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Why GPs should prescribe a low-carb diet for type 2 diabetes

We are doing patients and the NHS a disservice if we fail to advise them on the benefits of a low-carbohydrate diet, argues Dr Campbell Murdoch

It seems every week brings a new headline about the catastrophic epidemic of type 2 diabetes that is threatening to overwhelm our health service. But in my view we are largely ignoring the root cause of the problem and taking completely the wrong approach to tackling it – failing our patients and costing the NHS a fortune in the process.

Instead of giving patients unhelpful instructions to eat less – on a diet based on starchy carbohydrate – and exercise more, and then putting them on to more and more drugs, we should be listening to their experience and observing the growing body of evidence that cutting down on carbohydrate intake is the key.

I am seeing astonishing results in patients with type 2 diabetes who themselves chose to reduce their dietary carbohydrate intakes. Having seen the results, and after many hours of research to understand the physiology better, I believe it would be unacceptable for me not to offer advice on using a ‘low-carb’ diet to patients with type 2 diabetes.

At medical school 20 years ago I was taught that type 2 diabetes is a progressive disease. This is not true – turn off the ‘sugar tap’ and the disease begins to reverse. Type 2 diabetes is a problem of homeostasis. Our body uses its various hormones, including insulin, to maintain blood glucose homeostasis of 4–6 mmol/L, which is about 5g in an average adult. But when we constantly consume food that challenges our blood glucose level, the body takes the hit and shifts the excess glucose to fat storage. Eventually, probably as a homeostatic mechanism to prevent ever-increasing obesity, our body starts to push back – and blood glucose rises.

So what do I now tell patients? I explain how type 2 diabetes is a problem of high blood glucose, insulin resistance and hyperinsulinaemia, and advise them that one option to manage this is to avoid sugar, processed foods, and sweet fruits, and eat less carbohydrate. Instead they can eat ‘real food’ which includes lots of above-ground vegetables, a typical portion of protein (meat, fish, eggs, nuts etc) each day and as much healthy fat such as olive oil to satisfy their appetite.

In a typical patient you see impressive results within a couple of months, including a significant drop in HbA1c (80 mmol/mol down to 50 mmol/mol would not be unexpected, sometimes even more). Triglycerides plummet and high-density lipopoprotein (‘good’) cholesterol increases. People notice effortless weight loss, including losing their mid-riff (the ‘insulin tyre’) – one patient advised I owe them £750 as they had to buy new clothes!

Many patients suffering from dyspepsia are able to stop their PPIs. Importantly, these results seem to be maintained, despite the argument that ‘there is no long-term randomised controlled trial evidence for the benefit of low carb diets’. There is no long-term trial evidence because there are no such trials; the longest that look at low carb diets seem to be 24 months. Let’s not mislead people when we say there is no long-term evidence.

Some GPs worry they are going against guidelines by advising a reduction in carbohydrate intake. They need not be concerned. NICE guidelines on type 2 diabetes advise high-fibre low glycaemic index (GI) sources of carbohydrate, which in practical terms means things such as peppers and leafy greens. It does not mean potatoes and bread, which are high GI.

NICE also advises tailoring the carbohydrate to the individual. In my experience most people need to eat less than 130g of carbohydrate a day (a few small potatoes and the odd slice of bread) although those with severe insulin resistance may need to reduce carbohydrate to 50g or less – which generally means completely removing starchy carbohydrate from the diet.

Other concerns some people have include: ‘Carbohydrates are essential in our diet.’ This is not true, there is no such thing as an essential carbohydrate, and our livers are pretty nifty at gluconeogenesis if required. 

‘Ketosis is dangerous.’ Actually, nutritional ketosis and ketoacidosis are completely different physiological processes – Google it, and also consider what happens when people fast: they do not become ketoacidotic. Nutritional ketosis is not dangerous (it actually makes you feel pretty good!)

I would recommend looking into low carbohydrate diets for managing type 2 diabetes. It may be the most interesting CPD you have done for a while, it will revolutionise your consultations, and it may have a significant impact on your own health.

