Dr David Unwin shares details of how a GP practice in Liverpool has supported patients to achieve drug-free type 2 diabetes remission through dietary management

The aim of this article is to illustrate how we have completely revolutionised care for people with type 2 diabetes (T2D) at our five-partner, 9500-patient GP practice based north of Liverpool. We haven’t always been this upbeat about our diabetes care: between 1986 and 2012, we were overwhelmed by an eightfold increase in the number of patients with T2D, which left our diabetic clinics stretched and demotivated. We were also mystified by the cause of this epidemic and particularly unhappy with our care of younger patients—adding more and more drugs felt like a ‘sticking plaster’ on something far more fundamental. How could we know what was the best treatment when we were so unsure about the actual cause?

Why we changed our approach to diabetes management

Everything changed with a single patient consultation back in 2012. It became clear that this patient had managed to normalise her blood glucose, lose significant weight, and had come off her metformin—it was the first case of drug-free T2D remission we had ever seen. This led us to consider the patient’s claim: that T2D control depends largely on reducing the dietary load of glucose by not only giving up sugar, but also starchy carbohydrates (such as bread, rice, and potatoes) that digest down into significant amounts of glucose.

The concern over dietary glycaemic load is underpinned by recommendations in NICE Guideline (NG) 28, Type 2 diabetes in adults: management, first published in 2015 and updated in 2019. The recommendations remained unchanged across both guidelines and state:1

  • Encourage high fibre, low glycaemic index sources of carbohydrate in the diet…
  • Individualise recommendations for carbohydrate and alcohol intake…’.

In the past, our focus had always been on table sugar; however, following the experience with our patient in 2012, we investigated the glycaemic load of common foods and found to our great surprise that, as an approximation, a 150-g bowl of boiled rice could affect blood glucose to a similar extent as 10 teaspoons of sugar.2 This analysis led to the development of the Norwood Surgery version of a lower-carbohydrate diet plan.

Piloting a low-carbohydrate diet plan in Southport

We ran an initial pilot involving 19 patients who were opportunistically approached during routine appointments for their diabetes or via the impaired glucose tolerance register.3 Patients made an informed and personal choice whether to be involved and to follow the lower-carbohydrate diet plan, which emphasised the importance of giving up table sugar and replacing bread, potatoes, or rice with green leafy vegetables, full-fat dairy, eggs, meat, fish, berries, and nuts. Professor Roy Taylor, lead researcher of the Diabetes Remission Clinical Trial (DiRECT), helped with the publication of the results in 2014.3

One of the early successes we identified were group consultations, initially trialled due a shortage of funds. Patients, relatives, and carers were encouraged to attend sessions as some patients relied on others for food shopping or cooking. Group meetings also provided a forum for patients to offer practical support to their peers and a great training opportunity for new staff. Post COVID-19, these sessions have now become once-monthly Zoom meetings.

Another key aspect of the approach we adopted is reflected in NG28, which states: ‘Adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long-term interventions….’1 We have found that starting with a patient’s personal health goals and hopes engenders a more collaborative and effective approach to their care.4

Low-carbohydrate diets and medications in patients with type 2 diabetes: important considerations

In 2019, we co-authored a practical guide in the British Journal of General Practice on low-carbohydrate diets and how they interact with prescribed medications.5 A low-carbohydrate diet is safe for patients on metformin, however clinicians should be aware of three important considerations regarding other medications before advising their patients to follow a low- carbohydrate diet:5

1) Is the patient on insulin or oral agents such as sulfonylureas (e.g. gliclazide) or meglitinides that may increase risk of hypoglycaemia? Careful measurement of blood glucose alongside dose reduction or cessation of these antidiabetic medications is crucial to patient safety.

2) Is the patient on a sodium-glucose co-transporter-2 (SGLT-2) inhibitor? These, combined with a low-carbohydrate diet, have the potential to lead to diabetic ketoacidosis that may be masked by relative normoglycaemia. Low-carbohydrate diets should therefore be avoided in patients on SGLT-2 inhibitors, or these drugs stopped before initiating the diet.

3) Is the patient on antihypertensive medication? Lowering carbohydrate in the diet is associated with a lowering of blood pressure; therefore, patients already on antihypertensive medication may require dose reduction and/or cessation of this medication to avoid symptomatic hypotension.6

Impact on patient outcomes and costs

For patients who agreed to follow a low-carbohydrate diet, baseline and latest follow-up data were collected on:7

  • weight
  • glycated haemoglobin (HbA1c)
  • lipid profiles
  • blood pressure.

