For Richer, for Poorer: Low-Carb Diets Work for All Incomes

For 3 years, Ajala Efem's type 2 diabetes was so poorly controlled that her blood sugar often soared northward of 500 mg/dL despite insulin shots three to five times a day. She would experience dizziness, vomiting, severe headaches, and the neuropathy in her feet made walking painful. She was also — literally — frothing at the mouth. The 47-year-old single mother of two adult children with mental disabilities feared that she would die.

Efem lives in the South Bronx, which is among the poorest areas of New York City, where the combined rate of prediabetes and diabetes is close to 30%, the highest rate of any borough in the city.

Efem had to wait 8 months for an appointment with an endocrinologist, but that visit proved to be life-changing. She lost 28 lb and got off 15 medications in a single month. Efem did not join a gym or count calories; she simply changed the food she ate and adopted a low-carb diet.

"I went from being sick to feeling so great," she told her endocrinologist recently: "My feet aren't hurting; I'm not in pain; I'm eating as much as I want, and I really enjoy my food so much." 

Efem's life-changing visit was with Mariela Glandt, MD, at the offices of Essen Health Care. One month earlier, Glandt's company, OwnaHealth, was contracted by Essen to conduct a 100-person pilot program for endocrinology patients. Essen is the largest Medicaid provider in New York City, and "they were desperate for an endocrinologist," says Glandt, who trained at Columbia University in New York. So she came — all the way from Madrid, Spain. She commutes monthly, staying for a week each visit.

Glandt keeps up this punishing schedule because, as she explains, "it's such a high for me to see these incredible transformations." Her mostly Black and Hispanic patients are poor and lack resources, yet they lose significant amounts of weight, and their health issues resolve.

"Food is medicine" is an idea very much in vogue. The concept was central to the landmark White House Conference on Hunger, Nutrition, and Health in 2022 and is now the focus of a number wide range of government programs. Last month, the Senate held a hearing aimed at further expanding food as medicine programs.

Still, only a single randomized controlled clinical trial has been conducted on this nutritional approach, with unexpectedly disappointing results. In the mid-Atlantic region, 456 food-insecure adults with type 2 diabetes were randomly assigned to usual care or the provision of weekly groceries for their entire families for about 1 year. Provisions for a Mediterranean-style diet included: whole grains, fruits and vegetables, lean protein, low-fat dairy products, cereal, brown rice, and bread. In addition, participants received dietary consultations. Yet, those who got free food and coaching did not see improvements in their average blood sugar (the study's primary outcome), and their low-density lipoprotein (LDL)–cholesterol and high-density lipoprotein (HDL)–cholesterol levels appeared to have worsened. 

"To be honest, I was surprised," the study's lead author, Joseph Doyle, PhD, professor at the Sloan School of Management at MIT in Cambridge, Massachusetts, told me. "I was hoping we would show improved outcomes, but the way to make progress is to do well-randomized trials to find out what works."

I was not surprised by these results because a recent rigorous systematic review and meta-analysis in The BMJ did not show a Mediterranean-style diet to be the most effective for glycemic control. And Efem was not in fact following a Mediterranean-style diet.

Efem's low-carb success story is anecdotal, but Glandt has an established track record from her 9 years' experience as the Medical Director of the eponymous diabetes center she founded in Tel Aviv. A recent audit of 344 patients from the center found that after 6 months of following a very low–carbohydrate diet, 96.3% of those with diabetes saw their A1c fall from a median 7.6% to 6.3%. Weight loss was significant, with a median drop of 6.5 kg (14 lb) for patients with diabetes and 5.7 kg for those with prediabetes. The diet comprises 5%-10% of calories from carbs, but Glandt does not use numeric targets with her patients.

Blood pressure, triglycerides, and liver enzymes also improved. And though LDL cholesterol went up by 8%, this result may have been offset by an accompanying 13% rise in HDL cholesterol. Of the 78 patients initially on insulin, 62 were able to stop this medication entirely.

