Before low-carb: diabetes care without remission

• For 25 years, type 2 diabetes care focused on blood sugar prescriptions without investigating the causes; chronic disease care frequently misses underlying causes.
• Repeat prescriptions dominated while patients developed ulcers, amputations and escalating medication regimens; the work became management of decline.
• Before 2012, drug-free remission was absent in the practice; higher doses, additional drugs and eventually insulin were the usual progression.
• An NHS low-carb programme later achieved remission in approximately half of participating patients, a major change from earlier outcomes. [1]
• Severe dyslexia made medical training difficult despite a strong commitment to helping people; better patient outcomes renewed that purpose.

Publishing outcomes in a normal NHS surgery

• The first 18-patient low-carb case series documented major improvements and triggered hostility among some dietitians, endocrinologists and doctors. [2]
• Public heckling and hate mail led to baseline measurements, weekly follow-up, inclusion of poor outcomes and continuous programme audit.
• These audits improved clinical methods; observational data follow actual patients, with similar work emerging in multiple countries.
• A subsequent 186-patient NHS service evaluation found about 50% remission without expensive concierge care or a large dedicated team. [1]

How low-carb advice works

• Norwood Surgery diet sheets and protocols are available in BMJ Nutrition papers; no single carbohydrate limit applies to every patient. [1][3]
• With insulin resistance, glucose processing is impaired; lowering foods that raise blood sugar and increasing protein and healthy fats addresses this.
• Research commonly defines low-carb as under 130 g/day, while the effective level depends on individual glucose response.
• Goals and baseline HbA1c, weight, waist or CGM values guide reassessment; drug-free remission requires HbA1c under 48 mmol/mol (6.5%).
• Initial remission or satisfactory weight and long-term maintenance are distinct challenges.

Maintenance through feedback and psychology

• Longer participation at Norwood Surgery coincides with continued average HbA1c improvement; Jen Unwin's psychology input supports maintenance.
• Progress checks around six weeks and immediate CGM feedback connect glucose spikes with recently eaten foods, without waiting three months.
• The DiRECT programme achieved nearly 50% remission after one year, declining to approximately 12% after five years. [4]
• Birthdays, Christmas, holidays, bereavement and stress contribute to lapses, and almost everyone eventually needs renewed support.
• Persistent pressure to eat carbohydrates in the wider food environment makes ongoing support essential.

Food addiction and long-term adherence

• Failure to ask about food addiction left it unrecognized alongside the absence of remission; questioning patients revealed substantial cravings for bread and other carbohydrates.
• A food-addiction study connected addiction with a 670% greater likelihood of type 2 diabetes, making screening important. [5]
• Jen Unwin's CRAVED questionnaire sometimes identifies carbohydrate addiction throughout groups of approximately 30 people with diabetes.
• Severe mental-health symptoms can motivate sustained ketosis, while food addiction can interfere with ketogenic adherence, as Iain Campbell has observed.
• Moderation of bread, potatoes and other problem foods can fail for affected patients; abstinence can be more effective.

Growing acceptance and visible glucose responses

• An initially isolated and unpopular low-carb approach now has an international network, dozens of annual talks, thousands of attendees and continuing critics.
• CGMs expose glucose responses; a small bowl of cereal doubles Unwin's blood glucose and causes illness in his own type 2 diabetes.
• Some criticism attributes low-carb benefits entirely to weight loss, while other data indicate effects on diabetes beyond weight reduction.
• Approximately 30 papers have been published by the team, alongside clinical learning shared across countries.

GLP-1 drugs: benefits, limits and combinations

• Low-carb often lowers hunger and body weight; Isabella Cooper's work links nutritional ketosis to higher endogenous GLP-1. [6]
• Unwin's roughly 15 years of GLP-1 prescribing include reduced cravings for ultra-processed foods and alcohol alongside severe adverse outcomes.
• Two patients required intensive care: one nearly died of pancreatitis, and another needed removal of most of the bowel after stasis and necrosis.
• A minimal effective GLP-1 dose for limited duration with a discontinuation plan addresses escalating doses, adverse effects and weight regain.
• GLP-1 therapy offers an interval for reducing addictive foods and increasing protein, beyond simply decreasing portions of junk food.
• One patient lost 1 kg over five years with a GLP-1 drug and 27 kg over two years with low-carb; efficacy varies for both approaches.
• Real-world GLP-1 evidence indicates up to 50% discontinuation within two years, requiring plans beyond initial weight loss.
• For severe food addiction and poorly controlled diabetes, combining CGM, GLP-1 therapy and low-carb with collaborative decisions can improve adherence.

Medication safety during carbohydrate reduction

• Insulin, sulfonylureas and SGLT2 inhibitors need medication review as carbohydrates fall; practical clinician guidance is available in a published paper. [7]
• With CGM and close support, initial insulin dose reductions of 50%, followed by further reductions, have enabled some long-term users to stop insulin.
• SGLT2 inhibitors can cause euglycemic ketoacidosis, making hydration important on low-carb; doses are sometimes halved and eventually discontinued.
• Glucose in urine can lead to severe thrush; metformin and GLP-1 drugs are compatible with low-carb without intrinsic hypoglycemia risk.
• Individualized, clinician-led adjustments with monitoring are necessary.

The changing food environment

• In earlier medical training, type 2 diabetes was uncommon and absent among patients younger than 60; it now affects younger people.
• Limited genetic change over forty to fifty years implicates the changed food environment in the diabetes epidemic.
• Changing the food environment and addressing underlying causes could make type 2 diabetes rare again without relying only on medication.
• Low-carb is not appropriate for everyone, but ordinary NHS care has yielded remission, lower medication use and savings.

References

1. [04:52] 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
2. [07:40] Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice — https://doi.org/10.1002/pdi.1835
3. [11:14] Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years — https://doi.org/10.1136/bmjnph-2020-000072
4. [15:32] 5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: an extension study — https://doi.org/10.1016/S2213-8587(23)00385-6
5. [18:19] Food addiction is strongly associated with type 2 diabetes — https://doi.org/10.1016/j.clnu.2023.03.014
6. [26:21] Ketosis Suppression and Ageing (KetoSAge) Part 2: The Effect of Suppressing Ketosis on Biomarkers Associated with Ageing, HOMA-IR, Leptin, Osteocalcin, and GLP-1, in Healthy Females — https://doi.org/10.3390/biomedicines12071553
7. [32:40] Adapting diabetes medication for low carbohydrate management of type 2 diabetes: a practical guide — https://doi.org/10.3399/bjgp19X704525