Glycative Stress Research
Online edition : ISSN 2188-3610
Print edition : ISSN 2188-3602
Received : August 26, 2016
Accepted : October 7, 2016
Published online : December 31, 2016

Original article

Low Carbohydrate Diet (LCD):Long and short-term effects and hyperketonemia
Hiroshi Bando 1), Koji Ebe 2), Takumi Nakamura 3), Masahiro Bando 4), Yoshikazu Yonei 5)1) Tokushima University / Kitajima Taoka Hospital, Tokushima, Japan
2) Takao Hospital, Kyoto, Japan
3) Nakamura Orthopedic Clinic and Anti-Aging Center, Kawanishi, Hyogo, Japan
4) Department of Nutrition and Metabolism, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
5) Anti-Aging Medical Research Center, Graduate School of Life and Medical Sciences, Doshisha University, Kyoto, Japan

Abstract

Background: Discussion has continued concerning calorie restriction (CR) and low carbohydrate diet (LCD). LCD wasdeveloped by Bernstein, Atkins and others, and by our co-authors in Japan. In this study, we report and discuss long-term
effects in 2,699 cases, and short-term effects and hyperketonemia in 51 cases.
Subjects and Methods: Study 1 (long-term): Subjects were 2,699 cases with diabetes, metabolic syndrome, or both. Methods
included continuing LCD and measuring weight reduction in six to twelve months. Study 2 (short-term): Twenty-four
diabetics were compared on a CR diet (1,400 kcal/day, carbo-60 %) and a super-LCD (1,400 kcal/day, carbo-12%). We
recently tried insulinogenic index-carbo70 (IGI-carbo70) from glucose and immunoreactive insulin (IRI; 0, 30 min) for ameal of carbohydrates of 70 g. Study 3 (hyperketonemia): Blood ketone bodies and 3-hydroxybutylic acid (3-OHBA) were
measured in 51 diabetics with super-LCDs.
Results: Study 1: Weight reduction of more than 10 % was observed in 25.6 % of subjects, and more than 2.5 % was
observed in 78.8% of subjects. Study 2: Base data included HbA1c 7.7 ± 1.4 %, homeostasis model assessment (HOMA)-R 3.2± 1.9, and HOMA-β 44.5 ± 37.0. Responses of blood glucose to meals (0-120 min) were 156 → 236 mg/dL to CR and 116→ 141 mg/dL to LCD for ten days. Triglyceride value decreased from 143.4 ± 86.8 mg/dL to 93.9 ± 34.8 mg/dL on LCD
for ten days. IGI-carbo70 showed less than 0.5 in 75% of cases. Study3: Total ketone bodies were measured in four groups,
which were A (4 to 5 days), B (7 to 9 days), C (11 to 13 days), D (21 to 28 days), with an average value of 994 μmol/mL in
C, 36 to 623 μmol/mL in A, B, and D. As 3-OHBA value increases from normal (< 85 μmol/mL) to extremely high (3,577
μmol/mL), the ratio increases from 60 % - 70 % up to 90 %.
Conclusion: Long-term effects of LCD would be successful. Short-term effects revealed that the change from CR to LCD
in only ten days caused a significant decrease of blood glucose and triglycerides. Similar to the 75 g oral glucose tolerance
test (OGTT), intake of a meal with carbohydrates of 70 g would be clinically simple and useful as insulinogenic index(IGI)-carbo70. Super-LCD would increase blood ketone bodies about three fold of the standard level in four to five days.
These findings would be the fundamental data in the LCD area and contribute the research of glycative changes.

