brand new trial just came out looking at reversal of type 2 diabetes with lifestyle. they took
72 participants with type 2 diabetes and split them randomly. one group was just told to follow
National dietary guidelines. now, this trial was conducted in China so it was Chinese dietary
guidelines but they're not too different on the fundamentals, it was basically a diet with whole
grains, high in fiber and unsaturated fats and they were asked to eat about 50 to 65 percent of
their calories from carbohydrate, 15 to 20 percent from protein and 20 to 30 percent from fat, with a
maximum of seven percent coming from saturated fat, and they did this ad libitum, meaning you
can eat as much as you want quantity-wise of those foods, of that diet. the other group,
The intervention group, the actual experimental group, was put on the same diet but every 10
days they spent five days on a restricted diet, so 10 days at libitum, five restricted, another ten
at libitum, five restricted, and so on. and the restricted diet was 840 calories a day, so pretty
hypocaloric, and it was 46% of calories from carb, 46% from fat and eight percent from protein, and
they had three meals a day, breakfast, lunch and dinner, at specific times that were predetermined,
and those meals were delivered to them so that all the food was provided, and they were asked
not to eat anything else in between the meals. so just to recap, the control group was told
to eat according to the guidelines, ad libitum, as much quantity as they wanted, and the experimental
group ate the same diet but for every 10 days at libitum they had five days of restricted calories,
so the only difference between the two groups was the restriction. and they followed this protocol
for three months. so obviously the goal with the intervention is to restrict calories but instead
of doing it daily like in some trials, here it was intermittent, so every 10 days there were
five days of restriction, which might be easier for some people, if you know the Restriction is
limited in time, it's only a few days and then you go back to eating as much as you want,
might be easier to stick with. after three months of this protocol, the restricted group
lost about nine percent of their body weight. they weighed an average of 67 kilos before the
trial and they lost about six kilos. the control group, on the other hand, didn't lose significant
weight. they weren't very heavy to begin with, their BMI before the trial, average, was 24,
which in the western hemisphere is actually in the normal range, 25 is the cutoff for overweight. but
for Asian populations sometimes lower cutoffs are suggested, so for example The WHO suggests
the cutoff of 23 for a Chinese population, so by that measure these guys would be in the overweight
range. and their BMI fell from an average of 24 before the trial to an average of about 22 after
the trial, so it fell to the normal range even for an Asian Chinese population. in a addition
to the weight loss, their fasting glucose level also came down, it was about 140mg/dL before the
trial and it dropped to 113. and 126 is the cutoff for diabetes so their average was no longer in the
diabetic range after the trial, although it was still in the pre-diabetic range. the cutoff for
normal is under 100. and in the controls there was no significant change in fasting glucose. so both
the weight and the fasting glucose improved in the Restriction group. there was also a reduction in
the diabetes medication, 68% of participants in the Restriction group reduced their diabetes meds
and 50 percent stopped them altogether. after the three months of the trial, all the participants
were asked to continue eating according to those National guidelines for an additional three months
of follow-up but this time without restriction, so everybody was eating ad libitum. and at the end
of that second three month period, they measured their hemoglobin A1c, their glycated hemoglobin,
which is an average of the glucose levels over the prior three months. and the reason they did
that is that these are the new criteria to say that someone is in remission from their type 2
diabetes, you want to see a hemoglobin A1c under the threshold for diabetes, under that cutoff,
which is 6.5%. above that you're said to have type 2 diabetes, so you want to see a hemoglobin
A1c under that cutoff three months or more after someone has stopped their diabetes meds,
and if you see that you can officially say someone is in remission from their type 2 diabetes. and
I think the reason there is obvious, you want to see their glucose level naturally, without being
artificially pushed down by the medication, and the reason it´s three months is because that's the
time span that the hemoglobin A1c covers. so it makes sense. so their average hemoglobin A1c was
7.65% before the trial and it dropped to 5.66% at that six month mark. remember, it's three months
of restriction protocol plus three months of follow-up with ad libitum guidelines diet. so they
did drop below that diabetes cut off. and actually 5.7 percent is the cutoff for pre-diabetes,
so under 5.7 is the normal range for hemoglobin A1c, so the average for the Restriction group had
just barely made it into the normal range. and in the control group there was no significant
change to hemoglobin A1c. now, this drop is pretty respectable but this is the average of
the Restriction group, so it could mean a couple things, it could mean that everybody came down
from the diabetes range or it could mean that a percent came down a ton and some are still higher,
so next they looked at the participants one by one to determine how many were in remission, and it
was 47 percent that were medication-free and under the diabetes range, so officially in remission.
