**4.2 Education of the patient**

Therapeutic carbohydrate restriction usually entails eating a diet rich in whole foods that have been minimally or traditionally processed. Although meal replacement shakes or kits can be used to administer this diet, we will focus on using whole foods readily available in most grocery stores in this course.

The three principles of therapeutic carbohydrate restriction are as follows:


Patients are encouraged to eat only when they are hungry and stop eating when they are satisfied. Because TCR makes patients feel fuller, they no longer need to eat on a regular 3-meal-per-day schedule and can instead rely on their hunger cues.

Based on their preference, your patients can be encouraged to eat meat, fish, poultry, eggs, above-ground vegetables, nuts, cheese, and fatty "fruits" like olives and avocados. They can also use olive oil, avocado oil, coconut oil, butter, and ghee as fat sources. Patients should avoid sugary foods that would be restricted on any weightloss diet, including cake, cookies, ice cream, and other desserts, as well as pancakes, potato chips, fries, and soda and other sweetened beverages. You should also teach your patients why and how to avoid foods that are commonly portrayed as healthy, such as whole-grain bread and cereals, rice, beans, pasta, low-fat milk and dairy products with added sugar, and a variety of fruits. Because these foods are broken down into glucose, they may have unfavorable effects on blood sugar and insulin levels in those who are susceptible. These foods should be avoided when using therapeutic carbohydrate restriction to treat obesity, metabolic syndrome, or diabetes.

This usually results in a diet where carbohydrates account for less than 10% of total calories, protein accounts for 20–25% of total calories, and fat accounts for more than 65% of total calories. However, because we rarely ask patients to track their calories during TCR, data based on percentages of total calories is usually useless.

Furthermore, rather than a macronutrient ratio, the levels at which carbohydrates and protein exert metabolic effects appear to reflect absolute thresholds in grams consumed (Accurso et al., 2008; Layman, 2009). Instead of focusing on macronutrient percentages when educating your patients, you should focus on making food choices that limit carbohydrate intake, provide adequate-protein, and allow enough fat for satiety and flavor.

#### **4.3 Low carbohydrate diet and medication changes**

The issues that should be considered when patients taking diabetic medications decide to start a low GI diet. Particular care should be taken with sulfonylureas due to the risk of hypoglycaemia and SGL T-2 inhibitors due to the risk of euglycaemic ketoacidosis. Insulin requirements will often drop, and the healthcare provider should supervise this. The following are the points to consider while using diabetic medications in type 2 when on a low carbohydrate diet [37].

• Risk for hypoglycemia?

