Therapeutic carbohydrate restriction: lifestyle treatment for obesity, diabetes and cardiovascular disease

Source: Jeleefstijlalsmedicijn

More and more scientific research confirms it: therapeutic carbohydrate restriction (TCR) is a powerful lifestyle intervention with proven benefits for metabolic health. Whether it concerns weight loss, type 2 diabetes or cardiovascular disease, the approach offers an effective way to address and even reverse chronic conditions. What exactly is TCR, how does it work and who is it suitable for? This article provides an overview of the scientific basis of TCR and discusses how the approach can be applied in practice for optimal health.

Author: Jaap Versfelt
Medical reviewer: Yvo Sijpkens, internist

Reading time: 6 minutes

1. What is therapeutic carbohydrate restriction?

Therapeutic carbohydrate restriction (TCR) is an effective scientifically-based lifestyle treatment aimed at improving metabolic health, primarily by limiting carbohydrate intake. The treatment is supported by the Society of Metabolic Health Practitioners, an international group of physicians and scientists. TCR is increasingly applied in chronic conditions such as obesity, type 2 diabetes and cardiovascular disease (Hite, 2024).

Within TCR, two levels are distinguished:

The degree of carbohydrate restriction is tailored to the patient’s health status and goals, and activity level. In patients with diabetes, TCR can reduce dependence on medications. It is important that patients are well supervised so that medication can be safely adjusted.

Moderate carbohydrate restriction (50-130 grams of carbohydrates per day)
Strong carbohydrate restriction (less than 50 grams of carbohydrates per day).

2. What is the background of therapeutic carbohydrate restriction?

The idea of carbohydrate restriction was already popularised in the 19th century by William Banting, who described the benefits of carbohydrate restriction for weight loss (Letter on Corpulence, 1864).

Later, Robert Atkins brought it back to attention. Modern scientists such as Stephen Phinney, Jeff Volek and Sarah Hallberg have demonstrated with groundbreaking studies that a low-carbohydrate, high-fat eating pattern can contribute to weight loss and diabetes remission.

3. How does therapeutic carbohydrate restriction work?

We consume carbohydrates mainly in two forms: sugar and starch. Sugars come from products such as biscuits, sweets, sauces, soft drinks and fruit. Starch is found in foods such as potatoes, bread, pasta, rice and legumes. In the body, carbohydrates are converted to glucose (blood sugar).

TCR influences fuel distribution in the body by reducing dependence on glucose and stimulating fat burning. With lower carbohydrate intake, blood sugar levels remain more stable and the secretion of the hormone insulin decreases, causing the body to start using fatty acids as an energy source.

When carbohydrate intake is strongly restricted (to less than 50 grams per day combined with fasting) and insulin resistance decreases, the body can gradually enter nutritional ketosis. In this process, the liver converts fatty acids into ketones. The ketones can serve as an alternative fuel for the brain and muscles.

Glucose remains necessary for some bodily processes. But if glucose is insufficiently available from food, the liver will produce the necessary glucose itself. The liver does this by producing glucose from amino acids and fatty acids. This process is called gluconeogenesis.

4. What can you use TCR for?

Scientific research provides support for the use of TCR in various conditions where metabolic dysregulation plays a role. The approach can be effective for the following health problems:

Obesity Carbohydrate restriction contributes to weight loss, especially in people with elevated insulin levels. It promotes fat burning and helps with weight management (Soltani, 2023).
Type 2 diabetes Studies show that TCR can help stabilise blood sugar levels. In research into this lifestyle intervention, 57 percent of participants achieved remission (HbA1c <6.5%) (Goldenberg, 2021).
Cardiovascular disease A low-carbohydrate eating pattern may possibly reduce the risk of cardiovascular disease, with favourable effects on lipid profiles and inflammatory markers (Chatzi, 2024).

In addition, the neurological and mental benefits of carbohydrate restriction are increasingly being researched. A well-documented example is epilepsy, where strong carbohydrate restriction (ketogenic diet) can reduce the number of seizures in children when medication has insufficient effect (Kossoff, 2018). Furthermore, studies are ongoing into the possible benefits of a ketogenic diet in conditions such as autism and ADHD.

