Renewable fibers produced by forest trees provide excellentraw material of high economic value for industrialapplications. Despite this, the genes and corresponding enzymesinvolved in wood fiber biosynthesis in trees are poorlycharacterized. This thesis describes a functional genomicsapproach for the identification of carbohydrate-active enzymesinvolved in secondary cell wall (wood) formation in hybridaspen. First, a 3' target amplification method was developed toenable microarray-based gene expression analysis on minuteamounts of RNA. The amplification method was evaluated usingboth a smaller microarray containing 192 cDNA clones and alarger microarray containing 2995 cDNA clones that werehybridized with targets isolated from xylem and phloem.Moreover, a gene expression study of phloem differentiation wasperformed to show the usefulness of the amplificationmethod. A microarray containing 2995 cDNA clones representing aunigene set of a cambial region EST library was used to studygene expression during wood formation. Transcript populationsfrom thin tissue sections representing different stages ofxylem development were hybridized onto the microarrays. It wasdemonstrated that genes encoding lignin and cellulosebiosynthetic enzymes, as well as a number of genes withoutassigned function, were differentially expressed across thedevelopmental gradient. Microarrays were also used to track changes in geneexpression in the developing xylem of transgenic, GA-20 oxidaseoverexpressing hybrid aspens that had increased secondarygrowth. The study revealed that a number of genes encoding cellwall related enzymes were upregulated in the transgenic trees.Moreover, most genes with high transcript changes could beassigned a role in the early events of xylogenesis. Ten genes encoding putative cellulose synthases (CesAs) wereidentified in our ownPopulusESTdatabase. Full length cDNA sequences wereobtained for five of them. Expression analyses performed withreal-time PCR and microarrays in normal wood undergoingxylogenesis and in tension wood revealed xylem specificexpression of four putative CesA isoenzymes. Finally, an approach combining expressionprofiling,bioinformatics as well as EST and full length sequencing wasadopted to identify secondary cell wall related genes encodingcarbohydrate-active enzymes, such as glycosyltransferases andglycoside hydrolases. As expected, glycosyltransferasesinvolved in the carbohydrate biosynthesis dominated thecollection of the secondary cell wall related enzymes that wereidentified. Key words:Populus, xylogenesis, secondary cell wall,cellulose, hemicellulose, microarrays, transcript profiling,carbohydrate-active enzyme, glycosyltransferase, glycosidehydrolase

The long-term trend regarding wood is an increase in price. Because wood contributes to a large part of production costs, the efficient utilisation of wood is greatly desired to reduce production costs for kraft pulp producers. During the 1990s, the development of improved modified kraft cooking began, which led to higher yields. There was also a trend of terminating kraft cooking at a higher kappa number to maximise the overall yield. For hardwood, the defibration point became a critical setback in allowing this termination at a high kappa number. This thesis discusses how this issue has been tackled in the laboratory by using improved modified kraft cooking combined with extended impregnation to enable a decrease in reject content and shift the defibration point towards a higher kappa number for hardwood. This lab concept is referred to as extended impregnation kraft cooking (EIC), and this thesis reveals that EIC cooking efficiently reduces the reject content for both birch and eucalypt. By using EIC cooking, the defibration point was shifted to a kappa number of ca. 30 from ca. 20 using conventional kraft cooking. This study demonstrates the great potential for achieving a higher overall yield for eucalypt by terminating the EIC cooking at a high kappa number, but with the conditions used in this thesis, no improvement in yield was observed for birch.   An important issue is that the termination of kraft cooking at high kappa number increases the demand for extended oxygen delignification to reach a similar kappa number into bleaching, i.e., due to cost and environmental reasons. Extended oxygen delignification was shown to be possible for both birch and eucalypt EIC pulps (i.e., from kappa number 27 to 10) with an acceptable pulp viscosity number.   