Podcast Episode 33 Transcript – Exploring Non-Traditional Approaches to Type 2 Diabetes Management Part 2

Leah

00:00:09 – 00:00:10

Welcome to the ideal nutrition podcast. This is Episode 33. I am Leah Higl, and I am here with my co host Aidan Muir. And today we are doing part two of nontraditional approaches to type two diabetes management. So in part one, we went over just basic background stuff to kind of set us up for this podcast. But now we’re really going to get into the meat of it. 

Aidan

00:00:32 – 00:01:13

So going straight to business, we’re going to go with the most aggressive one. So we’re going to go with very low calorie diets. So the biggest study on this one of the most interesting study, at least is called the direct trial. So it came out in 2017, which is cool because it also means we have some follow up data in the study as well. And it’s a pretty large trial in that they had around 300 people total, but about 150 or 149 went into the intervention group, and the intervention was basically a just over 800 calories per day in the form of sheikhs for 3 to 5 months. Firstly, just taking a second to like that, like sinking. 

Aidan

00:01:14 – 00:01:40

Yes, like I often try to put myself in the shoes of people doing stuff. And I’m like, I care a lot about nutrition, and I would find that incredibly hard, even if it was something that would be beneficial for me. So that’s obviously hard from the low calorie perspective, but also being like, You can’t really eat out with friends and family and stuff like that for 3 to 5 months while pursuing that approach. 

Aidan

00:01:40 – 00:02:09

Very aggressive. But it’s an interesting approach in terms of the outcomes, and one of the things I absolutely loved about that study is that they did what they called a stepped food reintroduction for 2 to 8 weeks after that. So basically they weaned off the low calorie diet, which is not something you would regularly see people doing practice in the real world is in, like they did the shakes for 3 to 5 months. Then they take away one shake and replace it with a meal based on that kind of balanced plate model of like half vegetables, quarter protein, quarter plate carbs and then, after a bit they took away another shake out of the meal, and then they took away another shaken out of the meal.

Aidan

00:02:10 – 00:02:39

And then they did what they called structured support for long term weight loss mansions, which is also a bit of a key part of the study and that, like it was pretty intense in all aspects in terms that they had a lot of like healthcare professionals involved. Um, they had a lot of contact with doctors and dieticians and, like they had a lot of support. Okay, and obviously as it progressed, like over the years, they’ve got a lot less support. But like particularly on, they’ve got a lot of support. 

Aidan

00:02:40 – 00:03:11

And their goal was remission based on the criteria we talked about in the previous podcast. Except the only difference was they were only measuring it over a two-month time frame to call it remission, as in that to be off all of their anti diabetic medications and have a HbA1c of less than 6.5% which would classify them as non diabetic if they were to be tested the first time. Um, fascinating in that remission was achieved in 46% of the participants in the intervention compared to the control, which only had 4%. 

Leah

00:03:11 – 00:03:14

Yeah, that’s just such a huge difference. 

Aidan

00:03:14 – 00:03:55

Yeah, and that’s why it stands out, because it’s like very, very aggressive approach, but also insanely effective in comparison to a lot of other, more common methods. Which is why this discussion is really being hard because it kind of needs to be talked about, um as we spoke about the last podcast. Or as I mentioned, it’s kind of like losing a significant amount of body fat is a pretty significant factor in whether or not remission is likely to be achieved and, based on these statistics, are just going through it. 76 participants gained weight, so that’s something to stand out. Being like they was, they didn’t have to follow the diet. 

Aidan

00:03:55 – 00:04:31

You can’t gain weight on 800 calories. They didn’t have to follow the diet. It obviously shows how hard it is to follow that diet like that. That means quite a large percentage weren’t following it up. But that also makes it more interesting from a real world setting because it’s kind of like what’s possible in the real world. Not we care more about what’s possible in the real world than we care about people were all of their food is provided for them, Um, for this specific kind of scenario. Um, but out of the 76 participants, you can wait, None of them achieved remission. 7% of the people who lost 0 to 5 kg and maintain that over the 12 months we’re in remission.

