By David Spero, RN | February 5, 2013 11:48 am
Health professionals usually call Type 2 diabetes a chronic, progressive illness. “Chronic” means you’ll always have it. “Progressive” means you will almost certainly get worse. The best you can hope for is to slow its progression through your diet, exercise, and oral medicine or insulin.
The diagnosis of a chronic, progressive condition can feel like having a curse put on you. If you have to get worse, if you can’t avoid complications and premature death, then why struggle with your diet and managing your diabetes? In the words of Jenny Ruhl, a blogger with LADA (latent autoimmune diabetes of adults, sometimes called “Type 1.5” diabetes), “If there is nothing you can do, it is rational behavior to shift your energy elsewhere and enjoy life – including the foods you love – while you can.”
Although experts have called both Type 1 and Type 2 diabetes “chronic” and “progressive” for decades, some people with diabetes disagree. A Diabetes Self-Management Blog reader named Dennis wrote, “Last November I weighed 288 [pounds] with an [HbA1c level] of 7.1%. Diabetic complications had set in. Today, with a very low-carbohydrate diet, my [HbA1c level] is 5.6%. I’ve lost 35 pounds, my sugars are under control, and all my symptoms are gone!” (The HbA1c test gives an indication of average blood glucose level over the past 2–3 months. The American Diabetes Association advises most people with diabetes to aim for an HbA1c level below 7% to prevent complications.)
On the same note, a reader named Bob wrote, “By limiting carbs, my [HbA1c level] dropped from an 8.6% to a most recent reading of 4.9%.” And Terri posted, “I am a diabetic who eats a low-carb vegan diet. I am far healthier now at 53 than ever before and maintain perfect glucose control.”
Reports like these are called “anecdotal evidence” and are usually discounted by scientists. But even some doctors who used to consider diabetes a death sentence are now saying that Type 2 diabetes can be reversed, even cured (more on what “cured” means later).
In a talk published by online resource Medscape in December 2003, diabetes expert Roy Taylor, MD, professor of medicine at Newcastle University in the United Kingdom, stated that even good blood glucose control doesn’t slow the progression of complications much. Dr. Taylor said that the United Kingdom Prospective Diabetes Study (UKPDS, a landmark 20-year study published in 1998) showed that “intensive therapy made a difference” in eye damage, “but not a staggering difference, [and]…abnormal nerve function continues to progress.” Intensive blood glucose control, furthermore, “does not seem to be able to stop kidney damage.”
The UKPDS findings led Dr. Taylor and many others to conclude that ultimately, nothing can be done to stop the damage caused by Type 2 diabetes, so people who have it essentially got the message, “Do the best you can; we’ll help you with drugs, but you’ll go downhill anyway.”
But times change. On June 24, 2011, Dr. Taylor’s research group released a paper called “Reversal of Type 2 Diabetes: Normalization of beta cell function in association with decreased pancreas and liver triacylglycerol.” The paper details how 11 study subjects who were put on a 600-calorie diet for eight weeks regained normal insulin function, had normal lab results, and stopped taking all diabetes medicines, some after only one week. Quoted in the United Kingdom’s Daily Telegraph, Taylor said, “While it has long been believed that someone with Type 2 diabetes will always have the disease, and that it will steadily get worse, we have shown that we can reverse the condition.”
Starvation isn’t the only approach that may reverse Type 2 diabetes. In his book The Blood Sugar Solution, Mark Hyman, MD, writes that you don’t need an extreme diet, you don’t necessarily need weight loss, and you don’t need surgery. He says that just cutting out or drastically reducing starches and sugars, and exercising more, will reverse Type 2 diabetes in about 80% of people.
In thousands of anecdotal reports, people like Dennis and Terri say they have reduced or eliminated their diabetes medicines, brought their glucose and cholesterol numbers into the normal range, and rid themselves of symptoms and complications such as fatigue, neuropathy, eye damage, and protein in their urine. Others have reported less dramatic but still significant improvements.
At least four approaches, other than extreme caloric restriction, are claimed to reverse Type 2 diabetes in many people. Most involve dietary changes (often along with exercise), and they include low-carbohydrate diets, vegan diets, traditional diets for native peoples, and bariatric surgery. Let’s look at the evidence for each of these approaches.
