August 18, 2009

Can Type 2 Diabetes Be "Reversed?"

This is a question a lot of my readers ask me. Their doctors may tell them that if they lost weight they'd reverse their diabetes and there are books on the market that claim the same thing.

Unfortunately, the concept of "reversing" diabetes doesn't hold up well to scrutiny.

The media version is that Type 2 Diabetes is caused by gluttony and sloth and can be prevented or cured by diet and exercise, but the truth is quite different. The research makes it it very clear that overeating doesn't cause diabetes. You can read the documentation for this HERE.

This should help you stop blaming yourself for your condition if you have Type 2 diabetes, but it also implies that if you have the underlying condition, which manifests clear clinical indicators when people with diabetic heritages are young and thin, you aren't going to cure the underlying condition with simple interventions.

But what about the studies where interventions "prevent" diabetes? Well, a lot of them turn out to be studies where a group of people with marginal blood sugars--for example an average fasting blood sugar of 123 mg/dl (6.8 mmol/L)-- do something that keeps their blood sugar at 123 mg/dl compared to another group who start out the same but end up with a blood sugar of 126 mg/dl (7 mmol/L). Because diabetes is diagnosed with strict cutoffs, and the fasting cutoff for diagnosing diabetes is 125 mg/dl (7 mmol/L), the first group "prevents diabetes" and the second develop it. The actual difference between the two groups is minuscule and they both have the same likelihood of developing diabetic complications.

This is what happened in the DPP trial that supposedly found metformin "prevented" people with pre-diabetes from developing diabetes. As soon as the study was over, when the people taking metformin stopped taking it their blood sugar rose the couple of points that put them into the diabetic range. Had they prevented diabetes? Of course not. They had controlled their marginal blood sugars a bit, which is something else entirely.

Weight loss can make blood sugar control easier, and there are studies of people who have pre-diabetic blood sugars that make it look like losing weight can "prevent diabetes." But it is worth remembering that the vast majority of the obese who have pre-diabetic blood sugars will never develop diabetes. So interventions where people with pre-diabetes lose weight and with it the insulin resistance caused by overweight may make it look like they "prevented diabetes" but the intervention may have only been effective in those people whose marginal blood sugars were caused by factors other than the genetic damage that leads to diabetes--people, in short, who would never have developed diabetes.

It is also possible that the diet "prevented" diabetes by cutting hundreds of grams of carbs out of the diet--this happens when you cut way down on food. So blood sugar did drop--while the diet was in force, but will come right back up once the diet is abandoned, as most diets are.

This appears to be the main reason that gastric bypass appears to "reverse diabetes." As I blogged earlier, the long term data do not support this claim and over time people whose blood sugars improved with WLS see them deteriorate again.

Indeed, over my eleven years of interacting with the diabetes community online I have met a lot of people with diabetes who have lost enough weight to make it into the normal BMI range who have maintained their weight loss. I did that myself. I have never met anyone with diabetes whose blood sugars became truly normal after losing weight.

Now before I get a load of email from those of you who have cut the carbs, lost a lot of weight, and now have A1cs of 5.0 and fasting blood sugars of 83 mg/dl I want to take a moment to discuss what I mean by "truly normal".

True normal to me means you can eat anything and end up with a blood sugar under 100 at 90 minutes past mealtime. My son can do that. My 93 year old mother can do that. They don't have diabetes genes and they can metabolize any amount of carbohydrate. That's what I consider true normal. Roughly one third of the population appears to have that kind of blood sugar control.

Normal people are the ones who can go on a low fat diet and drop weight without feeling hungry--and who insist we people with diabetes should be able to do the same thing. Because they really can eat bananas on their oatmeal and see completely normal blood sugars, normal people have no clue what we people with diabetes are up against. And sadly, many doctors and nutritionists appear to have normal blood sugars which is one reason they give such flawed advice to the rest of us.

But those of us who have damaged glucose regulation systems are never going to be normal by that definition. If we think we will, because that's what the doctors tell us, and deny our selves food, overwork ourselves at the gym, because of that belief, only to learn we still can't eat a single bagel at coffee break without seeing our blood sugars soar, we may end up very disappointed indeed.

I believe one reason so many people with diabetes give up after a few years of pursuing diet and exercise is because they don't see the promised "reverse" no matter how hard they work--especially if they use the low fat strategies that too many dietitians and doctors still promote.

But this is a shame, becuase while we can't reverse our diabetes we can control that diabetes.

