Type 2 Diabetes: How to Reverse it
Diabetes is feared for its lifelong restrictions, treatment, and testing. It also causes a variety of complications, some life threatening. But is it truly a lifelong affliction, or can diabetes be reversed?
Diabetes has very close bonds with overweight and obesity. More than half of people with type 2 diabetes have a body mass index (BMI) of 30.0 or more. The possibility that reversing obesity might also reverse diabetes has fascinated scientists in recent years.
People with obesity who opt for bariatric surgery often lose significant amounts of weight. Some of them, who had diabetes, were able to reduce or entirely stop their use of oral antidiabetic drugs. This observation prompted the investigation of planned, controlled weight reduction as a strategy to reverse diabetes.
What is Diabetes?
Glucose is a simple carbohydrate, but is very important in our body as a source of energy. Carbohydrates in our food are broken down to glucose and transported by the blood to the organs, tissues, and cells. Some cells, like those in the brain, can only use glucose as their energy source.
Useful as it is, glucose has to be controlled. The body maintains blood glucose levels within safe limits. Diabetes is a condition wherein the control of glucose blood levels is improper. High levels of glucose over a prolonged period adversely affect several organs and systems in the body. Very high levels can also cause sudden dangerous conditions.
More than 400 million people in the world live with diabetes. The currently approved treatment plans are oral drugs and insulin injections to lower the blood glucose level and avoid the complications.
Despite decades of refinement, the treatment of diabetes is troublesome, expensive, and difficult to follow over a lifetime. People with diabetes are eager for a treatment that would free them from the expense, pain, and burden of daily drugs and injections.
Types of Diabetes
Diabetes is mainly of two types. They vary in their severity, treatment required, and amenability to control and reversal.
Type 1, earlier called insulin dependent diabetes mellitus (IDDM). This is usually an autoimmune condition causing the destruction of the insulin producing cells in the pancreas. It has to be treated by insulin injections, as there is no insulin production at all.
Type 2, earlier called non- insulin dependent diabetes mellitus (NIDDM). There is a relative deficiency of insulin, and various drugs and other methods are used for control. These people may need insulin when the disorder progresses. It is now known as Type 2 Diabetes Mellitus (T2DM).
Ninety percent of people with diabetes have this type, which we earlier considered a mild disease. We have since learned that NIDDM is far from benign. If not controlled effectively, it damages many organs and systems, chiefly the heart, legs, brain, eyes, kidneys, and nervous system.
Living with Type 2 Diabetes
People with diabetes are prescribed a glucose-lowering diet, an exercise plan, and other advice about controlling their disorder. It’s necessary to get used to the idea of dietary restrictions for a prolonged period.
When diabetes is diagnosed, a very low calorie diet (400-800 calories) can help bring down the blood sugar levels. However, most people can’t sustain such diets for long. Returning to the usual food intake causes diabetes to rebound.
People with diabetes must monitor their disorder regularly. This requires regular laboratory testing to assess glucose control and regular attendance at a clinic for altering the treatment from time to time. It is also necessary to watch for the complications of diabetes.
Eating for Reversal
Novel scientific thinking aims at reversing diabetes. Since diabetes is often associated with obesity, these plans have weight loss at their core.
The basis is a diet very low in carbohydrates. Such diets keep the blood glucose levels low, but lead to ketosis. Good monitoring is essential; serum beta-hydroxybutyrate levels should be kept between 0.5–3.0 mmol per liter.
Most people require carbohydrate restriction to less than 30 grams a day to achieve this. To compensate, protein intake should be 1.5 grams per Kg body weight, and fat intake should be increased to provide adequate calories. Supplementation with vitamins and minerals is required with such a restricted diet.
What is TDR (Total Diet Replacement)?
An extreme measure, replacing food completely with a liquid formula consisting of shakes and soups. The formula provides measured amounts of proteins, fats, carbohydrates, minerals, vitamins, and other essential nutrients.
For diabetes reversal purposes, the formula provides 800-850 calories a day. One such TDR formula provided 825–853 kcal/day, with 59% carbohydrate, 26% protein, 13% fat, and 2% fiber.
Such a formula will keep blood glucose low. Oral antidiabetic drugs are stopped when TDR is started, because blood glucose levels may fall abruptly. This is continued for 12 weeks, with regular monitoring of the blood sugar level. Oral antidiabetic drugs are reintroduced at low doses, if necessary.
A 12-week period of TDR usually leads to significant weight loss, after which food is reintroduced in a controlled manner. If BMI falls below 23 before 12 weeks, food can be reintroduced early. Some people may wish, or need, to continue TDR for up to 20 weeks.
There is no need for fluid restriction. Participants can drink as much water as they like, but not calorie sources like juices, milk, and soft drinks.
How Does Weight Loss Work?
We don’t fully understand it, but three mechanisms seem important:
- Reduction of fat deposited in the pancreas and liver.
- Return of first-phase insulin secretion to near normal.
- Reversal of liver insulin resistance.
Is a Cure Possible?
No, diabetes is a lifelong affliction. It cannot be permanently cured by any treatment known at present.
For decades, we have been keeping diabetes under control with exercise, oral drugs, and insulin injections. The new approach of extreme carbohydrate restriction does not cure diabetes, but reduces body weight and aids glucose level control. Almost everyone who tries it will be able to reduce or stop insulin injections and oral drugs.
