las

Welcome all seeking refuge from low carb dogma!

“To kill an error is as good a service as, and sometimes even better than, the establishing of a new truth or fact”
~ Charles Darwin (it's evolutionary baybeee!)

Saturday, September 29, 2012

Dysregulation of Glucose Handling: Underlying Defect, Permanent Damage or Fixable Milieu?

How many times have you heard some version of the following?
  • Sure starches are OK for 20-something CrossFitters
  • My body just can't tolerate carbohydrates
  • If I hadn't damaged my metabolism, maybe I could eat carbs now, but I can't
  • I used up my carb allotment as a kid so I can't eat them now (I blew out my pancreas)
  • Type II diabetes is a disease of carbohydrate intolerance
The list could go on.


When the topic of "safe starches" comes up on LC blogs or discussion forums, there's only betting on how many comments of the "I couldn't eat a half a potato, my BG would go through the roof" variety will be generated, not whether or not such comments will be made at all.  What is disturbing about this is the proportion of these comments that comes from NON-diabetics, many of whom seem to have been convinced that a normal glucose spike is abnormal, and that it is going to turn them diabetic any day now.  Many of the pre-diabetic or diabetics remain convinced that they've exhausted their pancreas with all that carb eating throughout their lives.  While there is a lot of confusion (I would perhaps call it controversy, but not contention) about this in the scientific community, but even those (researchers in the field)  who seem to favor carbohydrate restriction for the treatment of diabetes do not seem to blame carbs for the development of the disease.

Type 2 diabetes is clearly a progressive in nature, and yet there almost seems to be a regulatory switch that flips when someone goes from a little outta-whack to frank diabetic.  And yet, it remains unclear that it is necessarily a degenerative disease.  That current treatments generally do not seem to forestall the deterioration of pancreatic function is largely responsible for the "conventional wisdom" that T2 is an irreversible condition only to be managed to slow progression to insulin dependence.  For all the knocking of science and scientists going on out there, some rather amazing progress is being made elucidating the causes of diabetes.  Part of the problem as I see it, is there's more than one underlying cause for the collection of syndromes involving hyperglycemia.   You often have misdiagnosed 1.5's in the mix of study subjects  For the rest of this post realize I'm talking about the classic T2 -- that associated with obesity.

As I've blogged on here quite a few times before, there are these nagging "isolated" cases in the scientific literature where some even rather long-standing cases of diabetes have been rapidly reversed.  These include that crash diet study,  several studies on gastric bypass surgery in diabetics, and early insulin therapy (there are also cases of vagus nerve severance I've not addressed here).  In each of these cases, normal pancreatic function and response to the endogenously produced insulin has been restored in relatively short order -- from days to several weeks.  And here we are talking some of the most "metabolically deranged" on the glucose tolerance spectrum.

Now one could argue that there is recidivism -- many do relapse to diabetic -- though I think the rates of long term diabetes remission are rather impressive in many of these cases.   But here's the thing:
A Type 1 diabetic never has a single day of normal glucose homeostasis ... no matter the diet.  They have a permanent inherent defect (e.g. islets that don't produce insulin).
Just one single day of normal glucose homeostasis in a T2 diabetic is the proverbial black swan.  
Especially when we're talking such short time periods to achieve it.  This black swan argues against many of the theories as to what causes diabetes or what's going on metabolically in those who have it.   This is not to say there's not some predisposing genetic/physiologic make-up -- there are too many familial-linked inherent differences in various metabolic functions to discount this.  But whatever these mechanisms are, they just seem to work to flip the switch sooner towards dysregulation ... but there's a lot of evidence that the switch can be flipped back.  

Therefore looking at T2 as a progressive disease involving permanent degeneration is probably one of the more misguided general opinion in medicine.  Here is where the Vernons (LC, animal-based diet) and Fuhrmans (HC, plant-based diet) of the world seem to be on the same side but they aren't really.  The LC diabetes folks seem to collectively believe in a permanent glucose intolerance -- one that can be treated/managed by severely limiting dietary glucose, but that remains inherent in one's constitution.  Dr. Wheat Belly Davis describes his own diabetes only as in remission.  But folks like Fuhrman openly express their belief that diabetes can be reversed, not simply managed.   Unless one questions the success stories of Fuhrman (and they are subject to the same scrutiny as all success story reports, so may well be exaggerated), he has had patients reverse their diabetes.  And how do they know?  Well, they eat carbs and have NGT (normal glucose tolerance).

In both the crash diet study, blogged on here, here and here, and the early insulin therapy study, the subjects were given nutritional counseling and returned to a "normal" diet, albeit probably more aligned with the current wisdom in the EIT study.  Indeed in the crash diet study many participants even regained weight yet remained diabetes free by OGTT.  If memory serves, one participant in that crash study interviewed in the press remained diabetes free a year after the study, and his diabetes diagnosis had been several years prior.

