Carbs-independent remission

[chrisjohnh]

Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial

The DiRECT programme sustained remissions at 24 months for more than a third of people with type 2 diabetes. Sustained remission was linked to the extent of sustained weight loss.

www.thelancet.com

Be aware that the success reported at 2 years is in a subgroup of those maintaining their 10kg weight loss, so is a percentage of a percentage of the intervention group. i.e 64% of the 46% of the year 1 group.

Note also that in Direct, participants were still able to use diabetic mediation during and after the study. There was a small group of the intervetion group that seem to have been able to stop medicating, but in general the remission is not entirely due to the diet.

Although you cannot assume that an absence of evidence is proof of a concept, I note that your call for info of participants who have acheived and maintained remission has so far gone unanswered. It is probably that this is the wrong forum to ask this questipn , and the the DUK site may give better feedback since they advocate and funded the DIRECT study in the first place. also people in remission tend to stop using support forums if they are no longer considered diabetic.

Yes I agree that the info needed for an accurate view of those remitters’ dietary trajectories is what is missing from all the DiRECT publications to date.

 

[chrisjohnh]

But there's no such thing as "the science".
And why anyway..? if you go into remission through ultra low carb then why does "the science" matter if it has worked.
Personally I'm quite happy to have foiled the medical nonsense that T2 is" chronic and progressive and that I will end up on insulin" as I was told on diagnosis.

It is possible to have an interest in science independently of how it relates to one’s personal situation. As a scientist for 43 years I can vouch for this.

 

[chrisjohnh]

The other confounder raised by DIRECT is that the entry criteria for the study was quite restricted. Only those with a BMI over 37 (i,e, obese or morbidly obese) AND diagnosed with diabetes no more than 10 years prior, AND not insulin users were eligible. so a small subset of the majority of T2D. So the results cannot be read across to the general T2D population such as evidenced on this forum.

Readinfg the 2year report I also notice that the 64% remission result is referenced to the whole study group (Control+ intervention) and is referenced to 272 not the 149 of the intervention group. So members of the Control group also acheived remission in this time period. The results that are referenced to the intervention group at 2 year review is a reference to weight maintenance , and not to remission. So there is some obscuration going on there. Note also that the value of 272 mantioned above is less than the 298 that entered DIRECT at the start. Presumably this dropout is the adverse events mentioned in the text and seems high for 8 week diet plan and 2 year follow up.

Yes it is certainly the case that the study group was chosen on criteria not spanning the larger diabetic community. One of many confounders. And yes, the articulation and interpretation of the results for both intervention and control do merit a better write-up than this.

 

[chrisjohnh]

Yes it is certainly the case that the study group was chosen on criteria not spanning the larger diabetic community. One of many confounders. And yes, the articulation and interpretation of the results for both intervention and control do merit a better write-up than this.

But at the end of the day 53 maintained remission after a second year and without low carbing (the latter point told to me in personal correspondence with the PI).

 

[Oldvatr]

Yes I agree that the info needed for an accurate view of those remitters’ dietary trajectories is what is missing from all the DiRECT publications to date.

Sadly it is more thn that. You mention "the Science". Well, as one who has studied RCT trials over the years, it is normal that the published report states what happens in the Control Group, vs what happened in the intervention group. these results get stated together with limits and confidence criteria. Also what statistical methods have been applied to remove errors and discarded confounders. This data is essenrtial for a scientific report., and Taylor deliberately mixes and matches results to massage the dialogue in a way that is very unscientific. To give an example, he expresses insulin response using a mathematical formula he developed to include body weight, so that decreasing weight term gives a false indication of improved insulin response. Others in the same field do not use body mass or BMI in their results. So the claims made for this intervention to improve insulin output is not valid since the intervention itself is designed to induce weight loss.

Taylor did good work proving that the intervention reduces considerably the ectopic fat in the pancreas. He has also demonstrated that this same intervention brings the HbA1c down to good levels. What he has not done since is to demonstrate that in cases where the ' remission' has ceased, that the ectopic fat in the pancreas has increased. So he has not proven that the improvement in HbA1c is due to the fat removal. He has also not demonstrated that the 2 year remission candidates still have low ectopic fat levels by follow up MRI scanning.

