Type II Diabetes

Type II Diabetes (T2D) has reached epidemic proportions here in the U.S. and World wide. In part, the blame falls on the failure for earlier diagnosis and earlier interventions (2, 3, 13). T2D does not have to be a chronic progressive condition, it is possible to control and even reverse it if root causes are addressed properly. (1) The key pathology of T2D is disseminated arterial damage. This should be avoided at all costs. The recent policy statement by the AACE/ACE clearly states that evidence shows that T2D is part of a four part spectrum: insulin resistance, prediabetes, T2D, vascular complications. During the earlier stage of this spectrum, insulin resistance, compensatory hyperinsulinemia is damaging vasculature in later stages, prediabetes and T2D, hyperglycemia is adding to the microvascular damage. This spectrum can and should be addressed earlier rather than later with the safest and most effective of all treatments, structured lifestyle modification (13).

The primary blame of an individuals disease progression can be placed on dietary advice that panders the patients poor nutrition and lifestyle habits by using a pharmacologic only care model to mitigate separate aspects of the pathology. This approach creates what can be considered a metabolic facade of health (7). This, pharmacological only approach without the use of the properly targeted dietary and structured lifestyle modification does nothing to change the inevitable endpoints of the disease and at best only slows the disease process. The proper dietary advice has been known for close to one hundred years (8) but our urge to avoid confrontation and pacify patients by telling them what they would like to hear (“You can have desert, just don’t over do it and take your medications.”) rather than what they need to hear (“You really must avoid starch, sugar and processed food. These foods have a very unhealthy reaction in your body.”) is contributing to the rise of the epidemic (4). Recently, April 2019, the American Diabetes Association has recognized that a reduction of carbohydrates has provided the most evidence in its ability to control glycemia which also reduces hyperinsulinemia (14).

Compensatory hyperinsulinemia, insulin resistance, pre-diabetes and T2D are all part of a spectrum (5, 13). Each step is just one step closer to complete metabolic dysfunction, disease progression and further disseminated arterial damage. Research clearly suggests that the earliest signs, such as those conditions associated with metabolic syndrome or insulin resistance syndrome, are the earliest signs of Diabetes In Situ or diabetes in place (2, 5). Research, experimental studies and clinic experience clearly show that the proper dietary intervention in association with other lifestyle modifications can prevent, control and even reverse T2D in most individuals (1, 4, 6, 8, 9).

Special note: As of August 2018, Diabetes Australia, a nationally recognized authority on nutrition and diabetes and the U.S. equivalent of the American Diabetes Association, issued a new position statement as to the use of low-carb nutrition for type 2 diabetics. In part, the statement concluded, “In summary, this research indicates that lower carb diets are more effective at reducing blood glucose levels in the short term (three to six months) than higher carb diets and appear to be at least as effective as higher carb diets for long term blood glucose management (12-24 months) and weight loss.” At Restore, we believe the evidence is clear and continues to accumulate clearly suggesting that this approach is more effective long term (11). The study from University of Indiana is now well into it’s third year and is achieving marvelous long-term results (9).

Special note 2: As of April 2019 the American Diabetes Association in their publication Diabetes Care released a Consensus statement on the use of low carbohydrate and very low carbohydrate eating pattern as treatment for type 2 diabetes. From Page 6 of that publication – Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences. 

Along with a family history of T2D, providers should be looking to identify the development of risk factors (see Metabolic Syndrome), and when identified, counsel patients on the need to change as soon as any of these conditions present (13). Providers should know that most patients will need to be supported during this modification process. A few words in clinic by the  provider with a handout or two will usually be unsuccessful in motivating or helping the patient be successful. Providers must make a strong statement regarding the need to change and use primary care-referable resources to help support patients during the change process if reversal of these conditions is to be expected (9). These videos Can you Cure Diabetes?/Does Obesity cause Type 2 Diabetes and Obesity & Diabetes Explained: The Overflow Phenomenon (10, 11) are an excellent overviews of this subject and can provide insight into further research that may help to elucidate the issue further.

