Clinical Guidelines

Adele Hite, PhD, MPH, RD has coordinated the effort to get this clinical guidelines document to the point where it is publishable.  Her efforts have been nothing short of miraculous.  We have formed a board of advisers made up of experienced clinical practitioners and experts in the field to help us get this work done.  Currently this board consists of David Cavan, MD, FRCP; Mark Cucuzzella MD, FAAFP; Robert Cywes, MD, PhD; Georgia Ede, MD; Gary Fettke, MB, BS, FRACS, FAOrthA; Brian Lenzkes, MD; Timothy D. Noakes, MD, DSc; Bret Scher, MD; Franziska Spritzler, RD, CDE; David Unwin, MD, Eric C. Westman, MD; MHS; and William S. Yancy, Jr., MD, MSH.

Work is now underway to generate condition-specific addenda for these Clinical Guidelines.  It is clear that for certain chronic diseases the general intervention is not always enough.  Nuances and caveats often exist that can make the intervention more successful.  We will be starting with an addendum for Type 2 Diabetes.  After that we will start focusing on cardiovascular disease, neurological disorders, and all the other chronic diseases for which this protocol is appropriate.

This Clinical Guidelines document will be updated from time to time as the science evolves.  If you download or print this document out it is imperative that you return to this page regularly to ensure that you have the latest version.  Scroll to the bottom to find links to the pdf versions and the various language translations.

Patient safety and support is of the highest importance. For practitioners who do not have prescribing/de-prescribing privileges, this means ensuring that all patients using therapeutic carbohydrate restriction are assisted in adjusting medications as needed by a professional trained in this process.
Read the ‘Statement of Support‘ which can be found, together with the current list of supporters, at the end of this document.  Then please complete the form below if you would like to have your name listed on the document.  Updates to the list on the document will be published frequently and at least once a month.


Clinical Guidelines - General Intervention v1.3.7


Download the PDF


Give us your ideas and feedback on these Clinical Guidelines.  Make sure you read through the other comments to make sure you are not duplicating anything and add your new comment at the end.


Posted by Jane Jewell on December 28th, 2018 at 20:50

If patients are on insulin or sulfonylureas when beginning a low-carbohydrate diet, it is likely
that does will need to be reduced immediately to prevent hypoglycemia.

Change does to dose.

Posted by Doug Reynolds on January 10th, 2019 at 05:01

Thanks, Jane!

Posted by Laura Doty on January 6th, 2019 at 07:46

At our metabolic center we always check insulin at baseline, and then repeat it in 3 months, then 6 months. It can give helpful information in terms of presence of insulin resistance, can help to educate and motivate the patient about their current level of health and what may be contributing to weight gain, and it can be followed over time and seeing it decrease can be very rewarding for the patient and provides information about the effect of the dietary and lifestyle changes.

Posted by Doug Reynolds on January 10th, 2019 at 05:02

Thanks, Laura, we will submit this to the panel

Posted by Linda Anegawa on May 11th, 2019 at 19:37

This is fantastic! So appreciative of this important work.

Section 6.2 Regarding management of hypertension – at our program, we typically halve the doses or discontinue diuretics with the start of any very low carb intervention. We also advise patients to monitor BP at a bare minimum of once daily and/or before taking doses of any medications. Patients are instructed to call the care team with any SBP < 120 + orthostatic symptoms, or any SBP < 100.

I'm wondering if brief mention of these topics in the context of low-carb therapeutic interventions might be useful, as well:
(1) Obesity pharmacotherapy
(2) The unique needs of pre-and post-surgical bariatric patients
I have material if there is interest. Thank you!

Posted by Doug Reynolds on May 12th, 2019 at 13:10

Glad you have found it so useful, Linda. We will forward your suggestions to the panel of advisers!

Posted by Chris County on May 12th, 2019 at 08:54

4.5.1 Inpatient
Change to, “implemented in an inpatient setting.”

Posted by Doug Reynolds on May 12th, 2019 at 13:11

Thanks for your comment, Chris. We will forward your suggestion to the panel of advisers!

Posted by Ari on May 13th, 2019 at 02:07

In paragraph 2.6 about trans-fats, please make a clear distinction between natural ruminant transfats (healthy) vs. industrial, via hydrogenation generated transfats (unhealthy).

Posted by Doug Reynolds on May 13th, 2019 at 06:05

Thanks for your comment, Ari. We will forward your suggestion to the panel of advisers!

Posted by Don Wilson on May 20th, 2019 at 16:26

Typos/suggestions: sections: 4 – “knowledgeable determined”, 4.5.1 should be “inpatient”, 6.2 has note to be removed, 7.1, “if changes in those markers [is] a goal.” Missing [is].

