Early and long-term effects of acute caloric deprivation in obese diabetic patients

Reversal and Remission of T2DM - An Update for Practitioners

Over the past 50 years, many countries around the world have faced an unchecked pandemic of obesity and type 2 diabetes (T2DM). As best practice treatment of T2DM has done very little to check its growth, the pandemic of diabesity now threatens to make health-care systems economically more difficult for governments and individuals to manage within their budgets. The conventional view has been that T2DM is irreversible and progressive. However, in 2016, the World Health Organization (WHO) global report on diabetes added for the first time a section on diabetes reversal and acknowledged that it could be achieved through a number of therapeutic approaches. Many studies indicate that diabetes reversal, and possibly even long-term remission, is achievable, belying the conventional view. However, T2DM reversal is not yet a standardized area of practice and some questions remain about long-term outcomes. Diabetes reversal through diet is not articulated or discussed as a first-line target (or even goal) of treatment by any internationally recognized guidelines, which are mostly silent on the topic beyond encouraging lifestyle interventions in general. This review paper examines all the sustainable, practical, and scalable approaches to T2DM reversal, highlighting the evidence base, and serves as an interim update for practitioners looking to fill the practical knowledge gap on this topic in conventional diabetes guidelines.

Efficacy of low- and very-low-energy diets in people with type 2 diabetes mellitus: A systematic review and meta-analysis of interventional studies

AIMS

To review systematically and quantify the weight loss achieved through low- (LEDs) and very-low-energy diets (VLEDs) in people with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

Studies reporting the effects of diet-only interventions of up to 1600 kcal/d in people with T2DM were searched in MEDLINE, EMBASE and CINAHL up to July 2018. Changes in the primary (body weight and body mass index [BMI]) and secondary outcomes (glycated haemoglobin, blood lipids) according to energy restriction and duration of diet were modelled using restricted cubic splines.

RESULTS

Forty-four studies (3817 participants) were included. The overall quality of the evidence was moderate and limited to short-term interventions up to 4 months. Baseline mean weight and BMI were 92.1 kg and 36.6 kg/m² . VLEDs of 400 kcal/d led to 5.4% weight loss at 2 weeks, increasing to 17.9% at 3 months. More modest reductions of 7.3% were observed on LEDs of 1200 kcal/d and 2.0% on 1600 kcal/d after 3 months. No clear patterns emerged for secondary outcomes. Publication bias was significant for primary outcomes.

CONCLUSIONS

Through modelling, we were able to describe effective dietary deficit strategies to achieve weight reduction up to 4 months in people with T2DM. High-quality studies are required to further support clinical practice with evidence-based dietary interventions.

Nutrition and lifestyle intervention in type 2 diabetes: pilot study in the Netherlands showing improved glucose control and reduction in glucose lowering medication

Introduction

Prevalence of type 2 diabetes (T2D) is increasing rapidly and lifestyle interventions to reverse diabetes are seen as a possible solution to stop this trend. New practice-based evidence is needed to gain more insight in the actual, and above all scientific, basis for these claims.

Methods

This observational study with a pretest post-test design aimed to pilot a 6-month multicomponent outpatient group-based nutrition and lifestyle intervention programme on glycaemic control and use of glucose lowering medication in motivated T2D patients with a body mass index (BMI) >25 kg/m² in the Netherlands (February 2015–March 2016).

Results

74 T2D patients (56% female) aged 57.4±8.0 years with mean BMI 31.2±4.2 kg/m² and mean waist circumference 105.4±10.2 cm were included in the study. Compared with baseline, mean HbA1c levels at 6 months were 5 mmol/mol lower (SD=10, p<0.001) and the number of participants with HbA1c levels ≤53 mmol/mol after intervention had increased (from 36% (n=26/72) to 60% (n=43/72)). At baseline, 90% of participants were taking at least one type of glucose lowering medication. At 6 months, 49% (n=35/72) of the participants had reduced their medication or eliminated it completely (13%). Secondary outcomes were significantly lower fasting glucose levels (− 1.2±2.6 mmol/L), body weight (−4.9±5.1 kg), BMI (−1.70±1.69 kg/m²) and waist circumference (−9.4±5.0 cm). Plasma lipids remained unchanged except for a decrease in triglyceride levels. Furthermore, self-reported quality of life was significantly higher while experienced fatigue and sleep problems were significantly lower.

