Type 2 diabetes can be reversed with a low-calorie diet | Hacker News Reader

Type 2 diabetes can be reversed with a low-calorie diet

discover.dc.nihr.ac.uk

218 pointsDanBC98 comments

The headline is a bit misleading. We have previously known diabetes is reversible with low calorie diets. This study was notable for two things:

(1) finding that this holds true even six years into mild diabetes (previous studies were on much more recent diagnoses). This is useful information because of the widely held misconception that type 2 diabetes is just a disease of insulin insensitivity. Actually, over time, islet amyloid peptide is deposited in the pancreas where it slowly kills off beta cells and removes your ability to actually produce insulin. In effect (though not literally nor in every particular), type 2 dm slowly transitions into type 1. So it’s useful to know that six years out the pancreas is functioning well enough to allow dietary reversal.

(2) being funded by a private company pushing a meal replacement-and-weight loss coaching program, which used this private program as the intervention arm. Turns out that, yes, if you live on slimfast for 3 months you’ll lose weight and your diabetes will calm down.

That Lancet didn’t exactly lead with that latter point, oddly enough. The co is pushing for the NHS to fund their program in more locations, under the argument that bariatric surgery isn’t available to everyone. This is part of their PR push.

Bariatric surgery (not personal experience, but secondhand) is not a picnic and requires a large/equal amount maintenance/discipline post-op to not harm yourself or regress. Again, admittedly 2nd hand and would love to be corrected.

The more recent generation of bari surgery approaches are more gentle than the first generation. That said, I agree, it’s not a free pass.

Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction. The most successful have zero effects by 5-10 years out.

Bari surgery is the first and only intervention we’ve had that has shown sustained weight loss over 10 years.

I don’t mean to in any way understate its dangers or its difficulty. But from a medical standpoint, I have to raise a red flag when someone says “hey, instead of using the only treatment that’s ever been shown to have a sustained effect, you should use a variant of a treatment we’ve spent half a century proving doesn’t generally work.”

The linked article phrased it as being for people for whom bari isn’t an option, but even the Lancet article proper - iirc, as I read it at the beginning of the week - phrased it as, “there aren’t enough bari surgeons to go around, so in the meantime...”

Thank you!

Yes, the problem is (i am someone who was put on a VLCD of 800 calories a day- and didn't lose that much weight from it) that your body has a set metabolism that keeps slowing down as you lower calories over the years. I had no problem going on the vlcd besides fatigue. The reason is I was already only consuming 1200 calories a day. These diets don't work over the long haul. I realize my case isn't the most common, but they are now looking into microbiome therapy as a possible solution. This resetting of metabolism plagued the biggest losers from "the biggest loser" as well. I do hope more research is done, because in my case, following diets (and perhaps other medical factors like igg)slowed my metabolism to a ridiculous level. And I don't have diabetes or high blood pressure, luckily.

The notion of a metabolic set point is mostly a myth. The actual changes in resting metabolic rate from mild caloric restriction are very small. Most people underestimate how many calories they consume unless they carefully weigh and log everything.

My reading of the last 3 years of findings regarding changes in resting metabolic rate due to caloric restriction is that they could become big enough to explain the pattern of weight regain. Now, the specific quantification of the relationship between amount, lenght of caloric restriction and resting metabolic rate is, in my opinion, waiting for a trove of data we do not have yet.

well, my doc is head of bariatric surgery at nyu, so I'll pass on what you said. Btw, I do weigh and log everything.

"It is difficult to get a man to understand something when his salary depends upon his not understanding it" -Upton Sinclair

Your surgeon's income depends on people getting bariatric surgery. You can add in exercise to increase total calories burned to support a larger food intake and still lose weight.

> Your surgeon's income depends on people getting bariatric surgery.

Surgeons are usually good at doing other surgeries as well...

(1) that’s not a meaningful support of any kind of argument. It’s borderline vacuous.

(2) I’ve never heard a bari surgeon Not recommend lifestyle change. Most will ask you to do your best pre-op, to make the surgery as safe as possible. They will counsel you on the same post-op. Many have in-house dietitians to assist.

(3) Your argument implies the following: Bari surgeons pretend and contend diet doesn’t work, to keep the supply of customers coming. Fact check: diet was failing for decades, and only the resultant epidemic made something as extreme as cutting out pieces of a non-diseased GI tract not entirely insane. Go read another hundred diet books of the week; proclaim their findings from the rooftops. I’m pretty sure the bari surgeons aren’t going to run out of willing customers.

I think the problem is that most people, and that includes doctors and bariatric surgeons alike, don't really know how to diet.

Using only diet, I have successfully lost 90lbs and continue to lose.

