You did not actually mention the elephant in the room (No pun intended) - carbohydrates. I went from 170 lbs to 128 lbs simply by restricting my intake of carbohydrates. A1c and blood glucose, insulin, hsCRP, triglycerides, waist circumference, total:HDL ratio -- all plummeted. The only way to cure a sugar disease is to restrict its fuel.

dH,

great story. I'd say about 95% of the Type II diabetes I see is curable with your approach.  I don't understand the mechanism or the pathophysiology in those with glucose intolerance who are normal weight. Best of luck and congratulations on adding years to your life. Glad you didn't approach it like a "Look Ahead" cohort. You'd still weight 165 lbs and becoming more ill by the day.

Melissa

 

I would say 99% of type 2 diabetes is reversible with carbohydrate restriction (even in end-stage disease). The patient may need to be hospitalized to stop their insulin and watch their fluid balance, but it IS possible. Reversal of type 2 diabetes clearly improves long-term prognosis, so long as people do not slip back into the western diet. Every modifiable risk factor improves with carbohydrate restriction (BP, hsCRP, trigs, HDL, WC, BMI, WHR, IL-6, sdLDL, insulin, A1c, BG, etc, etc.).

Though I loathe the "Adkins diet" and believe it to be detrimental in the long run due to chronic acidosis (cardiomyopathy, hyperkalemia, rebound weight gain once discontinued)  Dr. Adkins taught us an important lesson about our carbohydrate addiction in America: it is letha and costly.A sharp reduction in carbs is important to overall health for the average individual. 

Melissa 

Interesting take... not sure I agree entirely though. The main take-home point is that with a few exceptions, our society is currently incapable of reversing the cascade of insulin resistance (leading to macrovascular events) on their own, even with the best of help from the health care system as it stands.  This underscores the establishment of a decades-long, unrelenting, underlying pathophysiology in the absence of very early intervention.  In other words, "you can't undo a 30-40 year process with 5-10 years of 10% change." 

The only meaningful alternatives, therefore, remain, what I have always suspected:  real medications at real doses in effective combinations (no, pravastatin 10 mg daily is not going to cut it), gastic bypass/sleeve/lap banding, and novel weight loss agents.   

Sure, talk to patients about diet/exercise/weight loss, especially if they are young.  But as the primary therapeutic intervention to reduce the incidence of heart attacks in this country?  You're wasting your breath-- and wasting time.  

Please do not describe Dr. Ornish as paleo - the vegan or vegetarian diet is not paleo.

 As far as reversing or completely avoiding the damage that high blood sugar causes, I would encourage you to read Dr. Richard K Bernstein's book "Diabetes Solution". Yes, it is possible to do this with truly normal blood sugars. Dr. Bernstein describes how this is done through a low carb diet and medication. He has had T1DM for over 60 yrs and his own story is amazing.

Dear Melissa,great writing, very rewarding reading.I really appreciated you bravery. Standing up against the lack of effectiveness of the study will displease a lot of VIT2DMPs, still, this is the way it is. Why didn’t you push your bravery a little further writing the worlds “bariatric surgery”? We will never defeat diabetes in the population without social equity and widespread education, and we will never reach the social equity and widespread education we need to do the job. So, on an individual basis, surgery might be the (easy?) way out of the disease. However, if lifetime medical costs are taken into consideration, bariatric surgery has been demonstrated to be very cost effective to treat both obesity and diabetes. The question is: who is going to tell it to the pharmaceutical companies (and the stock market)?Keep kicking!Giovanni Gulli

Same here. I read Taubes' Good Calories, Bad Calories in 2007, stopped eating carbs (well, ok, really, really cut back) started eating lots of fat (meat, butter, cheese) and with no goal in mind watched 30 pounds come off in the next 18 months. Six years later my BMI is still 24 and my pre-diabetic condition (fasting glucose of 110) is somewhat improved (typically less than 100), my triglycerides are below 100 (from 250-300 before) and my doc says my non-alcoholic fatty liver condition is gone. HDL stays at record highs (above 75).

The reluctance to eat fat (necessary if calories don't come from carbs) is widespread, but Taubes argues, with enormous data behind him, that fat is harmless. To this point, I'm a familial hypercholesterolemic (FH) with a TC of 600 and an LDL of 540, yet at age 66 my arteries are completely clear by EBCT. My cardiologist wants me to take lipoprotein lowering statins, but when I ask what he thinks how it might benefit someone with clear arteries he is unable to even hypothesize a benefit.