Taylor's department is involved in bariatric surgery support, and is emulating what that surgery achieves in gaining diabetic remission, but without surgey, and hence low cost. Again, there is no cross pollination of MRI scans to show that the surgery also removes pancreatic fat.

 

[chrisjohnh]

Sadly it is more thn that. You mention "the Science". Well, as one who has studied RCT trials over the years, it is normal that the published report states what happens in the Control Group, vs what happened in the intervention group. these results get stated together with limits and confidence criteria. Also what statistical methods have been applied to remove errors and discarded confounders. This data is essenrtial for a scientific report., and Taylor deliberately mixes and matches results to massage the dialogue in a way that is very unscientific. To give an example, he expresses insulin response using a mathematical formula he developed to include body weight, so that decreasing weight term gives a false indication of improved insulin response. Others in the same field do not use body mass or BMI in their results. So the claims made for this intervention to improve insulin output is not valid since the intervention itself is designed to induce weight loss.

Taylor did good work proving that the intervention reduces considerably the ectopic fat in the pancreas. He has also demonstrated that this same intervention brings the HbA1c down to good levels. What he has not done since is to demonstrate that in cases where the ' remission' has ceased, that the ectopic fat in the pancreas has increased. So he has not proven that the improvement in HbA1c is due to the fat removal. He has also not demonstrated that the 2 year remission candidates still have low ectopic fat levels by follow up MRI scanning.

Taylor's department is involved in bariatric surgery support, and is emulating what that surgery achieves in gaining diabetic remission, but without surgey, and hence low cost. Again, there is no cross pollination of MRI scans to show that the surgery also removes pancreatic fat.

Of course all scientists get some things wrong and we depend upon experimentation, critique and peer review to tease out the flaws and to make progress. I think you verge on being unkind to Taylor by giving the impression that he commits wilful obscuration or avoidance of inconvenient considerations, or that his many collaborators do also. That doesn’t ring true with me. But your penultimate para hits all the right nails on the head, this has been my exact frustration with that research programme and its reporting to date.

 

[bulkbiker]

Of course all scientists get some things wrong and we depend upon experimentation, critique and peer review to tease out the flaws and to make progress. I think you verge on being unkind to Taylor by giving the impression that he commits wilful obscuration or avoidance of inconvenient considerations, or that his many collaborators do also. That doesn’t ring true with me. But your penultimate para hits all the right nails on the head, this has been my exact frustration with that research programme and its reporting to date.

Prof Mike Lean one of the co-authors of the DiRECT study has in the past vilified low carb as "dangerous" and possibly leading to early death!
The claim that T2D is more frequent among low carb dieters is of course complete unsupported nonsense yet ...

 

[bulkbiker]

Prof Mike Lean one of the co-authors of the DiRECT study has in the past vilified low carb as "dangerous" and possibly leading to early death!
The claim that T2D is more frequent among low carb dieters is of course complete unsupported nonsense yet ...


View attachment 57575

Here's the nugget I was searching for...

 

[chrisjohnh]

Here's the nugget I was searching for...
View attachment 57576

I am aware of the mortality claims (and not only from him) and will be interested to watch that debate in the years to come…

 

[Lupf]

@chrisjohnh thanks for bringing this study to our attention. As a scientist myself I agree with you that "the science" is important. As long as LCHF is considered anecdotal evidence with sample sizes of as small as one, it will never become NHS or government advice. We might not like it and can get angry, but that won't change it.