In his book Dr. Bernstein’s Diabetes Solution: The complete guide to achieving normal blood sugars, (first published in 1997 and updated periodically since then), Richard Bernstein, MD, recounts how he stabilized his Type 1 diabetes and reversed most of its complications with a low-carbohydrate diet.
Bernstein discovered through self-monitoring that if he ate only very small amounts of slowly digested carbohydrates (those with a very low glycemic index), he could cover them with insulin and keep his blood glucose in the normal range. He found that his patients with Type 2 diabetes also had big spikes in after-meal blood glucose when they ate carbohydrate. They saw great improvement when they adopted his low-carb diet, even when insulin injections weren’t in the picture.
Since then, scores of books, articles, and Web sites have appeared that promote low-carb diets for diabetes. A group of people in the United Kingdom with both Type 1 and Type 2 diabetes created the Web site Low Carb Diabetic to report how they normalized their blood glucose levels. They write, “While some medications can help to reduce blood glucose, a reduction of the foods in the diet which raise levels in the first place can be sufficient to normalize them. Medication can therefore often be reduced and in some cases (Type 2 diabetics only) eliminated altogether.”
One Duke University study followed 82 obese people with Type 2 diabetes who were assigned to either a very-low-carb or a low-calorie diet. After six months, the low-carb group had a lower average HbA1c level and had lost more weight than the low-calorie group, and 95% were able to reduce or totally eliminate their diabetes medicines. Eric Westman, MD, director of Duke’s Lifestyle Medicine Program and lead author of the study, said, “If you cut out the carbohydrates, your blood sugar goes down, and you lose weight, which lowers your blood sugar even further. It’s a one-two punch.”
There are a wide variety of low-carb diets and books available, including Conquer Diabetes and Prediabetes by Steve Parker, MD; The Blood Sugar Solution by Mark Hyman, MD; and The 30-Day Diabetes Cure by Stefan Ripich, ND. You can also read dozens of diabetes blogs and Web sites that focus on low-carb diets (see “Resources”).
Vegetarian diets and vegan diets (no meat, eggs, or dairy) are known to help prevent diabetes. One two-year study of 25,000 people in the United States and Canada found that vegans had only one-fourth the risk of developing diabetes as nonvegetarians.
Dr. Neal Barnard, a professor at the George Washington University School of Medicine and president of the Physicians Committee for Responsible Medicine, is a leading proponent of a vegan diet for diabetes. On PCRM’s Web site, you can see many “success stories” of people who have regained normal glucose numbers on a vegan diet. One former police officer reports, “My [HbA1c level] dropped from over 9% to 5.3%, my cholesterol dropped from 221 to 148 points, and I have lost 74 pounds” over a six-year period.
In a Czech study published in 2011, 74 people with Type 2 diabetes were randomly assigned to either a vegetarian or a conventional diabetes diet. Both diets had the same low number of calories. Over 24 weeks, 43% of people in the vegetarian group were able to reduce their diabetes medicines, compared with only 5% in the conventional group. The vegetarian group lost more weight and had much better insulin sensitivity.
You might notice that a vegan diet is about as far as you can get from a typical low-carb diet, which is often heavy in animal products. How could they both be effective against diabetes? The connection may be that both diets, when done right, are low in refined grains and sugars. Many vegans eat a lot of carbs, but in a diabetes diet they tend to come from vegetables, fruits, beans, and nuts, not breads and sugars.
No group in the world has been hit harder by Type 2 diabetes than Native Americans and Pacific Islanders. To improve their health, some have gone back to their traditional diets. Although no major studies have been published on this topic, many people who take this approach seem to improve their health, including their diabetes.
The Waianae Diet Program is a community-based approach that uses a traditional Hawaiian diet to reduce chronic disease in Native Hawaiians. A study published in the American Journal of Clinical Nutrition reported that people on a native diet (low in fat, high in complex carbohydrate) lost significant weight and reduced their cholesterol and blood pressure, even though they were encouraged to eat as much as they wanted. The study did not examine glucose levels, but in other studies, blood glucose often corresponds to improvements in these other measurements.
