…I agree with the initial effectiveness of severe calorie restriction and intermittent fasting as short-term interventions in diabetic reversal. For overweight and obese individuals, it’s far easier to reduce food intake by 1,000 calories per day for several weeks than trying to burn 1,000 calories on the treadmill everyday.
Historical Background
Diabetes was a rare mysterious disease that had been documented for centuries. An ancient Egyptian manuscript described it as a disease with “too great emptying of urine”. A famous 5th century BC Indian surgeon, Sushrata, used the term “madhumeha”, which means “honey-like urine” to describe it. He mentioned that the sweet taste attracted ants and perfectly observed that the disease affected mainly the rich castes, due to the excessive consumption of rice, cereals and sweets.
Going by the symptom of frequent urination, Aretaeus, a 2nd century AD physician, introduced the term “diabetes”, which means to “pass through” or “siphon” in Greek. The English physician, Thomas Willis, who was not aware of Sushrata’s observation several centuries earlier, rediscovered the sweetness of urine in patients with diabetes. He described the disease as “pissing evil” and added the word “mellitus” (honey sweet) in 1675, to distinguish it from other kinds of diabetes. Diabetes ceased to be a fatal disease in 1922, when life-saving insulin was discovered in Toronto, Canada, and the oral anti-diabetes medicines were introduced in 1950s.
Insulin Resistance and Diabetes
According to International Diabetes Federation, diabetes is a chronic disease that occurs when the pancreas is no longer able to make insulin, or when the body cannot make good use of the insulin it produces, otherwise called insulin resistance. In spite of better understanding of the pathological progression of the disease, the conventional treatment of diabetes continues to be glucose-centered, as it was centuries ago.
The present clinical guidelines of the sequential addition of medications to lower blood glucose has been attributed to treating an infectious condition with Tylenol or Panadol to control the symptom of fever, without addressing the underlying disease with antibiotics. Therefore failure to target the underlying insulin resistance explains why the diabetes is regarded as a progressive lifelong medical condition. In fact, a study showed that about 50 per cent of patients with diabetes would ultimately require insulin shots within 10 years, in spite of aggressive glucose-lowering oral medications.
Insulin Resistance in Skeletal Muscle
Glucose dissolves in water and therefore cannot be stored efficiently but can be converted to “dry” storable sugar in the form of glycogen. However, the glycogen depots are limited and only the skeletal muscle and liver are specialised organs for storage of this sugar molecule. For example, a lean adult can only store up to 120 grams of glycogen in the liver, while the skeletal muscle can store about 400 grams. Therefore, to prevent high levels of blood glucose, significant amounts of it must be used right away as energy, while the rest has to be stored as glycogen or converted to fat by the liver.
In the diabetes condition, the core disease is insulin resistance and the rise in blood sugar is the symptom of this core defect. The chronic presence of blood glucose therefore puts pressure on the pancreas to secret excess insulin. The question is: What causes insulin resistance in spite of excessive insulin secretion? The simplest and obvious answer is that once glycogen depots are filled and individuals are routinely inactive, the muscle’s ability to pick up blood glucose is reduced or shut off. Given the fact that the muscle is responsible for 80 per cent of (insulin induced) blood glucose removal, this leaves high levels of glucose in the bloodstream. Therefore insulin resistance occurs first in the skeletal muscle and has been implicated in the early onset of diabetes. Over time, excessive amounts of blood insulin, in response to high blood sugar, results in insulin resistance in the liver (hepatic insulin resistance).
Insulin Resistance In the Liver and Fat Toxicity
In normal condition, the liver can store glucose as glycogen during feeding and make glucose from the scratch during overnight sleep and between meal times (fasting periods). However, in insulin resistance state, the liver begins to make glucose non-stop during fasting and feeding periods and thus worsening the blood glucose levels.
The long-term presence of high levels of blood glucose is injurious to the circulatory system and negatively affects whole health. To limit the effects of glucose toxicity, the liver is stimulated to continuously use glucose to make, store and export fat to distant organs. Unlike glycogen, whose storage is only limited to the liver and muscle, once the fat depots in the buttocks and under the skin are filled, excess fat from the liver can be exported and deposited inappropriately to any part of the body, except the brain, where they impair the normal functioning of the affected organs (lipotoxicity or fat toxicity). These “endogenous” fats, in addition to dietary sources, explain why obesity is closely linked with diabetes. In other words, obesity and diabetes are co-travellers and studies show that 90 per cent of people living with type 2 diabetes are overweight or obese.
