Reversing diabetes (type 2)

On 5th December 2017, we woke up to the headlines: “A cure for diabetes: Crash diet can REVERSE Type 2 in three months…” and “I beat type 2 diabetes with 200-calorie drinks”.

The headlines came from a study published in The Lancet entitled “Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.” (Ref 1)

The study made a bold claim: “Our DiRECT study provides the first evidence from a randomised trial of a dietary and lifestyle intervention with remission of type 2 diabetes as a primary outcome.”

The researchers said that they had searched articles published between 1st January 1980 and 30th October 2017 for non-surgical clinical trials with a primary outcome of remission of type 2 diabetes. “Our search terms were ‘diabetes and remission’ and ‘clinical trial’… No trials were identified.”

I don’t think that the researchers looked hard enough. Within minutes of seeing The Lancet study, Sam Feltham emailed me to say “what about the Dr Eric Westman paper?” (Ref 2) This classic study is in my EndNotes, it was referenced in two recent comprehensive reviews of low carbohydrate diets (Refs 3, 4) and it has been cited 226 times at the time of writing this post. It is fair to say that it is well known, therefore.

Westman et al undertook a randomised controlled dietary trial (first tick) in 84 people with type 2 diabetes (second tick). The primary outcome was the same measure of diabetes remission as The Lancet study – HbA1c and medication reduction/elimination (third tick). The 2008 paper used the word “reversing”, rather than remission. The conclusion of this study was “Dietary modification led to improvements in glycemic control and medication reduction/elimination in motivated volunteers with type 2 diabetes. The diet lower in carbohydrate led to greater improvements in glycemic control, and more frequent medication reduction/elimination than the low glycemic index diet. Lifestyle modification using low carbohydrate interventions is effective for improving and reversing type 2 diabetes” (my emphasis).

Other evidence before this study

There have also been other studies proving different components of the claim made in The Lancet paper:

* Remission in a randomised trial in PRE-diabetes.

In 2016, an article was published by Stentz et al entitled “Remission of pre-diabetes to normal glucose tolerance in obese adults with high protein versus high carbohydrate diet: randomized control trial.” (Ref 5) This study involved 24 people with pre-diabetes randomised to either a high protein (30% protein, 30% fat, 40% carbohydrate) intervention, or the typical high carbohydrate government advice (15% protein, 30% fat, 55% carbohydrate). All meals were provided to all participants for six months. After 6 months, 100% of the people on the high protein diet had remission of their pre-diabetes (defined as normal glucose tolerance), whereas only 33% of the high carbohydrate group had remission of their pre-diabetes.

* Remission in a non-randomised trial in type 2 diabetes.

In 2017, the seminal publication from the Virta Health team reported on a non-randomised intervention with 262 adults with type 2 diabetes. (Ref 6) This study involved the reduction/ elimination of medication, alongside a ketogenic diet (typical carbohydrate intake below 30g a day and protein intake targeted to a level of 1.5g per kg of body weight). The primary outcome was HbA1c. Weight and medication use were secondary outcomes. At 10 weeks, 15% of participants had achieved an HbA1c level of <6.5%, while taking no medication. The researchers concluded “biomarkers of type 2 diabetes can be reversed…”

* Remission in a randomised trial of diabetes and pre-diabetes, without mentioning remission or reversal.

The Saslow et al study from 2014 was a randomised controlled trial in adults with diabetes or pre-diabetes. (Ref 7) The intervention was a very low carb high fat ketogenic diet. The control was the standard advice from the American Diabetes Association. The primary end point was reduction in HbA1c. A secondary endpoint was discontinuation of diabetes medications. Both were significantly greater in the ketogenic diet group. While this small study did not claim remission or reversal of type 2 diabetes, it achieved these in a number of cases.

There is also a systematic review and meta-analysis of 20 randomised controlled trials (tick) for dietary interventions in type 2 diabetes (tick). I would be surprised if at least one of these had not achieved remission/reversal, defined by HbA1c and medication use. (Ref 8)

None of these studies was referenced by The Lancet paper.

The Lancet Study

The Lancet study involved 306 people recruited between July 2014 and August 2017 from 49 primary care practices in Scotland and the Tyneside region of England. The trial was described as a cluster-randomised trial. This meant that the 49 practices were randomly assigned to provide either the intervention or best-practice care guidelines (the control). The individuals recruited in each practice would then follow the protocol randomly set for that practice.

