Last week, we detailed the process of insulin resistance and how Type II Diabetes develops.
Diabetes is a disease of sustained energy overload that develops over many years. The body’s normal energy buffers gradually become overwhelmed, and stored energy in the form of fat disrupts the normal function of key organs. This disruption through a process called insulin resistance, creates a vicious cycle where energy once stored cannot be accessed, and the energy overload is perpetuated through hunger and increased appetite. Eventually, fat stored in the pancreas overwhelms the body’s ability to maintain normal blood sugars and the diagnosis of diabetes is made. On average it takes 10 to 15 years for this process to unfold.
So the logical question arises - can we reverse this process?
The short answer is yes.
The first line of evidence for this comes from bariatric surgery, where as long ago as 1992 studies showed that between 30 and 70% of diabetes can be reversed for over 10 years.
In more recent years, Dr. Susan Hallberg and her team at Virta Health, have shown reversal of diabetes through a dietary therapeutic intervention. Their results with a ketogenic diet, show that 60% of diabetics are in remission at the end of one year. Impressively, the population consisted of many individuals with longstanding diabetes as well as many taking insulin. Of those, 94% decreased dosage or eliminated insulin entirely by one year.
From my perspective the most powerful research has come out of the UK from Dr. Roy Taylor and his colleagues in Newcastle. Through a series of clinical trials, culminating in the DIRECT study. They systematically showed that insulin resistance correlates and is caused by fat in the liver in the liver, and the development of abnormal blood sugars and diabetes correlates and is caused by fat in the pancreas. Eliminating the fat in the pancreas can restore the body’s ability to release enough insulin after eating and eliminating the fat in the liver restores the body’s ability to maintain normal fasting blood sugars.
So how much fat do you need to lose in order to reverse diabetes?
If you had a magic wand and could eliminate fat directly from the pancreas and liver you would only need to eliminate less than 1 pound - as it is estimated that the amount of excess fat in the liver is approximately 400g with even less ectopic fat in the pancreas. Taylor’s group estimates that even as much as 1ml or 0.6g of fat reduction from the pancreas is enough to restore pancreatic insulin secretion in patients that respond to weight loss.
Of course, the challenge is that we do not have a magic wand so we must seek to lose weight and trust that some of it will come from the fat stored in our liver and pancreas that is causing our insulin resistance and diabetes.
The DIRECT study was a randomized clinical trial (the highest source of clinical information) that demonstrated that 86% of patients that lost at least 15kg were able to put their diabetes into remission. The therapeutic intervention was a hypocaloric diet (830 calories per day) provided by meal replacements.
Further research by Taylor has shown that patients that subsequently slipped back into diabetes regained pancreatic fat.
Common to all three lines of evidence, the degree of diabetes reversal correlates directly with the amount of weight lost.
So the evidence is clear that diabetes can be reversed provided you can lose enough weight and keep it off.
It’s that last bit - and keep it off that is problematic. The challenge with using a diet to lose this weight is that diets do not work over the long term. Temporary restrictive approaches - whether it be of calories (DIRECT study) or carbohydrates (VIRTA Health) are prone to regression.
The only way to get long term results is through a behavioral approach. Change habits in order to achieve sustainability.
The 4+2 Diabetes Reversal Strategy is built on this behavioral change model, incorporating an understanding of the physiology of insulin resistance and Type II Diabetes.
Step 1: Lower carbs to lower insulin
Decrease insulin requirements by decreasing the intake of simple and refined carbohydrates.
Replacing refined foods with whole foods with a special focus on fibre will result in less insulin required to maintain blood sugars. Pairing fibre rich, low glycemic, whole food carbohydrates with adequate protein and healthy fats helps normalize blood sugars after meals and provide steady glucose supply from food for hours.
Step 2: Restore the Muscle as the Glucose SInk
Recognizing the role of skeletal muscle as the key energy buffer for glucose; the next part of the 4+2 Diabetes Reversal Strategy is to leverage exercise and activity to increase the uptake of glucose from meals into muscle. This uptake in turn decreases the amount of glucose converted to fat by the liver.
Step 3: Be Kind to the Liver
The ability to maintain blood sugars while fasting is dependent on the liver making glucose from glycogen or other sources (gluconeogenesis). Fat in the liver causes insulin resistance and results in the liver over-producing glucose with a corresponding elevation in fasting blood sugar. Decreasing fat in the liver is necessary to reverse diabetes, therefore decreasing fructose and alcohol - two substances that are directly metabolized into fat in the liver is essential. In addition, focusing on gut health with adequate fibre intake has been shown to improve liver function.
Step 4: Restore Fat Burning
The first three steps create conditions that improve metabolic flexibility and allow the body to burn fat, but at the end of the day ‘less calories in, than calories out’ is necessary to lose weight. One of the most effective behavioral approaches to weight loss is time restricted eating starting at 12 hour of fasting and increasing to 14 to 16 hours as tolerated. Time restricted eating works because it eliminates nighttime snacking and results in fewer calories consumed making a deficit more likely. It also improves metabolic flexibility and the use of fat as fuel when fasting. When this is done after the first three steps, it is generally very easy to incorporate with minimal hunger symptoms.
The +2 in the Diabetes Reversal Strategy involves decreasing the negative effects of cortisol on insulin sensitivity.
Step 5: Learn to De-stress
Finding ways to bring down cortisol without resorting to calories improves our ability to lose weight. Techniques as varied as meditating, yoga, time in nature and pursuing your hobbies have been shown to dissipate stress and bring cortisol levels down.
Step 6: Sleep 7-8 hours per night
Inadequate sleep elevates cortisol and appetite, often driving poor food choices (ie. comfort foods high in both fat and simple carbohydrates). Studies clearly show that adequate sleep can reset our stress mechanisms resulting in lower cortisol levels and improve appetite control.
The 4+2 Diabetes Reversal Strategy works at the behavioral level to gradually and systematically shift to new healthy habits that are sustainable for the long run. Over time, blood sugars are better controlled, medications are reduced, weight is lost and diabetes is reversed. There is no magic to this - just sound evidence-based behaviours supported by science.
At Wellness Garage we have developed a number of programs to support people who want to take control of their health and reverse diabetes:
Our 4+2 Diabetes Reversal Group sessions are MSP funded group medical visits designed to provide you with all the information you need.
Our 1:1 Coaching Program provides you with individualized nutrition, exercise and health coaching support to guide you to your own reversal path.
Dr. Brendan Byrne