The Effectiveness of Low-Sugar Diets in the Management of Type 2 Diabetes Mellitus
Keywords:
low-sugar diet, type 2 diabetes mellitus, carbohydrate restriction, HbA1c, diabetes remission, medical nutrition therapyAbstract
This review examines the effectiveness of low-sugar diets in the management of type 2 diabetes mellitus, drawing exclusively on published clinical evidence and verified public data. Its purpose is to clarify what the term low-sugar diet can legitimately mean, to quantify the glycaemic and weight outcomes that sugar and carbohydrate restriction actually deliver, and to assess the safety, adherence, and cultural feasibility of these approaches for Indonesian patients. The method is a structured literature review of randomised controlled trials, systematic reviews, meta-analyses, and clinical guidelines, supplemented by public data from the International Diabetes Federation, the World Health Organization, and Indonesian national health surveys. The results show that restricting free sugars and sugar-sweetened beverages is consistently supported, that low-carbohydrate diets below 130 grams per day produce clinically meaningful reductions in HbA1c of roughly 0.3 to 0.5 percentage points and higher remission rates at six months, and that these advantages largely attenuate by twelve to twenty-four months as adherence declines. Weight loss, rather than sugar restriction alone, emerges as the strongest driver of remission, with the DiRECT trial reporting remission in 46 percent of an intensive weight management group against 4 percent of controls at twelve months, while medication adjustment is essential to prevent hypoglycaemia when carbohydrate intake falls quickly, and lipid monitoring is advised because low-density lipoprotein cholesterol rises in some patients on very low-carbohydrate patterns. Guideline positions from the American Diabetes Association, Diabetes UK, the World Health Organization, and the Indonesian PERKENI guideline converge on individualised carbohydrate moderation rather than prohibition. The novelty of this review lies in separating the evidence for sugar restriction specifically from the evidence for total carbohydrate restriction, and in translating the global evidence into the rice-centred, sweet-tea culture of Indonesia, where moderate, fibre-rich, and sustainable restriction is more realistic than ketogenic extremes.
References
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[29] A. Paoli, A. Rubini, J. S. Volek, and K. A. Grimaldi, "Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets," European Journal of Clinical Nutrition, vol. 67, no. 8, pp. 789-796, 2013, doi: 10.1038/ejcn.2013.116.
[30] M. Ichikawa et al., "Long-term effects of low-carbohydrate diet on glycaemic control and lipid profiles in patients with type 2 diabetes: a systematic review and meta-analysis," Journal of Diabetes Investigation, vol. 15, no. 10, pp. 1410-1421, 2024, doi: 10.1111/jdi.14271.
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[34] P. A. Dyson et al., "Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes," Diabetic Medicine, vol. 35, no. 5, pp. 541-547, 2018, doi: 10.1111/dme.13603.
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[36] J. Hironaka et al., "Efficacy of low-carbohydrate diet for type 2 diabetes in East Asian populations: a systematic review and meta-analysis," Journal of Diabetes Investigation, vol. 15, no. 12, pp. 1753-1766, 2024, doi: 10.1111/jdi.14326.
[37] Y. Yamada et al., "A non-calorie-restricted low-carbohydrate diet is effective as an alternative therapy for patients with type 2 diabetes," Internal Medicine, vol. 53, no. 1, pp. 13-19, 2014, doi: 10.2169/internalmedicine.53.0861.
[38] S. B. Seidelmann et al., "Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis," The Lancet Public Health, vol. 3, no. 9, pp. e419-e428, 2018, doi: 10.1016/S2468-2667(18)30135-X.
[2] H. Sun et al., "IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045," Diabetes Research and Clinical Practice, vol. 183, p. 109119, 2022, doi: 10.1016/j.diabres.2021.109119.
[3] Kementerian Kesehatan Republik Indonesia, Survei Kesehatan Indonesia (SKI) 2023. Jakarta, Indonesia: Badan Kebijakan Pembangunan Kesehatan, Kementerian Kesehatan RI, 2024.
[4] Kementerian Kesehatan Republik Indonesia, Laporan Nasional Riset Kesehatan Dasar (Riskesdas) 2018. Jakarta, Indonesia: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan, 2019.
