Guest post: “Now we know that our understanding of diabetes is wrong”

[MumsnetGuestPosts]

Type 2 diabetes has long been regarded as a life-long condition that steadily gets worse, always needing more and more tablets and eventual insulin injections. It is widely regarded as being caused by obesity.

Gestational diabetes, on the other hand, is believed to just disappear after pregnancy.

Now we know that all these ideas are wrong. Let’s look at them one at a time.

Life-long and inevitably progressive?

Since the late 1970s, I have been listening to my patients with type 2 diabetes and trying to understand exactly what was going wrong.

We studied each kind of tissue in turn – fat, muscle and liver. But then we had the opportunity to be able to look at what was happening in all three of them at the same time by using a powerful MRI scanner. Our early studies showed that too much fat in the wrong place caused problems with controlling glucose. We also learned that, after bariatric surgery, sugar levels returned to normal within days. Bingo!

As such, I was able to explain type 2 diabetes – in theory. That was 2006, and since then we have been steadily testing each bit of what I like to call the ‘Twin Cycle Hypothesis’. We have since proven that those cycles can be made to spin in the reverse direction – by losing about two-and-a-half stone in weight.

To do the studies, we needed a way of helping people lose that amount of weight. But, by that time, I knew why people found weight loss very difficult – the diet had to be an unexacting daily decision, cause little in the way of hunger and be followed for a short period of time only. Those early studies gave dramatic results.

In a recent study, I teamed up with Professor Mike Lean of Glasgow University to test this approach used by practice nurses (or dietitians) in Primary Care. Over two years, one in three people lost enough weight and kept it off. This meant that over one third of patients had become non-diabetic, no longer having to take any diabetes tablets at all.

Caused by ‘obesity’?

Obesity has a strict definition: a body mass index (BMI) of over 30. At the time type 2 diabetes is diagnosed, however, one in two people have a BMI of under 30. One in 10 have a BMI in the ‘normal’ range of less than 25.

Our studies show that if people who happen to have a very high BMI lose the same amount of weight (two-and-a-half stone) as those who aren’t considered ‘obese’, they can still become non-diabetic.

Ultimately, obesity does not cause type 2 diabetes. We have shown that it is, in fact, caused by around half a gram of excess fat inside the cells of the pancreas. Stored under the skin, fat is safe even though it may not be a welcomed sight to its owner.

Some people have a very low threshold for letting fat be stored outside what we call the ‘safe depots’. They might get type 2 diabetes at a BMI of 23. Other people have a higher threshold for letting fat build up in the wrong place.

As such, we should be talking about Personal Fat Thresholds instead. A person with true type 2 diabetes is carrying more fat than they can cope with metabolically – whatever their BMI. Pre-disposition therefore plays a large role in determining whether or not you might get the condition.

But beware of two things. Firstly, not all diabetes is type 2. Sometimes, type 1 diabetes (nothing to do with fat) can come on slowly in adult life and at first be confused with type 2. There are also rarer forms of diabetes. Secondly, a demographic time bomb is ticking: so many children are carrying more fat than is good for them and get to their early 20s already too heavy. They may get type 2 diabetes even without increasing weight in adult life.

Gestational diabetes forgotten after pregnancy?

Women who have raised blood sugar levels in pregnancy have an increased chance of getting type 2 diabetes in the future. The higher risks of heart trouble can kick in even before the slowly developing type 2 diabetes is recognised. Even more pressing is the fact that there is a much higher chance of diabetes in a subsequent pregnancy.

Our research has shown that in pregnancy when gestational diabetes has been picked up, very modest calorie restriction can avoid the need for tablets or insulin. Research now underway is gathering more detail about this approach.

We know for certain that losing weight before pregnancy results in a much lower chance of a baby being exposed to high sugars. There is very clear information about how the risk of all kinds of trouble in pregnancy and delivery rises with higher body weights and this applies especially to women who have had gestational diabetes.

The importance of getting down to your fittest weight in preparing for a pregnancy has not yet been empathized enough.

