March 7, 2017

Diseases

Is Type 2 Diabetes Reversible at Scale?

Read Time 6 minutes

If you’re reading this, you probably know that I’m obsessed with longevity. But to really understand longevity, you must understand metabolic health, insulin resistance and, by extension, one of its end-results: type 2 diabetes (T2D). Though my medical practice does not focus on type 2 diabetes, I have taken care of several patients with T2D over the past few years. When I was in medical school I was taught many things about T2D, but one stands out most: T2D is incurable, I was told. Once you have it, you’ve always got it, and the best one can do is “manage” it as a chronic—but irreversible—condition.

Image by CDC.gov

But is this really true? Asked another way, is T2D reversible?

My obsession is partly due to my personal journey to better metabolic health, which I’ve documented elsewhere on this blog, and spoken about publicly. But those facts alone, don’t fully explain why I wanted to be involved with Virta Health (I’ll get to them shortly). T2D is a massive societal problem that has the potential to literally bankrupt countries: More than 29 million Americans have T2D and more than 80 million are pre-diabetic. And whether you view it through the lens of population health, or the lens of an individual patient, T2D is perhaps the biggest healthcare challenge of our generation.

At the population level, T2D costs Americans more than $300 billion per year: one of every three Medicare dollars is spent on T2D, and one of every six healthcare dollars is spent on T2D. At the individual level, patients and payers (employers and insurance companies) spend thousands of dollars (often more than $10,000) in annual expenses for medications and procedures with significant side effects, and much higher risk of developing cardiovascular disease, cancer, Alzheimer’s disease, blindness, amputation and kidney disease.

The traditional approach—which is clearly not working—is to “manage” this chronic condition with medications and the ever-ubiquitous “eat-less-avoid-fat-exercise-more” lifestyle interventions. At best, this approach only slows down the progression of the disease. Furthermore, many diabetes drugs have their own side-effects and diabetes management has a dismal diabetes reversal rate of about 1%.  To date, the only clinically proven way to reverse T2D has been bariatric surgery, which is costly and not without risk. If one great thing has come from bariatric surgery, besides the obvious help to those have been successfully treated, it is that any physician or scientist paying attention to the results can’t help but notice that the reversal of T2D in these patients post-operatively seems uncoupled from their weight loss. In other words, adiposity, while correlated with T2D, is not likely the cause.

Every doctor has his (or her) “Patient 0”—the one who really got him (or her) thinking. I’d like to introduce you to mine, RB. When I met RB, he was a 37 year-old Mexican man with a family history of T2D who had a “high” glucose level on a screening blood test. His two-hour oral glucose tolerance test (OGTT) is below.

You don’t have to read these for a living to see this isn’t ideal. As you can see, his fasting glucose was 258 mg/dL and his fasting insulin, 30 uU/mL. When given 75 g of glucose, his glucose rose to 344 mg/dL at 60 minutes and 408 mg/dL at 120 minutes, all the while his insulin level fell from 30 to 24 to 23. These numbers alone confirm the diagnosis of T2D. But if we needed more evidence, his HbA1C was 9.7%, corresponding to an average blood glucose of 232 mg/dL (today the diagnosis of T2D is defined by HbA1C >= 6.5%, but I much prefer to use OGTT).

Ordinarily, for a patient with this degree of disease and beta-cell fatigue, I would have opted for at least two drugs, metformin (cheap) and a DPP4 inhibitor (not cheap) and most doctors would have gone straight to insulin, as well. However, due to the patient’s financial circumstances, we opted to only use metformin and dietary modification. The patient worked very long hours in construction and, frankly, was pretty much exercising all day, so there was no way adding more exercise to his day was going to work. If we were going to fix him, it had to be through nutrition. I spoke with one of my mentors, Dr. Naji Torbay, a remarkable endocrinologist who has the largest diabetes reversal program in Dubai and Lebanon, about this case. Even he thought it would be tough, but he’d reversed cases like this, so we gave it a shot.

What happened over the next 5 months surprised me, as even I did not anticipate the alacrity of RB’s reversal. Below is a snap shot of RB’s labs from March 1, 2016 about 5 months after the OGTT, above. On the right side you can see the results from September 28, 2015, including the HbA1C of 9.7%, the fasting glucose of 258 mg/dL, and the fasting insulin of 30 uU/mL (HOMA-IR calculated at 19.1).

As you can see, the HbA1C fell to 5.3%—that’s even below the threshold of pre-diabetes—and the fasting glucose and insulin fell to 102 and 10, respectively (HOMA-IR calculated at 2.5).

RB doesn’t have diabetes any more. RB will avoid the amputations that destroyed the lives of his family. RB will not die prematurely from heart disease in his 50s. RB got a new lease on life.