Good for you! I mean that. But your experience isn't everyone's experience. Mine isn't either. I said so. For one, men have much easier time losing weight. I'm not a man. I offered my singular experience to give support for those who might also be mystified after trying everything with a doctor. To those who think my surgeon is trying to get me to buy surgery by saying a diet won't work-- actually, my surgeon (also head of a weight loss clinic) recommended against surgery and against my eating less that I already do. There are a number of drugs that can help people trying to lose weight that aren't phentermine. Some people like me can't take them because of a family history of thyroid cancer or other diseases. But for those who can take these, they are helpful tools. Often, those who struggle with weight loss have struggled with it throughout their life for a host of reasons, only one of which may be eating and exercising habits. To the person who told me I could "add in exercise", what are you trying to accomplish with comments like this? Of course I exercise. People who struggle with this health issue need support and to know that there are other difficult cases sometimes and to keep at it anyway. I keep at it anyway, because being in shape and healthy matters to me and always has. I do an hour of cardio 5x a week and I weight train every other day. I was a serious athlete as a young person (high school/college) and never had trouble with weight gain/eating disorders. I definitely know how to add in exercise. In fact, I never didn't exercise in my life. When I hear simplistic comments like some of these that seem to be meant to shame someone for not exercising, or for having no willpower, or for just generally not being disciplined at losing weight, I have to ask myself where is this kind of thing coming from? I can't say for sure, but perhaps it is because they feel that way about themselves and it feels harsh to them so they throw it at other people so they don't have to deal with the discouragement. To these people I say: don't be too harsh with yourselves! You will do much better at all of these things if you support your own small successes every day. Ultimately, don't you want to succeed at being as healthy as you can? Well, you get there through encouragement and support of yourself. You get there hopefully with the help of better data, drugs, approaches, exercise, and emotional support as better and better research is done into weight loss. And this is what the OP was all about anyhow. One of the best things a person can learn from being an athlete is that if you have team support-- if you root each other on-- you raise the level of the team. People who are trying to lose weight, including yourselves, need this. Because the other raises cortisol levels, and we know what happens then.

I only have my own anecdotal experience to work from, but I genuinely believe that most Americans are so lost when it comes to diet that these last-resorts are all they have left.

I am very fortunate to have fallen in love with a Greek woman who has shared her family's diet with me. It's likely saved me from needing an extreme solution myself.

I think that in North America, we don't know the first thing about eating healthy. A big part of the Mediterranean diet is using high quality, expensive, olive oil with everything. My parents would blow a gasket if they knew that we paid for the fancy stuff. At $10/L it's more than my parents would ever spend, but it's honestly not noticeable as far as my budget is concerned. It's seriously a game changer.

By putting high quality olive oil in all you're food, everything becomes much tastier and satisfying than before. It allows you to eat and be satisfied with much less. The other key is to splurge on expensive, good looking vegetables.

Having delicious vegan recipes allows you to get your kicks without eating tons of saturated fats.

This allows you to be satisfied with less volume. It's made up through quality and taste. This is the foundation of a healthy diet, eating high quality tasty food.

The problem with the North American diet is that we don't have the same traditions of passing down recipes as they do in other parts of the world and so none of us know how tasty a simple dish can be. We then eat this processed crap that gets passed off as identical to the original when it's a fraction as tasty and nutritious. As a result, we compensate by eating far too much of it.

I think that this continent is in dire need of better recipes and respect for their ingredients. Until that gets integrated into the culture, we are doomed to depend on these extreme measures to stay at a healthy weight.

Don't get me started on drive-through culture or eating at your desk. Eating is something to be enjoyed, not rushed. When you rush your meal, you eat more and you aren't taking the time to enjoy any subtlety in the taste. This results, again, in overeating.

Do you have a source for this? It's a fairly trivial Google search to find papers making the counter-claim, but I'm aware that nutritional science is kind of a dumpster fire, and much of the research is at least a couple decades old.

>The actual changes in resting metabolic rate from mild caloric restriction are very small.

But only a small change in metabolic rate can easily produce ten or more pounds of additional weight a year.

I wouldn’t conflate “only diet” with “only treatment.” Stimulant drugs are a treatment that works over the long term—just not one that’s particularly free of side-effects.

—just not one that’s particularly free of side-effects.

Especially for the target audience of chronically morbidly obese people with diabetes!

> Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction.

This baffles me, because these results are trivially disproved. It's not particularly rare for people to lose weight and keep it off long term by changing their diets. Are the studies poorly constructed or are they just being misinterpreted?

But long-term, 10, 20 30 years out?

I can't name a single friend who has successfully dieted short term that has kept it off long term.

Is 30 years a reasonable expectation? Does someone who loses weight in their 50s have to literally die of old age before you'd grant that they'd 'kept it off'?

Actually... Yes.

Obesity related complication occurr with excess weight. So, if they were at their ideal weight at 50 yrs old and gained it back at 80 when they also incurred high blood pressure and diabetes, then they weren't successful.

That's why it's difficult. Most can lose weight at some point in their lives. But the weight eventually comes back, along with the other complications.