Conclusion

This pilot study showed that a 6-month multicomponent group-based program in a routine care setting could improve glycaemic control and reduce the use of glucose lowering medication in motivated T2D diabetics. A fully scaled study is needed to confirm these results.

Reversing Type 2 Diabetes: A Narrative Review of the Evidence

BACKGROUND

Type 2 diabetes (T2D) has long been identified as an incurable chronic disease based on traditional means of treatment. Research now exists that suggests reversal is possible through other means that have only recently been embraced in the guidelines. This narrative review examines the evidence for T2D reversal using each of the three methods, including advantages and limitations for each.

METHODS

A literature search was performed, and a total of 99 original articles containing information pertaining to diabetes reversal or remission were included.

RESULTS

Evidence exists that T2D reversal is achievable using bariatric surgery, low-calorie diets (LCD), or carbohydrate restriction (LC). Bariatric surgery has been recommended for the treatment of T2D since 2016 by an international diabetes consensus group. Both the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) now recommend a LC eating pattern and support the short-term use of LCD for weight loss. However, only T2D treatment, not reversal, is discussed in their guidelines.

CONCLUSION

Given the state of evidence for T2D reversal, healthcare providers need to be educated on reversal options so they can actively engage in counseling patients who may desire this approach to their disease.

A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes

Background

Type 2 diabetes (T2D) is typically managed with a reduced fat diet plus glucose-lowering medications, the latter often promoting weight gain.

Objective

We evaluated whether individuals with T2D could be taught by either on-site group or remote means to sustain adequate carbohydrate restriction to achieve nutritional ketosis as part of a comprehensive intervention, thereby improving glycemic control, decreasing medication use, and allowing clinically relevant weight loss.

Methods

This study was a nonrandomized, parallel arm, outpatient intervention. Adults with T2D (N=262; mean age 54, SD 8, years; mean body mass index 41, SD 8, kg·m⁻²; 66.8% (175/262) women) were enrolled in an outpatient protocol providing intensive nutrition and behavioral counseling, digital coaching and education platform, and physician-guided medication management. A total of 238 participants completed the first 10 weeks. Body weight, capillary blood glucose, and beta-hydroxybutyrate (BOHB) levels were recorded daily using a mobile interface. Hemoglobin A_1c (HbA_1c) and related biomarkers of T2D were evaluated at baseline and 10-week follow-up.

Results

Baseline HbA_1c level was 7.6% (SD 1.5%) and only 52/262 (19.8%) participants had an HbA_1c level of <6.5%. After 10 weeks, HbA_1c level was reduced by 1.0% (SD 1.1%; 95% CI 0.9% to 1.1%, P<.001), and the percentage of individuals with an HbA_1c level of <6.5% increased to 56.1% (147/262). The majority of participants (234/262, 89.3%) were taking at least one diabetes medication at baseline. By 10 weeks, 133/234 (56.8%) individuals had one or more diabetes medications reduced or eliminated. At follow-up, 47.7% of participants (125/262) achieved an HbA_1c level of <6.5% while taking metformin only (n=86) or no diabetes medications (n=39). Mean body mass reduction was 7.2% (SD 3.7%; 95% CI 5.8% to 7.7%, P<.001) from baseline (117, SD 26, kg). Mean BOHB over 10 weeks was 0.6 (SD 0.6) mmol·L⁻¹ indicating consistent carbohydrate restriction. Post hoc comparison of the remote versus on-site means of education revealed no effect of delivery method on change in HbA_1c (F_1,260=1.503, P=.22).

Conclusions

These initial results indicate that an individualized program delivered and supported remotely that incorporates nutritional ketosis can be highly effective in improving glycemic control and weight loss in adults with T2D while significantly decreasing medication use.

