LONDON — Remission of type 2 diabetes so that glucose-lowering medication is no longer needed has been achieved in around 20% of patients using a low-carbohydrate diet at a general practice in Northern England, indicate new data presented at the Diabetes Professional Care 2022 conference.
David Unwin, MD, a primary care doctor at Norwood Surgery, Southport, UK, saw his 125th patient with type 2 diabetes remission after they followed the low-carbohydrate program. “Of those patients who choose a low carb diet, 50% of them achieve remission, saving the NHS drug budget £68,000 per year on diabetes alone,” he reported.
His National Health Service (NHS) practice has 530 registered patients with type 2 diabetes. “We have seen drug-free remission happen 125 times in our practice, which is 20% of our entire NHS diabetic register,” he said during his keynote address.
He presented data on what predicts drug-free type 2 diabetes remission, reporting insights from an 8-year evaluation of the low-carbohydrate program in 186 patients. On average, patients who followed the diet had a mean decrease in A1c of 33%, as well as reductions in triglycerides of 30%, systolic blood pressure of 8.6%, total cholesterol of 10%, and cholesterol/high-density lipoprotein cholesterol (HDL-C) of 12%. Weight also dropped by an average of 10.3%.
And in patients who had followed the low-carbohydrate program for a mean of 34 months, 77% achieved remission if diagnosed up to 1 year prior to starting the program,16% achieved remission if diagnosed 1-5 years previously, and 11% achieved remission if diagnosed 6-15 years previously.
Ruth Tapsell, MBBS, a GP from Hartland Surgery, Devon, UK, has offered the low-carbohydrate program to her patients with type 2 diabetes for nearly 5 years.
“We’ve seen the same results as found by Dr Unwin, including multiple remissions from type 2 diabetes and prediabetes, as well as significant weight loss, especially in those who have yo-yo dieted and struggled with weight all their lives,” she said.
When asked whether she would add antidiabetic medication to the management of patients on the diet who showed a significant drop in A1c but did not achieve remission, she said: “Whether I’d add in drugs or not would really depend on the patient’s A1c, as well as whether they wanted to try drugs or not because some really don’t want them. But we do know the higher the A1c then the worse the outcomes, so I would certainly consider adding in drugs.”
Reversing the Type 2 Diabetes Epidemic
In 1986, Unwin’s practice of 9000 patients had 57 individuals with type 2 diabetes, but now this figure has leaped to 530. “That’s a tenfold increase, and that’s a problem not only for our practice, but across the UK, and across the globe,” he asserted.
“We have no extra funding, nor clinicians, to manage this tenfold increase in clinical need,” he said, adding that because “the damage of type 2 diabetes is a function of time, it’s worse if you’re younger. I see a huge difference in the appearance of the patients sitting in my waiting room — they’re heavier, notably the children.”
This cannot be a genetic change in one generation he explained, so, “there’s no reason, genetically at least, why we can’t reverse this situation back to type 2 diabetes being rare and affecting only older people.”
People with poorly controlled diabetes lose, on average, one third of their life expectancy, and in England alone, over 1 million people are living with the disease, said Unwin, highlighting its vast impact.
In budgetary terms, NHS England spends around £10 billion a year on diabetes — around 10% of its entire budget.
Unwin described how, in 2012, one patient in his practice reversed her diabetes and was able to come off her diabetes medications. This spurred him to develop and run low-carbohydrate diet groups, and now 20% of all patients with type 2 diabetes in the practice are in drug-free remission [defined as A1c in the nondiabetic range of < 6.5% without diabetes medication for at least 3 months].
“This is in an NHS practice without specific funding,” he pointed out.
The low-carbohydrate program is available for all patients with type 2 diabetes, but those diagnosed more recently are more likely to achieve remission, reported Unwin. “If you’ve had diabetes diagnosed in the past year you are 77% likely to achieve remission, but if diagnosed in the past 10 years, this reduces to 10%-15% achieving remission.”
But even those who do not meet the remission criteria can achieve some mitigation, he pointed out. “We found that the worse the diabetes is, the bigger the improvement in blood sugar control with a low-carb diet,” he added.
And nearly everyone hits a holiday or celebration and loses control. “The key is to know how to deal with this next time. We re-frame failure as a learning opportunity, and with this approach, we’ve had people in remission for 10 years,” he said.
Fundamentally, he sees people with diabetes as a puzzle, not a problem. “I’m intrigued by people with poor diabetic control, and I collaborate with them to work out that puzzle,” he said. “I ask them why they think they have high blood sugar and how do they think they could change that. With this approach, we are seeing some of the best results in the world.”
Aside from remission or mitigation, the other task is maintaining the results, which is largely psychological, he highlighted. “Patients need to pay scrupulous attention to both aspects [the remission/mitigation and the maintenance].”
Older people do better than younger ones, Unwin added, whose oldest patient in remission is 92 years old.
“Unexpectedly, older people show a greater improvement in blood sugar control on [a low-carbohydrate diet]. They’re organized, have time, and know how to cook,” he said.
Jen Unwin, PhD, consultant clinical and health psychologist, who is David Unwin’s colleague on the low-carbohydrate program, as well as his wife, provides psychological care to patients.
“Older people are also motivated to stay well. They don’t want to be ill. Their memory, energy, and sleep all improve remarkably. It’s an overall well-being improvement,” she observed.
Turning to those younger than age 50, she remarked that they can do well and can be divided into two groups. Those who understand the physiology can go away and resolve it, but for others, the carbohydrate addiction is greater.
“Why do intelligent people do silly things repeatedly? Younger people are more affected by the obesogenic environment, which has changed dramatically since the 1970s with sugar added to everything,” she pointed out.
“If you’re really addicted to bread — as many people are — you can’t moderate it. Likewise, if you’re addicted to chocolate, you can’t moderate it,” she said, referring to around 20% of their patients with type 2 diabetes who experience such compulsions and cravings. “They can’t just have one biscuit; they have to have the packet,” she explained. “The only way out for these people is abstinence.”
Moderation Does Not Always Work
In terms of clinical practice, David Unwin explained that individualization is key. “It’s about asking the patient, ‘What is your precise problem?’ One size does not fit all. Until someone understands their precise problem, they cannot solve it.”
He also pointed out that explaining the physiology helps. “Eating carbs makes you hungrier. The more you eat, the hungrier you get. They also raise your blood sugar,” he said. “So, in someone with type 2 diabetes, carbs make them hungry and put up their blood sugar. When some people hear this, they suddenly understand themselves. We see this in every clinic.”
Several other family practices in the UK have adopted the low-carbohydrate program for patients with type 2 diabetes, but it takes effort and resources to learn and implement it.
Most GPs are exhausted, and the idea of taking on a new approach is just one too many, he said, when asked why the low-carbohydrate program isn’t more widely available within the NHS. “It involves a new paradigm that doesn’t use drugs and it takes a while for patients to learn. But they do, and only one person in 10 years [since starting the program] has asked for drugs. People prefer to avoid lifelong drugs if they can.”
David Unwin, who was NHS Innovator of the Year in 2016, runs a Google group called the Public Health Collaboration, which has over 500 clinicians working together to spread uptake of the program.
David and Jen Unwin are scientific advisors to a US insurance company, and the proceeds go towards diabetes management. Tapsell has reported no relevant financial relationships.
Diabetes Professional Care 2022. November 16, 2022. Keynote presentation.
Information about the Low Carb Program is available here.
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