This seems like an odd way to split the data. Is it not the case that healthy-weight people sometimes gain weight in their old age? Your claim seems unfalsifiable: Whatever mechanism is at play that makes healthy-weight people gain weight later in life could also be at play for people who lost weight, and 30 years later regained it in their old age.

To put it another way, it's a silly bar to use to say that weight-loss programs must move their adherents level of health wrt weight past those of normal slim people, and that any weight gain from a former dieter is proof of a diet's failure of efficacy (while any weight gain from a formerly-healthy-weight, non-dieter is just happenstance).

It's tough to look at just the existing data to tease this out, but if you need to resort to a bar as absurdly stringent as that to make your point, I'm afraid it's not a very convincing one.

You’re begging the question. You assert it’s not particularly rare for people to lose weight and keep it off long term, and therefore it’s trivially obvious to prove that it’s not particularly rare. Except that all studies to date show that it -is- rare, especially for the group of people that are candidates for an intensive intervention like medically managed weight reduction or bari surgery.

The data show that over ten years average sustained weight loss in diet-and-lifestyle interventions is zero (actually, there’s usually weight gain). That doesn’t rule out particular rare exceptions, but they’re just that, and not useful for evaluating the intervention as a whole.

That's not what 'begging the question' means. If you say "iron doesn't rust" and I show you a rusty piece of iron, that's not 'begging the question' regardless of how many studies you can cite that show iron not rusting under various conditions.

And 'average sustained weight loss over a cohort' is the wrong measure, especially if your cohort are candidates for bariatric surgery (ie. pre-selected for being medically recognized as incapable of losing weight voluntarily) rather than just overweight people in general (a fair few of whom do choose do get back in shape.)

So, I dove into this a bit (as a professor in a related discipline but who doesn't study weight) and had some heated conversations with researchers in this and related areas. My impression is that those studies are controversial because they "define away" diet effects.

They often engage in a bit of semantic game-playing about the meaning of the term "diet."

The problem is a lot of the "diets don't work" conclusions are based on very strict assumptions about "diet" meaning "telling people to just lower their calorie intake" or "telling people not to eat certain foods." They don't necessarily mean giving strategies for lifestyle changes, or ways to avoid increased calorie intake, or replacements.

As a concrete example, one researcher I spoke to is a very publicly prominent advocate that "diets don't work," and gave a talk I attended. She was discussing studies of weight loss and was explaining how studies that instructed participants to do things like use smaller plates (to change perspective on how much food is being consumed) or strategies for coping with parties, etc. were not "diet" studies because they did more than just tell participants to diet out of sheer willpower.

So, in effect, diets, if they are defined as just telling people to lower intake, and nothing else, don't work. However, if you support them, and give them alternative behaviors or foods, or strategies for lowering intake, they do work.

What also became clear to me, and which people on this forum are maybe pointing out, is that there's also a lot of gamesmanship in these papers about individual trends and what counts as a control group. There are in fact people who do reliably lose weight on diets (you can see it in their individual-level-data graphs), but their trends are often explained away by switching controls ad hoc.

I was left very frustrated by these studies, because it wasn't clear to me why these researchers wouldn't be promoting the strategies, etc. more, or advocating more for understanding why people who lose weight on diets do lose that weight, to gain strategies. I got the impression they were trying to be sensationalistic or something, to gain attention, by trying to sound counter-intuitive.

As a side note, I've worked in bariatric clinics, and I can say from my experiences there they have their own brand of burying side effects and defining outcomes in such a way as to achieve success (for example, by only selecting "appropriate" individuals for surgery).

There are obviously some exceptions. I've met people who have maintained long term weight loss purely through lifestyle changes. There may not be many but they certainly exist.

There are also some interesting ideas in the interventional field regarding minimally invasive embolization of the left gastric artery to reduce hunger via inhibition of ghrelin production.

I hadn’t heard about that. But jfc, even with collateral circulation, I can only imagine the number of perfs you’d see! I mean, h. Pylori already destroys local microvasc - embolism the LGA and you’re begging for some tragic endings.

Or such is my arm chair hypothesis, at least.

Studies will also show that inducing and keeping them in coma is one of the foolproof ways to ensure a person never tells another lie over a period of 10 or 20 or 30 years.

Controlling or having a low calorie diet isn't a medical treatment [1], it's simply a choice an individual (in most cases) makes. They choose to not continue with the original choice after some time, so to club diet-control under 'medical treatment', and say that it doesn't work, is incorrect.

[1] https://www.wisconsin.edu/workers-compensation/coordinators/...

Edit, grammar.

Its a protestantic thing. If you have sinned, as in you couldnt keep your behaviour under controll- you must suffer and punish for your sin and repent.

Its the same thing that creeps into every drug discussion. Its one of those caddisfly larva conglomerates, where people glue lots of pseudo science onto theire "feel-good" opinions instead of really trying to solve the issue with realistic solutions.

You could sell the realistic solution to these individuals by telling how much the "sinners" suffer after the operation and how heartily they regret taking the left hand path.

