groups. We have also drawn on new evidence to develop additional guidance on being active during pregnancy and after giving birth, and for disabled adults. We want as many people as possible to make use of these guidelines to work towards and achieve the recommended activity levels. With that in mind, we have developed updated infographics to help bring these guidelines to life and make them easy for everyone to use. Being active every day provides a foundation for a healthier and happier life. The recommendations we made in 2011 on muscle strength have not achieved the recognition we believe they merit. We therefore want to underline the importance of regular strength and balance activities: being strong makes all movement easier and increases our ability to perform normal daily tasks. We want this report to be a catalyst for change in our attitudes to physical activity. Our environment can make it difficult to be healthy and our health is being damaged by inactivity. But the good news is that even small changes can make a big difference over time, such as using the stairs for a couple of floors rather than taking the lift or getting off the bus a stop early and walking the rest of the way. You always feel better for being active. We want as many people as possible to protect their future health and start their journey to a healthier life now. September 2019"

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Adapting diabetes medication for low carbohydrate management of type 2 diabetes: a practical guide

Authors: Campbell Murdoch, David Unwin, David Cavan, Mark Cucuzzella, Mahendra Patel

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.

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Effect of low-carbohydrate diets on cardiometabolic risk, insulin resistance, and metabolic syndrome

Authors: Blair J. O'Neill

"Purpose of review. An obesity epidemic has resulted in increasing prevalence of insulin resistance, hyperinsulinemia, metabolic syndrome (MetS), and cardiovascular disease (CVD). The Diet-Heart Hypothesis posited that dietary fat is the culprit. Yet dietary fat reduction has contributed to the problem, not resolved it. The role of hyperinsulinemia, the genesis of its atherogenic dyslipidemia and systemic inflammation in CVD and its reversal is reviewed. Recent findings. Overnutrition leads to weight gain and carbohydrate intolerance creating a vicious cycle of insulinresistance/hyperinsulinemia inhibiting fat utilization and encouraging fat storage leading to an atherogenic dyslipidemia characterized by hypertriglyceridemia, low HDL, and small dense LDL. The carbohydrate-insulin model better accounts for the pathogenesis of obesity, MetS, and ultimately type 2 diabetes (T2DM)and CVD. Ketogenic Diets reduce visceral obesity, increase insulin sensitivity, reverse the atherogenic dyslipidemia and the inflammatory biomarkers of overnutrition. Recent trials show very high adherence toketogenic diet for up to 2 years in individuals with T2DM, reversing their metabolic, inflammatory and dysglycemic biomarkers as well as the 10-year estimated atherosclerotic risk. Diabetes reversal occurred in over 50% and complete remission in nearly 8%. Summary. Therapeutic carbohydrate-restricted can prevent or reverse the components of MetS and T2DM."

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Fructose and hepatic insulin resistance

Authors: Samir Softic, Kimber L. Stanhope, Jeremie Boucher, Senad Divanovic, Miguel A. Lanaspa, Richard J. Johnson, C. Ronald Kahn

Excessive caloric intake in a form of high-fat diet (HFD) was long thought to be the major risk factor for development of obesity and its complications, such as fatty liver disease and insulin resistance. Recently, there has been a paradigm shift and more attention is attributed to the effects of sugar-sweetened beverages (SSBs) as one of the culprits of the obesity epidemic. In this review, we present the data invoking fructose intake with development of hepatic insulin resistance in human studies and discuss the pathways by which fructose impairs hepatic insulin action in experimental animal models. First, we described well-characterized pathways by which fructose metabolism indirectly leads to hepatic insulin resistance. These include unequivocal effects of fructose to promote de novo lipogenesis (DNL), impair fatty acid oxidation (FAO), induce endoplasmic reticulum (ER) stress and trigger hepatic inflammation. Additionally, we entertained the hypothesis that fructose can directly impede insulin signaling in the liver. This appears to be mediated by reduced insulin receptor and insulin receptor substrate 2 (IRS2) expression, increased protein-tyrosine phosphatase 1B (PTP1b) activity, whereas knockdown of ketohexokinase (KHK), the rate-limiting enzyme of fructose metabolism, increased insulin sensitivity. In summary, dietary fructose intake strongly promotes hepatic insulin resistance via complex interplay of several metabolic pathways, at least some of which are independent of increased weight gain and caloric intake. The current evidence shows that the fructose, but not glucose, component of dietary sugar drives metabolic complications and contradicts the notion that fructose is merely a source of palatable calories that leads to increased weight gain and insulin resistance.