[5] S. H. Ley, O. Hamdy, V. Mohan, and F. B. Hu, "Prevention and management of type 2 diabetes: dietary components and nutritional strategies," The Lancet, vol. 383, no. 9933, pp. 1999-2007, 2014, doi: 10.1016/S0140-6736(14)60613-9.
[6] V. S. Malik, B. M. Popkin, G. A. Bray, J.-P. Després, W. C. Willett, and F. B. Hu, "Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis," Diabetes Care, vol. 33, no. 11, pp. 2477-2483, 2010, doi: 10.2337/dc10-1079.
[7] L. Te Morenga, S. Mallard, and J. Mann, "Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies," BMJ, vol. 346, p. e7492, 2013, doi: 10.1136/bmj.e7492.
[8] World Health Organization, Guideline: Sugars Intake for Adults and Children. Geneva, Switzerland: World Health Organization, 2015.
[9] A. Reynolds et al., "Carbohydrate quality and human health: a series of systematic reviews and meta-analyses," The Lancet, vol. 393, no. 10170, pp. 434-445, 2019, doi: 10.1016/S0140-6736(18)31809-9.
[10] A. B. Evert et al., "Nutrition therapy for adults with diabetes or prediabetes: a consensus report," Diabetes Care, vol. 42, no. 5, pp. 731-754, 2019, doi: 10.2337/dci19-0014.
[11] Perkumpulan Endokrinologi Indonesia (PERKENI), Pedoman Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2021. Jakarta, Indonesia: PB PERKENI, 2021.
[12] R. D. Feinman et al., "Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base," Nutrition, vol. 31, no. 1, pp. 1-13, 2015, doi: 10.1016/j.nut.2014.06.011.
[13] A. Accurso et al., "Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal," Nutrition & Metabolism, vol. 5, p. 9, 2008, doi: 10.1186/1743-7075-5-9.
[14] E. C. Westman and M. C. Vernon, "Has carbohydrate-restriction been forgotten as a treatment for diabetes mellitus? A perspective on the ACCORD study design," Nutrition & Metabolism, vol. 5, p. 10, 2008, doi: 10.1186/1743-7075-5-10.
[15] F. Brouns, "Overweight and diabetes prevention: is a low-carbohydrate-high-fat diet recommendable?" European Journal of Nutrition, vol. 57, no. 4, pp. 1301-1312, 2018, doi: 10.1007/s00394-018-1636-y.
[16] J. Z. Goldenberg et al., "Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data," BMJ, vol. 372, p. m4743, 2021, doi: 10.1136/bmj.m4743.
[17] D. Thomas and E. J. Elliott, "Low glycaemic index, or low glycaemic load, diets for diabetes mellitus," Cochrane Database of Systematic Reviews, no. 1, p. CD006296, 2009, doi: 10.1002/14651858.CD006296.pub2.
[18] E. Sainsbury, N. V. Kizirian, S. R. Partridge, T. Gill, S. Colagiuri, and A. A. Gibson, "Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis," Diabetes Research and Clinical Practice, vol. 139, pp. 239-252, 2018, doi: 10.1016/j.diabres.2018.02.026.
[19] Y. Meng, H. Bai, S. Wang, Z. Li, Q. Wang, and L. Chen, "Efficacy of low carbohydrate diet for type 2 diabetes mellitus management: a systematic review and meta-analysis of randomized controlled trials," Diabetes Research and Clinical Practice, vol. 131, pp. 124-131, 2017, doi: 10.1016/j.diabres.2017.07.006.
[20] O. Snorgaard, G. M. Poulsen, H. K. Andersen, and A. Astrup, "Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes," BMJ Open Diabetes Research & Care, vol. 5, no. 1, p. e000354, 2017, doi: 10.1136/bmjdrc-2016-000354.
[21] P. D. McArdle et al., "The role of dietary carbohydrate in diabetes management: a systematic review and meta-analysis in European adults," Diabetic Medicine, vol. 36, no. 3, pp. 335-348, 2019.
[22] R. Huntriss, M. Campbell, and C. Bedwell, "The interpretation and effect of a low-carbohydrate diet in the management of type 2 diabetes: a systematic review and meta-analysis of randomised controlled trials," European Journal of Clinical Nutrition, vol. 72, no. 3, pp. 311-325, 2018, doi: 10.1038/s41430-017-0019-4.
