Will I need insulin eventually?

[AndBreathe]

But you can't blame the HCPs themselves for that, maybe the system we have to work in. Sorry I get massively angry when i read posts moaning about HCPs when behind us is a massive, creaking, inefficient system that let's us all down, patient or HCP. Sure, there are a few bad apples among us but there are in all jobs but we are under enormous pressure day on day with very little time allocated to each patient. If you haven't heard about your course then chase it, chase it, chase it, don't sit back and wait. I can only go by what's on offer in my area. And you've said yourself uptake is low, so why then is that the HCPs fault that no education has been given. Too many people take absolutely no personal responsibility for their own long term conditions, the asthmatic who smokes, the diabetic who eats choc, etc yet expect the NHS to pick them up and sort them.out

Yes, I agree it is not possible to HCPs, lumbered with doing clinics they have no interest in to become experts in everything, however, as an example, I know that at least one of the nurses in my practise is a T2 herself. Surely to goodness they would have had the get up and go to do a bit of research for themselves? No. That appears not to be the case.

However, I also contend that diabetes is one of the NHS's most expensive conditions - partly of course, due to the pure numbers involved. Would you think that in the face of that workload and the hit ontheir drugs budget they might be interested in investigating at a practise level what could be done to help their patients move towards the successes of David Unwin and several other GPs are now doing. My bunch?

"No thanks, that's not for us" - a direct quote.

I fear there is a long, long, long way to go in the world of T2 before we see any seismic shift in longer term outcomes.

Tragic, beyond measure.

 

[AndBreathe]

But you can't blame the HCPs themselves for that, maybe the system we have to work in. Sorry I get massively angry when i read posts moaning about HCPs when behind us is a massive, creaking, inefficient system that let's us all down, patient or HCP. Sure, there are a few bad apples among us but there are in all jobs but we are under enormous pressure day on day with very little time allocated to each patient. If you haven't heard about your course then chase it, chase it, chase it, don't sit back and wait. I can only go by what's on offer in my area. And you've said yourself uptake is low, so why then is that the HCPs fault that no education has been given. Too many people take absolutely no personal responsibility for their own long term conditions, the asthmatic who smokes, the diabetic who eats choc, etc yet expect the NHS to pick them up and sort them.out

I agree there should be personal responsibility, but in my case I was told not to worry about my T2, "We'll look after that for you".

Really?

The response in my head at the time cannot be typed in this forum, but suffice to say, I felt differently.

 

[KennyA]

Yes, I agree it is not possible to HCPs, lumbered with doing clinics they have no interest in to become experts in everything, however, as an example, I know that at least one of the nurses in my practise is a T2 herself. Surely to goodness they would have had the get up and go to do a bit of research for themselves? No. That appears not to be the case.

However, I also contend that diabetes is one of the NHS's most expensive conditions - partly of course, due to the pure numbers involved. Would you think that in the face of that workload and the hit ontheir drugs budget they might be interested in investigating at a practise level what could be done to help their patients move towards the successes of David Unwin and several other GPs are now doing. My bunch?

"No thanks, that's not for us" - a direct quote.

I fear there is a long, long, long way to go in the world of T2 before we see any seismic shift in longer term outcomes.

Tragic, beyond measure.

You're right about costs. Diabetes takes up 9% of the NHS budget (around £9 billion), and is forecast to rise to 17% of budget by 2035. 75% of these direct costs go on dealing with the long-term vascular complications, rather than the disease itself. 90 % of the cost is attributable to Type 2. This doesn't include add-on costs that aren't met from the NHS budget - benefits etc.

All figures from Bilous and Donnelly Handbook of Diabetes 5th ed.

You'd think that at a national level someone would spot the potential for a huge saving, wouldn't you?

 

[ianf0ster]

Of course it isn't inevitable that a T2D will end up on insulin, though restricting treatment for a dietary disease to medication only is certainly a way of increasing that risk.

