In June of 2020 the DIADEM-I study was published in The Lancet that replicated results from the DiRECT trial in the UK but this time, in Qatar. As a reminder, the DiRECT trial was one of the first mainstream trials to demonstrate that type 2 diabetes can indeed be put into remission through lifestyle changes.
This VERY exciting because results that are replicated give more credence to the hypothesis, AND the results were replicated in a DIFFERENT population of people which gives us more confidence that diabetes reversal isn’t just a thing for certain groups of people.
Brief Summary of DIADEM-1
The DIADEM-I study demonstrated that 61% of patients in the intervention group (N=70) were able to achieve remission in their type 2 diabetes at 12 months versus just 12% in the control group. The control group received standard medical care (i.e. meds and were told by their doctor to diet and exercise) while the intervention group underwent calorie restriction for 3 months and then re-introduced healthy foods thereafter; they did not take any medication.
The patients in the intervention group lost an average of 12 kilograms or 26 pounds at the 12 month follow-up while the control group lost an average of 4 kilograms.
There is a theme that unites the research published by DiRECT, DIADEM-1, and Virta (the keto people): fat loss.
Indeed, we know that in the initial stages of type 2 diabetes, fat builds up inside skeletal muscle and liver rendering these tissues resistant to insulin thereby increasing blood sugar.
In what Dr. Roy Taylor and colleagues (DiRECT investigators) deem the twin cycle hypothesis, fat accumulation in the liver is the first cycle and fat accumulation in the pancreas is the second cycle in type 2 diabetes that lead to overt hyperglycemia.
By losing weight in the form of fat loss, diabetes reversal appears to happen when the pancreas and liver become unclogged with a certain type of waxy fat: ceramide.
So, to relate this all back to the three bodies of evidence–DiRECT, DIADEM-1, and Virta– the patients who put their diabetes into remission lost an average of 10-15% of their body weight. Moreover, the more weight you lost, the more likely you would be to achieve remission of diabetes. In other words, you COULD still reverse diabetes with a smaller percent reduction in weight; you just have a smaller chance.
A Special Diet or Just Lose the Weight?
Virta currently hangs their hat on the keto diet as the foundation of diabetes remission. This involves achieving ketone levels in the blood of 0.5-3.0 mmol/L via a very low-carb diet. The keto diet generally consists of the following:
- Low carb–>Eating less than 30 grams of carbs daily
- High fat—> 70-80% of calories from fats
- Protein–> 1.5g/kg or 10-20% of calories from protein
Polyunsaturated and monounsaturated fats are “encouraged” over saturated fats, and you eat to satiety; no calorie counting!! It turns out that higher fat diets can lead to people naturally eating LESS because the foods make you feel…full!
In Virta’s studies, patients aren’t told to exercise nor calorie count which is a plus. Patients do achieve diabetes remission though there are some concerns which is a topic for another day. For now, my suspicion is that people see and hear keto and think, “great, I’ll just eat steaks, eggs, and cheese and I can reverse my diabetes!” Sound too good to be true??? 🙂
I am digressing a bit so to bring it all back, my take on Virta’s data is that patients achieved diabetes remission because…they lost weight likely because they were eating a diet that made them full and eat less calories over time. Yes, they were in ketosis which anyone under calorie restriction should be.
As a comparison, the DiRECT trial patients ate a very low calorie diet which was 55% carbohydrate and also achieved diabetes remission. Whether you’re eating carbs or fat doesn’t matter. If at the end of the day you are calorie restricted, you’ll burn energy stores, and lose weight. Who cares if it’s “keto” or “low-calorie?”
Well, YOU probably do which is most important (I do, too). Which route do YOU want to go? The good thing is that there are options. I honestly just don’t think at this point keto long-term is a great idea based on the available evidence for long-term outcomes of eating saturated fats and meat (see blue zones).
Now, I haven’t talked about plant-based diets yet which is another option for diabetes reversal and honestly, is likely better long-term. I’ll “plant” this in your mind for now and talk about it later.
Take home point: it seems losing weight is a critical piece if you want to reverse type 2 diabetes. If you’re ready to do that but don’t know where to start, send me a message on Facebook or email me directly!