"Control" means doing whatever it takes to give ourselves normal blood sugars. The people in the metformin study were controlling their blood sugars, not reversing their pre-diabetes. People who cut way back on their carbohydrate intake are controlling their diabetes. People who take a brisk walk after dinner to lower their blood sugar are controlling their blood sugar.

Control is different from reversal in that as soon as you stop using the tools and techniques of control your blood sugars will start climbing right back up.

It may take a couple weeks for the deterioration to set in. I often hear from people who report that have been eating low carb diets for months and have lost weight who say that when they eat carbs now they get much better blood sugars. They probably do, but if they keep eating carbs they will see those blood sugars start rise again and they'll also start gaining weight because the rising blood sugars will trigger the secondary insulin resistance which causes weight gain.

Once you have established good control, you can take the occasional day off without harm. But when the occasional turns into the daily, you will quickly learn the difference between control and cure.

You may have been told some drugs can "rejuvenate beta cells" and that they can reverse your diabetes. This claim has been made (and debunked) for Avandia, and is now being made, very loudly for Byetta and Januvia, though without compelling proof.

In fact, I have never yet seen a single study where the blood sugar improvements produced by a drug lasted for any significant time after the drug was discontinued. With one sole exception: people with Type 2 diabetes who are given insulin for a few weeks at diagnosis appear to have much better blood sugars years later. Details HERE. Unfortunately, very few people are given insulin at diagnosis. Instead they are given oral drugs, and none of them produce lasting effects when discontinued.

Someday science may find ways to truly reverse diabetes. But for now we have to be grateful we have learned how to achieve effective control. Because control works. If you keep your blood sugars normal you can avoid diabetic complications. The best way to do this is to follow the advice you'll find on HERE.

But when you find a method of control that works, don't expect your diabetes to go away. Because your diabetes wasn't caused by overeating or lack of exercise, it can't be cured by those tools either. Your diabetes can be managed, superbly, and we have to be grateful for that. But I'd like to see a cure and for me a cure would mean that I could stop counting carbs, stop testing blood sugar and have the same rock solid normal blood sugars a normal person would have.

The drug companies are not working on cures, because if you were cured you wouldn't need to buy $400 dollars worth of their drugs every month. Their drugs provide only control, and not very good control at that. Until we start funding research that is not undertaking to fatten someone's bottom line things are going to stay that way. Why kill the golden goose?

Drug companies sell doctors (and the public) the idea that their drugs do reverse diabetes. The media tell the public people with diabetes could prevent their condition and save the public a ton of money with a few "simple lifestyle changes."
Don't be taken in. We need cures and true reversal of diabetes and the first step to get there is for society to get out of denial.

The only way we will prevent diabetes is to eliminate the toxic pesticides and other pollutants that flow through our blood streams and modify the brains and pancreases of our fetuses. We need to stop prescribing SSRI drugs that modify blood sugar metabolism to every teenager who breaks up with their boyfriend. We need to realize that plastics are bioactive and get them out of our food supply--and our blood streams. We need to demand that fast food outlets take the MSG, transfat and high fructose corn syrup out of their offerings.

Once people have diabetes, we need to stop blaming them for it, and put some public money into looking for interventions that will really cure them, not just control them.

Will any of this happen? Not likely. Too many people make money from poisoning our environment and selling us bio-destructive products. But that is what we need.

UPDATE August 19, 2009: A day after I published this post, Scott Strumello drew my attention to this incredibly exciting piece of news:

Exsulin Corporation Announces Publication Of Phase 2 Trial Results For Novel Islet Regeneration Treatment In Type 1 & Type 2 Diabetes

I've been hearing about INGAP almost as long as I have been following diabetes. This INGAP trial (the drug has been renamed) involves a peptide that appears to actually regenerate islet cells in both Type 1 and Type 2 diabetes. Most importantly, the increased C-peptide values remained "after washout" i.e. after the drug was discontinued.

The company behind INGAP has had a lot of trouble getting funding over the years, probably because a cure would rob big pharma of its chronic disease cash cows.

Let's pray that the next stage of testing of this drug finds it is safe and that some company that cares more about your health than its profits will get behind it.

 

9 comments:

chmeee said...

Hi Jenny

An interesting and informative essay as always, but a few points spring to mind and I’m sorry if this is a little long ! :)

It is inconsistent to accept the normal criteria for diagnosing diabetes and then, if someone no longer meets them, to somewhat arbitrarily impose your own and deny that a person no longer has diabetes.

