A litany of high-impact health stories stood out in 2019, nearly all of them with endings that remain to be written.

These included record-breaking opioid settlements, a new treatment for cystic fibrosis, the promise and peril of large IT brands like Google and Apple moving into the healthcare space, and a devastating outbreak of serious lung disease in healthy young persons from vaping illicit THC.

But in terms of the health story with the greatest potential for taming sickness and the ballooning cost of healthcare, a case can be made for the recognition by health officials in 2019 of the ketogenic diet as a first line-treatment for type 2 diabetes.

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The ketogenic diet, as many by now know, is a low-carb diet on steroids, a calorically-unrestricted eating pattern in which just 10-20% of daily calories (or less than 50 grams) come from carbohydrates, with dietary fat making up the majority of remaining energy (roughly 70% of daily calories).

Type 2 diabetes, on the other hand, is an acquired metabolic disorder affecting 340,000 Minnesotans and 30 million Americans, one that currently extracts $250 billion in direct costs each year in the US, and which can lead to heart disease, hypertension, Alzheimer's, amputation, blindness and cancer.

Because it is often accompanied by obesity, type 2 diabetes is routinely attributed to overeating and lack of exercise, but a more precise description of its mechanism comes down to an elevation of the body's hormone insulin. Given that the body only releases insulin in response to dietary carbohydrates, type 2 diabetes is  arguably a food-borne illness, with the food in question being carbohydrates. That is the rationale, in any event, for treating the predominant illness of our time with a ketogenic diet.

"We need to recognize that conventional diets have not worked well, and reduce the scientific barriers to studying novel approaches, like the ketogenic diet," says Dr. David Ludwig, an endocrinologist at Boston Children's Hospital and professor of pediatrics at Harvard Medical School, in an email to Forum News Service. "These long-term studies will provide the definitive data to understand effectiveness for various chronic conditions, and potential side-effects."

Ludwig recently authored a  paper in the Journal of Nutrition  compiling the evidence for ketogenic diets, past and present, a paper complete with a section heading noting there is no human requirement for dietary fiber or carbohydrate. "A century ago," he reminds readers, "the ketogenic diet was a standard of care in diabetes, used to prolong the life of children with type 1 diabetes and to control the symptoms of type 2 diabetes in adult."

It was only following the discovery of insulin in the 1920s, Ludwig writes, that high carbohydrate diets gave us our present day medication protocols for type 2 diabetes, treatments anchored by the use of pricey commercial insulin analogs and daily ingestion of glucose-control medications.

Ludwig says he wrote the article to counter "a spate of negative articles (that) have been rewritten about the ketogenic diet by nutrition experts," articles focusing on rare side-effects.

'Viable approach'

The case for keto in 2019 kicked off in May, when the American Diabetes Association released a Consensus  Report calling low carbohydrate or very low carbohydrate diets a "a viable approach" for certain patients with T2D, including those hoping to reduce medications.

Describing the diets as "among the most studied eating patterns for type 2 diabetes," the nation's diabetes authorities added the caveat that ketogenic therapy for diabetes generally requries medical oversight to prevent hypoglycemia. In other words, keto can work so effectively in diabetics that should patients fail to carefully taper medications with medical guidance as their condition improves, they can become dangerously overmedicated.

June of 2019 saw the  release of still more arguments for keto, in the form of second-year trial results by researchers from Indiana University Health and Verta Health. Their non-randomized clinical trial of the diet produced data showing that more than half of 262 patients studied had reversed their illness on a remote-monitored ketogenic diet, with many having discontinued the need for all medications except for Metformin.

While noting that the Verta Health results should be interpreted with caution, Ludwig says these "exceptional outcomes at two years, with many participants coming off diabetes medications and improving blood glucose control, highlights the exciting possibility that diabetes can be reversed without bariatric surgery."

The arrival of keto for type 2 diabetes comes along at a time when the standard of care is increasingly coming up short. The year saw widespread shortages and price hikes for insulin, leading politicians to threaten price control legislation and stirring insurers to issue competing press releases touting their full- or highly discounted insulin coverage packages.

As endocrinology researchers from Mayo Clinic recently  wrote in the journal BMJ, "the body of evidence shows no meaningful benefit" for intensive glucose-lowering regimens when it comes to the health outcomes that matter most to patients. And as researchers from Norway  confirmed in 2018, telling high-risk individuals the advice to eat more "fiber and polyunsaturated fat," plus the familiar five servings of fruit and vegetables with "plentiful intake" of beans, wholegrain and low-fat dairy, produced no improvement either.

For its part, the device industry is taking steps to build a ketogenic diabetes care product line, offering portable ketone breath meters and continuous glucose monitors allowing patients to see the effects on their blood sugar of carbohydrate rich foods in real time.

Still to be determined is whether dietary officials will heed the call by groups like the Low-Carb Action Network to include a true low-carbohydrate diet in the next installment of the dietary guidelines. Under the current USDA definition, diets up to 45% carbohydrates, are deemed low-carbohydrate, a too-high allowance for carbohydrates potentially washing out the ability of researchers to accurately test the intervention for disease reversal and prevention.

Its new research on an old method. As Ludwig notes, "before insulin was discovered, a very-low-carbohydrate diet was considered the standard of care for diabetes. From this perspective, modern nutrition science may be in the process of ‘rediscovering the wheel,’ so to speak."