Imbalanced insulin action in chronic over nutrition: Clinical harm, molecular mechanisms, and a way forward

The growing worldwide prevalence of overnutrition and underexertion threatens the gains that we have made against atherosclerotic cardiovascular disease and other maladies. Chronic overnutrition causes the atherometabolic syndrome, which is a cluster of seemingly unrelated health problems characterized by increased abdominal girth and body-mass index, high fasting and postprandial concentrations of cholesterol- and triglyceride-rich apoB-lipoproteins (C-TRLs), low plasma HDL levels, impaired regulation of plasma glucose concentrations, hypertension, and a significant risk of developing overt type 2 diabetes mellitus (T2DM). In addition, individuals with this syndrome exhibit fatty liver, hypercoagulability, sympathetic overactivity, a gradually rising set-point for body adiposity, a substantially increased risk of atherosclerotic cardiovascular morbidity and mortality, and--crucially--hyperinsulinemia. Many lines of evidence indicate that each component of the atherometabolic syndrome arises, or is worsened by, pathway-selective insulin resistance and responsiveness (SEIRR). Individuals with SEIRR require compensatory hyperinsulinemia to control plasma glucose levels. The result is overdrive of those pathways that remain insulin-responsive, particularly ERK activation and hepatic de-novo lipogenesis (DNL), while carbohydrate regulation deteriorates. The effects are easily summarized: if hyperinsulinemia does something bad in a tissue or organ, that effect remains responsive in the atherometabolic syndrome and T2DM; and if hyperinsulinemia might do something good, that effect becomes resistant. It is a deadly imbalance in insulin action. From the standpoint of human health, it is the worst possible combination of effects. In this review, we discuss the origins of the atherometabolic syndrome in our historically unprecedented environment that only recently has become full of poorly satiating calories and incessant enticements to sit. Data are examined that indicate the magnitude of daily caloric imbalance that causes obesity. We also cover key aspects of healthy, balanced insulin action in liver, endothelium, brain, and elsewhere. Recent insights into the molecular basis and pathophysiologic harm from SEIRR in these organs are discussed. Importantly, a newly discovered oxide transport chain functions as the master regulator of the balance amongst different limbs of the insulin signaling cascade. This oxide transport chain--abbreviated 'NSAPP' after its five major proteins--fails to function properly during chronic overnutrition, resulting in this harmful pattern of SEIRR. We also review the origins of widespread, chronic overnutrition. Despite its apparent complexity, one factor stands out. A sophisticated junk food industry, aided by subsidies from willing governments, has devoted years of careful effort to promote overeating through the creation of a new class of food and drink that is low- or no-cost to the consumer, convenient, savory, calorically dense, yet weakly satiating. It is past time for the rest of us to overcome these foes of good health and solve this man-made epidemic.

Mild Caloric Restriction Decreases Insulin Requirements in Patients With Type 2 Diabetes and Severe Insulin Resistance

Type 2 diabetes (T2D) affects ~10% of the US population, a subset of whom have severe insulin resistance (SIR) (>200 units/d). Treatment of these patients with high-dose insulin presents logistical and compliance challenges. We hypothesized that mild caloric restriction would reduce insulin requirements in patients with T2D and SIR.This was a retrospective study at the National Institutes of Health Clinical Center. Inclusion criteria were as follows: T2D, and insulin dose >200 units/d or >2 units/kg/d. The intervention consisted of mild caloric restriction during a 3 to 6-day hospitalization. The major outcomes were change in insulin dose and blood glucose from admission to discharge.Ten patients met inclusion criteria. Baseline glycated hemoglobin A1c was 10.0 ± 1.6% and body mass index 38.8 ± 9.0 kg/m. Food intake was restricted from 2210 ± 371 kcal/d preadmission to 1810 ± 202 during the hospital stay (16.5% reduction). Insulin dose decreased from 486 ± 291 units/d preadmission to 223 ± 127 at discharge (44% reduction, P = 0.0025). Blood sugars decreased nonsignificantly in the fasting state (from 184 ± 85 to 141 ± 42, P = 0.20), before lunch (239 ± 68 to 180 ± 76, P = 0.057), and at bedtime (212 ± 95 to 176 ± 48, P = 0.19), and significantly decreased before dinner (222 ± 92 to 162 ± 70, P = 0.016).Mild caloric restriction, an accessible and affordable intervention, substantially reduced insulin doses in patients with T2D and SIR. Further studies are needed to determine if the intervention and results are sustainable outside of a hospital setting.

