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Practice point

Low carbohydrate diet to achieve weight loss and


improve HbA1c in type 2 diabetes and pre-diabetes:
experience from one general practice
Dr David Unwin Abstract
FRCGP, Principal in General Practice, The Norwood Patients with diabetes have long been exhorted to give up sugar, encouraged instead to take
Surgery, Southport, UK in fuel as complex carbohydrate such as the starch found in bread, rice or pasta (especially if
wholemeal). However, bread has a higher glycaemic index than table sugar itself. There are
Dr Jen Unwin no essential nutrients in starchy foods and people with diabetes struggle to deal with the
FBPsS, Consultant Clinical Psychologist, Southport & glycaemic load they bring. The authors question why carbohydrate need form a major part of
Ormskirk NHS Trust, UK the diet at all. The central goal of achieving substantial weight loss has tended to be
overlooked. The current pilot study explores the results of a low carbohydrate diet for a case
series of 19 type 2 diabetes and pre-diabetes patients over an eight-month period in a
Correspondence to:
suburban general practice.
Dr D Unwin, The Norwood Surgery,
11 Norwood Ave, Southport PR9 7EG, UK;
A low carbohydrate diet was observed to bring about major benefits. Blood glucose
email: david.unwin@GP-n84008.nhs.uk control improved (HbA1c 5114 to 404mmol/mol; p<0.001). By the end of the study period
only two patients remained with an abnormal HbA1c (>42mmol/mol); even these two had
Received: 8 November 2013 seen an average drop of 23.9mmol/mol. Weight fell from 100.216.4 to 91.017.1kg
Accepted in revised form: 6 January 2014 (p<0.0001), and waist circumference decreased from 120.29.6 to 105.611.5cm (p<0.0001).
Simultaneously, blood pressure improved (systolic 14817 to 13315mmHg, p<0.005; and
diastolic 918 to 8311mmHg, p<0.05). Serum gamma-glutamyltransferase decreased from
75.254.7 to 40.629.2 U/L (p<0.005). Total serum cholesterol decreased from 5.51.0 to
4.71.2mmol/L (p<0.01).
This approach is easy to implement in general practice, and brings rapid weight loss and
improvement in HbA1c. Copyright 2014 John Wiley & Sons.
Practical Diabetes 2014; 31(2): xxxx

Key words
type 2 diabetes; low carbohydrate diet; weight loss; primary care; diabesity; obesity; fatty liver;
liver enzymes

Background potato (GI index 85) has a higher


Before the discovery of insulin and glycaemic index than table sugar
modern drugs, carbohydrate (not itself (GI index 68).5 Dr John Briffa
just sugar) restriction was the only in his excellent book Escape the
realistic treatment for all diabetes.1 diet trap6 makes the point that,
More recently, the drive has been while fats contain the essential vita-
for a low fat and therefore higher mins A, D, E and K, carbohydrate
carbohydrate diet for all. It is inter- represents empty calories. So why
esting to note that despite the should people with diabetes take in
plethora of low fat and diet foods the concentrated sugar that is in
on the supermarket shelves, the starchy foods such as bread, pasta or
epidemic of central obesity and rice at all?
diabetes (diabesity) continues to Studies have shown good results
increase across the developed for a low carbohydrate/higher fat
world. After years of demonising fats diet in people with type 2 diabetes
some researchers are starting to and in those with central obesity.2,3,7
look at carbohydrate as a cause of However, the approach is generally
central obesity and diabetes.2,3 In frowned upon in the UK, despite the
2012, Emily Hu et al. showed a linear fact that many patients are trying it
dose-relationship between rice con- of their own accord. Googling
sumption and risk of type 2 diabetes diabetes.co.uk forum low carb, the
in a study involving more than low carbohydrate success stories
350 000 subjects.4 have had over 81 000 views. In 2011,
The authors interest was first a detailed pathophysiological study
sparked by the fact that even whole- showed that diet-induced weight loss
meal bread (GI index 71) or baked brought about falls in the fat content

