Reversing T2 versus lowering hba1c, LCHF versus low calorie

ajbod · May 24, 2023

As that link states early reduction in sugar levels is the trick to Beta cell improvement, not massive weight loss, low carb achieves a huge blood sugar drop rapidly. The main problem with type 2 diabetes, is the lack of action when prediabetic. That is the time the medical profession should pull out all the stops. Not wait until the situation is worse.
Personally i think everyone over the age of 25 - 30 should have an annual Hba1c, that way a trend can be spotted long before it becomes a real problem.

KennyA · May 24, 2023

Bad paw said:
I would respectfully suggest that it is the opponents of the low cal approach on here who are presenting the figures "artfully". Only the individuals who regained the weight were not still in remission after 5 years. 100% of those who maintained their weight loss were still in remission after 5 years. The method works, The failure of some people to continue to comply with the method after 5 years is not a feature of the low cal diet method but simply an indication of the failure of some of the individuals involved to keep it up it. In a drugs trial you would not include the people who initially started the trial, but then dropped out and stopped taking the drug, in the final results.
Opponents of the diet may be those who have themselves discovered their diabetes too late for it to work for themselves and do not want other newly diagnosed T2s, for whom it will probably work, to try it. Why would anyone want to prevent people who might benefit from it from trying it early while they still can?
Edit to add: Would you expect the low carb diet to work for people who didn't actually DO it/complete it? If not, why would yo expect the low cal diet to work for those who didn't do it?

You are suggesting that 100% of people who take part in a marathon finish it, because you only look at the ones who cross the finishing line.

This is classic survivor bias - "it was successful for everyone who made it through". No-one is suggesting that a small fraction (7%) of people on low-cal did not achieve and maintain remission in this study. But 93% dropped out, presumably because they could not maintain the lifestyle. We are not told about them. How realistic is it to recommend that sort of method as a route to managing a health condition?

Here's the actual figures.

Start of trial - 149 in each group (298 total) 40% of intervention participants were on meds compared to 84% in the control group.

after 1yr 68 of 149 (46%) in the intervention group were in remission
after 2yrs 53 of 149 (36%) in the intervention group were in remission
and
after 5yrs, of the 85 of the original 149 tracked for five years, 11 (23%) were in remission.

11 is 7% of the 149 original intervention cohort.

Lupf · May 24, 2023

Bad paw said:
A calorie is a "unit of energy equivalent to the heat energy needed to raise the temperature of 1 gram of water by 1 °C"
A calorie from fat is a unit of energy equivalent to the heat energy needed to raise the temperature of 1 gram of water by 1 °C
A calorie from carbs is a unit of energy equivalent to the heat energy needed to raise the temperature of 1 gram of water by 1 °C

It has no magical properties over calories from elsewhere. Cutting out carbs by itself will not produce weight loss. Only if the low carb diet is at the same time a low calorie diet, can that work. If you just replace the carbs calories with calories from other foods your weight will stay the same. I wonder if the "low carb same cals" people on here mistake their lower BGs as being an indicator of Diabetes remission instead of just blood glucose reduction, which is all it is.

A calorie is a unit of energy, but this is not the whole story.
Our body is not a combustion engine. Thus calories from carbs will have different effects than calories from fat.
Fatty foods are more satiating and reduce hunger. Sugary food give a quick fix and then make you hungry again in two hours.
This is how many people here have lost weight by simply changing diet to low carb without counting calories.

Furthermore just reducing calories will reduce your metabolic base rate, thus you will burn fewer calories and after a while you stop losing weight. More importantly you will always feel hungry, become miserable and give up at some point. In my view eating a "low calorie diet" is not sustainable in the long term. This leads to the well known yoyo dieting. On the other hand there are many people here who can sustain a lower BG/HbA1c and lower weight by having switched to a low carb high fat diet.