The other part of this thesis addresses aspects regarding the limitations in oxygen delignification. It has previously been shown in the literature that a high xylan yield of kraft cooking could negatively affect the efficiency of subsequent oxygen delignification. In this work, the increased xylan content in eucalypt kraft pulp within the range of 8–18% had only a marginally negative impact on the oxygen delignification efficiency after correcting for the HexA contribution to the kappa number. It is also desired to extend the oxygen delignification towards lower kappa number, i.e., below kappa number 10 to decrease the bleaching chemical requirement. In this study, the hypothesis that the reduced efficiency of oxygen delignification at low kappa numbers could partly be due to the formation of oxidisable carbohydrate-related structures (i.e., HexA and/or other non-lignin structures) was also tested. No formation was established. On the other hand, a final oxygen delignification stage in the bleaching could be an attractive alternative for reducing yellowing and enhancing brightness; in fact, this has led to the development of a patent (SE 528066). / Ved står för en stor del av produktionskostnaderna vid framställning av sulfatmassa. Då vedpriserna har ökat genom åren är ett effektivt utnyttjande av veden önskvärt för att kunna sänka produktionskostnaderna. Under 1990-talet förbättrades den modifierade sulfatkokningen vilket innebar möjlighet till högre massautbyte. För att maximera massautbytet styrdes kokningsprocessen mot ett högre kappatal. Detta har visat sig vara svårare för lövved än för barrved, eftersom defibrerbarhetspunkten utgör ett kritiskt hinder. I denna avhandling har laborationsstudier utförts där förbättrad modifierad sulfatkokning kombinerats med förlängd impregnering för att kunna sänka spethalten och därmed förskjuta defibrerbarhetspunkten mot ett högre kappatal. Detta koncept kallas för extended impregnation kraft cooking (EIC). EIC-kokning visade sig vara en effektiv metod för att minska spethalten hos björk och eukalyptus. Med EIC-kokning kunde defibrerbarhetspunkten höjas från cirka 20 till cirka 30. I denna avhandling klarläggs att det finns stora möjligheter att öka massautbytet för eukalyptus genom att avsluta sulfatkoket vid ett högre kappatal. För björk kunde ingen ökning av massutbytet uppnås genom ovanstående metod.   Vid ett högre kappatal efter sulfatkoket ställs även krav på förlängd syrgasdelignifiering, för att kunna behålla samma kappatal in till blekeriet. Det visade sig vara fullt möjligt att förlänga syrgasdelignifieringen för de EIC-kokade björk- och eukalyptusmassorna (d.v.s. från kappatal 27 till 10) med accepterad massaviskositet.   Den andra delen av avhandlingen tar upp aspekter på syrgasdelignifieringens begränsningar. Tidigare studier har visat att ett högre utbyte av xylan vid sulfatkokning kan vara negativt för syrgasdelignifieringens effektivitet.  I denna studie har det påvisats att en ökad xylanhalt i intervallet 8–18 procent i eukalyptusmassa endast har en marginell negativ inverkan på syrgasdelignifieringens effektivitet efter att kappatalet korrigerats för HexA. Det är önskvärt att förlänga syrgasdelignifieringen till ett lägre kappatal än 10 för att minska förbrukningen av blekkemikalier. I den här studien prövades hypotesen att syrgasdelignifieringens begränsningar vid låga kappatal, under 10, delvis skulle kunna bero på bildning av oxiderbara kolhydratrelaterade strukturer (d.v.s. HexA och/eller andra okända ”non-lignin”-strukturer). Ingen bildning kunde dock observeras. Däremot indikerades att ett syrgassteg i slutet av bleksekvensen skulle kunna vara ett eftersträvansvärt alternativ för minskad eftergulning och ökad ljushet, vilket ledde till ett patent (SE 528066). / QC 20120507

Syftet med denna pilotstudie var att studera om man hos pediatriska patienter som lider av sjuklig fetma kan se förändringar i metabolismen genom att ersätta den traditionella kosten med en kost bestående av hög andel fett och låg andel kolhydrater. De frågeställningar som används är om den förändrade kosten leder till en gynnsam förändring av metabola markörer samt hur patientupplevelsen av de nya kostråden är. Studien har både en kvantitativ och kvalitativ design. Totalt ingår 4 barn i åldern 4-17 år. Två av dessa har under fyra veckor ätit en kost bestående av hög andel fett (50-60E%) och låg andel kolhydrater (15-20E%). Efter avslutad intervention undersöktes hur metabola parametrar förändrats (blodprov) samt hur patienterna upplevt kosten (frågeformulär). Resultatet visar på att kostråden leder till en sänkning av triglycerider, glukos, HDL, total kolesterol och ASAT. Bland kontrollpatienterna ser man en ökning av triglycerider, HDL och total kolesterol. Upplevelsen av kostråden beskrivs som positiva, trots att nackdelar finns. Det finns en positiv attityd till att fortsätta med kostråden.

