Low Carb Diet as Treatment for Diabetes
The NHS currently spends £1.5 million an hour or 10% of its total budget on diabetes. This totals an estimated 11.7 billion a year for treatment of diabetes type 2 itself and critically, the complications of diabetes, with the latter representing a more significant amount. Over 8 billion of the total figures is for inpatient care arising from complications.
These figures do not take into consideration the cost of work absenteeism, early retirement, or social benefits, which total 15.4 billion a year.
Every year these figures are going up and up. However, NHS GP, Dr David Unwin, founder of the Low Carb Program has been utilising a low carbohydrate diet (LCD) as treatment for diabetes in his clinic for many years and has recently published his results.
Over a period of eight years, LCD was offered to all patients with an existing or new diagnosis of type 2 diabetes (T2D). Of those offered, 186 patients started a LCD, equalling 39% of his patients with T2D. Patients were given educational material plus on average three additional 10-minute appointments per year. They were also offered 90-minute evening group sessions every six weeks with relatives encouraged to attend.
Behavioural changes were employed, encouraging patients to consider their individual hopes and health goals, plus the hope of drug free remission for T2D. The average age of patients was 63, with 33 months the average time on LCD and an average weight loss of 10kg. HbA1c (glycosylated haemoglobin – effectively how sticky a person’s haemoglobin is, a long-term marker of blood sugar control) dropped from 63 to 46 mmol/mol*.
*Note: under 42 is normal, 42-48 pre-diabetic and over 48 diabetes).
Blood cholesterol levels fell on average by 0.5 mmol/L and triglycerides by 0.9 mmol/L. It is worth remembering that a LCD is also a high fat diet.
The overall remission rate was 51%, with those diagnosed within one year, achieving remission in 77% of cases. Even those with a 15-year history had 20% remission rates**.
**Note: even those still classified as diabetic had huge reductions in HbA1c.
The practice cost of diabetes per patient per year dropped to £4.94 while the national average is £11.30. Think about that in terms of cost savings for the NHS, spending £11.7 billion on diabetes a year. How many billions could they reallocate to other services straining under the weight of diabetes?
The discussion highlighted some interesting points to consider:
- Ongoing support was critical – the practice response to LCD has gone up and up since they gave more support in one-to-one sessions and in a group setting. This is both education and accountability.
- Focusing on LCD as a lifestyle not a diet – discussions around food as an addiction helped patients with their relationship with food.
- Frank honesty about the importance of weight loss for health – this was key to the outcomes. In contrast to this, they note their less experienced colleagues worried that talking about obesity was “fat shaming”.
Things they did not do, which could increase results even further from the literature and my personal clinical experience:
- Intermittent fasting – the 16-8 method is now well established as an effective way to help metabolic health. We have 24 hours in a day, fast for 16 and utilise an 8-hour feeding window. For most people the easiest way to employ this is by not eating breakfast, which is usually a very carbohydrate heavy meal. Break the fast around noon and consume 2 large, nutrient dense meals, with a focus on quality fat and protein, minimal carbohydrate with a low glycaemic load. Alternatively, two normal sized meals with snacks in between, aiming to finish in the evening usually around 8 pm. This is relatively easy to do as it makes your morning routine easier, thus is very sustainable and helps avoid a traditionally high carb meal.
- Eating your protein/vegetables in the meal first and carbohydrate/sugar last – we also know from multiple studies that doing this can drop blood glucose response in the hours after food by approximately 20-70%. But even better than that we have real world data with the same interventions over 3-24 months, showing significant reductions in long term marker HbA1c, compared to diet alone, without ordered eating.
- Consume apple cider vinegar (with the mother) – this is a traditional food with many suggested benefits. The acetic acid is an excellent addition to help blunt blood sugar spikes according to recent meta-analysis. The acid also helps people digest better as many older patients are under producing stomach acid which is critical for absorption of protein, minerals and B12. The acidity from the stomach is also the trigger for release of bile and pancreatic enzymes, which are critical for fat absorption and proper breakdown of carbohydrates respectively.
- Exercise – we encourage a blend of traditional cardiovascular, low level exercise and some high intensity internal training (HIIT). The latter is often best performed on a stationary exercise bike depending on the neuro-mechanical health of the patient and allows vigorous exercise to push the heart rate up for short periods. HIIT has been shown to often work better for weight loss than traditional cardiovascular exercise.
- Supplementally chromium and alpha lipoic acid – these are both well evidence-informed interventions to help lower blood glucose levels and restore insulin sensitivity.
Jenny is in her late 70’s, diagnosed with T2D in her early 50’s, and has a long history of yo-yo dieting using a low fat approach via Weight Watchers/Slimming World. She uses metformin and three blood pressure medications and is approximately 5 stones overweight.
She has tried a LCD before but failed as she struggled to increase her fat intake and ended up in a calorie deficit which led to binge eating. She refused to entertain the idea of not eating breakfast as she was always ravenously hungry upon waking and had been told it was the most important meal of the day. She subscribed to the online LCD group and found the educational information, daily group calls and forum, invaluable.
By stabilising her daily blood sugar spikes with the high fat LCD, she was also able to begin to extend her fasting in the mornings from 12 hours out to 16. This, plus a regular exercise regime, eating her vegetables/protein first, carbohydrate last, and apple cider vinegar, over period of 18-24 months, she lost 4.5 stones in weight. With her GP’s consent, she was able to slowly reduce her metformin, and finally remove it all together. She also was able to stop two of her blood pressure medications and reduce by 50% the remaining medication. She was officially in remission from T2D when she turned 80.
All too often, patients are simply given a prescription for metformin with no discussion on why they might be diabetic and how they might take an active role in their own health. Given Dr Unwin’s remarkable success with a patient-centred approach, we can only hope the NHS takes note, and the NICE guidance is modified to recognise that remission is possible via diet (the root cause). This could lead to huge saving of money, quality of life and additional years of life.
- Unwin D, Det al. What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss BMJ Nutrition, Prevention & Health 2023;e000544. doi: 10.1136/bmjnph-2022-000544 https://nutrition.bmj.com/content/early/2023/01/02/bmjnph-2022-000544.abstract
- Hadi A et al. The effect of apple cider vinegar on lipid profiles and glycemic parameters: a systematic review and meta-analysis of randomized clinical trials BMC Complementary Medicine and Therapies (2021) 21:179 https://bmccomplementmedtherapies.biomedcentral.com/articles/10.1186/s12906-021-03351-w
- Albosta M et al. Intermittent fasting: is there a role in the treatment of diabetes? A review of the literature and guide for primary care physicians. https://pubmed.ncbi.nlm.nih.gov/33531076/
- Akbari M et al. The effects of alpha-lipoic acid supplementation on glucose control and lipid profiles among patients with metabolic diseases: A systematic review and meta-analysis of randomized controlled trials Metabolism Clinical and Experimental 87 (2018) 56–69 https://www.metabolismjournal.com/article/S0026-0495(18)30153-7/fulltext
Article by Simon Billings
Founder of the Academy of Chiropractic Nutrition, a system of nutrition and functional medicine knowledge for chiropractors.