>Thing is, we have about half a century of consistent clinical findings saying, without exception, no diet-based approach shows long term weight reduction. The most successful have zero effects by 5-10 years out.

Does "diet" mean counting calories and eating less than you want to eat?

I ask because another approach, as in Susan Robinson's book The I Diet, is to eat as much as you want but just make sure it is foods that are moderately low in calories. In particular, avoid refined carbohydrates, potatoes, and fatty foods.

I have been following this approach for 5 years. I lost 50 pounds, I have no will power when it comes to food, but the pounds have stayed off.

I forgot, another principle is lots of fiber.

I have also lost a large amount of weight and kept it off for over a decade by changing what I eat.

In my case, I cut out refined carbohydrates (white rice, white bread, pasta, potatoes, etc.) and sugar (sweetened beverages, desserts). I still eat plenty of carbs that come with a large dose of fiber, such as oatmeal, peas, and beans.

At the same time, I increased my intake of animal fats and dairy.

We don't have solid evidence that amylin is killing islet cells, just circumstantial and in vivo work.

http://m.jbc.org/content/271/4/1988.short

It’s not like we can do much more than show “if I introduce this amyloid, beta cells die” in the lab. No one is going to experimentally administer the amyloid to real life patients to see if it kills their pancreas.

You could do it in mice. I mean, you can't but that's because mice have funny amylin, but people haven't really put in the work to suss that out.

...or you could not starve yourself on <900 calories a day and instead be a sane person and just eat low carb: https://link.springer.com/article/10.1007%2Fs13300-018-0373-... "Insulin therapy was reduced or eliminated in 94% of users; sulfonylureas were entirely eliminated in the CCI. No adverse events were attributed to the CCI." Wow, that's pretty extraordinary, isn't it? Every single person in the non-control group eliminated the need for sulfonylureatic compounds and a massive 94% reduced their insulin level or completely got off insulin altogether. All with no adverse affects being recorded.

You don't need to starve yourself or go on some ridiculous diet. You just need to eat low carb and eat clean (a.k.a. "real" food) and your body will begin to heal in nearly every case. I suspect the few test cases that didn't improve were so far gone they were too metabolically impaired to achieve any positive results. The damage was likely too extensive and age possibly played a factor. For everyone else, it appears they can get rid of diabetes...if they actually care enough to do so.

Repeated studies have shown that weight loss plays a bigger role than carb restriction. The article you linked showed a 12% weight loss in the experimental group, which also had continued support by a health coach throughout its duration, which was the actual intervention.

You make it sound like the intervention was carb elimination, rather than weight loss with a health coach. It was not.

Repeated studies have shown that carb restriction leads to weight loss.

No, repeated studies have shown that -any diet- leads to weight loss. Drawing anyone’s attention to what they’re eating in a detail-oriented way helps lose weight.

When someone says “carb restriction is the ticket,” they’re attributing the effectiveness -to the carb restriction-, explicitly, as having an effect on weight loss notably above and beyond that of calorie restriction.

Pretty much no decently structured studies have supported that. A couple animal studies suggest shit like HFCS has a much more severe short term effect on insulin than other foods, but they’re small, animal based, and “don’t eat junk food” is world away from “carb restrict.”

Carb restriction is a ticket because, if you can follow it, it almost magically stops craving and binging.

If you have a perfectly healthy relationship with food without having to constantly fight cravings, awesome, and nobody who needs to lose weight is like you.

YMMV. I have used keto to much success in the past, however I've found it impossible to stick with on a long term basis, even after giving it 6 months and really trying to make it work. My cravings for carbs was unbearable and made me miserable. My body seems to reject it now, as every time I try it I have a ravenous hunger for pasta, breads, chocolate. So it's not really a panacea for limiting hunger. Fat is more satiating yes, but it's also pretty joyless after a short while.

I find fasting to be more in tune with my life nowadays.

yeah. I was low carb for 18 months. I got down to 220 and felt really good except... I really wanted carbohydrates a lot. Even though I wasn't hungry.

The first week or so was really hard. Close to no carbohydrates and all I could think about was sweet things. Even after I reintroduced healthier sweet foods like fruit, it just didn't hit the same spots as a good sandwich or a bowl of pasta.

After I went back to regular food, I'd periodically do a month or so of paleo to try and the weight gain under control, but I got back up to 280. Currently I'm a couple of weeks into slimfast. I'm not hungry. I don't feel bad if grab a small piece of chocolate. Occasionally my evening meal is a small bowl of pasta, or a sandwich and I'm loosing a consistent amount of weight... for now.

Out of curiosity and if you recall, what were the approximate macros?

What you're talking about is addiction. It has nothing to do with food. People who tend towards addiction will be addicted to all kinds of things. Fighting addiction is very difficult, no doubt. If you recognize it as addiction instead of pretending that it's something else, that makes it easier.

You're not the arkades from buzz, by any chance?

