Why ‘Therapeutic Carbohydrate Restriction’ (or ‘Reduction’) May Communicate the Message Better than ‘Keto’ or ‘Low Carb’
Adele Hite, PhD, MHP, RDN, weighs in on the importance of the words being used to define the low-carb space
We’ve recently seen a noticeable increase in the use of the terms therapeutic carbohydrate restriction and therapeutic carbohydrate reduction (both abbreviated with the letters TCR), to describe the low carb way of eating, particularly when they are used in the clinical setting to address a wide variety of health issues.
As the Society of Metabolic Health Practitioners (SMHP) works to improve metabolic health around the world through education, training, and support of evidence-based nutritional approaches, one important objective has been to ensure that therapeutic carbohydrate restriction (or reduction) is seen as a valid therapeutic option or intervention.
“What we need to do is lower the barriers to admission to this community,” said Adele Hite, PhD, MPH, RDN, at a Standard of Care Feedback Session at the 2018 Low Carb San Diego Conference.
Part of the process of lowering the barriers involves using words that properly convey the intended message, and no one has invested more time in crafting the messaging around this topic than Adele, who earned her PhD in rhetoric, communication, and digital media. It was during that session in 2018 that the groundwork was laid for the Clinical Guidelines for Therapeutic Carbohydrate Restriction.
“We need to make it really easy for clinicians of every type—physicians, nurses, pharmacists, dietitians, nutritionists and others—to enter this community and to be able to offer carbohydrate restriction to patients as a therapeutic option,” Adele said. “Every person who comes into our offices with a metabolic condition, or other condition that can be addressed through the reduction of carbohydrates should be given this intervention (as an option).”
Joining Adele on the stage for that feedback session was Gary Taubes, the bestselling author of The Case for Keto (2020), The Case Against Sugar (2016), Why We Get Fat and What to Do About It (2011) and Good Calories, Bad Calories (2007). It was Taubes who had convinced Doug Reynolds, founder of both LowCarbUSA and the SMHP, to contact Adele to take on the endeavor of the feedback session in the first place.
What ultimately came out of that session, after countless hours of work over the next 10 months was the Clinical Guidelines document, a 20-page document containing carefully selected language designed to provide clinicians with a general protocol for implementing therapeutic carbohydrate restriction as a dietary intervention in hospitals or clinics.
The Guidelines were announced and formally published on the LowCarbUSA® site during the Low Carb Seattle Conference in May, 2019, and they have been embraced by the low carb medical community ever since. Management of the Guidelines was taken over by the SMHP when the non-profit professional organization launched in December 2020.
The usage of the term therapeutic carbohydrate restriction (and reduction) has been growing ever since, and the usage has frequently led to questions, both from practitioners and from individuals who have an interest in the low carb lifestyle.
So why the shift away from commonly used words like keto and low carb, and which is correct—therapeutic carbohydrate reduction or therapeutic carbohydrate restriction?
“First of all, the word keto as it’s used commonly doesn’t mean a thing.” said Adele. “It’s like the word paleo. It means what you want it to mean. People talk about the right keto macros, and the wrong keto macros, but according to what governing body? We want to give clinicians something to say besides keto or low carb, because we recognize the problems with those terms. Keto is undefined, and low carb is only relatively defined.”
Adele explained that by highlighting that this is a therapeutic approach, we are indicating that we’re talking about an intervention.
“This is not a diet like the cabbage soup diet,” she explained. “In the world of dietetics, we are taught what’s called medical nutrition therapy. When we talk about therapeutic carbohydrate restriction or reduction, we’re talking about medical nutrition therapy.”
Adele said the word “reduction” is often preferred over “restriction” by dieticians, especially those working with those with eating disorders.
“Restricting categories of food, or types of food can be really triggering for some,” said Adele, “so the word reduction can be more suitable in those situations.”
“We know from the Ancel Keys starvation experiments that when you take something away from people and they feel deprived, that can really focus their attention on what it is they can’t have. So in some circumstances, it would be better just to use the word reduction.”
Adele also explained that in some situations, an effective intervention could involve simply reducing carbohydrates from, say, 300 grams per day to 150, which is not what one typically thinks of when they hear the words carbohydrate restriction.