KEY WORDS: low carbohydrate diet (LCD), ketone bodies, 3-hydroxybutylic acid (3-OHBA),
HOMA-R, HOMA-β, diabetes mellitus

Corresponding to: Hiroshi Bando, MD, PhD
Tokushima University / Kitajima Taoka Hospital
Address: 1-61 Nakashowa, Tokushima 770-0943 Japan
TEL: +81-90-3187-2485 E-mail: pianomed@bronze.ocn.ne.jp
Co-authors: Ebe K, koji.ebe@gmail.com ;Nakamura T, takumi-e@sb3.so-net.ne.jp ;Bando M, b_moppy@hotmail.com ;Yonei Y, yyonei@mail.doshisha.ac.jp_ 193 _

Glycative Stress Research 2016; 3 (4): 193- 204(c) Society for Glycative Stress Research

Low Carbohydrate Diet : Long-Short-Effects/Hyperketonemia

Introduction

Metabolic syndrome such as obesity and diabetes mellitus
has recently increased, and Calorie Restriction (CR) and low
carbohydrate diets (LCD) have been noted in medical andhealth fields. In Europe and the United States, Bernstein,
Atkins and others 1, 2) have developed LCD, which has been
wide spread 3-8).
In Japan, the coauthors have successfully treatedthousands of patients with obesity, metabolic syndrome andother diseases 9-12). Ebe K first started in Japan in 1999 withmany books, and Bando H developed this movement withmedical presentations. We have developed a clinical study
and research of LCD 13).
From our clinical experiences, we report 1) long-term
effects of LCD on 2,699 cases, 2) short-term effects of
LCD, and 3) hyperketonemia due to LCD. This report would
contribute the pathophysiological role of ketone bodies
and glucose to glycative changes in patients with diabetes
mellitus and obesity.

Subjects and Methods

Study 1: Long effects of LCD

The subjects included 2,699 cases which were obese
patients associated with diabetes, metabolic syndrome, orboth. Methods included the treatment of a low carbohydrate
diet for the patients, and we compared body weight before
and after treatment; about six to twelve months at a stableweight.

Study 2: Short-term effects of LCD

Subjects included 24 patients with diabetes mellitus.
Ten were male, 14 female; with an average age of 61.6 ± 9.7
years, median of 62.5 years, and a range of 40 to 78 years.
They were admitted for further evaluation and treatment
for 12 to 14 days, in which they had the same protocol for
endocrine and metabolic examination. As for diet therapy,
they were on a conventional calorie restriction (CR) fromzero to two days, and a low carbohydrate diet (LCD) fromthree to 14 days. The former (CR) had 1,400 kcal/day, a 60
% calorie ratio from carbohydrates, with a breakfast of 450
kcal, 70 g of carbohydrates. The latter (LCD) (super LCD
formula by Ebe) had 1,400 kcal/day, (breakfast 400 kcal,
lunch 450 kcal, supper 550 kcal), a 12% calorie ratio fromcarbohydrates, with a breakfast of 400 kcal, and 12 g ofcarbohydrates.
1) On admission, the patients had fundamental tests including
blood glucose, HbA1c, immunoreactive insulin (IRI) andtriglyceride (TG) associated with calculating a homeostasis
model assessment (HOMA)-R and HOMA-β, and hadmeasured TG value on day 12.
2) Blood glucose (0, 30, 120 min.)and IRI values (0, 30 min)for breakfast on CR (day 2), and glucose values (0, 120 min)for breakfast on LCD (day 12) were investigated. We calculated
the increment of IRI (0 to 30 min)/increment of glucose (0 30min) for insulinogenic index-carbo70 (IGI-carbo70).

3) The concentration and components of blood ketone
bodies were measured at four to five days (group A), sevento nine days (group B) and 11 to 13 days (group C). These
data were inserted into Study 3.

Study 3: Elevated ketone bodies on LCD

We included 51 subjects with continuing LCD treatment.
Twenty-one were male, 30 female, the average age was 59.5
± 9.6 years, median age of 61.5 years, and a range of 34
to 78 years. They had continued super-LCD meals, which
include 12% of carbohydrates in calories.
As ketone bodies, 3-hydroxybutylic acid (3-OHBA,
β-hydroxybutylic acid) and acetoacetic acid ( AcAc,
acetoacetate) values were measured. In a clinical setting,a ketone bodies usually meant the value of 3-OHBA, andits standard range of 3-OHBA was less than 85 μmol/mL.
The cases were classified into four groups according to thecontinuing days for LCD, in which group A was for four tofive days, group B was for seven to nine days, group C wasfor 11 to 13 days and group D was 21 to 28 days. .

