A medically supervised low-calorie diet is proving to be successful at reversing type 2 diabetes, but is it the answer for all patients, asks Áilín Quinlan
AFTER more than 20 years struggling to manage type 2 diabetes with a heavy schedule of medication including three different types of insulin, Phyllis Bacon was confronted by a grim choice:
“I could either die or end up in a wheelchair,” recalls the 58-year-old upholsterer who was diagnosed with type 2 diabetes at the age of 32 and who, by her late 50s, was on three different kinds of insulin as well as medication for blood pressure, cholesterol and pain.
It was time, she decided, to change the way she lived her life. Last May, Phyllis embarked on a medically supervised 600 calorie-per-day diet and was taken off the insulin.
It’s early days yet, says the Kilbarrack, Dublin, resident, but she already feels significantly better.
Type 2 diabetes, which was once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition that affects the way the body metabolises sugar (glucose), an important source of fuel. With type 2 diabetes, the body either resists the effects of insulin, which is a hormone that regulates the movement of sugar into cells or doesn’t produce enough insulin to maintain a normal glucose level. Diabetes affects many major organs, including the heart, blood vessels, nerves, eyes and kidneys.
A growing body of research holds that very low-calorie diets can potentially have an impact on people with type two diabetes — recent studies carried out in Britain and Canada, have shown that people who embark on a crash diet can potentially reverse their diabetes. More and more evidence shows that people with type 2 diabetes who successfully lose weight can reverse their condition. For example, a very low-calorie diet of about 800 calories a day — roughly half of the recommended 1,600-2,000 calorie intake for an inactive woman — allows fat to be removed from the pancreas, returning insulin production to normal.
The findings of a 2016 study by Roy Taylor, Professor of Medicine and Metabolism at Newcastle University made international headlines after 30 volunteers with type 2 diabetes embarked on the same diet of 600 to 700 calories a day. Participants lost on average 14 kilogrammes — just over two stone. Over the next six months, they did not regain any weight.
Overall, 12 patients who had had diabetes for less than 10 years reversed their condition. Six months later those patients remained diabetes-free. Though the volunteers had lost weight they remained overweight or obese — but they had lost enough weight to allow normal insulin production.
“The study also answered the question that people often ask me: ‘If I lose the weight and keep the weight off, will I stay free of diabetes?’ The simple answer is yes,” explained Professor Taylor at the time.
A previous study led by Professor Taylor, published in 2011, also showed that diabetes could be reversed by a very low-calorie diet.
Last year a Canadian study showed that type 2 diabetes could be reversed in just four months by cutting calories, exercising and keeping glucose under control, a trial has shown.
Researchers at McMaster University in Ontario, Canada, proved it was possible to restore insulin production for 40% of patients.
This study involved a personalised exercise regimen for each trial participant, and reducing their calorie intake by between 500 and 750 a day.
After just four months, 40% of patients were able to stop taking their medication because their bodies had begun to produce adequate amounts of insulin again.
Francis Finucane, consultant endocrinologist at Galway University Hospitals and NUI Galway, says he uses the low-calorie approach for some patients for whom it is appropriate.
“After careful clinical assessment by the GP or endocrinologist some patients with diabetes can do well with a very intensive restriction of their calorie intake.
“There is some evidence that these interventions work well in the short term. They have a role to play for some patients, the question is, which patient?”
Further clinical research is needed, he says, because not all patients do well on these diets.
“My clinical experience in Galway is that about 50% of patients with type 2 diabetes who have been selected for such programmes don’t or can’t complete the programme.
“Only some type 2 diabetes patients can tolerate the low-calorie diet and those who do tolerate mainly do well but the problem is that they only do well for the duration of the diet and once they stop, the weight piles on and they revert.”
The incidence of type 2 diabetes— which usually develops slowly in adulthood, and is a progressive condition which can sometimes be treated with diet and exercise, though more often requires antidiabetic medicine and/or insulin injections — is steadily rising in this country.
Although the absence of a register of people in Ireland with diabetes means we cannot be sure of the exact figures, the total number of people living with diabetes in this country is believed to be nearly 226,000 of which about 16,000 have type 1 diabetes.
According to Diabetes Ireland, more than 854,000 adults over the age of 40 are now at risk of developing, or already have, type 2 diabetes. More alarmingly, according to the organisation, there are a further 304,382 in the 30–39 year age group who are now overweight and not taking recommended physical activity, leaving them at an increased risk of chronic ill-health. The International Diabetes Federation estimates that by 2030 there will be 278,850 people with type 2 diabetes here.
The news gets worse — given rising obesity levels in younger age groups, says Diabetes Ireland, the number of people now at risk of developing type 2 diabetes is likely to be in the region of 450,000.
Endocrinologist Prof Donal O’Shea, who is attached to UCD, points to the fact that diabetes-related costs now amount to between 10% and 12% of the total health budget.
“This is a massive sum. For a single condition to be costing that much is extraordinary,” he says, adding that despite the hype about their potential to reverse diabetes, low-calorie diets might not be the answer for everyone.
“This is an area being investigated. There is evidence from research that very calorie-restricted diets around or early after diagnosis, can reverse it and put diabetes into remission.
This is a new and exciting area, he says, one that takes the theory around managing type 2 diabetes a step further, proposing that an extreme diet might be able to reverse it in certain situations.
“However, the diabetes community has not yet got its head around how this happens or who it might be particularly suited to.
“To improve our health and reduce the incidence of type 2 diabetes, we need to be physically active, eat an all-round balanced diet and avoid highly processed foods high in fat and sugar — or eat less of these,” he advises.
