Remission of type 2 diabetes – a dietitian’s perspective, part 1: The low carb crew

“There is ample evidence to support the statement that it is possible to achieve remission in type 2 diabetes.” (1).

What is type 2 diabetes remission (T2DM)? Good question. The experts are actively trying to come to a consensus agreement on this. In 2009, the American Diabetes Association suggested two definitions of remission: partial remission or complete remission. More recently, the joint statement from the Association of British Clinical Diabetologists (ABCD) and Primary Care Diabetes Society (PCDS) (2019) suggested a single definition of type 2 diabetes remission being: HbA1c under the threshold of diagnosis (48 mmol/mol) with a fasting plasma glucose level <7 mmol/L at two separate occasions over six months, off all diabetes medication (a mouthful!).

Whatever your thoughts on the exact definitions of T2DM remissio, we can all agree that patients who achieve remissio, by any method, should and must continue with regular surveillance and management of other risk factors and yearly screening.

In this three-part series I will be examining three ways in which type 2 diabetes remission can be achieved: low carb, bariatric surgery and very low energy diets (VELD).

There are some clinicians who wonder whether we should be focusing on remission at all. I once attended a meeting with bariatric surgeons and endocrinologists, some of whom said the term “remission” may make many people with type 2 diabetes feel “a failure” should they be unable to achieve remission. This may be a fair consideration; recent studies tell us that remission is much more likely in those with shorter duration of type 2 diabetes (up to 6 years).

Remission will not be possible for all with T2DM, but this does not mean that best possible management for that individual should not be explored and encouraged, with all options on the table. As the diet “wars” and research continues, I will focus on the common ground among clinicians, researchers, dietitians and doctors – namely, that we all want what is best for our patients.

My experience using low carb diets

Obesity is a disease. Not everyone with type 2 diabetes is obese, but there are strong links. Robert Lustig (Professor of Neuroendocrinology and obesity expert) describes obesity as a combination of several factors: ‘physics, biochemistry, endocrinology, neuroscience, psychology, sociology and environmental heath all rolled up into one problem’.

There is often a stigma attached to type 2 diabetes. The idea that people with obesity or type 2 diabetes are ‘lazy and eat too much’ or that they should ‘eat less and move more’ are extremely unhelpful. Weight stigma among the general population, and among healthcare professionals (often an unconscious bias) are additional challenges we face when treating people with obesity and or type 2 diabetes.

I have worked in a busy London bariatric centre, and also in weight management and diabetes. Having seen patients from all walks of life, within the NHS and privately who have undertaken different treatments options for type 2 diabetes: pharmacological, bariatric surgery, very low energy diets and low carbohydrate diets, one thing is glaringly clear to me – one option does NOT fit all.

Low carbohydrate diets

Low carbohydrate diets, I believe, are an exciting and important new tool in the type 2 diabetes remission toolbox.

There has been some controversy over the use of low carbohydrate diets in recent years, so first of all, let’s clarify a few things. Low carbohydrate diets are not a “fad diet”, certainly not in the context of type 2 diabetes management anyway. Versions of low carbohydrate, high fat diets for treatment of diabetes have been described since the work of Alle, Stillman and Fitx in 1919 (2). Low carb diets are a safe and effective way of managing blood glucose levels and weight.

Perhaps some of this controversy lies in one’s understanding of what a low carbohydrate diet is. This graph has been adapted from Fienman et al (3)

 “The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate protein and fat are consumed.” (Institute of Medicine, 2005).

This means that carbohydrates are not technically an essential macronutrient. Initial reaction from some people, including healthcare professionals upon hearing the words ‘low carbohydrate diet’ is that we need carbohydrates to “fuel the brain”. This is factually untrue.

Luckily, for many people switching to a diet of less than 130g of carbohydrate is enough to see huge health benefits. The results from the Low Carb Program (which is now available in the NHS Digital app library) show that one in four people can put their type 2 diabetes into remissio, with many more reducing medication dependency

The British Dietetic Association in 2017 (4) acknowledged that low carbohydrate diets are safe and effective in the short term in managing weight, improving glycemic control and cardiovascular risk in people with type 2 diabetes (however, the first line dietary advice remains that people consume a diet high in carbohydrate (50-55% of energy). This advice has been widely criticised in the context of type 2 diabetes management.