@KennyA, @HairySmurf , I feel highlighting the 5 yr 93% failure rate (of maintaining T2D remission) for Prof Taylor's group is rather unfair, because of those who can't make the transition to 'normal healthy eating for a T2 diabetic' as the @ravensmitten, experience shows that is far from easy. Nor is it easy to maintain remission by Low Carb WOE because of either not finding a sustainable Low Carb in the first place, or of not monitoring 'carb creep'. but at least both 1yr and longer-term success rates as evidence both by Virta and Dr Unwin are better than for ND.

In my opinion, this personal fat threshold hypothesis is far from proven and clouds the issues of maintaining remission. In the 'blue' forum, because of Taylor's idea, there are people who say that remission is only possible if a person loses weight by calorie restriction rather than by a low carb WOE. In other words, by suffering hunger (no gain without pain). Some of them claim to be 'cured of T2D' in that they can eat as per 'EATWELL' , however I suspect that it's just that their luck just has not run out - yet!

 

[HairySmurf]

I don't think a 93% failure constitutes success, and that's what their own figures show from the five year DIRECT follow-up. Like many others, you've been taken in by the press releases. I don't think you were a member of these forums when the Taylor material was published, so you may have missed the thread that dealt with this - worth a read.

Direct Study - 5 Year Follow Up

https://www.diabetes.org.uk/about_us/news/weight-loss-can-put-type-2-diabetes-remission-least-five-years-reveal-latest-findings This hit the news channels yesterday, only picking up on it now. Not as inspiring as I might have hoped. Think I remember the initial headline data spoke about...

www.diabetes.co.uk

You're suggesting that I've been taken in by press releases, while directing me to a thread, from April last year, that discusses... a press release.

The actual 5 year follow-up paper was published just last week:

https://www.thelancet.com/journals/landia/article/PIIS2213-8587(23)00385-6/fulltext

93% failure, 5 years on from a soup & milkshake diet administered in a primary care setting, to a group of Type 2s chosen at random, several years after diagnosis for many. A paper illustrating that those who achieved 'remission' at 1 year (46%) and kept the weight off (perhaps those who continued to take it more seriously than the average randomer?) are still largely in 'remission'.

The Newcastle diet was successful relative to other non-surgical weight loss 'interventions' that have been attempted over the years (to tackle obesity), but was never going to instil the weight management disciple needed for long-term 'remission' success. The actual success rate for highly-motivated, newly-diagnosed Type 2s who lose a load of weight fast after diagnosis and keep it off long-term will likely go unrecorded in the annals of medical wisdom for some time to come, much as the successes of highly-motivated adherents of a low-carb diet do at present.

 

[HairySmurf]

@KennyA, @HairySmurf , I feel highlighting the 5 yr 93% failure rate (of maintaining T2D remission) for Prof Taylor's group is rather unfair, because of those who can't make the transition to 'normal healthy eating for a T2 diabetic' as the @ravensmitten, experience shows that is far from easy. Nor is it easy to maintain remission by Low Carb WOE because of either not finding a sustainable Low Carb in the first place, or of not monitoring 'carb creep'. but at least both 1yr and longer-term success rates as evidence both by Virta and Dr Unwin are better than for ND.

You are of course correct that it's far from easy, and my previous post suggesting it's all about disciple was unfair. I'm currently trying low-carb breakfasts and I'm find it hard. I find myself craving 'more' after eating, even though I don't feel hungry as such - I have a unfilled craving after eating. I've felt the same way after evening meals over the past few months while I've been on a moderate-carb weight-loss diet - a craving for more despite feeling my belly is full enough. I'd compare it to the craving for cigarettes when I gave up smoking - an urge to fill a hole and doesn't really need to be filled - the craving of an addict rather than simple hunger. I have no doubt that keeping the weight off when I do hit my target is going to be rough, a daily challenge for perhaps the rest of my life.

 

[KennyA]

You're suggesting that I've been taken in by press releases, while directing me to a thread, from April last year, that discusses... a press release.

The actual 5 year follow-up paper was published just last week:

https://www.thelancet.com/journals/landia/article/PIIS2213-8587(23)00385-6/fulltext

93% failure, 5 years on from a soup & milkshake diet administered in a primary care setting, to a group of Type 2s chosen at random, several years after diagnosis for many. A paper illustrating that those who achieved 'remission' at 1 year (46%) and kept the weight off (perhaps those who continued to take it more seriously than the average randomer?) are still largely in 'remission'.