To lose weight one should evaluate the diet and consider changing it just as much as looking at the overall calories. Most of us can lose weight with a crash diet, i.e. not eating a lot for a limited period of time. However losing weight is the "easy" part, keeping the the weight from increasing again afterwards is the challenge. Your body needs to get the correct amount of calories and for this you need a sustainable solution. As carby and sugary food are addictive, they increase hunger, thus by replacing carbs with fat it is typically much easier to not gain the weight back. Personally, I have banned anything low fat from my diet.

Finally I am a fan of intermittent fasting. I've successfully lost 10 kg and reduced my HbA1c to the 40s with this method. On fast days I restrict to 800 calories with no carby foods, but you can eat lots of vegetables and soup, so I don't feel hungry. In my view Intermittent fasting is based on evolution, i.e. when our ancestors had no luck hunting they switched to fat burning.

Jaylee · May 24, 2023

Bad paw said:
i have read all the articles you posted. Thank you for showing them. Two have seriously dodgy commercial conflicts of interest. All are about improvements in the management of T2 - mainly BG. I have always accepted that low carb improves BG dramatically. But there is nothing anywhere, in any of them, regarding improvement n the root cause of T2 ie Beta cell malfunction. They do also say, - several of them, that low carb improves lipid counts. This was new to me. I am glad to have found this out - thank you. I shall bear it in mind when I consider the content of my new, post-reversal, diet composition which I am working on at the moment. Though I have to say that despite the high carb diet (50% carbs) I am using at the moment, my blood lipids ae tolerably good, especially my triglycerides which these articles suggest are raised by carbs. ie Jan 2023; Hba1c 38; 1Total chol 4.3; hdl 1.3 ratio 3.3; LDL 2.6 Trigs 0.81

Hi,

You’ve done pretty well lowering your HbA1c to 38. What was it when you were diagnosed?

sw600 · May 24, 2023

Bad paw said:
There is a newer trial called "Retune" for people at the lower end of the BMI scale, but who are also T2 because of excess fat deposition on the liver and pancreas. It involves losing only 8% f their weight. These people, though of normal weight, still have too much fat on the pancreas for their particular body type. They represent about 10% of T2s an are sometimes called "TOFIs" Thin on the outside fat on the inside.

"Participants’ BMI averaged 22.4 kg/m² at the end of the study (reduced from an average of 24.8 kg/m²).

About three quarters (70%) of participants went into remission from type 2 diabetes during the study, with 50% of these going into remission after the first weight loss cycle.

People needed to lose on average 8% of their body weight to go into remission.

In the 14 out of 20 people who went into remission, their average HbA1c fell from 53mmol/mol at the start of the study to 45mmol/mol. Their blood pressure dropped despite taking less medication to treat this.

The participants’ liver and pancreas fat levels were higher than expected at the start of the trial but then decreased to normal levels after weight loss.

Participants reported feeling satisfied with their weight loss and health improvements and didn’t find it hard to keep the weight they'd lost off. "

ReTUNE study shows type 2 remission possible for people with lower body weight

While we know that obesity increases the risk of developing type 2 diabetes, 10% of people with type 2 diabetes have a BMI that is not in the obesity or overweight category.

www.diabetes.org.uk

Thanks but my BMI is 21 to start with. If I lost 8% that would put me on 60kg at 177cm, which I would not be able to achieve without losing some muscle mass ie not healthy. My problem is not caused by being fat, inside or out.

Deleted member 475901 · May 24, 2023

Bad paw said:
Low carbing, by itself, will bring down BGs quite dramatically. Drugs will also bring BG down. But both of these have to be kept up for life if you want to keep BGs down. However T2 is a progressive disease, and unless you get it into remission, over the years your BGs will keep on increasing and you will have to take more and more drugs and/or eat lower and lower levels of carbs to keep up. The UK Prospective Diabetes study found that T2's had usually lost about 40% to 50% of their beta cell function before they were even diagnosed, and that from then on they lost about a further 4% of beta cell function a year. Also, sadly, that "conventional treatments cannot reverse it's progress". Hence if you can restore the function of the beta cells with a low cal diet you will have a better chance of keeping BGs down permanently - or for at least as long as you don't regain the weight lost. The figure of only 50% success rate on Direct trials so often bandied about by their opponents is misleading. It was 50% of those who started the diet. But many dropped out or did not succeed in losing the requisite 15% of their weight. 87% of those who did went into remission. And though again some more failed to keep the weight off, all of those who did maintained their remission. Of course that still leaves a few for whom it didn't work. But at least they tried and gave themselves a chance. Possibly their beta cells were weaker out the outset - who knows? We are all different.