Professor Roy Taylor will be returning to this guest post to answer some user questions on Tuesday 18 February at 3pm.

The author is donating 100% of his proceeds from this book to Diabetes UK.

Life Without Diabetes is available on Amazon (RRP £9.99)

[hamstersarse]

This seems a little basic compared to the work that Dr David Unwin does in reversing diabetes

You make no mention of how to lose weight? Or why blood sugar may be raised?

[nevergetsabfp]

Why cant I do anything on this app nothing works!?

[BovaryX]

Is it true that 80 per cent of type 2 diabetics are obese at the point of diagnosis? Type 1 diabetics constitute 10 per cent of the total of diabetics. The conditions are often conflated and confused. How can they be differentiated?

[gassylady]

It’s great to see you on here getting the opportunity to share you research results. These have done so much to change the way type 2 diabetes will be viewed and managed in the future. I have managed to lose 15kg in the last year to reduce my chances of developing the disease and found your work inspirational.
Many thanks
A doctor who was taught all about the inevitable progressive nature of T2DM whilst at medical school in the mid 1980s !!

[Onceuponatimethen]

Fascinating - currently supporting dp with a massive family history of type 2 diabetes to lose weight

[Silvercatowner]

I really wish this post specified ' type 2' in the title. OH is type 1 and it's awful. My hopes were slightly raised by the thread title.

[LadyGAgain]

I'm interested in the HOW. How do I lose the 2.5 stone and keep it off?

[Onceuponatimethen]

Lady, this is what my oh has done so far:

He has given up alcohol (very high proportion of dietary sugar intake = alcohol)

He has started doing a walk every lunch time (aims for 10,000 steps daily but doesn’t always make it)

Stopped buying certain habitual things he’s always eaten a lot of - caramel popcorn etc

We’ve stopped going to McDonald’s as a family

He’s lost just under a stone so far

[Oblomov20]

This article is so incredibly disappointing.
It's so flimsy and says nothing of value. Where's the detail? Is this the best we've got?

Type 1 all my life here. I know 6 type 2's for whom weight loss has NOT reversed.

I might investigate and post again with an actual question to Proff Roy Taylor, for whom I normally have respect.

[Grasspigeons]

Hi - i had gestational diabetes in my second pregnancy. The weight thing interests me as i had a very healthy BMI going into the pregnancy. I am 5ft 5 and weighed just under 9st. The day after i gave birth i weight 8st 7lb so actually lost weight during the pregnancy.
I suppose i am asking does that mean my personal threshold is very low? . I am now 10st 7lb - i keep getting tested for ytpe 2 and my gp says not if when. So what is the best weigh to delay the onset?

[toomanypillows]

To those asking 'how', this is what I did :
I went on a low carb and low calorie diet and increased my exercise. Within three months my hba1c had reduced from 55 to 35.
I've had two more hba1c tests of 33 and 39 (all in the normal range)
I lost 3 stones initially. I still have more to lose, but my diabetes nurse said that whilst I am in remission, they will only consider it reversed if my bmi is below 25 and I am still in the 30s on my hba1c.

My low carb diet basically identifies a portion of carbs as (for example) 20g rolled oats, one slice sourdough bread, half wholemeal pitta bread.
I have three portions of carbs a day.

[Onceuponatimethen]

Wow too many you’ve done amazingly!!

[BigChocFrenzy]

For those interested in the HOW
Prof Taylor proposed a v strict diet to reverse T2:

A VLCD of 8 weeks on 800 cals per day,
normally composed of 600 cals shakes plus 200 cals non-starchy veg

This was based on what he found had already started to reverse T2 for some patients preparing for bariatric surgery

He carried out human trials on this, first at Newcastle Uni Hospital and most recently a large scale trial with the NHS

Scientific Papers:

https://www.ncl.ac.uk/media/wwwnclacuk/newcastlemagneticresonancecentre/files/banting-memorial-lecture.pdf

https://www.ncl.ac.uk/media/wwwnclacuk/newcastlemagneticresonancecentre/files/Web%20list%20of%20reversal%20publ.pdf

btw, this 800 cal VLCD is what Michael Mosely's low carb BSD / Fast800 is based on,
but Mosely uses food rather than shakes
Many on the Intermittent Fasting / 5:2 threads have had success with this

I don't know if Prof Taylor has also moved towards recommending solid food for wider public use ?
Or any other modifications ?

