The foreword to a report published by the Parliament of Western Australia (2019) 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. Some practitioners argue it is reversible.’
These aforementioned practitioners include Hallberg et al (2019), who note that before insulin's discovery in 1921, low-carbohydrate diets were commonly prescribed to treat diabetes. With the availability of exogenous insulin and the emergence of low-fat diets – which, axiomatically, are carbohydrate-enriched – the low-carbohydrate diet's goal of preventing raised blood glucose concentrations was supplanted by that of exerting blood glucose control through glycaemic control medication, including insulin (Hallberg et al, 2019).
The low-carbohydrate approach to diabetes is gaining traction. For example, a recent consensus report on nutrition therapy for people with diabetes or pre-diabetes stated that for certain people who are not meeting glycaemic targets, or where lowering anti-glycaemic medication is needed, reducing overall carbohydrate intake with low- or very low carbohydrate eating plans is a viable approach (Evert et al, 2019). In 2016, the World Health Organization's Global Report on Diabetes cited the Barbados Diabetes Reversal Study to determine the feasibility of reversing type 2 diabetes by incorporating a low-carbohydrate approach (WHO, 2016).
‘A low-carbohydrate approach can benefit patients with diabetes and save on diabetes drug-related expenditure’
Calls for a re-evaluation of the role of carbohydrate restriction in type 2 diabetes have not all been recent. In 2008, Accurso et al presented evidence supporting the rationale behind applying carbohydrate restriction as a means of improving glycaemic control and reducing insulin fluctuations. They concluded that carbohydrate-restricted diets were as effective for weight loss as low-fat diets and that ‘substitution of fat for carbohydrate is generally beneficial for risk of cardiovascular disease.’ (Accurso et al, 2008: 1).
In the UK, Southport GP Dr David Unwin's award-winning strategy showed how a low-carbohydrate approach can benefit patients with diabetes and save on diabetes drug-related expenditure.
Having observed that the meaning of the term glycaemic index (GI) was unclear to many health professionals and patients in relation to blood glucose concentrations, Unwin et al (2016) set about improving how patients with type 2 diabetes understood the importance of GI at the GP's 9000-patient practice. As an aide to understanding, the authors reinterpreted the GI using a ‘teaspoons of sugar equivalent’, and recorded quality markers for diabetes and obesity such as HbA1c and weight, with impressive results: the practice had a superior quality of diabetes control compared to the average for the surrounding area; a lower prevalence of obesity; and saved around £40 000 on diabetes-related drugs (Unwin et al, 2016).
Unwin's approach to the harmful effects of high-GI starchy foods in the treatment and prevention of obesity and diabetes is summarised in a series of seven infographics and endorsed by the National Institute for Health and Care Excellence in March 2019 (Public Health Collaboration, 2019). In 2018, Type 2 Diabetes - a Low GI Approach programme for health professionals, which he co-wrote for the Royal College of General Practitioners, was launched (Jephcote, 2019).
Low-carbohydrate, high-fat (LCHF) diets are keenly debated, with some arguing that their saturated fat content increases the risk of cardiovascular disease, and that they are nutritionally deficient. Zinn et al (2018) address these points, first citing studies from an accumulating evidence-base challenging the diet-heart hypothesis. Zinn et al (2018) designed two LCHF meal plans for two hypothetical cases representing the average Australian male and female weight-stable adult. They found that although the LCHF plans' macronutrient content did not align with Australian/New Zealand national dietary guidelines, they were nevertheless micronutrient replete, and ‘dispels the myth that these diets are suboptimal in their micronutrient supply’ (Zinn et al, 2018: 1).
In England for the financial year 2017/18, there were 53.4 million items prescribed for diabetes, costing £1012.4 million. This has increased by 22.6 million prescription items and £421.7 million since 2007/08 (NHS Digital, 2018). This fact, plus a spiralling obesity/diabetes epidemic, invite the inference that the problem is not being addressed successfully. Perhaps there is a role for low-carbohydrate diets as one part of a multi-factorial solution.