If you think I’m telling you this story to impress you, you’re mistaken. Countless doctors (though not enough) know how to do what I did with RB—it’s actually simple biochemistry, and if a former surgeon like me can learn it, certainly anyone can, as long as one has the ability to frequently and safely manage medications and guide necessary behavior change. But sadly, most people like RB don’t have this option, and even if I and countless other doctors devoted the rest of our lives to helping everyone like RB out there, we could not put a dent in this problem, which is where Virta Health comes in.

Disclosure: I am an advisor to Virta Health and I have invested in the company, because I believe their approach is the best one to solve this problem—not the other way around.

Is it possible to deliver systematic diabetes reversal results (like the case above) safely, sustainably, and at scale among average diabetics?

Of course, even with the correct biochemical/nutritional approach, there are number of challenges to make T2D reversal possible at scale:

  • Eliminating diabetes medications safely requires day-to-day (not monthly) careful adjustments by a physician. This is not how physicians work and would not be cost-efficient.
  • Anything nutrition related requires a very high degree of individualization based on health status, lifestyle preferences and other life circumstances. For the 1% DIY’ers (who probably disproportionally read blogs like this one) any extreme approach can work, but at a population level, it won’t be enough.
  • Both the patient and physician would need near real-time biomarker (e.g., CGM) data to adjust meds and the overall intervention. [By the way, I get asked all the time—mostly on Twitter—what CGM is…for those about to ask, here you go.]
  • All behavior change and lifestyle interventions have failed at scale because only a small fraction of the population is able to DIY through complex decisions in today’s environment and life circumstances. This would require a near real time “personal coach” who can address any situation (e.g., family struggle, travel, new job, holidays).

It appears that we may be a step closer to somebody solving this challenge. Today, the first results of a T2D reversal clinical trial were published in the Journal of Medical Internet Research that show a promising new way to look at T2D: it is reversible in a large percentage of average patients, safely and sustainably. The trial was conducted by Virta Health, an online diabetes reversal clinic, which uses technology and artificial intelligence to solve the above mentioned care delivery challenges. The entire intervention is managed by physicians and the nutritional approach is based on highly individualized carbohydrate restriction and nutritional ketosis (which I’ve written about extensively in the past and throughout this blog).

The trial took place in Lafayette, IN, in partnership with Indiana University Health.  A total of 262 women and men with T2D enrolled in the Virta Clinic. Average age was 54 (Stdev: 8); BMI 40.8 (Stdev: 8.9) and two-thirds of the patients were female.  The trial will continue for at least two years, and data from the first 70 days were published today.

After just ten weeks:

  • 56% of the diabetics enrolled achieved an HbA1C below the diabetic range (6.5%), while eliminating hypoglycemic medications
  • Almost 90% of insulin users had it either completely eliminated (close to 40%) or reduced
  • Mean body mass reduction was just over 7%, which is quite significant, but also shows that diabetes can be reversed before massive weight loss (i.e., it’s not the obesity that causes type 2 diabetes, which is consistent with the gastric bypass literature)
  • Patient completion rate was >90%, which is remarkably high in an outpatient-based intervention.
  • Reported feelings of hunger decreased from the pre-trial level (this seems to be a strong indication that will-power driven caloric restriction was not a factor in weight loss)
  • Importantly, there were no serious adverse events, no incidence of symptomatic hypoglycemia, and no incidents of ketoacidosis.

The trial is ongoing with one-year data expected to be published shortly.

Yes, this is only one clinical trial and 70 days is not very long, but these data force us to consider that there is another way to look at T2D: it is not a chronic condition that gets progressively worse. With the combination of the right science and technology, it can be reversed at scale and among average diabetics.  Clearly we need to look at the long-term success, and see many more patients succeed safely, but this is more promising than anything I have ever seen. I’ve seen some of the preliminary 1+ year analysis and the results look very impressive.  I look forward to sharing them as they become publicly available.

If you are interested, you can learn more about Virta and their diabetes reversal science here. I’m excited to be a very small part of this organization and I look forward to the day when every patient with T2D at least has the chance to try an approach that can potentially reverse their condition.

 

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.

181 Comments

  1. I was just having a conversation with a doctor about my Mom. She had adult onset diabetes. She is highly adverse to RX medication and decided to work on it with diet and supplements. For the last three years, her A1C has been in the normal range. Her endocrinologist said at her last appointment that he could not say “You are cured” because there is no cure for diabetes. But he also said he would have a hard time proving that she was, and under oath would not likely be able to say she was diabetic.

    I applaud your work and keeping us informed. Thank you.

  2. Hi, you wrote that ” To date, the only clinically proven way to reverse T2D has been bariatric surgery”. How about the studies of université of Newcastle an their next study similar to yours. Snipet from their page:”we have demonstrated that in many people who have had type 2 diabetes for up to 10 years, major weight loss returns insulin secretion to normal”. I cannot imagine that you are not aware of their two publications or more about diabetes reversal.