I don’t know what buzz is, so I don’t think so. But damnit, I thought I finally found a handle (almost) no one else was using - it’s available on most sites. Bah!

Nah, don't worry. Buzz was a Greek-language forum. Your handle is (proobably?) unique on the English internet :)

I've been on keto (carb restriction) diet (lifestyle?). Just some thoughts learned from the experience: it is incredibly easy to lose weight on carb restriction since hunger goes away and relationship with food changes.

I still like to eat but it's become more a number game. I eat once a day and structure my meal to hit my macros. Just figure out how many calories and protein / fat ratio and I can usually hit close to it with 1 meal and top up calories with butter coffee.

Also, I can instantly do a 1-day fast. It doesn't bother me at all. Every few days I stretch my intermittent fast to proper "just coffee and water today" fast. It's very refreshing.

Calorie restriction on carbohydrate heavy diet sounds like hell. Food cravings. Starvation.

Fasting on the other hand is a different story. Zen.

Yea, the shift in your eating habits is really kind of astounding.

I'm not even that close to keto levels of carb intake[1], but I've been progressively minimizing any processed carbs since college (and I'm lucky enough to have been raised eating fairly healthy, so my baseline was decent). At this point, there are certain foods that all my friends feel are impossible not to crave and give into occasionally, that I simply just don't enjoy. One of the biggest examples is fat+grain in its various forms: pizza, grilled cheese, many pastas, funnel cakes, etc etc etc. Don't get me wrong: I'm not completely incapable of enjoying these categories of food. It just needs to actually be well-made and have some flavor: by contrast, most of the people I know enjoy the wireheading effect of this combo per se. To me, this seems like the difference between eating a nice dessert and eating a bowl of straight white sugar.

This is something I think about a lot: there's so many unhealthy food items that I find pretty gross at this point that most of my well-educated, high-income social circles have resigned themselves to being a completely unavoidable flaw in the human brain[2]. It's kind of eerie to think about; My diet isn't even amazingly healthy, and I've already found myself brushing up against the "eccentric abstemiousness" that pg mentions in his essay on addiction.

[1] every time I lift weights, I crave carbs too much to drop them entirely: most of my carbohydrates come from beans, pulses, and certain green veggies.

[2] IMHO, this is the source of the popular-on-HN sentiment that each and every one of us are hopelessly devoid of agency when it comes to resisting the power of corporations to exploit the way our brains' taste centers work. The theory isn't implausible to me, but my experience indicates that you really don't need superhuman self-control to change your diet: it just takes time and patience.

> You make it sound like the intervention was carb elimination, rather than weight loss with a health coach. It was not.

And you make it sound like the intervention was weight loss with a coach, rather than carb restriction made possible by continuous care.

The authors assert that carbohydrate restriction was the main cause of lowered blood glucose, weight, and medicine use (weight loss was not the cause of the improvements; rather, it was one effect among others). Continuous care was required for medicine management and in order to sustain the diet, as clearly stated in the summary (emphasis mine):

> Blood sugar in patients with T2D can improve quickly when patients eat significantly fewer dietary carbohydrates. However, this demands careful medicine management by doctors, and patients need support and frequent contact with health providers to sustain this way of living. [...] After 1 year, patients in the CCI, on average, lowered HbA1c from 7.6 to 6.3%, lost 12% of their body weight, and reduced diabetes medicine use. [...] This suggests the novel care model studied here using dietary carbohydrate restriction and continuous remote care can safely support adults with T2D to lower HbA1c, weight, and medicine use.

They’re welcome to assert what they want, but that’s not the intervention they created.

>> The authors assert that carbohydrate restriction was the main cause of lowered blood glucose, weight, and medicine use (weight loss was not the cause of the improvements; rather, it was one effect among others). Continuous care was required for medicine management and in order to sustain the diet, as clearly stated in the summary (emphasis mine):

Well, to be fair, they didn't make any attempt to control for improvements due to weight loss alone. They compared their results with one "lifestyle change" study and one calorie restriction study (also with carbohydrate reduction, both of which references I didn't follow) and the difference in outcomes was not that groundbreaking, I'd say.

But I'm not a doctor, or a biologist and I can't really say for sure. I'd welcome some input from a specialist on this.

With you until that last part.. older populations that go through diabetes prevention / weight loss programs actually do better than younger folks. Also, "if they actually care enough to do so" is a tricky statement. Many folks that are overweight have tried losing weight numerous times only to gain it back and have leaned on confusing (and often incorrect) advice about diet, exercise and its relationship to weight loss (e.g. the food pyramid). They go through waves of motivation like anyone else. There's a good opportunity for the healthcare industry to engage with people at that level, in the way mental health professionals support people battling anxiety and depression. Would love to see more research targeted at that motivation point because I agree with you that the physiological mechanisms are pretty well understood at this point (at least in comparison).

For some people "starving" themselves is easier. It requires less decision making and therefore less decision fatigue. Intermittent fasting is a perfect balance of physical discomfort and mental effort for me.

