The type 2 diabetes medical community wakes up
For decades, the medical community has regarded type 2 diabetes (T2D) as permanent, progressive, and irreversible. Recent randomized controlled trials show this is false, at least for recently diagnosed cases. British diabetes researcher Roy Taylor developed the idea of reversing T2D with a structured program that begins with large, rapid weight loss. Taylor’s highly readable book, Life Beyond Diabetes, published in 2020, explains his program in detail. I highly recommend reading this book. His program has been refined and replicated several times as you’ll see below.
The DiRECT Trial
The Diabetes Remission Clinical Trial (DiRECT) recruited 306 people with T2D of less than 6 years duration to determine if a structured weight-loss intervention over 2 years would induce sufficient weight loss to reverse T2D (that is, achieve remission). Participants were recruited from 49 primary care medical practices in the UK. The trial was implemented by primary care staff. Results after 2 years showed that T2D reversal during the first year could continue through 2 years. The weight-loss intervention yielded far better results that standard medical care for T2D.
After 2 years, 11 percent of the weight-loss intervention participants lost 33 lbs of body weight compared to 2 percent of patients in the control group with standard medical care. After 2 years, 36 percent of the weight-loss intervention participants reversed T2D compared to 3 percent of patients in the control group. These results occurred despite only 40 percent of participants in the weight-loss group receiving anti-diabetes medication compared to 84 percent in the control group.
The odds of achieving remission increased in a step-wise manner as the amount of body-weight loss increased. In addition, patients in the weight-loss intervention had better diabetes-related cardiometabolic profiles than patients in the control group. This study showed that substantial weight loss (more than 22 lbs) could reverse T2D and sustain reversal over 2 years in a primary care setting. The cost of the structured weight-loss program amounted to less than half the annual cost of standard medical care for T2D patients. Given the huge financial and social costs of T2D worldwide, incorporating structured weight loss programs in primary care settings has the potential to save money and improve quality of life for T2D patients.
Three approaches to reverse type 2 diabetes
A 2019 narrative review summarized the evidence from three different approaches to reverse T2D. The first option is bariatric surgery, which current evidence shows to be the most effective means to reverse T2D. This procedure induces a rapid fall of blood glucose and T2D remission within days or a few weeks prior to substantial weight loss. This outcome suggests that hormonal signaling underlies the rapid remission. Major, seemingly positive changes in gut microflora, also occur. Bariatric surgery has potential major complications. Its relatively high price-tag of bariatric surgery may be offset by reduced expense arising from less medication.
A second approach to T2D remission involves patients eating a low-calorie diet, which makes sense given the link between overweight and obesity with T2D. Studies lasting up to 2 years show rates of complete or partial T2D remission that far exceed those of standard care. Long-term maintenance of a low-calorie diet limits the effectiveness of the low-calorie diet approach.
A third approach entails a low-carbohydrate diet. Definitions of ‘low carbohydrate’ differ, but 130 grams per day is a common upper limit. (By way of comparison, one carrot, apple, and orange and one serving each broccoli, green beans, cauliflower, spinach, Swiss chard, and pinto beans total less than 130 g of carbs.) A variant of the low-carb diet involves unlimited intake of protein and fat with a limit of 20 grams of carb per day. Interestingly, some patients on a very low-carb diet spontaneously reduce caloric intake for unknown reasons. Low-carb diets can induce T2D remission at higher rates than standard care over 1-2 years. Insufficient micronutrient intake is a potential concern, but taking a multi-vitamin with minerals might solve that. Maintaining a low-carb diet for the long-term poses a major challenge for many people. Continued support over the long term will likely be required for any approach in order to maintain T2D remission.
Is type 2 diabetes reversible in other parts of the world?
Researchers in Qatar conducted a study to see if intensive lifestyle intervention (ILI) similar to that used in the UK and the US would yield similar weight-loss and improved blood sugar control with patients from the Middle East and North Africa. One hundred forty-seven participants with T2D of less than 3 years duration and an average age of 42 years were randomized to the ILI or to standard medical care as the control group. LI started with low-energy, liquid meal replacement for 12 weeks, followed by gradual re-introduction of regular foods for 12 weeks followed by patients continuing their own low-energy diets for 26 weeks. ILI participants received behavioral change counseling every 2 weeks and were encouraged to get 10,000 steps per day.
From baseline to 12 months, participants in the ILI group lost significantly more body weight on average (26.4 lbs) compared to participants in the control group (8.8 lbs). The ILI group also showed significant improvements in cardiometabolic markers including HbA1c, waist circumference, fat mass, number of diabetes medications, number of anti-hypertensive medications, total cholesterol, and HDL-cholesterol compared to the control group. Diabetes remission (HbA1c less than 6.5 percent and no diabetes medications for at least 3 months) at 12 months occurred significantly more frequently in the ILI group (61 percent) than in the control group (12 percent). Similarly, normal blood sugar levels (HbA1c less than 5.7 percent) occurred significantly more frequently in the ILI group (33 percent) compared to the control group (4 percent). Overall, the ILI led to substantial weight loss and higher rates of T2D remission compared to standard medical treatment in patients from the Middle East and North Africa. At least over 1 year, T2D can be reversed.