Weak affinity interaction of monoclonal antibodies and carbohydrate antigens can be detected and quantified by alterations in the antibodies' intrinsic tryptophan fluorescence. These weak/transient binding events have been monitored by total internal reflection fluorescence (TlRF) by facilitating the change in intrinsic tryptophan fluorescence. This immunosensor followed instant changes in the antigen concentration with rapid association- and dissociation rate constants reaching equilibrium in a short time, without the need for regeneration. Furthermore, in a competition assay with extrinsic fluorescence labeling, it was established that Förster/fluorescence resonance energy transfer (FRET) can be applied for weak and transient interactions. By entrapping components in small semipermeable capsules, aconvenient flow system was fabricated allowing on-line measurements of maltose. Quantification of maltose concentration was achievable in the mM-range without need for regeneration.High specificty for maltose was exhibited in crude food-samples with quantification in accordance with batch analysis. Furthermore, a monoclonal antibody was developed for potential use as a glucose immunosensor for diabetes. Its ability to interact with glucose was determined by competitive weak affinity chromatography (WAC) to approximately 19 mM in dissociation constant. This antibody was developed to bind monosaccharides, especially glucose, by utilizing crossreation with a carbohydrate dextran polymer. Selectivity for glucose was greater than for the similar monosaccharides, mannose and galactose. This antibody, or a fragment, in a fluorescence platform is an alternative to monitor glucose in vivo where other glucose-binders might fail. / Att känna igen en motståndare är viktigt i många sammanhang, inte minst i kroppens immunförsvar som är utvecklat för att angripa främmande ämnen i kroppen. Antikroppen spelar en central roll i immunförsvaret där den lär sig att känna igen sin motståndare (antigen) och därmed binda sitt antigen. De antikroppsproducerande cellerna kan användas i laboratoriet för att producera antikroppar som härstammar från försöksdjur. I denna avhandling har antikroppar använts som binder betydligt svagare till antigenet än vad man i de flesta analyser använder sig av för att t.ex. detektera sjukdomar. Antikroppar som binder till olika typer av socker, däribland maltsocker (maltos) och blodsocker (glukos) har studerats. Dessa antikroppar har använts för att undersöka hur hårt de binder till sitt antigen beroende på temperatur och om antikropparna kan känna igen liknande motståndare (korsreaktivitet). Fördelen med dessa svaga bindningar är att antikroppen snabbt kan binda in och släppa sitt antigen istället för att nästan permanent sitta på sitt antigen, som vid starka bindningar. Bindningens styrka (affinitet) har i avhandlingen studerats med hjälp av fluorescensteknik och affinitets-separation. Den maltosbindande antikroppen har använts tillsammans med fluorescensteknik för att designa två olika biosensorer (immunosensorer). Immunosensorerna kan mäta förändringen av maltoskoncentration över tid, vilket är attraktivt i t.ex. livsmedelsindustrin när man vill mäta maltoshalten kontinuerligt under tillverkningen. Den glukosbindande antikroppen har använts i affinitets-separation för att bestämma dess affinitet mot glukos och olika polymerer av glukos. En glukosbindande antikropp är åtråvärt för att t.ex. kontinuerligt mäta koncentrationen av blodsocker genom huden hos diabetiker och därmed minska antalet blodprover man idag behöver ta.