Two years ago I was given the usual tests and diagnosed with type 2. Six months ago, at my doctor’s instigation, they were repeated, and he said said I no longer had type 2. My medical notes / history now reflect this. To put it another way, there is no objective test I am aware of that you, or indeed anyone, could do, that would say I have diabetes. Could I now ‘stuff my face with cake’ ad infinitum as a ‘normal ‘person – whatever that is ! – could supposedly do ? I have no idea, and it is not something I have any desire whatsoever to determine. I will say that while experimenting with my diet and what worked best for me I did have a period of several months where I ate porridge for breakfast yet maintained completely normal blood sugars. But I prefer bacon, egg and tomatoes, as I then don’t feel hungry before lunch time. Could I eat a pizza or some cake and be ok ? Yes; I have and sometimes do.My regular holidays in Italy also test this hypothesis.

Nor do I ‘overwork myself at the gym’ – I’m far too lazy and with two young children simply do not have the time. I average two and a half hours of exercise, typically running, a week. Though I do get my heart rate up to between 80% and 90% of maximum for me whilst doing it Nor does my weight change, and I have no difficulty in sticking to my diet. Would Richard Bernstein describe it as low carb ? No – but then, it probably could not be described as high carb either ! It works for me……. What is normal ? Well, one definition might be that which is the norm for someone. Certainly, I have a life style I feel confident that I can maintain; it is not – for me – difficult. I feel much better exercising as I now do and eating eating fewer carbs than I used to. BTW, when diagnosed I was not obese – BMI 25 – but I know I didn’t follow the general recommendations for exercise each week; I was a lazy slob, to put it mildly.


Why is all this important ? In denying that normality is possible you rob people of hope – see for example the ADA and DUK websites with their talk of the inevitable, progressive nature of diabetes.

Two other points on this:

There is a world of difference between telling an individual that they no longer have diabetes and telling them that they have good control. I know – from personal experience - which I prefer and which has the greater impact on my general well-being.

From a purely practical perspective, I can now, for example, get life insurance if I wish. I would no longer have to tick the ‘Yes’ box if asked whether I have diabetes – which would mean the application would either be declined or I would be quoted a ridiculous premium. No point to ‘reversal’ ?

I am not sure why I got it. I most certainly do not blame myself totally. Was it due to toxins in the environment? I have no idea, but if you believe this is so, then it is surely incumbent on you to explain the mechanism. What intrigues me is why, despite being exposed to the same environment, most people nonetheless do NOT get diabetes. Saying it is genetic is a cop out. Which genes ? What is the mechanism by which this works ? I also agree with you on the weight issue. Why is it that most people who are overweight do not get diabetes ? I could go on……

Finally, please do not take this as a personal attack. In the early days, I found your web site, devoured it, and put the information on it to good use. To say it was inspirational is an understatement and I am very grateful for the advice you gave. I may not always agree with you, but keep posting, good luck and my best wishes to you. Thank you.

trinkwasser said...

"Cure" and "reverse" are such weasel words. Over the years I've read of hundreds if not thousands of people who like me have largely normalised their BG, BP and lipids. But I only have to eat one of my aunt's chocolate cakes to know I am NOT cured and never will be, I'm just well controlled.

I do believe it is possible to improve insulin resistance on a long term if not permanent basis, which may give the illusion of a "cure" by making your insulin output go further, but nothing can replace that insulin output when it goes short.

Experimenting shows that I can wreck my IR on a temporary basis simply by spiking my BG. Part of the reversal may come from not doing that but most of it comes from not eating Healthy Whole Grains and other starches, fructose, Omega 6s, you know, all the things dieticians tell you to eat more of, and replacing them with saturated fats and other real foods: if trigs/HDL ratio is an indicator of IR then mine is around 1/15 of what it was. But that doesn't make my nonexistent Phase 1 insulin miraculously reappear.

Whether INGAP will achieve this remains to be seen. Probably not in my lifetime . . .

Jenny said...

Trinkwasser,

Scott Strumello posted elsewhere that the INGAP treatment is likely to cost something like $10,000 a whack and take multiple treatments. This makes it less likely most of us "high functioning" non-Type 1s will have access to it.

Except for the Bond Traders.

trinkwasser said...

Oh BTDT, can't get test strips and now my access to A1c is being limited to "save" money, which is then spent on statins. Rumour is that test strips will be denied to ALL Type 2s in forthcoming "updates" to treatment protocols so my lucky colleagues elsewhere who still get them will end up in the same boat, so I can't see this being Approved on the NHS. And the people who make such decisions all have private health insurance.

