When it comes to weight loss, low carb vs low fat diets are the most popular choices amongst dieters. In most cases, these diets tend to have similar goals. Both aim to make you leaner and healthier. However, there are major differences in the way they approach weight loss.

There are a lot of low-carb dietitians out there, and they all have their own interpretations on how to implement and maintain a low-carb lifestyle. One of the most common misconceptions is that low-carb dietitians are all alike, and there is no way to tell them apart. We want to show you what it takes to be a low-carb dietitian.

  1. Diabetes, obesity, and metabolism 2019: An evidence-based approach to developing low-carbohydrate diets for type 2 diabetes: a systematic review of interventions and methods [strong evidence].
  2. Nutrition Trials 2019: Effect of low-carbohydrate diets on low-density lipoprotein cholesterol levels in overweight and obese adults: systematic review and meta-analysis [strong evidence].
  3. Diabetes Research and Clinical Practice 2018: Effect of carbohydrate restriction on glycemic control in adults with diabetes: Systematic review and meta-analysis [strong evidence].
  4. European Journal of Clinical Nutrition 2017: Interpretation and effect of a low-carbohydrate diet in the treatment of type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials [strong evidence].
  5. BMJ Open Diabetes Research and Care 2017: Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes [strong evidence].
  6. British Journal of Nutrition 2016: Effect of low-carbohydrate and low-fat diets on body weight and cardiovascular risk factors: a meta-analysis of randomized controlled trials [strong evidence].
  7. PLoS One 2015: Dietary intervention for overweight and obese adults : A comparison of low-carb and low-fat diets. Meta-analysis [strong evidence].
  8. Obesity Reviews 2015: Does the ketogenic diet really suppress your appetite? Systematic review and meta-analysis [strong evidence].
  9. The British Journal of Nutrition 2013:Very low-carbohydrate ketogenic diet versus low-fat diet for long-term weight loss: a meta-analysis of randomized controlled trials [strong evidence].
  10. Obesity Reviews 2012: Systematic review and meta-analysis of clinical trials on the effects of low-carbohydrate diets on cardiovascular disease risk factors [strong evidence].

Also, ask your doctors and other health professionals (including dietitians) about our detailed guide for doctors who are skeptical of low-carb diets.

The American Diabetes Association’s path to a low-carb diet

Not too long ago, the American Diabetes Association (ADA) did not even recommend moderate carbohydrate restriction. For example, the 2005 standards of care for diabetes in medical nutrition therapy (MNT) state

A low-carb diet is not recommended for the treatment of diabetes. Although dietary carbohydrates contribute significantly to post-meal glucose levels, they are also an important source of energy, water-soluble vitamins and minerals, and fiber. Moreover, since the brain and central nervous system absolutely need glucose as an energy source, it is not advisable to limit the total amount of carbohydrates to less than 130 g per day.

But in 2011, based on the results of several studies, the ADA included the following statement in its standard care guidelines:

For short-term weight loss (up to two years), a low-carbohydrate, low-fat, low-calorie diet or a Mediterranean diet can be effective.

Then in 2012, at the request of the editors of ADA Diabetes Spectrum, I wrote an article on carbohydrate restriction for people with diabetes and prediabetes. It included a sample menu with 80 grams of net carbs and 55% of calories from fat, well above standard recommendations.

A year later, the ADA released a position statement on nutrition management in diabetes, written by several dietitians and other diabetes specialists, which included the following

  • Data on the ideal amount of carbohydrates for people with diabetes is inconclusive. Therefore, common goals should be developed together with the diabetic patient.
  • Several diets have been shown to be moderately effective in treating diabetes, including the Mediterranean style, dietary approaches to stop hypertension (DASH), plant-based diets (vegan or vegetarian), low-fat and low-carbohydrate diets.
  • Several diets are acceptable for the treatment of diabetes. Personal preferences and metabolic goals should be considered when recommending one diet over another.

At the time of publication of this article, I thought that these statements would enable nutritionists to think critically and make their clinical judgments when making dietary recommendations for diabetics and pre-diabetics – the vast majority of whom would benefit from a low-carbohydrate diet.