CHARACTERIZATION OF CARBOHYDRATE BASED VACCINES Variables influencing the immunogenicity and physicochemical properties of glycoconjugate vaccinesMany aspects can influence the immunogenicity of conjugate vaccines and the main variables investigated so far are the size of the saccharide moiety, the saccharide:protein ratio in the purified conjugate, the conjugation strategy, the nature of the spacer and the protein carrier. The size of the saccharide moiety and saccharide/protein ratio were investigated in different works such as Seppälä and Mäkelä in one of the first studies on the effect of size and chemistry on the immunogenicity of dextrans-protein conjugates found that dextrans of low molecular weight conjugated to chicken serum albumin, induced strong anti-dextran responses in mice, while increasing the dextrans' size resulted in reduced immunogenicity.47 Peeters et al. showed that a synthetic tetramer of Hib capsular polysaccharide repeating unit, conjugated to a protein carrier, induced in adult mice and non-human primates antibody levels comparable to a commercial Hib conjugate and higher than those induced by a trimer, indicating that for Hib a minimum of eight sugars is needed for a proper immunological response.48 Laferriere et al. found little influence of the carbohydrate chain length on the immunogenicity of pneumococcal conjugate vaccines in mice.49 Pozsgay et al. studied the immunogenicity in mice of synthetic Shigella dysenteriae type 1 LPS oligosaccharides conjugated to human serum albumin (HSA). The authors found that octa-, dodeca-, and hexadecasaccharide fragments induced high levels of lipopolysaccharide binding IgG antibodies in mice after three injections and were superior to a tetrasaccharide conjugate. The influence of the carbohydrate/protein ratio was different for the three conjugates. The octasaccharide-HSA conjugate with the highest density evoked a good immune response, while in the case of dodeca- and hexadecasaccharide conjugates, the median density was optimal.50 These studies suggest that oligosaccharide chain length and hapten loading might be interconnected in determining the immunogenicity of glycoconjugate vaccines. The spacer is a short linear molecule that is generally linked to the polysaccharide chain or to the protein or to both moieties, depending on the chemistry, used to facilitate the coupling between the protein and sugar. There are evidences in the literature which suggest that rigid, constrained spacers like cyclohexyl maleimide, elicit a significant amount of undesirable antibodies, with the risk of driving the immune response away from the targeted epitope on the hapten.51 52 The use of a flexible alkyl type maleimido spacer has been reported as a way to overcome the previous observed immunogenicity of cyclic maleimide linkers.53 A number of protein carriers have been used so far in preclinical and clinical evaluation of conjugate vaccines. 54 55 56 57 58 59 60Proteins such as diphtheria and tetanus toxoids, which derive from the respective toxins after chemical detoxification with formaldehyde, were initially selected as carrier because of the safety track record accumulated with tetanus and diphtheria vaccination. CRM197, a non-toxic mutant of diphtheria toxin61 which instead does not need chemical detoxification, has been extensively used as carrier for licensed Hib, pneumococcal, meningococcal conjugate vaccines and for other vaccines being developed. An outer membrane protein complex of serogroup B meningococcus has been used by Merck as carrier for their Hib conjugate vaccine.62 GSK in their multivalent pneumococcal conjugate vaccine introduced the use of the Hib-related protein D as carrier for most of the polysaccharides included into the vaccine.63 64 The team of John Robbins made extensive use of the recombinant non toxic form of Pseudomonas aeruginosa exo-toxin as carrier for Staphylococcus aureus type 5 and 8 as well as for Salmonella

Modern biorefineries provide a framework for the sustainable conversion of biomass to biofuels and biochemicals. In light of the recalcitrance of lignin in woody feedstocks, the native shrub eastern leatherwood is proposed as a model hypolignified species. Xylem tissue of this low-lignin plant contained syringyl-rich lignin that was more easily hydrolysed and did not appear to be localised in the middle lamellae. Also, leatherwood cellulose was less crystalline and the xylan was highly acetylated. While viable low-lignin plants will enable the sustainable utilisation of woody feedstocks, high-value bioproducts are needed to economise future biorefineries. The carbohydrate oxidoreductases galactose oxidase and glucooligosaccharide oxidase were studied for use in the oxidation and derivatisation of plant-derived polysaccharides for the production of such high-value bioproducts. The carbohydrate-binding module of galactose oxidase was necessary for recombinant protein production. Also, a mutant library of glucooligosaccharide oxidase variants was produced to generate enzymes with novel activity.

Modern biorefineries provide a framework for the sustainable conversion of biomass to biofuels and biochemicals. In light of the recalcitrance of lignin in woody feedstocks, the native shrub eastern leatherwood is proposed as a model hypolignified species. Xylem tissue of this low-lignin plant contained syringyl-rich lignin that was more easily hydrolysed and did not appear to be localised in the middle lamellae. Also, leatherwood cellulose was less crystalline and the xylan was highly acetylated. While viable low-lignin plants will enable the sustainable utilisation of woody feedstocks, high-value bioproducts are needed to economise future biorefineries. The carbohydrate oxidoreductases galactose oxidase and glucooligosaccharide oxidase were studied for use in the oxidation and derivatisation of plant-derived polysaccharides for the production of such high-value bioproducts. The carbohydrate-binding module of galactose oxidase was necessary for recombinant protein production. Also, a mutant library of glucooligosaccharide oxidase variants was produced to generate enzymes with novel activity.