PRACTICAL DIABETES VOL. 31 NO. 2 COPYRIGHT 2014 JOHN WILEY & SONS 1
Practice point
Low carbohydrate diet to achieve weight loss and improvements in HbA1c

We decided to trial the low carbo-


So what should I eat to control Diabetes or Pre-diabetes?
hydrate weight loss diet in a suburban
general practice for patients
Reduce starchy carbs a lot (remember they are just concentrated sugar). If possible cut out the
with raised HbA1c (>42mmol/mol
White Stuff like bread, pasta, rice though porridge, new potatoes and oat cakes in moderation
[6.0%]). In particular, we wondered
may be fine. Sugar cut it out altogether, although it will be in the blueberries, strawberries and
how any weight loss would be
raspberries you are allowed to eat freely. Cakes and biscuits are a mixture of sugar and starch that
matched by an improvement in other
make it almost impossible to avoid food cravings; they just make you hungrier!!
measured parameters such as HbA1c
and blood pressure (BP). There were
All green veg/salads are fine eat as much as you can. So that you still eat a good big dinner try
early concerns about the effect a diet
substituting veg such as broccoli, courgettes or green beans for your mash, pasta or rice still
with more eggs and butter in it would
covering them with your gravy, bolognese or curry! Tip: try home-made soup it can be taken to
have on serum cholesterol levels. The
work for lunch and microwaved. Mushrooms, tomatoes, and onions can be included in this.
question of the acceptability of the
approach was central and so it was
Fruit is trickier; some have too much sugar in and can set those carb cravings off. All berries are
decided to provide group sessions for
great and can be eaten freely; blueberries, raspberries, strawberries, apples and pears too, but
support and information sharing.
not tropical fruits like bananas, oranges, grapes, mangoes or pineapples.
We also wondered if group work
could help offset some of the costs of
Proteins such as in meat, eggs, fish particularly oily fish such as salmon, mackerel or tuna
this approach.
are fine and can be eaten freely. Plain full fat yoghurt makes a good breakfast with the berries.
Processed meats such as bacon, ham, sausages or salami are not as healthy and should only be
Method
eaten in moderation.
Over a couple of months the
approach was suggested opportunis-
Fats (yes, fats can be fine in moderation): olive oil is very useful, butter may be tastier than
tically to patients with raised HbA1c
margarine and could be better for you! Coconut oil is great for stir fries. Four essential vitamins
during routine GP or practice nurse
A, D, E and K are only found in some fats or oils. Please avoid margarine, corn oil and vegetable
appointments, or by approaching
oil. Beware low fat foods. They often have sugar or sweeteners added to make them palatable.
people on the impaired glucose tol-
Full fat mayonnaise and pesto are definitely on!!
erance register of the practice. The
age range was 3473 years. It was
Cheese: only in moderation its a very calorific mixture of fat, carbs and protein.
important that the patients choose
freely if this was of interest. The diet
Snacks: avoid. But un-salted nuts such as almonds or walnuts are great to stave off hunger. The
sheet (Box 1) was handed out with
occasional treat of strong dark chocolate 70% or more in small quantity is allowed.
the repeated emphasis on cut out
sugar, bread, pasta, rice and pota-
EATING LOTS OF VEG WITH PROTEIN AND FATS LEAVES YOU PROPERLY FULL in a way that lasts.
toes altogether. Baseline measure-
ments of weight, waist, BP, choles-
Finally, about sweeteners and what to drink sweeteners have been proven to tease your brain
terol, liver function, thyroid and
into being even more hungry making weight loss almost impossible drink tea, coffee, and
renal function were made. The
water or herb teas. Im afraid alcoholic drinks are full of carbohydrate for example, beer is
patient was asked to make a second
almost liquid toast hence the beer belly!! Perhaps the odd glass of red wine wouldnt be too
10-minute appointment if they
bad if it doesnt make you get hungry afterwards or just plain water with a slice of lemon.
wanted to take this further.
At the second appointment the
Where to get more info?
diet sheet was discussed so the
patient could tailor the diet to their
A book Escape the diet trap by Dr John Briffa (2013).6 Well researched and easy to read.
lives. Patients appreciated that we
tried very hard to help them under-
Internet Google about.com low carb diet for loads more info and recipes, or look into the closely
stand how and why the diet could
related PALEO DIET; also Google diabetes.co.uk forum low carb for contact, recipes and hints.
help them achieve their goal of
weight loss and health gain. It was
BEFORE YOU START get an accurate weight and measure your waist, re-weigh and measure found to be better to spend more
once a week to see how you are doing and ask for help if problems or little progress is being time on this than being too prescrip-
made GO ON DO IT!!! tive about the diet itself. No weigh-
ing of food was required; patients
Box 1. Advice sheet for patients were reminded to cut out the carbs
while eating more vegetables,
of the liver and pancreas and Obesity. According to SBU, the healthy fats and protein to avoid
returned blood glucose control to only clear difference among differ- hunger. Patients were given a choice
normal.8 In November 2013, a ent dietary recommendations is of monthly 10-minute one-to-one
Swedish expert committee, SBU seen during the first six months. reviews of progress or attending our
(Swedish Council on Health Here a low carbohydrate diet is evening Low Carb group meetings.
Technology Assessment), published more effective than todays conven- About half opted for each. All
their inquiry Dietary Treatment for tional advice. patients were weighed at each review

