The Challenge of Type 2 Diabetes Reversal
Why reversing type 2 diabetes is just too hard for both health professionals and individuals
When consulting with people with diabetes I’m asked almost daily:
“Can I get rid of my diabetes?”
It’s a question most health professionals answer tentatively. There’s a fine line between wanting to give people hope and making uninformed, whilst well intended promises.
Firstly I must disclaim that this article does not refer to type 1 diabetes, an autoimmune condition, which at this point in time cannot be reversed or cured.
For many people newly diagnosed with type 2 diabetes there is a window of opportunity to reverse the condition. To understand why reversing type 2 diabetes is time sensitive, it helps to understand the pathology behind it.
In simple, very unscientific terms, whenever we eat food which has carbohydrates, natural sugars or added sugars, these convert into glucose and move into our blood stream. From there, a hormone called insulin which is produced by the pancreas, assists in activating ‘glucose transporters.’ These transporters move the glucose from the blood stream into the millions of cells in the body.
Type 2 diabetes is initially characterized by insulin resistance which means the cells in the body do not allow insulin to do its job properly. So the amount of glucose that moves from the blood into the cells is reduced. Therefore, blood glucose levels rise. These blood glucose elevations cause acute symptoms such as fatigue, blurred vision, thirst and frequent urination.
When someone is first diagnosed with type 2 diabetes, they are generally still producing adequate amounts of insulin and are often producing more insulin than normal. This is because the pancreas is working harder to try to combat insulin resistance. Over time, the pancreas, for lack of a better term, may begin to ‘wear out’ thus producing less insulin.
Therefore, when someone has had diabetes for a longer period, they may have reduced insulin production. In this instance managing type 2 diabetes without medication is extremely difficult, due to the body’s need for insulin to keep blood glucose levels in the target range.
This indicates that the best time to ‘reverse’ diabetes is when someone is first diagnosed, or even earlier, when diagnosed with prediabetes, as this is when a person will most often still be producing adequate amounts of insulin.
Research suggests that if someone with prediabetes loses 5–7% of their body weight their risk of developing type 2 diabetes reduces by nearly 60%. In type 2 diabetes, losing a similar amount of weight can reduce the amount of diabetes medications required.
Whilst waiting 5, 10, 20 years before attempting to reverse type 2 diabetes, the amount of insulin produced by the pancreas will decrease. At that stage, despite significant lifestyle modifications, reversal of type 2 diabetes becomes near impossible.
So, with the boring pathophysiology class over and done with there are a couple of things that have been identified to have the potential to reverse type 2 diabetes, with a predominant focus on weight loss.
The first is bariatric surgery.
If someone can afford it and they have an elevated body mass index, then bariatric surgery has been evidenced to reverse type 2 diabetes in over 78% of cases. With bariatric surgery costing upwards of $30,000, it is often out of reach for many people.
Secondly, adopting a very low-calorie diet may reverse type 2 diabetes.
A very low calorie diet means an individual has approximately 800 calories per day. One study indicated that 68% of participants who consumed around 850 calories per day for three months achieved diabetes remission.
We have to remember that 800 calories a day isn’t much at all, especially if a person is used to eating more than 2000 calories a day, with some reports suggesting that people eat around 3600 calories per day on average.
To give an idea of what someone could eat on an 800-calorie day, I’ve provided a basic example below. Obviously there are many interesting and tasty recipes that can be adopted into this kind of meal plan.
Breakfast: 2 poached eggs (~139 calories), a cup of cherry tomatoes (26 calories) and a cup of mushrooms (15 calories) fried in a teaspoon of butter (36 calories) = 216 calories
Morning tea: 1 rice cake (23 calories) with a quarter of an avocado (56 calories) = 79 calories
Lunch: 100 grams of steamed chicken (142 calories) with 2 cups of salad greens (88 calories) (think lettuce, spinach, celery, cress, dandelion greens, onion, radish, bell pepper, sprouts, shallots, zucchini, broccoli, cauliflower) = 230 calories
Afternoon tea: A small apple = 45 calories
Dinner: 100 grams of steamed or poached fish (110 calories) with 2 cups of non-starchy vegetables (30 calories) (think brussell sprouts, broccoli, cabbage, Asian vegetables like bok choy). Add a dessert of a cup of fresh berries (~80 calories) = 220 calories
Total = 790 calories
Water has no calories, so H20 is the best choice to keep hydrated. Tea or coffee is ok, preferably black or with just a dash of milk but hold the sugar!
Sticking to an extremely low-calorie diet for a prolonged period would take a lot of will power and planning. Life is busy, we are often cooking meals for a number of other people in the family, good food is often more expensive than unhealthy food and convenience is a draw card for high calorie choices.
So this leads us to the third way to try to reverse diabetes, or at least reduce the reliance on diabetes medications:
Significant reduction in carbohydrate intake to less than 50 grams per day.
Putting this into perspective, a single banana contains around 25 grams of carbohydrate on its own, so reducing carbohydrates isn’t an easy feat either.