Keto, low carb, even the cabbage soup diet will all work equally well for weight loss as long as they contain fewer calories than you use. It is how much you eat that matters, not whether you eat any particular foods. I personally simply ate exactly what I had been eating before - just half as much. I thought reducing calories took up quite enough of my will power without actually changing my diet as well. Now that I have got the weight loss thing over with I am looking to improve my diet a bit, especially reducing saturated fat.

You are making some very definitive statements here, which do not all align with others' experiences, current theories in total or our understanding of human biology. At best, they are theories among some very diverse, and often poorly designed, research.

The old stories about fat consumption did not add up - eating fat does not raise cholesterol as we produce that ourselves.

Anecdotal evidence from hundreds of us is that we can successfully get into remission without cutting fats or counting calories. My low carb diet contained more calories than I was previously eating. The support from the NHS for low calorie diets ignored the fact that researchers imposed, as a by product, a low carb diet in order to go very low calorie.
I also, as do many others, resolved a fatty liver by eating more fats and fewer calories.

Deleted member 475901 · May 24, 2023

Bad paw said:
"Low carb can cause visceral weight loss, the same as low calorie can"
I think this is the fundamental error re low carb. Some do low carb and don't replace the calories with calories from other nutrients. In this case it can bring about weight loss. Others reduce their carbs but replace the calories saved with other foods. If the two completely different types of low carb are constantly misused interchangeably then people may begin to think that simply swapping the carbs calories with other calories will bring about weight loss. It won't. It can't. Because for weight loss you need to reduce energy intake so that energy used it taken from the body's fat stores. Carb reduction by itself can cause weight loss, but if the calories ae just replaced with calories from elsewhere the energy intake will remain as before and so will the weight.
Only eating fewer calories will achieve weight loss. Calories from all sources have the same effect on weight. It is absolutely not just calories from carbs that increase weight. Calories from other nutrients do so as well. Although of course they don't have the same direct effect on BGs.

The naive calories in calories out theory was disputed then overturned years ago. Not all calories are the same.

There’s no sugar-coating it: All calories are not created equal - Harvard Health

The view that calories are calories regardless of their source has been shown to be outdated. Foods with a low glycemic index are better because they tend to raise blood sugar more slowly, and they...

www.health.harvard.edu

And as I posted, many of us eat more calories but still lose weight. I'd tried too many low calorie diets before this and low carb plus extra fats was the only one where I lose so much and kept most of it off after a few years. My lipids improved, my fatty liver went back to normal and yet I included larger quantities of cheese, butter, double cream, olive oil, coconut milk, nuts, etc. etc.

Brunneria · May 24, 2023

Bad paw said:
https://www.tandfonline.com/doi/full/10.1080/00325481.2020.1771047

As is apparent from the diagram high insulin levels only occur in pre diabetes and very early diabetes. After that the beta cells start to fail, and T2's have the opposite problem INSUFFICIENT INSULIN
"The first stage in the development of T2D is insulin resistance. During this time beta cells are stimulated to increase insulin secretion in order to maintain normal glucose levels [Citation10]. By the time T2D is diagnosed, around 40–50% of beta-cell function is already lost, with a further loss of 4–5% expected each year thereafter [Citation11–13]. As such, a better understanding of the pathophysiology of T2D has important therapeutic implications for the timely use of treatments that address insulin resistance and progressive beta-cell failure. For example, rather than relying solely on measurement of A1C, monitoring beta-cell function has the potential to provide invaluable information about disease status" my bold

it is apparent from the diagram that insulin resistance is a huge factor in T2 (and pre and early T2).
thankfully, lowering carb intake also reduces insulin resistance - with all the massive health benefits that brings. Excellent, eh? And not necessarily something that happens on low calorie diets…

Having said that, the diagram shown is very, very one dimensional, since it does not show the impact of T2 medications, or the effect of dietary changes, exercise, weight loss, etc. all of which can profoundly alter the T2 trajectory.

