Thursday, June 30, 2011

Amazing, shocking, unbelievable news about type 2 diabetes and diet!

Have you caught the amazing, shocking, unbelievable news that type 2 diabetes can be managed through weight loss and lifestyle change?

I sure did.

Um, I first caught it in medical school nearly 20 years ago and see it virtually daily in my office.

I'm guessing if you've got type 2 diabetes, you caught that news from your doctor. In fact I'd be shocked to learn if there were a single type 2 diabetic on the planet who wasn't told at diagnosis that weight loss and/or lifestyle change could reverse the course of their disease, and while they'd need to maintain their losses/changes to maintain the reversal, that lifestyle can have at least as great an impact on disease course as drugs.

So how is it possible that suddenly it's making headline news?

Well you see there was this study that got published in the journal Diabetologia. In it, the authors report that when 11 recently diagnosed, non-insulin dependent, type 2 diabetics were put on a low-carb, 600 calorie diet for 2 months, their diabetes magically disappeared, and that in 7 of them, by adhering to lifestyle/dietary changes, it stayed gone for an additional 3 whole months.

Wanna know what else disappeared for the participants?

Weight. In the first week they lost nearly 10lbs, or 5% of their presenting body weights. By the end of 8 weeks, they lost nearly 30lbs or 13% of their presenting body weights.

So is it surprising that a recently diagnosed type 2 diabetic who loses 30lbs living off an extremely low calorie, low carb diet, can come off of their oral hypoglycemics?

About as surprising as a lemon tasting sour.

What's perhaps more surprising than the fact that this study was published (small sample size, not even remotely surprising results, and an incredibly extreme and potentially dangerous intervention) was the authors' first line assertion,

"Type 2 diabetes is regarded as inevitably progressive, with irreversible beta cell failure"
Really? Who regards it that way? Certainly not any doctors I know. Every doctor I know counsels their patients that lifestyle management (weight and/or fitness) can mitigate risk, and in many cases, even reverse the condition.

But here's the biggest bee in my bonnet.

Studies on extremely low-calorie dieting very clearly state that the vast, vast majority of dieters regain all of the weight they so rapidly lose. We also know that ultra-rapid weight loss leads to disproportionate muscle loss, which in turn may help to explain why folks who lose weight extremely rapidly, when they inevitably head back to their old lifestyles, gain back more weight than they lost. What this means for these study participants, is that there's an extremely real likelihood that they'll not only gain back the 30lbs they lost as participants of this study, but that they'll gain back more. What they'll also almost certainly gain back is their type 2 diabetes, and this time, consequent to their disproportionately lost muscle mass, and their greater than before regain, may well require more, not less, medication to manage their resurgent disease.

Ethics should have stopped this study dead in its tracks.

Finally, the authors' enthusiastic conclusion about their work?
"It carries major implications for information to be given to newly diagnosed patients, who should know that they have a potentially reversible condition and not one that is inevitably progressive"
To me anyhow, that demonstrates an incredible lack of perspective, as not only have physicians been counseling their newly diagnosed, type 2 diabetic patients that their condition is potentially reversible with lifestyle change for decades, but the intervention recommended by the authors in this paper is in fact likely to lead to a regain of both weight and type 2 diabetes. Taking this one step further, I'd argue folks who follow these authors' amazing, shocking, unbelievable, major-implications approach, their diabetes will in fact be "inevitably progressive".

Where's a good peer reviewer when you need one?

Lim, E., Hollingsworth, K., Aribisala, B., Chen, M., Mathers, J., & Taylor, R. (2011). Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol Diabetologia DOI: 10.1007/s00125-011-2204-7

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  1. Anonymous7:40 am

    As I understand it, a major aspect of type 2 diabetes is insulin resistance (and associated metabolic syndrome), not failure of the pancreas? and this study doesn't address that at all

  2. Paulette8:12 am

    Generally anything that self describes as "Amazing, shocking, unbelievable" is only unbelievable. The right adjectives are misleading and yes unethical. This kind of attention seeking headline seems to increase every year. I'm surprised there wasn't a statement that drug companies don't want this known. This kind of statement often accompanies an "amazing, shocking, unbelievable" discovery. An interesting attendant study could look at increased rates of depression caused by loss of a basic pleasure that is a well rounded tasty normal sized meal.

