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THE FOREVER MYTH
When the diagnosis first arrives it's a shock. Looking back, one short sentence on the UK's National Health Service website really brought home how much this disease would affect my life: "Diabetes is a life-long condition that causes a person's blood sugar level to become too high." It was the phrase "lifelong condition" that rattled me. At that time, as far as I was aware, there was no fix — I'd done this to myself, and there was nothing I could do about it.
When I was first diagnosed in early 2012, I entered a whole new world of tablets, tests and examinations. I'd walk home from the pharmacy with a large bag bursting with boxes of pills and struggle to find the space to store them. For several years these tablets became as much a part of my life as toothpaste and mouthwash (and took up a lot more space in the bathroom), and when they ran out I'd go back for another enormous supply.
If the medications were demoralising, the dietary advice was even more dispiriting. Since the 1980s, people with diabetes have been encouraged to eat a low-fat diet, including prodigious amounts of starchy carbohydrates. For decades, public health advice has encouraged us to believe that up to half our energy should come from carbohydrates, which typically means consuming 200g to 300g of carbs a day.
Many people now believe that this is quite wrong — that this can actually promote weight gain, lead to high blood glucose levels and encourage a dependence on medication that only increases over time, leading to sufferers being prescribed stronger and stronger doses as they get older. Arguably, much of the type 2 dietary advice over the last 30 years has at best promoted a medication-based maintenance regime and at worst compounded the problem for millions of people worldwide.
I had bought into the predictions that many websites were offering: the prognosis appeared to be very poor. I Googled the words "do most people with type 2 diabetes eventually need to take insulin by injection," and website after website told me that I would probably be injecting myself eventually. I started to study the eating advice online in search of help.
The UK's National Health Service tells us that "people with diabetes should try to eat a healthy balanced diet ... and to include starchy foods at every meal." We're told in an online NHS article, "The Truth about Carbs," that "the Government's healthy eating advice, illustrated by the 'Eatwell Guide,' recommends that just over a third of your diet should be made up of starchy foods, such as potatoes, bread, rice and pasta." The "Eatwell Guide" goes on to suggest we eat five portions of fruit and vegetables, drink lots of water and "try to go for lower-fat and lower-sugar products where possible, like 1 percent fat milk, reduced-fat cheese or plain low-fat yoghurt."
My subsequent experience was that this advice, about both carbohydrates and low-fat foods, was complete hogwash. It simply doesn't work if what you really want to do is lose enough weight to challenge the underlying cause of a type 2 diagnosis. Many others now agree, including some progressive doctors and nutritionists, diabetes charities, MPs (who have even been moved to write to the Prime Minister on the subject) and, above all, patients themselves.
As I settled into my diagnosis, a familiar routine developed. Automated letters from my doctor arrived with a request that I come in for an annual check-up or attend an eye scan or join a quit-smoking clinic. Prescriptions were sent directly to the pharmacy, and I would be summoned when they were ready. My disease was being "managed" in the most efficient way possible: it was a way to keep me stable, not a plan to conquer my diagnosis. I have nothing but the greatest admiration for my own personal GP, who provided endlessly wise counsel and sage advice in the years I had a diabetic diagnosis. The staff at the surgery I attended were both patient and attentive and offered encouragement, and always put up with my sulky attitude with considerable grace.
Annual check-ups were focused on the key issues of blood pressure, glucose scores, eye tests, waistline measurements and, rather unexpectedly, foot health. Diabetes can cause complications through nerve damage — a condition known as sensory diabetic neuropathy. For many people this can damage the feet and legs, as wounds become infected and very difficult to treat. Diabetes can also affect the circulation in your legs and feet as a consequence of peripheral arterial disease.
I went into a three-year sulk. I started skipping the appointments and throwing away the letters. Anyway, I was heading for daily injections in due course, so why bother? In my heart I knew it was all my fault. I had brought this on myself, and I was paying the price for a lifetime of bad habits.
Not long after my diagnosis, one of my best friends, Warren, came to stay. One morning I heard a loud exclamation as he opened the bathroom cabinet. 'What the hell?' he said as he came face-to-face with a precarious tower of medications.
Warren has lived all his life in northern California. He goes to the gym regularly, eats incredibly healthy food and spends his spare time sweating through hot yoga sessions and downing wheatgrass shots. His tall, lean, muscled and perfectly proportioned body is testament to his disciplined, sun-kissed, organic, West Coast lifestyle. He's a pale, lithe, muscled health nut who dances till he drops twice a week and never skips his early morning stretches.
By contrast, I was an overweight, indolent, lumbering middle-aged man who avoided physical exercise at all costs. I ate treacle tart and chocolate bars in alarming quantities. I drank litres of fresh fruit juice each day and consumed recklessly large amounts of sugar. My cornflakes were smothered in golden syrup, and I could demolish a whole Battenberg in one sitting. We were each impressive in our own ways.
