Remissions are possible
Weight-loss powders, so-called formula diets, help reduce weight quickly. Clinical studies have shown that these can be used successfully with type 2 diabetes and that the symptoms can even disappear permanently. In such cases, the medical profession talks of clinical remission.
Sir Muir Gray, a very eminent physician in the UK, is calling for classifying type 2 diabetes as ‘a walking deficiency syndrome’ and then treating it causally. In a nutshell: the patient must change his or her lifestyle.
Before it became possible to treat diabetes with insulin, Elliott P. Joslin, an American doctor who specialised in this illness, and incidentally after whom the famous Joslin Diabetes Center in Boston, Massachusetts, is named, ordered his patients to adhere to a rigorous diet programme. It comprised amongst other things two per cent carbohydrates and 75 per cent fat.1 Even as recently as the 1970s it was prominently publicised that one could even achieve diabetes remissions with such a diet.2
A similar approach was adopted when people with deregulated type 2 diabetes were still being treated as inpatients. The patients often received a diet of 1000 kcal, and one got them to participate daily in an exercise programme. They could be released after 14 days with less prescribed medication or smaller insulin dosages, but with better blood glucose levels.
The ‘achievements’ of pharmacology have let us forget that type 2 diabetes can also be treated without medication. However, a prerequisite for this is that the patient and the treatment team are willing to adopt a drug-free approach. Even then, implementing this as part of the daily routine presents a problem. Despite intensive diabetes training and nutrition counselling, not all patients are sufficiently aware of what healthy eating means and which food items are suitable. However, with the help of formula diets in combination with blood glucose monitoring, one can give them a tool with which they can reduce their calorie intake, at least in the short term.
Formula diets should only be used for a limited period and gradually replaced by meals. During the transition period, patients should determine their blood glucose levels before and after ‘normal’ meals. Usually they will then see a favourable development in their blood glucose levels with a diet that is rich in proteins and low in carbohydrates.
Study with type 2 diabetes test persons
There is a whole range of very good clinical studies that demonstrate the favourable effect of formula diets on type 2 diabetes.3 The subject was covered as recently as April 2016 in an article published in the New York Times4 that outlined the results of a British group working at Newcastle University in England. The group considered whether a formula diet could not only normalise the insulin resistance but also the β-cell function. For this, eleven people with type 2 diabetes were treated with a formula diet for eight weeks. The test persons were examined intensively before the start of the survey and then after one, four and finally eight weeks. The control group comprised eight people without diabetes. Age, sex and weight corresponded to that of the intervention group. The members of the control group were not treated and were also only examined once.
The fasting blood-glucose levels of those in the intervention group had already normalised from about 9.2 to about 5.9 mmol/l after a week of calorie reduction, so that there was even talk of a diabetes remission. Whereas basal insulin production fell, there was an increase in the stimulated insulin response like that in the control group. After eight weeks, the maximum insulin response even exceeded the respective values from the healthy control group.
Another study5 confirmed that after about seven days there was improved insulin secretion after a meal. Here, too, a formula diet was used. In a follow-up study6 involving 29 persons with type 2 diabetes, 15 of them achieved the same result. After eight weeks, 87 per cent of the persons who had had diabetes for a short time and 50 per cent of those who had had it for a long time exhibited non-diabetic fasting blood-glucose levels.
Lasting remission possible
A further investigation7 compared responders and non-responders. Responders were defined as those persons whose fasting blood-glucose level continued to remain under seven mmol/l after changing over to an isocaloric diet. In the whole group there was a reduction in the average body weight from almost 100 to 85 kilograms. The test persons could maintain their weight for six months. Of the 30 participants, twelve could be identified as responders. A further person joined them after six months. The scientists concluded that a formula diet could result in sustainable remission and that type 2 diabetes is possibly a reversible disease if there is significant weight loss and the duration of the diabetes is less than four years.
Formula diet as therapy
The therapeutical potential of a formula diet was demonstrated by a twelve-week investigation8 of 22 overweight persons with type 2 diabetes who were initially each injecting more than 100 units of insulin daily. During the first week of the study, the test persons had a formula diet for all three meals. This was low in carbohydrates and rich in proteins; the total energy intake was 1200 kcal a day. During the following three weeks they replaced two meals with formula diets, but their midday meal was low in carbohydrates and rich in protein. During the weeks five to twelve only the evening meal consisted of a synthetic diet. Within a few days, the test persons’ daily average insulin requirement had already fallen from 147 insulin units (U) to 91 U. After 12 weeks, it was only 65 U. At the same time, there was a significant reduction in the long-term blood glucose level HbA1c and bodyweight.
After one and a half years, both the test persons’ daily insulin requirement and bodyweight was still significantly lower than at the beginning of the study. Those participants who continued to use the meal replacement after the end of the trial were able to reduce their long-term blood glucose, HbA1c, their weight and their insulin requirement still further. Two participants ultimately stopped their insulin therapy completely.
Further investigations have shown that – regardless of the duration of the diabetes – a clinical remission can be achieved using a structured formula-diet program.9 While formula diets tend to be viewed critically in diabetology, the successes of metabolic surgery are acclaimed as an innovation by the medical profession, and their rapid effect is attributed to the therapy-related calorie reduction. Three recent studies10 that compared the short-term effects of a low-caloric formula diet and bariatric surgery (Roux-en-Y bypass surgery) on the diabolic metabolism came to the same conclusion.