Here at Restore Medical Fitness, in patients that have begun our intensive comprehensive program with HbA1c greater than or equal to 6.5%, we have seen the average HbA1c drop from 7.61 to 6.49 in 12 weeks on average. This reduction in HbA1c was also associated with a 29% drop in fasting triglyceride levels (from 188 to 133), a weight loss of 16 pounds and over 60% of patients were able to reduce and in some cases eliminate the use of blood glucose lowering medication while achieving these HbA1c reductions. n=53+

Note: these results we achieved with carbohydrate “reduction” nutrition approach NOT a truly low-carb or very-low carb approach. Recently, we have added the medical supervision for medical management to our program and the results are exceeding even these reported results. See Below for a sample or reach out to use for one of our many case study publications.

**Patients on blood glucose and/or blood pressure lowering medication should be under close medical supervision as alterations (reduction) in these medications can be expected (8).  At Restore Medical Fitness, our Type II Diabetes Program is a comprehensive intense intervention that uses real-time communication with patients and is medical supervised for medication management. Patients communicate with their health coach and our provider using a HIPAA complaint texting app and report daily fasting blood glucose readings. More to be published on this soon.

Below is just a sample of one of our patients progress. This is just 11 weeks:

1- Lim et, al., Diabetologia (2011) – Reversal of type 2 diabetes: normalization 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.

2 – Crofts et. al., Diabetes Research and Clinical Practice, 118 (2016) pp50-57 – Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database

Conclusion: Hyperinsulinaemia in the absence of impaired glucose tolerance may provide the earliest detection for metabolic disease risk and likely occurs in a substantial proportion of an otherwise healthy population. Dynamic insulin patterning may produce more meaningful and potentially helpful diagnoses. Further research is needed to investigate clinically useful hyperinsulinaemia screening tools.

3 – Sagesaka et. al., Journal of the Endocrine Society, May 2018, Vol 2, Iss 5 – Type 2 Diabetes: When Does it Start?

Conclusions: FPG was significantly elevated in those who developed diabetes at least 10 years before diagnosis of diabetes, and this was also the case in those who developed PDM. Glucose dysregulation precedes diagnosis of diabetes at least for 20 years.

4 – Feinman et. al., Nutrition 31 (2105) PP 1-13 – Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base

Conclusion and recommendations: ….This review has described 12 points of evidence based on published clinical and experimental studies and the experience of the authors. The points are supported by established principles in biochemistry and physiology and emphasize that the benefits are immediate and documented while the concerns about risk are conjectural and long term.

5- Joseph R, Kraft, MD, MS, FCAP 2008, 2011 Trafford Publishing, Diabetes Epidemic & You – Should everyone be tested? Absolutely NOT! Only those concerned about their future

From the back cover – “Normal blood sugar, normal weight, normal cholesterol do not exclude you from being a type 2 diabetic …one of the un-diagnosed millions! Yes- I do mean you!”

6- Taylor et al. August 2018, Cell Metabolism – DOI https://doi.org/10.1016/j.cmet.2018.07.003, Remission of Human Type 2 diabetes Requires Decrease in Liver and Pancreas Fat Content but is Dependent upon Capacity for Beta Cell Recovery

Summary: The Diabetes Remission Clinical Trial reported return and persistence of non-diabetic blood glucose control in 46% of people with type 2 diabetes of up to 6 years duration. Detailed metabolic studies were performed on a subgroup (intervention, n = 64; control, n = 26). In the intervention group, liver fat content decreased (16.0% ± 1.3% to 3.1% ± 0.5%, p < 0.0001) immediately after weight loss. Similarly, plasma triglyceride and pancreas fat content decreased whether or not glucose control normalized. Recovery of first-phase insulin response (0.04[−0.05–0.32] to 0.11[0.0005–0.51] nmol/min/m 2, p < 0.0001) defined those who returned to non-diabetic glucose control and this was durable at 12 months (0.11[0.005–0.81] nmol/min/m 2, p = 0.0001). Responders were similar to non-responders at baseline but had shorter diabetes duration (2.7 ± 0.3 versus 3.8 ± 0.4 years; p = 0.02). This study demonstrates that β cell ability to recover long-term function persists after diagnosis, changing the previous paradigm of irreversible loss of β cell function in type 2 diabetes.

