If you’re living with type 2 diabetes, one of the first things you’ll usually hear at a follow-up is whether your HbA1c has gone up or down, but there’s another detail worth looking at alongside that number: what happened to your medication? Bringing your HbA1c down is worth celebrating in itself, and if you’ve done that while safely reducing your medication dose with your healthcare team, that’s another win the lab report won’t show. At The Noakes Foundation, we’re interested in what changes to the food people buy, cook and eat can do for their blood glucose, from helping them reach their targets while taking medication to, for some people, achieving remission. [1,4]

What happens when we change the food?

Anyone who has gone to bed without eating and still woken up with high blood glucose might reasonably wonder where all that glucose came from. The liver releases glucose between meals, and insulin usually tells it when to slow down. When the liver becomes resistant to insulin, it can carry on releasing glucose even when there’s already enough, and over time the pancreas may struggle to make enough insulin to compensate. That’s how breakfast can get the blame for a glucose reading that was already high before the kettle went on. [2]

The liver and pancreas can respond on different timescales. In studies using substantial energy restriction, liver fat and fasting glucose fell within days, while recovery of the pancreas’s ability to release insulin promptly took longer. In a 2026 study, people diagnosed with type 2 diabetes more recently were more likely to reach remission on a very-low-calorie diet, even though those who had lived with type 2 diabetes for longer lost a similar amount of weight. So when two people lose roughly the same amount of weight and end up with quite different glucose results, some of the explanation may lie in how much insulin-producing capacity they can recover. [2,3]

Can people reach remission with everyday food?

This is the part of the research that comes closest to the work we do. In an eight-year primary care evaluation, Unwin et al. offered people with type 2 diabetes practical support to reduce their carbohydrate intake using ordinary food. Of the 186 people who took up the offer, 94 reached remission. That included 77% of those diagnosed within the previous year and around 20% of those who had lived with diabetes for more than 15 years. [4]

In the six-month DIREM randomised trial, remission was observed in 9 of 40 participants assigned to a diet that reduced both calorie and carbohydrate intake, compared with 1 of 40 in the control group. In the group that also practised time-restricted eating, 12 of 40 participants achieved remission, although the difference between the two dietary groups was not statistically significant. [5]

A systematic review of randomised trials published in The BMJ found that, at six months, a greater proportion of participants assigned to lower-carbohydrate diets had an HbA1c below 6.5% than those assigned to comparison diets when the analysis included people who were still taking glucose-lowering medication. When the definition also required participants to be off glucose-lowering medication, the estimated difference was smaller and statistically uncertain. Both findings matter, because bringing HbA1c below the diabetes threshold is a meaningful improvement, while reaching that level without glucose-lowering medication addresses the more specific question of remission. [6]

DiRECT provides a longer view of remission after a different dietary intervention, which began with low-energy formula meal replacement and continued with food reintroduction and support to maintain weight loss. After one year, 46% of the intervention group were in remission, compared with 4% receiving usual care. [7] At two years, 36% of the intervention group were in remission. [8] At five years, 11 of the 85 participants assessed in the extension group were in remission. [9] The five-year figure comes from a subset of the original intervention group, but it shows that remission can persist for years in some people and gives us a reason to keep measuring HbA1c well beyond the end of the initial programme. [9]

What happened to the prescription?

Remission has a specific clinical definition. It usually means an HbA1c below 6.5%, measured at least three months after stopping glucose-lowering medication. For some people, that’s a goal they want to work towards. For someone else, getting their blood glucose into a safer range while continuing medication, or keeping it there on less, may be the improvement that makes the biggest difference to their day. Each is worth counting… and celebrating. [1,10]

For many people, a rising HbA1c has meant another prescription or a higher dose, and sometimes that’s exactly what’s needed. This research gives us good reason to make structured dietary support part of that conversation too. When someone taking medication to control their glucose makes a substantial change to what they eat, they need a plan with their healthcare team to monitor glucose and adjust doses safely. Even in remission, regular HbA1c checks and routine screening for diabetes complications still matter. [1,10,11]

What advice are people taking home?

If the dietary advice you’re given at diagnosis still puts bread, cereal, rice or pap at the centre of most meals, when do you get to find out how your blood glucose might respond to eating less carbohydrate? We think that conversation belongs at the first appointment, before someone has spent months following the advice they were given and wondering why their HbA1c is still high. [4–6]

This World Diabetes Day, we’d like to see a whole-food, lower-carbohydrate approach offered from diagnosis as part of routine type 2 diabetes care. That means showing people what they could put on the plate, agreeing on how to monitor their glucose and making a plan to review medication safely. The next time HbA1c comes up for review, let’s give the dietary advice the same attention we give the prescription. [4–6,10]

References

1. Riddle MC, Cefalu WT, Evans PH, et al. Consensus report: Definition and interpretation of remission in type 2 diabetes. Diabetes Care. 2021;44(10):2438–2444. Article
2. Taylor R, Ramachandran A, Yancy WS Jr, Forouhi NG. Nutritional basis of type 2 diabetes remission. BMJ. 2021;374. Article
3. Schuppelius B, Lalama E, Zhang J, et al. Remission of type 2 diabetes depends on time since diagnosis and low-calorie diet composition: Results of a randomized controlled trial in individuals with overweight and obesity. Diabetes Res Clin Pract. 2026;233:113159. Article
4. Unwin D, Delon C, Unwin J, et al. What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutr Prev Health. 2023;6(1):46–55. Article
5. Badrooj N, Esteghamati A, et al. The effect of integrated lifestyle intervention incorporating calorie-carbohydrate restriction with or without time-restricted feeding for remission of type 2 diabetes (DIREM): A single blind randomised controlled trial. Endocrinol Diabetes Metab. 2026;9(3). Article
6. Goldenberg JZ, Day A, Brinkworth GD, 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. 2021;372. Article
7. Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster-randomised trial. Lancet. 2018;391(10120):541–551. Article
8. Lean MEJ, Leslie WS, Barnes AC, 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. Lancet Diabetes Endocrinol. 2019;7(5):344–355. Article
9. Lean MEJ, Leslie WS, Barnes AC, et al. 5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: An extension study. Lancet Diabetes Endocrinol. 2024;12(4):233–246. Article
10. Davies MJ, Aroda VR, Bajaj M, et al. Management of type 2 diabetes, 2026. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2026. Article
11. Valabhji J, Gorton T, Barron E, et al. Early findings from the NHS Type 2 Diabetes Path to Remission Programme: A prospective evaluation of real-world implementation. Lancet Diabetes Endocrinol. 2024;12(9):653–663. Article