Although these results aren't from a clinical trial, they're still highly meaningful because the current dietary standard of care for type 2 diabetes can only slow the progression of the disease, not cause remission. Indeed, the idea that type 2 diabetes could be put into remission was not seriously considered by the American Diabetes Association (ADA) until 2009. By 2019, an ADA report concluded that "[r]educing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia." In other words, the best way to improve the key factor in diabetes is to reduce total carbohydrates. Yet, the ADA still advocates filling one quarter of one's plate with carbohydrate-based foods, an amount that will prevent remission. Given that the ADA's vision statement is "a life free of diabetes," it seems negligent not to tell people with a deadly condition that they can reverse this diagnosis. 

A 2023 meta-analysis of 42 controlled clinical trials on 4809 patients showed that a very low–carbohydrate ketogenic diet (keto) was "superior" to alternatives for glycemic control. A more recent review of 11 clinical trials found that this diet was equal but not superior to other nutritional approaches in terms of blood sugar control, but this review also concluded that keto led to greater increases in HDL-cholesterol and lower triglycerides. 

Glandt's patients in the Bronx might not seem like obvious low-carb candidates. The diet is considered expensive and difficult to sustain. My interviews with a half dozen patients revealed some of these difficulties, but even for a woman living in a homeless shelter, the obstacles are not insurmountable.

Jerrilyn, who preferred that I only use her first name, lives in a shelter in Queens. While we strolled through a nearby park, she told me about her desire to lose weight and recover from polycystic ovarian syndrome, which terrified her because it had caused dramatic hair loss. When she landed in Glandt's office at age 28, she weighed 180 lb. 

Less than 5 months later, Jerrilyn had lost 25 lb, and her period had returned with some regularity. She said she used "food stamps," known as the Supplemental Nutrition Assistance Program (SNAP), to buy most of her food at local delis because the meals served at the shelter were too heavy in starches. She starts her day with eggs, turkey bacon, and avocado. 

"It was hard to give up carbohydrates because in my culture [Latina], we have nothing but carbs: rice, potatoes, yuca," Jerrilyn shared. She noticed that carbs make her hungrier, but after 3 days of going low-carb, her cravings diminished. "It was like getting over an addiction," she said.

Jerrilyn told me she'd seen many doctors but none as involved as Glandt. "It feels awesome to know that I have a lot of really useful information coming from her all the time." The OwnaHealth app tracks weight, blood pressure, blood sugar, ketones, meals, mood, and cravings. Patients wear continuous glucose monitors and enter other information manually. Ketone bodies are used to measure dietary adherence and are obtained through finger pricks and test strips provided by OwnaHealth. Glandt gives patients her own food plan, along with free visual guides to low-carbohydrate foods by Dietdoctor.com. 

Glandt also sends her patients for regular blood work. She says she does not frequently see a rise in LDL cholesterol, which can sometimes occur on a low-carbohydrate diet. This effect is most common among people who are lean and fit. She says she doesn't discontinue statins unless cholesterol levels improve significantly.

Samuel Gonzalez, age 56, weighed 275 lb when he walked into Glandt's office this past November. His A1c was 9.2%, but none of his previous doctors had diagnosed him with diabetes. "I was like a walking bag of sugar!" he joked. 

A low-carbohydrate diet seemed absurd to a Puerto Rican like himself: "Having coffee without sugar? That's like sacrilegious in my culture!" exclaimed Gonzalez. Still, he managed, with SNAP, to cook eggs and bacon for breakfast and some kind of protein for dinner. He keeps lunch light, "like tuna fish," and finds checking in with the OwnaHealth app to be very helpful. "Every day, I'm on it," he said. In the past 7 months, he's lost 50 lb, normalized his cholesterol and blood pressure levels, and lowered his A1c to 5.5%.

Gonzalez gets disability payments due to a back injury, and Efem receives government payments because her husband died serving in the military. Efem says her new diet challenges her budget, but Gonzalez says he manages easily.

Mélissa Cruz, a 28-year-old studying to be a nail technician while also doing back office work at a physical therapy practice, says she's stretched thin. "I end up sad because I can't put energy into looking up recipes and cooking for me and my boyfriend," she told me. She'll often cook rice and plantains for him and meat for herself, but "it's frustrating when I'm low on funds and can't figure out what to eat." 

