NHS 800 calorie diet for diabetes patients

I think the thing your missing is that it's a doctor monitored plan. The "food" given has been carefully designed to ensure that the patient is getting enough nutrients, so shouldn't encounter the same issues that someone doing it on their own will.

Also looking at details of the trial, the patients were given plenty of support afterwards helping them transition into an eating plan that provides for them going into the future, as opposed to letting people return back to their old eating habits.

Details on the trial
The published paper on the trial

The thing about type 2 diabetes is that if you can get out from under the obesity, in a lot of cases the insulin resistance improves to the point that medication is unnecessary. What they misleadingly call "reversing" diabetes - misleading because you are still diabetic and will get high blood glucose levels if you eat a big piece of cake, but able to have normal levels if you restrict carbs to what you can handle. My A1c after three months of a 1200 calorie diet went from 11, which is very high, to 4.7, which is completely normal.

Unfortunately a doctor's supervision will not prevent serious hair loss six months after three months of an 800 calorie diet which according to the article I read is "no fat." Doctors are not magical. And there's no real need to go 800 calories to get the same results, as my own case demonstrates, it just seems to be easier for some people (like my own mother) to literally torture themselves eating a liquid diet than to try to count calories. But it could be worth it.

I actually went back and read through the study summery more carefully. To be fair the results are pretty impressive. Of course I don't have access to the full study so I can't see if the summery is an accurate representation of the results, however, a tl:dr version for anyone who is interested:

- 306 T2D individuals aged 20–65 years, diagnosed within the last 6 years had a BMI of 27–45, and were not receiving insulin
- Split into two groups equal group, one on the trial diet (intervention), one following current best practice care guidelines (control). These were randomly assigned.
- Trial consisted of: total diet replacement (825–853 kcal/day formula diet for 3–5 months), stepped food reintroduction (2–8 weeks), and structured support for long-term weight loss maintenance.

Results after 12 months:
- 24% of intervention group lost 15kg or more. 0% of the control group achieved this
- Diabetes remission was achieved in 46% of intervention compared to only 4% in the control.
- Remission was more prevalent the more weight was lost, this was across both study groups.
- Mean loss was 10kg (intervention group) and 1kg (control group)
- Quality of life improved by 7.2points in intervention group, and decreased by 2.9 points in the control
- 4% of intervention group reported serious adverse events compared to only 1% in control. No serious adverse events led to withdrawal from the study.

Source



It's a shame I don't have the full study, as I would be interested in see how the weight management was once the participants finished their reintroduction program to 12 months (at the least 5 months worth of time). It appears some gained weight in this time, but I would be interested in how many continued to lose weight.

Also, I would be interested in the balance between the two groups. Wondering if there were other factors that could've affected the results (such as age, gender, BMI). Because, for example, people who have more to lose will obviously lose more numerically. However, would that affect their chance of remission. Is it that it's not the amount of weight loss in kgs that is the important factor, but the level of BMI(/bf%) that they reach?

Discussion point:
I think that the QoL improvement is a really interesting point, especially seeing as more people in the intervention group reported serious adverse events. Maybe it's that although it was tough, somehow it was seem as more "worth it" by the patients as they got very good results, compared to the control group who didn't see much improvement at all, and were probably struggling also, didn't see the struggle as worth it. I mean, anecdotally that fits with the theory I have that people would much rather really suffer badly for a couple of weeks, than barely suffer for a long period of time. (I mean, would you rather have excruciating pain for 1 day and then it be gone, or slight pain every day for a week? As someone who has experienced both thanks to periods, I can tell you which one I prefer: the 1 day one.)

Deviette wrote: »

[snip]

It's a shame I don't have the full study, as I would be interested in see how the weight management was once the participants finished their reintroduction program to 12 months (at the least 5 months worth of time). It appears some gained weight in this time, but I would be interested in how many continued to lose weight.

Also, I would be interested in the balance between the two groups. Wondering if there were other factors that could've affected the results (such as age, gender, BMI). Because, for example, people who have more to lose will obviously lose more numerically. However, would that affect their chance of remission. Is it that it's not the amount of weight loss in kgs that is the important factor, but the level of BMI(/bf%) that they reach?