“The whole idea is that both options can be used,” she explained. “This is part of the beauty of the flexibility of the acronym, TCR. Some people need restriction. Some people need reduction.”
Adele emphasized that the word therapy or therapeutic is used to distinguish medical nutrition therapy from public health nutrition.
TCR, she explained, is an intervention that is applied in a clinical setting, and should not be confused with generic preventive guidelines that might be applied to an entire population.
“You take a specific therapy, an intervention, not unlike a prescription medication or a surgical intervention, and you apply this intervention. In this case, it’s a nutritional intervention to a specific condition. That is very different from saying everybody should be doing this thing. And I am adamant about separating these things, because this is how we got in the mess with the Dietary Guidelines in the first place.”
Adele is critical of what has transpired over the years with the Dietary Guidelines, where a therapeutic intervention meant for people with specific risk factors for heart disease was extrapolated to the general public.
“That was inappropriate, and I think it’s also inappropriate in terms of carbohydrate reduction or restriction. Some people benefit from it. Other people are fine doing what they’re doing. Why interfere with that? So I think the therapeutic part is very important, because it does give us a clinical standing and specifically separates us from a public health preventive guideline.”
Adele explained her entire PhD program was about how to get one’s audience to use words in the way that you want them to be used, and how it’s difficult, if not impossible to force others to change how they use the words that are already being used.
“You’re not going to get the folks at Harvard, to stop calling diets with 45% carbohydrates, low carb diets,” Adele said, “but if we create our own space, carve out our own rhetorical space for therapeutic carbohydrate restriction, or reduction, they can’t come in and use that term inappropriately.”
For those looking to learn even more, Adele went into great detail about the importance of the words we use and how we use them, at the 2020 Low Carb USA Boca Conference during a presentation entitled Clinical Protocols and Standards of Care for Therapeutic Carbohydrate Restriction.
The Clinical Guidelines for Therapeutic Carbohydrate Restriction, provides clinicians with a general protocol for implementing therapeutic carbohydrate restriction as a dietary intervention in hospitals or clinics.
With the creation of the SMHP, the expectation is that the guidelines will continue to be refined, and work is now underway to create condition-specific addenda that will provide practitioners with protocols for type 2 diabetes, Type 1 diabetes, cancer and other conditions such as cardiovascular disease, neurological disorders, and other chronic diseases.
In an article written last December, Adele said “My big dream is for a clinical protocol to be written around type 2 diabetes, that does all of the things and has the same principles as we have in the general protocol,” said Adele. “It’s not a prescription that’s hard and fast, but rather a way of fitting a diet to a patient in a way that the patient can be successful.”
The expectation is that these guidelines will serve to bring practitioners together and lead to establishing Standard of Care around carbohydrate restriction.
The first principles of the Clinical Guidelines for Therapeutic Carbohydrate Restriction are as follows:
- Carbohydrate restriction is an effective clinical intervention that clinicians may use to help patients achieve therapeutic goals for specific conditions to be designated in “condition-specific protocols.”
- Carbohydrate restriction targets specific conditions and patient populations. Carbohydrate reduction is not a “cure all,” nor is it an appropriate intervention for all individuals.
- Carbohydrate restriction should be tailored to the individual patient. It is not a “one-size-fits-all” approach to care. Clinicians should adapt carbohydrate-restricted dietary interventions to the specific needs and health goals of their patients, in keeping with their own expertise, experience, and clinical judgment.
- When patients choose carbohydrate restriction as a therapeutic intervention, it is the responsibility of clinicians to provide the close monitoring and support needed to do so safely. Rapid physiologic changes can be expected, and medication management must be timely to avoid predictable interactions between these changes and common medications.
When one reads through the Clinical Guidelines, it quickly becomes apparent that there exists a wide chasm between therapeutic carbohydrate restriction and a word like “keto”, which, according to Adele “…simply has not been defined clinically, anywhere in the literature that I’m aware of. It happens to just be a word that’s easy to type into Google and search for, and it’s fun to say.”
Adele explained while there is no generally accepted definition of “keto”, there is an accepted definition for the “ketogenic diet”, which is specifically for neurological conditions.
“This is why a lot of dietitians get freaked out when they hear that people with diabetes are trying to lose weight using a ‘keto diet’. They think, why are you using a medical nutrition therapy specifically designed for epilepsy or some other neurological condition to lose weight?”