The Newcastle diet was successful relative to other non-surgical weight loss 'interventions' that have been attempted over the years (to tackle obesity), but was never going to instil the weight management disciple needed for long-term 'remission' success. The actual success rate for highly-motivated, newly-diagnosed Type 2s who lose a load of weight fast after diagnosis and keep it off long-term will likely go unrecorded in the annals of medical wisdom for some time to come, much as the successes of highly-motivated adherents of a low-carb diet do at present.

Indeed I did, because it demonstrates that the press release (which gained a lot of media attention last year) cynically obscures what actually happened.

And the link to the Lancet is the same paper trailed last year. If you look at the findings, this is the claim:

At 5 years, DiRECT extension participants (n=85) lost an average of 6·1 kg, with 11 (13%) of 85 in remission

The actual group was very definitely not a random selection of T2s.

Individuals were aged 20–65 years, who were diagnosed with type 2 diabetes within the previous 6 years, were living in Scotland and northeast England, had a BMI of 27 to 45 kg/m2, and [who] were not receiving insulin

149 were assigned to the intervention group. So of those, after five years, eleven were in remission. That's 7% of the original intervention group. And the definition of remission they used is an A1c of under 48, regardless of medication status. So maybe 7% is generous.

 

[ianf0ster]

Yes as @KennyA says, the original group in the first Direct study were anything but random T2D's. In comparison Dr Unwin's low carb T2D patients were merely selected by their willingness to try it - no matter what BMI, insulin dependance, or how long since original diagnosis. And he still had a better success rate - though there was limited organised support from Dr Unwin and his wife if they wanted it.

So, one might claim that availability of some support (such as this forum) may be a much bigger factor than the particular non-medical route taken.
Certainly both Dr Michael Mosely a well known British TV medical journalist with a medical degree whose dieting/diabetes books started out as strictly very low Calorie and incorporated more low carb over the years and even Roy Taylor himself have acknowledged the role of carbs int their recorded talks (even in a very low calorie diet.
Michael Mosely has recently further started talking about the role of Ultra Processed Foods (especially since Dr Chris van Tulleken started publicising the problem regarding obesity).

Edited to add link to Chris van Tullekan video:

 

[Melgar]

He has proved it, in the majority of cases, conclusively. The numbers are in his papers - lower fasting BG despite lower fasting insulin secretion - the liver is secreting less glucose even though the level of insulin needed to suppress it is less. Lower insulin resistance in the liver. The 12 month postprandial insulin numbers show greatly improved insulin secretion capability over time following fat reduction in the pancreas. Unless something else is going on in all the test cases over those 12 months apart from the initial weight loss, it's the weight loss.

A low carb diet will lower BG levels immediately - no surprise there. I've also read several times on this forum that fasting BG levels are the 'last to fall' on a low carb diet. Last to fall meaning following some weight loss? Or have I misunderstood? How long does it take the average Type 2 adopting a low carb diet to see BG levels drop from a high level to the 'normal' range first thing in the morning?

I don't deny anyone's lived experience or accounts on this forum. I would point out though that even Taylor doesn't claim weight loss works for everyone who has been diagnosed Type 2. Type 2 was defined by exclusion after all - it very probably encompasses a number of similar conditions which are difficult to distinguish and diagnose. This paper (free PDF linked on the page) lists 13 'major' forms of atypical diabetes, many (or most?) of which I believe get diagnosed as generic Type 2. Who knows how many 'minor' forms are known or suspected, or will be identified in future. Taylor being entirely right and contradictory personal experiences are not mutually exclusive.

Atypical Diabetes: What Have We Learned and What Does the Future Hold?

