In my last post, I was trying to help you understand that individuals who are about to develop type 2 diabetes have late disease. They are already maximally resistant to the effects of insulin, and they have lost about 80% of their insulin producing capacity. When they become diabetic, if they do not manage their diabetes aggressively, their damage to the pancreas will continue and their ability to make insulin becomes less and less. If they don’t manage their diabetes effectively, they become more and more like patients with type 1 diabetes with little or no insulin production.
The choice of treatment when diabetes is established is therefore critical. Most people with type 2 diabetes die or become disabled because of cardiovascular disease. Avoiding those consequences is the main goal of treatment. One of the popular ideas currently is type 2 diabetes reversal through diet. I agree that diabetes is a food disease and that changing what we eat is the key to successfully avoiding diabetic symptoms, complications, and cardiovascular disease. Everything that I have accomplished in medicine beyond seeing patients has been based on analysis of evidence and data. Changing what we eat is necessary but insufficient for the long term treatment of most patients with type 2 diabetes. Most patients will need lifestyle measures like diet and carefully chosen medications to live a longer healthier life. Diabetes treatments must be sustainable. They must be things that normal human beings can do consistently for decades.
This expert consensus article from the American College of Lifestyle Medicine defines what the experts agree on about dietary reversal of type 2 diabetes.
“1. Remission of T2D should be defined as HbA1c <6.5% for at least 3 months with no surgery, devices, or active pharmacologic therapy for the specific purpose of lowering blood glucose.
2. Diet as a primary intervention for T2D can achieve remission in many adults with T2D and is related to the intensity of the intervention
3. Diet as a primary intervention for T2D is most effective in achieving remission when emphasizing whole, plant-based foods with minimal consumption of meat and other animal products.”
Those are key points of agreement in this very detailed article and if you are interested in the topic, it is worth your time.
There is another expert consensus article from the Canadians on diabetes reversal that examines specific interventions and outcomes. The largest diabetes reversal trial mentioned in this review is the DIRECT trial. There were 306 participants in this trial, and they could not be diabetic for more than 6 years. Half of the patients were in the diet induced diabetes reversal arm and half remained in usual care. The aggressively treated patients had a total diet replacement with a liquid formula that provided them with just over 800 calories a day for 12 to 20 weeks (5 months). Then a plant-based diet was reintroduced over 2 to eight weeks. Diabetes remission was achieved by just under half of the intensively treated participants at 1 year, with just over a third in remission at the 2-year follow-up. My takeaway from all of this is that the intervention is very dramatic, and it was applied to patients with early diabetes. Even so, fewer than half the patients, achieved diabetes reversal at one year and a third at two years. The longer a person has been diabetic, the less pancreatic function they have on average and the less likely they are to respond.
At two years, two thirds of the patients did not achieve diabetes reversal. That means they will need a different approach. The intervention is also highly intensive. How many people with type 2 diabetes do you know that will consume no food for 5 months and live on 800 calories of liquid a day? I don’t know many at all. The transition over two weeks to a plant-based diet is also very intensive. I don’t see how this approach can be scaled and it is very important to look at the success rate objectively for anyone who makes that claim.
Achieving glucose levels lower than those required to diagnose diabetes is a worthy goal, but it must be based on an approach that most ordinary people can do. Most people are not going to drink only liquid for five months. They are not going to eat a plant-based diet with no processed carbs or animal products for the rest of their lives. Successful diabetes management requires an approach that most people can actually do and are willing to do for the rest of their lives. If they eat like that, they may not live longer, but it will definitely seem longer.
Diet is absolutely critical. A plant-based diet with fruits, vegetables, beans, peas, and nuts can be filling and satisfying. Adding lean meat, eggs, and seafood makes it much easier. Eliminating the packaged liquids and intensive professional interaction makes it less expensive too. The goal for diabetes prevention is a 30-pound weight loss. I have been prediabetic for 20 years. I have eaten lean meat, eggs, seafood, fruit, vegetables, beans, peas, and nuts most meals and eat what I want once a week. I have lost 70 pounds and my sugar numbers are better now than they were 20 years ago. That approach has an easy entry, requires no expensive packaged foods, and requires less professional interaction than this diabetes reversal approach.
There is a strong emphasis with diabetes reversal advocates in reducing and even eliminating medications. Our old approach of using any medication approved for diabetes to lower the sugar was deeply flawed. Some diabetes medications cause weight gain and episodes of low sugar. That is completely counterproductive and intensively lowering the glucose with those medications killed more people. Diabetes reversal is based on a draconian caloric restriction. Jardiance and metformin both favor weight loss and mimic that effect. Using those medications with similar best practice medications for cholesterol and blood pressure produces the greatest reductions in deaths and disability due to type 2 diabetes. It is not a matter of diet and exercise or medication. Both are required for most patients. Best practices bring it all together. Our treatments matter. Let’s follow the evidence.
Do you discount (meaning view as unindicative) A1C levels below 5.6, which in the US is widely interpreted as not prediabetic? Your comment appears to do so.
Thank you