The word ‘keto’ is great for marketing, according to Adele, but she envisions a future where we do a better job of communicating.
“I can walk into any store and find a dozen things or more on the shelf that have the word ‘keto’ on them. But what does it mean? It doesn’t mean a damn thing. It’s marketing. You have to sidestep that, and I feel like that’s what we are trying to do with therapeutic carbohydrate restriction. We’ll let the keto people do their keto thing.”
Learn more about the Society of Metabolic Health Practitioners:
- Join the SMHP and support the organizational efforts, participate in ongoing education, and join in discussion forums.
- Learn about the SMHP’s Metabolic Health Practitioner (MHP) accreditation process.
- Sign up for your free listing on the SMHP Practitioner Directory so that patients needing support can find you.
- Search for a practitioner or colleague using the SMHP Practitioner Directory.
- Read, download, share, and add your name to the list of supporters of the Clinical Guidelines.
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Thank you very much to Chris fir introducing the notions advanced by Adele Hite about the proper nomenclature of therapeutic carbohydrate reduction. It is a very powerful point to coin a terminology that is not only correct but offering a semantic bridge to many health professionals that do not make out the sense of what the word keto intends to convey. I would add, though, that given the fact that carbohydrate intolerance is so idiosyncratic and dependent on the quality and degree of insulin resistance, perhaps we should think about the terminology therapeutic carbohydrate calibration to incorporate the notion of individualized approach and the need to put in context nutrition, movement, sleep hygiene and de-prescribing of anti diabetic medication. Health practitioners diagnose and prescribe therapeutic carbohydrate reduction/restriction while other metabolic health practitioners support people in how to achieve results smoothly. I would also add that other than therapeutic interventions, there are individuals that seek carbohydrate restriction/reduction for general wellness aiming at healthy weight management, increased stamina, increased self-stem, and other wellness objectives which are not sharply focused on treating a health condition but rather oriented to better health and wellness. That audience may not identify readily with the notion of a therapeutic intervention. Metabolic calibration?
What a thoughtful comment! And I see your point that are health and wellness audience may not identify with the term therapeutic. In cases where we are proposing an alternative to the current standard of care then I think we need to retain “therapeutic.” When we’re talking about the enormous opportunities in improving metabolic health and wellness then “calibration” (or “recalibration”) seems like a great fit because we could apply that to so much more than carbohydrates. Look at the lasting impact of Dale Ornish’s work. A lifestyle program that achieved better results, not because the diet was ideal but instead because he built a community around it. It might help us to create a Venn diagram or an infographic that illustrates this.
The terms ‘low carb’ and ‘keto’ are laymen’s terms and help people to identify this way of eating when seeking dietary management. Educating the patient then involves explaining the difference between ‘low carbohydrate’ – LCHF and ‘very low carbohydrate’ – VLCHF approaches.
LCHF was previously referred to as ‘low carb high fat’ and PhD Dietitian Caryn Zinn from Auckland University initiated an important change years ago to ‘low carb healthy fat’. Researchers also use the terms LCHF and VLCHF.
There is nothing to stop people who are currently applying the term ‘low carb’ to a 45% carb ratio to do the same with TCR. This is not an appropriate reason to change the language. There is nothing wrong with the language.
Low carb or very low carb healthy fats describes this dietary approach perfectly. I believe ‘therapeutic carbohydrate restriction’ is a step down from that. It is less descriptive and completely ignores the fact that focusing on healthy fats is of equal importance. It should remain part of our message, and part of the dialogue.
Those of us who use these dietary approaches consider low carb intake to be over 50 g and under 130 g of carbohydrate. This isn’t technically correct as there are people who can tolerate higher carb and remain in ketosis, particularly with longer term use and optimal metabolic health. Very low carbohydrate approaches are not as easy to define, as the amount of carbohydrate it takes to enter ketosis is an individual approach and differs according to metabolic health and other factors. VLCHF should be described as ‘the amount of carbohydrate reduction required to induce ketone production and nutritional ketosis, as measured by urine, breath or blood’ (many studies fail to test for ketosis which is a fundamental flaw).
In case I haven’t made myself clear – I am apposed to this proposed change.