Aidan

00:04:31 – 00:05:12

34% of the people who lost 5 to 10 kg, 57% of those who lost 10 to 15 kg and 86% of the people who lost 15 kg or more wearing complete remission at the end of the 12 months. So it’s very, very correlated with the amount of weight that was lost. And just so we know some averages. So in the direct trial, the average body weight decrease was 10 kg at the end of the 12 months and in the control group, the yeah, and in the control group, the average weight increased by one kg on average. 

Aidan

00:05:12 – 00:06:02

So we’ve got the comparison of kind of like seeing a model of care in the UK and the direct trial they’ve got 2019 follow up data. So two years after the study showing that 24% of the intervention group was still down more than 10 kg, Um, and 64% of those people were still in remission. So that’s really interesting as well, because, as we talked about with the whole concept of weight regain and stuff like that, almost every study I’ve ever seen multiple years in a lot of people are regaining weight, common common theme that’s happening in this study. Still, it’s just that two years later there still was a significant amount of people who were in remission and had lost more than 10 kg and stuff like that as well. So the statistics I’m not saying good night. I’m not saying like that’s an incredible outcome and stuff like that. 

Aidan

00:06:03 – 00:06:37

But when you do compare to almost all other forms of diabetes remission kind of data without bariatric surgery, because bariatric surgery often leads to quiet good outcomes with diabetes, Um, particularly over the five year kind of time frame, Um, it is pretty impressive data in comparison to the other options and just jumping onto another concept as well. There was a 2020 study where they did the same study, except pretty much the same study. Except they did it with participants who had insulin. So they were insulin dependent Type two diabetes. 

Aidan

00:06:37 – 00:06:53

So a little bit more progress, and they’ve got great outcomes as well. The obvious challenge with insulin is that you have to adjust your dosage or stop taking insulin or whatever. If you were to do a low calorie diet, otherwise, that the hypoglycemia and that’s going to cause other issues, which is why we need, like, a pretty extensive medical team. 

Aidan

00:06:54 – 00:07:34

So and one last thing on that is that another interesting thing that this group was particularly passionate about kind of measuring was pancreas size and the fat content of the pancreas. So typically, with Type two diabetes the pancreas is a little bit smaller and is shaped a little bit differently as well, and typically contains a little bit more fat than a healthy pancreas, so to speak. And what they found in this study is that, or in that direct trial, is that the pancreas is actually increased a little bit and had a tiny bit less fat than it normally would have with people with Type two diabetes, which is there kind of logic behind being like. Not only is this improving insulin sensitivity is probably improving the ability of the pancreas to put out insulin as well. 

Aidan

00:07:36 – 00:07:39

What would be the downsides of this approach? 

Leah

00:07:39 – 00:08:05

Where do we start? I just I think that it’s the practicality of actually doing a diet like this, even though potentially great outcomes you’re like, How is how feasible is this in the real world? And just going back to that statistics on like is it? 76 participants out of the 149 ended up gaining gaining weight. That’s a really big percentage of people that like non compliance. 

Leah

00:08:06 – 00:08:33

To be honest, I’m kind of surprised by the compliance. They did end up getting even though most of a lot of them weren’t were not client. Um, but from what I understand, they were doing a lot of things in this study to follow up with clients. So with participants, um, so I don’t know. I think it’s one of those things that I’ve never ever done it in real life with clients. Um, but yeah, it’s a tough one. It just comes down to the practicality feasibility. 

Aidan

00:08:33 – 00:09:11

Exactly. It comes down to practicality. Another difficult thing is you do need the medical team around you for multiple reasons. One of it is in that study they stopped all diabetes medications and blood pressure medications. You can’t just do it on a whim, because if you were taking blood pressure medications, you would get low blood pressure and be at risk of passing out and stuff like that. So it’s kind of like you need a team around you. And the other factor is what If you were to try this approach and you could get in and see your GP infrequently and they adjusted the medication, they were on board, which would obviously you’d have to get them on board as well. 

Aidan

00:09:12 – 00:09:31

They discontinue the medications or whatever, and you try to for a couple of days, and then you came to the conclusion that you didn’t want to go down that route because, as we kind of said orders, I definitely feel like it’s a very hard thing to do, and it’s not appealing like I wouldn’t want to be on that link us to that period of time. Me personally. What if I want to try it, then came to conclusion that was like, I actually don’t want to do this. 