Create new structures
Type 2 diabetes should be scrutinised critically, namely in the sense of Sir Muir Gray. The conclusion that it is a disease like rheumatoid arthritis would only lead to the major portion of those affected being treated at first with up to four types of diabetes medication but ultimately and soon – like in America – to insulin doses of up to 500 U a day.
If, however, we classify type 2 diabetes as a ‘a walking deficiency syndrome’, we must establish structures in our health-care system that support doctors to achieve a permanent change in their patients’ lifestyles. The temporary use of formula diets is a motivation for those affected, but it is nevertheless essential to give them guidance with respect to healthier eating.
What this means in practice
- Above all, if the duration of the diabetes is short, a type 2 diabetes patient can be treated very well without medication.
- By means of a strict diet, it is even possible to achieve diabetes remissions.
- The use of a formula diet is impressive, with a rapid effect on the patient’s metabolic state and weight.
- The short-term use of formula diets is intended to act as a motivation for patients and is just as helpful in directing them towards a healthier diet.
- In the health-care system, structures must be created that help doctors and patients bring about a lifestyle change.
1 Westman EC, Yancy WS Jr, Humphreys M (2006): Dietary treatment of diabetes mellitus in the pre-insulin era (1914–1922). Perspect Biol Med 49:77–83.
2 Genuth SM (1977): Insulin secretion in obesity and diabetes:an illustrative case. Ann Intern Med 87(6):714–716.
3 Henry RR, Wiest-Kent TA, Scheaffer L, Kolterman OG, Olefsky JM (1986): Metabolic consequences of very-low-calorie diet therapy in obese non-insulin-dependent diabetic and nondiabetic subjects. Diabetes 35:155–164.
Amatruda JM, Richeson JF, Welle SL, Brodows RG, Lockwood DH (1988): The safety and efficacy of a controlled low-energy (‘very-low-calorie’) diet in the treatment of non-insulin-dependent diabetes and obesity. Arch Intern Med148:873–877 6. Rotella CM, Cresci B, Mannucci E, Rizzello SM, Colzi G, Galli G, Giannini S, Messeri G, Piani F, Vannini R (1994): Short cycles of very low calorie diet in the therapy of obese type II diabetes mellitus. J Endocrinol Inves 17 (3):171–179.
Wing RR, Marcus MD, Salata R, Epstein LH, Miaskiewicz S, Blair EH (1991) Effects of a very low-calorie diet on long-term glycemic control in obese type 2 diabetic subjects. Arch Intern Med 151:1334–1340.
Dhindsa P, Scott AR, Donnelly R (2003): Metabolic and cardiovascular effects of very-low-calorie diet therapy in obese patients with Type 2 diabetes in secondary failure: outcomes after 1 year. Diabet Med 20 (4):319–324.
Jazet IM, de Craen AJ, van Schie EM, Meinders AE (2007): Sustained beneficial metabolic effects 18 months after a 30-day very low calorie diet in severely obese, insulin-treated patients with type 2 diabetes. Diabetes ResClinPract 77 (1):70–76.
4 Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R (2011): Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 54:2506–2514.
5 Malandrucco I, Pasqualetti P, Giordani I, Manfellotto D, De Marco F, Alegiani F, Sidoti AM, Picconi F, Di Flaviani A, Frajese G, Bonadonna RC, Frontoni S (2012): Very-low-calorie diet: a quick therapeutic tool to improve β cell function in morbidly obese patients with type 2 diabetes. Am J Clin Nutr 95:609–613.
6 Steven S, Taylor R (2015): Restoring normoglycaemiaby use of a very low calorie diet in long and short-duration Type 2 diabetes. Diabet Med 32(9):1149–1155.
7 Steven S, Hollingsworth KG, Al-Mrabeh A, Avery L, Aribisala B, Caslake M, Taylor R (2016): Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes Care 39:808–815.
8 Kempf K, Schloot NC, Gärtner B, Keil R, Martin S (2014): Protein-rich meal replacement significantly reduces insulin demand, HbA1c and weight long-term in type 2 diabetes mellitus patients with > 100U insulin/day. J Hum Nutr Diet 27 (Suppl 2):21–27.
9 Martin S, Kempf K (2014): Einsatz von Formuladiät als Basistherapie bei Typ-2-Diabetes. Dtsch Med Wochenschr 139 (21):1106–1108.
10 Jackness C, Karmally W, Febres G, Conwell IM, Ahmed L, Bessler M, McMahon DJ, Korner J (2013): Very low-calorie diet mimics the early beneficial effect of roux-en-Y gastric bypass on insulin sensitivity and β-cell function in type 2 diabetic patients. Diabetes 62:3027–3032.
Lingvay I, Guth E, Islam A, Livingston E (2013): Rapid improvement in diabetes after gastric bypass surgery: is it the diet or surgery? Diabetes Care 36:2741–2747.
Lips MA, de Groot GH, van Klinken JB, Aarts E, Berends FJ, Janssen IM, Van Ramshorst B, Van Wagensveld BA, Swank DJ, Van Dielen F, Willems van Dijk K, Pijl H (2013): Calorie Restriction is a Major Determinant of the Short-Term Metabolic Effects of Gastric Bypass Surgery in Obese Type 2 Diabetic Patients. Clin Endocrinol (Oxf). doi:10.1111/cen. 12254.