[23] F. L. Santos, S. S. Esteves, A. da Costa Pereira, W. S. Yancy Jr., and J. P. L. Nunes, "Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors," Obesity Reviews, vol. 13, no. 11, pp. 1048-1066, 2012, doi: 10.1111/j.1467-789X.2012.01021.x.
[24] N. B. Bueno, I. S. V. de Melo, S. L. de Oliveira, and T. da Rocha Ataide, "Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials," British Journal of Nutrition, vol. 110, no. 7, pp. 1178-1187, 2013, doi: 10.1017/S0007114513000548.
[25] M. E. J. Lean et al., "Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial," The Lancet, vol. 391, no. 10120, pp. 541-551, 2018, doi: 10.1016/S0140-6736(17)33102-1.
[26] M. E. J. Lean et al., "Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial," The Lancet Diabetes & Endocrinology, vol. 7, no. 5, pp. 344-355, 2019, doi: 10.1016/S2213-8587(19)30068-3.
[27] S. J. Hallberg et al., "Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, non-randomized, controlled study," Diabetes Therapy, vol. 9, no. 2, pp. 583-612, 2018, doi: 10.1007/s13300-018-0373-9.
[28] C. F. Kirkpatrick et al., "Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate (including ketogenic) diets for the management of body weight and other cardiometabolic risk factors: a scientific statement from the National Lipid Association Nutrition and Lifestyle Task Force," Journal of Clinical Lipidology, vol. 13, no. 5, pp. 689-711.e1, 2019, doi: 10.1016/j.jacl.2019.08.003.
[29] A. Paoli, A. Rubini, J. S. Volek, and K. A. Grimaldi, "Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets," European Journal of Clinical Nutrition, vol. 67, no. 8, pp. 789-796, 2013, doi: 10.1038/ejcn.2013.116.
[30] M. Ichikawa et al., "Long-term effects of low-carbohydrate diet on glycaemic control and lipid profiles in patients with type 2 diabetes: a systematic review and meta-analysis," Journal of Diabetes Investigation, vol. 15, no. 10, pp. 1410-1421, 2024, doi: 10.1111/jdi.14271.
[31] L. O'Connor et al., "Prospective associations and population impact of sweet beverage intake and type 2 diabetes, and effects of substitutions with alternative beverages," Diabetologia, vol. 58, no. 7, pp. 1474-1483, 2015, doi: 10.1007/s00125-015-3572-1.
[32] P. J. Moynihan and S. A. M. Kelly, "Effect on caries of restricting sugars intake: systematic review to inform WHO guidelines," Journal of Dental Research, vol. 93, no. 1, pp. 8-18, 2014, doi: 10.1177/0022034513508954.
[33] M. J. Franz et al., "Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process," Journal of the Academy of Nutrition and Dietetics, vol. 117, no. 10, pp. 1659-1679, 2017.
[34] P. A. Dyson et al., "Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes," Diabetic Medicine, vol. 35, no. 5, pp. 541-547, 2018, doi: 10.1111/dme.13603.
[35] A. Adam-Perrot, P. Clifton, and F. Brouns, "Low-carbohydrate diets: nutritional and physiological aspects," Obesity Reviews, vol. 7, no. 1, pp. 49-58, 2006.
[36] J. Hironaka et al., "Efficacy of low-carbohydrate diet for type 2 diabetes in East Asian populations: a systematic review and meta-analysis," Journal of Diabetes Investigation, vol. 15, no. 12, pp. 1753-1766, 2024, doi: 10.1111/jdi.14326.
[37] Y. Yamada et al., "A non-calorie-restricted low-carbohydrate diet is effective as an alternative therapy for patients with type 2 diabetes," Internal Medicine, vol. 53, no. 1, pp. 13-19, 2014, doi: 10.2169/internalmedicine.53.0861.
[38] S. B. Seidelmann et al., "Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis," The Lancet Public Health, vol. 3, no. 9, pp. e419-e428, 2018, doi: 10.1016/S2468-2667(18)30135-X.
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