The participants were aged between 20-65 years and they had been diagnosed with type 2 diabetes within the previous 6 years. They had BMIs in the range 27-45 kg/m2 and were not taking insulin. There were a number of interesting exclusions for participants. People were not allowed to take part in the trial if they had any of the following: weight loss of more than 5kg within the past 6 months; current HbA1c of 12% or more (≥ 108mmol/mol); current treatment with anti-obesity drugs; and/or presence of an eating disorder. There were other exclusions, but these piqued my interest, as they gave the study a higher chance of success.

The intervention involved i) removal of diabetes and blood pressure medications on day 1; ii) total diet replacement with a 825-853 kcal/day liquid formula for 3-5 months; iii) “stepped food reintroduction” for 2-8 weeks; and iv) “structured support for long-term weight loss maintenance”. There was next to no information in the article about steps iii and iv – I’ve written to the corresponding author to ask what the food and calorie intake was in these two key phases, after the liquid diet.

Please note the immediate, profound, implications of (i) – participants were taken off diabetes and blood pressure medications on day 1. The paper noted that blood glucose and blood pressure were regularly monitored to see if drugs needed to be reintroduced. This means that it is now known (if it were not before) that people with type 2 diabetes can be taken off medication and that type 2 diabetes can be managed with diet. The low carb community has been saying this for years.

The study set out to measure two primary outcomes: weight loss of 15 kg or more, and remission of diabetes, which was defined as HbA1c of less than 6.5% (<48 mmol/mol) after at least 2 months off all anti-diabetic medications, between baseline and 12 months.

The results were reviewed at 12 months. Weight loss of 15 kg or more was recorded in 36 people (24%) in the intervention group and in no one in the control group. Diabetes remission was achieved in 68 (46%) people in the intervention group and in 6 (4%) people in the control group. Remission was closely connected to weight loss. 76 people gained weight during the study! None of these 76 people achieved remission. Remission was achieved in: 6 of 89 people who maintained a 0-5kg weight loss; 19 of 56 people with a 5-10kg weight loss; 16 of 28 people with a 10-15kg weight loss and 31 of 36 people who lost 15kg or more.

The average (mean) weight reduction was 10 kg in the intervention group and 1kg in the control group. These are impressive results.

The diet

The first phase of the intervention was three months long and this could be extended to five months if wished by the participant. This phase involved a meal replacement diet with four sachets a day, each sachet providing approximately 200 calories. The macronutrient composition of the liquid phase of the diet was 59% carbohydrate, 13% fat, and 26% protein. As noted above, there were no details in the paper about the food reintroduction phase (of 2-8 weeks) or the “ongoing structured programme for long-term weight loss maintenance” thereafter. The structured food reintroduction phase was reported to contain “about 50% carbohydrate, 35% total fat, and 15% protein.” That was the only information provided.

One of the newspaper articles covering the study contained more detail. Two of the participants in The Lancet trial, Isobel and Tony, were interviewed by the Daily Mail. Isobel, 65, was diagnosed with type 2 diabetes in 2011. She was put on medication, but her blood sugars actually increased and she gained weight and was put on even more medication. In 2013 she “jumped” at the opportunity of taking part in the trial. Isobel started in October 2014 at 15 stone and stayed on the milkshakes for 17 weeks, after which time she was down to 12 stone 4lb. Her blood sugars were reduced and her diabetes was in remission. Isobel described the next two years as “calorie restriction of 1,000-1,200 a day”. She now says she eats normally, but she monitors her weight and eats less as soon as she gains. Isobel will need to sustain perpetual calorie reduction to maintain her weight loss and diabetes status. As Stunkard and McLaren Hume showed back in 1959, barely 2% of people achieve significant sustained weight loss with calorie deficit beyond 2 years. (Ref 9)

Tony, 52, had huge motivation to adhere to the trial, as his father had died from complications of type 2 diabetes. He was 14 stone 7lb at the start of the study in October 2013 (at 5’8″). After 12 weeks Tony’s weight was 11 stone and his diabetes was in remission. He is now 11 stone 9lb and describes his current diet as “porridge for breakfast, cheese salad for lunch and chicken salad for dinner.”

