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Sunday, July 3, 2011

The Diabetes "Crash" Cure Revisited

I think there were some issues brought up in the comments of my original offering on this topic to warrant a followup post.

OnePointFive made the following remarks (excerpts) I'd like to address:
I thought that the trial was interesting and that'more research is needed' but with so few subjects and only a 12 week follow up (in the paper) didn't justify the 'cure' headlines.
I agree, I think the word *cure* subsequently splashed across headlines is a bit of an overstatement.  Even in the short follow-up period, 3/11 had their diabetes return.   So even though all were theoretically "cured" at 2 months, this was not permanent once they reverted to a normal diet.   Since the average gain was just over 3kg or almost 7 lbs, it would be interesting to see the individual data, and if the three who reverted back were the ones who gained the most due to returning more full bore to their former habits.  My gut says probably!  


However quite often the measures of diabetes are FBG, HbA1c and fasting lipid levels.  Dr. Eric Westman would appear to not want to diabetes status using an oral glucose tolerance test, knowing that low carbers will fare poorly by this measure.  And therein lies the crux of the matter.  This study measured pancreatic function and tissue responsiveness to a glucose challenge and, apparently, all 11 were cured.  That the cure didn't stick  in some, or was only demonstrated to stick for a short time in this study, is likely due changes in diet during the follow-up period back to the previous habits that caused pancreatic fat to revert to previous levels (or above some individual threshold).  Again, the individual data would be nice here, as my gut tells me the three reverters gained the most and/or put more fat into their pancreata than the others.

It's like saying Insert Effective Antibiotic Here is not a cure for Insert Infectious Disease Here because the infection returns in those who don't take their full course of antibiotics, when virtually 100% of infected people are infection free after taking the appropriate course.  Not a perfect analogy but ...

OnePointFive said:
As you can imagine, these dramatic headlines has resulted in numbers of people who are determined to try this for themselves.   You can't buy optifast without prescription in the UK so it's already become a question of where to source the product elsewhere. 
Since before Oprah wiggled into her size 10 Calvins on a liquid diet, folks have been trying extreme approaches like this and tried "do it yourself" alternatives for such diets that can be obtained without medical supervision.  I guess what I'm getting at here, is that the researchers demonstrated a successful approach.  Unfortunately they cannot really control what is made of it in the headlines or how -- often desperate people -- will respond.  We spend an inordinate amount of money subsidizing smoking cessation programs and such here in the US, etc.   Perhaps the government can play a role in helping those who need access to such a program, said access, so that they won't resort to more dangerous DIY efforts.
OPF:  I'm concerned that many won't be able to sustain the diet without the support offered in the trial and thus feel a failure and that others will persevere yet not have the desired resuts. How will they feel then ?
No better or worse than if other strategies fail them? Again ... the expectations would have to be managed by those actually promoting programs based on this research.  If I were going to try this, I'd summon as much support as I could muster.  Which brings me for a bit to the comments made by another person going by the name perishedcore.  Perished "mused" over such a potential program:
I wonder what would happen if those folks spent time sequestered in a hotel/dorm setting and the experiment over the 8 weeks did this:
1st week: all meals are prepared for subjects.  Subjects have a structured curriculum and practice food shopping, food, storage, food prep and cooking for paleo-ish/med type diet w/ cals aimed at target weights (the usual no refined and highly processed foods, no seed oils, no added sugar, gluten free, ec). Subject also have seminars in increasing activity per their individual needs, time to exercise under phys tx supervision and coaching, cooking classes, health classes, etc.
Weeks two through six they do the same, and the last two weeks, they follow the diet on their own at home but meet in the groups for the classes and coaching. Have the diets customized to be aimed at permanent adherance instead of the extremem cal. restriction. Do the lab measures at 1, 8, 16 and 26 weeks out.
No doubt the ultimate success of ANY dietary approach is long term compliance.  Obviously 600 cal/day is not a long term strategy, but transitional counseling, etc. and all the same strategies employed by Jenny (counselors), WW (group meetings) etc.etc. are just as appropriate here.  In the end, most dietary strategies for controlling diabetes (and we'll leave the management vs. cure semantics aside for this statement) boil down to compliance and CHANGE in lifestyle/habits.  Just as weight loss and maintenance does.  It doesn't make a person a bad person if they fail, but it also doesn't invalidate an approach as a possible cure just because it is difficult to adhere to.  Many a person has refused treatments that might improve one part of their lives/health because "side effects" are sacrifices they're not willing to make.  Perished, maybe we should open up a clinic :-)  Indeed of the original recruits, 2 failed to complete the 8 week initial phase and aren't included in the final analysis.

Back to OPF for one last quote:
I know of one who wants to try who has been T2 for many years, has gone through the whole gamut of medication,takes basal insulin and is still obese despite a low carb diet. At the opposite end of the spectrum I know of another, relatively recently diagosed with a BM1 of 24. Neither would have been eliglble to be a subject in the trial.
One seemingly unnoticed aspect of this study was that none of the participants took any diabetes meds during the course of the study.   Here was the in/exclusion criteria:


  • diabetes duration <4 years
  • stable BMI 25–45 kg/m2
  • excluded if being treated with thiazolidinediones (e.g. Actos, Avandia), insulin, steroids or beta-blockers, with a serum creatinine >150 mmol/l, with a serum alanine transaminase level >2.5-fold above the upper limit of the reference range,
  • or if there were contraindications for MRI. 
Of those included two taking sulfonylurea discontinued that 2 months in advance of the study, and the seven taking metformin discontinued use one week prior to the study.  Unlike many other studies where part of the success is measured by the percentage of participants able to reduce or eliminate medications entirely, those "cured" in this study were "full blown" in their diabetes to start, and whatever the end result it was not pharmaceutically influenced.  Oh ... except the study authors are a bit lipophobic because they allowed statins to continue ... sigh.