Regarding the DIRECT study, I had a look and agree with you that the information you want is not available. What did they eat in these two years? Did they continue to take medication?. What I also consider relevant is that you had to be very obese with BMI > 37 to be included in the trial, so the findings might not apply to T2s like you and me who lost 10 to 15 kg.
For participants in the DIRECT study, who maintained their weight, I would apply what I call the "There is no free lunch" theorem (pun intended). Any diet, not only the Newcastle diet is not sustainable in the long run. Basically if you go on a diet of just reducing calories, you lose weight but you also lower your metabolic base rate, so your body will require fewer calories. At this point will stop losing weight and feel hungry and miserable all the time. At some point you will give up and gain weight again. On the other hand fatty food is more satiating, so increasing the fraction of fat in your diet will allow you to not feel hungry and you'll be able to keep your weight. LCHF is based on this. Thus to make weight loss sustainable you need to change your diet. I claim that "There is no free lunch" also applies to the DIRECT participants.
My hypothesis is that the DIRECT participants who maintained their weight, had to significantly change their diet. As you know there is low hanging fruit, such as cutting out fizzy and sugary drinks. IMHO it is very likely, that they reduced the carb fraction in their diet by a significant fraction. Why would they do this? The study indicates that the participants increased their happiness considerably. So if you were at a BMI of 37 and lost around 20kg , possibly more, you will be able to do things, such as sport, play with children, ... again. This is a powerful motive for people to find a way to keep their weight. So it is possible that they managed to reduce carb intake whilst maintaining or possibly increasing fat in their diet without being told. This is only a hypothesis and we do not have data to corroborate or disprove it. @chrisjohnh if you have connections to medical researchers, please suggest such a study.

My own story (again a sample size of one) is consistent with this. In 2019 I did Michael Mosley's 5+2 diet with 600 calories on fast days and lost 10 kg. This brought down my HbA1c to 42. It is now three years in which I managed to keep this weight. I don't count carbs on normal days, but have continued fasting for 2 days a week, as this works well for me. However I noticed that I've significantly reduced portion size of anything carby, e.g. potatoes in my diet. Pasta, which I love, is now a rare treat. I might eat a half slice or a slice of bread a couple times a week, but no more. Thus my carb intake should be around 100 to 150 h similar to @chrisjohnh To compensate I've increased my fat intake, mainly cheese and oily fish, and eggs. Thus my diet has changed considerably from 4 years ago. Since end of 2019 my HbA1c has stayed in the pre-diabetic range, which is great, as I didn't take this for granted.

 

[bulkbiker]

it will never become NHS or government advise

The Low Carb Programme from this very site is available through some surgeries....

 

[Lupf]

The Low Carb Programme from this very site is available through some surgeries....

This is of course good, but is due to individual GPs

I could have written my point maybe clearer,
but what I meant is the top level NHS advice,
https://www.nhs.uk/conditions/diabetes/
which points you to the Eat well plate and

• eat a wide range of foods – including fruit, vegetables and some starchy foods like pasta
• keep sugar, fat and salt to a minimum
• eat breakfast, lunch and dinner every day – do not skip meals

 

[lovinglife]

My new GP surgery advocates low carb and even Keto, I’m newish (2years) to this surgery so don’t know how long they have been doing it. The nurse said that she has quite a few keto followers and overall their markers are the best.

 

[Oldvatr]

But at the end of the day 53 maintained remission after a second year and without low carbing (the latter point told to me in personal correspondence with the PI).

The official recommendation from Newcastle as published in their booklet for the diet is that the follow on diet should be no more than 25% of what was eaten prior to the intervention. This is a major reduction of intake.

I presume this is the report you are referencing

Weight loss can put Type 2 diabetes into remission for at least two years – the latest findings from DiRECT

The results were announced today at our Professional Conference and published in The Lancet Diabetes & Endocrinology. The results The new results build on the first year findings, announced in December 2017, which showed that 46% of participants were in remission after twelve months. A year...

www.diabetes.org.uk

So you have to lose and maintain a drop of greater than 12 kg, and generally 15.5kg AND be less than 10 years since DX. It seems that many of the reference control group also acheived this weight loss and remission without needing the ND diet intervention (i.e. 46% did it in year 1, but 64% did it by Year 2. But there is no mention that many of them are still using diabetic medication, so that is an omission of note. Why is that omitted? It is mentioned in the full report, but the press release omits it. This is exactly the hype that is used to promote the diet plan, for which there is at least two books written on the subject.