According to Native American leader Liz Gray, “Before the 1930’s and 1940’s, diabetes was not a plague on the Native American population…The biggest problem is the federal food program. Those foods are totally stripped of nutrients, and that’s all that the tribes on the reservations have.”
Some Native Americans are replacing government food with traditional foods. In an article called “Native American Traditions Return to Heal Diabetes,” New American Media reports on Wisconsin tribes that are replacing packaged food with food “harvested from the land, such as maple syrup, venison, perch, and wild rice. In the woods, there’s wild turkey, partridge, bear, and rabbit. Local waters have plenty of walleye, pan fish, trout, and other fish. And the reservation thrives with wintergreen, leeks, apples, juneberries, and other plants to harvest.” One Native American, Bob Wilmer, said that his cholesterol and glucose numbers are great because of both the food and the physical activity involved in obtaining it. He says more and more people are “trying to fight the epidemic of Type 2 diabetes in Indian Country through a return to traditional foods, exercise, and public health education.” These programs are taking off in tribes throughout the United States, Canada, and the Pacific Islands.
Bariatric (“weight-loss”) surgery such as gastric bypass and gastric banding frequently puts Type 2 diabetes into remission. This means that the signs of diabetes disappear – often within days, before any significant weight is lost. This phenomenon was completely unexpected when it was first discovered a few years ago and has led to a surge in the number of surgeries performed.
How does weight-loss surgery reverse diabetes? Some experts believe remission occurs because the surgery affects gut hormones, which somehow impact pancreas function. This could be happening, but Dr. Taylor thinks the remission might actually occur because the surgery severely limits what people can eat. This hypothesis was the inspiration for his 600-calorie diet study. To date, no one knows what the exact mechanism is, but it is clear that bariatric surgery has let tens of thousands of people stop taking their diabetes medicines.
Bariatric surgery has significant side effects and risks, however, which may include digestive problems, nutrient deficiencies, and even death. Dr Iain Frame, director of research at Diabetes UK, which supported the 600-calorie diet study, noted that the study’s positive outcome “shows that Type 2 diabetes can be reversed [through diet] on a par with successful surgery without the side effects.”
Dr. Bernstein has found that when blood glucose levels are controlled, the body starts to heal itself and many complications improve. Most reversible seems to be neuropathy in the feet. Sexual dysfunction seems highly reversible as well, based on studies that have examined the topic. Retinopathy (eye disease) and nephropathy (kidney disease) also seem to improve when blood glucose levels come down.
Some complications, however, may be more difficult to reverse. A complication that has progressed beyond a certain point may persist even upon a return to normal blood glucose levels, since some tissue damage can be irreversible. If you are blind or experiencing kidney failure, it is highly unlikely that these problems will disappear entirely. It is always possible, though, that there will be noticeable improvement, no matter how “far along” your diabetes is.
The idea of reversing Type 2 diabetes is still considered somewhat extreme. Opposing voices raise several objections, such as the following:
No studies. The evidence of success is almost all anecdotal, critics say, so it can’t be given much credit. Actually, there are several studies, including the ones cited in this article, but they are small. There aren’t any large, well-controlled, multicenter studies on dietary approaches like those that exist for drugs.
There will probably never be any large studies on reversing Type 2 diabetes with food and exercise because they are too difficult to conduct, because most doctors currently don’t even accept the premise, and because there is no product to sell if an intervention is deemed successful. Richard Kahn, MD, former Chief Science and Medical Officer of the American Diabetes Association, said, “It’s very difficult to study long-term diet changes in the real world, where people often don’t know exactly what they’re eating.”
In Dr. Taylor’s 600-calorie-per-day study, all the meals were liquid and given to subjects by study administrators. Along with green, nonstarchy vegetables, this was all they could eat. To repeat these methods for a study of 10,000 people would be expensive and difficult.
The data say progression is inevitable. Maybe not, actually. True, most people with Type 2 diabetes do experience progression of the disease and complications. But reversal proponents say that this is because they stay on high-carbohydrate diets.