5. What does therapeutic carbohydrate restriction consist of?

TCR focuses on a high intake of natural, unprocessed foods, with a balanced distribution of macronutrients:

Carbohydrates Intake is usually limited to less than 130 grams per day, with a more intensive variant going below 50 grams. The focus is on avoiding refined sugars, white flour and starchy products such as bread, rice and potatoes. Non-starchy vegetables such as leafy greens, broccoli and cauliflower can be eaten.
Proteins The recommended intake is 1.2 to 2 grams per kilogram of ideal body weight, depending on individual needs and activity level. Good sources are meat, fish, eggs and full-fat dairy products. Vegetarian options are tofu, tempeh and nuts such as almonds and pecans.
Fats These form the primary energy source in TCR. Healthy saturated and unsaturated fats from natural sources such as meat, fish, dairy, avocados, nuts, olive oil and coconut fat form the basis. Refined seed oils, such as sunflower oil, are best avoided.

6. Common challenges and how to address them

Although TCR offers many health benefits, some people may experience challenges in the initial phase:

Side effects Fatigue, dizziness and headache due to electrolyte loss occur in the initial phase. Extra salt intake and sufficient fluids help prevent this (Brands, 2012).
Constipation Can be remedied with fibre-rich, low-carbohydrate vegetables and sufficient water intake. Magnesium supplementation can also help.
Muscle cramps Muscle cramps are often a result of magnesium deficiency. Magnesium supplementation is then recommended.
Elevated LDL cholesterol In some people, especially lean and active individuals, LDL may rise. Initial studies show, however, that this is often accompanied by low triglycerides, high HDL cholesterol and a favourable change in LDL particle size, without signs of atherosclerosis (Budoff, 2024).

7. Maintaining TCR in the long term

Although TCR offers many benefits, maintaining it in the long term can be challenging due to social and environmental factors. Approximately 70 percent of food in supermarkets is ultra-processed and rich in rapidly absorbable carbohydrates, making healthy choices more difficult.

Stopping carbohydrate restriction often leads to the return of the original condition(s). This underscores that TCR is not a temporary intervention, but a structural lifestyle adjustment.

Scientific sources for this article

Banting, W. (1864). Letter on corpulence, addressed to the public. Harrison.
Brands, M. W., & Manhiani, M. M. (2012). Sodium-retaining effect of insulin in diabetes. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 303(11), R1101—R1109. https://doi.org/10.1152/ajpregu.00390.2012
Budoff, M., Manubolu, V. S., Kinninger, A., Norwitz, N. G., Feldman, D., Wood, T. R., Fialkow, J., Cury, R., Feldman, T., & Nasir, K. (2024). Carbohydrate restriction-induced elevations in LDL-cholesterol and atherosclerosis: The KETO trial. JACC Advances, 3(8), 101109. https://doi.org/10.1016/j.jacadv.2024.101109
Chatzi, C. A., Basios, A., Markozannes, G., Ntzani, E. E., Tsilidis, K. K., Kazakos, K., Agouridis, A. P., Barkas, F., Pappa, M., Katsiki, N., & Rizos, E. C. (2024). Effect of different dietary patterns on cardiometabolic risk factors: An umbrella review of systematic reviews and meta-analyses. Nutrients, 16(22), 3873. https://doi.org/10.3390/nu16223873
Goldenberg, J. Z., Day, A., Brinkworth, G. D., Sato, J., Yamada, S., Jonsson, T., Beardsley, J., Johnson, J. A., Thabane, L., & Johnston, B. C. (2021). Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: Systematic review and meta-analysis of published and unpublished randomized trial data. BMJ, 372, m4743. https://doi.org/10.1136/bmj.m4743
Hite, A. (Coordinator). (2024). Clinical guidelines — General intervention (Version 1.3.9). Society of Metabolic Health Practitioners. https://thesmhp.org/clinical-guidelines/
Kossoff, E. H., Zupec-Kania, B. A., Auvin, S., Ballaban-Gil, K. R., Bergqvist, A. G. C., Blackford, R., Buchhalter, J. R., et al. (2018). Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open, 3(2), 175—192. https://doi.org/10.1002/epi4.12225
Soltani, S., Jayedi, A., Abdollahi, S., Ahmadi Vasmehjani, A., Meshkini, F., & Shab-Bidar, S. (2023). Effect of carbohydrate restriction on body weight in overweight and obese adults: A systematic review and dose—response meta-analysis of 110 randomized controlled trials. Frontiers in Nutrition, 10, 1287987. https://doi.org/10.3389/fnut.2023.1287987