    • Thanks for sharing, Peter.

      I used to wonder what the goal should be; reference ranges in test results suggest EPA: 0.2 – 1.5% and DHA: 1.2 – 3.9% but I believe those could just be population averages and not necessarily ideal levels?

  3. The virtahealth blog mentions this very recent study/publication: http://diabetes.jmir.org/2017/1/e5/, with some well known names in the author list.

    I wonder if/why NuSi never(?) considered launching studies in this area, instead of supporting the nonsensical experiments by Hall et al.

    It’s also related to Gary Taube’s latest book. Do you still have any (professional) connections?

  4. Patient is insulin resistant but confused as to whether pre-diabetic. A1c 5.8-5.9 & fbs of 94-95 unchanged last 5 years before and after LCHF (Hyman EFGT 5/4/15 to current, avg 40-50 g carb/day). Excellent results for trig/HDL going to 68/66 from 4 @1yr, no hbp ever, bmi to 23 from 26.5, small LDL-p to 212, etc BUT no improvement A1c or fbs. Patient broke down last week and got first glucose meter and did lots of testing for typical meals resulting in projection of 101 average bg, not 130 indicated by A1c. Have you ever seen someone where CGM or representative metering indicates much LOWER avg blood glucose than A1c formulae?

    Where is the cutoff point for avoidance of atherosclerosis progression (patient has Agatston score last August 166, concentrated in widowmaker and a family history CHD) and other diabetic complications? Patient metering is 95-120 for vast majority of LCHF meals and had 96,145,92 (fasting/60min/90min ) after 100 gram carb cheat meal, with bg hardly ever going below bedtime and awake readings of 96. Do you believe like Jenny Ruhl in Blood Sugar 101 studies quoted that staying under 140 at all times will avoid most complications? Are Virta costs effective or necessary for borderline patients like the one mentioned here?.

  5. Dr. Attia: Sorry for being off-topic, but I am a little alarmed that you have stopped talking about the ketogenic diet altogether even when talking about diabetes.

    I never had any issues with being diabetic or even pre-diabetic. However, I was around 150 pounds overweight until I discovered your blog around 3 years back. Got convinced by your writings here to try the ketogenic diet and have been doing that for 3 years now. Lost around 135 pounds in 1.5 years and have maintained the loss for over a year now. I understand that you are now working on longevity etc. but would like to know if you have changed your opinion on the ketogenic diet? My blood work is all fine but it is a little disconcerting that you almost never publicly talk about ketosis anymore. I follow you on twitter etc. If you have changed your mind on the ketogenic diet – would be helpful to find out.

    Also, want to emphasize that your writings on the ketogenic diet have changed my life. I know you don’t get paid for this blog, so THANK YOU from me and from countless other people who have lost weight and become healthier because of your blog.

  6. Dr Attia,
    Have you written any articles that explain why blood glucose levels may rise drastically on a ketogenic diet? I have a friend who was warned he was pre-diabetic with a A1C of 5.6. I recommended a ketogenic diet, as I have had great results from it. After 4 months he has lost 26lb and is feeling good but went for an updated A1C and it was 7.6. Can you become or advance to being diabetic while on a ketogenic diet? He is still over weight and fairly sedentary, tends to stay in stress-mode and is usually up all night working while taking short naps during the night and day. Can stress (cortisol) cause such high BG levels when consuming a very low carb diet?
    Thanks for pointing me in the right direction.

    • Pretty much in the same situation as your friend, I am quite puzzled at where all this blood glucose come from…

  7. Since Lipase is an enzyme involved with the absorption of fats, would an HF/LC diet have anything to do with an elevation of someone’s Lipase level on their Hepatic Panel?
    TIA

  8. Dr. Attia,
    Incredibly grateful for all the information you have shared with us, you have improved mine and many lives around me.
    I am curious to know if having coffee in the morning hinders the benefits of IF? I’ve been doing IF for about 4 years, mostly because I feel like I function better fasted, easier to follow macros, more flexibility on the diet, plus it’s very convenient not having to prepare/eat food early before going to work. But I still want the other possible benefits, autophagy, insulin sensitivity, etc..

  9. I’ve shared with you on Twitter some basics in the past but I wanted to share more info. I was diagnosed with T2D in May 2015 with an A1C of 11.7, Fasting Glucose of 223, TC of 247, Trigs at 211, HDL 41, LDL 164. My doctor handed me a test kit and a prescription for Metformin. He also said “eventually you will be taking insulin, everyone does”. Worst day of my life! I hate needles!!!!!