I feel no physical discomfort when doing the standard 16/8 schedule these days and only feel slight discomfort on a 22/2 schedule. I'd much rather do this than have to meal plan and have anxiety over what restaurant my friends chose for the night.

But I also understand that it's not for everyone and wouldn't push judgement on anyone who chooses some alternative method of controlling weight/insulin sensitivity

Calorie restricted diets confer other benefits like slowing the aging process. [1]

Additionally, it's quite common for those embracing a keto/atkins diet to use it as a warrant to eat copious amounts of red meat or any meat at every meal. There's substantial evidence suggesting such a diet increases risks of a number of serious cancers.

A friend of mine has been using the keto diet to try lose weight for a few years now. He burns through bulk cases of SlimJim beef sticks on a weekly basis. I am not looking forward to the future hospital visits. The last time I tried going on a hike with him he nearly collapsed on the first climb. I'm not trying to suggest keto diets are inherently bad for you, but it certainly seems more likely to be problematic than calorie restriction when viewed through the lens of how the average American is going to apply the keto concepts.

[1] https://www.nih.gov/news-events/nih-research-matters/calorie...

If your friend is just eating copious amounts of meat without any care for vitamin and mineral intake, then of course this leads to suboptimal nutrition. It's worth saying that recommended daily allowances are set for entire populations, and not individuals, and individuals' genes determine specific requirements. For example, people with the genetic mutation responsible for Morton's toe [1] typically absorb B6 with 65% efficiency compared to those who don't have this mutation [2]. Without adequate B6, zinc is also absorbed less.

Another consequence of bad health on low-carb diets can come from high intake of linoleic acid (omega-6). This is found in "vegetable" oils such as canola, sunflower and nut (even though they are actually not vegetables) [3]. We're told to take this fatty acid for our health, but we only need trivial amounts when our diet is optimal, and too much can disrupt the way that cell mitochondria work.

One fact I find absolutely amazing is that in cancer studies with rats, tumour formation is heavily influenced by levels of linoleic acid in their diet [4].

[1] https://en.wikipedia.org/wiki/Morton's_toe

[2] https://www.sciencedirect.com/science/article/pii/S030698771...

[3] http://www.mdpi.com/2227-9032/5/2/25

[4] https://www.ncbi.nlm.nih.gov/pubmed/3921234

Tell you friend to watch What the Health [1]. Sure, it provides a somewhat biased view on the topic of eating too much meat, but it is thought provoking anyway.

[1] https://en.wikipedia.org/wiki/What_the_Health

Based on what's in the linked wikipedia article I'm doubtful this would actually do less harm than good, all while causing him to question my judgement.

The study you quote was funded by Virta Health Corp. a health startup that advertises "The Virta treatment [that] reverses type 2 diabetes". They use this study as their main advertising item, quoting it extensively on their site, calling it "groundbreaking" etc etc.

Besides the fishy smell emanating from this, and to address your comment directly, the quoted study compared the proposed treatment against "usual care", i.e. ordinary diabetes treatment.

More specifically, the study did not directly compare the proposed treatment to other dietary or lifestyle interventions and particularly not to calorie restriction diets. It does, however, quote the results of such studies:

The CCI [Continuous Care Intervention] reduced HbA1c by 14 mmol mol−1 (1.3%) at 1 year. HbA1c reductions up to 7 mmol mol−1 (0.6%) via intensive lifestyle intervention [25] and 11 mmol mol−1 (1.0%) via an energy-restricted low-carbohydrate diet with partial food provision delivered via an outpatient setting [26] were previously reported.

So the difference between this and one selected calorie restriction diet (which was also a low-carbohydrate diet) was small (3%). These are just two studies, so it's hard to draw a conclusion.

Anyway, I'm not a doctor or a biologist so I don't know just by looking at the studies to say what is significant and what isn't. For instance, sulfonylurea treatment was reduced in the "CCI" group, like you note, but that group already had ~24% lower use of sulfonylureas than the baseline to begin with. What does that mean? And what does it mean that people took less medicine at the end of a study? Did they absolutely need all the medicine they were taking at the start? Do you know how to answer those questions? Because I certainly don't.

A single study, quoted by someone who isn't a doctor to people who also aren't doctors over the internet, doesn't really mean anything.

We've known that low-calorie dieting has this effect for some time; unless I'm missing something, this looks like solid confirmation of this point but isn't adding much knew to our understanding of diabetes prevention. The big challenges in this space are adherence, scaling access to treatment and creating long-term lifestyle change that will help the patient maintain the weight that is lost.

There's good evidence that ketogenic diets have an additive metabolic effect beyond pure calorie restriction which is exciting. Virta Health is doing some interesting work here and just published some results that speak to this: https://link.springer.com/article/10.1007%2Fs13300-018-0373-...

The only novelty in this study was doing it in people with longer term diabetes than most such studies.