My guess on the thiaz's is that these might impact pancreatic cells directly at an intracellular level.  The discontinuation of sulfonylureas and metformin in the times would presumably be in order to return them to baseline.  Regardless of the time since diagnosis, progression to insulin dependence of any sort indicates a more advanced point in the progression.  It's my understanding that although the need for insulin is a rather high percentage over time, we're talking a decade or more.   I'm really not sure about the 25 BMI cut-off, but I guess this was their way to compare to the candidates for bariatric surgery.  

In any case, I don't think this exclusion from a study would in any way preclude your friends from trying this.  

Diabetes Boot Camp anyone?  I'd give it a try were I diagnosed.  Perhaps the rather rapid actual reversion to NON-diabetic is enough of a motivation for at least some to find a way to maintain the state.  This study at least gives some hope that it can be done, in short order.  But it's no panacea.

7 comments:

bentleyj74 said...

I had an interesting thought reading this.

Might be totally off track but in reading the suggestion to life train people to know how to manage basic self care it just popped into my head that the obesity boom doesn't ONLY correlate to increased carbs and snack foods it also correlates to mom and dad both work all day with few or no older siblings/grandparents running the show in their stead.

I wonder if a fair amount of the people who can't manage their "minutes" in order to structure a day of proper eating and sleeping and moving...I wonder if they have no real ability to perceive what "normal" looks like in practice?

What if they have gotten through a large portion of their lives not making any choices for themselves?

Schools tell you when to show up then move you through your day including a cafeteria line but the way that a student moves through a day is totally out of touch with how an adult does.

What if the appeal of fast food is that it closely approximates their conditioning and the only choice they have to make is whether they want combo number 1 or 2?

blipton said...

How long is the starvation / fasting supposed to last.. and has there been any study that shows the results FAR after a normal diet resumes?


BTW, is the Restriction Addiction ebook available yet?

LWC said...

I can answer a couple of these questions, if I may:
In papers and lectures, Dr Roy Taylor says the diet treatment (liquid shakes + vegetables for 600-800 calories) lasts 8 weeks. Glucose production returns to normal within the first week and normal pancreatic function resumes by the end of the 8 week period.


His Newcastle group is enrolling people now in a long term (two year duration) study to look at what happens after a normal diet resumes vs a control group which will follow the standard (UK) diabetic protocol.

carbsane said...

Thanks! I think it was heartening to note that even though some regained some weight, the glucose tolerance remained. By heartening, I mean that this is added evidence for the visceral/hepatic/pancreatic fat is the last to accumulate and first to go away model. I know (private communications) of various work in progress involving fasting and such, and it would seem to me that any number of strategies could be employed to retain the "cure" depending on the individual.


Some may do well with a regimented, same thing every day, kind of plan, but many of these backloading, side loading, free meal, IF, whatever plans really are different means to the same end. How about one fast day a week? Two 1000 cal deficit days per week? Things like that.

carbsane said...

To be honest, I'm not making any "plans" public until end of May. Too busy with real life work and family stuff, and trying to put out new material here and there. Hopefully this summer, some version of the book gets back out there.

LWC said...

In his Diabetes Summit presentation, Taylor was careful to say that it was important not to return to the eating pattern that caused the problem in the first place. But your further comments are very interesting. They suggest that Moseley's 5:2 diet (not really fasting, but kinda) could be applied? (I have personal interest here, hence the question).


I read Yoni Freedhoff's dismissal (again) of the Newcastle's groups "advance," but I disagree. Sure, slow and steady weight loss might get you to the same point-- but slow and steady hasn't proved doable for most, else fad diets wouldn't be flourishing. Taylor's intervention offers the prospect of short term, predefined "pain" for big time gains. I'm no medical practitioner, so this speculation is worth every penny you paid to read it, but quick, substantial (off the drugs?!?) results hold more appeal to those who would rather not change ANYthing (again speaking from experience). Especially if 8 weeks of pain can be maintained with 2 days of (wife enforced) calorie deficit (5:2).


Doing the 5:2 seems to have established stasis here (on the hairy edge of any number of diagnosis) fwiw.

carbsane said...

I like Yoni, but I think that he's let some of the "grind" of essentially being an obesity doctor get to him a bit on this. I just re-read his piece and my own original offering, and I should likely edit that. I was more agreeing with his protestations that diet and lifestyle ARE first line and "proven" methods of treatment for T2 (vs. Wheat Belly's take). But I'm kind of puzzled by his saying that he was puzzled by Taylor's assertion vis a vis diabetes being incurable and progressive. The insurance companies treat it that way and it seems that pharmaceutical treatment doesn't seem to stop the progression of the disease. There are also many doctors, not just the armchair physicians and such out there, who believe that beta cell destruction has already occurred once you're diabetic and the best you can do from now on is pamper the ones you have left.

I see this as all the more reason for drastic intervention as soon as possible. I am NO fan of crash diets for weight loss sake alone. This is a different matter entirely, and I think the rapid loss may well be "different" than the slow and steady. It seems to drain the swamp as I like to put it, and with proper insulin secretion the fat tissue is able to handle the load again.

I agree with your thought process. If you've got a goal -- and I'd say reversing diabetes is HUGE -- and a relatively short "pain" to power on through, go for it. Taylor's literature clearly states it's not for everyone and if it triggers someone, well then, don't try it.

I'm quite puzzled as well with what I see as kneejerk backlash to ANY mention of fasting as a strategy. And, as you say, 5:2 is not even a full fast. I've yet to see anything in the literature that would indicate this is potentially harmful as you're well short of any sort of adaptation. I'd certainly give it a try.

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