As one my patients, a very happy male in his mid-60s, testifies:

‘I was initially quite angry when told I could reverse my type 2 diabetes. I was angry because for 12 years the NHS (doctors, consultants and internet) told me the disease was irreversible and progressive. And of course they are right, if you follow the standard low fat high carbohydrate dietary advice.

‘I changed to a real food, low carbohydrate, healthy fat diet in August last year and the results are, at least to me, a miracle. I no longer take diabetes pills, or pills for gout, or for high cholesterol, and I take fewer blood pressure pills. I have far more energy and now enjoy life to the full.'

Dr Campbell Murdoch is a GP in Somerset, RCGP clinical advisor and Public Health England physical activity clinical champion

Further reading and resources

I recommend the books The Obesity Code by Dr Jason Fung, as well as his book Complete Guide to Intermittent Fasting. I also recommend The Real Meal Revolution by Professor Tim Noakes for a further dive into this area which includes great recipes. Dr Aseem Malhotra’s very recent book The Pioppi Diet is also excellent.

The website www.dietdoctor.com is very informative, and a great resource for patients and doctors, as is www.diabetes.co.uk.

There is also a huge network of GPs and other healthcare professionals across the country, who are very willing to share their knowledge. I would be very happy for anyone to contact me at campbell.murdoch@nhs.net

 

 

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Readers' comments (27)

  • Yes I agree. I advise patients to visit www.diabetes.co.uk/low carb

    www.dietdoctor.com is a fantastic resource.

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  • I concur. If you are opiate or alcohol resistant, the answer is not to give you more alcohol or morphine, so why are we giving type 2 diabetics insulin?
    Solution is diet and exercise to up regulate receptors and drop insulin requirements.
    Carbs should be related to activity, so as not to raise insulin further, thereby inducing greater resistance.

    Blood sugar solution by Mark Hyman is book I recommend to patients. Also tell them all it's reversible.

    Thanks for the article

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  • I sometimes tell them 'Bread is cake'.

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  • Excellent article, thank you Campbell.
    I too have some very happy patients using this approach. However I find some people very resistant to the idea that their diet, based on government guidelines, may not be a healthy diet for them. Also these people really want to believe that the medication they are on is doing what it needs to do. I guess denial comes before anger.
    So next article could be about how you have the conversations with those already years down the medication path and who feel their diet is healthy and their control is good (e.g HbA1c in 60's).

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  • Also you didn't mention the reversal in fatty liver. I measure GGT before and after starting low carb and as expected there can be dramatic reductions.

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  • I should have included in the resources the fantastic UK charity the Public Health Collaboration. www.phcuk.org . Great simple resources for patients and info for healthcare professionals.

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  • Been recommending low carb, healthy fat for ages, the proteins and fats keep the stomach fuller for longer, delay gastric emptying and this helps reduce snacking. If you are looking at patient lipids using a lipid subfraction is quite useful too rather than just assuming all LDL is the same, its the small dense LDLs 4,5,6,and 7 that do the damage... LDL 1 and 2 are quite harmless, the evidence for using statins in those without the dangerous small dense LDLs is lacking and these patients probably don't need nor benefit from them.
    I have a patient here has lost 30kg by going full fat and ditching the carbs. Her period pains and her 'mental fog' has lifted too...... I also find patients rheumatological pains often improve if the diet is stuck too over a number of months.
    Sugar is the culprit. Anyone who recommends low fat just isn't looking at the evidence........ Carbs are the new cigarettes!!! :-) Chips will be coming in packs of 20 soon...... and sold in plain bags....

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  • Another area here which is also connected seems to be osteoporosis, full fat dairy and low carb protects bone loss.....

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  • Heartened to see so many agreeing with my own beliefs about the benefits of low-carb diet. Surely it has to become mainstream advice soon?

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  • Excellent article. Wholeheartedly agree with the author and also all those who have commented.

    An easy read that I have recommend for patients is "The 8 week blood sugar diet" by Michael Moseley, this can be purchased online for £3-4.

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