Quality of life in type 2 diabetes mellitus after a very low calorie diet and exercise

OBJECTIVE

To evaluate whether the addition of exercise to a very low calorie diet (VLCD) has beneficial short- and long-term effects on health-related quality of life (QoL) in obese patients with type 2 diabetes mellitus (T2DM).

METHODS

We included 27 obese, insulin-dependent T2DM patients in a 16-week VLCD study, of whom 13 participated simultaneously in an exercise program (VLCD+E). Before, immediately after and 18 months after the intervention anthropometric measurements, glucoregulation and QoL (SF-36, HADS, NHP and MFI-20) were assessed. Patients were compared to healthy lean and obese (matched for body mass index) controls matched for gender and age.

RESULTS

At baseline, T2DM patients had significantly worse QoL scores in 18 and 14 of the 22 subscales of the QoL questionnaires, compared to lean and obese controls, resp. The 16-week VLCD (n=27) decreased bodyweight (-25.4±1.3 kg, p<0.0001, p=0.179 between groups), and improved glucoregulation (HbA1c -1.3±0.3%, p<0.0001, p=0.488 between groups) and 9 (VLCD-only) and 11 (VLCD+E) of the 22 subscales of QoL. After 18 months, in the VLCD+E group the QoL subscales did not differ from those in obese controls and only 4 of the 22 subscales were significantly worse compared to lean controls. However, in the VLCD-only group 17 and 13 of the 22 QoL subscales were significantly worse compared to the lean and obese controls, resp.

CONCLUSION

A 16-week VLCD induces considerable weight loss, metabolic amelioration, and major improvements in QoL in obese T2DM patients. The addition of exercise is of paramount importance for the maintenance of better QoL.

Effects and clinical potential of very-low-calorie diets (VLCDs) in type 2 diabetes

A recent study has shown that obese patients with newly diagnosed type 2 diabetes who lose 10% of their body weight are more likely to achieve glycaemic and blood pressure targets, despite weight regain. A well-established non-surgical method for achieving weight loss >or=10% within 3 months is the use of very-low-calorie diets (VLCDs). In patients with diabetes, VLCDs are associated with rapid improvement in glycaemia and cardiovascular risk factors. The present review analyses the evidence from available trials on the effects of VLCDs on body weight, glycaemic control and complications, and their potential for clinical use in diabetes management.

Sustained beneficial metabolic effects 18 months after a 30-day very low calorie diet in severely obese, insulin-treated patients with type 2 diabetes

Eighteen insulin-treated obese type 2 diabetic patients were followed for 18 months after they followed a 30-day very low calorie diet (VLCD, 450kCal/day) with the cessation of all glucose-lowering medication. After the 30-day VLCD, caloric intake was slowly increased to eucaloric and glucose-lowering medication was restarted if necessary. On day 0 and 30 of the VLCD and after 18 months follow-up, bodyweight, blood-pressure, glycaemic control and lipid levels were measured. The 30-day VLCD significantly reduced bodyweight (-11.7+/-0.7kg, mean+/-S.E.M.) and improved dyslipidaemia, hypertension and glycaemia. As a group, this effect was sustained at 18 months follow-up despite the fact that patients used less lipid-, blood-pressure- and glucose-lowering medication. Especially, the use of insulin was significantly reduced: 18 out of 18 patients on day 0 (mean 137+/-22units/day); 5 out of 18 patients at 18 months (86+/-14units/day). Patients using insulin at 18 months had regained weight to prediet levels, but still had a better cardiovascular risk profile compared with before the dietary intervention. Thus, a once-only 30-day VLCD leads to a sustained improvement in glycaemia, dyslipidaemia and blood-pressure up to 18 months follow-up in obese type 2 diabetic patients, even, although to a lesser extent, in patients who regained body-weight.