As our understanding of the pathophysiology of diabetes evolves, we increasingly recognize that many patients may have a form of diabetes that does not nea

diabetesjournals.org

I agree with that statement. Your link on 'Atypical diabetes' was an informative read. Bear in mind they don't know whether I am type 1 or 2, so with that in mind, I still have one foot in the T2 camp, I have thought for some time they simply push everyone into a type 2 diagnosis even though they are displaying atypical reasons for their raised blood sugars that simply don't fit within the T2 diagnostic pattern. These individuals' blood sugars remain stubbornly high despite living a lifestyle that, according to the medical establishment, is the very lifestyle they are advocating T2 diabetics adhere too in order to lower their blood sugars to within the normal healthy range! There is something seriously amiss. One could argue that for these individuals it is an insulin secretion issue, that it has nothing to do with lifestyle, but genetics. Even if these individuals are at the low end normal weight, very fit ( when I talk about fitness I am not talking about a kick around on a Saturday afternoon's game of football, but a sustained program of training) and eat a reduced carb diet, in all honesty would and should bring blood sugars down, but it doesn't, or if it does then by not much.

A number of people, and many people on this forum are perplexed as to why they even have prediabetes /diabetes because they are thin, very fit and eat a healthy are definitely atypical. It seems to me like two different diseases.

 

[AndBreathe]

You're suggesting that I've been taken in by press releases, while directing me to a thread, from April last year, that discusses... a press release.

The actual 5 year follow-up paper was published just last week:

https://www.thelancet.com/journals/landia/article/PIIS2213-8587(23)00385-6/fulltext

93% failure, 5 years on from a soup & milkshake diet administered in a primary care setting, to a group of Type 2s chosen at random, several years after diagnosis for many. A paper illustrating that those who achieved 'remission' at 1 year (46%) and kept the weight off (perhaps those who continued to take it more seriously than the average randomer?) are still largely in 'remission'.

The Newcastle diet was successful relative to other non-surgical weight loss 'interventions' that have been attempted over the years (to tackle obesity), but was never going to instil the weight management disciple needed for long-term 'remission' success. The actual success rate for highly-motivated, newly-diagnosed Type 2s who lose a load of weight fast after diagnosis and keep it off long-term will likely go unrecorded in the annals of medical wisdom for some time to come, much as the successes of highly-motivated adherents of a low-carb diet do at present.

The random aspects of the study (and almost all other randomised studies) is merely a selection for, in this case, the soup and shakes approach or “standard care”.

as I understand it, participants were volunteers, understanding that randomisation. They were not individuals selected randomly from a Newcastle population of T2s. I can only imagine that to have volunteered, and signed up for 12 weeks of what I would find mind crushingly boring eating they volunteers must have been somewhat motivated at the outset at least.

 

[HairySmurf]

The random aspects of the study (and almost all other randomised studies) is merely a selection for, in this case, the soup and shakes approach or “standard care”.

as I understand it, participants were volunteers, understanding that randomisation. They were not individuals selected randomly from a Newcastle population of T2s. I can only imagine that to have volunteered, and signed up for 12 weeks of what I would find mind crushingly boring eating they volunteers must have been somewhat motivated at the outset at least.

Entirely correct in that it was not a truly random selection of T2s. There were selection criteria. However in a randomized control trial the participants are not told what they are signing up for. Willing and motivated to participate in a study yes. Willing to go on a 12 week soup and shake diet in an attempt to put their diabetes into remission through weight loss? The control group weren't even told that much until two years later.

My point about randomness was to illustrate how people who know exactly what they're signing up for and why they're doing it might might get better results, as a percentage of participants, than a group who are willing to participate in a study of some kind without knowing the details or the potential benefits in advance. Getting the weight loss done as soon as possible after diagnosis is another factor. Some data from the NHS Pathway to Remission programme is due soon. I for one am very interested to read how that's going - whether they beat Taylor's 46% at year 1.

 

[HSSS]

But you can't blame the HCPs themselves for that, maybe the system we have to work in. Sorry I get massively angry when i read posts moaning about HCPs when behind us is a massive, creaking, inefficient system that let's us all down, patient or HCP. Sure, there are a few bad apples among us but there are in all jobs but we are under enormous pressure day on day with very little time allocated to each patient. If you haven't heard about your course then chase it, chase it, chase it, don't sit back and wait. I can only go by what's on offer in my area. And you've said yourself uptake is low, so why then is that the HCPs fault that no education has been given. Too many people take absolutely no personal responsibility for their own long term conditions, the asthmatic who smokes, the diabetic who eats choc, etc yet expect the NHS to pick them up and sort them.out

Sure the entire system is buckling and you have a thankless task and there are indeed many patients who don’t help themselves.

