Why low-carbohydrate high-fat diets help some diabetics reverse the condition without medication

One late spring morning five years ago, Rajesh Dudeja sat in a bed in South Delhi’s Max Hospital, waiting to be called for surgery to remove a painful cyst at the bottom of his spine. When his doctor conducted a routine blood sugar test before surgery, he found Dudeja’s level was dangerously high. It was 700 mg/dl, five times what is considered normal after a meal.

“You should be in coma,” the doctor told him incredulously.

That is how Dudeja discovered he had diabetes. He was 40 years old at the time and severely obese, weighing over 140 kg. While recovering from the operation, he bought a glucometer and started monitoring his blood sugar. Finding it about 2.5 times higher than normal, he consulted an endocrinologist at Indraprastha Apollo Hospitals, and was put on insulin shots four times a day and other medication. He was advised to avoid sugars, fatty food, processed or refined food such as chips and maida, and instead eat whole wheat bread and eggs.

“Insulin did help, though the blood sugar level would still be on the higher side,” Dudeja recalled. “But I was getting fed up of insulin. When you take insulin you suddenly feel good and after some time you suddenly feel fatigued. It would be like a roller coaster ride.”

His elevated sugar level was taking a toll. It was damaging his nerves which manifested as an almost constant ache in his feet. It was also weakening his immune system, and he once caught a severe urinary tract infection. “Sometimes my eyes would suddenly start rolling,” he said. “While driving I would lose focus and have double or triple vision.” Such vision problems can be due to a sudden dip in blood glucose after taking insulin or even a sign of nerve damage due to diabetes.

This went on for six months. “One day I thought, ‘I do not care if I die, but I am not going to take this’,” said Dudeja. “It was like being on drugs and I thought I had better give it up.”

He took a big risk and stopped taking insulin and medicines without consulting his doctor. “There was no question of seeing the doctor; which doctor would advise going off medicines like that?” he said. “If diabetes is a lifestyle disorder, I was going to put my life back in order.”

He completely stopped eating sugar, rice and potato, which quickly raise blood glucose, and started having low-fat, so-called diabetic-friendly products such as NutriChoice biscuits and Coke Zero. This brought his glucose level down to prediabetes. But even after three years of pursuing this regimen, he lost only four kg and his blood sugar level could not be nudged down any further.

All this while he kept looking for information on managing diabetes and obesity. He found a TED Talk on low-carbohydrate high-fat diets. With a little more reading, he was convinced that this was what he needed. He switched from eating supposedly diabetes-friendly whole-grain food to eating more fat while maintaining moderate protein in his meals. Kebab, chicken, cottage cheese, fish, non-starchy vegetables, nuts, butter, cream and olive oil became his staples.

Dudeja saw quick results. Within a week, his blood glucose level came down to normal and stayed there for a year, over which time he also lost 36 kg. All this without doing any physical exercise. “I didn’t know diabetes could be reversed until it happened to me,” he said.

What does ‘reversing diabetes’ mean?

Diabetes, short for diabetes mellitus, is a disease in which the body does not produce enough insulin or does not respond adequately to the insulin it makes. Insulin is a hormone produced in the pancreas that regulates blood sugar and energy storage. Diabetes is characterised by elevated blood sugar. If left untreated, it can lead to organ damage, even death.

Diabetes mellitus is of two types. Type 1 usually develops in children and adolescents. Their pancreas produces very little or no insulin, so they have to take insulin injections for life. Type 2 usually occurs in adults and accounts for at least 90% of diabetes cases in the world. In type 2, the pancreas initially produces a lot of insulin but the body cannot make good use of it. This is followed by decreased insulin production because of the loss of insulin-producing beta cells in the pancreas that have been working overtime.

Type 2 diabetes has long been thought of as a chronic condition which requires the patients to follow dietary precautions, exercise and take combinations of medicines just to control their blood sugar. Diabetes has also been considered a progressive condition – it usually gets worse over time, with the patient needing more and more medication and insulin. Most patients remain on lifelong medication costing thousands of rupees a month. Uncontrolled diabetes often results in severe complications such as kidney damage, blindness, loss of limbs, stroke and heart attack.

But a growing body of clinical and anecdotal evidence shows that some people are able to reverse type 2 diabetes or send it into remission by switching to low-carbohydrate high-fat, or LCHF, diets, or to very low-energy diets. As per a consensus definition by a multispeciality group of doctors, a diabetic who has brought his glucose level down to normal and maintained it for at least a year without diabetes medication is considered to be in remission.