Looking at that diagram, one could very easily be mislead into thinking that all T2s are doomed (doomed, I say) to an inexorable escalation of insulin resistance, loss of insulin production, and loss of beta cells. Plus, apparently, all on a set schedule… Good job we know better, isn’t it?

Fortunately, there are many, many people here on the forum who have very, very different experiences.

My own experience is that carb restriction knocks calorie restriction out of the ball park, over the stands, and somewhere into the next county.

Bad paw · May 24, 2023

Jaylee said:
Hi,

You’ve done pretty well lowering your HbA1c to 38. What was it when you were diagnosed?

55

Bad paw · May 24, 2023

KennyA said:
You are suggesting that 100% of people who take part in a marathon finish it, because you only look at the ones who cross the finishing line.

This is classic survivor bias - "it was successful for everyone who made it through". No-one is suggesting that a small fraction (7%) of people on low-cal did not achieve and maintain remission in this study. But 93% dropped out, presumably because they could not maintain the lifestyle. We are not told about them. How realistic is it to recommend that sort of method as a route to managing a health condition?

Here's the actual figures.

Start of trial - 149 in each group (298 total) 40% of intervention participants were on meds compared to 84% in the control group.

after 1yr 68 of 149 (46%) in the intervention group were in remission
after 2yrs 53 of 149 (36%) in the intervention group were in remission
and
after 5yrs, of the 85 of the original 149 tracked for five years, 11 (23%) were in remission.

11 is 7% of the 149 original intervention cohort.

Again you are counting all the people "in the intervention group". The ones to count are ONLY the ones in the intervention group who lost the requisite amount of weight. The others who failed to lose the weight are not relevant to this count. You could hardly expect them to be in remission if they didn't do the diet, or didn't keep it up. As I asked earlier would you expect someone who didn't keep up the low carb diet to go into remission?
In the original cohort 87% of those who lost the required amount of weight were still in remission after a year
Personally I wold like to see further investigation into the unfortunate remainder - 13% who lost the necessary weight to find the reasons why. Were they a particular age group? Was it longer since their diagnosis? Did they have higher HBA1C at baseline? Did they have higher BMI at baseline? How could they be helped?

Sax · May 24, 2023

Even Taylor supports low carb as a route to achieve remission. If the person behind the Direct study says its one way to do it why not accept it:

British doctor pioneers low-carb diet as cure for obesity and type 2 diabetes

A lifestyle approach developed by Dr David Unwin shows benefits that could have significant health implications

www.theguardian.com

Note the irony of him saying people may find it hard to maintain, when most of his patients lose remission due to lack of a sustainable diet to move onto post weight loss. The low calorie diet is unsurvivable in the long term - humans can't live on 800 calories in the form of shakes. Going back to a normal diet is likely to lead to loss of remission as the higher carb intake - in my experience and also reflected in Taylors results - leads to rapid weight re-gain.

You are trying to separate remission into "true remission", and a category of "very good diet control". In reality its a spectrum. I can eat 130 - 150g of carbs OK, but as soon as I go above that it slips away, and I lost 30% of my body weight at peak.

Edit; read the study again. Most Direct patients who went into remission came back out of remission. They kept up the low calorie diet for the required period, but Taylor has no clue how to off-ramp his patients into a permanent stable safe diet that maintains that gain - if he did, he wouldn't have less and less in remission after each following year.

