Since originally blogging on the type 2 diabetes remission a while back (find it here) I’ve been getting many more enquiries about this. This is in no small part to the media coverage on the diet.
It makes sense really. If you were diagnosed with type 2 diabetes in the past you wouldn’t have received any information about a possible remission diet. Now there is an olive branch for patients to do something about it.
However, is all that it seems? Most patient enquires I receive are from folk who have had the disease for a number of years or are taking multiple therapies. Others may not quite comprehend the lengths they may need to go to in order to produce the necessary changes associated with remission.
What I want to do today is explain in a bit more detail the things you may not know about the remission diet. I think it’s important to offer insight into the background behind it, your healthcare teams expectations and worries, and basically outline the pros and cons of such diets.
The research paper that appears to have kicked off all the buzz was published at the end of 2017 by Dr Taylor and colleagues (find it here). They recruited 306 patients who had been diagnosed with type 2 diabetes in the last 6 years. Interestingly they did this study in a primary care setting to help resemble how this may work in GP surgeries. The researchers split the patients into 2 groups to help compare one against the other. Group 1 followed a low calorie diet of 800kcal per day for 3-5 months followed by a maintenance phase. Group 2 were not given a diet to follow and carried on as normal. By the end of the study both groups had 149 patient completing the study at 1 year.
The diet group saw 68 of the 149 patients achieve diabetes remission needing no diabetes medications. The patients who lost the most weight were more likely to induce diabetes remission. In fact, 86% of patients losing 15kg or more in body weight managed to put their diabetes into remission compared with 7% of those losing 5kg or less.
By shifting fat from around the body including the liver and pancreas, the body is able to recapture its insulin sensitivity. This means it is able to control glucose levels to pre diabetes levels.
What you may not know
This research isn’t new at all. A quick literature search shows us evidence going all the way back to the 1980s on this topic. We’re not even talking one or two papers either. There’s a whole bunch.
Over the decades weight loss has been shown to improve type 2 diabetes control over and over again.
Why the hype around Dr Taylors research then?
First, previous research papers may not have had sufficient patient numbers dedicated to looking at diabetes remission specifically. In other words, they were either looking at other measures as their primary outcomes, not looking at remission specifically or didn’t have enough patients to draw sufficient conclusions. As far as I’m aware, this concept of remission is what has people talking.
Second, diabetes has exploded in prevalence in the previous two decades. Ten percent of the total NHS budget is spent on diabetes care. That’s £10 billion per year. Ninety percent of this budget is spent on type 2 diabetes care. That’s £9 billion for a mostly preventable disease. Therefore, it’s no surprise this diet is creating some noise.
Not for everybody
A recent paper by Taylor and colleagues in 2018 found there are responders and non responders to the remission diet. It would seem non responders are people who have had diabetes for a long time and/or patients that have higher glucose levels. This is consistent with what I see in practice when seeing patients day to day. This is because over time the insulin producing cells of the pancreas begin to lose their function. The pancreas struggles to compensate for high glucose levels and thus starts working overtime. Left alone this ultimately leads to the pancreas wearing itself out.
I had one chap recently who completed the diet and lost 21kg in 8 weeks. He had come off all diabetes medication to follow the diet. Although I’m sure the weight loss would have done him the world of good, his HbA1c actually increased from 72mmol/mol to 98mmol/mol. This demonstrated a significant decline in insulin production in his pancreas. In other words, his diabetes is incurable. This is not to be confused with unmanageable, as it is still very manageable.
Pros of the diet
I think one thing the prospect of remission gives people with type 2 diabetes is hope. Some are happy to live with it and can be quite ambivalent about the whole thing. Perhaps they don’t quite fully comprehend what is happening to them or they just don’t mind. I don’t know.
However, there are many people who don’t want to accept this as their fate. Once upon a time, if the doctor diagnosed type 2 diabetes, it wasn’t widely known you can do something about it. Now there is much more awareness lifestyle change can make a huge difference to your diabetes control. This has to be more of a motivator than a static disease diagnosis.
