Discovery that sudden, drastic weight loss could reverse type-2 diabetes was a eureka medical moment. Until then the disease had largely been seen as a progressively deteriorating, chronic illness.
Then, in 2011, after a five-year study, Professor Roy Taylor of Newcastle University revealed that the condition could be reversed by decreasing fat inside the liver and pancreas.
Focusing on encouraging people to change what they eat helps reverse the disease process
In 2009, an analysis of more than 600 studies into bariatric surgery, by scientists at the University of Minnesota, had found that, in addition to dramatic weight loss, the procedure had a radical, and almost immediate, effect on type-2 diabetes.
Such revelations were a turning point for some in the approach to treatment and doctors continue to report astounding results as a result of weight loss.
Dr David Cavan, diabetes consultant and former director of policy for the International Diabetes Federation, says: “We now know, beyond any doubt, that type-2 diabetes is a lifestyle disease. Focusing on encouraging people to change what they eat helps reverse the disease process.”
Low carb and low calorie diets can push diabetes into remission
In June, the All-Party Parliamentary Group for Diabetes concluded: “Type-2 diabetes is a state of carbohydrate intolerance where people struggle to metabolise, not just glucose, but also the carbohydrates that digest down into glucose. In this context, it makes sense to cut back on both sugar and refined carbohydrates. This can be done in several ways: bariatric surgery, very low calorie diet or lower carbohydrate diet.”
GP and group ambassador Dr David Unwin says: “Each has pros and cons, but all three approaches can lead to a medication-free remission of type-2 diabetes, a concept which gives hope to many people.”
The very-low-calorie-diet approach stems from the pioneering work by Professor Taylor who, following two trials, concluded that a body starved of food would turn to the next best source of energy in excess stores of fat, in particular that clogging the organs responsible for controlling blood sugar levels.
Professor Taylor is now involved with DiRECT, a five-year study backed by Diabetes UK, exploring the long-term effects of a restricted diet with additional support for patients returning to a normal diet afterwards.
Initial findings, in December 2017, revealed that almost half the participants (46 per cent) were in remission after 12 months and no longer taking medication for diabetes.
Nikki Joule, policy manager at Diabetes UK, says: “The early results have been positive. This could have major implications for how we approach the treatment of type-2 diabetes in future if the trial can be rolled out on a larger scale.”
Sudden changes to diet are challenging and not always sustainable
NHS England is now considering introducing the DiRECT approach on a pilot basis. However, there are drawbacks. “The difficulty with a very-low-calorie diet is that you are essentially starving yourself,” says Dr Unwin. “In my opinion, most people with diabetes have it not because of stress or lack of exercise, but because of diet. For that very reason, it’s quite difficult to suddenly eat less. It’s not for everybody.”
Dr Cavan, author of Reverse Your Diabetes and co-author of The Low-Carb Diabetes Cookbook, agrees. “This approach was developed as an experiment to see if rapid, sudden weight loss reversed the process, which it did. But I don’t think it was envisaged it would become a treatment as such, which it has done,” he says. “With a low-carb approach, it might take longer to lose the weight, but the great advantage is that it’s a manageable, long-term lifestyle change; you are not going on a crash diet.”
Dr Unwin says: “People don’t realise that starchy carbs break down into sugar. Someone might think they are having a healthy breakfast with cereal, brown toast and orange juice, but the effect on their blood glucose levels is the equivalent of 21 teaspoons of sugar. Whereas scrambled egg, smoked salmon and coffee with cream is the equivalent of just one teaspoon of sugar.”
However, the NHS Eatwell Guide advises basing meals on potatoes, bread, rice, pasta or other starchy carbohydrates and says: “Starchy food should make up just over a third of the food we eat.”
Surgery, fasting and pills also alternatives to diets
The parliamentary report into diabetes concludes that remission rates for type-2 diabetes are better after surgery than with dieting and lifestyle interventions, and wants to see the 5,000 operations performed annually in the UK increased to 55,000.
Another diet-based approach is fasting or time-delayed eating. “Like very low calorie and low carbs, this reduces the glycaemic load or the amount of glucose that is eaten and then transferred to the blood,” explains GP Dr Campbell Murdoch, chief medical officer for www.diabetes.co.uk, although fasting isn’t necessarily low calorie.
Options also include diet pills. Trials of appetite suppressant lorcaserin showed a success rate of 7.1 per cent in normalising blood sugar levels. And there are supplements, such as CuraLin, which claims to have a significant beneficial effect on levels.
Changing your diet is key to tackling type-2 diabetes
However, as GP Dr Ian Lake, who has type-1 diabetes, says: “Expecting any drug or remedy by itself to help a condition caused by a sub-optimal diet and lifestyle would seem optimistic. There are no shortcuts to overcome an unhealthy lifestyle. No one has ever gone into remission by medication alone.”
Reducing stress and increasing physical activity, while beneficial, are also unlikely to send the condition into remission without diet also being targeted. “Diet is at least 80 per cent of the issue,” says Dr Cavan. “Unless you change your diet, you’re unlikely to see changes.”
So with opinion and guidance varying so widely what’s the way forward? For Dr Cavan and other devotees of the low-carb approach, the answer is obvious. “A lot of us have moved to low carb as a logical approach. We found it works. Interestingly, the American Diabetes Association, along with the European association, have just updated their guidelines to, for the first time, endorse a low-carb approach,” he says.
“It’s not the only approach, but they say it’s a good safe and inexpensive way in moving forward and treating it. I think it’s only a matter of time before the same occurs in this country. But it is very difficult at the moment as people are still being told different things.”
Experts warn that prediabetes, where blood glucose levels are higher than normal, but not high enough to be classed as diabetes, is becoming a global phenomenon.
Some estimates suggest that one in every three people have prediabetes, leaving them at a higher risk of developing type-2 diabetes.
However, progression is no longer considered inevitable. “Twenty years ago patients with prediabetes were told ‘go away and come back when you’ve developed type-2 diabetes’,” says diabetes consultant Dr David Cavan. “We now know that it is the best time to support people in making lifestyle changes to, not only stop diabetes developing, but return blood glucose levels to normal.”
Lack of symptoms makes diagnosis difficult. “But being overweight, inactive, having high blood pressure, a family history of type-2 diabetes or a south-Asian background are all risk factors,” Dr Cavan adds.
A large waist or “beer belly”, indicating central obesity, is cause for concern, says nutritionist Dr Sarah Brewer. “Fat cells packed around your internal organs are unusually active,” she explains. “This visceral fat leaks fatty acids into the circulation, producing a number of hormones associated with insulin resistance.
“Lifestyle changes, such as losing weight, exercising more and eating a healthy diet, can reduce the risk of type-2 diabetes by 58 per cent in people with impaired glucose tolerance.”
Diabetes UK runs a Know Your Risk online tool and also supports the NHS Diabetes Prevention Programme. “There are positive early signs that participants are losing weight and reducing their risk as a result of the programme,” says Diabetes UK’s Nikki Joule.