Diving Be hind T ype 2 Dia b e te s Re ve rsa l He a dline s: WHAT DO WE T E L L OUR PAT I E NT S?
• 1) Ide ntify how r e ve r sal is de fine d and ac hie ve d ac r oss multiple studie s, inc luding gastr ic bypass studie s • 2) e xplor e two biologic al r e asons r e ve r sal patte r ns ar e diffic ult to sustain and the soc ial me ssaging be hind ac hie ve me nt and sustainability of those patte r ns • 3) list at le ast thr e e ways to navigate patie nt que stions about type 2 diabe te s r e ve r sal or r e mission
• Wr ite down 2- 3 que stions or c omme nts you he ar fr om patie nts about T 2D r e ve r sal • What ar e your pe r sonal fe e lings about T 2D r e ve r sal? Is it possible ? How like ly do you think it is? (wr ite down a pe r c e ntage ) • How do you de fine diabe te s r e ve r sal?
• “With time and de dic atio n, type 2 diabe te s c an be re ve rse d, and the re sults c an be ve ry re warding, with le ss tire dne ss and be tte r all-ro und he alth.” - Diabe te s.Co .Uk • “T his me ans we c an no w se e type 2 diabe te s as a simple c o nditio n whe re the individual Ame ric a n Dia b e te s Asso c ia tio n has ac c umulate d mo re fat than the y c an c o pe with . . . thro ugh die t and pe rsiste nc e , & patie nts are able to lo se the fat and po te ntially re ve rse the ir diabe te s.” - Pro f. Ro y taylo r, Wo rld He a lth Org a niza tio n c o -le ad o f DI RE CT study • “ Virta c an re ve rse type 2 diabe te s quic kly and sustainably.” - Virta he alth
y Of “Re mission” A Stor
Conside r ations Compar e & Ove r vie w of De fining T 2D for our Patie nts Re ve r sal Studie s Contr ast Re ve r sal Re ve r sal vs and & SOS Study Studie s Re mission He althc ar e T e am
• • CV Events (MI, CVA, • Retention • Time Before T2D Meds Weight Loss > Or = 15 • A1c CV Death, Inpt Tx Needed Kg (33 Lbs) • HOMA‐IR (Insulin Or C‐ • Partial Or Complete Chest Pain) • • Weight Loss Goal Of Remission: Year 1 peptide) Remission Of T2d • Fasting Glucose • Weight Defined By < 6.5%, Off >7% (Individual Goal • Fasting Insulin • Glycemic Control Dm Meds X 2 Months; 10%) • Remission A1c <6.5% • Fasting C‐peptide • Cardiac Risk Factors Year 2 <6.5% Off Meds • Weight X 1 Year, No Meds (Secondary Outcome)
• Primary • Overall Mortality • Secondary: • Changes in body weight, risk factors, energy intake, and physical activity • Difference in the incidence of risk conditions over 2‐ and 10‐year periods • Difference in the rate of recovery from risk conditions over 2‐ and 10‐year periods Torgerson JS, Sjöström L. (2001). The Swedish Obese Subjects (SOS) study‐‐ rationale and results. Romeo, et al (2012)
SUPPORT INTERVENTION : POPULATION: PHYSICAL NUTRITION • Year 1: RD or RN visit • INTERVENTION: INTERVENTION: Recruited >1500; • Initial 30 minutes/day • 800 calories/day in every 2 weeks, then • 298 Included every 4 weeks. • Recommended an • T2D W/In 6 Years form of supplement • Year 2: average appts (60% carb) x 6 month additional 15,000 • Median 3 Year 7.7 over year • Food re‐introduction • Step counters steps per day (approx. • A1c 7.6% 1.5‐2 hours) from 6 • “Relapse”—weight gain after 6 months • months on Medication Use >2kg or diabetes • Diet Alone 24% returned: Weight loss med (orlistat), Meal • I Drug 48% replacement, short • 2+ Drugs 28% term use of daily supplement restarted “T 2DM is a c o mplic a tio n o f we ig ht g a in a nd e xc e ss b o dy fa t, a nd it is no t ne c e ssa rily a pe rma ne nt Diabetes Remission Clinical Trial. c o nditio n.” Published Results. Retrieved from https://www.directclinicaltrial.org.uk/
POPULATION: SUPPORT INTERVENTION: PHYSICAL NUTRITION • INTERVENTION: Recruited 15,500 • RD, psychologists, INTERVENTION: • 5,145 Included • 1200‐1500 if less than • Initial 30 exercise physiologists, • T2D W/in 6 Years 250 lb; 1500‐1800 > Weekly x 6 months; minutes/day, 6 days a • A1c 7.3% 250 lb 3x/mon next 6 months; week • Encouraged to do 2 • (intervention group > 90 ) • Recommended an Medication Use • Campaigns to continue • Diet Alone 13% meals w/shake or increase to an • Non‐Insulin Use snack bar motivation & engagement • Did not meet >5% weight additional 10,000 replacement 72% • Goal to just eat steps per day (approx. • Insulin 15% loss at 6 months or more 1‐1.5 hours) than 2% weight regain = • Higher Education/ restricted intake meal replacement, (wean off Higher Incomes classes/equipment for supplements) cooking/exercise, orlistat Study wa s sto ppe d e a rly due to la c k o f b e ne fit (no diffe re nc e wa s se e n in CV e ve nts). Wadden, et. al. 2006
