When you have diabetes, getting blood sugar under control as soon as you find out that it’s off is critical, because diabetes may be reversible. Small, easy lifestyle changes like walking 30 minutes every day and limiting your intake of simple carbs are an ideal way to start. But if those don’t work, you might want to go extreme, says Craig Primack, M.D., president-elect of the Obesity Medicine Association. These three go-hard strategies are, well, hard. But so is having diabetes.

Go Keto (Carefully)

Eating fewer simple carbs to lower your blood sugar is a mainstay of any diabetes-management plan. But in a 2017 University of Michigan study, people who went on an ultra-low-carb keto diet—consuming 20 to 50 grams of carbs per day (you’d get that in a medium apple)—improved their blood-sugar control, body weight, and number of meds more than those who ate a moderate-carb, low-fat diet.

The downside: It’s not just important to talk to a doctor before you try this—it’s critical. While this eating plan can be helpful, it can also put anyone with diabetes who is on insulin or insulin-regulating meds at risk of ketoacidosis, a state in which the body’s pH falls to a potentially fatal level. You definitely need to contact your doc before you try this and stay in touch during the process.

Eat Super-Low Calorie

Nine hundred calories a day isn’t a lot, but a 2018 study published in The Lancet found that when people with type 2 diabetes stuck to just under that count, 46 percent of them achieved remission. Very low-calorie diets like this decrease the rate at which the liver produces glucose and improve that organ’s insulin sensitivity, per new research from Yale.

The downside: VLCDs come with a risk of nutritional deficiency and can shift how your body manages fluids, so your blood pressure, electrolytes, and blood sugar can swing in dangerous directions. The diets can be quite effective, but don’t try one without medical supervision, Dr. Primack says.

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Re-Plumb Your Pipes

Bariatric surgery is linked to diabetes improvements or remission in up to 80 percent of people who get the procedure. Within days of going under the knife—as much as a year before substantial poundage is shed—people are often able to reduce or quit their meds (including insulin). Experts are still trying to tease out why it works, but gastric bypass is the most effective of all forms of bariatric surgery at putting diabetes in remission, says Holly Herrington, R.D., a certified diabetes educator at Chicago’s Northwestern Memorial Hospital.

The downside: It’s not the easy way out. Gastric bypass takes your stomach from the size of a football to that of a pouch that can hold about two ounces of food at a time. And you can’t fully absorb nutrients from whatever you do eat, so you need lifelong supplements, Dr. Primack says. But for those who have the combination of diabetes, a BMI of 35 or more, and the inability to manage their weight and blood sugar with medication or counseling from a physician, the potential benefits can outweigh the risks.

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