Hi all
Now returned from Spain and I watched the show last night. It is indeed a very edited version although I accept that's to be expected. I think the following would be helpful to clarify, although I would emphasise this is general info and doesn't replace any individual medical advice:
1. HbA1c 43 prior to diet was on metformin. This was stopped and bg monitored during the weight loss stage.
2. Tina was not 'put' on an extreme diet, she chose the option she felt best suited her. The same amount of weight loss should produce equal improvements with less of a calorie deficit over a longer period i.e. it's taking in fewer calories than your body needs which is the key factor, and sustaining this until you reach your target.
3. The filming during the diet was the early stages when hunger was a major factor. As time went on Tina lost her cravings, felt great and wasn't hungry. A low calorie diet does require commitment to undertake and commitment to long term changes to keep the weight off long term, but the experience is in most cases not as bad as people expect once they get started.
4. Regarding the question of reversal/remission. Tina only had 8 weeks to make the changes and have her tests redone. It was a great change in her HbA1c in that space of time and reflected her blood glucose values without medication, but I agree this one figure should not be used on its own to determine success. Her next HbA1c test after she has transitioned to a maintenance diet will tell her more about whether the effect is sustained. The tests of Beta cell function are only done in a research setting not in routine practice. It is the initial release of insulin from the pancreas after a meal (the 'first phase' response, which is impaired by fat in and around the pancreas, and this is what can return to normal levels with sufficient weight loss. If there has been permanent damage to the beta cells (as can happen with long duration diabetes, high HbA1c etc) then full recovery of Beta cell function may not be possible, but it's hard to predict at the start how an individual will respond (hopefully results from DiRECT will shed more light on predictors for achieving remission).
5. Re LCHF diets, I favour finding a dietary approach that suits the individual in front of me, which could be very different from public health messages about diet. T his would include low carb diets, time restricted eating and med diets, all of which are evidence-based. The DUK position statement in May this year is very helpful and clarifies that carbohydrate restriction is of value in T2DM and that carb intake 'to tolerance' should be advised. It stops short of recommending LCHF not due to evidence of harm but due to lack of sufficient evidence for no harm (if that makes sense). Expert multi-disciplinary groups will be reviewing the evidence and making recommendations later this year both on defining T2DM remission and on the use of LCHF diets for diabetes.
There is no 'one best diet' that will suit everyone. Whilst I understand that individuals who do well with a particular approach want to share their success and experiences with others, there is a risk that the potential value of other approaches is not acknowledged or recognised. Dietary preferences and habits are very different, as are the challenges that people face in following any given 'set diet', as well as their motivation to do so.
In general would never advise a more restricted diet than is necessary, it makes it less enjoyable and harder to sustain long term. One of the main issues with the low carb evidence that is sufficiently high standard to be included in evidence reviews is that outcomes when compared to low fat diets are superior over 3-6 months but comparable by 12 months, probably because carb intakes in the low carb groups have crept back up - often interpreted as low carb diets aren't sustainable. I would hope with finding a level of carb restriction that maintains the metabolic benefits but does allow greater variety of food choice, along with increasing awareness among HCPs that these approaches can be supported, that long term sustainability would be improved. I think we are moving towards that.
Finding a carb tolerance level could be done in a number of ways, either by cutting right back until target weight is in sight and then gradually increasing the daily carb intake, pulling back to the tolerated level if blood glucose/weight/cravings increase. Or it could be done the other way around, gradually reducing carb portions, choosing lower GI carbs and seeing how this affects diabetes outcomes. If you lose weight and have a good HbA1c on 150g carbs per day then great, carry on at that level. If your HbA1c is still above target then try a lower intake if you prefer to try this than take medication. A diabetes dietitian should be able to give individualised advice and support on this basis, especially for anyone taking medications associated with risk of hypos as these would need to be adjusted, seek advice from your diabetes team.