The pilot studies are open access (or can be found in preprint versions) and have interesting details about success. I actually wrote a summary for a family member. I'll paste the summary below. But to answer your question about body fat, the working hypothesis is that it is more about pancreatic fat (which probably increases hand in hand with liver fat) that leads to T2D. Subcutaneous fat is not really the issue. Everyone has a "personal fat threshold" where you start storing fat viscerally- that's when you start getting sick. You need to diet to get below that threshold and remove the fat in the organs. Of course, the amount of visceral fat lost does tend to track pretty well with total fat lost, so that is the measure reported in the larger studies. There are some studies (on fatty liver) that suggest that more extreme calorie restriction (and consequently ketogenic) does preferentially use visceral fat first, but there are other studies that don't seem to show any benefit from 600 cal diets vs. modest calorie deficits. So, this 800 cal protocol might give added benefit vs. just losing weight, though weight loss does reverse T2D. Or it might not.

My summaries were formatted, but pasting them into MFP has stripped everything. I tried to clean it up, but it is probably still ugly. I don't have time to clean it up more today, but I will this weekend, if people are interested, and I'll either repost it here or put it on a webpage and share a link.

Okay, here is the long summary of the 5 initial papers. :
Type 2 Diabetes reversal as proposed by R. Taylor, Newcastle University.
http://www.ncl.ac.uk/magres/research/diabetes/reversal/#overview
The website has information for patients as well as doctors & scientists.

Background (taken from [1]) :
-Metabolic abnormalities of type 2 diabetes (T2D) can be reversed by bariatric surgery.
-This reversal is attributed to the substantial weight loss.
-A study that assigned people to conventional treatment (lifestyle modification programs, dietary advice, oral hypoglycaemic agents and insulin) or adjustable gastric band + conventional treatment found that T2D was reversed in 13% of the conventional group and 73% of the surgical group. (Note that the conventional group lost essentially no weight as a group, while the gastric band group lost ~ 40 lbs (26 kg).) Reversal is defined as HbA1c< 6.2% and fasting plasma glucose of <7.0 mmol/l when off all treatment.
-Several studies show that the reversal of T2D from bariatric surgery lasts for at least years. (Longest study mentioned had a 6 year follow-up, and 86/88 patients were normal at the 6 yr point)

Reversal via diet:
Taylor et al. proposed to replicate the reversal of T2D using diet alone.
First study [2]:
-Eleven people with type 2 diabetes (49.5 ± 2.5 years, BMI 33.6 ± 1.2 kg/m(2), nine male and two female) were studied before and after 1, 4 and 8 weeks of a 2.5 MJ (600 kcal)/day diet. All were <4 years from diagnosis with T2D
-After 1 week of restricted energy intake:
*fasting plasma glucose normalised in the diabetic group (from 9.2 ± 0.4 to 5.9 ± 0.4 mmol/l; p = 0.003).
*Insulin suppression of hepatic glucose output improved from 43 ± 4% to 74 ± 5% (p = 0.003 vs baseline; controls 68 ± 5%).
*Hepatic triacylglycerol content fell from 12.8 ± 2.4% in the diabetic group to 2.9 ± 0.2% by week 8 (p = 0.003).
*The first-phase insulin response increased during the study period (0.19 ± 0.02 to 0.46 ± 0.07 nmol min(-1) m(-2); p < 0.001) and approached control values (0.62 ± 0.15 nmol min(-1) m(-2); p = 0.42).
*Maximal insulin response became supranormal at 8 weeks (1.37 ± 0.27 vs controls 1.15 ± 0.18 nmol min(-1) m(-2)). Pancreatic triacylglycerol decreased from 8.0 ± 1.6% to 6.2 ± 1.1% (p = 0.03).
*Normalisation of both beta cell function and hepatic insulin sensitivity in type 2 diabetes was achieved by dietary energy restriction alone. This was associated with decreased pancreatic and liver triacylglycerol stores. The abnormalities underlying type 2 diabetes are reversible by reducing dietary energy intake.

After the first study received press coverage, a number of people attempted to replicate the method on their own and reported the results to the Taylor group. This group ended up being more diverse than the original study (especially with respect to number of years with T2D) As these results are self-reported, they should be taken with a grain of salt. Taylor summarized these results [3]:
-Size: (n = 77: 66 men, 11 women).
-Median diabetes duration was 5.5 years (3 months-28 years).
-Reversal of diabetes was defined as achieving fasting capillary blood glucose < 6.1 mmol/l and/or, if available, HbA1c less than 43 mmol/mol (6.1%) off treatment.
-Self-reported weight fell from 96.7 ± 17.5 kg at baseline to 81.9 ± 14.8 kg after weight loss (P < 0.001).
Reversal of diabetes was observed in 80, 63 and 53% of those with > 20, 10-20 and < 10 kg weight loss, respectively. There was a significant correlation between degree of weight loss and reported fasting glucose levels (Rs -0.38, P = 0.006).
-Reversal rates according to diabetes duration were: short (< 4 years) = 73%, medium (4-8 years) = 56% and long (> 8 years) = 43%.