Statistical analysis

Data were shown as the mean ± standard deviation. As
for the analysis of two groups, a t-test and Mann-Whitney
U-test were used, and the Spearman method was adopted
from the correlation of ketone body study. We used JMP(Version 8) statistical analysis software (JMP Japan Divisionof SAS Institute Japan Ltd., Minato-ku, Tokyo, Japan) andthe Microsoft Excel analytical tool with a four step method.
A significance level of less than 5% was obtained using thetwo-tailed test and was considered to indicate a significant
difference.

Ethical considerations

The present study was conducted in compliance withthe ethical principles of the Declaration of Helsinki andJapan’s Act on the Protection of Personal Information,
and with reference to the Ministerial Ordinance on Good
Clinical Practice (GCP) for Drug (Ordinance of Ministry of
Health and Welfare No. 28 of March 27, 1997). No ethics
committee meeting was held. We obtained the informed
consent from subjects concerning this questionnaire.

Results

Study1 showed the weight reduction rate in 2,699 cases,in which 567 subjects (21.2%) had weight reduction of 2.5%
to 4.9%, 854 (32.0%) reduced 5.0% to 9.9%, 683 (25.6%) reduced 10% and more than 10% ( Fig. 1 ). Thus, 2,104
subjects (78.8%) showed weight reduction of 2.5% andmore than 2.5%.
Study2 showed the following data.
1) Fundamental data on admission is in Table 1, and the dataof HOMA-R and HOMA-β are in Fig. 2, in which 18, andsix cases in 24 cases, respectively, showed ranges outside of
the normal ranges.

_ 19 4 _Glycative Stress Research

2) Blood glucose values of zero and 120 min on day two(CR) and day12 (LCD) were shown in Fig. 3, in which thevalue of the latter was decreased from the former.
Serum levels of triglyceride (TG) were measured on
day two with CR, and day 12 with LCD, and showed 143.4± 86.8 mg/dL, and 110.3 ± 69.3 mg/dL, respectively, with asignificant difference (p< 0.05, n = 22) ( Fig. 4 ). These data
were calculated without two cases with extremely high TG
values on day two.
3) The values of blood glucose and IRI (0, 30 min) wereincreased in response to breakfast of CR including 70 gof carbohydrate ( Fig. 5 ). Simultaneously, we have recently
tried to calculate for insulinogenic index (IGI) for 70 g ofcarbohydrates, similar to the 75 g oral glucose tolerance test
(OGTT) and the insulinogenic index ( Fig. 6 ). They showed
less than 0.5 in 75% of the cases.
4) Several correlations among multiple markers were shownin Fig. 7. HbA1c values had a significant negative correlation(N)with HOMA-β, and not a significant correlation with HOMA-R(Figs. 7a, b). IRI values had a significant negative correlation
with fasting glucose, and a positive correlation with HOMA-β(Figs. 7c, d ). IRI increments for 70 g of carbohydrates showedsignificant positive correlation with HOMA-β, and not asignificant correlation with HOMA-R (Figs. 7e, f ). In contrast,
the IRI value in 30 minutes had a significant correlation
with both HOMA-R and HOMA-β ( Figs. 7g, h).
As for Study3, the value of blood ketone bodies (3-OHBA+ AcAc) in 51 cases on LCD is shown in Fig. 8. In fourgroups, cases with extremely high values were observed ingroup C, and the levels were almost same in groups A, B
and D.
Fig. 9 shows the value and ratio of 3-OHBA. Its value
was from normal values to 3,577 μmol/mL, and the ratio
was around 60% to 70% when the values were within thestandard and three fold levels (less than 85 μmol/mL and255 μmol/mL). As 3-OHBA level increases, its ratio increases
approximately up to 90%.

21.2%

1000

32.0%

25.6%

854

567
500

44 9

441

172

137
4

13

< -10

< -5

46

16

0
<0

0.1 <

2.5 <

5.0 <

10 <

15 <

20 <

25 <

weight reduction (%)

Fig. 1. Weight reduction rate in 2,699 cases.

