TLDR

Diabetes is what happens when high blood sugar wreaks havoc on the body because either with type I diabetes, the pancreas cannot produce insulin for various reasons or with type II diabetes, no matter how much insulin the pancreas produces, it is not enough insulin to meet the high levels of blood sugar because of insulin resistance (insulin is ignored by cells and blood sugar is not taken up). But fortunately dietary carbohydrate is the main lever here.

My summary is that at this point we have enough long term studies (at least a year) comparing low carb, very low carb, mediterranean diets, low fat diets etc, that the American Diebetes Association chose to cite them in 2019, (https://diabetesjournals.org/care/article/42/5/731/40480/Nutrition-Therapy-for-Adults-With-Diabetes-or), weighing in that hands down the very low carb diets will help you manage your glycemic outcomes on type I or II diabetes, and the A1C outcomes will be equal to or better than what available medications can do. But they strongly underline that registered dietician nutritionists are the key factor because although very low carb and even mediterranean styles have strong outcomes, adherence is the biggest barrier. But as they write, medical nutrition therapy is a covered medicare benefit, so that is good news.

Some quoting from that ADA Report

My go-to for links to the latest nih studies and just well written articles on this topic is dietdoctor.com, and I’m glad that here they pointed out the ADA report, “Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report”. It is amazing that it took the ADA until 2019 to write this, but they finally did it!

This report starts out with a strong statement about the efficacy of nutrition as a therapy of diabetes

And that it saves money!

“This Consensus Report is intended to provide clinical professionals with evidence-based guidance about individualizing nutrition therapy for adults with diabetes or prediabetes. Strong evidence supports the efficacy and cost-effectiveness of nutrition therapy as a component of quality diabetes care, including its integration into the medical management of diabetes; therefore, it is important that all members of the health care team know and champion the benefits of nutrition therapy and key nutrition messages. Nutrition counseling that works toward improving or maintaining glycemic targets, achieving weight management goals, and improving cardiovascular risk factors (e.g., blood pressure, lipids, etc.) within individualized treatment goals is recommended for all adults with diabetes and prediabetes.”

But they underline this should be managed care.

“The American Diabetes Association (ADA) emphasizes that medical nutrition therapy (MNT) is fundamental in the overall diabetes management plan, and the need for MNT should be reassessed frequently by health care providers in collaboration with people with diabetes across the life span, with special attention during times of changing health status and life stages “

They recommend use of medical nutritional therapy throughout and defer to #registered-dietician-nutritionist but they avoid “one size fits all” recommendations

In the section “Is MNT effective in improving outcomes?”

This statement is blunt about nutrition being more effective than currently available medication.

“Reported hemoglobin A1c (A1C) reductions from MNT can be similar to or greater than what would be expected with treatment using currently available medication for type 2 diabetes (). Strong evidence supports the effectiveness of MNT interventions provided by RDNs for improving A1C, with absolute decreases up to 2.0% (in type 2 diabetes) and up to 1.9% (in type 1 diabetes) at 3–6 months. Ongoing MNT support is helpful in maintaining glycemic improvements ().”

And further along the language is more precise about carbohydrates

“Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences.”

“For select adults with type 2 diabetes not meeting glycemic targets or where reducing antiglycemic medications is a priority, reducing overall carbohydrate intake with low- or very low-carbohydrate eating plans is a viable approach.”

They point to two significat randomized controlled trials

Dietary Intervention Randomized Controlled Trial (DIRECT) , lasting 2 years showing best #a1c results for the #[[low carb]] group,

The #PREDIMED trial, 4 years, wow, This one was #mediterranean-style-pattern vs #low-fat-pattern , so after 4 years, “glycemic management improved and the need for glucose-lowering medications was lower in the Mediterranean eating pattern group”

More references from that DietDoctor article

( from here )

From here, this is a good #meta-analysis review from #2022 of 8 #randomized-controlled-trial.

The #ketogenic-diet showed much greater reduction in #a1c after 6 months.

And “It was superior in decreasing triglyceride levels, increasing high-density lipoprotein cholesterol levels, and reducing the use of antidiabetic medications for up to 12 months.”

But it seems they say the benefit disappears after 12 years and they attribute to reduction in diet adherence #adherence to #restriction #[[low carb]]

Reversal and remission

Going back to the ADA report, here is their synthesis about remission

From the section, “What is the role of weight loss on potential for type 2 diabetes remission?”

Basically “remission”, divided into “complete remission” and “partial remission”, is defined by these two trials as the maintenance of earlier glycemic levels without diabetic medication for at least a year.

The Look AHEAD trial (177) and the Diabetes Remission Clinical Trial (DiRECT) (138) highlight the potential for type 2 diabetes remission—defined as the maintenance of euglycemia (complete remission) or prediabetes level of glycemia (partial remission) with no diabetes medication for at least 1 year (177,178)—in people undergoing weight loss treatment. In the Look AHEAD trial, when compared with the control group, the intensive lifestyle arm resulted in at least partial diabetes remission in 11.5% of participants as compared with 2% in the control group (177). The DiRECT trial showed that at 1 year, weight loss associated with the lifestyle intervention resulted in diabetes remission in 46% of participants (138). Remission rates were related to magnitude of weight loss, rising progressively from 7% to 86% as weight loss at 1 year increased from <5% to ≥15% (138). Diet composition may also play a role; in an RCT by Esposito et al. (179), despite only a 2-kg difference in weight loss, the group following a low-carbohydrate Mediterranean-style eating pattern (see Table 3) experienced greater rates of at least partial diabetes remission, with rates of 14.7% at year 1 and 5% at year 6 compared with 4.7% and 0%, respectively, in the group following a low-fat eating plan.