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Fructose and metabolic health: governed by hepatic glycogen status?

Authors: Aaron Hengist, Francoise Koumanov, Javier T. Gonzalez

Fructose is a commonly ingested dietary sugar which has been implicated in playing a particularly harmful role in the development of metabolic disease. Fructose is primarily metabolised by the liver in humans, and increases rates of hepatic de novo lipogenesis. Fructose increases hepatic de novo lipogenesis via numerous mechanisms: by altering transcriptional and allosteric regulation, interfering with cellular energy sensing, and disrupting the balance between lipid synthesis and lipid oxidation. Hepatic de novo lipogenesis is also upregulated by the inability to synthesise glycogen, either when storage is inhibited in knock-down animal models or storage is saturated in glycogen storage disease. Considering that fructose has the capacity to upregulate hepatic glycogen storage, and replenish these stores more readily following glycogen depleting exercise, the idea that hepatic glycogen storage and hepatic de novo lipogenesis are linked is an attractive prospect. We propose that hepatic glycogen stores may be a key factor in determining the metabolic responses to fructose ingestion, and saturation of hepatic glycogen stores could exacerbate the negative metabolic effects of excessive fructose intake. Since physical activity potently modulates glycogen metabolism, this provides a rationale for considering nutrient–physical activity interactions in metabolic health.

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Intermittent fasting and weight loss

Authors: Stephanie Welton, Robert Minty, Teresa O’Driscoll, Hannah Willms, Denise Poirier, Sharen Madden, Len Kelly

Intermittent fasting shows promise for the treatment of obesity. To date, the studies have been small and of short duration. Longer-term research is needed to understand the sustainable role IF can play in weight loss.

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Low carbohydrate ketogenic therapy as a metabolic treatment for binge eating and ultraprocessed food addiction

Authors: Sethi Dalai S, Sinha A, Gearhardt AN

"Purpose of review. The aim of this study was to highlight the recent advancements and future directions for potential use of a low carbohydrate ketogenic dietary approach to treat binge eating and ultraprocessed food addiction. Herein, we explore proposed mechanisms of why a diet low in refined carbohydrates, processed sugar and higher fat content may be helpful in alleviating symptoms. Recent findings. Emerging evidence suggests there may be a metabolic role in development of maladaptive eating. These findings broaden our understanding of eating psychopathology causes. Ultraprocessed, refined or high glycemic index carbohydrates are a possible trigger mediating neurochemical responses similar to addiction. The carbohydrate-insulin model of obesity supports observations of these foods triggering abnormal blood sugar and insulin spikes subsequently leading to changes in metabolic and neurobiological signaling. This results in overeating symptoms and hunger exacerbation, which differs from observed effects of healthy fat consumption and lack of similar insulin spikes. As supported in recent case series, significantly reducing or abstaining from these addictive-like ultraprocessed foods and highly refined carbohydrates could be considered a treatment approach.Summary The current review highlights recent and pertinent evidence with respect to theoretical and practical application of low carbohydrate ketogenic therapeutic approaches for ultraprocessed food addiction and binge eating symptoms."

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Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report

Authors: Alison B. Evert, Michelle Dennison, Christopher D. Gardner, W. Timothy Garvey, Ka Hei Karen Lau, Janice MacLeod, Joanna Mitri, Raquel F. Pereira, Kelly Rawlings, Shamera Robinson, Laura Saslow, Sacha Uelmen, Patricia B. Urbanski, William S. Yancy Jr.