Simple in design
The diet is quite simple in its design. Follow 800kcal per day for 3-5 months. There isn’t too much to think about really. This could be particularly helpful because sometimes I find explaining how to follow a balanced diet for weight loss to people in clinic tricky. Not because the information is complicated. Instead it is because I find many patients can’t get their ahead around how to eat small amounts of everything, including treats. There is no set plan with conventional healthy eating advice. It is more to do with intuitive eating and choosing the correct options 80-90% of the time without overdoing it the other 10%. This is what some patients struggle to grasp.
In fact, classic lifestyle intervention studies using exercise and diet do not seem as effective as LCD interventions. Lifestyle interventions have not been proven to induce the same weight loss effects as LCD. Though lifestyle interventions help to improve diabetes control, I’ve yet to find a study that has achieved similar results as the LCD.
It’s worth bearing in mind though all the participants in these studies are also overweight. The very development of type 2 diabetes in most people tells us weight management and regular physical activity have unlikely been high on the priority list. As a result, their concept of healthy eating and exercise may be much different from someone who actually does sufficient exercise and healthy eating to induce remission or prevent type 2 diabetes. Furthermore, often patients have other conditions aside from type 2 diabetes which may hinder their ability to get sufficiently active.
So these patients may be unable to reach exercise levels and achieve healthy eating patterns consistent with what is necessary to induce diabetes remission routinely.
Those that have remained active throughout their life and have followed sufficient healthy eating principles are unlikely to go onto develop type 2 diabetes. So how much is enough we still don’t know.
If the 800kcal per day remission diet does induce remission and you can stay in remission, the health benefits to you and the cost savings to the NHS will be massive.
Cons of the diet
It wasn’t too long ago we used to look upon LCD as extreme measures. These diets are not sustainable and much attention needs to be paid to the long term maintenance. It’s no good putting your diabetes into remission but then returning to your usual diet and lifestyle.
LCD are really hard to follow too. These diets will take all the enjoyment out of eating. You will likely be reminded of this diet with every growl of the stomach and every shake you drink or low calorie meal you eat.
Most evidence looking at what happens long term after a LCD shows people rebound to pre diet levels somewhere between 1-5 years. This has also been known since the 1980’s. This isn’t just a question of lack of will power either.
The body is not designed to deprive itself. It wants to eat. That is primal instinct. During such a diet you are literally fighting nature. LCD tells your brain it needs to look for food because as far as it’s concerned this period of food scarcity may not end.
Keep in mind the remission study offered 8 hours of specialist dietetic support over the 3-5 months. If you can get this through the NHS you are one of the lucky few in the country. For most people, you will be on your own.
We also need to manage expectations with the diet. It will not work for everyone. The evidence thus far shows this is much more effective in newly diagnosed patients who lose over 15kg. Those diagnosed for more than 6 years or taking multiple diabetes medications may need to brace themselves. The results might not be quite what you were expecting. It may still be worth trying it but the window for remission may have past.
Exercise is also not recommended on this diet. Due to the low calorie intakes you will be having it can be risky to further expend extra energy. Exercise brings many benefits aside from weight management. Therefore, any diet that limits exercise is obviously quite an extreme measure.
Medication management is also a big consideration. Do not just start this diet if you are taking sulphonylereas and/or insulin. Significantly cutting your carbohydrate and calorie intake will leave you highly prone to hypos. Make sure you speak with your diabetes team before commencing this diet.
Those following a healthy balanced diet can also put the disease into remission without following a LCD. Four patients in the DiRECT study who were assigned to the group with no intervention managed to put their diabetes in remission. Unsurprisingly these were the patients who also lost weight. A more balanced diet may be more of a slow burner approach. However, it is more sustainable and doesn’t run the risk of relapse once the LCD phase is complete.
The results look promising for the diabetes remission diet. I’m not convinced I am overly sold on it just yet for all the reasons stated above. My first line treatment would always be a complete lifestyle overhaul.
If you are someone with an element of disordered eating i.e. can’t lose weight/stick to diets/yo yo this diet may not be the long term solution.
Remember, we are always thinking long term. If you don’t develop the necessary dietary habits to sustain your initially improvements via the LCD you may be putting yourself through a lot of misery for nothing.
On the other hand, if you can’t diet sustain a normal lifestyle change, I suppose improving your diabetes control, even if for short periods, is better than leaving it uncontrolled.
If considering this diet speak with your healthcare team to see if it something you may benefit from.