Well, the more the merrier is as true for scientific studies as for sex parties. The point is that no two studies are going to be set up in the exact same way, so it's interesting to examine the results of slightly different experiments.

But probably more importantly, because there is no study that can claim 100% certainty for anything, having many studies confirm the same effect is always a good thing.

Sticking to a very low calorie diet is super hard. You'r body starts producing all kinds of hormones to get you to eat more. I fight against this every day. So, I've created a tool that shows me all the lowest caloric density foods and ranks. It also ranks foods by nutrients too: highest nutrients per calorie: https://kale.world/c

It seems that a keto diet/lifestyle does this in a far more enjoyable way than restricting calories to such a low level. Mixing in restricting to zero calories (aka fasting) also helps. Either way I'm so happy to see people start to attack this problem with smarter food choices.

Nutritional ketosis was also recently shown to reverse type 2 diabetes. That approach might be more sustainable for some patients.

https://blog.virtahealth.com/one-year-clinical-trial-outcome...

(2017) (At least the study itself: "Published on 10 December 2017.")

Previous article: https://www.theguardian.com/society/2017/dec/05/radical-diet...

And discussion: https://news.ycombinator.com/item?id=15873389

> (2017) (At least the study itself: "Published on 10 December 2017.")

So, two months ago? Who cares if it's on the other side of an arbitrary point in time?

loeg is politely pointing out a large, recent, discussion. That's a useful thing to do.

I quoted the specific portion because if the propensity of people here to immediately jump in and "tag" articles with the year they were published. If loeg had left the quoted line out if its post I would not have mentioned anything.

Does anyone know what the UK NHS means by a 'formula diet'? The overview says,

> The program involved... going on a formula replacement diet. This consisted of 825 to 853 calories per day...

and the published abstract also refers to

> ...825-853 kcal/day formula diet...

So what's the formula? Was it a commercial feeding formula such as Ensure? Or a dietician's list of approved foods? What was the macronutrient ratio?

Might be slimfast

http://www.dictionary.com/browse/formula?s=t

Definition 6.

They are using the word "formula" as in "baby formula."

I found this announcement of a follow-up study [1], which

> will see 140 people with Type 2 diabetes spend between eight and 20 weeks consuming just 800 calories per day, mainly in the form of nutritionally-complete formula shakes.

The phrase "nutritionally-complete" indicates a meal replacement; probably not Slimfast or Ensure, neither of which is suitable for 100% meal replacement, but something like Huel or Soylent, which are. However, being a medical operation, I would bet it will be some hospital-approved TPN [2] such as Jevity [3].

[1] https://www.diabetes.org.uk/About_us/News_Landing_Page/Low-c...

[2] https://en.wikipedia.org/wiki/Parenteral_nutrition

[3] https://nutrition.abbott/uk/product/jevity

I think the conclusion is false and the real culprit is low-sugar, not low-calorie.

Insulin production is directly influenced by sugar levels. It is not influenced by caloric intake. I didn't read the whole article but I bet their method is flawed and further study is required.

I did read it. They might have other method issues, but not that one you mention. In this analysis the did not focus on insulin secretion or sensibility.

You are right in a sense. The authors used to say that it does not matter what you eat, as far as is a lot of caloric restriction. That was back in 2016, when I interviewed them. I hope now they will disagree if someone comes with a 800 calorie diet made of sugar only.

It's fat, not sugar

https://nutritionfacts.org/2016/11/17/fat-is-the-cause-of-ty...

> Weight loss of 15kg or more was achieved by 24% of the intervention group compared to none of the usual care group.

> Diabetes remission occurred in 46% of the intervention group compared to 4% of the usual care group. It only occurred in people who had lost weight.

Unless the people with type 2 diabetes were fit and going underweight for the experiment, instead of implying overweightness is normal, could we say that a high calorie diet can maintain or accelerate diabetes?

This rephrasing suggests prevention.

Fair, but I think there's something to the opposite tone. A lot of people know that if you're healthy, you can generally avoid type 2 diabetes. Saying it basically 1:1's with weight issues is... important. Prevention is important, but there's this idea weight loss is impossible, or keeping weight off is impossible, and boy howdy that isn't true.

>could we say that a high calorie diet can maintain or accelerate diabetes. Yes we can say that. But we can say the same about an isocaloric diet and a negative balance diet of 5 or 10% deficit. It is better said as the paper did.

That's fantastic news.

I do have a question, how safe is 830 calories/day for a diabetic? For an otherwise healthy person I can see it being safe with medical supervision but for an individual already seeing blood sugar spikes due to diabetes, I wonder about the dangers?

I guess what I am getting at is that this intervention for diabetes might only be safe enough to try in early stage even if it would work for more progressed diagnosis.

The subjects were under medical supervision ...

Also, non-insulin dependent which lowers the risk considerably

I never claimed they weren't.

I asked about the safety of diabetics on low calorie diets. I have no idea how stringent the entry criteria was for this study, they could have picked the [otherwise] healthiest diabetics they could find.

