Telemedicine and low-carbohydrate diet reduce diabetes medications and promote durable remission

In a recent study published in the journal Diabetes research and clinical practiceresearchers evaluated a telehealth intervention aimed at helping patients with type 2 diabetes (T2D) follow a very low-carbohydrate diet to achieve nutritional ketosis.

Their findings showed that the intervention resulted in higher retention levels, including weight loss, 17.4% increase in HDL cholesterol, 18.4% decrease in triglycerides, and 43.6% decrease in sensitive markers, including 5% reduction in inflammatory markers. This represents a significant health improvement over the years. C-reactive protein (hs-CRP), improved cardiometabolic health, and diabetes remission.

Although T2D has traditionally been considered a progressive chronic disease, emerging evidence suggests that treatments can reverse it, lowering glycated hemoglobin (HbA1c) levels and eliminating the need for hypoglycemic drugs. This suggests that it can be reduced.

Ultimately, this may lead to durable remission without the need for drug therapy. Remission is defined as glycated hemoglobin less than 6.5% for at least 3 months without the use of hypoglycemic drugs.

Hyperglycemia is associated with an increased risk of diabetes-related complications, so remission is associated with significant health benefits in the long term. Methods to achieve remission include insulin therapy, surgery, and nutrition-related therapies that severely restrict carbohydrate and calorie intake.

Restricting carbohydrates may improve cardiovascular health and blood sugar control, but studies primarily considered a two-year time period.

In this study, researchers aimed to examine the long-term effects of the telehealth intervention, focusing on diabetes status, blood sugar levels, weight, medications, and cardiometabolic health.

Study participants were people with T2D and a BMI greater than 25. They were initially recruited for a study comparing a 2-year continuous care intervention (CCI) to usual care (UC), but those in the CCI group were offered a 3-year continuation at the end of the study. did.

Of the 194 CCI participants, 169 continued. The intervention took place online, with no face-to-face meetings. CCI was delivered remotely through an app and provided telemedicine nutritional counseling and diabetes medication management.

The app instructed participants to adhere to a carbohydrate-restricted diet (less than 30 grams per day) to achieve and maintain nutritional ketosis. The app allowed participants to track their weight, blood sugar levels, and beta-hydroxybutyrate (BHB) while interacting with a health coach and doctor. Participants can also join an in-app peer support community.

Medication withdrawal was managed by removing metformin only if there was a contraindication or intolerance. Measurements were taken at the start of the study and at 1, 2, 3.5, and 5 years, and inflammatory markers, weight, and blood tests were collected.

The average age of participants over the five years of the study was 54.2 years, and nearly 68% were women. There were no significant differences in baseline characteristics between those who completed the 5 years and those who dropped out.

After 5 years, 20% of participants achieved diabetes remission, and 32.5% of them had glycated hemoglobin levels below 6.5% without medication or on metformin alone. Of those who achieved remission at 2 years, 57.6% remained in remission at 5 years, suggesting that the intervention was effective.

Sustained improvements were seen in several health markers, including a 0.3% reduction in HbA1c, 7.6% weight loss, and a 30.6% reduction in fasting insulin levels. Additionally, inflammatory markers such as hs-CRP decreased by 43.6%, and HDL cholesterol increased by 17.4%. These improvements were achieved despite a significant decline in the use of antidiabetic drugs.

Just over 61.3% of participants achieved a 5% weight loss, and nearly 40% maintained a 10% weight loss. Factors associated with remission include lower fasting insulin, better adherence, weight loss, decreased efficacy of diabetes medications, and shorter duration of diabetes.

During the study period, the use of antidiabetic drugs decreased from 85.2% to 71.3%, and the use of drugs other than metformin decreased from 55.7% to 32.8%. Average daily insulin dose decreased significantly from baseline.

This study used various statistical models to assess changes over a 5-year period. Linear mixed-effects models were used to account for within-subject correlations over time, adjusting for covariates such as age, gender, and duration of diabetes. HbA1c, body weight, fasting insulin, and cardiovascular markers were analyzed across five time points (baseline, 1 year, 2 years, 3.5 years, and 5 years) to understand trends over time. The statistical significance of the changes was confirmed, with adjusted p values ​​indicating significant reductions in fasting insulin, inflammatory markers, and lipid profiles, indicating that the benefits of the intervention were strong and sustained.

The remission rate in this study exceeded that in other well-known lifestyle therapy trials. For example, the Look AHEAD trial achieved a remission rate of 7.3% at 4 years, while the DiRECT trial reported a 13% remission rate at 5 years. In contrast, 20% of participants in this study reached remission after 5 years, and 32.5% achieved HbA1c levels below 6.5% without medication or with metformin alone. The high rate of sustained remission in this study may be due to sustained carbohydrate restriction and continued support from the care team.

This study shows that carbohydrate restriction therapy with continuous telecare can achieve and maintain T2D remission, with 20% of participants achieving remission after 5 years and 15 of 24 at 4 years. He remained in remission. 32.5% of participants achieved recovery without medication or using metformin alone. Even in participants who did not reach remission, their blood sugar levels remained stable and their drug use decreased.

Sustained reductions in HbA1c, fasting insulin, and inflammatory markers highlight the effectiveness of this approach in reducing long-term health risks. Furthermore, the reduction in medication burden with a 40% reduction in medication effectiveness score further demonstrates the clinical value of the intervention.

Remote care, peer support, access to care teams, and clinical success contributed to high retention rates. Forty-seven percent of participants stayed with the program for five years and saw improvements in blood sugar levels, weight, and cardiovascular health. Improvements in cardiovascular health were maintained after 5 years, with significant reductions in inflammatory markers and reduced cardiovascular risk during this period.

Diabetes management typically involves increased drug use, but this study showed that the need for drugs decreased and some participants were able to stop taking their prescriptions completely. The remission rates achieved in this study exceeded those achieved in other lifestyle therapy trials.

The strength of this study is its long duration and broad applicability to newly diagnosed as well as T2D patients. However, there was no comparison group throughout the 5 years, and the ethnic diversity of participants was limited.