Anyone trying something like the DiRECT trial diet to achieve remission?

[DevGuy]

I was diagnosed in Oct last year. Put on weight (18kg) after a leg injury, and fasting blood glucose shot up from pre-diabetes territory (around 5.6 - 5.8 mmol/l) into full-fledged diabetes.
Since then, have lost 16 kg, and daily finger-prick tests suggest I may be back to pre-diabetes. (Ranges between 4.2 mmol/l and 7.2 mmol/l fasting).
I know the latter reading is higher than pre-diabetes, but it's down from 9.3 mmol/l 3 months ago.
I used to do alternate-day fasting, which I stopped for a couple of years because of a separate, minor health issue.
Since Oct last year, 16 kg weight loss achieved by getting back on ADF (4 feeding sessions per week). I run as well, but still have a slight roundness to my belly, which is frustrating. (6-foot tall male, 55yo, 73kg currently. Aiming for 69kg in the next 2 months).
Morning after fasting day, blood sugar is around 4.2 - 4.8
Morning after feeding day (feeding evening, actually - I eat all my small meals in a roughly 5-hour window), it can be around 6.8 - 7.2. (Used to be significantly higher even 3 months ago). 1000mg Metformin 4 times a week only (on feeding evenings).
Will get an HBA1C done again in early Oct. (Last one was 5 months ago: 7.1 %)
Key question at this time: my morning readings after a feeding session the previous evening are down, but tend to be in the 7 mmol/l region if I my last feed was within a shorter period of time, leaving me with clearly slower gut motility in the morning. (I can feel some food in my belly still).
Has anyone else had this problem?
Another question: how many hours of overnight fasting do you give yourself before you do your morning finger-prick test?
Thanks!

 

[Dr Snoddy]

Firstly I admire your fortitude in sticking to this regime. When you do have meals what do you actually eat? Also, given your age, have you looked at tables for age and exercise related BMI?

 

[DevGuy]

Firstly I admire your fortitude in sticking to this regime.
Thanks. I followed this regimen for 6 years before a minor issue forced me to stop. Then, 2 years ago, I suffered a leg injury that had me on crutches for more than 6 months. This was followed by the first pandemic lockdowns. The combined result was a lot of weight gain, pushing my blood sugar - which had been in the medium pre-diabetic range for 16 years - into the red.

When you do have meals what do you actually eat?
The base of my meals is 500g of spinach for the ecdysterone, to minimise lean tissue loss. The spinach is microwaved to reduce volume through evaporation, so there's space in the stomach for the rest of the meal.
Handful of nuts, small piece of cheese, glass of milk, cooked legumes, the equivalent of 1-2 slices of bread (not always). A can of oily fish, or a small fillet of salmon, twice a week. The occasional egg, boiled or sunny side up.
Weekly calories add up to <12K, so in deficit. Because I'm fairly active, the actual need is more than 15.5K.
I do have a long history of slow gut motility following a childhood bout of severe Hepatitis A in a tropical country, and there's evidence of a link between gastric motility and diabetes - but there no clarity in the literature around whether this contributes to higher blood sugar, or is a result of hyperglycaemia.
I generally spread my feeding time over 5 hours. But this is not possible to do every day. It wasn't last evening. So my feeding time was contracted to 3 hours. Whenever I do this, the next morning my finger-prick test shows higher-than-usual blood sugar. This morning, it was 7.2 mmol/l. After a 30-min moderate run, it dropped to 5.8. Another 3 hours later, it was 4.4.
In the morning, before the test, I did feel still a little full, with the slight burning sensation in the stomach from undigested food.
Yesterday, my readings were 4.2 and 4.4 (this was before the evening meal time).

