Paleo devotees are still waiting for mainstream nutritional science to recognize the demonstrated, profound anti-diabetic effects of their nutrient-dense, naturally low-carbohydrate diet.
Unfortunately, based on a recent meta-analysis by Professor Nita Forouhi et al  that surveyed diet-based diabetes therapies, they will have to wait a bit longer.
Researchers have once again sidestepped Ancestral living in favor of pills, surgery and “crash” dieting.
Part One of this series examined the study which showed a clear bias toward Western dietary norms, and concluded that weight loss is the best therapy for diabetes—based on bariatric surgery results.
Forouhi et al explored other therapies that could challenge the mainstream, including low-carb diets, but declared them “controversial” or “difficult.” Instead, the study noted that bariatric surgery often normalizes blood glucose levels—and endorsed diets which mimic it including high-sugar liquid meal replacement “crash” diets.
Even worse, this idea has been taken to new extremes by a separate team of researchers, who are developing an oral medication intended to mimic bariatric surgery.
The surgery pill: eat your cake without having it
Published in the same month as the Forouhi study, a separate paper by Yuhan Lee et al  proposed going one step further—an oral medication that mimics bariatric surgery – for the same reasons: short term improvement in blood glucose markers.
The proposed “therapeutic luminal coating of the intestines” is being developed to “block glucose absorption” and also to deliver biologics and other medications to the lower intestine with less pre-digestion.
The authors claim their product “will emulate a critical part of bariatric surgery in a non-invasive way.”
As of this writing, the drug creates a transient paste that coats the intestines, blocking up to 43% of ingested glucose in the first hour, dropping to 25% after the third hour. The paste takes three days to disperse.
Long-term side effects of its use are not explored in the paper.
Weight loss at any cost?
Healthy, sustainable improvements in body composition are certainly therapeutic for diabetes and many other ailments. The benefits range from reduced inflammatory cytokines (secreted by excess adipose tissue) to simple relief on load-bearing joints.
However, surgery to promote weigh loss (or a “crash” low-calorie diet) are extreme steps—and not indicated, or sustainable, for most diabetics or healthy individuals.
These sudden, disruptive lifestyle changes (not to mention discomfort and possible surgical complications) should be a last resort—even if they produce short term results and temporarily improved blood glucose markers.
One follow-up study of bariatric surgical patients showed reasonable weight loss (77 percent after one year, dropping to 56 percent in five years) but diabetes remission was only 51 percent after one year, and 21 percent at five years. 
This short term success may justify surgery (and its risks) for the morbidly obese, but as Yuhan Lee et al point out in their paper on Therapeutic Luminal Coating of the Intestine, most diabetics are not surgical candidates to begin with.
Nor does the Lee paper examine diet. The focus is simply on inhibiting glucose uptake.
The issue is that surgery or ultra-low calorie diets (or intestinal paste) don’t address fundamental dietary issues. Post-surgery dietary recommendations still include grains, cereals and processed foods (like “creamed soups”) . Sugar is discouraged but not eliminated.
As even new Paleo dieters realize, grains, sugars, seed oils and processed foods all contribute to inflammation, glucose insensitivity… and lead back to diabetes.
Surgery in a pill… is still a pill
While “coating the intestines to prevent glucose uptake” may have clinical applications, it also sidesteps the idea of healthy dietary changes.
Instead, it implies that we can eat whatever we like–and take yet another pill to protect us from our diet’s worst effects.
But how sustainable is reliance on medication to insulate us from lifelong, chronic intestinal permeability, systemic inflammation, and elevated blood glucose?
Not everyone thinks this is a good idea.
Dr. Fiona Godlee, is the editor-in-chief of The BMJ, an international medical online journal. She addresses this issue in a penetrating article: Pills are not the answer to unhealthy lifestyles. 
Referencing the Forouhi study among others, she criticizes the multi-billion-dollar market for drugs aimed at lifestyle-based diseases like T2D, hypertension, and fatty liver disease.
…pills can’t be the answer to diseases caused by unhealthy living. As well as unsustainable cost for often marginal benefit, they always cause harm. Rather than medicating almost the entire adult population, let’s invest our precious resources in societal and lifestyle change, public health, and prevention. [Emphasis added.]
When “unhealthy living” is normal
Surgery. Unsustainable, non-satiating crash diets. Intestinal paste.
These extreme, short term strategies all tiptoe around the idea that fundamental dietary change might work—or at least be worth a try. They also highlight the deeply entrenched  nature of conventional dietary norms.
The Forouhi study acknowledges how hard it is for patients (or anyone) to adopt significant dietary changes. Elimination of unhealthy foods or food groups is dismaying or even threatening to many people.
Mainstream media often reinforces this perception.
Articles like The problems with elimination diets, by Paige Smathers, RD,  and Overwhelming thoughts about food can have a profound impact on overall health, by Devrie Pettit, RD.N  appear often. They make the case that “average dieters” can’t handle giving up certain foods—and shouldn’t be expected to do so.
Both of these dietitians (and many others) claim the stress isn’t worth the health benefits.
But is it really that hard to stop eating unhealthy food?
Paleo living: the common-sense alternative
Every Paleo dieter knows healthy dietary changes are possible—and well worth the effort. Thousands of Paleo converts permanently eliminate grains, sugars, dairy, seed oils, and processed foods every day.
They do all this without surgery or drugs—or the associated discomfort, lifestyle dislocation, and expense.
They don’t panic over absent pasta.
Most don’t require medical supervision, except to reduce medications for ongoing ailments (like diabetes.) Their nutrient-dense, highly satiating pre-agrarian diet is sustainable, enjoyable and promotes vibrant good health.
This writer (down 40 pounds) has been Paleo for almost three years, has had exactly one cold in that time, is no longer pre-diabetic, clinically obese or hypercholesterolemic…and will never go back.
- “Dietary and nutritional approaches for prevention and management of type 2 diabetes,” 6/13/2018, published in The BMJ by professors Nita G. Forouhi, Anoop Misra, Viswanathan Mohan, Roy Taylor, and director William Yancy, retrieved here
- “Therapeutic Luminal Coating of the Intestine,” 6/11/2018, published in Nature Materials by Yuhan Lee, Tara E. Deelman, Keyue Chen, Dawn S.Y. Lin, Ali Tavakkoli & Jeffrey M. Karp, retrieved here
- “Bariatric Surgery Patients See Weight Gain After ‘Honeymoon’ Period,” published on Healthline.com by Brian Krans, 8/5/2015, retrieved here
- “Gastric bypass diet: What to eat after the surgery,” published on MayoClinic.org by Mayo Clinic Staff, 9/21/2018, retrieved here
- “Pills are not the answer to unhealthy lifestyles,” published in The BMJ by Dr. Fiona Godlee, 7/12/2018, retrieved here
- “The reality of food addiction,” published on ThePaleoDiet.com by Casey Thaler, B.A, NASM-CPT, FNS, 7/24/2014, retrieved here
- “The problems with elimination diets,” published on KSL.com by Paige Smathers, RD, 7/18/2017, retrieved here
- “Overwhelming thoughts about food can have a profound impact on overall health,” published on KSL.com by Devrie Pettit, RDN, 9/11/2018, retrieved here