and their fasting glucose at this six-month mark was 104 in average. so it was 140 before the
trial, 113 after three months of restriction and 104 after another three months of follow-up. now,
some variation between measurements is normal, but I was actually pretty surprised by this,
because usually what you see when the intervention itself is over is you tend to see a drift towards,
in the direction of Baseline values, so kind of a rebound, but here they actually seem to improve a
little bit further, they're almost in the normal range for fasting glucose, which is under 100.
after that, they continued to follow them for a total of one year, so three months initially of
randomized intervention and then nine months total of follow-up, and at the one year mark, fasting
glucose was 111. so starting to see a bit of a rebound. similar level to the three month. Mark
and hemoglobin A1c was 6.33% so also some rebound but not all the way back to Baseline. whereas
their body weight was still six kilos below Baseline. so they kept it off pretty good, and
it's interesting that both their fasting glucose and hemoglobin A1c rebounded a bit but their
weight stayed pretty stable, so I wonder if there are some inaccuracies in the measurements or maybe
there's some weight-independent effect that raised glucose. they also looked at something called
complete remission, which is where you have both a fasting glucose measurement and your hemoglobin
A1c in the normal range, so not just under the diabetes threshold but under the pre-diabetes
threshold as well, so both metrics in the normal range, and about a third of the volunteers from
the Restriction group were in complete remission at the one year mark, which is pretty respectable.
another cool thing about this trial is that they're still following them, they're going
to go all the way to five years of complete follow-up, so that'll be published, it'll be
really interesting to see because normally you see a pretty significant drop off of the gains
a couple years after a dietary intervention. for example, in Roy Taylor's direct trial, where they
used a low calorie diet to achieve weight loss, 46% of participants were in remission at one year
and by the two-year mark it had come down to 36 percent. so two major takeaways from this trial,
the first one is the potential. it's possible to achieve complete remission from type 2 diabetes
just with lifestyle tweaks and to get completely off medication. this is still very surprising to
a lot of people including some doctors. for a long time there was a belief that type 2 diabetes was
irreversible, that it was a lifelong condition. when I was in medical school we didn't talk about
reversing it or putting it in remission, we talked about managing and medicating,
so it's really important to keep learning because the science doesn't stop. and I hear this from
viewers regularly, "hey my doctor told me there was nothing that could be done and he just put me
on some meds", and then they Google it and they find this information and they get very upset,
and that's understandable, so this has to become general knowledge, we have enough trials
demonstrating the possibility of remission, half the participants were no longer in the diabetic
range after a few months just with some tweaks to the diet, nothing fancy, nothing expensive, every
doctor needs to know that this is a possibility. now, the second takeaway is a dose of reality,
that this rebound is a common observation, in this trial we can kind of justify it because they told
them to stop restricting, but we see this in all kinds of Trials, during the intervention,
an initial period of improvement followed by a rebound, so people struggle to keep their gains
in the long run even though they've been shown how to do it and they've felt the Improvement
in their own skin, they still oftentimes fall off the wagon, that's how hard this can be. the other
sobering realization is that these interventions never work for everyone, we always see that,
in this trial half the people were still in the diabetic range, about half, 47 percent were in
remission, the other half were still diabetics, so the diet, or the intervention, didn't work for
those folks, and the same is seen in DiRECT, at one year about half of the volunteers are not in
remission and at two years it's two-thirds. people also often ask about Virta, which is a study using
very low carb diets, and they had about 20 percent of the participants in remission at the 2 two-year
Mark and about 50 percent had normal glucose levels but were still on some medication, like
metformin. now, there's going to be a temptation to compare these trials directly one to one, the
number of remission is larger in this one so this diet is better than that diet, we can't really do
that, too many methodological differences, the experimental design is completely different so
it doesn't really work out that way but we can clearly see that all of these interventions work
for some people and don't work for others, so at the end of the day very important to remember
we're dealing with human beings living in the real world, it's not robots, so none of these diets are
a Magic Bullet that's going to end diabetes but having this repertoire at our disposal,
all this evidence, could potentially help millions and millions of people if it's well utilized. this
is why I always harp on sustainability, finding a diet that's sustainable for you, that you feel you
can stick with for the Long Haul, for decades, and that it's not a chore, right? that it's
enjoyable for you to do it, all of this so that you don't become another case of rebound. the
other question I've been getting a lot is about some medications like tirzepatide and semaglutide,
some meds that have shown pretty impressive results in somewhat recent trials, and we
have a whole video on that in the pipeline so stay tuned. here's more information on putting
type 2 diabetes in remission using diet and here's my interview with Roy Taylor,
who supervised the DiRECT trial. I guess he directed DiRECT, there you go, see you over there