What is Remission?
Remission is the aim of this treatment plan—maintaining normal blood glucose and HbA1c levels without taking drugs.
People with diabetes whose HbA1c level is less than 6·5% (<48 mmol/liter), after at least two months not taking any antidiabetic drugs, are considered to have achieved remission.
Is It Easy?
Nothing about diabetes is easy.
This regime, involving strict adherence to a very restricted diet, is challenging to follow over a long period. One study carried out in America provided regular and easy communication with dieticians and other health care providers to participants. There was also a support group of peers.
Even so, only 83% of people remained with the program after a year; roughly one in six left it. It needs considerable determination to live with rigorous restrictions for a long time.
What Does the Science Say?
There are no 100% cures in medical science. However, the numbers achieved so far are encouraging.
One general practice in England advised their type 2 diabetes patients to follow a low-carbohydrate diet. Patients lost significant weight and had a fall in their HbA1c levels. More importantly, 46% of these diabetes patients achieved drug-free remission.
The American study, carried out at multiple sites in the country, also advised people with type 2 diabetes mellitus to follow a low carbohydrate diet and weight loss methods. They reported a significant improvement in blood sugar, fasting insulin blood levels, and other biochemical measures of diabetes.
HbA1c (also known as glycated hemoglobin) levels are a measure of glucose levels over a prolonged period. One year after enrolling in this trial, 69% of participants had levels below 6.5%, compared to 19% at the beginning.
More importantly, many people in this study were able to reduce their medication requirements. Many were able to stop antidiabetic drugs completely. These drugs included gliptins (Dipeptidyl peptidase-4 (DPP-4) inhibitors), sulfonylureas, SGLT-2 inhibitors (canagliflozin, dapagliflozin, and empagliflozin), and thiazolidinediones (pioglitazone and rosiglitazone).
Impressively, 40% of insulin users were able to stop using it; the other 60% were able to reduce the requirement to half.
These people also lost significant weight on the controlled diet.
Is Weight Loss Essential?
Losing weight is probably the key determinant of successful reversal of type 2 diabetes.
Normal blood glucose levels can be achieved by low carbohydrate diets alone. However, people who do not lose weight have short-lived benefits. As soon as the low carbohydrate plan is relaxed, the blood sugar levels shoot up.
One study in England and Scotland measured the effect of weight loss on diabetes remission. Their results are striking.
No participant that gained weight achieved remission. Remission rates increased with weight loss—7% in those who lost 0-5 Kg, 34% in those who lost 5-10 Kg, 57% in those who lost 10-15 Kg, and 86% in those who lost 15 Kg at least.
Are Such Restricted Diets Safe?
The people in these studies were followed up for at least a year, and some longer. There were rare, temporary findings of acidosis, raised uric acid levels, and other parameters, but no major, long-term effects. Increased protein in the diet was associated with higher levels of blood urea, but within normal limits.
Who Should Not Attempt Diabetes Remission?
Diabetes remission is dependent on obesity reduction and subsequent metabolic benefits. It is not suitable for everyone.
- Type 1 diabetes. These people need insulin to maintain life.
- Long-standing type 2 diabetes. Results are best in people who have had the disorder for less than six years.
- People unable to tolerate the severely reduced diet, or those who cannot lose weight for any reason.
- People with major illness like cancer, heart disease, eating disorders, pregnancy, depression or other psychiatric illness, etc.
How Can You Achieve Remission?
Diabetes is a lifelong accompaniment, and short-term solutions are not appropriate. Dietary and lifestyle modifications should be such that you can maintain them for an extended period.
You will need a lot of determination, and support from various experts.
- A nutritionist to customize a low-carbohydrate diet for your weight and other conditions.
- A physician to ensure you do not have any condition that makes such drastic dietary changes hazardous.
- A laboratory to monitor blood sugar, glycated hemoglobin (HbA1c), ketosis, lipids, and others at regular intervals.
- A diabetes expert or unit to monitor the remission therapy, and add drugs and adjust their doses as required.
- Good communication between the different healthcare professionals.
- Easy communication with your primary care physician in case of any complications.
Is Remission Permanent?
Currently, we do not know. This approach is novel, and is still a work in progress. We have evidence that remission can last up to two years. Long-term studies are ongoing, and we should have better answers soon.
The DiRECT study in England found that about a third of people with diabetes were in remission after two years of the intensive weight loss regime. However, most participants had regained weight. Of those who had maintained at least a 10 Kg weight loss, 64% were still in remission.
People living with type 2 diabetes should look at remission as a goal. Not everyone can achieve complete remission; there are too many factors determining outcomes in diabetes. Some will continue to have higher than normal glucose levels and need some drugs.
However, people who strictly adhere to the diet and treatment, lose weight, and strive for remission will always be rewarded. Their glucose control will be better, drug requirements will be lowered (along with costs and side effects), and the threat of organ damage and complications will be lessened.
Brown A, et al. Dietary strategies for remission of type 2 diabetes: A narrative review
Hallberg SJ et al. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study
Lean MEJ et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial
Leslie WS et al. The Diabetes Remission Clinical Trial (DiRECT): protocol for a cluster randomized trial
Unwin D, et al. Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years