2 PRACTICAL DIABETES VOL. 31 NO. 2 COPYRIGHT 2014 JOHN WILEY & SONS
Practice point
Low carbohydrate diet to achieve weight loss and improvements in HbA1c

and usually had a BP check and waist had lost several kilograms; they were
In April 2013, a 55-year-old patient
measurement. Blood tests (HbA1c, surprised by this as they had not felt
presented with tiredness, polydipsia and
cholesterol, liver function, renal hungry on the low carbohydrate diet
an HbA1c of 84mmol/mol. There was
function) were repeated on average but it had nevertheless worked. For
marked hepatomegaly; a fatty liver was
every two months. some, carbohydrates appeared to be
confirmed on ultrasound scan, associated
The emphasis at follow up was addictive and increase appetite, so
with deranged liver function tests (GGT
reflecting upon what worked for that as they gave up carbohydrates
was 103 U/L). After three months on a low
each patient and identifying per- they felt much less hungry. All
carbohydrate diet her liver was normal on
sonal goals, while giving advice on patients reported increases in
ultrasound, the HbA1c was down to
how to better tailor the diet to indi- energy levels. An unexpected result
41mmol/mol, and GGT was 12 U/L. She
vidual needs. It was notable that of the diet was that two of the part-
reported feeling great, 10 years younger
participants never lost their results ners, the practice manager, the
and has lost 17cm off her waist.
sheets and were keen to have the deputy practice manager and both
latest figures added on. We also Box 1. A case example practice nurses all went on the diet
handed out graphs of their progress and remain on it.
to engage their families. higher cholesterol. The majority The mechanistic basis of the
reported improved energy and well- normalisation of blood glucose con-
Results being, and many began exercising. trol after significant weight loss has
All data are expressed as mean stan- recently been explained.8 Decrease
dard deviation. A two-tailed paired Discussion in body fat brings about decrease in
students t-test was used to compare It was observed that a low carbohy- the ectopic fat in both liver and pan-
data before and after intervention. drate diet achieved substantial creas, and release from the fat-
Nineteen patients entered the weight loss in all patients and induced metabolic inhibition allows
programme with just one dropping brought about normalisation of resumption of normal function.9
out in the early stages (though there blood glucose control in 16 out of An initial concern had been the
was weight loss, the diet just didnt 18 patients. At the same time, effect of increase in consumption
suit the individual). Of the 18 who plasma lipid profiles improved and of eggs and butter on serum
persisted with the diet, all had BP fell allowing discontinuation of cholesterol. The 15% improvement
substantial weight loss. Initial weight antihypertensive therapy in some observed raises interesting questions
fell from 100.216.4 to 91.017.1kg individuals. about the cholesterol dogma. These
(mean weight loss 8.64.2kg; Patients were found to be most questions have recently been well
p<0.0001). Waist circumference motivated to diet when they have aired elsewhere.10