NT RIME XPE ION E ARVAT A ST SOT MINNE
• DIRE • MINNE CT ST UDY SOT A ST ARVAT ION E XPE RIME NT • Calor • 800 Calor ie s 1600— r atione d fur the r if not ie s/ Day me e ting we ight loss goals---adjuste d • 30 Min + 15,000 + Ste ps/ Day (= 8 we e kly • E Mile s/ Day; 56 Mile s/ We e k) xe r c ise –Walk 22 Mile s / We e k (3 • L OOK AHE AD ST UDY Mile s/ Day) • 1200- 1800 Calor ie s/ Day • 30 Min + 10,000 + Ste ps/ Day (= 5 Mile s/ Day; 35 Mile s/ We e k Baker & Keramidas, 2013
• DIRE • MINNE CT ST UDY SOT A ST ARVAT ION E XPE RIME NT • Constipation • Obse ssive thoughts/ c r • T avings for food e mpe r atur e Inse nsitivity • T • HA e mpe r atur e Inse nsitivity • HA • Dizzine ss • Dizzine ss • F atigue • Mood Change • F atigue / De c r e ase s in stamina • Nause a/ Indige stion • Mood Change (Ir r itability, de pr e ssion, apathy) • Diar • Musc le Sor r he a e ne ss/ Re duc e d Coor dination • Hair • Hair L oss L oss • Basal Me tabolic Rate (BMR)de c r e ase by 40% Baker & Keramidas, 2013
• Unable to determine SUPPORT INTERVENTION : PHYSICAL NUTRITION INTERVENTION: • Remote monitoring • Carb restriction 30g/day recruited INTERVENTION: • Not defined • 349 Included equipment (Scale, BP cuff, to attain 0.5–3.0 mmol BS & Ketone meter) with • Mean Time w/T2D 8‐ L−1 blood BHB levels ongoing contact with (modifications to health coach and MD or NP 10 Years • Onsite education 1x weekly • A1c 7.6% “personal tolerance” after) x 12 weeks; bi‐weekly x 12 • • Protein 1.5g/kg Medication Use weeks, monthly x 6 • Diet Alone 12‐ months, quarterly year 2 • Fat intake to satiety • Peer support group 13% • Food journal to track • Supplements • Insulin 30‐46% hunger cravings, energy, recommended mood Hallberg, McKenzie, Williams, et al. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open‐Label, Non‐ Randomized, Controlled Study. Diabetes Therapy 9, 583–612 (2018)
• Unable to determine PHYSICAL NUTRITION INTERVENTION: SUPPORT INTERVENTION: • 1500 calories/day recruited INTERVENTION: • Monthly RD appointments x • Goal of 175 • 215 Included women 1 year; bimonthly appts • New diagnosis minutes/week thereafter (6 appts/yr in f/u) 1800 calories/day men • A1c 7.7% (30 min, 6 days • Recorded food & activity • Med Diet: High fat a week) • journals (including (>30%); 50% carb Medication Use • Low Fat: Low fat (<30%) housework, occupational, • None recreational activity) Esposito, et al. (2009) Annals of Internal Medicine, 151: pp 306‐315.
2020 RANKING OF DIABE T E S DIE T S BY US NE WS “ME DIT E RRANE AN” DIE T “L OW- GL YCE MIC” DIE T “KE T O” DIE T “PAL E O” DIE T “F AST ” DIE T (WIT H A F OCUS ON F AST ING) Source: https://health.usnews.com/best‐diet/best‐diets‐overall
• WE • INCRE IGHT CYCL ING ASE INCIDE NCE OF CARDIAC • Change s in: PROBL E MS • Inc r • Musc le Mass e ase In # Of We ight Cyc ling • Insulin Re sistanc e / Hype rinsuline mia E pisode s = Highe r Odds Of Poor • HT Car diovasc ular He alth N and L ipids • Gluc ose L e ve ls Studie s de monstr ate ke to die t r e sulte d in fast, shor t- te r m we ight loss, with fast r e gain. Rhee, 2017; Byun et al, 2019, D'Souza et al (2020)
NUT RIT IONAL INT E RPRE T AT IONS W/ OUT ME DICAL GUIDANCE KE T O DIE T ME D DIE T Protein 1.5g/kg Fat Intake >30% e GF R ADA ADA Protein 0.8g/kg Sat Fat Intake <10% Wha t kind o f inte rpre ta tio ns o f hig h fa t o r ke to die ts ha ve yo u se e n?
• Recruited 8966 SURGICAL INTERVENTION: • 4047 Included • Fixed or variable banding, vertical banded • Paired Matched Control with WLS Participant gastroplasty, or gastric bypass • BMI 40‐42 USUAL CARE INTERVENTION: • No limitations on non‐surgical treatment • Fasting BG 156 mg/dl • Medication Use 48% Torgerson JS, Sjöström L. (2001). The Swedish Obese Subjects (SOS) study‐‐ rationale and results. Romeo, et al (2012)
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