While diabetics are normally advised to eat unrefined carbohydrates and less fat, some like Dudeja are going off medicine by eating more fat and much less carbohydrate. Some others are trying fasting.

However, Dudeja is aware that this reversal can be temporary. If he stops his diet, chances are his diabetes will return.

This approach to treating diabetes might be unconventional but it is not new. Before the discovery of insulin in the 1920s that gave primacy to medication, controlling diet was standard treatment. Leading diabetologists of the time – among them Elliot Joslin, after whom the world’s largest diabetes research centre Joslin Diabetes Center at Harvard University is named – tested different approaches. They tried diets low in carbohydrate but high in fat. They tested the effect of prolonged fasting. They also employed low-energy diets. They found that eating very little carbohydrate as well as eating very little food without specifically reducing carbohydrate was helpful in treating the disease.

How does lowering carbohydrate intake work?

The underlying pathological condition in diabetes is insulin resistance, meaning the body ignores the action of insulin.

After a meal, a person’s blood glucose level goes up. Carbohydrates in a meal – like bread, rice, potato – are mostly broken down into glucose that is released in the bloodstream. The pancreas then releases insulin, which prompts the cells to take up glucose and use it for energy. It also signals storage of excess glucose as glycogen or fat for future use.

Over time, in some cases, cells might become resistant to insulin so that the body has to produce more and more insulin for cells to absorb glucose. When the body fails to meet the increasing demand for insulin, blood sugar begins to rise and the result is type 2 diabetes.

The primary stimulators of insulin production are sugar and other carbohydrates; fats hardly trigger insulin production. Some medical researchers even call diabetes a disease of carbohydrate intolerance. The fastest way to stabilise blood glucose and lower insulin levels is to reduce carbohydrate intake, according to David Ludwig, an endocrinologist and nutrition researcher at Harvard University. For some diabetics, blood sugar level may be normalised by cutting sugar and easily digestible carbohydrates such as potato and rice from a diet. A person like Dudeja with more severe glucose intolerance has to keep away from even pulses, most fruits and whole-grain bread. This kind of severe carbohydrate restriction drastically shrinks food choices and, therefore, requires careful meal planning. Drastically reducing carbohydrate intake is also shown to improve insulin sensitivity.

In contrast, insulin shots and some diabetes medications lower blood glucose by raising insulin levels. Since insulin speeds up fat synthesis and storage, weight gain is usually one side-effect of aggressive insulin therapy, explain Dr Stephen Phinney and Dr Jeff Volek, the world’s leading experts on low-carbohydrate diets. This is counter-productive because diabetics need to lose weight to reduce their glucose levels. High insulin is also associated with a higher risk of heart disease and cancer.

Diabetics and doctors try LCHF diets

Jason Fung, a kidney specialist in the United States, makes a bold claim in his new book The Diabetes Code. He says that type 2 diabetes is “almost always” reversible and that treating it with insulin-raising drugs only makes it worse.

Fung also treats his patients with LCHF diets and fasting. “Regular fasting, in addition to lowering insulin levels, has also been shown to improve insulin sensitivity significantly,” he writes in a blog post. “Most diets reduce highly insulin-secreting foods, but do not address the insulin resistance issue…Fasting is an efficient method of reducing insulin resistance.”

Ravi Krishna, a software professional from Andhra Pradesh who lives in Australia, has tried fasting to reverse his diabetes. He was diagnosed with diabetes 11 years ago, when he was still in his 20s and in Bengaluru. “Deep inside I was very confident that type 2 diabetes can be reversed,” he said. “But every doctor and every other person told me I could not do it.”

Krishna is a Baha’i, and he noticed the therapeutic effects of fasting while observing the 19 days of dry fast from sunrise to sunset prescribed by his faith. Then he came across Fung’s videos. At that time he had been diabetic for over seven years, with high random sugar level of 370 mg/dl. He also had other complications of the disease. He could hardly walk because of peripheral vascular disease, had high blood pressure and high cholesterol, and was obese. He went on an extreme fasting regimen – he ate only during a narrow window of a few hours each day for more than five months. At the end of it, his blood glucose as well as his glycated haemoglobin levels became normal. He did this for over two years and, Krishna said, he not only reversed his diabetes but all associated complications “without a single medication”.