Low-carbohydrate diets have a reputation for being expensive because people often start eating pricier foods, like meat and cheese, to replace cheaper starchy foods such as pasta and rice. Eggs and ground beef are less expensive low-carb meal options, and meat, unlike fruits and vegetables, is easy to freeze and doesn't spoil quickly. These advantages can add up.

A 2019 cost analysis published in Nutrition Journal compared a low-carbohydrate dietary pattern with the New Zealand government's recommended guidelines (which are almost identical to those in the United States) and found that it cost only an extra $1.27 in US dollars per person per day. One explanation is that protein and fat are more satiating than carbohydrates, so people who mostly consume these macronutrients often cut back on snacks like packaged chips, crackers, and even fruits. Also, those on a ketogenic diet usually cut down on medications, so the additional $1.27 daily is likely offset by reduced spending at the pharmacy.

It's not just Bronx residents with low socioeconomic status (SES) who adapt well to low-carbohydrate diets. Among Alabama state employees with diabetes enrolled in a low-carbohydrate dietary program provided by a company called Virta, the low SES population had the best outcomes. Virta also published survey data in 2023 showing that participants in a program with the Veteran's Administration did not find additional costs to be an obstacle to dietary adherence. In fact, some participants saw cost reductions due to decreased spending on processed snacks and fast foods.

Cruz told me she struggles financially, yet she's still lost nearly 30 lb in 5 months, and her A1c went from 7.1% down to 5.9%, putting her diabetes into remission. Equally motivating for her are the improvements she's seen in other hormonal issues. Since childhood, she's had acanthosis, a condition that causes the skin to darken in velvety patches, and more recently, she developed severe hirsutism to the point of growing sideburns. "I had tried going vegan and fasting, but these just weren't sustainable for me, and I was so overwhelmed with counting calories all the time." Now, on a low-carbohydrate diet, which doesn't require calorie counting, she's finally seeing both these conditions improve significantly.

When I last checked in with Cruz, she said she had "kind of ghosted" Glandt due to her work and school constraints, but she hadn't abandoned the diet. She appreciated, too, that Glandt had not given up on her and kept calling and messaging. "She's not at all like a typical doctor who would just tell me to lose weight and shake their head at me," Cruz said. 

Because Glandt's approach is time-intensive and high-touch, it might seem impractical to scale up, but Glandt's app uses artificial intelligence to help with communications thus allowing her, with help from part-time health coaches, to care for patients. 

This early success in one of the United States's poorest and sickest neighborhoods should give us hope that type 2 diabetes need not to be a progressive irreversible disease, even among the disadvantaged. 

OwnaHealth's track record, along with that of Virta and other similar low-carbohydrate medical practices also give hope to the Food-Is-Medicine idea. Diabetes can go into remission, and people can be healed, provided that health practitioners prescribe the right foods. And in truth, it's not a diet. It's a way of eating that must be maintained. The sustainability of low-carbohydrate diets has been a point of contention, but the Virta trial, with 38% of patients sustaining remission at 2 years, showed that it's possible. (OwnaHealth, for its part, offers long-term maintenance plans to help patients stay very low-carb permanently.) 

Given the tremendous costs and health burden of diabetes, this approach should no doubt be the first line of treatment for doctors and the ADA. The past two decades of clinical trial research has demonstrated that remission of type 2 diabetes is possible through diet alone. It turns out that for metabolic diseases, only certain foods are truly medicine. 

Tools and Tips for Clinicians: 

• Free two-page keto starter's guide by OwnaHealth; Glandt uses this guide with her patients.
• Illustrated low-carb guides by Dietdoctor.com
• Free low-carbohydrate starter guide by the Michigan Collaborative for Type 2 Diabetes
• Low-Carb for Any Budget, a free digital booklet by Mark Cucuzzella, MD, and Kristie Sullivan, PhD
• Recipe and meal ideas from Ruled.me, Keto-Mojo.com, and Dietdoctor.com

Nina Teicholz, PhD, is an investigative science journalist, author, and thought leader in nutrition. In 2024, she received a PhD in nutrition focused on evidence-based nutrition policy. She is also the founder of the Nutrition Coalition, an independent nonprofit dedicated to ensuring that US dietary guidelines align with current science.