Low calorie vs. low carbohydrate

A very low calorie diet is also a low carbohydrate diet. The Lancet study diet, providing 825-853 kcal/day, of which 59% was carbohydrate, thus provided 122-126g of carbohydrate a day. Professor Tim Noakes and Dr Johann Windt defined <130 g carbohydrate/day as an LCHF diet. (Ref 3) 850 kcal/day is also quite high for a very low calorie diet. In 2011, Professor Roy Taylor (the corresponding author in The Lancet study) was the senior author on an article about a trial involving 11 people, which concluded that type 2 diabetes could be reversed with extreme calorie restriction (600 kcal/day in this trial). (Ref 10) 600 kcal/day would be well below 100g of carbohydrate per day.

I will update this post when I hear back from the corresponding author on the food and calorie intake beyond the liquid diet phase. We don’t know the carbohydrate intake for Isobel, but Tony’s typical diet, as described above, could be under 100g of carbohydrate per day.

This brings us to…

The options


You wouldn’t think so with the fanfare from this study, but it has been known for some time that a number of interventions can reverse type 2 diabetes. There are currently three options:

1) Bariatric surgery. As the Virta study reported: “The most comprehensive study of surgical intervention to prevent or reverse type 2 diabetes is the Swedish Obese Subjects Trial demonstrating an 8-fold reduction in the incidence of the disease at 2 years.” (Ref 11)

Barbaric surgery (as the “Word” spell-checker corrects it to!) comes with many other complications, lifelong supplementation and long term nutritional deficiency and so should be the absolute last resort. (Bariatric surgeons often describe a bypass as a last resort, when calorie deficit diets have been tried and failed. However, I have not seen low carb tried as a ‘last resort’ before barbaric surgery).

Professor Roy Taylor also presided over a very valuable clinical trial, which demonstrated that the improvement in glucose control observed for type 2 diabetics, following gastric bypass, was due to the calorie restriction (and thus a bypass wasn’t necessary to achieve benefit). (Ref 12) Taylor had first reported this fact – “The effect of the surgery is explicable solely in terms of energy restriction” – in an article in 2008. (Ref 13)

2) A very low calorie diet. As this Lancet study confirmed, a very low calorie diet can put type 2 diabetes into remission, but this has been known for some time. The Virta article (McKenzie et al) contained an excellent synopsis of evidence available to date. In their introduction, McKenzie et al listed a number of studies – from 1976 to 2017 – that used very low calorie diets to control blood glucose levels, while stopping or reducing diabetes medications. Just because the word “remission” is new, the achievement is not. The Bauman et al study, from 1988, was described by McKenzie et al as “After 19 months, 10 patients remained in remission”. (Ref 14)

3) A low carbohydrate diet. A very low calorie diet is also a low carbohydrate diet, but a low carbohydrate diet per se can put type 2 diabetes into remission. (Refs 2,6,7,15,16)

The importance of this study

This study is potentially the most important public health publication of 2017. IF this study can place “remission of type 2 diabetes” at the forefront of primary care objectives in the UK (and then hopefully worldwide), it will be a game changer for the epidemics of obesity and type 2 diabetes.

For approximately 10 years, the low carbohydrate community has been screaming for a dietary solution to be used for obesity and type 2 diabetes. This community is tiny compared to the low calorie world. IF this low calorie option opens the door for dietary solutions, then primary care providers should be obliged to offer patients any proven dietary options:

Would you like very low calorie (which is also low carb), which comes with hunger, nutritional deficiency, inability to socialise (during the liquid phase at least) and a lifelong demand on your willpower? Or would you like low carbohydrate, which avoids hunger, is nutritionally rich, is catered for in any restaurant from McDonalds (no bun) to The Ivy and which is being sustained without monk-like discipline?

The low carb community needs to emphasise the flexibility of approach more. The hard core of 5% carbohydrate, 15% protein and 80% is not necessary to achieve weight loss and remission of type 2 diabetes. Many people can do very well in the LCHF range of carbohydrate intake, rather than at the ketogenic level, as defined by Noakes and Windt. (Ref 3) Dr David Unwin has achieved remission in diabetes with a very pragmatic and practical diet sheet. (Refs 15, 16) Dr David Cavan, with work not yet published, has been reversing type 2 diabetes in Bermuda with carbohydrate intake nearer 100g/day than 25g/day. (Ref 17) Such intake is likely to be far more acceptable to patients and is aligned with the carbohydrate intake in this low calorie study.