Carbohydrates are known to play important roles in a large number of physiological and pathological processes. Conceivably, “binders” of carbohydrates of biological importance could be used as diagnostic and therapeutic agents. Currently, lectins are the major available tools in research for carbohydrate recognition. However, the available lectins often have cross-reactivity issues, along with the high costs and stability issues. Therefore, there is a critical need to develop alternatives (lectin mimics). In this regard, there have been very active efforts in developing different “binders”, such as small molecule lectinmimics and aptamers. Among all the small molecule lectinbmimics developments, boronic acid stands out as the most important building blocks of the sensors design for carbohydrates biomarkers due to its intrinsic binding affinities with diols. To address a fundamental question that whether boronic acid also binds to six-membered ring sugars, with very limited precedents, we provided a concrete experimental evidence of the binding. Specifically, a series of isoquinolinylboronic acids were found to have remarkably high binding affinities with fluorescence change upon binding to representative sugars. Most importantly, these isoquinolinylboronic aicds showed weak but very encouraging bindings with six-membered sugar model. All these promising results paves the way of using boronic acids, especially isoquinolinylboronic acid as building blocks for chemosensors design for biological carbohydrates biomarkers, which universally contain six-membered ring and liner diols. Aptamer provides another alternative way for sensors development for carbohydrates biomarkers as lectin mimics. Compared to lectins, they are normally cheaper and more stable. However, there is much less options. Another challenging area for aptamer-based lectin mimics development is the difficulty to differentiate changes in glycosylation patterns of a glycoprotein, which affect the function of a glycoprotein and thus recognized as biomarkers. To address this major challenge, our group first demonstrated that the incorporation of a boronic acid into DNA would allow for the aptamer selection process to gravitate towards the glycosylation site. To examine the generality of boronic acid incorporation, increase the structural diversity, and broaden the application of boronic acid-modified DNA, a series of B-TTP analogues with simplified structures were designed, synthesized, and successfully incorporated into DNA. A simple route was also developed using 1,7-octadiyne as a linker for both Sonogashira coupling with thymidine and CuAAC tethering of a boronic acid moiety. This paves the way for the preparation of a large number of B-TTPs with different structural features for aptamer selection or array analysis. Finally, bacterial quorum sensing has received much attention in recent years because of its relevance to pathological events such as biofilm formation. As one of the very first groups that developed a series of antagonists for AI-2 mediated quorum sensing, we herein designed and synthesized a series of analogues based on the structures of two lead inhibitors identified through virtual screening. Besides, we also examined their inhibitory activities, twelve of which showed equal or better inhibitory activities compared with the lead inhibitors. The best compound showed an IC50 of about 6 mM in a whole cell assay using Vibrio harveyi as the model organism. This encouraging results and SAR discuss also paves the way for the finding of more potent compound through further structure optimization.

The primary purpose of this study was to determine the effect of ingesting an 8% carbohydrate (CHO) beverage during a moderate intensity exercise trial on performance outcomes, fuel utilization and blood glucose levels of wheelchair athletes (spinal cord injury (SC I) or cerebral palsy (CP)). The secondary purpose was to analyze the dietary intake of the eight participants and to determine if they were meeting current sport nutrition guidelines for macronutrients and fluids recommended in the joint position statement developed by the American Dietetic Association (ADA), the American College of Sports Medicine (ACSM) and Dietitians of Canada (DC).<p> Under random, double blind conditions eight athletes (6 males, 2 females); mean age 36 ± 8.5 y with a SCI (n = 7) or CP (n = 1) completed two exercise trials on an adapted stationary hand cycle; each trial was 60 minutes in duration at 65 % VO2peak followed immediately by a 30-minute performance trial. During the first 60-minutes the participants were given four 200 ml dosages (15, 30, 45, 60-min) of an 8% CHO beverage or a taste-matched placebo beverage. Blood lactate and glucose levels were sampled during the 60-minute exercise trial (pre, 20, 40, 60-min) and immediately after the 30-minute performance trial (post, 2, 5, 10-min). Heart rate was monitored continuously during the exercise and performance trial. Expired gas samples were also taken for 5-min periods during the exercise trial and then continuously during the performance trial. These values were used to calculate respiratory exchange ratio (RER) and carbohydrate oxidation. Dietary intake was assessed with a three day food record.