Jenny Ruhl points out that “although the UKPDS did show that even patients with good control deteriorated over time, ‘good control’ was defined to mean [HbA1c] test values near 7.0%. This is only mediocre control at best. It corresponds to an average blood sugar over 155 [mg/dl] and frequent spikes over 200.” Ruhl goes on to explain, “It is very likely that most UKPDS participants spent hours [after meals] with their blood sugars over 300 mg/dl…people who eat a lower-carbohydrate diet can keep their sugar below the 140 mg/dl level” where blood vessel damage is believed to start.
Follow-up is too short. There’s no telling how long the benefits of these diets will last because they haven’t been studied for long enough. In weight-loss diets, 90% to 95% of dieters regain all the weight they have lost within five years, and usually within two years. It is possible that diabetes reversal will also fail over time for most people. In the case of starvation diets like Dr. Taylor’s, very few people can stay on them for an extended period. In his study, 4 of the 11 subjects had relapsed to diabetes-level blood glucose levels after only three months. Most of the rest probably have by now.
According to health writer Kimberly Pollock, a Dutch study found that “83% of gastric bypass patients and 62% of gastric banding patients were able to stop taking medication for their diabetes within a few days of surgery. Even at one- and two-year follow-ups, those patients remained off medication. However, by the 10-year follow-up, only 36% of all patients were able to maintain normal blood glucose levels without medicine.”
But many low-carb, vegetarian/vegan, and traditional diets are not calorie-restrictive and may be sustainable. They are described by proponents not as diets but as permanent lifestyle changes. Some of Dr. Ripich’s successful readers say that the new foods they have adopted on his diet are much more enjoyable than the sweets and starches they have given up. Some followers of Dr. Bernstein’s approach have been sticking with it for 20 years or longer, with normal or near-normal blood glucose levels throughout that time.
It’s too difficult. Some critics say that very few people can stay on programs like these. Changing eating habits is hard, especially when your friends, coworkers, and family members continue to eat in ways that are unhealthy for you. Sweets and starches are widely available, cheap, and tasty. Healthy food is harder to get, more expensive, and less familiar to many people’s tastes. Getting exercise is also hard for many people, especially when they’re not used to it, when they’re too busy or too tired, or when their environment doesn’t provide an easy way to do it. So it may be unrealistic to expect many people to make these changes.
Many people who claim to have reversed diabetes, however, say it was no great feat. The Low Carb Diabetic Web site’s authors claim that they all have normal glucose numbers and that it “wasn’t hard to accomplish.” Diabetes Self-Management Blog reader Anna writes that after she was diagnosed with Type 2 diabetes 11 years ago, she changed her diet and exercise patterns and has been off all drugs, with normal glucose numbers, for more than 5 years. “It can be done, and it actually can be done quite easily,” she says.
Anna points out that “reversal” doesn’t mean you can forget all about diabetes. “You will never be able to lounge on a sofa popping bonbons” she writes, “but you will also not have to be a prisoner to drugs and symptoms and worry over a future consumed by illness.”
People can’t change or don’t want to change. Doctors often prescribe weight loss to patients, who usually don’t lose it or don’t maintain whatever loss they achieve. So many doctors have the sense that people can’t change. But weight loss is a bad indicator of what people are capable of doing in other areas, simply because it is so difficult; our bodies try very hard to regain lost weight. If given a goal that they can actually accomplish, many people are willing to make changes and to work hard in the process.
It doesn’t work for everyone. This is certainly true. According to Dr. Hyman, about 20% of people experience nutrient deficiencies, chronic infections, intolerance of dairy or gluten, chemical toxicities, low thyroid function, or other problems that can reduce the effectiveness of lifestyle changes and will need correction before diabetes can be reversed. Other people who supposedly have Type 2 diabetes may actually have Type 1 or MODY (maturity-onset diabetes of the young, or monogenic diabetes) and will continue to need insulin, although lifestyle changes may still improve blood glucose control. Drs. Bernstein, Hyman, Parker, and Ripich all advise seeking help from a doctor when making any changes to your self-management routine.
It’s too late for many people. It’s true that the more damage a person’s pancreas, liver, or blood vessels have suffered, the slower recovery is likely to be. Some complications may not be totally reversible. If you read any of the books or Web sites listed in “Resources,” though, you will probably find stories of people whose diabetes was more advanced than yours but who still managed to reverse it to some degree. And by following their examples, perhaps you can, too.
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