Five hundred sixty-seven subjects (21.2 %) had a weight reduction of 2.5 % to 4.9 %, 854 (32.0 %) had 5.0 % to 9.9 %,683 (25.6 %) had 10 % and more than 10 %. Thus, 2,104 subjects (78.8 %) showed weight reduction of 2.5 % and morethan 2.5 %.

_ 195 _

Low Carbohydrate Diet : Long-Short-Effects/Hyperketonemia

Table 1. Base data of the patients.

1) Fasting values
Fasting glucose
HbA1c
IRI

156.4 ± 55.4 mg/dL
7.7 ± 1.4 %8.5 ± 4.9 μU/mL

Triglyceride

143.4 ± 86.8 mg/dL

HOMA-β44.5 ± 37.0

HOMA-R

3.2 ± 1.9

2) Meal loading (carbohydrate 70 g)
Glucose (0 min)161.7 ± 51.6 mg/dL

Glucose (30 min)212.4 ± 60.9 mg/dL

I RI (0 min)

8.5 ± 4.9 μU/mL

Glucose (increase)50.8 ± 25.8 mg/dL

I RI (30 min)22.7 ± 15.0 μU/mL

IGI- carbo70

0.39 ± 0.38

I RI (increase)

14.2 ± 12.7 μU/mL

IRI, immunoreactive insulin; HOMA, homeostasis model assessment; IGI-carbo70,
insulinogenic index-70 g of carbohydrate in calorie-restricted (CR) diet. Data areshown in mean ± standard deviation.

HOMA - R

10

HOMA - β20044.4± 37.0

5100

3.2 ± 1.960
2.5

HOMA -β

HOMA -Ｒ

150

50

40

1.6

0

0

Fig. 2. HOMA-R and HOMA-β of the patients.

As for HOMA-R, the normal range is usually under 1.6 and a value more than 2.5 suggests the presence of insulin
resistance (n = 24). As for HOMA-β, the normal range is from 40 to 60 (n = 24). Bar indicates standard deviation.
HOMA, homeostasis model assessment.

_ 19 6 _Glycative Stress Research
400

Blood Glucose (mg/dl)

300

200

100

0

0 min

120 min
Day 2

0 min

120 minDay 12

Fig. 3. Blood glucose values after zero min and 120 min for breakfast on day two and day 12.

The subjects were on a calorie restriction diet (CR) on days zero to two (n = 24), and on a low carbohydrate diet(LCD) on day three to13 (n = 24). Both regimen had same calories of 450 kcal. Bar indicates standard deviation.

500

serum Triglycerade value in fasting (mg/dl)

1372a
1267b
400

300

200

100

0

day 2

day 12

Fig. 4. Serum triglyceride level in fasting on day two and day 12.

The patients were on calorie-restricted diet (CR) with carbohydrate ratio 60 % 1,400 kcal/day in day zero to two, and on low
carbohydrate diet (LCD) with carbohydrate ratio 12 %, 1,400 kcal/day on day three to13. The average value of TG decreased
from 233.9 ± 324.6 mg/dL to 110.3 ± 69.3 mg/dL (mean ± SD), with a significant difference (p < 0.01), when two cases were
included (a: n = 1,372, b: n = 1,267). When we exclude two cases, TG value decreased from 143.4 ± 86.8 mg/dL to 93.9 ±34.8 mg/dL (mean ± SD), with significant difference ( ＊ : p < 0.01). TG, triglyceride; SD, standard deviation.

_ 19 7 _

400
60

50

300

40
200
30

I R I (μU /m L )Plasma Glucose (mg/dL)

20
100
10

0

0

0min

30min

0min

30min

Fig. 5. Responses of glucose against meals including 70 g of carbohydrate.

The responses of glucose and IRI were from 161.7 ± 51.6 mg/dL to 212.4 ± 60.9 mg/dL, and from 8.5 ± 4.9 μU/mL
to 22.7 ± 15.0 μU/mL, respectively (n = 22). IRI, immunoreactive insulin.