  3. More Registered Dietitians being paid for intensive counseling would be GREAT!!! Wait a minute we have been doing that for years, but just not being covered for multiple visits. But they will cover chiros and ND's...hmmmmm!!!

  4. Anonymous10:05 am

    I want to throw another thing here if I can. It's an offside, but it pertains kids as well as adults.

    I work in computer store. Every day I hear customers stress out about not being able to have their computers attached to them like another limb, and a bunch of whining and crying about having to leave it with us - even for a measly hour - to have it fixed. It's quite annoying.

    Some days it's the old dude who's retired but doesn't know what to do with himself without his computers to monitor his email and stocks all day, every day. I suggested to one he go to a coffee shop and read a book while relaxing. He snapped, "Why would I want to read a book?" I finally broke down and told him to head to the downtown library to get himself back online if his retired life was so important he can't go a few hours disconnected. *insert massive eye rolling*

    And then there are the customers like the man who just walked out, sighing heavily b/c I said no we couldn't fix his 10-y-o laptop and he's best to replace the while thing because "it's just for the little kids" at home to play on all day.

    I have to bite my tongue hard not to say, "I can suggest something else for them to play with all day long, and it's located outside, in the sunshine, with grass around it and other kids to fight over it with - it's called a park!"

    Anyway, my whole point here is that there are far too many lies we tell ourselves all day long to justify our new lifestyles, and even more excuses not to unplug and get outside.

    I get frustrated to no end with my sister-in-law who is type II and eats like a horse but doesn't go for even a small walk each day. I know her feet hurt because she's let this get so out of hand, but still, she went to a food clinic where they helped her adjust and she's walking now, not hobbling. One would think she'd want to move around more now that she can, right? Wrong.

    *le sigh*


  5. I wish more Doctors were like you. The truth be told, most are passing on bad advice in support of the USDA Dietary Guidelines, and I know Canada isn't too much different. I have a close diabetic friend whose Doctor seems SHOCKED that a Paleo diet prevents him from having to take insulin anymore (he used to inject 60 units a day). It is treatable and reversible.

    Doc - double kudos for posting this straight forward advice while personally benefiting from bariatric surgery.

  6. Anonymous10:59 am

    Dr. Freedhoff doesn't "benefit" from bariatric surgery.

    He's not a surgeon.

  7. Soylent8:48 pm

    Thanks for publishing this, it clears up my confusion. I saw all the headlines and thought to myself "I'm no scientitian, but haven't we known this for years?". Even The Biggest Loser shows people who are able to stop taking their diabetes medicine because they've lost weight and when your paper is less informed than The Biggest Loser, you know it has problems.

  8. I have three uncles.. All have been diagnosed with diabetes. One of them is an extremist. He has been overweight in the past but he has also but underweight. He was diagnosed about 15 years ago and has changed his lifestyle for the better when he has been happy, but he has been depressed for the last few years and he is now abusing insulin. We have found him in a comatose state a few times now and has been near death but he won't accept help and we really don't expect him to live much longer.

    Another was diagnosed 10 years ago, he takes insulin every day and maintains his lifestyle. He is not overweight but was a big junk food eater. Min 6L of coke a day, sweets etc.... now he just chooses all the same foods but the sugar-free aspartame laden versions. I expect he is going to live like that for many years to come because he does not want to change.

    My third uncle, the oldest, is a retired fireman and he was diagnosed last year. He turned his lifestyle around and is now eating amazingly well, working out in a gym in the winter and is back working on his land for the summer and his goal is to never inject himself once with insulin.

    I wish the others would follow their big brothers example. Lifestyle changes really can make the difference.

  9. just wanted to say amen from a fellow in pediatric endocrinology [at the front lines!!].