Thank you, doctor. It is odd to hear a physcian use the worde "cure" with regard to Type 2, but I am with you on this, (which is why we titled our book The 30-Day Diabetes Cure). I'm also with you in encouraging physcians to become more pronounced and outspoken witht heir patients about "getting serious" about this

life-threatening condition.  I think more doctors would, if there was a clear strategy about what really works for reversing Type 2.  Clearly, as Look AHEAD shows, “eat less and move more” isn’t that advice. The tragedy of Look AHEAD is that it will confirm the notion in the minds of many physicians that diet and lifestyle isn’t a viable approach.  Neither is merely losing weight.  Please consider that Type 2 isn’t a consequence of weight gain. Rather, weight gain is a consequence of insulin resistance.  We have seen that when a Type 2 stops consuming the foods and beverages that trigger insulin (the body’ fat storage hormone), stored triglycerides are transformed into essential fatty acids and are metabolized into energy.  Dietary fat isn’t the foe.  Rather, it is the official low-fat (high-carb) diet that has been recommended to us since the 1980s that is largely responsible for the current epidemics of obesity, Type 2, and cardiovascular disease.  Look AHEAD fed this diet to its participants (only one-third less of it!) and it failed to move the needle.  What is preventing the NIH to conduct a large-scale study on carb-restriction as the only variable?  Americans consume 170 pounds of sugar per capita per year.  How can we continue to maintain that dietary fat is responsible for these health problems?  Armed with a real research results, doctors would be able to deliver the same unequivocal message to their patients (“excess carbs kill”) as they now do regarding smoking (“tobacco kills”). If we are honest, we must look at the political issues which may be blocking this inquiry: resistance from both the food and drug industries. The situation is a Gordian knot that is hog-tying doctors and strangling patients.  While I applaud your spirited encouraging of doctors to be more outspoken, the research community must first give them something to speak out about.  Studies such as Look AHEAD won’t provide them with the information they need to truly help their patients.  Respectfully, Jim Healthy.

I agree with this. Lifestyle modification is not dead - it is the content of LM that matters most. Applying a low fat diet is a known failure. Diabetics need carb restriction to get off insulin (type 2's anyway) and to reverse (and yes cure) their disease. Diabetics are by definition carbohydrate intolerant (synonyms: glucose intolerant, metabolic syndrome, etc). It is the one type of food they cannot tolerate without displaying all the downstream manifestations of this disease. It is very sad that the NIH will not fund a carb restriction trial with hard endpoints, but there are enough data out there to advocate this approach to our patients.

Thank you. 

Sorry, the last paragraph should be:

See also “Low-carbohydrate diet scores and risk of type 2 diabetes in men,” Am J Clin Nutr. 2011 Apr;93(4):844-50, where: “the score for high animal protein and fat was associated with an [37%] increased risk of Type 2 diabetes": HR 1.37. ... A high score for vegetable protein and fat was not significantly associated with the risk of T2D overall but was inversely associated with T2D in men aged <65 y (HR: 0.78)." 

So -- a big difference in low-carb diets. 

Great article. Yet again a headline that misinforms the public

You are very ... cool.  I wish more doctors thought and felt as you do.  Jim H

S Nelson - I completely agree with you. I advocate a plant-based, carbohydrate-restricted pesco-vegetarian diet, with a minimum of animal saturated fat and dietary cholesterol, and emphasis on MUFA's and PUFA's as a dietary fat source. Carbohydrates in the diet are extremely complex and fibre-dense -- our ancestors even a thousand years ago subsisted on prickly pear cactus with a glycemic index of only 7!!  Seven!!!  You can't get fruit with a GI of 7 today (unless you count olives and avocados as "fruit" - they are the only fruit I consume, other than a small amount of tomatos).