decreased from 120.29.6 to recently been diagnosed with hyper- The 47% improvement in serum
105.611.5cm (p<0.0001). tension, diabetes or pre-diabetes. We GGT was another unexpected find-
Blood glucose control improved wonder if health professionals always ing. The patients with the highest
significantly (HbA1c 5114 to make the most of this window of initial levels seemed to improve the
404mmol/mol; p<0.001). Only two opportunity to work together with most, but on average there was a
patients remained in the abnormal our patients on weight reduction. In drop of approximately 35 U/L. For
range (>42mmol/mol); even these the past, the doctors on the team years, patients with raised GGTs had
two had seen an average drop of simply delegated this to the dieti- told us they didnt drink alcohol.
23.9mmol/mol. Simultaneously, BP tians, whereas showing real interest Now that the role of carbohydrate in
improved (systolic 14817 to can demonstrate to our patients just excess of requirements, especially
13315mmHG, p<0.005; and dias- how central weight loss can be to the fructose component, is better
tolic 918 to 8311mmHg, p<0.05). good health. understood in the genesis of fatty
Serum GGT (gamma-glutamyl- The authors were struck by the liver, it is clear that excess carbohy-
transferase) decreased from energy and enthusiasm as patients drates can be a cause of fatty liver.9,11
75.254.7 to 40.629.2 U/L took control of their lives instead of There are resource implications
(p<0.005). Total serum cholesterol waiting patiently for doctors and for this. The average person with
decreased from 5.51.0 to nurses to solve their problems. As diabetes required about 30 minutes
4.71.2mmol/L (p<0.01). GPs we are more at home in charge of doctor or nurse time in the first
Seven patients were able to come of one-to-one consultations, so the month, then about 15 minutes per
off medication: metformin (one first group sessions were a bit daunt- month. The groups run with about
completely and two have halved ing. It helped to get into the habit of 810 patients in each time and last
their dose), perindopril and lacidip- finding out what the patients best just over an hour, so this helped our
ine, as BP control improved so hopes or goals were and what was efficiency. This level of support is
much. Additionally, metoclo- going well so far. After a few meet- not needed indefinitely: after about
pramide, omeprazole and lanzopra- ings, members of the group were try- four months most can be dis-
zole were discontinued, as symptoms ing to help each other, often making charged to more routine follow up.
of acid reflux improved. sensible suggestions. Furthermore, this would be offset by
Box 1 provides a case example. Repeatedly, patients would step possible drug budget savings.
All 18 participants lost weight and on the scales expecting not to have An important consideration is the
had improved HbA1c, and none had lost weight, only to find that they long-term outcomes of weight loss

PRACTICAL DIABETES VOL. 31 NO. 2 COPYRIGHT 2014 JOHN WILEY & SONS 3
Practice point
Low carbohydrate diet to achieve weight loss and improvements in HbA1c

