Peer-reviewed evidence refutes the idea that type 2 diabetes (T2D) is a progressive, irreversible, drug-dependent condition. For example, in 2021, a review published by the British Dietetic Association stated that ‘total dietary replacements and low-carbohydrate diets have been demonstrated as being effective in facilitating weight loss and remission of T2D.’ This is cited by the authors of a practical primary care-based study (Unwin et al, 2023) undertaken at Southport's Norwood surgery in northwest England, whose low-carbohydrate diet approach to T2D is helping revolutionise the condition's management.
The study
Of 186 T2D patients who chose a low-carbohydrate approach — which included one-to-one GP consultations, plus group consultations and personal phone calls as necessary — not only did 97% improve their diabetic control, but 77% of those who had T2D for less than 1 year achieved drug-free remission in a matter of months. Further, Norwood surgery spent £4.94 per patient annually on diabetes drugs compared with £11.30 for local practices, translating to annual savings of £68 353 compared with the area average.
Low-carbohydrate approach
The Norwood study lead author Dr David Unwin (Twitter @lowcarbGP) — NHS Innovator of the Year 2016 and Ambassador for the All-Party Parliamentary Group on Diabetes — helped publish a Royal College of General Practitioners e-learning module on the low-carbohydrate approach that has been adopted by over 1500 GPs to date. Unwin told Practice Nursing: ‘This has always been something of a “grass roots” revolution enabled by social media, particularly Twitter. Many doctors have realised the potential of a low-carb approach by a patient presenting with amazing results … as I was! Many people with T2D,’ adds Unwin, ‘are excited by the hope of drug-free remission; others have heard how “cutting the carbs” aids weight loss without hunger, and both fuel a steady increase in people trying the approach, generating significant results.’ Unwin also highlights a free low-carbohydrate app by GP Dr David Oliver of Freshwell Health Centre, Essex (https://www.freshwell.co.uk), and emphasises the logic of low-carbohydrate dieting: ‘High blood sugar concentrations damage arterial walls and are linked to all-cause mortality, so it's sensible to control sugars and starches that raise blood sugars. Illness or stress can raise blood sugar, but 95% of high blood sugars I see in practice are due to patients’ diets. After nearly three years on our diet only 5 out of 186 people had failed to improve their HBa1c.’
Clinical improvements
Report co-author Dr Simon Tobin (Twitter @DocRunner1) is a full-time NHS GP and Diabetes Lead at Norwood surgery, describes witnessing how a low-carbohydrate approach helps T2D patients: ‘For the first time I can offer my patients hope. One patient in her mid-80s had an HbA1c of 135 mmol/mol (14.5%), mainly due to eating biscuits. Over six months, after not eating biscuits, her HbA1c plummeted to 48 mmol/l (6.6%) and she came off metformin too.’
Low-carbohydrate strategies and type 1 diabetes (T1D)
Many of Tobin's T1D patients have benefited from carbohydrate reduction: ‘Years ago,’ he explains, ‘the common advice was “eat what you want and adjust your insulin to keep your sugars in the normal range”. We're now aware that if high insulin doses are used for years, T1D patients can develop insulin resistance (like T2D) requiring further insulin for sugar control. The best way to avoid this is to “turn off the tap” and reduce sugar and carb intake.’
However, Tobin stresses that T1D patients need to take great care when considering carbohydrate reduction: ‘There's a significant risk of hypos if insulin doses are not reduced at the same time and this should only be done in close collaboration with a diabetes specialist health care professional.’
Psychological support and a low-carbohydrate approach
Unwin et al (2023) note that ‘the T2D remission rate at the Norwood surgery has improved every single year since 2017.’ Why is it effective? ‘We believe that offering hope of a better future is essential, coupled with clear messages delivered by supportive peers and professionals’ (Unwin et al, 2023). An important aspect of this is psychological support. Co-author Dr Jen Unwin (Twitter @jen_unwin) is a clinical health psychologist and told Practice Nursing that ‘it's always worked well to get the clinicians to start with the person's motivation: what do they want to be better? Also encouraging small, achievable changes which the patient themselves suggest rather than “advice”! It's also helpful for patient and clinician to reflect on what works and what has improved. Most participants noted benefits in their mental as well as physical health and this further motivated them to keep going. Finally, group support is central for most people to maintain long-term gains.’
Practice nurses and low-carbohydrate approaches to T2D
Catherine Briscoe is one of a team of three practice nurses at Norwood surgery. What would she advise fellow practice nurses considering a low-carbohydrate approach for their T2D patients? ‘Talk to them about starchy carbs and sugars, show patients David Unwin's sugar infographic charts (https://phcuk.org/sugar/), and introduce them to the Freshwell Health Centre app.’ Patients, says Briscoe, are often shocked at how much sugar is in what they had considered to be a healthy breakfast choice of cereal and fresh juice: ‘This knowledge empowers patients, giving them hope that they can control their own health and wellbeing without medication. It's so motivating when they return after a few weeks to have their HbA1c reviewed and find that their efforts have often been rewarded with dramatically reduced readings.’
Briscoe also suggests that practice nurses try it themselves: ‘I started low-carb and felt better in terms of energy, mental clarity and improved understanding of the pitfalls patients may experience. Bread is often the biggest hurdle as it's convenient and seems to be everywhere. I now discuss the importance of meal planning with patients, and we analyse a typical daily diet together, considering options.’
Finally
Unwin et al (2023) state: ‘People with established long-term T2D which may be poorly controlled could benefit from looking carefully at reducing sugar and starchy carbohydrates.’ Thus confirming that advice in the Eatwell Guide (Public Health England, 2018), encouraging people to ‘base meals on potatoes, bread, rice, pasta or other starchy carbohydrates …’ is neither helpful nor, as Harcombe (2017) shows, evidence-based.