1

0.8

Insulinogenic Index-carbo 70 (IGI-carbo 70 )/dl)

Low Carbohydrate Diet : Long-Short-Effects/Hyperketonemia

0.6

0.4

0.2

0

Fig. 6. A trial for calculating insulinogenic index (IGI) for meals including 70g of carbohydrate.

As the same concept for IGI in 75 g oral glucose tolerance tests (75g OGTT), insulinogenic index-carbo70 (IGIcarbo70) is calculated in order to speculate the ability of insulin. IGI-carbo70 was 0.39 ± 0.38 in mean ± SD, and 0.39
± 0.08 in mean ± SEM (n = 20). OGTT, oral glucose tolerance test; SD, standard deviation; SEM, standard error mean.

_ 19 8 _Glycative Stress Research

10200
y = 0.0 7 x + 2.6
r = 0.0 5
p = 0.4 2

6
4

100
50

2

a.

0

2

4

6

8

10

b.

12

HbA1c (%)

250

150

0

5

10

15

20

25

d.

IRI in fasting (μU/m L )HOMA -β

HOMA - R

4

12

20

25

y = 5.7 x − 4.0
r = 0.82
p < 0.001

0

0

5

10

15

IRI in fasting (μU/m L )y = 1.54 x + 22.6
r = 0.49
p < 0.05

100
50

0

15

30

45

f.

60

IRI increase (μU/m L )
10

0

0

15

30

45

60

60

80

IRI increase (μU/m L )200
y = 0.04 x + 2.3
r = 0.4 3
p < 0.05

y = 1.72 x + 5.4
r = 0.71
p < 0.001

150

HOMA -β8HOMA - R

10

HbA1c (%)

150

6

2

6
4

100

50

2

g.

8

200
y = 0.007 x + 3.12
r = 0.12
p = 0.29

8

0

6

50

10

e.

4

100

100

0

2

150

200

c.

0

200
y = - 3.3 x + 190.8
r = 0.39
p < 0.05

HOMA -βFasting glucose (mg/dL)

300

50

y = -15.3 x + 164.1
r = 0.55
p < 0.01

150

HOMA -β

HOMA - R

8

0

20

40

60

h.

80

IRI in 30 min. (μU/m L )

0

0

20

40

IRI in 30 min. (μU/m L )Fig. 7. Correlation among HbA1c, HOMA-R, HOMA-β, IRI (fasting, increase, 30 min) and blood glucose (n = 24).
a: Correlation between HbA1c and HOMA-R, not significant.

b: Correlation between HbA1c and HOMA-β, significant, p < 0.01.

f: Correlation between IRI increase and HOMA-β, significant, p < 0.05.

g: Correlation between IRI in 30 min. and HOMA-R, significant, p < 0.05.
c: Correlation between fasting IRI and fasting glucose, significant, p < 0.05. h: Correlation between IRI in 30 min. and HOMA-β, significant, p < 0.001.
d: Correlation between fasting IRI and HOMA-β, significant, p < 0.01.
HOMA, homeostasis model assessment; IRI, immunoreactive insulin.
e: Correlation between IRI increase and HOMA-R, not significant.

_ 19 9 _Low Carbohydrate Diet : Long-Short-Effects/Hyperketonemia

(
(

2000

4000)
3081)

totle ketone bodies (μmol / L )1500

994± 960

1000

613± 338

623± 437500

363± 182

0group A

group B

group D

group C

Fig. 8. The value of blood ketone bodies in 51 cases on LCD.

According to continuing days on LCD, we classified four groups, in which group A is four to five days (n = 4), B is seven to nine days (n = 5),
C is 11 to 13 days (n = 21), D is 21 to 28 days (n = 21). Cases with extremely high value were observed in group C, and the levels were almost
same in group A, B and D. LCD, low carbohydrate diet. Bar indicates standard deviation.