Posted by Doug Reynolds on May 21st, 2019 at 09:02

Thanks for your comment, Don. We will forward your suggestions to Adele and the panel of advisers!

Posted by Beverly Williams on May 21st, 2019 at 13:30

On Page 1, under 2. Background and definitions, Line 3 …Dr. William Harvey, who prescribed (a) [not as] diet that restricted starches…

I found that one of the items that I found that needed correction/clarification has already been identified by Doug Reynolds. (Page 14 Clinical Guidelines, Line 9 …”if changes in those markers (are) [to match a plural subject] a goal.”

In the last paragraph on this same page:

Pharmacists…monitoring and education patients with… (either 1. or 2.)

1. complex pharmaceutical regimen(s)
2. (a) complex pharmaceutical regimen.

Thank you for providing us with the ability to participate in the preparation of this draft. I sincerely hope that more doctors will become aware of this tool to use in treating patients, outside of the traditional ADA way. My husband who is a severely overweight, out of control, diabetic completely disregards my advice on healthy eating. He ignores the fact that I have been researching diabetes for at least 45 years because of the strong genetic factor of diabetes in my own family. I have been following the keto way of eating for about 6 months and I know that it works!

Posted by Doug Reynolds on May 22nd, 2019 at 05:25

Thanks for your comments Beverly and it is a total pleasure. Responses like this are the reason we keep doing this. I have a huge problem with my mother developing dementia and refusing to listen so I feel your pain. I hope both of them see the light as the momentum around this builds and we can save both of them!

Posted by Beverly Williams on May 21st, 2019 at 13:41

Excuse my typo:

Pharmacists…monitoring and education patients with… (either 1. or 2.)

Should read:

Pharmacists…monitoring and educating patients with…(either 1. or 2.)

Posted by Bron Matthews on May 25th, 2019 at 20:19

Great work by everyone involved!
4..45.2 is probably supposed to be 4.5.2.

Posted by Doug Reynolds on March 3rd, 2020 at 10:24

Thanks, Bron!

Posted by BobM on May 28th, 2019 at 13:00

In 3.2, the blood sugar of <110g/dl should be <110mg/dl (milligrams per deciliter).

Section 4.3, I can pretty much guaranty they will not know what a Kraft protocol is, though perhaps this would provoke some research.

Section 5.3.3: "Another possible intervention for muscle cramps, with a low potential for adverse side effects is a spoonful of pickle juice." I would add a comma after "effects". (Was this section added by Tim Noakes?)

Section 6.3, comment about beta blockers and lipolysis. I have been on carvedilol for 6 years and low carb/keto for 5.5, and have lost about 60 pounds while gaining about 10 pounds of muscle. It may be that I would have lost more weight (could lose more), but this is one status point indicating maybe not all beta blockers are the same.

Posted by Doug Reynolds on March 3rd, 2020 at 10:32

Thanks, Bob!

Posted by silvio fontana on May 29th, 2019 at 00:59

Carbohydrate restriction specifically tailored for those with severe GIT dysfunction. Many suffer daily and constantly with IBS-C, D, Leaky Gut, Fodmap, Salicylates, Fructose and Dairy Intolerance, Histamine and many varieties of food intolerance’s/sensitivities and often are not included in the mainstream of LCHF as are those with Obesity, T2D Insulin issues, and Epilepsy.
Food choices are somewhat limited under these severe gut issues

Posted by Lizzie Herring on October 23rd, 2019 at 05:48

I would like to download and print the Clinical Guidelines but have not been able to.

Posted by Ty on November 7th, 2019 at 12:05

How would one cite this PDF in their references?

Posted by Doug Reynolds on March 4th, 2020 at 06:48

It depends on the type of citation style used, but most ask for the following in some form or another:

Author(s): Hite, AH et al. [If the citation format requires all authors, it can be: Hite, AH & Advisory Board at LowCarbUSA. Or it can list all the authors, like so: Adele H. Hite, David Cavan, Robert Cywes, Georgia Ede, Gary Fettke, Brian Lenzkes, Timothy D. Noakes, Bret Scher, Franziska Spritzler, Eric C. Westman, and William S. Yancy, Jr.]
Year: 2019
Title: Clinical Guidelines for Therapeutic Carbohydrate Restriction

Posted by Bill Wilharms on February 11th, 2020 at 09:40

How would this diet work for a person who in the last year suffered a heart attack and had two stents put in and the heart attack was mainly because I do not produce very much good cholesterol?

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