"This Consensus Report is intended to provide clinical professionals with evidence-based guidance about individualizing nutrition therapy for adults with diabetes or prediabetes. Strong evidence supports the efficacy and cost-effectiveness of nutrition therapy as a component of quality diabetes care, including its integration into the medical management of diabetes; therefore, it is important that all members of the health care team know and champion the benefits of nutrition therapy and key nutrition messages. Nutrition counseling that works toward improving or maintaining glycemic targets, achieving weight management goals, and improving cardiovascular risk factors (e.g., blood pressure, lipids, etc.) within individualized treatment goals is recommended for all adults with diabetes and prediabetes. Though it might simplify messaging, a “one-size-fits-all” eating plan is not evident for the prevention or management of diabetes, and it is an unrealistic expectation given the broad spectrum of people affected by diabetes and prediabetes, their cultural backgrounds, personal preferences, co-occurring conditions (often referred to as comorbidities), and socioeconomic settings in which they live. Research provides clarity on many food choices and eating patterns that can help people achieve health goals and quality of life. The American Diabetes Association (ADA) emphasizes that medical nutrition therapy (MNT) is fundamental in the overall diabetes management plan, and the need for MNT should be reassessed frequently by health care providers in collaboration with people with diabetes across the life span, with special attention during times of changing health status and life stages (1–3). This Consensus Report now includes information on prediabetes, and previous ADA nutrition position statements, the last of which was published in 2014 (4), did not. Unless otherwise noted, the research reviewed was limited to those studies conducted in adults diagnosed with prediabetes, type 1 diabetes, and/or type 2 diabetes. Nutrition therapy for children with diabetes or women with gestational diabetes mellitus is not addressed in this review but is covered in other ADA publications, specifically Standards of Medical Care in Diabetes"

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Saturated Fats and Health: A Reassessment and Proposal for Food-Based Recommendations: JACC State-of-the-Art Review

Authors: Arne Astrup, Faidon Magkos, Dennis M. Bier, J. Thomas Brenna, Marcia C. de Oliveira Otto, James O. Hill, Janet C. King, Andrew Mente, Jose M. Ordovas, Jeff S. Volek, Salim Yusuf, Ronald M. Krauss

The recommendation to limit dietary saturated fatty acid (SFA) intake has persisted despite mounting evidence to the contrary. Most recent meta-analyses of randomized trials and observational studies found no beneficial effects of reducing SFA intake on cardiovascular disease (CVD) and total mortality, and instead found protective effects against stroke. Although SFAs increase low-density lipoprotein (LDL) cholesterol, in most individuals, this is not due to increasing levels of small, dense LDL particles, but rather larger LDL particles, which are much less strongly related to CVD risk. It is also apparent that the health effects of foods cannot be predicted by their content in any nutrient group without considering the overall macronutrient distribution. Whole-fat dairy, unprocessed meat, and dark chocolate are SFA-rich foods with a complex matrix that are not associated with increased risk of CVD. The totality of available evidence does not support further limiting the intake of such foods.

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Scientific evidence underlying contraindications to the ketogenic diet: An update

Authors: Mikiko Watanabe, Dario Tuccinardi, Ilaria Ernesti, Sabrina Basciani, Stefania Mariani, Alfredo Genco, Silvia Manfrini, Carla Lubrano, Lucio Gnessi

First identified as a feasible treatment for intractable epilepsy, the ketogenic diet (KD) has recently gained popularity thanks to growing evidence on applications such as weight loss, most importantly, but also NAFLD, cancer, neurologic conditions and chronic pain. As with any treatment, whether pharmacologic or not, the KD might not be an appropriate intervention for every individual, and a number of contraindications have been proposed, now deeply rooted into clinical practice, excluding de facto many patients that could benefit from its use. However, many of these concerns were expressed due to the absence of clinical studies conducted on fragile populations, and an assessment of lately emerged evidence relative to KD safety is currently lacking and much needed. We herein provide a critical revision of the literature behind each safety alert, in order to guide through the treatment options in the case of subjects with an indication to the KD and a borderline safe situation. Based on available evidence, the possible use of this diet as a therapeutic intervention should be assessed on a patient-to-patient basis by adequately skilled medical doctors, keeping in mind current recommendations, but reading them through the knowledge of the current state of the art.