3 - OHBA ratio in ketone bodies (%)

100

90

80

y = 6.6 ln (x) + 37.9
r = 0.80
p < 0.001

70

60

0

1000

2000

3000

4000

3 - OHBA value in blood (μmol / L )Fig. 9. Correlation between 3-OHBA value in blood and 3-OHBA ratio in ketone bodies (n = 39).

When 3-OHBA value is within the standard level and its three fold level (less than 85 μmol/mL and 255 μmol/mL) the 3-OHBA ratio in
ketone bodies are around 60 % to 70 %. As 3-OHBA values increase, the ratio of 3-OHBA increases up to approximately 90 %. 3-OHBA,
3-hydroxybutylic acid.

_ 200 _Glycative Stress Research

Discussion

4) High-Carbohydrate Diet: > 45%

1) Long effects of LCD

Our coworkers and we have continued to develop
clinical studies and research of LCD for many years 9-13).
The degree of weight reduction seemed to be satisfactory(Fig. 1). Weight check-up after LCD intervention wasmeasured when the weight became stable in six to 12 months.
The diet protocol was started on super-LCD (carbohydrate
12%, avoiding staple food such as rice and bread inthree meals), and after the standard-LCD (carbohydrate
24%, avoiding staple food in two meals) and petit-LCD(carbohydrate 36%, avoiding staple food in one meal) wereapplied, depending on the situation of the patients, which
can reduce the weight gain rebound 9-12). Reports with morethan 2,000 cases have been rare, and our results would be
fundamental data in light of ordinary outpatient care.
Through our investigation, we can suggest several
characteristic aspects, such as 1) adequate education of meals
and daily life, 2) behavioral changes in the most patients, 3)
spontaneous continuation of LCD after the research protocol,
4) wide spread of LCD by recommendation of the patient for
his or her family and acquaintances and 5) social information
and recognition of short and long term effects of LCD.

2) Weight reduction of LCD

Our results could be compared with recent reports for
LCD. Randomized controlled trials (RCTs) have consistently
shown that LCD reduces body weight, with mean reductions
ranging from 2.1 to 14.3 kg over at least six months ofintervention 14).
Weight reduction between CR and LCD showed that
7.4% versus 9.0% in 227 cases 15), and 1.5 kg versus 5.3 kg
in 148 cases one year later 16). From 53 reports with 68,128
cases, the long-term effects depend on the intensity of theintervention 17). On the contrary, meta-analysis of 19 papersof 3,209 cases revealed no significant difference of weight
reduction in LCD and other diets 18).
Compared with these reports, our result would be
successful particularly because weight reduction for LCD
was remarkable in the cases, reducing more than 10% in
25.6 %, and more than 5% in 57.6 %.

3) International comparison of LCD

Despite the differences in weight change on diets, LCD
resulted in similar or greater improvement in inflammation,
adipocyte dysfunction, and endothelial dysfunction than astandard low-fat diet among obese persons.
In the light of appellation, LCD and CR have been used
for a long time, but recently, new and different terms have beenused. They are high fat, low carbohydrate (HFLC) diet; lowfat, high carbohydrate (LFHC) diet 20); very low-carbohydrate
ketogenic diet (VLCKD); low fat diet (LFD) 21-23); higherprotein (HP) diet (38% carbohydrate, 30% protein, 29%fat);higher-carbohydrate diet 24); and low carbohydrate (120 g
carbohydrates/day) and low fat diets (30% energy from fat/day) 25).
Consequently, our three types of LCDs seem to beequivalent as follows: Super-LCD is equivalent to 1) VLCKD,
standard-LCD to 2) LCD and petit-LCD to 3) ModerateCarbohydrate Diet. In actual medical practices of diabetes,
we have adapted three types of LCDs to each patient withadequate situations.