A second clinical study examined the dietary intervention (8 weeks, 600-800 Kcal/day) in patients diagnosed < 4 years (short duration) or >8 years (long duration) [4]:
-Size: n=29. Short duration: n=15. Long Duration: n=14.
-Similar weight loss was achieved in the short- and long-duration groups (14.8 ± 0.8% and 14.4 ± 0.7% respectively; P = 0.662).
-Clinically significant improvements in blood pressure and lipid profile were seen regardless of diabetes duration. -In the long duration group:
*Blood pressure: systolic- 160 to 133 mmHg, diastolic: 90 to 80 mmHg
*Total cholesterol: 4.8 to 3.7 mmol/l
*Triglycerides:1.5 to 1.0 mmol/l
non-HDL cholesterol: 3.4 to 2.4 mol/l
*No change in HDL
*A total of 87% of the short-duration group and 50% of the long-duration group achieved non-diabetic fasting plasma glucose levels at week 8. (Note that these results are similar to those obtained by the self-reported group in ref [3])
I didn't summarize short duration because my family member is in the long duration group. But the results were much better.

Analysis/ Other thoughts from ssbbg:
The glucose response heterogeneous in the long-duration group with some responding rapidly, some responding slowly, and others not responding at all. (see Fig. 4 in ref. 4). Ssbbg note: it is possible that the success rate could be improved with a longer intervention as several of the slow responders were showing continual improvement but did not reach the required level of fasting glucose to be considered successful by 8 weeks.

Taylor has suggested in press interviews than normal slow weight loss will have the same effect, but this has not actually been tested. The large trial currently underway [5] again uses a severe calorie deficit (800 kcal/d). Biochemically, there are some differences between a slow weight loss and this protocol, though it isn’t clear if these differences are relevant. Most obviously, these diets end up being ketogenic. For another, there is some literature suggesting that fasting & severe calorie restriction also lead to altered biochemistry.

Taylor shows that some of the beneficial effects come within the first few weeks of calorie restriction. These seem to be correlated with decrease in liver fat, which decreases rapidly within the first 2 weeks of severe calorie restriction. (see ref [1], p. 1783 and references therein). SSBBG Questions: Could a single two week intervention produce some beneficial results? Could two week interventions coupled with “diet breaks” eating at maintenance produce the same results as a straight 8 week 600 kcal intervention? Might this be psychologically easier that extreme dieting for 8 weeks? Especially in the case of a long term diabetic, where a >8 week intervention might be needed to reach maximal benefit?


References:

1. Taylor R. Pathogenesis of type 2 diabetes: Tracing the reverse route from cure to cause. Diabetologia. 2008;51(10):1781-1789. doi:10.1007/s00125-008-1116-7.
PMID: 18726585
https://www.ncbi.nlm.nih.gov/pubmed/?term=18726585

2. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: Normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia. 2011;54(10):2506-2514. doi:10.1007/s00125-011-2204-7.
PMID: 21656330
https://www.ncbi.nlm.nih.gov/pubmed/?term=21656330

3. Steven S, Lim EL, Taylor R. Population response to information on reversibility of Type 2 diabetes. Diabet Med. 2013;30(4):2011-2014. doi:10.1111/dme.12116.
PMID: 23320491
https://www.ncbi.nlm.nih.gov/pubmed/?term=23320491

4. Steven S, Taylor R. Restoring normoglycaemia by use of a very low calorie diet in long- and short-duration Type 2 diabetes. Diabet Med. 2015;32(9):1149-1155. doi:10.1111/dme.12722.
PMID:25683066
https://www.ncbi.nlm.nih.gov/pubmed/?term=25683066
5. Leslie WS, Ford I, Sattar N, et al. The Diabetes Remission Clinical Trial (DiRECT): protocol for a cluster randomised trial. BMC Fam Pract. 2016;17(1):20. doi:10.1186/s12875-016-0406-2.
PMID: 26879684
https://www.ncbi.nlm.nih.gov/pubmed/?term=26879684