Which brings us back to the question I asked, which was how this could scale to older or in worse health individuals suffering from type 2 diabetes? Even with medical supervision.

It would only be a problem if you took insulin and then did not eat. Given that type two diabetics cell’s are stuffed full of sugar from insulin resitance, not eating or eating less can only help.

> I do have a question, how safe is 830 calories/day for a diabetic?

They're largely not at risk of anorexia, if that's what you're asking. "Somewhere in the neighborhood of 85% of people who develop type 2 diabetes are overweight or obese."[0]

> For an otherwise healthy person I can see it being safe with medical supervision but for an individual already seeing blood sugar spikes due to diabetes, I wonder about the dangers?

That's why it's done under medical supervision. A very low calorie diet (VLCD) should result in fewer blood sugar spikes, not more, simply due to the body having less sugar available.

[0]: https://www.health.harvard.edu/blog/diabetes-can-strike-hard...

From what I’ve read about 15-20% of adults diagnosed with T2 actually have a slow progressing form of T1.

I was diagnosed T2 in my early 30s. Really confused me. I was normal weight, active, year round bike commuter, long distance runner, vegan, etc. and couldn’t make any sense of it.

After about 2 frustrating years I ended up on insulin and got finally correctly diagnosed as T1.

The thing I learned is that most doctors don’t think very hard about whether their diagnosis matches up with what they’re seeing in front of them. To them, high A1C in an adult = T2. They see it so often, they don’t think beyond that.

I lost 60kg in the last year after being diagnosed with type 2 diabetes, following a moderated carb and low calories diet, with 1h of gym almost every day of the week.

The latest HbA1c was 5.5%, which is inside the range for 'normal' people (https://en.wikipedia.org/wiki/Glycated_hemoglobin)

I gained ~50 kg after quitting tobacco. But I'm not sure that it'd work the other way around. I do recall that "feeling hungry" and "needing a cigarette" were quite fungible. But then, smoking is obviously a huge cancer risk factor. Maybe vaping isn't so bad.

And for what it's worth, testosterone supplementation disappeared my prediabetes. Also less white hair, and better muscle health.

And Type 2 diabetes can be entirely prevented thru low sugar diets.

Hello,

I see many people on here deriding low calorie diets as “starving.” As someone who was 100+lbs overweight I can attest that low-carb, diet, exercise, weight training were not sufficient to help.

For whatever reason, genetics combined with work and lifestyle, I was unsuccessful with any commonly recommended diet for reducing body mass, I tried for years.

Recently, I lost 40lbs using intermittent fasting and then continuos fasting. The experience was night and day, I have written about my experience here: http://rexstjohn.com/thoughts-fasting-part-iv-lost-40-lbs-tw....

Starving is the wrong way to frame this diet approach. I want people to change their minds about how they frame the problem of obesity. If you have 10 lbs of excess body fat, that represents 35,000 stored calories. Your body is used to doing much more work and exerting much more energy to locate food than what we do in modern society. If you wanted an Apple 100 years ago, chances are you had to walk for 30 minutes.

Furthermore, our bodies are adapted to numerous days of fasting. If you are hunting a wounded deer over rough terrain, you don’t have room to carry a refrigerator with you - you burn stored reserves. If your crop fails and you have to wait three months to eat again subsisting off of grass and worms for vitamins, your body can do that too (I don’t recommend it).

In my research I have found numerous examples, personal blog accounts and scientific studies backing them of people fasting for a week or greater and suffering no ill effects. The real issues with fasting occur only after many weeks, with low vitamin / potassium / electrolyte consumption or when you fast while having low body fat resulting in true starvation.

In the example of the man who fasted 360 days and lost 350+lbs, doctors had him eating supplements and brewers yeast (protein, low calories) and they documented very few noticeable negative side effects which were addressed by adjustments to supplementation.

Starvation is when your body consumes itself. This happens when you completely exhaust your stored fats. Fasting becomes riskier after the first 21 days, the really dangerous effects such as referring syndrome only occur in extreme situations where you had indeed been starving for a period of time before eating.

I have lost 40lbs in the last year using these approaches and recommend them to everyone I meet. Fasting is a skill anyone can learn.

I believe fasting is the best way to lose weight, don’t call it starving.

Water fasting. But people don't want to listen.

Flat assertions of efficacy unadorned by empirical support may not be well received. However, I am sure that the idea is taken seriously by most, and that supporting evidence would be of great interest.

I used to back it up by quite a bit of data but I get downvoted to oblivion regardless of all the effort. Why bother anymore. I put it here, whoever is interested can research on their own.

Meaning restricting water intake? Or general fasting with only water consumed?

Usually general fasting with only water consumed. Many practitioners will allow unadulterated coffee or tea. I haven't seen much evidence to indicate that dry fasting provides additional health benefits over water fasting.

TL;DR

If pancreases produces less insulin, eat less calories.

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