It just cost me a dollar to find out I was 110 after my lunch, IMO money well spent.

Of course at this price point there will be no access to INGAP in the (other) Third World countries where diabetes is running rampant, and in many of them test strips are also too expensive, we were discussing elsewhere how to modify diets in Malaysia at no cost to the sufferers.

Bast said...

I was diagnosed as pre-diabetic in 2003 and type 2 in 2004. I weighed 355lbs and was prescribed metformin 500mg 2x a day. It did nothing.

In 2007 I started exercising regularly and following the ADA exchange diet and lost 120lbs. At the start of my diet change and exercise my A1Cs were 6.0 and fasting sugars 100.

It's been three years now and my levels have always been good. Last June I took it upon myself to lower my dose from 1000mg to 500mg once a day and nothing changed. My levels have still been excellent.

I've noticed that ever since I started controlling my diabetes that my sugar never soars it drops. I eat all sort of foods and carbs just not at the same meal.

I'm wondering if it is possible for me to stop taking metformin when I reach my goal weight.

Jenny said...

Metformin is a drug that it won't hurt you to stop. It doesn't cause rebounds or other problems.

So you can stop and see what happens. Just be vigilant about weighing and if you see the weight going up, go back on it sooner rather than later.

It's much tougher to lose the second time than the first for many of us, so you don't want to think, "I lost a lot of weight before, so I can do it again, sometime."

Debstarock said...

June 4th 2010
I was diagnosed with Type 2 Diabetes April 23rd 2010. I am 46 years old. No diabetes I can find within family but had Gestational with both my pregnancies. Youngest child being 8. My doctor perscribed me Diabex and told me to go about my day but watch what I eat. He also told me not to rush out and buy a BSL monitor - which I did! My hubby and I also went home and emptied the pantry and fridge of food that would still be OK to eat after months of storage! I took the tablets for 4 days and felt dizzy and my vision was suffering from the the side effects. I threw them in the bin and decided I can do this on my own and fortunately I was in the position where I could. 7 weeks later I have lost 10 KG's and am now 69KG's. My blood sugars are VERY much in control. Saying that I am like a dog with a bone and was VERY scared. If I stick to this I know I will be doing the best thing I can for myself and not get cocky and think it is ok to revert back to my old food habits which were poor for the condition that I have. I feel 20 years younger and would recommend this to not just diabetics but EVERYONE. It's like putting a GOOD quality oil into your motor instead of one much less refined. If you want a copy of what I eat please email me on
debsta6@bigpond.net.au
I would love to share it with you :) Life is great and I look HOT now too :) I now know it is not something to be afraid of but to get control of and then you are a winner. :)

coolghoul said...

Thank you for providing such a frank and honest appraisal.

I plan to manage and control my diabetes - and remain cognizant that failing to do so will certainly result in further complications.

Walker said...

I am dissappointed that everyone keeps banging on about some multinational pharmaceutical conspiracy to keep us all on bad drugs that are designed NOT to cure us, because "they" don't want to ruin their market. Do you realise what codswhallop that is. The Pharma industry are desperate to find the next blockbuster, cos it will make them money. If they can really find a drug that cures diabetes (type 1 or 2), heart disease, asthma etc...they would.. in a flash! Trouble is, such drugs will all be recombinant type proteins and MABs, which costs a fortune to develop, produce and register..hence they all cost £10K+ a year, if they ever get to market..and no one can afford it...well a few, but not those who really need it.
So stop blaming all your woes on the evil drug industry...if it wasn't for the GSKs, Pfizers, Abbotts et al...we'd be dying in our millions by the common killers of yester-year. Drug companies need to be incentivised to find new drugs...just like YOU need to be incentivised to go out to work. If all we do is let factories in India pump out generic copies that deny big pharma of their revenue streams, which they use for more research (and salaries OMG!)...we'll just end up with a stalled drug development programme. OK, not all drugs will change mankind for ever...some are just "me too's"...and that's why we rely on doctors, the gatekeepers with a decade of intensive training, to make informed decisions on what to use. If they are so easily manipulated by 25 year old drug reps to Rx rubbish...then that's their problem...and they should be struck off for malpractice.
But mostly, they do make good decisions for us....mostly...which is why we're living longer now...so more us us are getting ill from diseases of middle age.
So get a grip...pharma Cos are not the enemy - Modern, longer lives are the issue...and how we manage this growing "problem".
J. Walker

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