For healthy individuals, everyone can do without the extra plate, and no one would starve by skipping meals now and then, as it forces the body to draw from fat stores and promotes good health. In other words, intermittent fasting, calorie restrictions and regular physical activity are generally safe for a healthy population.
Severe Calorie Restriction and Diabetes Reversal
Moderate and sustained weight loss of 5 to 10 percent has been reported to decrease fasting blood sugar and reduce the need for multiple diabetes medicines. In fact, a study demonstrated that dramatic weight loss following bariatric surgery reversed type 2 diabetes in obese patients and about 90 per cent of these patients remained in remission after 10 years. Professor Roy Taylor of Newcastle University thought this dramatic diabetes reversal couldn’t have been due to the surgical effects, as he observed that these patients underwent surgery solely for weight loss and that restoration of normal fasting blood glucose occurred within a few days, long before weight loss occurred.
He proposed that fasting sugar normalisation was due to sudden decline in fat stores in the liver, as the body is forced to turn inward for energy substrates due to sudden forced food restriction from the surgery. In a 2011 landmark study, Professor Roy Taylor reproduced diabetic reversal with severe calorie restriction of 600-800 calories per day among 11 overweight and obese participants in eight weeks. Using Magnetic Resonance Imaging, he reported a decrease in liver fat stores by 30 per cent within 7 days and these continued to decrease throughout the eight weeks to match the control non-diabetic group. The glucose production by the liver also decreased from 2.40 to 1.59 and remained normal throughout the study. Over the period of the study, fat stores in the pancreas declined progressively from 8 per cent to 6.2 per cent. The integrity of pancreatic insulin secretion steadily increased with decreasing fat content and was no different from the non-diabetic group in eight weeks. In a 2017 follow-up study consisting treatment group of 149 subjects, he and his colleagues reported 68 per cent diabetic reversal that was sustained for one year. With average weight loss of 33 pounds, the diabetic remission persisted even though the participants were still overweight and obese and some had been diabetic for up to six years.
However, these studies reported poor compliance with recommended physical activity, but the participants who were highly motivated complied with severe calorie restrictions. With poor outcomes in weight control in the last 30 years, long term compliance with severe food restrictions and diabetic reversal remains to be seen.
Conclusion
A Toronto nephrologist, Dr. Jason Fung, who has keen interest in diabetic reversal, recommends intermittent fasting, which helps to promote whole body fat depletion, reduce high levels of insulin and facilitate overall weight loss. He described diabetes as a “dietary disease” that can only be resolved with diets and not multiple medications.
As a physical activity advocate, I agree with the initial effectiveness of severe calorie restriction and intermittent fasting as short-term interventions in diabetic reversal. For overweight and obese individuals, it’s far easier to reduce food intake by 1,000 calories per day for several weeks than trying to burn 1,000 calories on the treadmill everyday.
However, humans have survived for centuries in “high physical activity flux”, where physical exertions come before consumption. In fact, modern hunting and gathering societies continue this pattern of lifestyle and are known to hunt up to three days without much to eat. Therefore attempts to cut back on consumption without physical activity is always met with immediate low body metabolism and a return to weight gain, long term. For a sustained diabetes remission programme, compliance with regular activity would be an effective measure for weight maintenance and provides additive effects in fat depletion in skeletal muscles and other organs. In fact, a bout of exercise can improve insulin sensitivity in the muscle for up to two days, depending on the intensity and duration of exercise.
For healthy individuals, everyone can do without the extra plate, and no one would starve by skipping meals now and then, as it forces the body to draw from fat stores and promotes good health. In other words, intermittent fasting, calorie restrictions and regular physical activity are generally safe for a healthy population. However, all diabetic patients who desire to go on calorie restriction and regular exercise must consult their physicians for safe supervision.
Mukaila Kareem, a doctor of physiotherapy, writes from the USA and can be reached via makkareem5@gmail.com
