Rethinking Type 2 Diabetes Treatment
Based on the work of Gary Taubes, an investigative science journalist and author
Gary Taubes argues that type 2 diabetes should be viewed not simply as a disease of elevated blood sugar, but as a disorder closely connected to insulin resistance and the body's difficulty handling carbohydrates.
Traditional treatment can successfully lower blood glucose with medications. Taubes asks a different question: if carbohydrates are the nutrient that most directly raises blood glucose, why not substantially reduce the amount a person with diabetes eats?
Carbohydrate restriction can lower blood glucose, reduce medication requirements, help with weight loss, and—in some people—contribute to remission of type 2 diabetes.
Low-carbohydrate diets are now recognized as one evidence-based option for managing type 2 diabetes, although they aren't the only effective approach.
Rethinking an Old Disease
In his book Rethinking Diabetes, Taubes examines the history of diabetes treatment and asks:
If people with diabetes have difficulty handling carbohydrates, shouldn't reducing carbohydrates be a central part of treatment?
Before insulin became available in the 1920s, physicians knew that carbohydrates increased blood glucose, and carbohydrate restriction was sometimes used to manage diabetes.
For people with type 1 diabetes, diet could not replace the missing insulin. The discovery of insulin was lifesaving.
Type 2 diabetes is different. People generally continue producing insulin—often substantial amounts—but their tissues become resistant to its effects.
Taubes argues that useful lessons about carbohydrate restriction were gradually overlooked as medications became increasingly effective at controlling blood glucose.
Carbohydrate Intolerance
Taubes sometimes describes type 2 diabetes as carbohydrate intolerance.
Carbohydrates—particularly sugars and rapidly digested starches—have the greatest immediate effect on blood glucose. Reducing them generally reduces post-meal glucose excursions and the amount of insulin needed to manage them.
Improvements can include lower blood glucose and A1C, lower triglycerides, weight loss, and reduced medication requirements. Results vary among individuals.
Can Type 2 Diabetes Go Into Remission?
A more precise term than “reversal” is remission.
Type 2 diabetes remission generally means blood glucose has fallen below the diabetic range for a defined period without glucose-lowering medication.
Remission has been demonstrated with low-carbohydrate diets, substantial weight loss using other dietary approaches, and bariatric surgery.
Taubes emphasizes reducing carbohydrates and insulin demand. Other researchers emphasize weight loss and reducing excess fat in the liver and pancreas. Both approaches can improve insulin sensitivity and glucose control.
What Does the Evidence Say?
Clinical trials of low-carbohydrate diets have found improvements in blood glucose, triglycerides, weight, and medication requirements.
The American Diabetes Association (ADA) recognizes reduced-carbohydrate eating as one evidence-based option while also recognizing Mediterranean and other healthy eating patterns. It emphasizes that nutrition should be individualized.
The American Diabetes Society (ADS) takes a more strongly low-carbohydrate position, considering carbohydrate restriction central to its approach to type 2 diabetes.
Its leadership includes physicians and researchers associated with low-carbohydrate and metabolic approaches, including Ken Berry, M.D., Ben Bikman, Ph.D., and Mariela Glandt, M.D.
Why the Criticism of the ADA?
Critics argue that the American Diabetes Association was slow to recognize the benefits of low-carbohydrate diets, despite years of research showing improvements in blood sugar and reduced medication requirements. Its 2019 nutrition consensus report explicitly recognized low- and very-low-carbohydrate diets as viable options for certain people with type 2 diabetes.
The ADA has also faced questions about its substantial financial support from pharmaceutical and food companies. While corporate funding does not establish that its recommendations are influenced, critics believe these relationships deserve greater scrutiny, particularly when dietary changes may reduce the need for medications.
What About Fat and Cholesterol?
Low-carbohydrate diets frequently lower triglycerides and raise HDL cholesterol.
LDL cholesterol is less predictable. It falls in some people, changes little in others, and can rise substantially in some.
Cardiovascular risk factors should therefore be monitored rather than assuming everyone responds to a low-carbohydrate diet in the same way.
Medication Safety
Someone with diabetes who substantially reduces carbohydrate intake can experience a rapid fall in blood glucose. If insulin or certain glucose-lowering medications are continued at the same dose, dangerously low blood glucose can occur.
Medication may need to be adjusted promptly under appropriate medical supervision.
Newer medications, including GLP-1 receptor agonists and SGLT2 inhibitors, can also provide important benefits for appropriate patients.
The choice doesn't have to be diet or medication. Treatment may combine dietary change, exercise, weight management, and appropriately selected medications.
What I Find Valuable About Taubes
Taubes has spent much of his career questioning assumptions about nutrition, obesity, insulin, and diabetes.
His greatest contribution may be his willingness to examine accepted medical ideas and ask whether the evidence supports them.
Scientific consensus is important, but consensus can change. That doesn't mean established advice should automatically be distrusted. It means we should remain willing to ask:
What is the evidence? How strong is it? What assumptions are we making? And what happens when we test alternatives?
For me, Taubes's central question about diabetes remains compelling:
If your body has difficulty handling carbohydrates, shouldn't reducing carbohydrates be one of the options considered?
Learn More
Taubes's book examining the history of diabetes treatment and the evidence for carbohydrate restriction.
Taubes writes about nutrition science, diabetes, obesity, and the difficulties of reaching reliable conclusions in nutrition research.
Information about several dietary approaches to diabetes management, including reduced-carbohydrate eating.
The American Diabetes Society presents its case for carbohydrate restriction in managing type 2 diabetes.
Videos
A discussion of the ideas in Rethinking Diabetes, including insulin, carbohydrates, and the history of diabetes treatment.
Dr. Eric Westman interviews Dr. Jason Fung about type 2 diabetes, insulin resistance, carbohydrate restriction, and intermittent fasting.
Dr. William Davis discusses how reducing dietary carbohydrates can improve blood sugar and insulin resistance in people with type 2 diabetes.
Dr. William Davis interviews Dr. Eric Westman about carbohydrate restriction, insulin resistance, type 2 diabetes, and cardiovascular risk.