Also, given your age, have you looked at tables for age and exercise related BMI?
My BMI is 21.7. OK for my age.
But I do think that the last vestiges of fat remaining in my body are marbled hard around my viscera. They're really hard to dislodge - the weighing scale needle is moving down too slowly now, and it is frustrating. Some of this loss will inevitably be lean tissue. The weight loss is averaging around 1kg every 18 days or so. The target, as I said above, is 69kg. I weigh myself only on Friday mornings, with Thursday a full fast day. So Friday is usually the day I weigh lightest in the week.

Thanks for your response.

 

[Oldvatr]

For the benefit of anyone that may be confused by your posts here, the diet protocol you are using is not a variant of DIRECT (as per the opening post of this thread), but is, nonetheless, a restricted-calorie diet aimed at weight loss. The DIRECT study had a daily calorie restriction of 800 cal (0.8kcal) and you estimate your weekly calorie budget to be 12k, so is double the daily DIRECT allowance. You are also using exercise as part of your regime, which is not required for the DIRECT plan.

That said, the aims of both diets are the same, so we are able to make comparisons. You are achieving good glycemic control, but have plateaued in the weight department. Your intermittent fasting (Alternate Fasting Days) works for you, but those on DIRECT probably benefit from the daily routine, and your method may be too strict for some. I admire your stamina. I also envy your readings, but then I am only doing a gentle LC diet, and not needing to lose any weight.

The aim of both is remission so that normal service can resume after the diet plan ends. In DIRECT this is a fixed-term diet, and should not be continued beyond term. It achieves around 47% remission success (apparently) but will tend to unravel if the follow-on diet does not maintain the weight loss. We have your evidence that when lockdown interfered with your routine, your sugar control went awol, suggesting you need to maintain your protocol at an intense level to maintain good control. So it may not be offering remission. I fear you need more stamina in the future.

That seems to be the main differences between the two protocols.

 

[DevGuy]

Thanks for responding, Oldvatr.

I hope you don't mind considering my key questions (copied again below).

Key question at this time: my morning readings after a feeding session the previous evening are down, but tend to be in the 7 mmol/l region if I my last feed was within a shorter period of time, leaving me with clearly slower gut motility in the morning. (I can feel some food in my belly still).
Has anyone else had this problem?
Another question: how many hours of overnight fasting do you give yourself before you do your morning finger-prick test?

 

[Oldvatr]

Thanks for responding, Oldvatr.

I hope you don't mind considering my key questions (copied again below).

Key question at this time: my morning readings after a feeding session the previous evening are down, but tend to be in the 7 mmol/l region if I my last feed was within a shorter period of time, leaving me with clearly slower gut motility in the morning. (I can feel some food in my belly still).
Has anyone else had this problem?
Another question: how many hours of overnight fasting do you give yourself before you do your morning finger-prick test?

I do not use IF myself, so cannot pass comment. Personally, I found my early morning FBG readings were close to my pre-meal readings in the evening, so I dropped the morning tests and use the main meal PRE as my yardstick. I do eat a breakfast which is always the same items that I have tested before (including toast) so I saved myself pecuniae in the process.

I suggest you read some of the works by Jason Fung, who is an IF guru.

 

[DevGuy]

This is a very interesting study:
https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.2005143

 

[Oldvatr]

The potential use of the CGM as a diagnostic tool is not unexpected, but this paper puts forward a strong case for it to be used as a 'natural' approach since it allows the subject's environment to be examined over time rather than a single point test in a lab.

It is of interest, but again not unexpected, that cornflakes+milk is liable to spike us, but more importantly, it also spikes 'normal'; people too, thus laying bare the lie that that this particular breakfast is a healthy option for all.

The idea that Joe Public could use a CGM for a while, and then download it to an app on their phone to get a diagnosis without GP and blood tests is good. If they can then link this to a diet plan that is personal to them, then this is a bonus. How good it remains to be seen, and it is early days for this approach.

I am a bit concerned that it does not mention T1D anywhere, and assumes all their subjects will end up as T2D in time. They are presumably working on this concept to get a better diagnosis of insulin deficiency effects vs Insulin Resistance effects, but it is not part of this paper.