Dr. Michael ...Your prognosis and prescription for our current Type 2 dilemma borders on the dismal. On what grounds do you claim that "our society is currently incapable of reversing the cascade of insulin resistance on their (sic) own, even with the best of help from the health care system as it stands." Please describe, sir, what this "best help" Type 2 and heart patients are receiving from current health care system? Are physcians informing new T2s that they have the possibility of reversing their conditions and escaping a life sentence of medication? An what educational/motivational assistance to these oatients are physcians being compensated for providing? From my perspective, our healthcare system is doing little to nothing to change the lifestyle habits and commercial conditioning that public has been receiving since early childhood via advertising that use cartoon characters and sports heroes to influence diet and lifestyle habits. Forgive me if I detect a lack of empathy and compassion from you regarding psychological conditioning that has created this health crisis. That T2s feel powerless and hopeless isn't due to their inherent laziness and disregard for their health and happiness. They don't need to be medicated and surgically altered like dumb animals or retarded children. What they need -- what we all need and yearn for -- is to be educated, inspired, and uplifted. In these areas, we are failing patients and society. The "solutions" you propose should only be considered when we have tried our utmost to influence behavior toward awareness and to defend and protect patients from the unfair and overwhelming advantage that the food and drug industries exert over mainstream consciousness and behavior. In my opinion, the medical community has the obligation to protect patients from harm and to lead them to more healthful behaviors. This requires standing against "the system" when the system is causing harm and profiting from a status quo that perpetuates ignorance. In this case, we are not "wasting our breath" or "wasting time." this is our duty, obligation, and opportunity to move humanity forward. With all due respect, sir. 

INSANE ARTICLE E DANGEROS. HbA1c < 6 for all diabetic patients? SHE GO TO STUDY..

I believe you missed my point. I am not aiming for a Hba1c pharmacologically, but with dietary discretion, exercise, achieving a low normal BMI, a normal Hba1c can be achieved by most-but achieved by few in our corn fed society.

Melissa

I like that line about our "corn fed society". Might as well add to that our "fruit-filled, sugar-addled, wheat- and potato-starch overwhelmed, fructose-drugged, peas- and oats-entangled society".  See a common denominator here?  It's all about carbohydrates.  And avoiding processed foods, dietary cholesterol and saturated fat (which I view as only slightly lesser villains).  Some, too, object to salt - not me, as you need it on a carb-restricted diet (the less insulin your pancreas secretes due to very steady glucose levels on carb restriction, the less tubular reabsorption of salt and water occurs). Breakfast this morning - 0.1% yogurt with 5 grams of CHO per 3/4 cup serving, nine types of nuts and seeds mixed in together with organic cocoa nibs (whole), a large glass of water and decaffeinated coffee, two avocados (intact) and 10 small manzanilla olives. Total carb load after deducting fibre - probably about 7-8 grams.  The average carb load of the average North American diet - 300-450 grams of carbs per day.

 No wonder LOOK-AHEAD failed so dismally. It's truly sad. 

THE PROBLEM is THAT THERE ARE MORE AND MORE 'IS CLEAR THAT THE metabolic COMPENSATION HAS LITTLE EFFECT ON EVENTI CV AND THIS HOW MEDICAL we have to accept FRANCESCO

Your comment encapsulates everything I dislike about the medical community. I'm sick to death of doctors putting sick people on drug treatments that will only partially mask the side effects of the underlying condition and will never, ever cure them; let alone allow them to enjoy good health.

If you were to look at the current literature you would find plenty of studies that show chronic disease (such as Type II diabetes) is linked to unnaturally high intake of sugar and other refined carbs. The cure is as simple as removing carbohydrates from the diet - there's no need to put people on a drug regimen that only benefits the drug companies, insurance companies and doctors.

The medical community does a disservice to their patients with their attitude that only drug treatments can cure chronic disease. Until things change in that aspect Americans will continue to get sicker and sicker.

In the defense of doctors, I must say that if you blood sugar is 400 and the patient is overweight, we can't just wave a magic wand and fix it tomorrow. That's is where oral hypoglycemics come in. BUT.....it's like a surgery. We need antibiotics to fix the infection-THEN we must do the surgery to fix the underlying cause of the infection. If we just keep giving antibiotics (the oral hypoglycemics and/OR insulin in a Type II patient), and do nothing else....the infection (elevated blood sugars) continue to kill us slowly.

So, forgive us "MD's" for having to reach for these meds frequently and criticize us often for not taking the time it takes to teach about diet. FINALLY, if your Hba1c is still 8-as a patient, you have a personally responsiblity to do research, ask some questions and fix it. When it comes down to it, "no one loves you like "you" love you". Love yourself enough to hit "google" and figure out a comfortable plan and obtain a nutritionist to help you treat and in many instances "CURE" your problem.

DH,

What is the scoop on Cinnamon? Thinking of adding that to my daily diet, but just wanted your take.....