There is no evidence that intermittent fasting (diets that incorporate periods of fasting and non-fasting during a defined time-scale) is the answer either, he says.
“It’s very good if you are a mouse — it has been proven to make mice age more slowly and live longer, but we don’t have evidence for that in humans.”
However, he acknowledges, if the aim is to reduce overall calorie intake in a person who is overweight or obese, who can stick to it, and finds it works, well and good.
“Some people will report doing very well by reducing their calorific intake a few days a week — some people find it works for them.”
In September, Dr Eva Orsmond, who has been working in the field of diabetes and weight loss for 17 years, will publish her latest book, Reverse Type 2 Diabetes.
“Type 2 diabetes lives in visceral fat,” she explains. “This produces inflammatory hormones. When people lose their visceral fat their insulin resistance goes. The strict calorie-controlled diet reduces the visceral fat. The bottom line is if you put the weight back on, the diabetes will come back,” she says.
“I put people on a very low-calorie diet which would be about 800 calories a day,” she says, adding that some people could stay on this diet for up to a year depending on how much weight they have to lose.
Orsmond has worked with patients who reversed their diets by losing as much as 13 stone in a year, or as little as a stone in 40 days — it’s a very individual matter, she says.
However, she has found, she says, that those who have managed to reverse their diabetes and come off the drugs by losing weight, will often fight hard to maintain weight loss.
“You have to change your eating habits and continuously look after the diet,” she explains. “It is almost impossible for a type 2 diabetes patient to lose weight while on diabetic drugs, because a side-effect of many of these drugs is putting on weight,” she says.
It is crucial, she points out, for a patient on diabetic medication to begin fasting under strict medical supervision where their medication is adjusted by their doctor.
As for the prevention of diabetes? “Maintain a normal weight,” advises Orsmond, who plans to add to her clinics in Dublin and Galway with a new service based in Cork in September.
“It is all about maintaining a healthy weight. Most people today have energy excess from eating too much,” she says, adding, however, that maintaining a normal weight in today’s world is very difficult.
“It requires hard work to maintain weight, let alone lose it. You need to reduce your overall calorie intake over a long period, and after that, maintain a completely different way of eating.”
PREVENTING the onset of type two diabetes is all about diet, emphasises consultant nutritionist Gaye Godkin.
“The focus needs to be on the nutritional composition of the plate rather than the calorific total of the plate,” she says, adding that she is not a supporter of the very strict calorie-controlled approach to weight loss, as she feels it can be very difficult to maintain this long term.
What we need to do, she believes, is to educate people to navigate and negotiate their food environment, because “89% of people who lose weight” put it back on.
“Exercise is one of the best ways to manage and treat type 2 diabetes because it up-regulates the receptors on the cells which take glucose. Diet is the other. My take is to cut out simple carbohydrates like bread, biscuits and cakes. Ensure protein diversity and fibres that support gut health, because type 2 diabetes is enormously connected with gut health. Fibre is the key to type 2 diabetes prevention.
“A diet high in processed meat puts the consumer at higher risk of type two diabetes, for example.
“I’m not a fan of people using shakes as a food replacement unless they are ill or hospitalised or they are elderly. In essence, they may have a short-term effect but they are certainly not the answer to treating it. Whether they are prescribed or not, it’s not a long-term healthy solution. Patients need to change their relationship with food.”
Diabetes Ireland recognises the fact that low calories diets have a part to play in rapid weight loss over short periods of time, but, warns the organisation’s medical director, Dr Anna Clarke, people should be aware of two things — such diets should always be carried out under medical supervision and that a calorie intake of about half the normal recommended calorie intake for adults poses a variety of challenges to the participant. These include interacting with others in social situations where food is being consumed, or in terms of having the necessary fuel in the body to exercise sufficiently, while daily interactions with others may become challenging because high ketone levels resulting from low-calorie diets can result in an altered breath odour.
“In addition, people may experience headaches and other symptoms as a result of withdrawal from certain substances, hence the need for medical supervision,” she adds.
Therefore anyone who has been recently diagnosed with type 2 diabetes and has a lot of weight to lose — and the motivation to lose it — should seek medical support before embarking on a low-calorie diet, urges Dr Clarke.
“For all people with diabetes, consider a target weight loss of 5%, and if possible 10% and do it through a healthy diet with increased physical activity.
“Most of us underestimate our calorie intake from food and over-estimate the amount of exercise we take.”
At the end of April, Mary*, a businesswoman in her 40s who was diagnosed with type 2 diabetes several years ago, and had been on medication for the condition, decided on a change of approach.
After several years of struggling to lose weight and trying to cope with an ever-increasing diversity of and dosage of diabetes medication, she felt nothing was helping. Eventually, her feet started to go numb, which resulted in her being put on still more medication.
“I was always tired and my blood-sugar levels were always high, and the medicine didn’t seem to have any impact on my condition.” She was eventually hospitalised after experiencing a bad reaction to a new tablet.
Disillusioned, she decided to try under medical guidance a very low-calorie diet of about 800 calories a day.
“I lost 10 pounds in the first two weeks and so far have lost nearly one and a half stone. My blood sugar levels, which were very high while I was on the medication, are now lower than they have been in years,” she says.
“I am not on any medication. I find the low-calorie diet really good. It is as if my body has started working with me. I feel great, I got my sense of humour back, my energy levels are 100% better and I am very active.
“I’ve been on the diet for around two months and it seems to be working far better than the medication ever did. The numbness in my toes is also going away.”
*Not her real name