    Most recent tests are: AIC of 5.6, Fasting Glucose 117, TC 153, Trigs 58, HDL 51, LDL 90. NO Metformin. I’m sure my numbers are even better now. I get new lab work soon.

    The solution: No bread, pasta, rice, potatoes. Real food only. Meat with fat, Eggs, Veggies, limited berries, butter, heavy cream. Basically Keto!

    All of this was accomplished doing research on everything Attia and others you reference! You, Dr. Peter Attia, saved my life! You have to have self discipline but how I feel today is all the motivation I need to continue.

    Thank you so much!!!!!!!!!!!!!!!!!

    p.s. I changed doctors. My new doctor said he’s never seen this before but keep doing what I’m doing.

  10. Hello Dr. Attia,

    Thank you so much for sharing the wealth of knowledge from your personal journey and research. I was just curious what is the best way to book a consultation appointment?

  11. Thank you for mentioning Virta Health. I was so excited to find out more about them on their web site. I live in an area of Colorado without good forward thinking doctors who know how to treat T2D, as you do. I was ready to jump on their bandwagon, when they told me they only take people under 70. I can’t tell you how disappointed I was. I am a very fit young LCHF 74 year old who just has a BG/IR problem. Any thoughts from you as to their reason for this?

  12. Dr. Attia,

    Do you think diet sodas containing artificial sweeteners such as aspartame, sucralose, acesulfame potassium, etc., contribute to body fat gain or interfere with losing body fat, assuming someone is eating the same number of calories and types of food they usually eat when not drinking diet soda?

  13. Peter, PLEASE write your book – your material is the first place I turn with any health questions. Recently my wife had bloods showing ‘high’ cholesterol. I read your entire series on cholesterol now she is WELL within the healthy range.

    Thanks.

  14. Wow – Virta Health looks like an amazing organization – I realized my doc (who is brilliant) is an advisor! I did have a question in relation to IR- I have read a few scientific articles claiming to prove how fat and protein cause IR by inhibiting the glucose transport pathway. If this is true, how do low carb/high(er) fat/normal protein diets work to decrease insulin levels and blood glucose? I wear a dexcom and see a rather large rise in blood glucose after I eat protein and to a lesser degree fat, but I am not entirely convinced that there isn’t a bigger part of a picture that isn’t being taken into account…what are your thoughts on this?

  15. The grandfather of my girlfriend is a type 2 diabetic and used to be severly overweight.
    He complained about being hardy able to get his bloodsugar below 200.
    The diabetis expert at his doctor´s office recommended a diet that consisted soley of carbs – pasta without fat in the sauce, milk rice with sugar etc..
    I could convince him to give keto a try instead.
    After the second meal on the first day of his diet his bloodsugar was 105…
    After 10 days he did not need his nighttime insulin shot anymore. Seems sensible to me as he allready had a tumor removed from his liver.
    Long story short – happy to hear that more people will have access to a quality dieatary intervention instead of pumping insulin into their bodies.

    • Kind of frustrating, isn’t it, Peter? What if he was just given this advice at the beginning? I’m sorry he had to go through so much, but glad you were there to help him.

  16. Aloha Dr.Attia!
    Our teacher Dr. B.L. Rassovsky told once, that the best way to get a patient to loose weight is to brake his jaw. It was a mental model of a true situation: when a patient has his jaw immobilized and eats only liquid food, in couple of weeks he looses an efficient amount of pounds. My question is: Having these real people with immobilized jaws, doomed to starve for a while, could we find out, when does the satiety click in their brain, while patents are on unusual diet. Is the brain chemistry involved in this case? does its profile improve/change within two- three weeks (I mean neurotransmitters)? does it correlate with new insulin sensitivity/C-peptide level, glucagon? How about cortisol level (are patients stressed by the situation during healing)?
    When we were getting into ABCs of diabetes, we were told, that there is a kind of diabetes that can manifest because of change in the brain activity after stress for example, not because the changes in pancreas itself. How much the brain chemistry imbalance would contribute into insulin resistance, does it change during immobilization. Are there any changes after returning to the usual diet?
    Psychologists are ambivalent about food addiction- does it really exist, or not. I think, some answers you could get from collaboration with neuroscientists.
    Thank you for TED talk about possible sequence: insulin resistance-> obesity. It makes sense.

    • The broken jaw question is basically one of putting someone on a full liquid diet, which is different from fasting. The composition of that FLD can vary greatly and will likely determine the efficacy (in resolving metabolic derangement) and misery (to the patient). It basically comes down to fuel partitioning. The sooner the patient’s RQ comes down and their obligate dependence on glycogen is mitigated, the better they get.

  17. On the standard blood test my insurance coverage allows, they test for Oxidized LDL.
    Is that of lesser or greater significance than the insignificant (when not related to LDL-P) LDL level?

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