Roy Taylor, Professor of Medicine


Key points and Metabolism, Newcastle Uni-
versity, provided helpful discussion,
! It could be said that starchy foods such as bread, pasta or rice are just concentrated sugar, statistical advice and comment in
and as such may represent a block to good diabetic control; even wholemeal bread has a the writing of this paper.
higher glycaemic index (71) than table sugar itself (GI index 68). This is the basis for the
low carbohydrate diet currently gaining popularity via the internet Declarations of interests
! A low carbohydrate diet was trialled in a primary care setting for 19 diabetic or There are no conflicts of interest
pre-diabetic patients, bringing about improvements in health markers over an eight- declared.
month period. Blood glucose control improved HbA1c 5114 to 404mmol/mol
(p<0.001) as did weight which fell from 100.216.4kg to 91.017.1kg (p<0.0001)
References
! Patients reported the diet was surprisingly easy to comply with and also noticed increasing 1. Westman EC, et al. Dietary treatment of diabetes
energy levels. Seven patients were able to come off medication of one form or another mellitus in the pre-insulin era (19141922).
Perspect Biol Med 2006;49:7783.
2. Volek JS, Feinman RD. Carbohydrate restriction
achieved with a low carbohydrate might do to help this group of improves the features of Metabolic Syndrome.
diet. This was investigated in a small patients enjoy better health. Metabolic Syndrome may be defined by the
response to carbohydrate restriction. Nutr Metab
study by Nielsen and Joenssen.12 (Lond) 2005;2:31.
Sixteen people who lost weight on Conclusions 3. Nordmann AJ, et al. Effects of low carbohydrate
a low carbohydrate diet, from Based on our work so far we can diet vs low fat diets on weight loss and cardiovas-
cular risk factors: a meta-analysis of randomized
100.64.7 to 89.24.3kg, without understand the reasons for the inter- controlled trials. Arch Intern Med 2006;166:
close follow up were 93.114.5kg net enthusiasm for a low carbohy- 28593. [Erratum in Arch Intern Med 2006;
after 44 months.12 This study drate diet; the majority of patients 166:932.]
observed initial HbA1c was 8.01.5% lose weight rapidly and fairly easily; 4. Hu EA, et al. White rice consumption and risk of
type 2 diabetes: meta-analysis and systematic
falling to 6.91.1% after 44 months. predictably the HbA1c levels are not review: BMJ 2012;344:e1454.
A positive approach to achieving far behind. Cholesterol levels, liver 5. Foster-Powell K, et al. International table of
substantial weight loss in a suburban enzymes and BP levels all improved. glycemic index and glycemic load values. Am J Clin
Nutr 2002;76:556.
general practice has brought about This approach is simple to imple- 6. Briffa J. Escape The Diet Trap, 4th edn. London:
normalisation of blood glucose con- ment and much appreciated by Fourth Estate, 2013.
trol in most patients who engaged people with diabetes. 7. Accurso A, et al. Dietary carbohydrate restriction in
type 2 diabetes mellitus and metabolic syndrome:
with this approach and major time for a critical appraisal. Nutr Metab (Lond)
improvements in serum cholesterol Acknowledgments 2008;5:9.
and liver enzymes in all. The clinical We are so grateful for the enthusias- 8. Lim EL, et al. Reversal of type 2 diabetes:
benefit is accompanied by possible tic collaboration of the patients Normalisation of beta cell function in association
with decreased pancreas and liver triacylglycerol.
cost benefits, despite need for involved, and also for the support of Diabetologia 2011;54:250614.
increased time input. all practice staff and the partners of 9. Taylor R. Type 2 diabetes: etiology and reversibility.
Scientifically, this work repre- The Norwood Surgery. Diabetes Care 2013;36:104755.
10. Malhotra A. Saturated fat is not the major issue.
sents only a small series of cases; also Heather Crossley, RGN, did a lot BMJ 2013:347:f6340.
there is no evidence yet that the of this work at the practice. 11. Lustig RH. Fructose: Its Alcohol Without the Buzz.
findings would generalise to other Dr Simon Tobin gave assistance Adv Nutr 2013;4:22635.
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something an average practice team is much appreciated. Nutr Metab (Lond) 2008;5:14.

4 PRACTICAL DIABETES VOL. 31 NO. 2 COPYRIGHT 2014 JOHN WILEY & SONS