Anup Singh, who runs an LCHF forum for diabetics called dLife.in, says he has seen two kinds of diabetics who gravitate towards LCHF. “Most of them look for it when they have lost all hope and are landing in all kinds of trouble, and now diabetics in their 20s and 30s are getting desperate as they have a long life ahead,” he said.

An engineer in Indore, Singh reversed his own diabetes with LCHF seven years ago at the age of 48. According to a poll he conducted, 200 members of the forum had attained normal glycated haemoglobin levels by following LCHF diets.

Fung’s forceful advocacy of LCHF diets and fasting has also influenced Dr S Vijayaraghavan, a primary care physician in Chennai. In early 2014, Vijayaraghavan chanced upon Fung’s videos on obesity and diabetes. “It completely changed my perspective,” he said. He tried LCHF himself for weight loss before recommending it to his patients. He estimates that of the diabetic patients he has treated, about 100 stopped needing medicines from between a week and a month of changing diets. While he keeps a record of his patients’ progress, he has not documented the results for research purposes. “The concept of diabetes is wrongly understood by the mainstream,” said Vijayaraghavan. “This is gross injustice to the patient.”

Dr Jaishankar, diabetes consultant in Chennai, has been watching Vijayaraghavan’s unconventional treatment. He has witnessed the dramatic improvements but is waiting for long-term results.

Jaishankar too tried the diet for weight loss but gave up in a few days. “The charm of life was gone. I would rather eat normally,” he said. “For Indians, it is very difficult to quit eating rice and wheat.”

Conventional advice is moderation

Most diabetologists agree that Indians eat too much carbohydrate, which accounts for 65%-70% of energy from the average Indian diet. Conventionally, diabetics are advised to moderate their carbohydrate intake rather than make drastic cuts as is the case with LCHF diets, which allow for no more than 5%-20% of the energy from carbohydrates.

“One of the main problems in the diet of Indians is excess carbohydrate in the form of rice and wheat,” said Dr V Mohan, chairman of Dr Mohan’s Diabetes Specialities Centre, a chain of hospitals across India. “If this can be reduced and replaced with protein and the right type of fat, reversal of diabetes may be possible.”

Mohan stresses, however, that in more advanced stages diabetes cannot be reversed.

About the very low-carbohydrate version of LCHF called ketogenic diet (5% of energy from carbohydrate) that Dudeja adopted and very low-calorie (600 cal) diets, he said, “These are extreme diets and while they definitely work in the short-term, and people get very impressed by the rapid weight loss which occurs, they are not sustainable in the long run. Also, we do not have long-term data on possible side effects or safety or efficacy of such diet.”

Dr Rajeev Chawla, president-elect of the Research Society for the Study of Diabetes in India, also advocates moderation. “You need to have 45%-50% dietary intake of carbohydrates, mainly complex carbohydrates, 15% fat and 25% protein,” he said.

A moderate diet with emphasis on complex carbohydrates, stress reduction and exercise also help reverse diabetes, although more slowly and rarely in severe cases. “In my 40 years of experience I have seen many overweight patients – 10% to 15% – reversing diabetes without medicines by following dietary restriction, exercise, yoga and meditation,” said Dr C Munichoodappa, chief diabetologist and founder director of The Bangalore Hospital and former president of the Diabetic Association of India. “The duration of reversal varies from two years to 10 years.”

Nutritionist P Janaki Srinath, a member of the national executive committee of the Indian Dietetic Association, treats her patients with a low-carbohydrate high-protein diet. “This type of diet can have a remarkable role in reversing diabetes if proper counseling is given,” she said. “The problem is that no one explains to the patient how medicines impact their body. Once they have complications, they really search for alternatives to medication.”

She says both fasting and ketogenic diet can bring down medicine requirement within a day but must be tried under medical supervision.

The majority of diabetes patients on standard dietary treatment remain on expensive medication. Many hospitals in India even advise bariatric surgery to severely obese diabetics since it is known to rapidly reduce weight and reverse diabetes. In such surgeries, the stomach size is reduced or the food is made to bypass part of the stomach and small intestine. This induces under-eating or poor absorption of nutrients or both. Bariatric surgery costs between Rs 2 lakh and Rs 7 lakh and carries the risk of complications and nutritional deficiency. Doctors consider it a last resort.

Dudeja’s first doctor had told him he was a fit case for bariatric surgery. But Dudeja avoided invasive surgery by switching to his LCHF diet that cost him nothing. So far he has seen only positive effects. “My energy levels doubled, no fatigue, never fell ill again, no brain fog, a sharper and calmer mind,” he said.