7 – Washburn, P.J., International Journal of User-Driven Healthcare, 6, 1, 2016 – Health Ballistics: Multiple Reference Point Informed Probability Theory
Conclusion: If an individual is afflicted with a chronic disease and does not know the realistic end point of their current health trajectory, they will never be fully ready, willing, motivated or able to make an informed, reliable, accurate and precise healthy behavioral decision in their current state of partially health informed reality. Alteration of health reality is accomplished by health informing the individual about the negatives of unhealthy behavior and the positives of healthy behavior.

Summary: … This outcome is in reference to an individual’s nominalized Health Wealth Commodity value, preservation and reacquisition. Individual’s uninformed behavior will significantly affect their overall health and is based upon the notion that what an individual does not know will with high probability lead to unhealthy behavioral decisions; further reinforcing unhealthy trajectories, leading to highly probable and predictable poor health outcomes. Intuitively, an individual will therefore not change their health trajectory unless informed of their highly probable and realistic health trajectory with disease as an end point….

8 – Yancy, et. al., Nutrition & Metbolism, 2005, 2:34, – A low-carbohydrate, ketogenic diet to treat type 2 diabetes

Conclusion: The LCKD improved glycemic control in patients with type 2 diabetes such that diabetes medications were discontinued or reduced in most participants. Because the LCKD can be very effective at lowering blood glucose, patients on diabetes medication who use this diet should be under close medical supervision or capable of adjusting their medication.

9 – Hallberg, et.al., Diabetes Therapy, Feb 2018 – Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Labeled, Non-Randomized, Controlled Study

Conclusions: This study demonstrated that a T2D intervention combining technology-enabled continuous remote care with individualized care plans encouraging nutritional ketosis can significantly reduce HbA1c, medication use, and weight within 70 days [23], and that these outcomes can be maintained or improved through 1 year. Most intervention participants with HbA1c reported at 1 year achieved glycemic control in the sub-diabetes range with either no medication or the use of metformin alone. Related health parameters improved including blood pressure, lipid-lipoprotein profile, inflammation, and liver function. Ongoing research will determine the continued sustainability, effectiveness, and safety of these behavioral and metabolic changes.

10- What I’ve Learned – Can you Cure Diabetes? | What causes Type 2 Diabetes?

11 – Tay, J et. al, The American Journal of Clinical Nutrition, Vol 102, Issue 4, October 2015, – Comparison of low- and high carbohydrate diets for type 2 diabetes management: a randomized trial

Conclusions: Both diets achieved substantial weight loss and reduced HbA1c and fasting glucose. The LC diet, which was high in unsaturated fat and low in saturated fat, achieved greater improvements in the lipid profile, blood glucose stability, and reductions in diabetes medication requirements, suggesting an effective strategy for the optimization of T2D management. This trial was registered at www.anzctr.org.au as ACTRN12612000369820.

12 – What I’ve learned – Obesity & Diabetes Explained: The Overflow Phenomenon

13 – Mechanick, J et. al., Endocrine Practice Vol 24 No. 11 November 2018 – Dysglycemia-Based Chronic Disease (DBCD): An American Association of Clinical Endocrinologists Position Statement

Conclusion: Recognizing and managing prediabetes is a necessary component for an effective personalized and population-based T2D care plan. In order to substantiate this position, AACE has formulated a DBCD multimorbidity care model consisting of four distinct stages in the general context of ABCD (adiposity based chronic disease) and cardiometabolic health and specific context along with insulin resistance-prediabetes-T2D spectrum that are actionable in a preventive care paradiagm.

14 – Evert, et. al., Diabetes Care – April 2019 – Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report

from Page 6 – Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences.