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Can Diet Reverse Type 2 Diabetes?

Discussion in 'Endocrinology' started by Dr.Scorpiowoman, Jan 17, 2019.

  1. Dr.Scorpiowoman

    Dr.Scorpiowoman Golden Member

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    Pilot program in England will study 5,000 patients to find out

    The concept of diet and weight loss to promote health is not a new one. However, the results from the DiRECT trial are novel since patients with type 2 diabetes demonstrated restoration in beta cell function following an intensive diet intervention that resulted in substantial weight loss. In fact, almost half saw remission of their diabetes. These dramatic results have previously only been seen in studies examining the outcomes of bariatric surgery. This exciting revelation should encourage both patients and providers that remission and even reversal of type 2 diabetes is an achievable goal without surgery.

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    However, these promising results should be interpreted with caution given the rigorous conditions of the study environment. Patients had to follow a highly restrictive liquid diet consisting of roughly 800 calories a day for 3-5 months, followed by a period of food re-introduction, all with a formal support program along the way. These conditions are more difficult to apply to a real-word setting. For example, at 12 months, the DiRECT study group recorded a weight loss of 15 kg or more in 24% of participants in the intervention group, while real world data from over 14,000 overweight or obese participants in the 1999-2006 National Health and Nutrition Examination Survey (NHANES) found that long-term weight-loss maintenance of at least 15% was achieved by only 8.5% of participants. Furthermore, the study included only individuals who had been diagnosed with type 2 diabetes for 6 years or less and were not on insulin. It is known that these patients are more likely to see a reversibility in beta-cell function, and therefore the results cannot be extrapolated to patients with a longer duration of the disease.

    Despite these limitations, the study allowed for some flexibility in protocol to account for participants’ diverse lifestyles, and the completion rate was relatively high. The National Health System (NHS) in England now plans to pilot the intervention on a wide scale in up to 5,000 people in England. Notably this will be done in the primary care setting, in which the majority of non-insulin using patients with type 2 diabetes are managed. It will be informative and interesting to see where longer term results land both in the clinical trial and real-world setting.

    Full Critique

    Can a weight management program reverse type 2 diabetes?

    The National Health System (NHS) in England plans to find out. In a radical approach, thousands of people will receive help to battle type 2 diabetes and obesity with a structured program that includes a liquid diet of just over 800 calories a day for 3 months and a period of follow-up support.

    The NHS program -- which will be piloted in up to 5,000 people in England -- comes on the heels of the Diabetes UK-funded DiRECT (Diabetes Remission Clinical Trial) study, in which nearly of half of type 2 diabetes patients who went on a similar diet plan achieved remission at 1 year.

    Controlled trials like DiRECT showed that insulin-producing cells of the pancreas could be rebooted once remission had been achieved, noted Shareen Forbes, MBchB, PHD, of the University of Edinburgh in Scotland. "This was an important observation which had not been noted previously as it was assumed that beta cell function, once lost, probably could not be recovered," she said.

    DiRECT Results

    In the DiRECT study, type 2 diabetes remission -- defined as achieving an HbA1c less than 6.5% without using anti-diabetic drugs for at least 2 months -- was tied largely to weight loss.

    Study participants had type 2 diabetes for up to 6 years and were not receiving insulin. Researchers randomized them to either a weight management program provided by dietitians or trained nurses (n=149) or a control group that followed guideline-based best practices (n=149).

    Participants in the intervention group stopped all anti-diabetic and anti-hypertensive drugs at the start of the study. For 3 to 5 months, they replaced their regular food habits with a liquid diet of about 825 to 850 calories a day. They then were reintroduced to food for 2 to 8 weeks, followed by a structured support program for weight loss maintenance.

    At 12 months, 46% of the intervention group had achieved remission of type 2 diabetes. Overall, the group dropped an average of 10 kg (22 lbs), compared to 1 kg (2.2 lbs) in controls. Remission occurred in 86% of patients who lost 15 kg (33 lbs) or more.

    "The old ideas about lifelong, irreversible processes can be laid to rest, along with beta cell death or apoptosis," said DiRECT researcher Roy Taylor, MD, of Newcastle University in England.

    Results of DiRECT and other research emphasize the importance of excess body fat in type 2 diabetes, Taylor noted. "In the series of studies we have conducted over the last decade, we have learned that type 2 diabetes is preceded by raised levels of liver fat, that at diagnosis, fatty liver is prominent in most, and that this fat is exported to the rest of the body as excess VLDL [very-low-density lipoprotein] triglyceride and is taken up by the pancreas," he said.

    "We also have learned that this metabolic stress causes beta cell switch-off of specialized function (dedifferentiation), that this is reversible for a period of time that varies between individuals -- for about 50% in the first 10 years after diagnosis -- and that once reversed, type 2 diabetes does not recur, provided weight regain is avoided," he added.


    Support Matters

    Similar patterns also emerged in the more recent DROPLET (Doctor Referral of Overweight People to Low Energy total diet replacement Treatment) trial.

    In DROPLET, only 15% of patients had diabetes and these patients did not stop all diabetes medications before the intervention, said researcher Nerys Astbury, PhD, of the University of Oxford in England. "Participants with type 2 diabetes were kept on metformin because as we saw it, there was no reason to take them off this, other than to claim remission," she explained.

    Still, participants who consumed 810 calories a day for 8 weeks in the total diet replacement (TDR) intervention arm of DROPLET -- and had weekly behavioral support for 12 weeks and monthly support for 3 months -- achieved lower HbA1c than controls at 1 year, Astbury said. "The findings support the notion that a low-energy TDR program is tolerable and leads to substantially greater weight loss and greater improvements in HbA1c in people with obesity, regardless of their diabetes status," she noted.

    Behavioral support was an integral part of both DROPLET and DiRECT. "The determinants of success are to recognize that a focused, time-limited period of weight loss using a decision-free method -- a packet of liquid diet each meal -- is humanly feasible and achieves major weight loss, and to recognize that this must be followed by supportive management to avoid weight regain," Taylor pointed out.

    "It's important to listen to patients and realize that a high proportion of folks with type 2 diabetes really hate the diagnostic label and its threats and will take effective action if it is explained to them," he added.

    NHS Pilot

    Follow-up support also will be a core component of the NHS program, which will aim to help people avoid obesity-induced heart attacks, strokes, and cancers in addition to type 2 diabetes.

    Currently,the health service in England spends about 10% of its budget on diabetes treatment. "The NHS Long Term Plan is going to give people the power and the support to take control of their own lifestyles so that they can help themselves while also helping the NHS," Simon Stevens, Chief Executive of NHS England, said in a statement.

    But fighting type 2 diabetes in the long run will take cooperation from the food industry "to cut junk calories and added sugar and salt from processed food, TV suppers, and fast-food takeaways," Stevens added.

    In the meantime, the DiRECT study will explore long-term effects of its intervention, while the NHS will roll out its pilot program with general practitioners prescribing the diet plan to up to 5,000 patients this year. The NHS approach will be "a welcome recognition of the considerable personal and health economic benefits of the new understanding of type 2 diabetes," Taylor said.


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