So I was pleased when the ADA went further in its 2019 consensus report (again written by diabetes experts, including several dietitians) and endorsed carbohydrate restriction as not only acceptable, but the most effective option for controlling blood sugar in people with diabetes:

  • Research shows that low-carb meal plans can improve blood sugar levels and potentially reduce the use of antihyperglycemic medications in people with type 2 diabetes.
  • Reducing total carbohydrate intake in people with diabetes has provided the most evidence for improving blood glucose levels. It can be used in different diets to meet individual needs and preferences.
  • Although the recommended carbohydrate intake for nondiabetic adults is 130 g/day and is determined in part by the glucose requirements of the brain, these energy requirements can be met by endogenous metabolic processes, including glycogenolysis, gluconeogenesis (via metabolism of the glycerol component of fats or gluconeogenic amino acids of proteins) and/or ketogenesis in the context of very low carbohydrate intake.

I understand how frustrating it can be to read negative reviews of low-carb and keto diets from your peers. However, the path taken by the ADA to approve carbohydrate restriction shows us that while it takes a while for nutritionists and health organizations to change their stance on a long-held nutritional belief, it does happen!

Potential consequences of low-carb practices

Consider the possible reaction of dietitians who are biased against low-carb diets. Several dietitians have told me personally that they have been reprimanded or lost their jobs because they practiced carbohydrate restriction on their patients.

The most notable case is that of Jennifer Elliott from New South Wales, Australia. After working as a dietitian for more than 30 years, Jennifer received a formal complaint from another dietitian objecting to her recommendation of a low-carbohydrate diet to patients with diabetes and metabolic syndrome. She was eventually written out by the Australian Dietetic Association and lost her job. To learn more about Jennifer’s story, click here.

To my knowledge, there are no other cases outside of Australia of dietitians whose degrees have been revoked due to the use of low-carb products.

Your clinical practice should always be evidence-based. Now that we have clear guidance from respected organisations like the American Diabetes Association and Diabetes UK (both of whom include RD in their guideline development groups) on the use of low-carbohydrate diets in the treatment of type 2 diabetes, this is very helpful.

Moreover, clinical research has shown that the low-carbohydrate approach is safe, effective and suitable for the treatment of conditions such as obesity and metabolic syndrome. Knowledge of the literature can help you in areas where there are no clinical guidelines. However, there may be no clear dietary recommendations or evidence for a particular aspect of the patient’s condition – for example, stage III renal disease or familial hypercholesterolemia.

In these cases, you need to know what the relevant medical institutions recommend on the subject and be sure that you have thought through your approach and can defend it with clinical scientific evidence. This entails both benefits and risks.

In some patients, for example, LDL cholesterol can rise significantly on a low-carb diet. The dietary approach you use to solve this problem must be justified based on published evidence. If you can’t defend your approach with published clinical studies, make sure you know what the consensus of the relevant medical authorities is to reassure you. This is important for your own protection.

Make sure to include a disclaimer for your practice

While including a disclaimer on your company’s website does not fully protect you from complaints, it is best to make it clear that your own nutritional recommendations differ from those of many major medical organizations.

Here’s a disclaimer I use on my website that can be adapted to the country you live in:

Although I am a healthcare professional, I am not a doctor and cannot diagnose or treat diabetes or other diseases; I can only provide nutritional advice and recommendations. Some of the dietary recommendations I make are not generally accepted as evidence-based practices and are not sponsored, approved, recommended, or endorsed by the U.S. Department of Agriculture (USDA), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the American Heart Association (AHA), or the Academy of Nutrition and Dietetics (AND). Always consult your doctor before switching to a low-carb diet or making other dietary changes.

Low-carb diets: a growing race

I believe that as dietitians, we can help people become healthier by making individualized recommendations based on the clinical needs and personal preferences of the patient. This includes eating nutrient-rich, minimally processed foods that are low in carbohydrates, both animal and plant-based. Fortunately, the number of people following or wishing to follow a low-carb diet is constantly increasing.

However, we must be diplomatic and respectful in our dealings with colleagues who do not yet share our views, in order to remain professional and protect ourselves from attack. As the experimental and anecdotal evidence for carbohydrate restriction accumulates, I am confident that more and more dietitians will see the importance of this approach as an alternative for patients and clients.

Email me at [email protected] if you are a dietitian interested in joining a private Facebook group of international low-carb dietitians.

Franziska Spritzler, RD

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