 

[Oldvatr]

This is of course good, but is due to individual GPs

I could have written my point maybe clearer,
but what I meant is the top level NHS advice,
https://www.nhs.uk/conditions/diabetes/
which points you to the Eat well plate and

• eat a wide range of foods – including fruit, vegetables and some starchy foods like pasta
• keep sugar, fat and salt to a minimum
• eat breakfast, lunch and dinner every day – do not skip meals

There is indeed a dichotomy in what the NHS says and does.

 

[chrisjohnh]

@chrisjohnh thanks for bringing this study to our attention. As a scientist myself I agree with you that "the science" is important. As long as LCHF is considered anecdotal evidence with sample sizes of as small as one, it will never become NHS or government advice. We might not like it and can get angry, but that won't change it.

Regarding the DIRECT study, I had a look and agree with you that the information you want is not available. What did they eat in these two years? Did they continue to take medication?. What I also consider relevant is that you had to be very obese with BMI > 37 to be included in the trial, so the findings might not apply to T2s like you and me who lost 10 to 15 kg.
For participants in the DIRECT study, who maintained their weight, I would apply what I call the "There is no free lunch" theorem (pun intended). Any diet, not only the Newcastle diet is not sustainable in the long run. Basically if you go on a diet of just reducing calories, you lose weight but you also lower your metabolic base rate, so your body will require fewer calories. At this point will stop losing weight and feel hungry and miserable all the time. At some point you will give up and gain weight again. On the other hand fatty food is more satiating, so increasing the fraction of fat in your diet will allow you to not feel hungry and you'll be able to keep your weight. LCHF is based on this. Thus to make weight loss sustainable you need to change your diet. I claim that "There is no free lunch" also applies to the DIRECT participants.
My hypothesis is that the DIRECT participants who maintained their weight, had to significantly change their diet. As you know there is low hanging fruit, such as cutting out fizzy and sugary drinks. IMHO it is very likely, that they reduced the carb fraction in their diet by a significant fraction. Why would they do this? The study indicates that the participants increased their happiness considerably. So if you were at a BMI of 37 and lost around 20kg , possibly more, you will be able to do things, such as sport, play with children, ... again. This is a powerful motive for people to find a way to keep their weight. So it is possible that they managed to reduce carb intake whilst maintaining or possibly increasing fat in their diet without being told. This is only a hypothesis and we do not have data to corroborate or disprove it. @chrisjohnh if you have connections to medical researchers, please suggest such a study.

My own story (again a sample size of one) is consistent with this. In 2019 I did Michael Mosley's 5+2 diet with 600 calories on fast days and lost 10 kg. This brought down my HbA1c to 42. It is now three years in which I managed to keep this weight. I don't count carbs on normal days, but have continued fasting for 2 days a week, as this works well for me. However I noticed that I've significantly reduced portion size of anything carby, e.g. potatoes in my diet. Pasta, which I love, is now a rare treat. I might eat a half slice or a slice of bread a couple times a week, but no more. Thus my carb intake could be around 100 to 150 h similar to @chrisjohnh To compensate I've increased my fat intake, mainly cheese and oily fish, and eggs. Thus my diet has changed considerably from 4 years ago. Since end of 2019 my HbA1c has stayed in the pre-diabetic range, which is great, as I didn't take this for granted.

Thank you for this extensive response. I likewise believe that the determination of how unmedicated patients should control their diabetes through diet and lifestyle absolutely must be by scientific progress and appropriate acknowledgement of that by the medical profession. The latter is not going to be much swayed by our protestations that we’ve solved the problem ourselves by not eating cornflakes or whatever. For the sake of all the millions of future diabetics it will need science to get to the bottom of it all. Just as we do not solve our own infections by trying to brew potions in our garden sheds.
Regarding the DIRECT remitters I guess that in their second year they were on a diet having modest calories, maybe 2000 or so, and carbs above 150 plus sufficient fat to maintain stability. We cannot know from the publications. Only in personal exchanges with the Prof did I learn that none of the remitters was on carbs below 130g in their 2nd year of the study.
For myself I can live with my own carb restrictions with a sort of contentment. Mine are restricted so far for no other reason than that I chose to go low on the day after diagnosis, just to hedge my bets, but all my focus and discipline in those first few months was on caloric deficit as the primary line of attack. I know that many here do not believe in CICO, but as it happens I do, just my little quirk.
Thank you - and to Oldvatr - for checking the DIRECT papers.

