The Lowdown on the Evidence for Diabetes Reversal

Type 2 diabetes is 100% a reversible disease, but you won’t hear this mentioned much in the traditional health care setting. Are doctors, nurses, and pharmacists evil people who don’t care? Definitely not. Quite frankly, we’ve become so caught up in being efficient at work and chasing lab numbers that no one has stopped to ask, “Why are we doing this again?”
Nearly HALF of all Americans have pre-diabetes and type 2 diabetes, and it is spreading across the world like wildfire. This disease starts 10-20 years before you show symptoms so it’s highly likely we’re all working our way to diabetes given our shared consumption habits. The cost of diabetes is  at least $327 billion each year dwarfing the cost of diseases like heart disease, stroke, and cancer. We need to pay attention because diabetes is a silent pandemic that will bankrupt us.

Source: International Diabetes Federation

Who cares about reversing diabetes?! Just get the A1c below 7 and call it good!!! Well, we know from the early trials like ACCORD, ADVANCE, and VADT that intensive glucose control can reduce microvascular complications of type 2 diabetes but not macrovascular complications nor mortality. There should be no confusion: lowering the A1c is generally a beneficial thing for most patients with type 2 diabetes. The long term benefits just aren’t as clear as they are in type 1 diabetes. 

So can people actually reverse their type 2 diabetes? Absolutely. What evidence do we have? Well, our friends across the pond were the first to show evidence in the DiRECT Trial published in February of 2018. Briefly, their goal was to have patients lose weight and sustain the weight loss to achieve remission of diabetes. They were given a low-calorie liquid diet of 825-853 kcal per day for 3 months and then were reintroduced to a prescribed diet thereafter. At 12 months, 46% of patients (N=149) in the intervention group achieved diabetes remission compared to just 4% in the control group. That’s a NNT of 3. Whooa. This study did include patients with multiple comorbidities; however, the average baseline A1c was just 7.7% and patients on insulin were excluded. Patients lost an average of 10 kg at 12 months of follow-up.

Photo by Kristina Paukshtite

In July 2018, Furmli S, et al. out of the University of Toronto published a case series of 3 patients who reversed their diabetes through the use of therapeutic fasting. Of note, two of the three patients had diabetes for over 20 years, one patient had a high A1c of 11%, and all patients were using relatively high doses of insulin. The patients fasted for 24 hours either every other day or tri-weekly. Patients achieved diabetes remission after follow-up of 7-11 months. Interestingly, all patients were able to discontinue their insulin with a minimum of just FIVE DAYS and a maximum of 18 days. Patient weight loss ranged from 10-18% of body weight. 

Finally, Virta Health has published interesting work on reversing diabetes by implementing a very low carbohydrate diet to induce ketogenesis. In a nutshell, by restricting carbohydrate intake you can push your body to break down stored adipose tissue into fatty acids and subsequently into ketones to be used as energy instead of using glucose that would have come from the carbohydrates. Virta has shown that patients can eat to satiety and still reverse their diabetes by inducing nutritional ketosis. At 2 year follow-up, 53.5% of patients (N=262) achieved diabetes reversal. Not one patient in the control group (N=87) who received usual care via ADA guidelines achieved reversal nor did they get off medications. Of note, baseline A1c’s in this population were 7.6% and patients on insulin were included. Patients lost an average of 10% of their body weight at 2 years of follow-up.

Photo by Canva

These three sources of evidence reveal some interesting aspects about diabetes reversal. First and foremost, you CAN lower your blood sugar effectively and get off medication through your diet! Of course, people have done this anecdotally before these trials. All patients in these studies lost weight which is highly correlated with diabetes risk, and the interventions were sustainable over time. DiRECT and the Toronto case report had some version of intentional calorie restriction whereas Virta allowed their patients to eat to satiety. The crazy thing is, all patients lost weight. Previous evidence has suggested that patients who eat real, whole food will self-regulate their appetite and not overeat. We also know that fasting has metabolic effects INDEPENDENT of weight loss. That is, if two people eat the same amount of calories but differ in the window of the day that they eat them, they will engender different metabolic effects. More on that later 🙂

Of course, these are not large, randomized controlled trials like we see with drug trials; however, they are well-designed, have WAY less conflicts of interest than drug trials, and are coming from reputable clinical sites. I applaud the researchers for doing this work. I roll my eyes a bit when health profession colleagues make statements like the following about diet choices to treat medical conditions: “Well we don’t know if it’s safe so we can’t recommend it until large, randomized controlled trials are performed.” Really? Since when do we need permission to try eating different foods or try fasting? I say why wait for a study that no one will fund to implement lifestyle changes that anyone can do! Obviously there are exceptions here but you get my point.

Until next time!

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