Hope and diabetes remission

• Continuous glucose monitors (CGMs) reveal glucose around the clock and make clinical work easier. A scientific advisory role with Abbott Laboratories is a conflict of interest. Hope, N=1 evidence, and sustaining improvements are central to diabetes care.
• Chris had poorly controlled type 2 diabetes at about age 40, weighed 19–20 stone, and had hypertension and fatty liver. Relatives' amputations frightened him. British mortality modelling links each year of poorly controlled diabetes to a loss of roughly one-third of a year of expected life. [1]
• Chris achieved long-lasting drug-free diabetes remission through carbohydrate restriction. After 25 years of GP work without such cases, the NHS practice achieved 159 remissions, 23% of its diabetes register, alongside about £370,000 in cumulative diabetes-drug savings. His case was published in the BMJ in 2015. [2]
• Offering patients a choice between dietary change and lifelong medication changes the clinical conversation. Metformin can cause diarrhoea in about 30% of patients; nobody offered this choice in the Southport practice declined the lifestyle approach.
• These changes provide hope for patients and renewed professional satisfaction for clinicians. Burnout had almost ended the GP's career in 2012, but outcomes like Chris's supported continuing clinical work at age 68.

Anecdotes, black swans, and clinical discovery

• At a Swiss Re nutrition meeting in Zurich, academics dismissed and humiliated a woman who had lost weight and improved her blood pressure and mental wellbeing by reducing carbohydrate. Her individual experience had relevance and did not warrant dismissal as an anecdote.
• One black swan disproves the universal hypothesis that all swans are white. Similarly, an N=1 case can overturn a universal clinical assumption; replication then establishes whether the outcome occurs again.
• Chris was an early black swan for fatty liver: his ALT was abnormal for roughly a decade, from 2002 to 2012, then improved markedly after carbohydrate restriction. A low-fat diet is not the only dietary approach that can help fatty liver.
• Another woman had abnormal GGT and ALT and non-alcoholic fatty liver disease for over eight years; specialists blamed her dietary fat or alcohol. After carbohydrate reduction for prediabetes, her liver tests normalized.
• Liver-function tests sometimes improved within three weeks. A series of 95 low-carb patients, followed for nearly 13 months, had an average GGT improvement of about one-third and a before–after P value below 0.0001. [3]
• Repeated measurements in a single person permit statistical testing: Christine Delon analysed Chris's 13 pre-intervention and 15 post-intervention liver results with a Wilcoxon rank-sum test using continuity correction and obtained a very small P value. A clinical anecdote with serial measurements is data.
• Another patient had eight years of conventional diabetes care, changed diet in October 2020, and maintained six years of drug-free remission; mean HbA1c fell from about 65 to 44 mmol/mol with a very small P value. Further N=1 analyses are being assembled for publication.
• Clinical curiosity is essential. An initially angry patient demonstrated the possibility of drug-free diabetes remission, while many clinicians overlook the causes of substantial changes achieved by their patients.
• Other individual cases included reduced ankle swelling and discontinuation of furosemide. One man in his 80s, near death from heart failure and troubled by diuretics, could wash his car after two months of low carb, mow his lawn a month later, and lived for years.
• Blood pressure fell so much during low-carb eating that standing caused light-headedness. Subsequent work with cardiologist Professor Adrian Brady examined blood pressure and cardiovascular-risk changes and led to a publication. [4]
• A challenge concerning potential renal damage from higher protein intake prompted an audit of renal results. Kidney function improved over several years, leading to a publication on renal function during low-carb care. [5]

Evidence, trials, and real-world applicability

• Results from randomized controlled trials often differed from outcomes in routine general practice. The standard evidence pyramid ranks expert opinion and cases below cohort studies, RCTs, and meta-analyses; this hierarchy was challenged in a BMJ Nutrition editorial. [6]
• Thousands of weight-loss trials have consumed enormous resources—one search yielded roughly 28,000 results—while obesity has kept worsening. Academic funding incentives encourage more RCTs without necessarily solving clinical problems.
• RCTs seek high internal validity by controlling variables and excluding complicated patients. Routine patients often have hypertension alongside depression, arthritis, hypothyroidism, reflux, and multiple medications; trial populations can therefore have weak external validity in everyday clinics.
• Effective outcomes in ordinary clinics can be examined for replication in the UK, Australia, New Zealand, Germany, and North America and for plausible physiology. These are ways to establish external validity despite variation in specific interventions.
• An evidence square gives trials a role in isolating mechanisms while giving scientific evidence, clinical experience, and patient experience equal importance without automatic hierarchy.
• At the Zurich meeting, a senior academic responded to a question about clinicians contributing by saying academics must solve the problems first. Professor Roy Taylor subsequently apologised on behalf of academia, affirming the importance of clinician participation.
• David Sackett's vision of evidence-based medicine integrates best research evidence, individual clinical expertise, and patient choice. It is not cookbook medicine, and rigid guidelines cannot erase clinical judgement or personal experience. [7]

