Can Type 2 Diabetes Be Permanently Reversed?

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Can Type 2 Diabetes Be Permanently Reversed?

Can Type 2 Diabetes Be Permanently Reversed?

The feasibility of sustained relief from diabetes is a controversial topic, with one side citing successful research while the other questions the long-term practicality and current definitions of relief.

Recently, at the annual meeting of the European Association for the Study of Diabetes (EASD) held in Hamburg, Germany, experts discussed the practicality of sustained relief from diabetes in the real world.

Professor Roy Taylor from Newcastle University in the UK believes that through a series of studies involving low-calorie diets for type 2 diabetes patients, he has demonstrated that permanent relief from type 2 diabetes is indeed achievable in the real world.

He outlined his research, starting with the Counterpoint study in 2011, which confirmed the potential reversal of type 2 diabetes through a very low-calorie diet.

The study also indicated that type 2 diabetes is caused by excess fat in the liver and pancreas, and reducing fat within organs is crucial for relieving the condition.

However, Counterpoint was just a short-term conceptual validation study, and further research is needed to prove that the normalization process continues beyond the low-calorie diet phase.

Can Type 2 Diabetes Be Permanently Reversed?

Counterbalance and DiRECT Trials

In the 2016 Counterbalance study, 30 type 2 diabetes patients underwent an eight-week ultra-low-calorie diet (consuming 800 calories daily from shakes and soups) before returning to a normal diet.

The results suggested that if weight loss is maintained, type 2 diabetes can be reversed for at least six months.

However, both of these studies were conducted in research centers, and the crucial question remains whether type 2 diabetes can be reversed in primary care settings in daily management.

The DiRECT trial, coordinated between Newcastle and Glasgow and conducted by general practitioners, aims to answer this question. It involved 298 type 2 diabetes patients in a randomized controlled trial, including a 12-week very low-calorie diet phase followed by weight maintenance support.

Long-term Results and Implications

Professor Taylor stated, “In 2018, this groundbreaking study indicated that relief from type 2 diabetes is possible through dietary intervention in primary care. One year later, the intervention group’s weight was, on average, 10 kilograms (22 pounds) lighter than baseline, with 46% of diabetes patients experiencing relief—they discontinued all glucose-lowering medications. Two years later, their weight was still 8.8 kilograms (19.4 pounds) lighter than baseline, and 36% of individuals experienced relief.”

“Subsequently, we extended the study for three more years to investigate the program’s long-term benefits. Participants in the extended study received nurse or nutritionist appointments every three months at their general practitioner’s clinic, during which they received advice on maintaining weight loss. Those most successful in avoiding weight regain continued to stay in a relieved state. Five years later, their weight was still 8.9 kilograms (19.6 pounds) lower than baseline, and they remained in a relieved state. However, only 23% of those in a relieved state at two years remained so, as the overall weight in the intervention group had partially rebounded. The message here is that only those who can maintain their weight can sustain relief, and it’s certain that those who revert to their original weight will experience a recurrence of type 2 diabetes.”

Professor Taylor’s research also identified the fundamental causes of type 2 diabetes and the biological principles behind relief.

His research indicates that excess fat in the liver hinders insulin’s normal function. It also increases the normal process of fat output from organs, including the pancreas, thereby hindering the normal functioning of insulin-producing beta cells. Weight rebound leads to increased liver fat, increased fat output from the liver, and a decline in beta cell function.

National Impact and Real-World Applicability

The results of the DiRECT study inspired a nationwide relief plan in England, which utilizes very low-calorie diets to promote weight loss and reverse type 2 diabetes.

Early results of the National Health Service (NHS) “Type 2 Diabetes Remission Pathway” program show a weight loss of 10.3 kilograms (22.1 pounds) after 12 months, comparable to the results of the DiRECT trial.

Professor Taylor stated, “So it’s clear that achieving relief from type 2 diabetes through necessary weight loss is feasible in the real world, as long as sufficient support is provided to avoid weight rebound, enabling sustained relief. Avoiding weight regain is challenging, but it’s possible and can lead to long-term relief.”

Professor Kamlesh Khunti from the University of Leicester in the UK spoke against this proposition.

Professor Khunti believes that sustained relief from type 2 diabetes is not feasible in the real world. He utilized research evidence on lifestyle interventions such as low-calorie diets, GLP-1 receptor agonists, and weight loss surgery to explain his reasons.

He explained that methods of relieving the condition through lifestyle interventions, including low-calorie diets, have been validated in multiple studies. However, these studies suggest that behavior change is difficult to maintain in the long term.

Critique of Lifestyle Interventions and Relief Definitions

This includes the DiRECT trial, often cited as evidence that low-calorie diets can achieve relief from type 2 diabetes. However, DiRECT reported data on only 53 sustained relievers after five years, constituting approximately 7% of those initially randomized to low-calorie diets.

Professor Khunti stated, “The cost-effectiveness analysis of the DiRECT study is also debatable. Other studies suggest that weight lost through lifestyle changes will ultimately rebound. Changes in hormone levels increase appetite, prompting weight regain. Weight regain also leads to associated obesity—where lost muscle is replaced by fat. Additionally, research has not demonstrated that low-calorie diets can reduce the risk of microvascular complications (such as retinopathy and neuropathy) or lower the risk of macrovascular complications (such as coronary artery disease).”

Another key issue is the definition of relief. The latest definition from the American Diabetes Association, EASD, and the Diabetes UK is that relief refers to HbA1c < 6.5% three months after stopping glucose-lowering treatment. Unfortunately, most intervention results do not meet this definition. For example, GLP-1 receptor agonists used to treat type 2 diabetes and obesity have shown significant effects in reversing type 2 diabetes. Despite these impressive results, participants cannot stop taking glucose-lowering medications according to the current definition.

Comparing Other Interventions

The most convincing long-term relief data come from weight loss or bariatric surgery, with nearly one-third of people remaining in a relieved state after 15 years.

“Metabolic surgery also shows benefits for microvascular and macrovascular issues. The same applies to GLP-1 receptor agonists,” said Professor Khunti. “However, bariatric surgery is a fairly intense procedure and is not suitable for everyone. It is also associated with serious adverse events, some of which may be fatal. In summary, sustained relief is not possible in the real world—at least, not according to the current definition of relief. Perhaps it’s time to rethink the terminology; if defined as ‘high blood sugar relief after accepting or not accepting glucose-lowering treatment,’ then more people can achieve relief in the real world.”