OBJECTIVE To assess the long-term effects of dietary interventions on glycemic control, need for diabetes medications, and remission of type 2 diabetes. RESEARCH DESIGN AND METHODS Originally, in a two-arm trial design, overweight, middle-aged men and women with newly diagnosed type 2 diabetes were randomized to a low-carbohydrate Mediterranean diet (LCMD; n = 108) or a low-fat diet (n = 107). After 4 years, participants who were still free of diabetes medications were further followed up until the primary end point (need of a diabetic drug); remission of diabetes (partial or complete) and changes in weight, glycemic control, and cardiovascular risk factors were also evaluated. RESULTS The primary end point was reached in all participants after a total follow-up of 6.1 years in the low-fat group and 8.1 years in the LCMD group; median survival time was 2.8 years (95% CI 2.4–3.2) and 4.8 years (4.3–5.2), respectively. The unadjusted hazard ratio for the overall follow-up was 0.68 (0.50–0.89; P < 0.001). LCMD participants were more likely to experience any remission (partial or complete), with a prevalence of 14.7% (13.0–16.5%) during the first year and 5.0% (4.4–5.6%) during year 6 compared with 4.1% (3.1–5.0%) at year 1 and 0% at year 6 in the low-fat diet group. CONCLUSIONS In patients with newly diagnosed type 2 diabetes, an LCMD resulted in a greater reduction of HbA1c levels, higher rate of diabetes remission, and delayed need for diabetes medication compared with a low-fat diet.