So, Dysregulation of Glucose Handling:

  • Underlying Defect?   Sure, in T1's and 1.5's there is a manifest defect in pancreatic function.  In T2's?  Clearly there are some underlying predispositions, but also, clearly, these predispositions do not necessarily manifest in diabetes, nor are they irreversible.  If there was some sort of pre-existing glucose intolerance, then perhaps 1 in 100 might be able to see reversal, however temporary, from any of the aforementioned interventioned.  That we see significant, often majority responses argues heavily against the defect being an underlying one.  
  • Permanent Damage?  Again, that we can see rapid reversals in so many argues strongly against this being the case either from overuse of the pancreas or from glucotoxicity.  Which is not to say that some physiological damage/deterioration may not have already occurred that may impact health, but whatever causes the impaired glucose metabolism appears to not be permanent absent beta-cell destruction.
  •  or Fixable Milieu?  I'll go a step further than fixable milieu for those who have never been diabetic.  For these people, it is far more likely than not that there is nothing wrong with their metabolisms at all other than mistaking normalcy for "everybody is a diabetic" memes.   Even for many diabetics, it most certainly seems fixable.   There certainly seems to be more evidence to support reversibility than not.  More, rather than fewer, can probably not only handle, but likely even thrive on diets with moderate and even high carbohydrate content (context dependent) once they have fixed their metabolisms.
In coming weeks I plan to address blood glucose levels, glycation and other things that I feel have often been misrepresented in the low carb community.


5 comments:

Charles Grashow said...

http://www.diabetologia-journal.org/Lim.pdf

Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol

"Conclusions/interpretation Normalisation of both beta cell function and hepatic insulin sensitivity in type 2 diabetes was achieved by dietary energy restriction alone. This was
associated with decreased pancreatic and liver triacylglycerol stores. The abnormalities underlying type 2 diabetes are reversible by reducing dietary energy intake."

http://www.bbc.co.uk/news/health-13887909

"The 11 participants in the study were all diagnosed with Type 2 diabetes within the previous four years.

They cut their food intake drastically for two months, eating only liquid diet drinks and non-starchy vegetables.

Fat loss
After one week of the diet, researchers found that the pre-breakfast blood sugar levels of all participants had returned to normal.

MRI scans of their pancreases also revealed that the fat levels in the organ had decreased from around 8% - an elevated level - to a more normal 6%.

Three months after the end of the diet, when participants had returned to eating normally and received advice on healthy eating and portion size, most no longer suffered from the condition."

http://pediatrics.aappublications.org/content/123/1/214.full

Reversal of Type 2 Diabetes Mellitus and Improvements in Cardiovascular Risk Factors After Surgical Weight Loss in Adolescents

CONCLUSIONS.
Extremely obese diabetic adolescents experience significant weight loss and remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass. Improvements in insulin resistance, β-cell function, and cardiovascular risk factors support Roux-en-Y gastric bypass as an intervention that improves the health of these adolescents. Although the long-term efficacy of Roux-en-Y gastric bypass is not known, these findings suggest that Roux-en-Y gastric bypass is an effective option for the treatment of extremely obese adolescents with type 2 diabetes mellitus.

http://sciencediabetes.posterous.com/some-thoughts-on-the-recent-type-2-diabetes-r


http://www.eurekalert.org/pub_releases/2006-01/aps-tds010606.php


http://www.huffingtonpost.com/dr-mark-hyman/reverse-diabetes_b_918539.html

Craig in CT said...

I know that low fat advocates like to claim these diets reverse diabetes. But when I look at some of the studies they reference, you do not often see demonstrations of normal glucose metabolism. Typically there will be reductions in A1C and fasting blood sugar. But the after numbers are often still in the diabetic or pre-diabetic range (e. g., reducing A1C from 8.4 to 7.0 is not "cured").

ejazz1 said...

I have my diabetes well under control, you could say I have reversed my type 2 diabetes, my A1C has been 4.2 or 4.1 for the last 8 1/2 years after losing 150 lbs on the dash diet and maintaining the weight loss. I eat between 350 to 400 grams of carbs a day and have normal fasting levels in the 70's to low 80's and 2 hrs postprandial levels usually between 85 and 105. But I don't consider myself cured of diabetes. I believe to be considered cured one would have to return to eating the same diet before being diagnosed with type 2 and not have any of they symptoms or increased levels in blood sugar associated with type 2. I have no desire to return to my old way of eating so I have no way to prove this. But I would think if I did I would experience the same symptoms as before.

bentleyj74 said...

I'm not entirely certain...but I might disagree ejazz. Why would you expect to be able to return to a diet that caused a 150 pound weight gain without consequence in order to consider yourself well?

ejazz1 said...

I would not, my point is the term reversing diabetes does not mean someone is cured of type 2 diabetes. Once it is under control by diet and/or medication it is a life long process to keep it under control.

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