With these three strategies reported to assist in type 2 diabetes reversal, why do I feel a little reluctant to talk to patients about them?
Firstly, the research and academic world has been somewhat slow to catch up to the concept of reversing type 2 diabetes. Health professionals who pushed this agenda were until recently almost gagged by the lack of high-quality publications supporting the approach.
Thankfully this is quickly changing. However, it has only been in recent years that diabetes associations have developed informational materials about low carbohydrate/calorie diets and managing diabetes.
There are now many forums citing the value of low calorie and/or low carbohydrate diets in diabetes management. However, unfortunately in the health professional world, these groups of people have at times been referred to as the abnormal zealots we should be wary about.
Secondly, I work with a lot of dietitians who still push high carbohydrate diets because that’s what their professional associations cite. It becomes very difficult to support a person with diabetes in reversing their condition when the dietitian next door is telling them to eat in excess on 150 grams of carbohydrate per day.
I’ve often seen people eating more than they used to, due the input of a dietitian, which goes against the whole approach to type 2 diabetes management and lifestyle modification. Don’t get me wrong, I also know many fantastic dietitians that understand the pathology behind type 2 diabetes and support their patients to achieve their goals, whether that be losing weight or reducing their need for diabetes medications. It is just unfortunate that as a health professional, I still have to vet the dietitians I refer my patients to.
Finally and most significantly, the reason why I am cautious in my response to the ‘can I get rid of my type 2 diabetes’ question is because I know how much individual motivation and self-control is required. I don’t want to give people unfounded hope if they don’t possess the internal capacity and drive. This is however, something I can’t measure objectively. None-the-less I can read the reactions I get from some of my patients.
If I bluntly or even kindly say something along the lines of:
“Okay, if you want to try to reverse your diabetes then evidence says you need to reduce your calorie and carbohydrate intake.”
The faces starting back at me are often not happy which I can fully understand as who doesn’t love a good bowl of creamy pasta and porridge?
The next line of questioning often goes something like:
“Well if I can’t eat bread or potato what can I eat?”
To which my response may be something like:
“Do you like eggs?”
“Yes”
“Then eat eggs. Do you like meat?”
“Yes.”
“Then eat meat. Do you like Greek yogurt and cheese?”
“Yes.”
“Then eat Greek yogurt and cheese.”
This back and forth could go on for some time before it starts to sink in that there are actually a lot of foods that can be eaten freely and a lot we can eat in smaller portions. However, nine out of ten times the person I’m talking to will say that they can’t possibly significantly reduce carbohydrates or calories because of reason A, reason B and reason C and I totally get how easy it would be to focus on all the things the person feels like they CAN’T eat or need to limit.
I believe most people would prefer to continue eating high carbohydrate and caloric foods and take diabetes medication instead. Eating less or changing the way we eat is a lot harder than just taking a tablet or two or three every day.
Why do we prefer to be reliant on medication and thus more susceptible to the progression of type 2 diabetes as well as the associated complications as opposed to eating differently?
Why don’t we back ourselves and our most easily accessible resource — our will power?
I don’t really have the answer. It’s tricky to measure individual levels of motivation and will power and to date there’s no ‘magic bullet’ to promote or enhance the two of these. If we could we’d all be trim, fit, high achieving individuals living life to it’s fullest, with healthy living a focused priority.
I’ve seen some of the devastating impacts of type 2 diabetes. I’ve seen amputations, kidney failure and blindness. In my mind, skipping the bread is a small price to pay to maintain long term health. However, not everyone has seen what I’ve seen.
Type 2 diabetes is more commonly seen as ‘not serious’ because it is an invisible condition which so many people across the globe have. Would taking my patients for a walk into the renal dialysis unit enhance will power and motivation? I’m not so sure.
Do you think health professionals are sometimes scared to tell it how it is. Namely, that diabetes is serious and requires a heck of a lot of effort to avoid its potential dire consequences. Or perhaps it’s much easier for a health professional to prescribe a tablet, than spend the time supporting an individual to make big dietary and lifestyle changes.
If someone has a broken leg however, and the health professional tells them to rest, this is totally okay and expected and reasonable. Yet if someone has type 2 diabetes and are encouraged to reduce calories and carbohydrates then the healthcare professional is being unreasonable and mean. The healthcare professional is being judgemental, rude and non-empathetic.
This is far from the truth. I find it so much harder to have up front blunt conversations with my patients as I don’t want to upset them or make them feel inadequate or have any shame. It took me years to realise that by not having frank conversations I wasn’t helping my patients. Sure, initially we all felt better, but later down the track, when the patient ended up having a significant diabetes-related complication, neither of us felt okay.
Being cruel to be kind might seem like a cop out, but it is the reality.
People newly diagnosed with type 2 diabetes need to be provided with all the information and all the support. They then can make an informed choice regarding their diabetes management, knowing their own individual capacity whilst having a full understanding of the potential consequences of their choice.
If we don’t provide people newly diagnosed with type 2 diabetes with the opportunity to aim for reversal of their condition from day one through low calorie and low carbohydrate diets then we are doing them a complete disservice.
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