But.
We see in here all the time keen motivated people who have been given frankly terrible advice if given any at all beyond “lose weight”. How can they help themselves if they are not given all the options available? Or the course they go on, eventually, is a rehash of the eatwell plate (all courses are not the same in all areas) telling them bananas, oats, and wholemeal bread are a good idea. Yes for some it’s a step in a better direction but let’s be real the bar isn’t set high and so many HCP still believe it’s progressive so what’s the point making people miserable with a more rigorous diet options. Or worse are so out of date they think low carb is having one sandwich less a day. As I said it’s about laying out ALL the options and helping the patient choose the one that they feel they can stick with long term and reviewing that regularly.

 

[AndBreathe]

Entirely correct in that it was not a truly random selection of T2s. There were selection criteria. However in a randomized control trial the participants are not told what they are signing up for. Willing and motivated to participate in a study yes. Willing to go on a 12 week soup and shake diet in an attempt to put their diabetes into remission through weight loss? The control group weren't even told that much until two years later.

My point about randomness was to illustrate how people who know exactly what they're signing up for and why they're doing it might might get better results, as a percentage of participants, than a group who are willing to participate in a study of some kind without knowing the details or the potential benefits in advance. Getting the weight loss done as soon as possible after diagnosis is another factor. Some data from the NHS Pathway to Remission programme is due soon. I for one am very interested to read how that's going - whether they beat Taylor's 46% at year 1.

Participants sign up on the basis they will be assigned to either group, randomly.

participants will (or should) understand the study objectives before signing up. Nobody in their right mind would or should sign up for a study without understanding the risks and/or rewards. How could they possibly give the necessary informed conset?

 

[VashtiB]

I think you also fail to acknowledge the proportion of T2 who have little to no interest in modifying their eating Gand drinking.

I am involved in research at our local NIHR, and am repeatedly shocked and disappointed by the number off T2 delegates only interested in the next wonder drug that’ll allow them to carry on as if no diagnosis ever occurred.

Cries of, “ I could never give up bread”, “I do an active job” “I’m just a bad diabetic”, or such like abound, even when neuropathy, strokes or cardiac illness is already in their medical history.

I agree with this. I think sometimes as a society we have got perhaps a little too used to 'having a pill for everything'. I find it so sad when I talk to people and they automatically assume that they can't do low carb without actually considering it.

Many here will remember my pity party when first diagnosed and realising that I would need to go low carb. I did well and truely feel sorry for myself.

I also have a very difficult relationship with food. I also have struggled for many years- if there was an Olympics event about counting calories I could compete for Australia. My answer has been to go very low carb. I am not fortunate enough to be able to sustain a way of eating that allows more carbs. Very low carb is what has worked for me. I will freely admit that I did find it challenging and still do from time to time but it's something I have been able to sustain.

But there is no one size fits all. We all need to deal the hand we have been dealt with and make decisions that are right for us. For some people that does mean taking insulin. In others that means lowering your their carb intake. What for me is important is that you try to manage your blood sugar levels so as to avoid the consequences of high levels. It needs to be a way that allows you to live your life as fully as possible. Diabetes is only a part of the equation.

So my response to @Talya2022 is I don't know whether you will need insulin or not- all I can say is that it's great that you are controlling your levels and I hope that continues. Good luck

 

[Melgar]

I am stating the obvious here, but I know a number of people who would rather take blood sugar lowering meds than go on a diet that reduces their blood sugars down into the 'normal' range. They will make concessions for sure, but they will not reduce their carbs enough to achieve recession. I know of at least two people in my circle who say they would rather die 5 years early than live on a diet that makes them feel miserable for the remainder of their lives. People make choices about how they live their lives out, not through ignorance or lack of will power, but choice. It would certainly be a sin if they were not informed of the consequences of high blood sugar for sure, but when they know the consequences and opt for meds and not diet, it is their choice. I would also add that diabetes is a slow killer, as we all know. The consequences of high blood sugars are not felt until blood sugars hit a certain level and people feel ill from it, feeling like hell is a motivator for change. Unlike other food intolerances where the effects are dramatic and immediately unpleasant, people can live their lives and not even know they have high blood sugars. So sticking to these strict diets can be challenge, no matter how many carb free delicious recipies are shown to them. It's about informed choices.

