Type 2 Diabetes Research: Reflections & highlights for 2021

We’re proud to say that since the launch of DMP back in 2015, we’ve been pioneering change in terms of dietary treatment of type 2 diabetes – we’ve been sharing knowledge about the benefits of low carb diets. 

Back then low carb diets were considered controversial. Frowned upon by diabetes organisations and many health professionals alike — even though the research was already there. 

Criticisms included:

• Not enough evidence to support recommending low carb eating plans to people with type 2 diabetes
• Cutting out an entire food group (grains) will lead to nutrient deficiencies
• You can’t get enough dietary fibre with low carb diets
• Higher fat intake will increase risk of heart disease
• Higher fat intake will lead to weight gain

Really, the criticisms have been many. Yet over the years, these issues have been challenged by a growing number of research studies that have demonstrated the opposite. 

Not enough evidence to support recommending low carb to people with type 2 diabetes

It was only in 2018 that international diabetes guidelines reached a consensus that low carb diets were a suitable option for people with type 2 diabetes [1,2].

The American Diabetes Association medical care guidelines were updated in 2020 to include the following statement:

“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 preference.” [3; p.S51]

This statement was carried over to the 2021 medical care guidelines [4; p.S56], since the evidence base for the benefits of low carbohydrate eating plans for people with type 2 diabetes cannot be denied. 

Cutting out an entire food group (grains) will lead to nutrient deficiencies/ You can’t get enough dietary fiber with low carb diets

Plenty of people in modern society currently have nutrient deficiencies due to overconsumption of processed foods and poor quality diets [5]. Interestingly, cutting out grains cuts out a lot of the processed garbage, since majority of processed foods are grain-based—increasing overall carb and sugar content. 

Nutrient intake in anyones eating plan will depend on the foods chosen and the construction of an individuals eating plan. Any diet, including diets considered healthy, like the DASH diet, can be nutrient deficient [6]. Not surprisingly, higher carbohydrate diets have been linked to lower intakes of many nutrients too [7].

It is a common misconception that the only place you can get dietary fibre is grains. You can get fibre from many other sources besides grains. 

• Nuts and seeds
• Vegetables
• Fruits
• Small amounts of beans and legumes 

Some of these items provide high amounts of fibre, more than grains. For example, 1 cup brown rice = 3.5 g fibre, 1 tablespoon chia seeds = 5 g fibre.

Higher fat intake will increase risk of heart disease

The whole fat debate goes back a long way and you can explore the ins and outs of it by searching online (Zoe Harcombe is an expert in this arena). It’s interesting that low carb diets have received so much criticism, since there was never any substantial evidence to support low fat diets [8,9].

In terms of low carb for people with type 2 diabetes, the evidence base has demonstrated that higher fat intake appears to IMPROVE heart disease risk factors [10-14]:

• Lowering triglycerides
• Increasing HDL cholesterol (the stuff considering “good”)
• Generally, no difference is seen between study groups for LDL cholesterol (the stuff considering “bad”)
• Improvements in blood pressure are also observed [15]

Higher fat intake will lead to weight gain

Reviews have demonstrated that low carb diets—that will almost always increase your fat intake as a natural consequence of lowering carbs—generally lead to better weight loss than other diets [10]. 

Here’s a chart from an interesting 2021 paper [10]:

All the items marked LCD have improved on a low carb diet in people with type 2 diabetes – note body weight in the first column.

The grey boxes indicate where the items were not reported in studies. 

The dash (-) indicates no differences between diet groups. 

This is a really great chart to visually show that compared to other diets, a low carbohydrate eating plan improves:

• Body weight
• HbA1c
• Triglycerides
• HDL cholesterol

Research Highlights in 2021

Two of the most meaningful things that came out of research in 2021, were:

1. A systematic review and meta-analysis looking at diabetes remission

This was a great paper by Goldenberg and team [16]. It was the first review to only include studies of low carbohydrate diets (<26% carbs), and not those with moderate carbs as well. The results found that low carb diets achieved greater remission than other diets (control groups). 

2. Acknowledgement that diabetes remission is possible

Researchers and practitioners were once ridiculed for even suggesting that remission of diabetes was possible. After all, diabetes is a progressive disease where you’re destined to get worse, prescribed more drugs, develop more complications…right?

WRONG!

It has been demonstrated that diabetes can be put into remission.

The definition of remission has been debated. According to a scoping review of studies, published in PlosOne Med in 2020, there were 96 different definitions of remission! 

Goldenberg [16] suggested the definition of remission as: 

HbA1c <6.5% with or without the use of diabetes medication (p.3)

While the most recent position statements from Diabetes UK [17] and Diabetes Australia [18], suggest the definition of remission:

“where HbA1c levels return to below 6.5% (48mmol/mol) and which is sustained for at least 3 months in the absence of glucose-lowering medications.”

Either way, if you can obtain and maintain a blood sugar level <6.5% with only metformin, or without any medication, you will be considered to have diabetes remission in some circles. 

The general target for HbA1c is <7.0% but research has indicated that HbA1c <6.0% further prevents complications [19]. If that is a goal you can achieve, keep working towards it. 

The strategies to achieve remission are:

• Bariatric surgery
• Very low carb ketogenic diets (<10% energy intake from carbs)
• Very low calorie diets (<800 cal, often by using meal replacement shakes)
• Low carbohydrate diets (10-<26% energy intake from carbs)

The evidence suggests that losing 10-15% body weight induces remission [18].

From a practical perspective, here at DMP we encourage a low carb diet, not a ketogenic diet. While keto can certainly be beneficial. The research indicates, and so does our long-term experience, that keto can be more difficult to adhere to in the long term [16, 13, 11].

Low carb on the other hand provides a wider array of food sources, more flexibility and can be sustained long term—that’s one very important aspect of any eating plan. 

Definition of low carbohydrate eating

Low carb is defined as 10-<26% energy intake from carbs. You might have also seen it described as <130 grams per day—that is an amount if you’re consuming 2000 calories. But what if you are consuming more calories? Or you’re a health professional wanting to recommend more or less calories to patients?

Take a look at the following chart. This is the Carb-Cal Model we published in Diabetes Research and Clinical Practice [20]. The Carb-Cal Model outlines how the carb amount changes as calories change. 

If a person is consuming 1600 calories day, then 120 grams of carbs would not be considered low carb, but moderate carb. The Carb-Cal Model can be a useful tool to work out your carb intake, or for health professionals recommending low carb. 

To make recommendations easier, we normally suggest a range of 50-100 grams per day. These recommendations will keep people well within the low carbohydrate range, where we’ve found people are getting great results.

Low carbohydrate eating is a healthy way of eating for people with type 2 diabetes, that offers great benefits. 

Over the years, we’ve been sharing this information and have supported many people to transform their lives. It’s wonderful to see the tune of the world slowly changing so that we can support more people with type 2 diabetes to get healthier.

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