<p> No significant differences were apparent between beverage trials for total distance (km), average speed (kmhr-1) or maximum speed achieved (kmhr-1). Significant differences were evident for blood glucose values, RER and CHO oxidation between the two beverage trials (p< .05). At the end of the 30-minute performance trial blood glucose values were significantly higher in the CHO trial (4.8 ± 1.3 mmol.l-1 vs. 4.0 ± 0.5 mmol.l-1 for placebo trial; p< .05). The CHO beverage resulted in higher CHO oxidation during the last 5 minutes of the performance trial, 2.1 ± 1.0 gmin-1 vs. the placebo beverage 1.9 ± 1.0 gmin-1 (p< .05). The CHO beverage trial resulted in significantly higher RER values during the final 5 minutes of the exercise trial and during the final 10 minutes of the performance trial. At the 20-25 minute mark RER values were significantly higher with the CHO beverage trial (1.04 ± 0.10) vs. the placebo trial (1.01 ± 0.11) (p< .05). During the final 5 minutes of the performance trial RER values were also significantly higher with the CHO beverage trial (1.06 ± 0.11) vs. the placebo trial (1.01 ± 0.10) (p< .05). The results indicated the participants were not meeting the current dietary guidelines for able-bodied athletes and active adults. Only 25% of the participants met the daily caloric requirements for active adults. Carbohydrate recommendations of 6 to 10 gkg-1 body weightd -1 were not met by any of the wheelchair athletes Seven participants were within the acceptable macronutrient range (AMDR) for CHO. For protein intake, 63% of the participants were meeting the protein recommendations active adults and all of them were within the AMDR. Average caloric intake from fat exceeded current recommendations of 20 to 25%; two participants were above the AMDR. The results demonstrate that the 8% CHO beverage consumed during exercise resulted in higher CHO oxidation rates and elevated blood glucose values, but it did not result in a performance gain.

Diabetesmellitus typ 2 ökar kraftigt både i Sverige och i övriga världen. Detta kanrelateras till sämre matvanor och övervikt. Förvirringen kring vad människorska äta för att hålla sig friska och sunda har aldrig varit större. Det finnsskilda uppfattningar och media sänder olika budskap. Sjuksköterskan ska arbetaefter vetenskap och beprövad erfarenhet, och ska därmed kunna ge rättinformation till patienter avseende kost. Syftet med litteraturstudien var attkartlägga effekterna av lågkolhydratkost till patienter med diabetes typ 2genom att sammanställa aktuell forskning. Resultatet visade bland annatbetydande viktreduktion samt minskning av HbA1c och antidiabetika.Inga negativa effekter på kardiovaskulära riskfaktorer sågs. Sjuksköterskan kandärför ge information om lågkolhydratkost och dess effekter för att underlättaför diabetes patienter att ta beslut i sin egenvård. Det ställer dock krav påuppföljning från sjukvården för att undvika hypoglykemi hos patienterna. Dåartikelsökningen endast genererade i kvantitativa studier behövs det iframtiden kvalitativa studier för att få fram effekterna av lågkolhydratkost påpatientens upplevelse av hälsa och livskvalitet. Det behövs ocksåuppföljningsstudier för att få fram långtidseffekterna av att ätalågkolhydratkost för diabetiker. / Diabetes mellitus type 2 is increasing rapidly in Sweden and all over the world. This can be related to bad eating habits and overweight. The confusion about what people should eat to stay healthy and slim has never been bigger. There are different ideas and media sends different messages. The nurse shall work for science and proven experience, and will therefore be able to provide the right information to patients regarding diet. The purpose of this study was to identify the effects of low carbohydrate diet in patients with type 2 diabetes by compiling the current research. The result showed among other things, significant weight reduction and decrease of HbA1c and antidiabetic medications. No negative effects were observed on the cardiovascular risk factors. The nurse can therefore provide information about low carbohydrate diet and its effects to make it easier for diabetics to make decisions in their self-care. It does however require follow-up from health care to avoid hypoglycaemia in patients. Since the article search only generated in quantitative studies, qualitative studies are needed in the future to obtain the long term effects of low carbohydrate diet in patients experience of health and quality of life. It also needs follow-up studies to obtain the long term effects of eating low carbohydrate diet for diabetics.