Reversing Diabetes with Weight Loss: Stronger Evidence, Bigger Payoff

With Roy Taylor, MD, Domenico Accili, MD, and Amy Hess-Fischel, MS, RD, LDN, CDE 

Every year, about 1.5 million Americans learn they have diabetes.1 However, there are more than 7 million adults who have diabetes but haven’t been diagnosed,1 according to the American Diabetes Association. This matters since we are learning that the best chance of reversing diabetes seems to occur very early in the onset of the disease. Finding from several recent studies indicate that the timing of diagnosis matters alot.2-5

If you have diabetes, your doctor may have encouraged you to consider making lifestyle changes; for many, that may include losing weight. While that same message has been discussed for years, recent evidence suggests that achieving about a 10% weight loss may be even more important than experts thought—with a payoff that is greater than previously imagined.

It is possible to reverse type 2 diabetes with 10-15% weight loss.

Reversing Type 2 Diabetes Possible Especially with a Recent Diagnosis

Substantial weight loss can potentially put your diabetes into remission, says Roy Taylor, MD, professor of medicine at the University of Newcastle in the U.K. His research team has shown in studies over the past several years that this can happen.2-4 In finding from the Diabetes Remission Clinical Trial (DiRECT), they found that 46% of the 149 participants in following a strict liquid diet program experienced remission at the one-year mark.2 Only 4% of the comparison group that wasn't following the strict diet managed to reverse their diabetes.

In a new analysis based on that study,3 Dr. Taylor looks more closely at why losing a substantial amount of weight may actually ''turn back on'' the insulin-secreting beta cells. "In those who were able to get back to a healthy weight range, their beta cells were able to begin working again," he tells EndocrineWeb. And the remission, according to Dr. Taylor, occurs because of a decrease in liver and pancreatic fat.

In this analysis of 64 patients who participated in an intense weight loss program as part of the DiRECT study,3 against a group of patients who did not follow a strict liquid diet, Dr. Taylor found that liver fat levels declined in response to weight loss. The same was true in the pancreas, with a decreased in fat content seen following meaningful weight loss.

On average, those in the intensive liquid diet group lost about 15% of their starting weight which for a 200-pound person was about 30 pounds.

Dr. Taylor can't say why some who lost at least 10% of the initial body weight achieved remission of their diabetes, with a hemoglobin A1c of less than 6.5%, while others did not. However, he says that “86% of those in the main study who lost more than 33 pounds reversed their diabetes status, and more than half of those who lost anywhere from 22 to 33 pounds experienced remission,” so they no longer had a diagnosis of type 2 diabetes.

Diabetes Remission Possible—No Longer Too Good To Be True

The findings from this series of studies ''adds up to a major change in how type 2 diabetes should be viewed," Dr. Taylor tells EndocrineWeb, "It is indeed a potentially reversible condition.” For that reason, an intensive weight loss program should be started as after the diagnosis is made as possible.

We now know enough about type 2 diabetes, he says, to know that reversing the diagnosis is possible at least for some people. "T2D is simply due to too much fat deposited inside the liver and pancreas of people who happen to be susceptible to this fat-induced damage," he says.

What is not yet clear is why normalization of liver and pancreas fat did not reverse diabetes in everyone, it appears that individuals with a T2D diagnosis for a brief time are much more likely to go into remission with sufficient weight loss, he says. He even had one a patient who reversed his diabetes following dramatic weight loss after 24 years with a T2D diagnosis; while this patient might be an outlier, it suggests that tackling weight loss is worth a try to avoid the serious complications facing anyone with diabetes long-term.

Yet, for some it seems that having a diagnosis for even three years was too far out even after weight loss to achieve a reversal of their T2D status;3 the reasons for this still need to be assessed.

US Diabetes Expert Endorses Findings: T2D Can Be Reversed

This most recent analysis reflects expert opinion not only in the UK but also among experts in the US and elsewhere, says Domenico Accili, MD, Russell Berrie Foundation Professor of Diabetes at Columbia University School of Medicine in New York City. He was not involved in the Taylor study but has conducted researched on beta cells and diabetes.4

Dr. Taylor said diabetes researchers have been discussing the probability that the insulin-producing beta cells in patients with type 2 diabetes may not be dead, just dormant (essentially hibernating) and that achieving a 10-15% weight loss seems sufficient to reactivate them.