[Onceuponatimethen]

Blimey that sounds intense!!

[BigChocFrenzy]

Yep, I just skimmed his book:
he suggests 2-3 months of VLCD to lose enough to reverse T2

He recommends a short sharp loss, but says a slower loss would also work if you can't do VLCD

his book says - IFF the person hasn't had T2 too long -
then 10 kg loss is the target to reverse T2 for someone under 80kg, 15 kg for a heavier person
(his book goes up to 180 kg)

[mammmamia]

I have a similar question to @Grasspigeons

I am 5ft 5 and weigh 9st, healthy BMI of 21 and very active.

I have a strong family history of diabetes but clearly don’t need to lose weight - what’s the advice for people like me to postpone the inevitable? All the advice is around obese people losing weight - if I lost 2.5 stone I’d keel over!

[Localocal]

This is an interesting article indeed. We have a huge diet industry peddling the idea that obesity causes diabetes, when the evidence shows only a correlation, not a causality. Nevertheless the NHS, too, pushes people to go on calorie restricted or category restricted diets with no evidence that a) they work (more than 90% of people who lose 10% of their body weight or more on a restrictive diet will gain it back) or b) that the obesity directly caused the diabetes. Yes I know some people have died and reversed their diabetes. But they may have died by reducing sugar intake, which may have caused both the diabetes reversal and the weight loss.

[BigChocFrenzy]

Your book is proposing a VLCD for 2-3 months

A question about exercise:

A VLCD would significantly reduce glycogen stores, so anyone already training for say a half-marathon should presumably choose another time to start the VLCD

However, what about the gym rats on MN ?
For those who regularly do an hour or more most days, lifting weights and / or doing HIIT, martial arts - can this continue during the VLCD ?

On our 5:2 threads, most people can manage HIIT and lifting,
although prolonged cardio sessions (> 45 minutes) like running or swimming often don't go well with fasting

[ProfessorRoyTaylor]

Hello everyone!

Thank you for your questions so far, which I'll now start to answer.

[ProfessorRoyTaylor]

@BigChocFrenzy

Your book is proposing a VLCD for 2-3 months
*
A question about exercise:*

A VLCD would significantly reduce glycogen stores, so anyone already training for say a half-marathon should presumably choose another time to start the VLCD

However, what about the gym rats on MN ?
For those who regularly do an hour or more most days, lifting weights and / or doing HIIT, martial arts - can this continue during the VLCD ?

On our 5:2 threads, most people can manage HIIT and lifting,
although prolonged cardio sessions (> 45 minutes) like running or swimming often don't go well with fasting

During the weight loss phase is a very important that a new exercise programme is not started. this ami of the 8 weeks is to achieve weight loss, and extra exercise will prevent of minimise this (compensatory eating, partly conscious and partly uncousncious is the reason). So no extra activity. Current vigorous activity, if already habitual can be continued although there will indeed be a drop in performance. The goal is worth this temporary drop.

[ProfessorRoyTaylor]

@Localocal

This is an interesting article indeed. We have a huge diet industry peddling the idea that obesity causes diabetes, when the evidence shows only a correlation, not a causality. Nevertheless the NHS, too, pushes people to go on calorie restricted or category restricted diets with no evidence that a) they work (more than 90% of people who lose 10% of their body weight or more on a restrictive diet will gain it back) or b) that the obesity directly caused the diabetes. Yes I know some people have died and reversed their diabetes. But they may have died by reducing sugar intake, which may have caused both the diabetes reversal and the weight loss.