The most critical contribution of this Lancet study is that the control was “best-practice care by guidelines.” No one receiving “best-practice care by guidelines” lost 15kg or more and just 4% of people in this group achieved diabetes remission vs. 46% of people in the intervention group. This study has proven that current ‘best practice’ guidelines are achieving next to nothing. They are a pathway to more medications over time and ultimately the eyesight and limb loss, which is the most horrific end game for diabetics (both types).

This study has not only shown that “remission” should be firmly at the forefront of primary care objectives; it has surely shown that current guidelines are medical malpractice.


 

References
Ref 1: Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet 2017.
Ref 2: Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & metabolism 2008.
Ref 3: Noakes TD, Windt J. Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review. Br. J. Sports Med. 2017.
Ref 4: Feinman RD, Pogozelski WK, Astrup A, et al. Dietary Carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base. Nutrition (Burbank, Los Angeles County, Calif.) 2014
Ref 5: Stentz FB, Brewer A, Wan J, et al. Remission of pre-diabetes to normal glucose tolerance in obese adults with high protein versus high carbohydrate diet: randomized control trial. BMJ Open Diabetes Research &amp; Care 2016.
Ref 6: McKenzie LA, Hallberg JS, Creighton CB, et al. A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes. JMIR Diabetes 2017.
Ref 7: Saslow LR, Kim S, Daubenmier JJ, et al. A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabetes. PLoS One 2014.
Ref 8: Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. The American journal of clinical nutrition 2013.
Ref 9: Stunkard A M-HM. The results of treatment for obesity: A review of the literature and report of a series. A.M.A. Archives of Internal Medicine 1959.
Ref 10: Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 2011.
Ref 11: Sjöström L, Lindroos A-K, Peltonen M, et al. Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery. New England Journal of Medicine 2004.
Ref 12: Steven et al. “Calorie restriction and not glucagon-like peptide-1 explains the acute improvement in glucose control after gastric bypass in Type 2 diabetes.” Diabetes Med. (2016).
Ref 13: Taylor R (2008) Pathogenesis of type 2 diabetes: tracing the reverse route from cure to cause. Diabetologia 51:1781–1789
Ref 14: Bauman WA, Schwartz E, Rose HG, Eisenstein HN, Johnson DW. Early and long-term effects of acute caloric deprivation in obese diabetic patients. Am J Med 1988
Ref 15: Unwin D, Unwin J. Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice. Practical Diabetes 2014.
Ref 16: Unwin DJ, Cuthbertson DJ, Feinman R, VS S. A pilot study to explore the role of a low-carbohydrate intervention to improve GGT levels and HbA1c. Diabesity in Practice 2015.
Ref 17: http://bernews.com/2017/05/argus-offering-diabetes-reversal-programme/

19 thoughts on “Reversing diabetes (type 2)

  • avatar
    February 11, 2018 at 1:39 pm
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    Zoe, minding the store on a Sunday morning! Now that’s impressive.

    For anyone who hasn’t seen Professor Roy Taylor’s presentation on the results of his earlier study here’s the link:

    https://campus.recap.ncl.ac.uk/Panopto/Pages/Embed.aspx?id=c3bef819-e5f4-4a55-876f-0a23436988ed

    The MRI scans he shows are very impressive, first of the huge amount of fat in the patient’s liver and pancreas, and secondly how all the liver fat and most of the pancreas fat had gone after 8 weeks. While we might argue about the way he went about it, there’s no denying how valuable that research is in demonstrating that fatty liver and the overt symptoms of diabetes can be reversed. interestingly, I remember reading somewhere that prior to the development of insulin and diabetes drugs physicians would starve their T2DM patients to cure them. Talk about déjà vu!

    Of course the real question is, you may have restored pancreatic function but are you still insulin resistant? High insulin levels are as destructive as high glucose levels, possibly even more so. I started to put on weight at the age of 35, coinciding with moving in with my semi-vegetarian girlfriend which greatly increased my carbohydrate intake. Over 12 months I probably put on 20 kilos where previously I had been pretty lean. At the time I attributed it to giving up playing sport and the stress and long hours of a new job. Now I think that the high carb diet kicked me into insulin resistance. Yet it wasn’t until age 60 that I was diagnosed with diabetes. I would argue that I became diabetic at age 35.