 

[AndBreathe]

This gets to the heart of the issue and the science will have to get the bottom of it. Although we are a large community of self-helpers, and ostensibly doing very well in many cases, it does not add up to a means of advancing objective knowlege.

To my mind, this is why it is very important that those of us who can participate in all manner of health research.

For example, the study I participated in a year or so ago, into heart health/failure in those with an historic diagnosis of T2 was ticking over nicely. A sub-set of participants was identified and sought of participants in remission from their T2. Both groups participated in the same research, undergoing the same examinations and tests.

Frankly, this activity is beginning to bring out questions and raising some eyebrows. I couldn't say it begs more questions than it answers, but it is leading to a desire to find funding to do bigger studies for a greater understanding. I call that, even in these early stages, as a big win.

Sometimes researchers go down a path looking for specific answers, but a bit like any journey they sometimes encounter unexpected results - good and bad. Unless we are offering ourselves up to be looked at, it makes some of these discoveries very had to come by.

I am very excited by what is actually beginning to happen, and I'd rather focus on the future than studies we might or might not be committed to as a sure-fire means of finding answers.

The Low Carb Programme from this very site is available through some surgeries....

Quite a lot now, along with some workplace arrangements, if you have a look at the DDM Health website. I was surprised myself when I looked about a week ago.

 

[AndBreathe]

This gets to the heart of the issue and the science will have to get the bottom of it. Although we are a large community of self-helpers, and ostensibly doing very well in many cases, it does not add up to a means of advancing objective knowlege.

To my mind, this is why it is very important that those of us who can participate in all manner of health research.

For example, the study I participated in a year or so ago, into heart health/failure in those with an historic diagnosis of T2 was ticking over nicely. A sub-set of participants was identified and sought of participants in remission from their T2. Both groups participated in the same research, undergoing the same examinations and tests.

Frankly, this activity is beginning to bring out questions and raising some eyebrows. I couldn't say it begs more questions than it answers, but it is leading to a desire to find funding to do bigger studies for a greater understanding. I call that, even in these early stages, as a big win.

Sometimes researchers go down a path looking for specific answers, but a bit like any journey they sometimes encounter unexpected results - good and bad. Unless we are offering ourselves up to be looked at, it makes some of these discoveries very had to come by.

I am very excited by what is actually beginning to happen, and I'd rather focus on the future than studies we might or might not be committed to as a sure-fire means of finding answers.

 

[Lupf]

There is indeed a dichotomy in what the NHS says and does.

yes, there is, and it is a good sign.
It is always good to check what people do and not what they tell you.
This applies to all parts of life. If everybody always would do what they have been told, we would still live in caves.
Progress is made one GP at a time.
New ideas and technologies are invented because someone did not read or adhere to the rule book.

 

[pixie1]

I have wondered whether any of our members with T2D has achieved remission through deliberate weight loss and then maintained it for at least a year whilst regaining no weight and, subject to that strict proviso, consuming as many carbs as they fancied. The investigators in the DiRECT trial take the view that this is what remission really means, i.e. being able to eat freely provided no weight gain. Literally all their participants who remained in remission after 2 years did not adopt a low carb to do it, so I am told.

Weight loss is the side effect of reducing glucose levels to maintain normal or near normal levels, through low carbing. Maintaining a low carb diet, then glucose levels and weight is also maintained. If carbohydrates start creeping into the diet and being as strict, then both glucose levels and weight start to increase. For me both go hand in hand. I cannot eat freely as I would rapidly increase my weight. I am 9 years in. I am dubious about the claims.