Bad paw · May 24, 2023

If people have done well on low carb diets then I applaud that. We all have to choose the approach that works best for us -including drugs if people prefer to use those to lower their BGs.
What concerns me is that whilst low carb can be done at any time, eg after low cal has been tried and failed, low cal has to be done as immediately after diagnosis as possible. There is a time limit after which it's chances of working to improve beta cell function and thereby reverse T2, dwindle. So I think it is vital that Newbies should be told about it while they are in with a chance of having it work for them. I have two much loved family members with T2. None of us knew of the low cal reversal method at the time they were diagnosed, -indeed it may not even have been discovered at that time -and it now saddens me to watch them struggle with their T2.

HSSS · May 25, 2023

Bad paw said:
If people have done well on low carb diets then I applaud that. We all have to choose the approach that works best for us -including drugs if people prefer to use those to lower their BGs.
What concerns me is that whilst low carb can be done at any time, eg after low cal has been tried and failed, low cal has to be done as immediately after diagnosis as possible. There is a time limit after which it's chances of working to improve beta cell function and thereby reverse T2, dwindle. So I think it is vital that Newbies should be told about it while they are in with a chance of having it work for them. I have two much loved family members with T2. None of us knew of the low cal reversal method at the time they were diagnosed, -indeed it may not even have been discovered at that time -and it now saddens me to watch them struggle with their T2.

This is getting repetitive.

What you mean is weight loss, particularly around the organs, to improve beta cell function, within a few years of diagnosis. That is what the Newcastle trial is about. They happened to use a low calorie method to achieve this. They have agreed any method of weight loss will do. You are fixed on method rather than the goal. They were not. So if you mean to reference that study you are getting the details wrong.

Then you have to decide what that weight loss actually achieves (IR reduction, beta cell recovery, something else?) and if it is sustainable by the method chosen (93% of the Newcastle trial didn’t find low enough calorie sustainable to achieve remission for 5yrs. Only 48% did at one year).

ajbod · May 25, 2023

Low carb treatment was the gold standard worldwide, BEFORE Insulin was discovered. It's been around far far longer than low calorie. We get caught up in supposed progress, forgetting what our ancestors learnt. You keep banging on that ONLY low calorie can improve the Pancreatic function. The truth is, nobody has studied properly the effects of low carb, because there is no money to be made out of it. Virtually all modern medical research programs have a specific aim, which is rarely the headline that it's published under. But always with an angle of huge INCOME!
The vast majority is funded by Pharmaceutical companies, who are not interested in curing anything, just the next must have lifelong drug therapy. KERCHINGGGGGG.
The low calorie short sharp shock treatment does work, but it is itself actually low carb. The major problem is the patients don't learn what is good for them to eat, so the few that can actually last the course, afterwards are back at square one, albeit lighter in weight. And as soon as they start eating a normal diet, ie what gave them diabetes in the first place, we all know where that's heading. Still as so many have to, they can always have another go.
As you are maintaining your remission and weight i applaud you, BUT you are very much in the minority. As the study showed VERY few can actually last the course, and remain in remission, you are one of the lucky ones.

KennyA · May 25, 2023

Bad paw said:
Again you are counting all the people "in the intervention group". The ones to count are ONLY the ones in the intervention group who lost the requisite amount of weight. The others who failed to lose the weight are not relevant to this count. You could hardly expect them to be in remission if they didn't do the diet, or didn't keep it up. As I asked earlier would you expect someone who didn't keep up the low carb diet to go into remission?
In the original cohort 87% of those who lost the required amount of weight were still in remission after a year
Personally I wold like to see further investigation into the unfortunate remainder - 13% who lost the necessary weight to find the reasons why. Were they a particular age group? Was it longer since their diagnosis? Did they have higher HBA1C at baseline? Did they have higher BMI at baseline? How could they be helped?

Yes. that is true. I am of course counting all the people who tried the intervention that was being tested. That is the point, and is the nature of scientific study - "We tested intervention X on 149 people, and at the end of five years we found 11 of the 149 (7%) to be in remission" is effectively just that.

People who do not comply with a low carb lifestyle or stay low carb may or may not stay in remission. If I followed your logic however I would be excluding all individuals who did not or could not comply and I would be claiming (as you have for low-calorie) high levels of success for low-carb. That would be (at best) junk science and faulty logic.