The average HbA1c for patients joining the programme was 65.5 mmol/mol (8.1%) demonstrating the poor initial diabetic control across the group.7 In October 2020, we published our data—collected from March 2013 to March 2019—in BMJ Nutrition, Prevention & Health.7 By March 2019, 128 people with T2D had opted to follow a lower-carbohydrate diet for an average duration of 23 months. Drug-free T2D remission (as defined by Professor Taylor8) was achieved by 59 individuals (46%). Significant improvements were observed in all cardiometabolic markers (see Table 1):

  • the average improvement in HbA1c was significant at 17.5 mmol/mol (1.6%), despite net deprescribing of 25 diabetic medications; for example, four participants were able to come off insulin altogether7
  • similarly, the improvements in blood pressure highlighted in Table 1 were observed despite 20% of drugs for hypertension being ‘deprescribed’ in the group7
  • the improvements in lipid profile on a low-carbohydrate diet may surprise some, but are consistent with a recent meta-analysis, which concluded: ‘Large randomized controlled trials of at least 6 months duration with carbohydrate restriction appear superior in improving lipid markers when compared with low-fat diets’ 9
  • data up to October 2020 (as yet unpublished) show 175 people have followed a low-carbohydrate diet for an average of 30 months, and 85 of these have achieved T2D drug-free remission.
Table 1: Analysis of cardiometabolic variables in a cohort of 128 patients with type 2 diabetes as measured at baseline and at the end of service evaluation period
Cardiometabolic variableBaseline measure
Median (IQR), p<0.001
Latest follow up
Median (IQR), p<0.001
Matched pairs
n (%)

Weight (kg)

99.7 (86.2–109.3)

91.4 (79–101.1)

124 (96.9)

HbA1c (mmol/mol)

65.5 (55–82)

48 (43–55)

127 (99)

Serum cholesterol (mmol/l)

4.9 (4.1–5.7)

4.4 (3.8–5.0)

83 (64.8)

HDL cholesterol (mmol/l)

1.2 (1.0–1.3)

1.3 (1.0–1.5)

96 (75.0)

Chol/HDL ratio

4.0 (3.0–5.1)

3.7 (2.9–4.4)

83 (64.8)

Triglyceride (mmol/l)

2.6 (1.6–3.2)

1.7 (1.0–2.1)

85 (66.4)

Systolic BP (mmHg)

144 (135–151)

133 (126–140)

95 (74.2)

Diastolic BP (mmHg)

83.1 (78–90)

78 (70–82)

95 (74.2)

Median age of the cohort was 63 years (IQR=54–73). Mean duration of diet was 23 months (SD=16.8).

IQR=interquartile range; BP=blood pressure; Chol=total cholesterol; HbA1c=glycated haemaglobin; HDL=high density lipoprotein; T2D=type 2 diabetes; SD=standard deviation

One of the biggest surprises was the effect on total prescribing of drugs for diabetes: following the initiative, our practice now has the lowest spend in our area on diabetes prescribing, which stands at £50,000 less per year than the average for our CCG. Figure 1 clearly shows we are the cheapest of the 17 local practices. According to OpenPrescribing.net data for the year ending 01 April 2020,10 our spend per patient in this area was £4.91 compared with the national average at £9.52, which was nearly double. This opens up the prospect of huge national savings, possibly around £200 million per year!

Figure 1. Spend on antidiabetic drugs versus patient list size

Figure 1: Spend on antidiabetic drugs by GP practices in Southport and Formby CCG10

OpenPrescribing.net, EBM DataLab, University of Oxford, 2020 

Spend on antidiabetic drugs (British National Formulary 6.1.2) per 1000 patients on list versus GP practices in Southport and Formby CCG (Norwood Surgery shown in pink), April 2020 

Key advice for GPs and CCGs looking to adopt our approach

We have developed a Royal College of General Practitioners eLearning module on T2D and the low-glycaemic index (GI) diet, which takes about 30 minutes to complete and is free to all GPs and practice nurses.11 This could be a good place to start for HCPs who are interested in following a similar approach. As mentioned earlier, we begin by finding out what our patients’ goals are with respect to their diabetes: common aims are weight loss and to no longer need lifelong medication. We then supply information relevant to the goals, helping people to make better dietary choices: most people know that sugar itself is not a good choice, but few are aware that starchy carbohydrates are in effect sugar too as predicted by the GI.

It also helps to explore with the patient how insulin actually deals with high blood sugar. In practice we use the infographic shown in Figure 2 to illustrate this. Insulin pushes glucose out of the bloodstream into muscle cells for energy, but excess glucose is pushed into abdominal fat and liver cells; this leads to central obesity and fatty liver disease,12 which is now estimated to affect around 25% of the population.13 It follows that avoiding excess dietary glucose makes sense as fatty liver is a cause of insulin resistance itself.14 This model helps to explain how the low-carbohydrate diet may be helpful. Other useful resources include our diet sheet and low-carbohydrate protocol as published in BMJ Nutrition, Prevention & Health in October 2020.