As I saw his reaction to the medications, I realised that I'd normalised my diagnosis and the tablets that came with it. I'd succumbed to the idea that this was a "lifelong condition" without ever stopping to question it, believing wholeheartedly that there was nothing I could do about it and excusing myself from the effort of trying.
I came across a study by Newcastle University's Magnetic Resonance Centre that saw some people reverse type 2 diabetes by following a strictly monitored clinical diet. Eleven people had attempted to reverse their diagnosis by drastically cutting their calories to just 600 a day for two months. The subjects' austere regime was made up of liquid diet-replacement shakes, plus a further 200 calories a day of non-starchy vegetables. They were matched to a control group and monitored over eight weeks. At the end of the trial, seven out of the original 11 volunteers were diabetes free. My world stood still for a moment as I absorbed the implications of what I had read. Perhaps the grim prediction that I was heading for daily insulin injections was just plain wrong?
Many people lose weight to change the way they look. They want to get rid of the visible fat that accumulates around their midriff or that gives them flabby arms or a double chin, but the key issue for many type 2 patients is that internal fat can compromise the vital functioning of the liver and pancreas. This fat needs to be banished for the body to be able to effectively re-start and regulate its own blood glucose.
Professor Roy Taylor of Newcastle University, who led the study, was quoted as saying:
To have people free of diabetes after years with the condition is remarkable — and all because of an eight-week diet. While it has long been believed that someone with type 2 diabetes will always have the disease, and that it will steadily get worse, we have shown that we can reverse the condition.
THE RELATIONSHIP BETWEEN BODY FAT AND TYPE 2 DIABETES
Body mass index (BMI), the measure of weight compared with height, has long been thought to be an indicator of diabetes risk. There's a commonly held belief that overweight people are at greater risk of type 2 diabetes than those with healthy BMIs. But according to research, 70 percent of severely obese people don't have diabetes and there are some very slim people who do. So what's the truth?
Research suggests that a predisposition to adult onset diabetes actually depends on how well your body stores fat, and this is different for everybody. Many people are advised to shed the visible stomach fat that accumulates over years of bad eating habits, but it appears that for some people, diabetes can be triggered by the accumulation of internal fat that disrupts the liver and pancreatic functions — organs crucial for producing insulin and regulating blood sugar.
A research paper on the website of the scientific journal Clinical Science refutes the view that type 2 diabetes is solely a result of obesity or being very overweight. Instead, it argues that once someone goes above his or her own "personal fat threshold," the body's ability to control blood sugar starts to deteriorate until it eventually malfunctions. Crucially, the evidence also suggests that for many people, this process is reversible. Reduce the internal fat, and the body can restore blood glucose levels and insulin production to normal.
Not all type 2 diagnoses are the same. There are people for whom this excess fat issue isn't relevant. Their diagnosis comes from other causes, such as old age, pregnancy or chronic illnesses. Diabetes can be caused by chronic pancreatitis, and monogenic diabetes can't be reversed using weight loss. And for people who have had a type 2 diagnosis for more than six years, the odds of reversing the disease are rather lower.
I began to wonder if my own diabetes was being caused by internal fat that was compromising my normal organ function. If I could lose the weight and purge the fat, if my pancreas spluttered back into life and if my liver function wasn't too damaged, then perhaps my insulin levels would stabilise and the diabetes would just go away? It was a lot of ifs but it sounded reasonable, and it was the only thing I had to go on.
Professor Roy Taylor, who led the original Newcastle University study, has published a simple and elegant five-page advisory. In it, he makes the point that while substantial weight loss must be achieved, the speed of the weight loss is less important than the actual drop in weight. A small line buried in the document caught my attention: "Any pattern which brings about substantial weight loss over a period of time will be effective," he announced. The all-important word here was "will". Not "may," but "will". This single word was the spur I needed. Suddenly, instead of being told this was a life-long condition, I had a choice. I had the opportunity to do something about my diabetes, and if it worked, it might have a long-term effect.
If any further proof was needed, the results of a new and wider trial were published in November 2017. This study saw 306 people recruited from 49 primary care practices in Scotland and the Tyneside region of England achieve astonishing results. The study involved withdrawing all anti-diabetic and anti-hypertensive drugs, a total diet replacement with an 825 to 850 kcal/day formula for three to five months, a stepped food reintroduction over a two- to eight-week period and structured support for long-term weight loss maintenance.