Meta-analyses (studies of studies) consistently show that low carbohydrate diets perform at least the same if not better in comparison to low fat diets in the shorter term. So, should it not at least be offered as a choice? Of course it should. It is true that the longer-term data on remission of type 2 diabetes via a low carbohydrate diet does not yet exist. Anecdotally, and certainly within my clinical practice, remission of type 2 diabetes can be sustainable for many years. I believe this diet is particularly valuable in the long term as many people report  they are completely satisfied after food.

In my past experiences of dishing out Eatwell Guide advice in weight management clinics, it was downright depressing. Low fat, high carb diets, with an emphasis on calorie counting (eating less and moving more), simply do not work for many people.

How to use the low carb approach

So, how do we use a low carbohydrate diet safely in clinical practice? As always, discussing pros, cons and side effects should be done before starting any diets or lifestyle changes. Liaising with GPs or medical teams regarding the de-prescription of medication is also very important, especially for those on insulin and sulfonylureas.

Implementing a low carb approach need not be complex. Empowering patients with some very basic physiology can be useful. The British Dietetic Association recognises that: “All types of carbohydrate will increase your blood glucose level. Some people find it helpful to reduce the quantity of carbohydrate in their diet to help control blood glucose levels”.

Sugars and starches (including those recommended with each meal for people with type 2 diabetes) break down into surprisingly large amounts of glucose in the body – which in turn, can raise blood glucose levels. Explain these basic facts to your patient, it is their absolute right to know this – and it is then their own choice as to what they do with this information.

First steps:

• Cut out highly processed foods (sweets, cakes, biscuits etc.), and focus on eating real food as much as possible.

Next steps:

• Significantly reduce starchy carbohydrates and replace with non-starchy vegetables where possible.
• Eat moderate amounts of protein and do not fear fat from whole food sources eg: dairy, eggs, avocados, nuts, seeds, oily fish.
• Learn to love food again!

In 1989, Bernhard Naunyn described fat as the “chief food for the diabetic”.

Most of us will agree that dietary fat has been wrongly demonised for many years. Most patients tell me when they eat fats (from whole, unprocessed foods) they feel more full, more satisfied and clearly have less of a postprandial (after meal) blood glucose response. This is life changing for many people, having been a slave to hunger and cravings for much of their lives. Eating nuts, cheese and other foods which they may have been told to avoid for a long time is a real delight for many of my patients.

A really memorable patient for me was one who had been referred by a diabetes specialist nurse, something along the lines of, “please make sure she is eating enough carbs, as we need to start her on insulin”. She was hostile initially, saying she was fed up of seeing “judgey dietitians”. We discussed her options, as she desperately wanted to avoid insulin. The option of low carb had never been discussed with her before, in fact it had been dismissed by her other healthcare professionals. I feel this is wrong in so many ways.

We had a really enjoyable discussion about different options, and she wanted to try low carb. She was lucky enough to be able to self-fund a CGM (continuous glucose monitor) and started to check her response to carbs after meals.  During her next appointment, she was rather annoyed, and asked why on earth she had been told to have porridge and banana for breakfast for many years, when it consistently increased her blood glucose level into the high teens. Good question! A few weeks later, her diet had changed dramatically to a lower carb, healthy fat diet, guided by her own blood glucose levels. She was over the moo, having stopped her gliclazide and proudly doing a dance around the clinic room. She narrowly avoided a lifelong journey of insulin, and instead was on the road to type 2 diabetes remission.

As with many people who follow a low carbohydrate lifestyle, she could not believe how much energy she had, and how she no longer felt constantly hungry. It’s moments like this that make being a dietitian enjoyable for me.

We can argue that the long-term randomized evidence is not yet there, however it seems to meet that supporting people to choose a diet of lifestyle which suits them clearly shows benefit.

In part two of this series later I will be detailing how bariatric surgery is being utilized to help achieve type 2 diabetes remissio, and in part 3 I will look at very low energy diets.

Want to learn more and become confident with the low carbohydrate approach for the management of prediabetes and type 2 diabetes? Register your interest for healthcare professional training here.

Tara Kelly

Registered Dietitian & Research Associate

Dietitian at Diabetes Digital Media

References

1. Remission of Type 2 Diabetes: A Position Statement from the Association of British Clinical Diabetologists (ABCD) and the Primary Care Diabetes Society (PCDS)
2. Alle, FM. Stillma, E, Fitz, R. 1919. Total Dietary Regulation in The Treatment of Diabetes. The Rockefeller institute for Medical Research.
3. Feinma, D. et al (2015) Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base. Nutrition.
4. British Dietetic Association (2018) Policy Statement – Low Carbohydrate Diets for the management of Type 2 Diabetes