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The biochemistry of low-carbohydrate and ketogenic diets

Authors: Richard D. Feinman

"Purpose of reviewTo summarize the underlying biochemical basis for low-carbohydrate and ketogenic diets (LC/KD) and provide mechanisms to account for demonstrated effectiveness.Recent findings.LC/KD continue to have success, to outperform other diets as well as most drugs for weight loss and diabetes treatment. In many cases, LC/KD can effect remission (absence of drugs) or reversal (only metformin or nondiabetes drugs) of type 2 diabetes and can provide a significant adjunct to pharmacology in type 1. Medication is reduced or eliminated in most cases. The results are consistent with the biochemical rationale which stresses the global effects of the glucose-insulin axis. Summary. Evidence for the superior effectiveness of LC/KD for metabolic disease is now overwhelming. At the same time, the approach has received only limited support, and in many cases, persistence of the traditional opposition. Clinical practice or research must confront this crisis in order to bring practice in line with current science and to avoid continued harm to medicine and ultimately, the patient."

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The effects of low-carbohydrate diets on cardiovascular risk factors: A meta-analysis

Authors: Tingting Dong, Man Guo, Peiyue Zhang, Guogang Sun, Bo Chen

"Background.Low-carbohydrate diets are associated with cardiovascular risk factors; however, the results of different studies are inconsistent. Purpose The aim of this meta-analysis was to assess the relationship between low-carbohydrate diets and cardiovascular risk factors. MethodFour electronic databases (PubMed, Embase, Medline, and the Cochrane Library) were searched from their inception to November 2018. We collected data from 12 randomized trials on low-carbohydrate diets including total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, and blood pressure levels, as well as weight as the endpoints. The average difference (MD) was used as the index to measure the effect of a low-carbohydrate diet on cardiovascular risk factors with a fixed-effects model or random-effects model. The analysis was further stratified by factors that might affect the results of the intervention. Results From 1292 studies identified in the initial search results, 12 randomized studies were included in the final analysis, which showed that a low-carbohydrate diet was associated with a decrease in triglyceride levels of -0.15mmol/l (95% confidence interval -0.23 to -0.07). Low-carbohydrate diet interventions lasting less than 6 months were associated with a decrease of -0.23mmol/l (95% confidence interval -0.32 to -0.15), while those lasting 12–23 months were associated with a decrease of -0.17mmol/l (95% confidence interval -0.32 to -0.01). The change in the body weight in the observation groups was -1.58kg (95% confidence interval -1.58 to -0.75); with for less than 6 months of intervention,this change was -1.14 kg (95% confidence interval -1.65 to -0.63),and with for 6–11 months of intervention, this change was -1.73kg (95% confidence interval -2.7 to -0.76). The change in the systolic blood pressure of the observation group was -1.41mmHg (95% confidence interval—2.26 to -0.56); the change in diastolic blood pressure was -1.71mmHg (95% confidence interval—2.36 to -1.06); the change in plasma HDL-C levels was 0.1mmHg (95% confidence interval 0.08 to 0.12); and the change in serum total cholesterol was 0.13mmol/l (95% confidence interval 0.08 to 0.19). The plasma LDL-C level increased by 0.11mmol/l (95% confidence interval 0.02 to 0.19), and the fasting blood glucose level changed 0.03mmol/l (95% confidence interval -0.05 to 0.12),which was not significant.Conclusions This meta-analysis confirms that low-carbohydrate diets have a beneficial effect on cardiovascular risk factors but that the long-term effects on cardiovascular risk factors require further research."

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Ultraprocessed Food: Addictive, Toxic, and Ready for Regulation

Authors: Robert H. Lustig

Past public health crises (e.g., tobacco, alcohol, opioids, cholera, human immunodeficiency virus (HIV), lead, pollution, venereal disease, even coronavirus (COVID-19) have been met with interventions targeted both at the individual and all of society. While the healthcare community is very aware that the global pandemic of non-communicable diseases (NCDs) has its origins in our Western ultraprocessed food diet, society has been slow to initiate any interventions other than public education, which has been ineffective, in part due to food industry interference. This article provides the rationale for such public health interventions, by compiling the evidence that added sugar, and by proxy the ultraprocessed food category, meets the four criteria set by the public health community as necessary and sufficient for regulation—abuse, toxicity, ubiquity, and externalities (How does your consumption affect me?). To their credit, some countries have recently heeded this science and have instituted sugar taxation policies to help ameliorate NCDs within their borders. This article also supplies scientific counters to food industry talking points, and sample intervention strategies, in order to guide both scientists and policy makers in instituting further appropriate public health measures to quell this pandemic.

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Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion

Authors: Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E

The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.

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