The ReTune Study
Type 2 diabetes typically develops in people with overweight or obesity. Nevertheless, about 14 percent of persons with T2D have normal body weight. UK scientist Roy Taylor developed the ReTUNE study to test the Personal Fat Threshold Hypothesis. It states that some people have limited ability to store body fat safely under the skin. These people have a low personal fat threshold, above which fat gets stored in their liver and pancreas, leading to T2D. Participants included 20 persons with an average age of 59 years, average body-mass index (BMI) of 24.8, and with T2D diagnosed within the previous 6 years. Another cohort of participants with normal blood sugar levels, no first-degree relatives with T2D, and matched to the experimental participants in terms of post-intervention BMI, sex, and age served as a control group. The experimental group participants engaged in two successive, 2-4 week cycles designed to induce 5 percent weight loss through substitution of regular food with replacement meal products and up to 200 grams per day of non-starchy vegetables. Next, the experimental group participants engaged in 4-6 weeks of weight stabilization with a Mediterranean-type diet supervised by a research dietician. Relevant data were collected from participants at baseline, 8, 16, 24, and 52 weeks.
After 52 weeks and compared to baseline, the experimental group lost a significant 16.9 lbs of body weight, reduced BMI by 2.4 units, reduced waist circumference by 8.3 inches, and reduced visceral fat by 8.0 square inches. In addition, the experimental group significantly reduced liver fat, total triglyceride, VLDL triglyceride, HDL-cholesterol, and increased pancreatic beta-cell function (all in the healthy direction). The ReTUNE Study confirmed the Personal Fat Threshold Hypothesis: 70 percent of participants with normal or near-normal BMI values reversed their T2D despite stopping all glucose lowering agents after weight loss. Thus, the mechanism by which T2D develops (excess liver fat, fatty acid production by and export from the liver) is the same for regardless of body weight. Recently diagnosed T2D diabetes can be reversed with significant body fat loss via drastic caloric reduction over several weeks or months to lower body fat to below a person’s particular fat threshold.
Patients in Australia reverse type 2 diabetes
Prompted by two recent articles that showed the effectiveness of intensive lifestyle interventions to reduce recently diagnosed T2D, researchers in Australia conducted a similar 12-month intensive lifestyle intervention this time with 155 patients with T2D diagnosed up to 6 years previously from 25 primary care practices in New South Wales, Australia. These patients with an average age of 52 years had T2D up to 6 years duration and HbA1c levels more than 6.5 percent at baseline. The intervention was designed to elicit an initial large and rapid weight loss by substituting normal food with 3-4 low-energy total dietary replacement meals per day over 13 weeks. During this phase, participants were encouraged to consume daily 2 or more liters of water, 2 cups of low-starch vegetables plus a tablespoon of oil, and psyllium husks if constipation ensued. Participants were also encouraged to get 15,000 daily steps. After the initial phase ended, participants entered an 8-week structured food reintroduction. Over time, the meal replacements declined and healthy low-fat meals gradually increased accompanied by advice from dieticians. All glucose medications were discontinued. If HbA1c levels rose above 6.5 percent or if weight gain occurred, participants were offered rescue plans with reintroduction of one meal replacement product daily or resumption of the initial rapid weight loss phase.
At 6, 9, and 12 months, 64, 60, and 56 percent of the patients, respectively, experienced remission of T2D. Patients who lost more weight were significantly more likely to have T2D remission than patients who lost less weight. Specifically, as patient weight loss increased from 5, to 5-10, to 10-15, and to more than 15 percent of their initial body weight, their odds of achieving T2D remission increased from 38, 45, 75, and 87 percent. This and previous studies contradict notions that T2D is permanent, progressive, and irreversible. Widely available intensive lifestyle interventions could dramatically reduce the prevalence of T2D in the near future.
The American Diabetes Association gets onboard
The American Diabetes Association publishes the journal, Diabetes Care. The previous summary features an article by Hocking and others published in Diabetes Care. In case readers didn’t grasp the significance of the Hocking article, Shahrad Taheri, the lead author on a recent study that showed diabetes remission in a population from the Middle East and North Africa (see above), provided context. Taheri noted that recent intensive lifestyle interventions have led large percentages of T2D patients to reverse T2D. Contrary to what many physicians understand, it’s simply not true that T2D is always a permanent, progressive, and irreversible disease. Which is not to say that reversing T2D is easy. To the contrary. However, the upside potential of broadly offered intensive lifestyle interventions offers hope that the tide of T2D will subside
What to do
If you or someone you know has been diagnosed with T2D or pre-diabetes, know that these conditions can be reversed. Odds for reversal increase for diabetes of shorter duration. If you have a T2D diagnosis, you have probably exceeded your personal body fat threshold. This refers to body fat that can be safely stored under the skin as opposed inside your internal organs, especially your liver and pancreas. To remedy this situation, you’ll need to lose body fat, perhaps of lot of it. While losing a lot of weight may not sound attractive, having T2D and its complications (kidney failure, loss of eyesight, amputations) is far more unattractive. Ask your primary care provider to recommend an evidence-based weight loss program for you.