 

[HairySmurf]

Participants sign up on the basis they will be assigned to either group, randomly.

participants will (or should) understand the study objectives before signing up. Nobody in their right mind would or should sign up for a study without understanding the risks and/or rewards. How could they possibly give the necessary informed conset?

That's not how it works. Telling people what the objectives of a controlled trial of this nature is might distort the results. If you told everyone that the scientists behind the trial believed weight loss might 'reverse' their diabetes then some participants would likely take action of their own accord. The DiRECT trial was a test of of a weight loss intervention, a thing that can be prescribed to people, not a test of the actions people might take given specific, unproven information. I'd be very surprised if the 'intervention' group in the trial were told more than it was a study of the effects of weight loss on diabetes, and the control group definitely weren't told until after the 2 year data were gathered, otherwise they wouldn't be a useful control.

EDIT - This is false, my apologies. DiRECT was the second trial based on weight loss, so the results of the first trial would have been available to all participants. I read that the results were not shared with the control group until after the 2 year mark and this is true, though the effects of weight loss in an intensively controlled setting were already established, so no reason not to share with all participants.

 

[AndBreathe]

That's not how it works. Telling people what the objectives of a controlled trial of this nature is might distort the results. If you told everyone that the scientists behind the trial believed weight loss might 'reverse' their diabetes then some participants would likely take action of their own accord. The DiRECT trial was a test of of a weight loss intervention, a thing that can be prescribed to people, not a test of the actions people might take given specific, unproven information. I'd be very surprised if the 'intervention' group in the trial were told more than it was a study of the effects of weight loss on diabetes, and the control group definitely weren't told until after the 2 year data were gathered, otherwise they wouldn't be a useful control.

So, in your world, participants sign up for a great big, unquantified adventure?

No wonder research recruitment can be challenging.

As a matter of interest, have you ever participated in the sort of mystery trial you describ?

 

[HairySmurf]

So, in your world, participants sign up for a great big, unquantified adventure?

No wonder research recruitment can be challenging.

As a matter of interest, have you ever participated in the sort of mystery trial you describ?

Apologies, you are correct and I was making bad assumptions based on something I read. I'm an idiot.

 

[Sally66]

I think it is important to remember the multitude of factors that lead to Type 2. I went on the course and was fascinated to notice that the only overweight people in the room were the two NHS ladies delivering the course neither of whom had Type 2. It was an excellent course. It was explained to me that weight gain is as much a symptom of type 2 as a cause. The function of the pancreas and liver also explained very well. Low carb clearly is the key to BG control and weight loss comes as a result. As we age our organs are less efficient, we slow down and mobility reduces. It is therefore, clear that glucose control over time will become more of a struggle. Whilst we are able to eat healthily and exercise it is possible to have a diet where we can enjoy food and avoid craving carbs.

One thing I think is very important to understand are the psychological impacts of aType2 diagnosis. Those with previous or existing eating disorders will be aware that this is a psychological illness. I don’t know of any research studies into this but it would not surprise me at all if, in fact, that illness may have contributed to your diabetic condition. Stress and trauma most certainly is a significant factor.

 

[AndBreathe]

Apologies, you are correct and I was making bad assumptions based on something I read. I'm an idiot.

If you live near to an NIHR, honestly, get involved. It is fascinating.

These days a lot of their focus groups and PPI involvement is done via Teams, so it is possible to be involved from afar.

I have participated in research, been a Co-author on study output published papers and regularly give feedback on proposed studies. I have also declined to participate in one study, not because I felt it unethical or unsafe, but I plain old didn’t fancy being randomly selected into the “active treatment” group, so there is a lot of info up front and plenty time to research and consider active participation, or not, in any given study.

Informed consent, and the right to withdraw, is taken very seriously.

There is a lot to be involved with, if you want to.