    The reliance by doctors on blood glucose levels and the glucose tolerance test to diagnose diabetes ignores the fact that by that time we’re at the end stage, and greatly understates the size of the problem. What they should be checking is insulin response – as Joseph Kraft pointed out 40 years ago! By Kraft’s yardstick the majority of the population are already diabetic.

    Reply
  • avatar
    February 11, 2018 at 8:07 am
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    Hi Zoe,

    The Lancet article is behind a paywall, so I’ll take your word for it that they are advocating a low-fat diet. At least this study undermines the current paradigm that diabetes is irreversible and will only get worse and worse. If we can get the majority of doctors to accept that, the next step is to convince them that low-carb is the best way to do that.

    Roy Taylor’s research is valuable in demonstrating WHY calorie restriction works (or in our case carb restriction). Prof Taylor proved that conclusively with his MRI pictures showing how the reduction in fat in the liver followed by that in the pancreas allows the pancreas to resume production of insulin, so that blood glucose drops to normal. Yes most people can achieve that over time with a LCHF diet, but why not accelerate the process by fasting?

    The reason why they went for a liquid shake diet in this and Taylor’s previous study is probably that:
    (a) it’s an easy way to ensure people only get 800 calories/day, whereas if they prepare their own meals they’ll tend to overeat; and
    (b) they don’t believe that people can stick to a zero-calorie fast.

    However, as anyone who has actually done one can attest, a water-only fast isn’t difficult and requires no more than average willpower. I’m currently on Day 13 of a fast and having no difficulties at all. What could be simpler? No calorie counting, no figuring out what to eat, no cooking! Already I’ve lost 3 kilos, dropped my blood pressure 10 points and my fasting BG from 13.4 to 6.5. If Roy Taylor can eliminate fatty liver and fatty pancreas in 8 weeks of 600 cal/day, then a diet of zero calories should do it in less.

    As I see it, the way to reverse your diabetes is to combine periods of extreme calorie restriction (by fasting) with LCHF for weight maintenance. That visceral fat is not just causing insulin resistance and reduced insulin output, but also releasing inflammatory factors, so get rid of it ASAP! Luckily, Prof Taylor’s work has shown that when you have a calorie deficit the visceral fat is the first to go. As a bonus, both fasting and LCHF maintain metabolic rate and muscle mass, whereas the HCLF diet doesn’t. Did the Lancet paper address the issue of metabolic rate or muscle retention?

    Reply
    • avatar
      February 11, 2018 at 8:27 am
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      Hi Stuart
      Well done on your results! I think the liquid diet (or fasting) takes away the “What shall I eat?” question, which leads many carb addicts astray. The minute you ask this question, your mind starts answering “bread/cakes/biscuits/pasta”! The liquid/fast takes away this choice and lets someone settle into a routine of not thinking about food.

      The Lancet article didn’t mention “muscle” at all. Searching for “metabolic” revealed this as one of the references. https://link.springer.com/article/10.1007%2Fs00125-017-4503-0

      Might be interesting
      Best wishes – Zoe

      Reply
  • avatar
    January 16, 2018 at 7:41 pm
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    Zoe, this is an awesome analysis. The last sentence is the essence of current nutrition guidelines (in the US as well): “This study has not only shown that “remission” should be firmly at the forefront of primary care objectives; it has surely shown that current guidelines are medical malpractice.”
    Angela

    Reply
    • avatar
      January 16, 2018 at 7:50 pm
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      Thanks Angela!

      Reply
  • avatar
    December 28, 2017 at 6:23 am
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    Thanks for sharing this informative blog with us.

    Reply
  • avatar
    December 22, 2017 at 9:50 pm
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    Oh dear, Zoe, you don’t really understand logic, do you?

    Look, cutting carbs is Bad. Wrong. Wicked. Evil. Unless you cut fat and protein at the same time, then it becomes good.

    Avoiding grains, “vegetable” oil and processed food is a symptom of an Eating Disorder. A diet of synthetic gloop based on sugar, soy oil and additives is perfectly acceptable.