Those who lost the greatest amounts of weight were the most likely to be successful. A staggering 86 percent of people who lost 15kg (33 lb) or more put their type 2 diabetes into remission. More than half the people who lost between 10kg to 15kg achieved remission. Overall remission was achieved in 46 percent of the participants. The headline messages from this study, summarised by Professor Mike Lean MA MD FRCP, Professor of Human Nutrition at the University of Glasgow, are so revolutionary that they're worth reproducing in full (with permission, see page 145):
Type 2 diabetes is a hateful disease, gradually, silently damaging vital organs and bodily functions. It is especially serious and shortens life significantly in younger people (under age 70-75). It is almost always in people who are overweight. We have shown, in research funded by Diabetes UK, that type 2 diabetes is not necessarily permanent. It can often be reversed into remission (non-diabetic again, taking no anti-diabetes medications) by sustained substantial weight loss.
With substantial weight loss (over 15kg) almost 9 out of 10 can achieve a remission (no longer diabetic, non-diabetic HbA1c, taking no drugs for diabetes treatment).
With weight loss of 10kg to 15kg, still over half can achieve a remission.
These figures apply to people with type 2 diabetes for up to 6 years. With longer duration, remission is still possible but less likely.
For smaller people (e.g. body weight under 70kg), lesser weight losses may be successful.
We do not yet know how long a remission of type 2 diabetes will last, but the key is maintaining the weight loss, and possibly losing more weight at a later stage.
Achieving a remission is the best bet to prevent, or at least delay, the complications of diabetes, but cannot guarantee that they will be avoided for all patients as other factors may apply (e.g. high blood pressure).
A full summary of the groundbreaking DiRECT trial is available online. There's a qualification here: the volunteers in this trial weren't representative of the whole diverse population of the UK. This may be important for future research, as there is compelling evidence that type 2 diabetes is more prevalent in different populations around the world.
Studies that focus on disparities in glycaemic control have often been contradictory and have been compromised by excessively broad population and ethnicity categories, small sample sizes, limited follow-up, inadequate adjustment for socioeconomic differences and variations in levels of access to (or use of) healthcare. A large nationwide observational study from the Swedish National Diabetes Register between 2002 and 2011 aimed to comprehensively map glycaemic control in a large diverse cohort of patients with type 2 diabetes. Their results called for more individualised management and increased efforts from the medical system to eliminate inequalities. Many scientists believe that type 2 diabetes is a consequence of both genetic and environmental factors, and the full implications of this for different people from different backgrounds attempting to reverse their disease through diet will only be fully understood in the decades ahead.
Progress is achingly slow. Doctors are only gradually becoming aware of the advances in research from the DiRECT trials. A brief paragraph from the earlier Newcastle study declared, "It will take years for this new knowledge to become incorporated into textbooks and guidelines, so your doctor may be wary of information from the Internet. Therefore, here are some notes for you to take to your doctor."
There is surely something terribly wrong here. It seems almost unbelievable that patients need to become their own primary advocates for the advances in treatment of one of the most widespread illnesses of our generation. The National Health Service in the UK, staffed by dedicated and committed people who work long hours in service of the nation's health and well-being, is one of the country's greatest national assets. It is an extraordinary institution, and we are enormously fortunate to have it. But the inability of the medical profession to change swiftly and respond decisively to this revolution in the treatment of type 2 diabetes is deeply discouraging for the millions of people who suffer from this disease, many of whom might just stay on medications for decades.
Despite how promising the early trials sounded, I knew that the clinical approach wasn't for me. There was no way I could restrict myself to such a small daily calorie limit; I didn't have the self-control. Plus, to do the diet properly, I needed to get hold of the same magic meal replacement shake used in the trial. Clinical-grade food replacement products can be surprisingly tricky to get hold of, and many need to be prescribed by a doctor. I considered buying generic alternatives and even tried a few over-the-counter products, but they were all horrible. Professor Taylor refers to his approach to diet as "vigorous," and after considering the options for a while, I decided that his hard-core approach was simply impossible.
I knew enough to be aware that a calorie-restricted diet alone was unlikely to be sustainable in the long term. And in truth, I doubted my willpower to keep with the programme. There were other things about the original trial that made me wince. I've always loved food — not just eating, but also cooking and sharing meals with friends. The blanket prohibitions on meat, fish, poultry, carbs, dairy, fruit and alcohol filled me with gloom. Then there were the recipes. The original Newcastle meal ideas consisted of eight vegetable soups, a single salad, a recipe for tomato sauce and a salsa. If I wasn't enjoying the food in front of me then I was sure to fail. I needed something slower, less brutal and much more achievable.(Continues…)
Excerpted from "Conquer Type 2 Diabetes"
Copyright © 2019 Richard Shaw.
Excerpted by permission of Hammersmith Books Limited.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
About this book,
The forever myth,
The doughnut moment,
Preparation: week zero,
A food diary,