5) Short-term effects of glucose and TG

TG levels showed rapid and significant decreases
through super-LCD for ten days from 143.4 ± 91.4 mg/dL
to 93.9 ± 34.8 mg/dL. It is well known that LCD makes TG
decrease in former studies. RCT of 23 reports until 36 months
with 29.7 mg/dL decrease 26), RCT of 227 cases at 12 months
with 37 mg/dL decrease 15), meal of carbohydrate less than
40 g/day for 12 months with a 14.1 mg/dL decrease 27),
lack of supple meals (rice) one to two times per day for six
months with 16 mg/dL decrease 28), LCD including 43% ofcarbohydrate with 14.9 mg/dL decrease for five weeks 29) andAtkin’s method for 14 days with TG decrease from 154 mg/
dL to 89.9 mg/dL 30, 31) which is similar to our result.
As for human research of LCD for six to 12 months,
there is a limitation in research design because subjects
have meals at home. In contrast, our design was performedthat the patients were admitted and examined with superLCD including carbohydrates of 12%, suggesting higher
reliability and significance of LCD research.

6) Trial for IGI-carbo70

In Japan, our methods for LCD have been utilized andprevalent in clinical practice for years because of simple
and easy to understand the content. Three types and ratiosof carbohydrates were super-LCD without three staple foods(12%), standard-LCD without two staple foods (22% - 25%)and petit - LCD without one staple food (35% - 40%).
The content of LCD can be compared with theinternational situation of LCD. Recently, Bernstein andFeinman et al 19) suggested definitions and related commentsof LCD as follows: 1) Very low-carbohydrate ketogenic
diet (VLCKD): Carbohydrate, 20 to 50 g/day or <10% of
the 2,000 kcal/day diet. 2) Low-carbohydrate diet: <130 g/
day or < 26% total energy. The ADA definition of 130 g/day
is its recommended minimum. 3) Moderate-Carbohydrate
Diet: 26% to 45%. Upper limit, approximate carbohydrate
intake before the obesity epidemic (43%).

To speculate the function of pancreatic beta cells,
insulinogenic index (IGI) analysis in 75g OGTT has beenused until now 32-34). However, IGI is not so applied to diabetic
patients already diagnosed, because of rapid hyperglycemia.
Current study includes blood glucose and insulin values
on 0 and 30 minutes after breakfast including carbohydrate
70 g. From these data, we calculated and showed “insulinogenic
index-carbo70 (IGI-carbo70)” in Figs. 5 and 6, because ofalmost same weight of glucose.
As a reference, there is a report of hyperglycemia due toa bowl of rice topped with beef (gyudon) 35). Twelve healthy
subjects were given three test foods, which were steamed
rice (230 g), “gyudon” with or without ginger (15 g), including
78 g, 82.9 g, and 83.5 g of carbohydrates each. Blood glucose
was elevated by 65 to 75 mg/dL after 30 min, and details
were investigated in light of the area under the curve (AUC)of glucose increments.

_ 2 01 _Low Carbohydrate Diet : Long-Short-Effects/Hyperketonemia
From these data, it is noteworthy that even normal
subjects have hyperglycemia against 80 g of carbohydrate infood, and that postprandial research of glucose and insulin
would be useful and important. In Fig. 6, 3/4 of cases of
IGI- carbo70 were less than 0.5, suggesting a possible usefulmarker in the future.

7) HOMA-R and HOMA-β

As for mutual correlations, higher HbA1c suggests
lower HOMA-β, indicating decreased secretion ability( Figs. 7a, b). Glucose profile seems to be influenced withfactors such as obesity, insulin resistance, secretion ability,
and mean amplitude of glycemic excursions (MAGE) ( Figs.
7c, d ). Increased IRI value indicating of insulin secretion
ability showed no significant correlation with HOMA-R,
suggesting less of a relationship with insulin resistance( Figs. 7e, f ).
It is known that IRI values in 120 min for 75g OGTT
correlates with the level of HOMA-β, which is compatible
with the significant correlation with p < 0.001 ( Fig. 7h).
HOMA-R showed a significant correlation with IRI values in
120 min without a significant correlation with IRI increase( Figs. 7e, g ), suggesting elevated fundamental IRI values,
due to insulin resistance.
HOMA-R and HOMA-β were applied to the evaluation
for insulin resistance and secretion, in which reliability would
be increased when fasting glucose is less than 140 mg/dL
and 130 mg/dL, respectively. Consequently, there are possible
fluctuations of reliability that the former has rather decreased,
and the latter has rather increased. As for the limitation of theresearch design, further investigation would be necessary.
HOMA-R and HOMA-β were originally proposed by
Matthews et al 36), and have been used widely and highly
estimated. Recent development includes using C-peptide
values alternatively 37), and newly trials for iHOMA2 38),
expecting further useful analysis methods.

