A Food-Based, Low-Energy, Low-Carbohydrate Diet for People With Type 2 Diabetes in Primary Care

Growing evidence suggests diabetes is not a lifelong, progressive condition and dietary changes alone can lead to diabetes control and remission (1). As previously discussed on CrossFit.com, low-carbohydrate diets are a specifically promising intervention and have been shown in multiple trials to improve glycemic control, in some cases leading to outright remission (2). Previous research has found a variety of carbohydrate-restricting regimens to be effective, with those involving greater reductions in absolute carbohydrate intake — i.e., a ketogenic diet or a combination of calorie and carbohydrate restriction — leading to greater improvements in glycemic control (3). Most trials involving low-calorie, moderately carb-restricted diets have included artificial diets (e.g., shakes and supplements), which limits their generalizability. This 2019 pilot study specifically tested the impact of a food-based, low-calorie, low-carbohydrate diet on diabetes.

Researchers recruited 33 subjects from primary care practices in Oxfordshire, U.K. All subjects were diabetics with a BMI > 30. Randomization was 2:1, with 21 subjects randomized to the intervention group and 12 to control.

Control subjects maintained usual care (receiving standard dietary advice in line with U.K. guidelines) for 12 weeks. Intervention group subjects were instructed to limit calories to 800-1,000 per day, with less than 26% coming from carbohydrate and a minimum of 60 grams of daily protein (4). To simulate a broadly generalizable program, dietary education and instruction was minimal: four 15-20 minute sessions with a nurse practitioner during weeks two, four, and eight. After following this diet for eight weeks, subjects increased calorie intake to a level that led to weight stability (5).

The intervention group lost an average of 9.5 kilograms over 12 weeks (compared to 2 kilograms in controls). Intervention group subjects improved across a variety of measures of glycemic control including HbA1c (63.2 – 46.9 mmol/mol, 25%), fasting glucose (10.0-7.2 mmol/L, 18%) and fasting insulin (95.1 – 72.9 mmol/L, 23%). All changes were significantly different from both baseline and control; no significant improvements in glycemic control were observed in control group subjects.

Intervention group subjects were on an average of 1.4 anti-diabetes medications and 1.4 antihypertensive medications prior to enrollment. Seven subjects (33%) were able to discontinue at least one medication in each category over 12 weeks. No subjects in the control group discontinued any medication. Notably, subjects in the intervention group cited the desire to reduce or cease medication use as a significant motivating factor for continued compliance. No subjects reported side effects or negative events.

The success of this trial is consistent with a growing body of research indicating non-pharmaceutical, non-surgical interventions can reduce the severity of, or even reverse, diabetes. Given the inability of standard-of-care practices (medication, general dietary advice, surgery) to sustainably reverse diabetes without major side effects, additional research is warranted. Researchers should test the impact of various interventions that improve insulin sensitivity and glycemic control — including carbohydrate restriction and exercise — to broadly and sustainably reverse diabetes.

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Notes

1. Type 2 diabetes: Treating not managing; Primary-care led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster-randomized trial; Doctor referral of overweight people to low energy total diet replacement treatment (DROPLET): Pragmatic randomized controlled trial; James Lind Alliance Priority Setting partnerships: Diabetes (Type 2) Top 10
2. Adapting diabetes medication for low carbohydrate management of type 2 diabetes: A practical guide; Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre‐diabetes: Experience from one general practice
3. Dietary approaches to the management of type 2 diabetes (DIAMOND): Protocol for a randomised feasibility trial
4. Notably, subjects’ absolute carbohydrate intake — no more than 65 grams per day — is only slightly greater than that prescribed in many low-carb diets that do not involve deliberate calorie restriction (e.g., Atkins, ketogenic diets).
5. From the authors: “Dietary advice focused on excluding sugary and starchy foods high in carbohydrates entirely from the diet (with the exception of dairy and limited fruit intake), strict portion control and minimal use of fats and oils. Participants were advised to eat fresh vegetables or salad and small amounts of lean meat and fish.”