Ophthalmologist and 2020 Australian of the Year DR JAMES MUECKE has been a prominent voice in a recent government inquiry into the state of diabetes in Australia. After completely changing his view on type 2 diabetes in 2019, he’s now on the crusade to convince his medical peers the solution is simpler than once thought.
I’ve been treating the blinding complications of type 2 diabetes for nearly 35 years. For most of that time the management involved painful laser burns to the peripheral retina to hopefully reverse the ingrowth of abnormal new blood vessels that could bleed in an instant and permanently blind the afflicted eye. Or it involved laser burns close to the fovea to attempt to stimulate absorption of the fluid collecting from leaky blood vessels, risking permanent damage to the vision.
Over the past decade and a half, much of this laser has been replaced with injections into the back of the eye of an antibody that can either halt the growth of the new blood vessels in the periphery or seal up the leaky blood vessels at the macula. It’s a miraculous innovation that has revolutionised the treatment of diabetes-related eye disease.
I was always the guy at the end of the line treating the end-stage complication, the most feared complication – loss of vision – of what I now realise is an avoidable man-made dietary disease. Never once did I consider my role to include discussion of lifestyle interventions that could not only prevent type 2 diabetes, but could also potentially put the condition into remission. That is, until I read a ground-breaking book in late 2019.
The Diabetes Code, by Canadian renal physician Dr Jason Fung, taught me that type 2 diabetes can be reversed naturally. It was a revelation to me. I always thought type 2 diabetes was a progressive disease, ultimately requiring oral medication, injectable insulin, a raft of unpleasant and unavoidable complications and an untimely death. Afterall, that is what I’d been taught in medical school. The message was reinforced by a variety of public health associations working in the diabetes space.
In 2020, I was selected to be on the Expert Advisory Group for Australia’s National Diabetes Strategy. I managed to get the opportunity for remission included in that document for the very first time. The strategy was published in late 2021. This was a turning point for the management of type 2 diabetes in Australia. At last, patients had hope. Hope their condition could be turned around. Hope they didn’t have to face a multitude of crippling complications and crippling expenses.
I started to talk about remission with my patients, initially the ones with vision-threatening eye disease, who I was actively treating with regular eye injections. Perhaps 100 patients. A drop in the ocean compared to the estimated 200,000 in Australia with vision-threatening retinopathy due to their diabetes. All but one of that 100, a mere 1%, were aware of this life-changing opportunity.
I wrote to the GPs for each of these patients, asking, sometimes pleading, for the concept of remission to be explored with our mutual patient. Most of my letters were seemingly ignored. Some doctors disowned their patients. Some took it on board. More often than not, it was the patient who had to insist that their GP give it a go. I recommended a local nutritionist who specialises in dietary change to attempt remission. I encouraged active participation of the GP because of the potential need for de-prescribing diabetes medications. Eventually, all these patients returned to me for their injections. And I monitored their progress.
I still remember the very first patient who put his diabetes into remission. He was a man in his late 60s who had type 2 diabetes for over a decade and had been receiving eight-weekly injections into both eyes for many years. At the first visit back to me after commencing his dietary change, he had come off his insulin in less than two months. By the next appointment, he had discontinued all his oral medications. He had lost a heap of weight. He told me he was thinking more clearly, that he was seeing more clearly, and that he’d never felt better. I noticed over the next couple of years that I was able to increase the interval between eye injections, something I had not previously been able to achieve. He is now off his injections altogether and the macula in both eyes has remained free of recurrent swelling.
I have noticed a similar response in all my patients with type 2 diabetes who have made the appropriate change in their diet, whether receiving eye injections or not. The macular oedema improves in all, and in most cases, resolves completely. I have recently published a case report of a young woman whose macular oedema due to her diabetes resolved in both eyes within nine months following a change in diet alone. A larger series of case reports is to follow.
Editor’s note: Since this article was written Dr James Muecke and colleagues reported 15 cases of people reversing their diabetic macular oedema (DMO) using only their diet.
And I’ve noted a similar response in patients with macular oedema due to retinal vein occlusion. This is the single most satisfying experience of my 40-year medical career. I wish all my ophthalmic and optometric colleagues can experience the joy of turning around a patient’s chronic disease, and of reversing its vision-threatening complications
By using food as medicine, rather than using tablets, injections or surgery.
And what dietary change is so profoundly impactful on type 2 diabetes? It’s quite simple – real food. My dietary recommendations are to avoid the dual metabolic disruptors of highly refined sugar and seed oils. I also urge patients to eliminate the industrially-created, ultra-processed food-like substances which often contain them, and which now make up close to half of the calories in the diets of Australians.
Some patients may need to be stricter with their carbohydrate consumption – if you have any type of diabetes, you are in essence intolerant of carbs. The limiting of carbs to less than 30g per day is known as a ketogenic diet and it induces a state where the body moves into a safe zone of nutritional ketosis and uses ketone bodies rather than glucose as fuel.
Guidelines for using carbohydrate restriction and promoting healthy natural fats, also known as ‘therapeutic carbohydrate reduction’, have now been written for Australia. They have been endorsed by Diabetes Australia and the Australian Diabetes Society. The next phase is to incorporate this critical principle into the practice of doctors and diet practitioners across the country. Plans are progressing well.
I gave evidence to the Parliamentary Inquiry into Diabetes in late 2023. A number of practitioners and patients with lived experience also gave evidence. The report, The State of Diabetes Mellitus in Australia in 2024, has just been released. I was delighted to read these words in the report: “There was significant evidence revealed about the importance of low carbohydrate diets in all forms of diabetes and this needs to be further promoted and evaluated.”
Recommendation 2 states: “The committee recommends that the National Health and Medical Research Council expedites a review of the Australian Dietary Guidelines, and ensures that the revised guidelines include adequate information for Australians living with diabetes.”
There is at last hope for people living with type 2 diabetes.
I just need my medical and nutrition colleagues to understand and embrace the concept.
Other key recommendations from ‘The State of Diabetes Mellitus in Australia in 2024’, include:
• The government explores the potential for effective national screening programs for all forms of diabetes, particularly type 2 diabetes
• The government implements a national public health campaign to increase public awareness of the early signs of all forms of diabetes mellitus
• The government funds the development of education-based obesity screening information and resources
• That equitable access to healthcare for people living with all forms of diabetes be improved through: longer appointments with a healthcare provider subsidised by the MBS; access to case conferencing models of healthcare, especially in rural and remote areas; access to telehealth services; increase in the number of item numbers for allied health consultation for those with diabetes for diabetes educators and dieticians and other allied health providers
• Access to diabetes educators, including in high-risk outer metropolitan, rural and remote communities
• Subsidised access to Continuous Glucose Monitors (CGMs) is further expanded
• Explore expanding subsidised access to insulin pumps for all Australians with type 1 diabetes
• The government undertakes a review of the price and choice of insulin pumps in Australia
• The government, subject to a positive recommendation from the Pharmaceutical Benefits Advisory Committee, expands the eligibility criteria for Glucagon-like Peptide-1 (GLP-1) receptor agonists, particularly for high-risk patients.
More reading
Ophthalmic voice prominent in 2024 national diabetes inquiry
AI scan for diabetes has potential to save sight and money
Missed health checks for type 2 diabetes costing Australia billions