Figure 2- Practice infographic used to help people with type 2 diabetes to understand insulin

Figure 2: Practice infographic used to help people with type 2 diabetes to understand insulin

Summary

At its heart, our approach is about working with our patients to help them make better dietary choices, particularly around cutting sugar and starchy carbohydrates. The approach has developed a lot since we started in 2013. Initially we concentrated on ‘mild’ T2D—those just on metformin or managing the condition by diet alone—but over time our confidence has grown. We now regularly help people with T2D reduce or even give up insulin. We have recorded 85 cases of drug-free T2D remission to date (data on file) and, according to national data available from OpenPrescribing.net,10 we have the lowest spend in our CCG on diabetes drugs per 1000 of the population. We currently spend about £50,000 a year less than is the average T2D drugs budget in the local area.

In summary, cutting sugar and starchy carbohydrates is one way to work with your patients to improve their health. For many patients, drug-free T2D remission is a realistic goal, bringing hope to patients and clinicians alike.

Dr David Unwin

GP, Norwood Surgery

RCGP National Champion for Collaborative Care and Support Planning in Obesity and Diabetes and RCGP Clinical Expert in Diabetes

Key points

  • The pilot programme was initiated at Norwood Surgery in Southport based on the rationale that T2D control depends on reducing the dietary load of glucose
  • Patients understand that sugar itself is an unhealthy choice, but are generally unaware that starchy carbohydrates (such as bread, rice, and potatoes) also digest down into significant amounts of glucose
  • The concern over dietary glycaemic load is underpinned by recommendations in NICE Guideline 28, which encourage high-fibre, low-GI sources of carbohydrate
  • Low-carbohydrate diets can interact with diabetes medications and there are number of considerations that clinicians should be aware of before advising patients to take part
  • A number of factors contributed to the success of the low-carbohydrate diet initiative:
    • patients were informed about the programme and then made a personal decision about whether to take part
    • group consultations were held to support participants and patients/carers were also encouraged to attend
    • focusing on a participant’s personal health goals at the outset engendered a more collaborative approach to their care
  • Out of 175 participants who reported following a low-carbohydrate diet for an average of 30 months, 85 individuals achieved drug-free T2D remission—significant improvements were observed across all cardiometabolic markers
  • The programme also led to significant savings due to reduced spending on diabetes prescribing
  • A low-carbohydrate diet can make drug-free T2D remission a realistic goal.

T2D=type 2 diabetes; GI=glycaemic index

References

  1. NICE. Type 2 diabetes in adults: management. NICE, 2015 (updated 2019). Available at: www.nice.org.uk/ng28
  2. Unwin D, Haslam D, Livesey G. It is the glycaemic response to, not the carbohydrate content of food that maters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance 2016; 1 (1). Available at: insulinresistance.org/index.php/jir/article/view/8/11
  3. Unwin D, Unwin J. Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice. Practical Diabetes 2014; 31 (2): 76–79.
  4. Unwin J, Unwin D. A simple model to find patient hope for positive lifestyle changes: GRIN. Journal of Holistic Healthcare 2019; 16 (2): 18–22. Available at: bhma.org/a-simple-model-to-find-patient-hope-for-positive-lifestyle-changes-grin/
  5. Murdoch C, Unwin D, Cavan D et al. Adapting diabetes medication for low carbohydrate management of type 2 diabetes: a practical guide. Br J Gen Pract 2019; 69 (684): 360–361. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC6592353/
  6. Unwin D, Tobin S, Murray S et al. 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. Int J Environ Res and Public Health 2019; 16 (15): 2680.
  7. Unwin D, Khalid A, Unwin J et al. 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. BMJ Nutrition, Prevention & Health 2020; 0. doi:10.1136/ bmjnph-2020-000072
  8. McCombie L, Leslie W, Taylor R et al. Beating type 2 diabetes into remission. BMJ 2017; 358: j4030.
  9. Gjuladin-Hellon T, Davies I, Penson P, Amiri Baghbadorani R. Effects of carbohydrate-restricted diets on low-density lipoprotein cholesterol levels in overweight and obese adults: a systematic review and meta-analysis. Nutr Rev 2019; 77 (3): 161–180.
  10. OpenPrescribing website. Analyse. Search GP prescribing data. Available at: openprescribing.net/analyse/#org=practice&orgIds=N84008&numIds=6.1.2&denom=total_list_size&selectedTab=summary (accessed 14 December 2020).
  11. Unwin D, Lake I. Type 2 diabetes and the low GI diet. RCGP eLearning course 2018 (updated 2020). Available at: elearning.rcgp.org.uk/course/info.php?id=291
  12. Smith G, Shankaran M, Yoshino M et al. Insulin resistance drives hepatic de novo lipogenesis in nonalcoholic fatty liver disease. J Clin Invest 2020; 130 (3): 1453–1460.
  13. Araújo A, Rosso N, Bedogni G et al. Global epidemiology of non-alcoholic fatty liver disease/non-alcoholic steatohepatitis: What we need in the future. Liver Int 2018; 38 (Suppl 1): 47–51.
  14. Taylor R. Banting Memorial lecture 2012: reversing the twin cycles of type 2 diabetes. Diabet Med 2013; 30 (3): 267–275.

Showcasing local best practice in diabetes