Veelgestelde vragen

What are the health benefits of carbohydrate restriction?

Therapeutic carbohydrate restriction (TCR) offers various health benefits, including weight loss, improved blood sugar regulation, reduced insulin resistance, favourable effects on lipid profiles and inflammatory markers in cardiovascular disease. There are also indications for neurological benefits in conditions such as epilepsy, and effects in autism and ADHD are being researched.

Can a low-carbohydrate diet help with type 2 diabetes?

Yes, scientific studies show that therapeutic carbohydrate restriction (TCR) can be effective for type 2 diabetes. It helps stabilise blood sugar levels and in research 57% of participants achieved remission (HbA1c <6.5%). TCR can also reduce dependence on diabetes medication, with good medical supervision being essential. Such results are also evident from dozens of other studies.

How does therapeutic carbohydrate restriction work in the body?

TCR works by reducing dependence on glucose and stimulating fat burning. With lower carbohydrate intake, blood sugar levels remain more stable, insulin secretion decreases and the body starts using fatty acids as an energy source. With strong restriction (<50g per day), the body can enter nutritional ketosis, where the liver produces ketones as alternative fuel for brain and muscles. For essential processes, the liver produces glucose itself via gluconeogenesis.

What are possible disadvantages and side effects of a keto diet?

In the initial phase, side effects may occur such as fatigue, dizziness and headache due to electrolyte loss (solvable with extra salt intake and sufficient fluids). Other challenges are constipation (solvable with fibre-rich vegetables and water), muscle cramps (often due to magnesium deficiency) and in some people elevated LDL cholesterol (often accompanied by favourable changes in other cholesterol values).

How effective is weight loss with a low-carbohydrate diet?

Carbohydrate restriction is effective for weight loss, especially in people with elevated insulin levels. Due to reduced insulin secretion, fat burning is stimulated which contributes to weight management. Scientific research such as that by Soltani (2023) confirms the effectiveness of TCR for weight loss in obesity.

What can I eat on a TCR meal plan?

A TCR meal plan consists of natural, unprocessed foods with emphasis on: 1) Limited carbohydrates (usually <130g per day, or <50g for the strong variant), mainly non-starchy vegetables such as leafy greens and broccoli; 2) Proteins (1.2-2g per kg ideal body weight) from meat, fish, eggs, dairy or plant sources such as tofu and nuts; 3) Healthy fats as primary energy source from meat, fish, dairy, avocados, nuts, olive oil and coconut fat. Avoid refined sugars.

Does carbohydrate restriction affect cardiovascular disease?

Yes, a low-carbohydrate eating pattern may possibly reduce the risk of cardiovascular disease. In a very extensive study (which included 25 meta-analyses each with multiple RCTs), a carbohydrate-restricted diet appears to have the greatest effect of all diets studied on risk factors for cardiovascular disease (Chatzi, 2024). Although LDL cholesterol may rise in some people, this is often accompanied by low triglycerides, high HDL cholesterol and a favourable change in LDL particle size.

How many carbohydrates can I eat to get into ketosis?

To get into nutritional ketosis, carbohydrate intake must be strongly restricted to less than 50 grams per day. At this low intake, combined with decreasing insulin resistance, the liver converts fatty acids into ketones that serve as alternative fuel for brain and muscles. The exact amount can vary per person, depending on individual factors such as metabolism and activity level.

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