You, however, seem quite happy to count only the people for whom the intervention worked, and you claim that this is not a problem. You therefore want us to look at only the 11, out of the 149 starters, who crossed the marathon finish line. You are quite clear that you are excluding the 93% of the test subjects for whom low calorie was (on the evidence) not a sustainable option. I would say this is a classic case of survivor bias, but it is actually a bit unusual because you are fully aware of your conscious bias.

I don't expect you to agree with this because if you did your entire structure ( your quote - ...put diabetes, as opposed to just blood sugar, into remission, the only way is a calorie reduced diet) collapses.

The point of this is two-fold - personally , what works for an individual, and more widely, in terms of public health, what works for most people. The two may not be the same. It's the public health aspect that's in many ways most relevant - an intervention that sees 93% failure over 5 years is not one to recommend in general - while it may work for some individuals. On the evidence of this study, that would likely be a small (7%) proportion of the T2 population.

Bad paw · May 25, 2023

KennyA said:
Yes. that is true. I am of course counting all the people who tried the intervention that was being tested. That is the point, and is the nature of scientific study - "We tested intervention X on 149 people, and at the end of five years we found 11 of the 149 (7%) to be in remission" is effectively just that.

People who do not comply with a low carb lifestyle or stay low carb may or may not stay in remission. If I followed your logic however I would be excluding all individuals who did not or could not comply and I would be claiming (as you have for low-calorie) high levels of success for low-carb. That would be (at best) junk science and faulty logic.

You, however, seem quite happy to count only the people for whom the intervention worked, and you claim that this is not a problem. You therefore want us to look at only the 11, out of the 149 starters, who crossed the marathon finish line. You are quite clear that you are excluding the 93% of the test subjects for whom low calorie was (on the evidence) not a sustainable option. I would say this is a classic case of survivor bias, but it is actually a bit unusual because you are fully aware of your conscious bias.

I don't expect you to agree with this because if you did your entire structure ( your quote - ...put diabetes, as opposed to just blood sugar, into remission, the only way is a calorie reduced diet) collapses.

The point of this is two-fold - personally , what works for an individual, and more widely, in terms of public health, what works for most people. The two may not be the same. It's the public health aspect that's in many ways most relevant - an intervention that sees 93% failure over 5 years is not one to recommend in general - while it may work for some individuals. On the evidence of this study, that would likely be a small (7%) proportion of the T2 population.

I would not expect merely joining a study to cause reversal. Just losing 15% of your weight. Whether on a study or not.

KennyA · May 25, 2023

Bad paw said:
I would not expect merely joining a study to cause reversal. Just losing 15% of your weight. Whether on a study or not.

I don't recall anyone promoting the advantages of "merely joining a study" for either fat loss or glycaemic control. The point being made was that the intervention being studied failed to achieve remission at the five year mark for 93% of those in the low-calorie intervention group.

The question of whether a 15% weight loss triggers or would trigger "reversal" for everyone is separate. The evidence of several people (me included) on this thread is that blood glucose can be brought into normal range long before 15% weight loss has occurred. Since getting my blood sugar back in range, I have subsequently lost about 20% of body weight, having had a number of diabetic symptoms for some twelve years prior to my eventual diagnosis in 2019. The diabetic symptoms went as glycaemic control was achieved, not after fat loss.

Incidentally, what do you mean by reversal? Do you mean something different to remission? My working definition of remission (as used by my local GP practice) is blood sugars in normal range (that is, not above 42), for a continuous twelve month period, without medication use in that period. I don't use the term "reversal" as it carries an implication of a return to a former state.

CatsFive · May 26, 2023

Brunneria said:
<snip>doomed (doomed, I say) <snip>

Yes, Private Frazer!

Reversing T2 versus lowering hba1c, LCHF versus low calorie

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ReTUNE study shows type 2 remission possible for people with lower body weight

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There’s no sugar-coating it: All calories are not created equal - Harvard Health

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British doctor pioneers low-carb diet as cure for obesity and type 2 diabetes

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