My work primarily has been aimed at understanding the mechanisms causing diabetes and also underlying reversal to normal. Briefly this involves removal of the critical tiny amount of fat from the pancreas and is nothing to do with sugar intake. Indeed, the low calorie liquid replacement meals are relatively high in sugar as a percentage.

[tribeleader]

I asked my GP about doing the keto diet. He told me absolutely not. It would mess with meds and could be dangerous. So how do you lose weight and not mess with meds??

Currently on metformin, gliclazide & dapagliflozen and last blood test was 67. I'm 53, 5'2 and 15 stone and have been type 2 for over 10 years (highest bloods were 78)

[ProfessorRoyTaylor]

@mammmamia

I have a similar question to *@Grasspigeons*

I am 5ft 5 and weigh 9st, healthy BMI of 21 and very active.

I have a strong family history of diabetes but clearly don’t need to lose weight - what’s the advice for people like me to postpone the inevitable? All the advice is around obese people losing weight - if I lost 2.5 stone I’d keel over!

Dear mammmamia,
This is a hugely important question.
Let me start with a caveat. At the low range of BMI's there is a greater risk that the diabetes is not 'type 2' but is either a genetically determined type (MODY) or slow onset type 1 diabetes. Both are rare, and for a person with a BMI of 21 yet a typically type 2 diabetes onset it is more likely that they have real type 2 diabetes.
A person only develops type 2 diabetes is they have become too heavy for their own body, and for the individual, BMI is irrelevant. Some of us can tolerate very large amounts of fat and will never get type 2 diabetes where some who constitutionally have a lowish BMI can get type 2 diabetes with small weight gain. This 'Personal Fat Threshold' for developing type 2 diabetes is a very important concept.
This is not at all just theoretical. In the Nurses' Health study in the US, the risk of getting type 2 diabetes was FOUR TIMES greater in women who rose to a BMI of 22-24, compared with those who stayed below a BMI of 22.
So you personally would be well advised to be able to fit into the jeans you wore when you were 21!
The most anguished messages I receive are from people in your position who have actually developed type 2 diabetes.

[ProfessorRoyTaylor]

@BigChocFrenzy

Yep, I just skimmed his book:
he suggests 2-3 months of VLCD to lose enough to reverse T2

He recommends a short sharp loss, but says a slower loss would also work if you can't do VLCD

his book says - IFF the person hasn't had T2 too long -
then 10 kg loss is the target to reverse T2 for someone under 80kg, 15 kg for a heavier person
(his book goes up to 180 kg)

Dear BigChocFrenz,
Yes, that is correct. The reason for the advised rapid weight loss is that this is achievable by by folk in shapr contrast to the slowly slowly method - whichis successful for very few to lose 15kg. I devised this approach originally because I knew that at around 7-800 calories per day hunger was minimal and also that use of one packet per meal cut out the cumulative burden of of decisions - what to eat, how much to eat, is this a level spoonful etc.
So metabolically, the time course does not matter, but the human aspect of things dictates that fast is much more successful.

[ProfessorRoyTaylor]

@tribeleader

I asked my GP about doing the keto diet. He told me absolutely not. It would mess with meds and could be dangerous. So how do you lose weight and not mess with meds??

Currently on metformin, gliclazide & dapagliflozen and last blood test was 67. I'm 53, 5'2 and 15 stone and have been type 2 for over 10 years (highest bloods were 78)

Dear tribeleader,
This has to be set in context. A sudden drop in carb intake could put you at risk of low blood sugar attacks because of the gliclazide (the metformin and the dapagliflozin will not be any problem).
On my university website (go.ncl.ac.uk/diabetes-reversal) there is an information sheet for GPs. This explains how to manage medication such as gliclazide or insulin in establishing the weight loss phase in people with definite type 2 diabetes.
In all our studies we stop all tablets on day one of the diet. Fastting blood sugar falls to normal within 7 days.
The simple answer to your point is that meds can be withdrawn - undersupervision and with monitoring of blood sugar. Do discuss with your GP first. Note that NHS England will be rolling out a pilot version of this programme in April, so it is not wild, wacky stuff!