Insulin treatment and the problem of weight gain in type 2 diabetes

PURPOSE

Insulin therapy has been shown to benefit the prognosis in patients with type 2 diabetes, but its initiation and intensification is often delayed through concerns about hypoglycemia and weight gain. In addition, weight gain is linked to the pathophysiology of type 2 diabetes and contributes to the overall risk for adverse cardiovascular outcomes. This article attempts to summarize this issue and examine the options available for weight management.

METHODS

A broad range of literature has been reviewed to distill important, consistent facts about insulin and weight gain and the options available for limiting the problem.

RESULTS

Unfortunately, the great benefits of insulin therapy may be potentially undermined by weight gain. Weight gain is physiologically and psychologically undesirable, especially in patients with diabetes who are already overweight. The fear of weight gain with some medications contributes to psychological insulin resistance, which may discourage patients from commencing or following insulin regimens. However, new diabetes treatments and lifestyle interventions can be used to mitigate these problems.

CONCLUSIONS

The exact choice of insulin and oral medications and weight loss interventions are important considerations in the overall management of patients with type 2 diabetes. Changes in a patient's lifestyle, such as modifications to diet and implementing an exercise program, are first-line treatments for type 2 diabetes and can also counteract insulin-induced weight gain.

Food frequency questionnaire results correlate with metabolic control in insulin-treated veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study

OBJECTIVE

To validate food frequency analysis as a predictor of metabolic status in persons with type 2 diabetes and to identify psychosocial factors affecting dietary adherence.

METHODS

Three hundred forty-seven subjects with stable, insulin-treated type 2 diabetes completed a food frequency questionnaire and six instruments measuring different psychosocial attributes. Eight metabolic parameters were used as principal endpoints. Data from the food frequency questionnaires were used to estimate daily energy intake and determine each subject's adherence to seven dietary standards derived from the 2003 Dietary Recommendations of the American Diabetes Association. We excluded 105 subjects reporting daily energy intake <1,000 kcal because these results were considered unreliable. Subjects were then categorized into three groups depending on their adherence rates to American Diabetes Association dietary standards.

RESULTS

Subjects with the lowest dietary adherence had the poorest metabolic control. Adherence to dietary standards was particularly poor among subjects with metabolic syndrome (2.1%) and/or obesity (4.1%). The most important determinants of following recommended dietary practices were positive attitudes, fewer social barriers, and a conviction that diet could control diabetes.

CONCLUSIONS

For subjects with type 2 diabetes reporting a dietary intake of >1,000 kcal/day, food frequency questionnaire data could identify those with poor metabolic control. Nutrition interventions to improve metabolic control should focus on reducing fat intake and emphasizing the importance of diet. Multidisciplinary efforts should be directed at overcoming social barriers to recommended dietary practices and to treating depression.

Hypocaloric Parenteral Nutrition Support in Elderly Obese Patients

Hypocaloric nutritional support has been successfully used to achieve positive nitrogen balance in obese patients. However, advanced age is associated with changes in substrate metabolism. To evaluate the efficacy of this practice in elderly patients, we retrospectively reviewed 30 obese patients requiring parenteral nutrition support. Total caloric requirements (TCR) were calculated on the basis of the Harris-Benedict equation. Patients were given a minimum of 1.5 g/kg/day protein, 75 per cent of TCR when current body weight was >120 and ≤150 per cent of ideal body weight (IBW), and 60 per cent of TCR if current body weight was >150 per cent of IBW. The patients were divided into two groups: Group I (N = 18) patients were age <60 and Group II (N = 12) patients were ≥60 years of age. Only one of the Group I patients (143.2 ± 25.7% IBW, received 18.2 ± 3.7 kcal/kg/day and 1.6 ± 0.4 g/kg/day protein), but five of the Group II patients (141.3 ± 14.4% IBW, received 18.3 ± 2.6 kcal/kg/day and 1.7 ± 0.3 g/kg/day protein), had negative nitrogen balance ( P = 0.025). Apparently, elderly obese patients have limited capacity to mobilize their fat stores as energy sources and may continue to undergo protein catabolism with hypocaloric high-protein nutrition support. Therefore, this form of nutritional support should be used with caution in elderly obese patients.