Audits and practice-wide outcomes

• Routine audits of baseline and follow-up data began because of concern that carbohydrate restriction might increase cardiovascular risk. Subsequent data showed favourable changes across all cardiovascular-risk measures monitored in the practice.
• After an average of about 33 months, an audit found weight about 10% lower, HbA1c roughly one-third lower, total cholesterol about 10% lower, HDL about 9% higher, cholesterol ratio about 12% better, and LDL about 13% lower. Professor Roy Taylor was senior author on the published analysis. [8]
• This NHS practice audit had an Altmetric score near 3,400 versus roughly 40 for an average paper and coverage from 26 news outlets. Routine clinical service audits need no ethics approval and are suitable for publication, including in the Journal of Metabolic Health.
• In a newer unpublished analysis with Ben Bikman, the diabetes register contains 551 patients and average low-carb follow-up is 39 months. Roughly half chose low carb, half of those achieved drug-free remission, about 27% of the whole register is in remission, and those without remission still improved HbA1c by about 2%.
• Average HbA1c reductions were compared: about 9 mmol/mol for dapagliflozin, 12 for metformin, and 21 for GLP-1 medicines. The low-carb group achieved about 21 mmol/mol, matching the GLP-1 figure; Tro Kalayjian has observed similarly strong lifestyle results.

Maintenance and ultra-processed food addiction

• Initial success does not guarantee durability: one person's weight cycled repeatedly and ultimately rose from 90 to 136 kg. Long-term maintenance is the holy grail, with ultra-processed food addiction as a major obstacle.
• John, a successful businessman with severe knee pain, could not qualify for urgently needed knee arthroplasty despite years of effort beginning in 2021. His wife found he got up at 4 a.m. to eat discarded bread crusts even with detergent on them; she later used bleach as a deterrent.
• Warnings and persistent pressure were ineffective for John. Abstinence from bread, a CGM, and eventually a GLP-1 drug helped him qualify for and undergo knee arthroplasty and resume running his business.
• About 30% of people with type 2 diabetes have food-addiction symptoms. [9] In group consultations run since 2013, every participant assessed with Jen's CRAVED questionnaire scored in its high range, supporting routine identification of addictive eating.
• Direct questions can identify specific foods that are difficult to control, commonly bread, biscuits, or pizza. Patients often recognise these foods but may conceal them or respond defensively because abstinence feels threatening.
• For addictive foods, moderation perpetuates the cycle, while abstinence is necessary, as with alcohol or nicotine. Continued support is important because addiction can be in remission while vulnerability persists.
• Dietary change needs voluntary commitment and appropriate timing. Someone dealing with divorce or attending solely because of a spouse may be unready; patients can decline initially and return months or years later when willing to engage.
• Addictive behaviours can shift among foods, alcohol, and cigarettes. Chris gave up bread, subsequently struggled with salted peanuts, and returned from a cruise drinking a bottle of red wine daily; with recurring support and a CGM, his fluctuating HbA1c reached its best result.
• Rationalisations for addictive eating include earned rewards, restarting on Monday, keeping food for grandchildren, and prolonged holiday indulgence. Anger at abstinence can help identify a problem food, and moderation perpetuates the cycle.

Further cases of hope

• Josh was 25, weighed 158 kg, had sleep apnoea, and had HbA1c of 57 mmol/mol. Before three months in South America, he received a low-carb information sheet and a CGM and used glucose readings to learn which foods to avoid.
• Josh returned with HbA1c of 31 mmol/mol, subsequently lost 39% of his body weight, maintained drug-free diabetes remission, and ran a half-marathon. He achieved these outcomes without bariatric surgery or GLP-1 medication and learned to manage his health.
• His December 2024 CGM trace stayed low. Low-carb eating commonly reduces hunger, and research links carbohydrate reduction with increased endogenous GLP-1 response.
• Dave weighed 112 kg on his 60th birthday and had severe type 2 diabetes; a major change after 16 weeks was another black-swan case.
• Another recent patient had HbA1c fall without drugs from 79 mmol/mol (9.4%) to 46 mmol/mol (6.4%) in eight weeks. Emerging practice data show eight weeks is the most common time to drug-free remission.
• Billy ate ten Weetabix every morning with milk and sugar—equivalent in carbohydrate impact to 37 teaspoons of sugar. Changing that breakfast helped him manage diabetes and participate actively in his own care.

References

1. [03:24] Estimating life years lost to diabetes: outcomes from analysis of National Diabetes Audit and Office of National Statistics data — https://doi.org/10.1097/XCE.0000000000000210
2. [05:59] A patient request for some "deprescribing" — https://doi.org/10.1136/bmj.h4023
3. [14:21] Can dietary carbohydrate restriction improve obesity and abnormal liver function? A general practice service evaluation looking at weight and gamma-glutamyl transferase results over 7 years — https://doi.org/10.1111/obr.13118
4. [22:04] Substantial and Sustained Improvements in Blood Pressure, Weight and Lipid Profiles from a Carbohydrate Restricted Diet: An Observational Study of Insulin Resistant Patients in Primary Care — https://doi.org/10.3390/ijerph16152680
5. [22:25] Renal function in patients following a low carbohydrate diet for type 2 diabetes: a review of the literature and analysis of routine clinical data from a primary care service over 7 years — https://doi.org/10.1097/MED.0000000000000658
6. [24:23] Reducing overweight and obesity; so how are we doing? — https://doi.org/10.1136/bmjnph-2023-000836
7. [31:47] Evidence based medicine: what it is and what it isn't — https://doi.org/10.1136/bmj.312.7023.71
8. [36:07] What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss — https://doi.org/10.1136/bmjnph-2022-000544
9. [46:07] The prevalence of food addiction and its association with type 2 diabetes: a systematic review with meta-analysis — https://doi.org/10.1017/S000711452500008X