Melissa

Ooops,

Could not let the salt comment go by: It's a villian in my part of the world: Spells big legs, shortness of breath and elevated BP's

Melissa

From the Look AHEAD study protocol:

 2.6 Need for a Randomized Clinical Trial on Weight Loss and Health in Diabetes
Given the paucity of data on the impact of weight loss on morbidity and mortality, an increasing number of critics in both the lay press and professional literature have questioned whether obesity should be treated at all. They point to pharmacologic improvements in treatment of obesity’s comorbid conditions, such as hypertension and dyslipidemia, that are effective without weight loss and the observational literature showing increases in mortality with weight loss.
Observational studies attempting to determine health effects of weight loss have limitations, such as the inability to separate intentional from unintentional weight loss (e.g., as a result of illness) or the inability to control adequately for preexisting illness and other confounding factors. The limitations of observational studies attempting to determine the effects of weight loss and/or physical activity on health can be addressed only through randomized intervention studies designed to measure changes in health outcomes that accompany intentional weight loss.

If you're 45, with a BMI of at least 25, and diagnosed with DM (the study entry criteria). an intervention of supervised weight couseling with exercise and diet did no better than education at reducing macrovascular events over a study period of 5-10 years, with the trial terminated early due to futility.  No improvement in events were seen despite sustained improvements in BP, A1C levels, and lipid measurements.  No matter what you were hoping for, these are reasonable conclusions from this study. 

From Dr. Anne Peters, a study investigator:

 "We do know that weight loss and exercise can prevent diabetes," said Peters. "I am a big advocate of prevention, both early prevention of obesity altogether, as well as prevention of diabetes in individuals who have become overweight. Lifestyle changes can help prevent diabetes. Once you have diabetes, I think weight loss and exercise can have benefits, but they are not going to reduce the risk for the primary outcome that we set for Look AHEAD, which was a risk for macrovascular events or death."

I do agree that a prospective, randomized trial for a carbohydrate-restricted diet is needed, but this will take many years.  I currently "believe" in this approach and it is what I recommend to most patients.  Similarly, however, the evidence base for this is also lacking. Many posters above treat this as a foregone conclusion, which it isn't.  

Sure, there are some exceptional cases where a very motivated person can probably do themselves a world of good and get dramatically better. But for the typical  5'5", 240 lb. diabletic, with 80-100 lbs to lose?  There is no existing diet or exercise regimen, of any intensity, which is of proven benefit in preventing heart attacks, no matter how much we wish there was.  The same is not true of certain medications-- statins, in particular-- and the evidence for weight loss procedures looks very good so far. 

 

Cinnamon - have heard that it lowers blood glucose "naturally", but I don't know anything about long-term safety. Personally I would be worried that it would trigger sweet-tooth like cravings, since so many candies and sweets buried in our primordial memory were coated with cinnamon (especially around holiday time). Studies by David Jenkins at the University of Toronto show that nuts and legumes both lower HbA1c, but I would suggest avoiding starchy beans such as chickpeas and red kidney beans, as well as starchy nuts such as cashews and chestnuts (other nuts and seeds are A-ok).

There's alot of dogma built up around salt. 

Ummmmmm,  WRONG!

Any study that relies on food frequency questionaires should be ignored....period.

This study is loaded with flaws, and I'll let Denise Minger lay it out for you.

Enjoy,

http://rawfoodsos.com/2010/09/08/brand-spankin-new-study-are-low-carb-meat-eaters-in-trouble/#more-580

Cinnamon

Was taking ½ teaspoon daily in a protein shake....a nice spice, but has minimal effects on blood sugars or anything else of benefit.

D Ribose is the power therapy for insulin control and heart muscle function...1 level teaspoon daily.

D-Ribose is a five-carbon sugar that constitutes the backbone of RNA, a biopolymer that is the basis of genetic transcription. D-Ribose is related to deoxyribose, as found in DNA. Once phosphorylated, ribose can become a subunit of ATP, NADH, and several other compounds that are critical to metabolism like the secondary messengers cAMP and cGMP.

The Allopathic way is Metformin which is the best medicine can do.

Agree with the comments on the deleterious effects of Carbs/Wheat.

BTW...S Nelson must be double-jointed.. to do that with nuts.

Dear Melissa,

you skipped my comment about bariatric surgery. I'd love to know your view about it.