Recent research by Dr. Taylor and others, Dr. Accili says, suggests that ''maybe there is more room for lifestyle modification than we previously thought," and it just may have a bigger effect than was realized.  

T2D is Reversed with Intensive Physician-Led Liquid Diet Program 

The program used in the DiRECT study was intense.3 Participants followed a very rigid very low-calorie weight loss plan, in which Phase 1 consisted of the following:

  • Specially-formulated 800 calorie liquid diet
  • Consisted of 4 shakes that replaced all meals
  • First phase of plan lasts for 3 to 5 months
  • During this intense weight loss phase, no exercise is encouraged.

"When people who have obesity are asked to exercise [as well as diet intensely], they are apt to overcompensate by overeating more," Dr. Taylor says.

Phase 2 entails a gradual process of replacing one shake at a time with a solid meal for two months or so. An important strategy is the use of a smaller plate: a luncheon sized plate for all meals. The patients are educated to prepare meals that contain about 30% fewer calories than they were eating at the start of the program. Phase 3 is considered the weight maintenance phase during which physical activity is strongly encouraged.  

"Boosting the activity level in the weight management phase is really important," he says. Weight maintenance for his participants, as for most people, is the greatest challenge, so adding daily physical activity is a key ingredient to keeping the lost weight off. "I don't think we have all the answers for weight maintenance, yet," he tells EndocrineWeb.

Fortunately, the reversal of T2D seems to last. Even as the weight in some of his participants crept up four or five pounds, he says, they still remained in remission. However, Dr. Taylor suggests that there may be a ''personal fat threshold." One person who loses 30 pounds, for instance, might have crossed that threshold at 10 pounds and may still have wiggle room; others may need to lose more and keep it off to stay diabetes-free.

Even someone in the ''healthy” weight range, he says, may have too much fat deposited in their liver and pancreas for their body to cope, so they develop diabetes.

For anyone who receives a new diagnosis of type 2 diabetes, Dr. Taylor says, there are two choices. Take medications and wait for what he calls the ''downward spiral of ill health,'' meaning expect the complications of diabetes. Or, commit to an intensely focused commitment to weight loss, then exercise and adjusted eating, to see if they can reverse their diabetes and keep it from returning.

Many Ways to Achieve Needed Weight Loss: Find What Works for You

Absolutely, weight loss should be the number one goal for those newly diagnosed who are overweight, says Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE, who is the Transitional Program Coordinator at Kovler Diabetes Center in Chicago, Illinois. And, it should remain a goal for anyone who has had type 2 diabetes, as well.

She says, “The need for weight reduction may not be pushed aggressively enough, but should be going forward.” When she sets goals with her patients, she makes sure ''every recommendation is meant to aid in weight reduction and lead to a reduction in blood glucose, such as reducing portion sizes, eliminating sugar-sweetened beverages and juices, and adding physical activity.''

However, she finds that many of her patients are not motivated to stick with these lifestyle changes, especially the effort necessary to see the kind of weight loss that reversed diabetes in the Direct trial.

Dr. Taylor has had a vastly different experience. At least half of our patients respond with shock upon receiving a diagnosis of diabetes, and many are willing to do anything if it means they can avoid this lifelong disease.3

If you have diabetes, here are some good articles to inspire you and hopefully introduce some strategies that might finally help you to lose unwanted body weight:

Ms. Hess-Fischl reminds her patients "it is not impossible."  At the right time, and over time, it [the weight loss] can happen.

"Small changes lead to small successes, which in turn increase the confidence needed for patients to continue to lose more weight,'' she tells EndocrineWeb. However, findings from the Direct trial might just offer another approach for some people to consider.

 

Dr. Taylor and Dr. Accili report no relevant disclosures. Hess-Fischl is a consultant for Roche Diabetes Care and on the speaker's bureau for Sanofi.

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