    Avoiding meat and fat is NOT an Eating Disorder but also perfectly acceptable. I kid you not, I just read an article bashing “fad” diets which had keto top of the list, followed by the Pioppi Diet. This led to another article listing Vegetarian as the “best diet for diabetes”, and Vegan as third best. I think the DASH diet was second, but by then my brain had fled screaming from my skull.

    SADly (pun intended) I suspect that although an increasing number of doctors (like mine) and nurses, and even a few dieticians are starting to accept low carb the numbers which accept veg(etari)an diets is at least an order of magnitude higher, and growing rapidly. I bet this stuff is vegan.

    ISTR a load of people doing this the first time it was reported, a few years back, but I don’t remember what were the outcomes when they returned to their “healthy diet” later.

    http://sci-hub.hk/10.1016/S0140-6736(17)33102-1

    I’ll read the details later.

    Meanwhile thousands of patients, including especially on the ADA Forum, and elsewhere, have been “reversing” their diabetes with LCHF for well over a decade now. None of these people have been studied, and in fact I know several who were rejected from studies for being “too well controlled”. Then there were studies by Mary Gannon and Frank Q Nuttall going back at least that long, using what they called LoBAG diets – Low Biologically Active Glucose. The ADA pulled their funding presumably because they kept coming up with the “wrong” answer.

    Though people have criticised Virta for charging for what is effectively available for free elsewhere, I’m optimistic that they will actually release further studies of their successes which may somewhat dent the Clue Armour of the doctors and dieticians who reject every success as “just anecdotes”.

    Reply
    • avatar
      December 26, 2017 at 11:13 pm
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      OK two things that stuck out like Harvey Weinstein at a hen party

      ” After review of data from the first
      practices to enter the study, it was necessary to tighten
      the criteria for diagnosis of type 2 diabetes to exclude
      patients who had already achieved non-diabetic HbA1c.
      The inclusion criteria were revised to specify that the
      most recent HbA1c value should be greater than 6·0%
      (>43 mmol/mol) and, if less than 6·5% (<48 mmol/mol),
      individuals should still be receiving antidiabetic medication.
      "

      So some subjects had already "reversed" their diabetes. Pity they didn't break them out and study how they did this.

      I also noticed that their lipids didn't change much. In the Real World low carbers routinely hugely increase their HDL and drop their trigs. When this doesn't occur (as in many studies) I suspect the trial was rigged.

      I dug out the protocol

      https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0406-2

      here's the stuff they were fed

      https://www.cambridgeweightplan.com/whats-the-plan/products

      Gosh how did I guess what the gloop was?

      AFAICR the previous study used either Optifast or Medifast – one was prescription only and used in the trial, the other was OTC and used by the people who were emulating the study.

      "Declaration of interests
      NB reports funding from Counterweight and Cambridge Weight Plan,
      outside the submitted work. MEJL reports personal fees from
      Counterweight during the conduct of the study, and non-financial
      support from Cambridge Weight Plan outside the submitted work.
      MT is co-founder and Director of Changing Health. GT reports
      funding from Cambridge weight plan outside the submitted work.
      HMR reports employment by Counterweight during the study, and is
      shareholder in Counterweight outside the submitted work. NS reports
      grants and personal fees from Boehringer Ingelheim; personal fees
      from Janssen, Eli Lilly, and Novo Nordisk; and grants from
      AstraZeneca, outside the submitted work. LM reports employment by
      Counterweight during the conduct of study, and employment from
      Cambridge Weight Plan outside the submitted work. All other authors
      declare no competing interests."

      So there you go. Apart from flogging foodlike products they are obviously locked into the "diabetes is caused by being fat and being fat is caused by eating fat and being a lazy bastard" paradigm and nothing to do with carbs. No wonder DUK supports them.

      Reply
      • avatar
        December 27, 2017 at 3:19 pm
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        Hi Chris
        Great spot on the protocol point – those who had reversed already. That’s like in statin trials when they take those who suffer side effects out of the trial!

        I was aware of all the conflicts. I heard they’ve got a substantial amount from the liquid diet folk – not surprising when it ends up giving them a clinical trial like this! The Cambridge diet is effectively a vitamin and mineral pill delivered in a sugary milk shake! And to think you could get the nutrients from meat, fish, eggs, dairy and veg!

