Almost a century ago the Lancet warned that ‘it is the starchy carbohydrate foods rather than the more quickly and readily metabolised fats which are responsible for much of the alimentary type of obesity’ (Anon, 1926); an 18-country study found that ‘high carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality’ (Dehghan et al, 2017); and Wincanton-based GP Dr Campbell Murdoch and colleagues reported that a low-carbohydrate diet in the management of type 2 diabetes ‘can lead to improvements in the condition, reduced medication burden, and (where needed) weight loss’ (Murdoch et al, 2019).
By contrast, the advice of Public Health England (2018) to ‘base meals on potatoes, bread, rice, pasta or other starchy carbohydrates’, appears incongruous, given that Harcombe (2017a; 2017b) and Harcombe et al (2017) have shown that current UK dietary guidelines are not evidence-based.
The effect of low-carb on those with type 2 diabetes
Meanwhile, some are finding that low-carbohydrate diets are meeting the challenge of diabetes. For example, Southport-based GP Dr David Unwin—NHS Innovator of the Year 2016—and colleagues found that ‘adherence amongst people with type 2 diabetes or glucose-intolerance to … [a low-carbohydrate diet] for an average of two years resulted in significant improvements in blood pressure, weight and lipid parameters despite “deprescribing” of 21.5% of the total drugs for hypertension’ (Unwin et al, 2019). A Report from the Parliament of Western Australia (2019)—citing Unwin's work—states: ‘If there is one thing to take away from this report it is that type 2 diabetes can go into remission and it need not be a life-long progressive chronic illness’.
Low-carb diets may help individuals achieve drug-free remission of diabetes, improvements in blood pressure and weight loss
This is confirmed by many GPs and practice nurses who favour the low-carbohydrate diet approach. Unwin, Ambassador for the All-Party Parliamentary Group (APPG) on Diabetes, told Practice Nursing: ‘My wife Jen is a clinical psychologist, and in 2012 we got the idea of Hope for type 2 diabetes. One of my patients had put her diabetes into drug-free remission by cutting sugar and starchy carbs. I wondered if this could be replicated, but the practice was overstretched and understaffed. Rather than a fear-based approach, Jen suggested a hope-based one, including group consultations to augment a low-carbohydrate diet. We could help twenty people at a time’.
Seven years later, 275 of Unwin's patients (142 with type 2 diabetes) have chosen a low-carbohydrate diet, maintaining it for an average of 2 years. ‘So far,’ adds Unwin, ‘71 people have achieved drug-free remission of diabetes; average weight loss exceeds 9 kg; and total weight loss exceeds two metric tons!’.
Comparable results have been achieved by Catherine Cassell—lead general practice nurse for diabetes at Yeovil's Preston Grove Medical Centre—who was nominated for the RCNi's Patient's Choice Nurse of the Year Award 2018 for her low-carbohydrate diet work: ‘Discovering low carb 3 years ago was life-changing for myself and many of my patients. I went from presenting an outlook of type 2 diabetes being a chronic disease to one of hope that patients could achieve remission by adopting a low-carb lifestyle without medication. Patients are taking control of their lives and improving their health and wellbeing’.
Cost savings for the NHS
Cassell—who in 2018 addressed the APPG in Westminster with Unwin—has 34 patients who have achieved drug-free type 2 diabetes remission with low-carbohydrate diets, and sees improvements in glucose control, lipids, liver function and kidney function: ‘There's a cost saving in not having to initiate oral medication on diagnosis and also de-prescribing for patients who had type 2 diabetes for some time but have improved their glucose control with low-carb lifestyles’.
Cost savings were demonstrated by Unwin et al (2016), who reported that following a low-carbohydrate diet approach, their 9500-patient practice ‘compared to the average for the area was found to have; a significantly better quality of diabetes control, lower obesity prevalence whilst spending around £50 000 less per year on drugs for diabetes’.
Type 1 diabetes and low carb
Is there a different approach to type 1 diabetes patients compared to type 2 diabetes patients? ‘Both groups,’ explains Cassell, ‘need support when adopting a low-carb approach. Most type 1 diabetes patients count their carbs and are aware of how much insulin to take relative to their carb intake. They should be counselled that fewer carbs equals less insulin and they need to be both “hypo-aware” and aware that they'll need to test their blood glucose concentrations more often. Many type 1 diabetes patients now choose a low-carbohydrate diet to manage their condition and find they're having the best glucose control they've ever had, with fewer hypoglycaemia and hyperglycaemia episodes.’
How can practice nurses adopt this approach?
What advice for practice nurses considering a low-carbohydrate diet approach in their own practices? ‘Try a low carb lifestyle,’ Cassell suggests, ‘and see how you feel. I've lost over two stone since “practising what I preach” and feel great. This is inspiring and motivating for my patients. I've a renewed passion for my work and feel I'm making a difference in my patients' lives'. In February 2020, Cassell and colleagues furthered the low-carbohydrate diet theme when they organised a successful Primary Lifestyle Conference in Birmingham, which was aimed at NHS health professionals in primary care.
‘Discovering low carb 3 years ago was life-changing for myself and many of my patients.’
One refinement of the low-carbohydrate diet approach is the multi award-winning Low Carb Program (https://www.lowcarbprogram.com/) developed by Diabetes Digital Media (DDM) in collaboration with Dr Unwin. Its evidence-based behaviour change programme has helped over 430 000 people with type 2 diabetes, prediabetes and obesity. NHS-approved, the Low Carb Program is available as a digitally delivered app, which can be downloaded onto smartphones and other devices. NHS users can benefit from the Low Carb Program for free via referral from an NHS health professional. In 2019, DDM's Chief Operating Officer Charlotte Summers was named ‘Digital Leader of the Future’ at the Future Stars of Tech awards and the Low Carb Program was invited to the NHS Innovation Accelerator, which supports uptake and spread of proven, impactful innovations across England's NHS, benefitting patients, populations and NHS staff.
Further endorsement of low-carbohydrate diets comes from Gloria Lamptey, a Diabetes/Vascular Clinical Nurse Specialist at North Middlesex University Hospital NHS Trust, who has recommended the Low Carb Program to over 50 patients, saying, ‘everyone who does it well has great results, with an estimated 9 out of 10 reducing their blood sugar concentrations, losing weight and in some cases reducing blood pressure levels’.
Dr Unwin says, ‘In my lifetime I've seen an eight-fold increase in the prevalence of type 2 diabetes. I worry that soon nobody will remember a time before obesity and diabetes became normalised in society’. The successful low-carbohydrate diet approach implies that this diabetes trend is reversible.