Is Diabetes Reversible? Part 3

In Part I of this series, we reviewed the extent and impact of the diabetes epidemic and noted that the traditional approach to diabetes was clearly not working to prevent or reverse diabetes.
 
In Part II, we dove into the science to show that we have had evidence that Type II Diabetes could be reversed through bariatric surgery.  What was most interesting was the fact the improvements in blood sugar control and diabetes emerged well before the weight loss resulting from the surgery.  The trigger theory of the twin cycle postulates a mechanism behind this dramatic and immediate improvement and suggests a path where therapeutic diet interventions could accomplish the same effects as bariatric surgery.
 
From this theory, the key to diabetes reversal lies in improving liver function and decreasing the liver’s role in diabetes by changing the fat flows from the liver - the key steps:

• improve insulin sensitivity in muscle 
• stop the consumption of fructose
• stop the consumption of alcohol
• reduce the level of caloric intake to reverse the flow of fat from the liver 

The next question is does the composition of the hypocaloric diet matter to the reversal of diabetes?
 
Here the evidence is mixed between evidence from diets of varying:
 
The DIRECT study (http://www.directclinicaltrial.org.uk)  in the UK - took 298 Type II diabetics people through a randomized controlled study:

• half received a structured weight management program consisting of a hypocaloric - 830 kcal, (61% Carb 13% Fat, 26% protein) - total diet replacement followed by food reintroduction (50% Carb, 35% Fat, 15% Protein)
• the other half received standard care from their GP

The results were dramatic:

• 86% of individuals that lost 15kg or more put their Type II DM into remission (HbA1c < 6.5% and no diabetes medications)
• In total 45.6% of diabetics in the structured program achieved remission, compared with 4% in the standard care group.

​VIRTA Health has recently (https://www.virtahealth.com) research published the 1 year results of their study of 300 Type II Diabetics

• 60% reversal
• 94% reduction of medication
• 1.3% reduction of HbA1c
• 30 lbs weight loss
• decreased risk of heart disease
• lower blood pressure
• reduced inflammation markers

What is interesting is the difference in composition of the VIRTA diet:

• carbohydrates were restricted to the level required for ketosis to occur - generally in the range of less than 30g per day
• protein targeted at 1.5 mg/kg (and adjusted as necessary to maintain ketosis)
• fat to satiation
• The breakdown of macronutrients in a well-formulated ketogenic diet usually fall in the range of Carbs 10-15%, Protein 10-20% and Fats 65-75%

This ketogenic approach was specifically not calorie restricted.
 
The VIRTA study included longstanding diabetics and those on insulin while the DIRECT study spefically excluded these populations.
 
Both studies clearly show that therapeutic nutritional intervention can reverse diabetes.
 
In both studies, changes in blood sugars came before weight loss and correlated with changes in liver function - suggesting similar mechanisms: reducing the metabolism of carbohydrate into fat by the liver, and reversing the flow of fats from storage to utilization.
 
In my opinion, the biggest practical difference between these approaches is calorie restriction vs carbohydrate restriction and which is easier to sustain over time.
 
This is where a ketogenic approach may have advantages.  It has been proposed that there is a metabolic advantage to ketosis whereby a 'calorie is not a calorie'.  In other words ketogenic diets cause a greater expenditure of energy than non-ketogenic diets.  Scientific evidence for this is limited, and if there really is an advantage, the effect is likely small and would not explain why people lose weight when carbohydrates are restricted to the point of ketosis.  This common observation of sustainable weight loss with ketosis is more likely explained by three attributes of nutritional ketosis:

1. Improved fat burning: once the body is keto-adapted, fat is burned at twice the rate compared to when carbohydrates are a major component of the diet  (Phinney 1983, Volek 2016)
2. Decrease in appetite: in nutritional ketosis people report diminished intensity of hunger and cravings
3. Positive metabolic effects of ketones: beta hydroxy butyrate (BHOB) the pre-dominant ketone,  turns on the body’s innate defenses against oxidative stress and inflammation (Schimazu 2013, Youm 2014), and it also acts to reduce insulin resistance at its source (Newman 2014).

 
Bottom Line:

• Type II DM is reversible and diabetes remission is sustainable
• Therapeutic nutritional approaches that reverse the liver's production of triglycerides and stop the ectopic deposition of fat are required to reverse diabetes
• Reversing the flow of fat from storage to utilization results in weight loss -the degree of weight loss achieved correlates with diabetes remission
• These effects can be achieved through calorie reduction or carbohydrate restriction and nutritional ketosis
• Nutritional ketosis has other benefits relating to the metabolic effect of ketones to reduce oxidative stress, inflammation and direct actions on insulin sensitivity.

 
How can these findings be applied to diabetics today?

• Individualized therapeutic approaches need to be designed by health professionals to take into account overall health status, lifestyle patterns, beliefs and circumstances.
• Dramatic changes, as studied by DIRECT and VIRTA, require day-to-day adjustments of diabetes medications - directed by a physician or a pharmacist.  A DIY approach can be very dangerous.  (for example in our practice - we find that immediate reductions of insulin and other diabetic medications in the range of 30-50% are required to avoid dangerous hypoglycemic episodes).
• Digital monitoring of blood glucose and BHOB are required for therapeutic nutritional ketosis programs.
• This data must be shared on a platform that allows immediate feedback from a physician directed coach.
• Approaches that do not use real food will be have a challenging secondary phase of food reintroduction (as seen with the DIRECT approach).

 
At Wellness Garage, we will soon be launching a Diabetes Remission and Reversal program that:

• applies a real-food therapeutic nutritional approach tailored to an individual's current circumstances
• carefully tracks all aspects of a person's health before, during and after the program
• monitors ketones and blood sugars and provides immediate physician-led feedback and guidance for reduction of diabetes medications.
• incorporates the appropriate level of exercise in the program, carefully calibrated to the nutritional intervention.