All the authors are from Stanford University USA. I note that one of them has the same surname as does a purveyor of cornflakes. The research is public-funded so there does not seem to be any undue influence from industry or politics. It is also of note that the role of carbohydrates was barely mentioned, and LC diest was not included in their lifestyle options. I hope this will be corrected when the lifestyle method selector becomes part of the App.

 

[Mbaker]

In your shoes I would not attempt any further weight loss, I would look to increase skeletal lean mass, so upping your weight via muscle mass. I view it as shifting from the Mo Farah type body to Linford Christie, as muscle mass is a glucose sink and positively associated with longevity.

I used to weigh 10 kg less (circa 80 kg @ five eleven, loads of cardo). My A1c was mid to late 30's. Now at 90 kg, A1c is the same, but fbg is around a point lower, post prandial glucose is lower, dead lifts are 120% more (100 kg to 220).

My 6 pack was more defined at 80 kg, but my newer protocol I know will be better in around a year for the following reasons. I optimised my 80 kg protocol down to 9% body fat and felt terrible training 3 hours a day with chronic cardio. I am more muscular in general now, much, much stronger, lower blood pressure.

My major 2 changes have been additional animal protein and displacing cardio with more resistance training, cutting my total exercise time in half. This time around the optimisation is muscle, I think if you bias towards this you'll achieve your objectives. The mistake I made during my change to my new regime was being too liberal with the fattier keto foods, should have gone easier on the dairy, so maxed out at 92 kg, now in the 90 range.

 

[bulkbiker]

Direct isn't about fasting.. it is deliberate caloric restriction where you eat "enough" to survive but also mess up your metabolism.
Fasting i.e. abstaining from food for certain periods whilst superficially similar is not about restricting calories but about restricting eating windows.
For example I can eat 1 meal a day but still put away 3,000 calories in that meal.
That's intermittent fasting but not calorie restriction.

 

[DevGuy]

In your shoes I would not attempt any further weight loss, I would look to increase skeletal lean mass, so upping your weight via muscle mass. I view it as shifting from the Mo Farah type body to Linford Christie, as muscle mass is a glucose sink and positively associated with longevity.

I used to weigh 10 kg less (circa 80 kg @ five eleven, loads of cardo). My A1c was mid to late 30's. Now at 90 kg, A1c is the same, but fbg is around a point lower, post prandial glucose is lower, dead lifts are 120% more (100 kg to 220).

My 6 pack was more defined at 80 kg, but my newer protocol I know will be better in around a year for the following reasons. I optimised my 80 kg protocol down to 9% body fat and felt terrible training 3 hours a day with chronic cardio. I am more muscular in general now, much, much stronger, lower blood pressure.

My major 2 changes have been additional animal protein and displacing cardio with more resistance training, cutting my total exercise time in half. This time around the optimisation is muscle, I think if you bias towards this you'll achieve your objectives. The mistake I made during my change to my new regime was being too liberal with the fattier keto foods, should have gone easier on the dairy, so maxed out at 92 kg, now in the 90 range.

Good to know you've got such excellent control with your regimen.

I've achieved several benefits from my approach, including remission of incipient arthritis and calming of allergies.
I do light resistance exercises as well.

The DiRECT trial's findings, including commentary around the results that goes beyond the design of the trial (which was designed the way it was for reasons of implementation) are what drives my approach.

Also a significant motivator is this extract from a news article after the actor Tom Hanks was diagnosed with T2D 9 years ago:
"My doctor said, 'Look, if you can weigh as much as you weighed in high school, you will essentially be completely healthy and will not have type 2 diabetes.' And then I said to her, 'Well then I'm going to have type 2 diabetes because there is no way I can weigh as much as I did in high school."
"I weighed 96 pounds in high school," Hanks added, calling his teenage self "a very skinny boy."