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0032 - Low carbohydrate nutrition for diabetes

Diabetes is one of the fastest growing chronic condition in the world. Close to 10% of the population is living with diabetes. That is more than 460 million people worldwide - with half of the cases undiagnosed - and this number is expected to rise to 700 million by 2045! Diabetes causes more than 4 million deaths every year - more than 10% of total deaths - due to health complications.

This condition occurs when the pancreas cannot make enough insulin (type 1 diabetes or T1D) or when the body cannot make good use of the insulin it produces (type 2 diabetes or T2D, the most common type of diabetes). T2D results from genetic, environmental and lifestyle factors. It develops over several decades, when the body becomes "insulin resistant" and is no longer able to respond to insulin signaling, which results in hyperglycemia (high blood glucose levels).

Nutrition plays an essential role in T2D management and prevention as it impacts glycemia control and body weight. T1D used to be treated with severe carbohydrate restrictions. However, with the advent of insulin therapies, the recommended carbohydrate intake increased together with insulin delivery to control glycemia. By the 1980's, a diet with up to 60% of calories from carbohydrates became the standard of care. Unfortunately, evidence now suggests that the overconsumption of refined carbohydrates is a major driver of the current T2D epidemic.

The research on low-carbohydrate diets (LCD)

In the past 15 years, more than 50 scientific studies, as well as overwhelming clinical and anecdotal evidence have shown that dietary carbohydrate restriction is an effective approach for diabetes management. It significantly improves the markers of diabetes (blood glucose and insulin levels, body weight, cholesterol profile, waist circumference, blood pressure...), leads to significant reductions in diabetes medication, and can even reverse T2D, without notable side effects.

Some studies followed diabetics for years while others observed significant improvements in just a few weeks. 60 to 70% of diabetes medication is typically discontinued after 1 year of LCD and insulin therapy is reduced in more than 90% of the cases (versus 23% with the standard of care). The reduction or discontinuation of medication happens even quicker with very low-carbohydrate diets and some diabetics may need to reduce their insulin dosage by 50% almost immediately. The lower the carbohydrate intake, the better the results, although even a 30% carbohydrate diet can lead to notable improvements.

Well-formulated LCD have also been proven to reduce hunger and cravings, inflammation, and the risk of developing certain cancers and diseases associated with insulin resistance or inflammation. For instance, a study who followed diabetics for 44 months observed a significant reduction of cardiovascular events (9% with LCD versus 67% in the control group).

Some clinics now specialise in reversing T2D with LCD. For instance, Virta in the US reverses T2D in 60% of patients after 1 year and decreases or eliminates insulin therapy in 94% of the cases, while also safely reducing obesity, bad cholesterol, hypertension and inflammation.

Endorsement by health organisations

Various diabetes and health organisations around the world have now endorsed LCD as a therapeutic option for T2D, although usually not as the first line of treatment. Sweden (2013), Iceland (2016), Australia (2016 and 2018), Czech Republic (2017), the UK (2017), the US (2018 and 2020) and Canada (2020) recognised that low- and especially very low-carbohydrate diets are safe and effective to improve glycemic control, manage body weight and reduce the need for medication.

In 2019, a Western Australia government committee observed that T2D can go into remission with a LCD and that the Australian Dietary Guidelines “should not be used for people with diabetes”. In the US, the Association of Diabetes Educators started teaching the use of ketogenic diets to manage T1D and T2D. This year, the American Diabetes Association reported that reducing carbohydrate intake for diabetics "has demonstrated the most evidence for improving glycemia", although this statement is buried in a long document and is not a main recommendation.

The use of LCD could therefore be proposed as a first approach to treating T2D and to reducing medication in T1D. However, despite the evidence, the current standard of care does not typically use dietary carbohydrate restriction. It relies on medication and remains suboptimal: controlling glycemia with insulin can be challenging, diabetic medication is expensive, can have serious side effects and does not address the root causes of diabetes.

Why do low-carbohydrate diets work?

The T2D epidemic is mostly due to increased carbohydrate consumption. Of all the macronutrients, carbohydrates have the greatest effect on blood glucose and insulin levels. Fat alone does not impact insulin levels and proteins have a moderate impact. Apart from starvation, carbohydrate restriction is the most efficient dietary intervention to decrease blood glucose levels, insulin production and body weight, allowing the reduction or elimination of diabetes medication.

Carbohydrates are found in many foods: grains, cereals, flour, processed foods, milk, fruits and vegetables. After ingestion, they are broken down into glucose (sugar) in the blood and excess glucose is pulled out by insulin. Overtime, the overconsumption of carbohydrates results in excess insulin production, which desensitises insulin receptors and creates insulin resistance: more and more insulin is required to remove excess blood sugar. Blood sugar and insulin levels remain elevated, which worsens oxidation, inflammation and eventually leads to T2D, obesity and an increased risk of developing chronic diseases.

How to safely adopt a low-carbohydrate diet?

A low-carbohydrate nutrition might sound restrictive but it is very simple and can be delicious: wholesome unprocessed foods such as fatty cuts of meat or chicken, eggs, fish, full-fat dairy products, non-starchy vegetables, avocados, olives and olive oil, coconut and coconut oil, nuts and seeds, mushrooms, berries, herbs and spices. The best results are obtained with less than 50g of carbohydrates per day or 10% of daily calories. Calories do not need to be restricted: carbohydrates are replaced by healthy fats for energy and proteins for satiety and muscle mass preservation.

Diabetics adopting a LCD should be under close medical supervision or capable of adjusting their medication, as it can significantly lower their blood glucose levels. There could also be contra-indications for people with certain health conditions such as liver, heart or kidney diseases, gallbladder issues, gastric bypass or certain enzyme deficiencies.

In summary, a well-formulated low-carbohydrate nutrition is a well-researched, safe and effective option to significantly improve or reverse T2D. While it is not a cure, as going back to a standard Western diet rich in carbohydrates would trigger the return of T2D, it can reduce or remove the need for diabetes medication, improve general health and might be much more appealing than a life-long treatment with medication.

This article is for educational purposes only. It is not a substitute for professional medical advice and is not intended to diagnose, treat, cure, heal or prevent any disease or medical condition. See full Disclaimer here. I encourage you to do your own research and to discuss with a qualified healthcare practitioner the options that could work the best for your specific circumstances.

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