Three experts presented various approaches to optimizing nutritional health during Efficacy, Engagement, and Sustainability of Dietary Management Options in Type 2 Diabetes—Time for a Reappraisal? The session can be viewed by registered meeting participants at ADA2023.org. If you haven’t registered for the 83rd Scientific Sessions, register today to access the valuable meeting content through August 28.
Weight Loss
Effective weight loss can lead to lasting remission of type 2 diabetes, according to Roy Taylor, MD, Professor of Medicine and Metabolism, Newcastle University, United Kingdom.
Dr. Taylor defined type 2 diabetes as a state of excess fat above a personal threshold inside the liver and pancreas. He hypothesized that weight loss is the most significant factor in managing type 2 diabetes.
He helped lead DiRECT, a clinical study that placed participants on a regimented low-calorie (about 800 calories per day) diet to measure the effects of weight loss on type 2 diabetes. Participants’ average liver fat decreased by 30% in seven days. Over eight weeks, researchers saw a slow increase in beta-cell function among the study’s cohort. At the start of the study, the baseline average liver fat for participants was approximately 36%; by the end of the trial, the average liver fat was 2%. He showed that these trends broadly remained the same after six months.
“All of these mechanisms are reversible and stay reversed,” Dr. Taylor said.
He emphasized that this is not just an effective strategy for patients struggling with obesity; in fact, Dr. Taylor asserted that type 2 diabetes isn’t related to obesity on an etiological level. The more important element is the percentage of weight a patient has gained over time.
“Any weight gain in adult life, unfortunately, is adverse tissue,” he explained.
Some expected participants to quickly regain the weight lost during the study, but in a five-year follow-up to DiRECT, participants still weighed 6.1 kg (13.4 lbs) less on average.
“The most exciting finding was the 54% reduction in serious side effects—a mixture of infections, strokes, and a rather dramatic decrease in cancer presentations,” Dr. Taylor said.
He recommended that all newly diagnosed patients be offered this method of management. For existing patients, the program still provides an opportunity to decrease the need for medications and improve overall quality of life.
Low Carbohydrate Diets
Low carbohydrate diets (LCDs) and very low carbohydrate diets (VLCDs) can reduce A1C levels, reduce or eliminate the need for medication, and lead to improvements in cardiovascular health for patients with type 2 diabetes, explained Nia Schwann Mitchell, MD, MPH, Assistant Professor of Medicine, Duke University.
Dr. Mitchell advocates for LCDs because of the effects on patients’ glucose levels. According to a study she cited, participants who adhered to a LCD or VLCD saw a 47% reduction in A1C levels after three months but a 36% drop after six months. This group saw no significant changes after 12 or 24 months.
LCDs can also lead to the remission of type 2 diabetes, she said. A systemic review and meta-analysis of randomized trial data found that participants on LCDs or VLCDs were 87% more likely to experience remission than control diets after six months.
“Individuals who use VLCDs or LCDs can reduce their doses or eliminate diabetes medications altogether,” Dr. Mitchell said.
For cardiovascular health, LCDs can improve triglyceride and high-density lipoprotein levels.
LCDs can also often lead to weight loss in the short-term (three to six months), but one of the most challenging aspects of LCDs is patient adherence. Dr. Mitchell said patients were more compliant with low-fat diets (90%) and Mediterranean diets (85%) than LCDs (78%). She emphasized that this approach was particularly challenging for vegetarians and vegans.
In conjunction with prescribing LCDs for patients with type 2 diabetes, Dr. Mitchell recommends reducing glucose-lowering medications, avoiding sodium-glucose cotransporter 2 (SGLT2) inhibitors, and monitoring lipids.
Glycemic Excursion Minimization
Glycemic excursion minimization (GEM) is an alternative lifestyle treatment that could lead to a paradigm shift in the management of type 2 diabetes.
“Instead of reducing weight, the focus in this approach is reducing post-nutrient glucose excursions,” explained Daniel Cox, PhD, Professor of Psychiatric Medicine and Professor of Internal Medicine, University of Virginia.
Conventional programs focus primarily on a reduction in weight and adipose fat levels to reduce the body’s resistance to insulin. GEM is concerned with diminishing the rise of blood glucose while hastening the recovery of blood glucose as the levels begin to drop after spiking.
GEM recommends replacing high glycemic load foods with a low glycemic load diet. However, the program encompasses more than a participant’s diet.
First, patients are encouraged to spend four days focusing on their priorities, activity levels, food intake, and changes in blood glucose levels. Next, to hasten blood glucose recovery, participants are encouraged to sit less, sleep more, and integrate some light to moderate exercise into their routine. In the third stage, participants diminish the rise of blood glucose levels by replacing high glycemic load foods. The final challenge is to sustain positive results while avoiding relapse.
Dr. Cox said he recommends participants become “glucologists” by closely monitoring the effects food has on their bodies.
“I’ve learned if I drink an all-day IPA beer, it barely budges my glucose, but if I drink an Imperial Stout, it might push my blood glucose up 70 points,” he said. “And so, with that information, I’m learning what to choose from and what not to choose.”
Dr. Cox shared several studies that showed GEM effectively lowered patients’ A1C and body mass index (BMI) while also exhibiting psychological benefits, such as an increase in perceived patient empowerment and lower levels of distress. The program is highly cost-effective and may be successfully self-administered with minimal coaching required.