Main themes and illustrative quotes related to dietitians’ experiences of prescribing therapeutic CHO-restricted diets in Canada
| Theme | Quotes |
| 1. Interpersonal context | ‘Benefits noted, but hate the “fear” around carbs’. (Respondent #28) ‘Yes, that’s usually where the disagreement between nurses and dietitians come into place in the north. Some nurses have tried keto diets personally and have prescribed these diets to patients based on their personal experiences instead of scientific evidences’. (Respondent #23) “A number of our [Nurse Practitioners]/[Registered Nurses] are very vocal supporters of the ketogenic diet and seem to prescribe it for nearly everyone”. (Respondent #24) ‘Adjunct discussions on mindful eating, family influence and potential impacts and food literacy and food security’. (Respondent #4) ‘Discussing “keto” popularity with parents of T1D at diagnosis to clear confusion with DKA and ketone testing vs keto diet’. (Respondent #3) “If I have a client adament [sic] to avoid medication, I lay out all the options and the pros and cons. They can then make an informed decision”. (Respondent #32) |
| 2.Personal experience and knowledge | “When I started, I could never imagine recommending low CHO, however, the science is there for some individuals”. (Respondent #32) “It makes me question all the advise [sic] that we have been giving and how it may not have been the best advise for some of our patients/clients”. (Respondent #15) ‘More open to carbohydrate restriction as a therapeutic option for some patients’. (Respondent #1) “I can provide substitutes and strategies to help implement the diet”. (Respondent #18) “I teach carb ‘awareness’ for both weight loss and glycemic control”. (Respondent #14) “more emphasis on the same things we’ve always said: reduce the junk carbs and watch the starch portions and fruit. Just giving it a new title of ‘moderate carb restriction’ vs ‘low carb restriction’ and ‘keto or very low carb restriction’”. [sic] (Respondent #40) ‘Its understanding energy and nutrients, mental health and physical needs, vitamins, minerals, and processed foods’. (Respondent #27) ‘Discussing “keto” popularity with parents of T1D at diagnosis to clear confusion with DKA and ketone testing vs keto diet’ (Respondent #3) “Helps me understand what clients may go through and have empathy with them, help with their food choices and help them with ideas on how to maintain high fibre while restricting carbohydrates”. (Respondent #37) “I have seen the benefits of a CHO restriction in a diabetes population”. (Respondent #33) “I find it useful in weight management where a person feels they have food addiction”. (Respondent #6) “I find the benefits far outweigh any benefits from mainstream moderate/high carb, low fat approach, over and above weight loss”. (Respondent #35) “If you watch what the glucose excursion is on a sensor with ingestion of carbohydrate and lower carb strategies, it is very clear that eating high carb makes managing diabetes more challenging”. (Respondent #8) “To manage diabetes, we see over and over again the benefits of following a lower carb diet to reduce postprandial blood glucose rises”. (Respondent #9) “The incredible benefits not only in me, but in my family, and friends influence my approach, of course”. (Respondent #42) ‘Started LCHF [Low-carb high-fat] private practice. Took primal health coach certification’. (Respondent #43) “I have opened a private practice to assist others to implement LCHF diets, safely, with considerations of supporting the gut microbiome”. (Respondent #46) “Teach my colleagues that low fat high carb diets is probably helping the population become more and more obese”. (Respondent #34) “with regards to the growing evidence about the link between high-sugar diet and cardiovascular disease. Renal pts [sic] are at increased risk of CVD, also many of my dialysis clients have Type 2 DM” (Respondent #19) |
| 3. Regulatory environment (scope of practice) | ‘More of a conservative approach to carb intake for diabetes management then what the CPGs may suggest’. (Respondent #7) ‘Started LCHF private practice. Took primal health coach certification’. (Respondent #43) “I have opened a private practice to assist others to implement LCHF diets, safely, with considerations of supporting the gut microbiome”. (Respondent #46) ‘Frustration that it is not accepted by the conventional models and colleagues’. (Respondent #36) “I try to encourage patients to limit sugars/processed carbs—The fact that there is really no Low Carb Diet available in hospital is a Major Limitation to how we can help patients who need to reduce their inflammatory markers”. (Respondent #12) |
| 4. Patient-centred care | “I will recommend a carbohydrate reduction when it appears as if it would benefit the individual client”. (Respondent #24) ‘More open to support patients if they think it is enjoyable and sustainable’. (Respondent #22) ‘more open to clients desires to experiment with this diet’ (Respondent #13) “I am open to client questions about it and will work with those who are trying to limit CHO [sic]”. (Respondent #16) “I’m more open to carb restriction in my practice but do not recommend very low carb diets to patients as maybe high risk for my patient population DM [sic]”. (Respondent #26) “Renal pts [sic] are at increased risk of CVD, also many of my dialysis clients have Type 2 DM2”. (Respondent #19) “I find it useful in weight management where a person feels they have food addiction”. (Respondent #6) “I use carb restriction with appropriate patients”. (Respondent #30) ‘It works for some people but definitely not all’. (Respondent #39) ‘Balance and quality macronutrients and client centered always’. (Respondent #10) “Helps me understand what clients may go through and have empathy with them, help with their food choices and help them with ideas on how to maintain high fibre while restricting carbohydrates”. (Respondent #37) “When I started, I could never imagine recommending low CHO, however, the science is there for some individuals. If I have a client adamant to avoid medication, I lay out all the options and the pros and cons. They can then make an informed decision”. (Respondent #32) |
CHO, carbohydrate; CVD, cardiovascular disease; DKA, diabetic ketoacidosis; DM, diabetes mellitus; LCHF, low-carb high-fat; T1D, type 1 diabetes.