Thank you very much

Giovanni Gulli

Giovanni,

My profound apology. I did not mean to skip your comment. Advantages of a successful Bariatric surgery: Here goes: makes one fit into the CT scanner more easily. Banishes the need for insulin. Improves quality of life. Makes shopping easier. Improves lipids. Down side: Surgical risk . iron deficiency and even malnutrition in some. 

Do I advocate it? If patients are so morbidly obese they have gotten themselves in to such a corner that they cannot exercise, then I do advocate it. I've probably pre-op'd many patients for it in my 20 years at the request of other physicians and have advocated for it successfully in 8 patients who have now collectively lost around 500 pounds. I have two more I've seriously pushed to consider it because they are slowly dying of obesity. One patient developed aplastic anemia and died a few years following the surgery, probably unrelated to his surgery. 

 Does it prevent heart attack/stroke? I think it's intuitive but earlier short term studies really did not demonstrate an  impact on mortality. More recently data supports it's beneficial. 

NOTHING beats a treadmill and a pair of sneakers. When folks "think" they have no willpower and they've "tried everything", then I ask them to consider it. 

Hope that helps and thanks for baiting me!!!

Melissa

I disagree entirely with the comment that nothing beats a treadmill and a pair of sneakers. Sorry. All that is going to do in a morbidly obese person is promote severe knee OA and increase appetite. Remember that phrase our mothers used to use when we were kids, "Go out and run up an appetite before dinner"? Exercise is the lousiest way to lose weight. First of all, it is incredibly inefficient at burning calories - one had to run on a treadmill for half an hour to burn the equivalent of a single slice of toast. Why not restrict carbs instead?  People far outstrip their ability to burn off calories through exercise simply by eating the wrong types of foods, day after day after day (and yes it accumulates).

 Yes I ask my patients to exercise, but only after they have lost the weight. This way they are not promoting a ravenous appetite and destroying their joints with all that morbid weight pounding on cartilage and intervertebral disc spaces.

What is frankly surprising is howe we have come to believe as a society that simply eating less and exercising more is enough to lose weight (a simple law of thermodynamics, right?). As a matter of fact, we are exercising now more than we ever have in our leisure time and eating less calories on average than 30 years ago. Yet 70% of the population is overweight or obese! The reason is simple: food choices and industrial food production. Carbohydrate-laden food choices, to be specific.

Acute exercise in previously sedentary individuals is however great at making people drop dead from MI's and SCD, and when they don't do so, making them feel they can eat that extra serving of ice cream (because they "earned it"), and in general making them more hungry and tired.  Wonder why all those runners are so skinny?  They've not only modified their level of activity to exercise more; they've (more importantly) modified their diet.

No wonder Michael Phelps needs to consume 8000 calories per day...

DH

Point well taken. I still argue that if we teach our children to exercise and eat well, we will off-set the entire obesity epidemic. I stick by my opinion on that. I understand your point about morbidly obese folks......They are largely stuck unless they get bypass or suddenly tap into the will power they don't know they had. 

Natural approach is best if it can be achieved-exercise, diet and you can do non-weight bearing or less weight bearing exercise until you can get the weight off-swimming, stationary bike, gazelle, etc.

Diet Pills have never worked and on the long term never will. I'm confident of that.

Melissa 

 

Agreed. But yet another mythology has been expressed that needs to be exploded - that the morbidly obese have no will power. Really what they lack is education and knowledge about what is making them obese. I suggest you read Gary Taubes eye-opening book entitled "Why we get fat: and what to do about it". It certainly opened my eyes - and eventuated in my weight loss and many of my patients. There are really too many myths in this very important area of public health:

-eating fat makes you fat

-a calorie is just a calorie (whether it comes from carbs, protein or fat)

-what you eat you must burn through exercise

-and the corollary, obesity is caused by an imbalance of food intake and physical exertion

-the obese lack willpower, or they are lazy, or stupid

In essence, it's all a matter of appropriate food choices and proper nutrition. Big industry and big sugar and big wheat and big fruit will continue to make us obese, diabetic, dyslipidemic and hypertensive. Add to this the ignorance of most physicians, nurses and nutritionists who see and treat obese patients and give them useless advice about eating fewer calories and exercising more. No wonder we are failing so miserably and 70% of us are overweight or obese (and that's by relatively insensitive BMI criteria - to speak nothing of using waist circumference or waist-hip ratio or MRI).