        Best wishes – Zoe

        Reply
  • avatar
    December 20, 2017 at 7:20 am
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    Hi Zoe

    Wonderful summary of the article and (missed) evidence. Getting DM2 “remission” into mainstream medical thinking is the key win in this study. I think maintenance of caloric restriction in a non trial environment is (as most of us know) super hard. Whereas LC lifestyle does not require hunger to be successful. The word diet to everyone seems (incorrectly) to imply some degree of ongoing hunger …. a throwback of course to the calorie theory. And a LCHF diet (as known by all those that have followed this) does lot require caloric limitations hence hunger is not part of that lifestyle. We know fat has far better satiety properties…

    Finally. I agree with your 3 options. Surgery. Caloric restriction. And LC. But would intermittent fasting be a 4th? Not sure of studies supporting that (yet) but one can see it as yet a further option or possibly a variation of caloric restriction albeit intermittent.

    Thanks again for all the great work you’re doing in this space.

    John

    Reply
    • avatar
      December 20, 2017 at 8:13 am
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      Hi John!
      Good point on the fasting – I didn’t include it because I’m not aware of any published evidence yet that it can put T2D into remission. Please anyone post a link and I’ll update happily.

      It could fall under calorie restriction currently, but I suspect that there is something unique about fasting that could put it in a category of its own. Prolonged and regular resting of the whole blood glucose handling mechanism must be of particular benefit?

      Hope you’re not on a plane somewhere for Xmas – have a good one!
      Best wishes – Zoe

      Reply
  • avatar
    December 19, 2017 at 10:09 am
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    Hi Zoe
    Thanks for the very useful summary of this important paper, which we have been tracking since its pilot phase, and in which Diabetes UK have invested their largest ever grant.
    For me an important issue is the high non responder rate, and no clear indication of what identified the responders from the non responders.
    For that diet to be widely applicable people living with diabetes are going to have to buy the Very Low calorie Diet (VLCD) commercially, and it would be useful to know who is most likely to respond to it.

    Reply
    • avatar
      December 19, 2017 at 3:53 pm
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      Hi Colin
      Good points – have you tried emailing the corresponding author? Professor Roy Taylor? The email is on the paper. I go a vague response about the diet after the liquid phase – I’ll update the post with it asap.
      Best wishes – Zoe

      Reply
  • avatar
    December 15, 2017 at 9:47 pm
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    I am type 1. I am bewildered that low-carb is not offered to us as a method of eating either (in Australia, had to find and implement it on my own). It is only logical when the injected/pumped insulins plus the methods of delivering it are not the same as a non-diabetic. It is only logical when the carb processing part of us is no longer working. It is only logical that you also need to adjust eating to match this regime. Injecting insulin or pumping it is not the same as a person’s body making their own on demand. Low carb will closely match this with minimal fuss. I too rejected the idea initially because it seemed too onerous but the benefits (short term I can measure at least) are working for me. Low carb means injecting less insulin so less dangerous hypos. I dont know what will happen long term but as far as I can see normal blood sugar levels are the leading cause of nothing (ie wont cause the dreaded long term complications).

    Reply
    • avatar
      December 16, 2017 at 7:51 am
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      Hi LmC
      As the sister of a Type 1, I couldn’t agree with you more. It seems criminal not to advise all diabetics – either type – to limit their intake of carbohydrate. Some people do quite well below 130g/day (Prof Noakes defined some helpful categories in his BJSM paper) – others do better at near ketogenic levels. No diabetic – in my honest opinion – should ever get near the 55%+ advised by our dear governments. And yes, eye sight loss and amputations are the visible signs of the harm that the current advice is doing. I hope and think that there might be law suits one day.
      Best wishes – Zoe

      Reply
  • avatar
    December 14, 2017 at 1:45 pm
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    “Barbaric” surgery indeed. I know several people who’ve had this done fairly recently. They all seem to be doing well. One gentleman who had surgery about 6 years ago has put back all the weight simply by drinking “full strength” Coke and other soft drinks in industrial quantities.

    Me, I’ll stick to my low carb diet. Mostly (apart from that essential morning coffee) I do the 16-8 intermittent fasting thing, only eatiing lunch and dinner. Every few months I’ll do a 500 calorie/day “fast” for a couple of days. Bone broth and eggs (usually hardboiled) and coffee — it’s surprisingly satisfying and I’ve gone 4 days doing that without getting hungry. It does wonders for my blood glucose levels too.

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