Could Carb Restriction Lead to Diabetes Remission? 

Study examines the effectiveness of nutritional ketosis in reducing medication usage and increasing the chances of diabetes remission. 

There have been quite a few studies that have explored using non-pharmaceutical approaches to gain better management of a patient’s type 2 diabetes. The three main strategies that have demonstrated slight diabetes remission include bariatric surgery, very-low-calorie diets (VLCD), and nutritional ketosis, which is accomplished with carbohydrate restriction. Both bariatric surgery and VLCD have shown substantial clinical evidence of improving glycemic control; however, between cost and rapid weight regain within 3-6 months, these approaches fall short in successful results over time. In efforts to investigate just how clinically significant nutritional ketosis may be, researchers looked at the effects of continuous remote care intervention using carbohydrate restriction on the reduction of hyperglycemia in patients with type 2 diabetes. 

Participants with type 2 diabetes in this non-randomized control study were grouped as either receiving continuous care intervention (CCI) or usual care (UC). Patients in the CCI group were instructed to reach and maintain nutritional ketosis through carbohydrate restriction, daily protein intake at a target of 1.5g kg-1, sufficient dietary fat, fluid, vitamins, and minerals. They also received access to a web-based app that provided educational resources, personalized support, and tools that tracked their biomarkers. The UC group, in contrast, received care from solely their primary care physician or endocrinologist. A registered dietician also counseled them on recommendations by the American Diabetes Association (ADA) on nutrition, lifestyle, and diabetes management. Primary outcomes were retention, HbA1c levels, fasting glucose, fasting insulin, c-peptide, and weight. Secondary results were long-term body composition changes observed in the CCI group, including bone mineral density, abdominal fat content, and lower extremity lean mass. Cardio-vascular, liver, kidney, and thyroid markers were also assessed. To evaluate change over time in diabetes-related outcomes, researchers used linear mixed-effects models. McNemar’s tests were used to determine differences in the number of participants meeting specific criteria at baseline versus follow-up.  

A significant reduction in HbA1c levels, weight, and triglyceride levels were seen with the CCI group after a 3.5 year follow up. This group saw a considerable decline (from 84.6 to 67.1%) in the percentage of participants who were prescribed diabetes medication—altogether, nearly 71% of diabetes medications other than metformin were discontinued. Furthermore, the portion of participants who shifted to either no medications or monotherapy rose from 52.5 to 81.9%. Strikingly, 22% of participants were also able to maintain remission between the second and third year of treatment. At the two-year follow-up, there were still consistent data on improved HbA1c levels, glycemia reduction, and less medication use. The number of participants who met the criteria for diabetes reversal increased from baseline to 53.5% in the CCI group compared to no change with the UC group. Diabetes remission was seen in 17.6% of participants in the CCI group and only 2.4% within the UC group. Participants in the CCI group also had a 10% mean weight reduction compared to no change in the UC group. Results will be reassessed at 5-year follow up.  

At the 3.5-year follow up, this study proved that CCI could improve HbA1c levels, fasting glucose, reduce medication use, and substantially improve metabolic risk markers for participants. The study did experience limitations in generalizability due to the lack of randomization and racial diversity. Further studies could investigate the connection between dietary adherence and health improvements. Conclusively, continuous remote monitoring has proved to improve diabetic status by multicomponent CCI and low carbohydrate intake.  

Practice Pearls: 

• Participants with type 2 diabetes in the CCI group showed significantly lower HbA1c levels, fasting glucose, weight, and triglyceride levels than the UC group.
• Participants with type 2 diabetes in the CCI group had higher percentages of medication reduction diabetes remission than the UC group. 
• Further studies are needed to evaluate the connection between dietary adherence and health improvements. 

Mckenzie, Amy, et al. “SUN-LB113 A Continuous Remote Care Intervention Utilizing Carbohydrate Restriction Including Nutritional Ketosis Improves Markers of Metabolic Risk and Reduces Diabetes Medication Use in Patients With Type 2 Diabetes Over 3.5 Years.” Journal of the Endocrine Society, vol. 4, no. Supplement_1, 2020, doi:10.1210/jendso/bvaa046.2302. 

Athinarayanan, Shaminie J., et al. “Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 2-Year Non-Randomized Clinical Trial.” Frontiers in Endocrinology, vol. 10, 2019, doi:10.3389/fendo.2019.00348. 

Maya Palmer, PharmD. Candidate, Florida A&M University College of Pharmacy 

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