8) Ketone bodies and LCD

Hyperketonemia has usually been classified as 1)
diabetic ketoacidosis (DKA) and 2) physiological ketosis. The
former shows that blood sugar is more than 300 mg/dL withacidosis, and ketone bodies are 20 to 25 mmol/L 21, 39). As forthe report of DKA 19 cases, average values are as follows:
glucose 650 mg/dL, pH 7.13, T-ketone 10.2 ± 1.8 mmol/L,and acetoacetic acid (AcAc) 2.7 ± 0.5 mmol/L, 3-OHBA 7.5± 1.3 mmol/L, the ratio of 3-OHBA 74% 40).
On the contrary, the latter shows that blood glucose is ina normal range and plasma ketone body levels increase six
to eight mM during a prolonged fast without giving rise toclinically hazardous acidosis 21). The cause is usually fromstarvation and a ketogenic diet, and was proposed by the
famous biochemist Crebs, who was given the Nobel Prize 41).
In our study ( Figs. 8, 9 ), we started diet therapy as
super-LCD that has 1,400 kcal/day, 12% carbohydrates and
42 g of carbohydrates per day. Blood values of ketone bodies
were 160 to 4,000 μmol/L (0.16 to 4 mmol/L) in Fig. 8, andthat of 3-OHBA was 136 to 3,577 μmol/L (0.14 to 3.58
mmol/L) in Fig. 9. Our data would be compared with similar
situations of previous reports.
The blood values of a healthy person are 72 to 90 mg/
dL of glucose and less than 0.2 mmol/L of ketone bodies.

Fasting increases blood ketone bodies, and 3-OHBA levels
after fasting are 0.3 to 0.5 mmol/L in 24 hours, one to two
mmol/L in two to three days, three mmol/L in three to fourdays 42) and four to five mmol/L in seven to ten days.
When patients with obesity continue fasting for 40 days,
they would not show acidosis and their 3-OHBA values
are six to eight mmol/L with the ratio of 3-OHBA at about
78% 43).
During fasting, giving 150 g of glucose per day forseven days would make 3-OHBA less than 0.5 mmol/L. In
contrast, discontinuing glucose administration would resultin elevated 3-OHBA, with 4.3 mM in ten days and 4.8 mM
in 12 days 42). Glucose intake of 20 to 40 g is associated with
3-OHBA of approximately one mM, but wide variations
exist between people 42).
From several comparisons of previous reports, we
can compare 3-OHBA value in three to four days, where
three mmol/L in fasting 42) versus 0.36 mmol/L in 42 g ofcarbohydrate for super-LCD ( Fig. 8 ). Furthermore, we cancompare the ratio of 3-OHBA in ketone bodies, whereapproximately 78% in six to eight mmol/L of ketone bodies
due to continuous fasting 43) versus about 60 % to 90 % in
0.1 to three mmol/L due to LCD ( Fig. 9 ). These data would
be the fundamental data in the research concerning ketone
bodies.

Conclusion

We have continued clinical studies and research of LCD
for many years. These studies revealed that for 1) long– term
effects; weight reduction more than 10 % was 25.6 %, morethan 2.5% was 78.8% in 2,699 cases, 2) short-term effects;
blood glucose and triglyceride values decreased significantly
in 10 days, 3) ketone bodies and 3-OHBA were elevated due
to super-LCD meals from four to five days. These findings
are fundamental data in the LCD area and contribute theresearch of glycative changes.

Acknowledgements

A summary version of this article was presented at the89th Scientific Meeting of Japan Endocrine Society Annual
Congress, Kyoto, 2016.

Statement of conflict of interest_ 202 _

Non contributory.

Glycative Stress Research

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