Leah

00:09:31 – 00:09:34

I want to explore our options. So I’m going to do something else. 

Aidan

00:09:34 – 00:09:48

Yeah, then you’d have to get back onto your medications like it’s very hard to do, like they were in a great snow for and I’m in the same campus. I haven’t done it with any of my clients. I don’t have an interest in doing it with any of my clients, but I do have an interest in watching this space and seeing how it goes. 

Leah

00:09:48 – 00:10:09

I think it’s like the fact that they got those amazing results. It’s definitely noteworthy. And that we do have two has to be a part of this conversation, particularly in regards like bariatric surgery and everything like that. Something that I wonder, is those 76 participants. Did they gain a lot more weight than the control group gains? Do you know the statistics? 

Leah

00:10:09 – 00:10:22

I don’t know those statistics of a weird one, but I wonder if trialing a diet like that puts you at risk of binge eating and gaining weight. than you would if you didn’t do anything in the first place. And therefore having a worse outcome. Yeah, random thought.

Aidan

00:10:22 – 00:10:55

But, mathematically, we could figure it out based on some of the stuff we went through in terms of Yeah, because if the average weight loss was 10 kg in the intervention group, we could figure it out. I agree. Because it’s like, yeah, like what does happen with those people we’ve talked about, Like, the mental burden, stuff like that? Like even the feeling of value, so to speak, in terms of, like, if you’ve attempted that and then you remain in the study and you’re still trying to do what the people are telling you to do, and you stay in and you keep following up with them, they would be a hard, hard thing to go through. 

Aidan

00:10:56 – 00:10:59

Yeah. Next one. You wanna talk about low carb diets? Yeah. 

Leah

00:10:59 – 00:11:46

Let’s get on to low carb diet. So this is definitely I would still consider this at some point, an aggressive approach, but nowhere near as aggressive as the very low calorie approach we’ve just talked about. So it is probably one of your more popular ones you’d see people take as a nontraditional approach. So obviously low carb diets are going to address that blood glucose level issue. Um, while you’re on it, at least so less carbs, less glucose, less insulin required. So its mechanisms Pretty simple in regards to type two diabetes. Um, but the argument that’s usually made against low carb diets is going to be the adherence. So it kind of similar to what we talked about with the very low calorie diets and their low adherence. Um, we see a very similar thing, sometimes in very, very low carb diets. 

Leah

00:11:46 – 00:11:52

Um, but a study that you’ve noted here Yeah, the CSIRO or is it a statement? 

Aidan

00:11:52 – 00:12:29

They did a low carb diet studies So they’ve got their book, the CSIRO Low carb book. Oh, yeah, yeah, yeah. So basically, the CSIRO, they did a study where they was 12 months. So they got people to do aim for less than 50 grammes of carbs per day to start off with, which arguably could be a ketogenic diet, particularly the people of the size who were in the study like it’s borderline ketogenic diet and then increasing to less than 70 grammes of carbs per day. Later on in the study to improve adherence was that kind of thing, like maybe that’s an extra serving of fruit or like, toast or something like that, Like it makes it a little bit easier. 

Aidan

00:12:30 – 00:12:45

The interesting thing, because I do agree with you on the adherence thing. But the interesting thing in this study was that their adherence based on their criteria of what it takes to adhere to the study, I think the average weight loss was somewhere between five and 10 kg. Things around 10 kg. Um, don’t quote me on that one between five and 10 kg. 

Aidan

00:12:46 – 00:13:25

Um, their criteria for adherence lead to slightly more people in the low carb group sticking to the plan enough to be included as part of the end result than in the lower fat, higher carb in comparison kind of group. Um, they both got good results in a study like the standard model of care style diet got good results. Um, but the adherence was slightly higher, but there’s a few things that one mathematically, the numbers don’t fully stuck up in terms of like if they stuck to the diet 100% their weight loss actually would have been a little bit more. So. We know that adherents still wasn’t perfect, Um, but better than expected, better than expected that like that it stood out to me.

Aidan

00:13:26 – 00:13:45

That’s why I remember this years later because it stood out to me. But the other thing that I’ve often said to clients when I’ve mentioned this study and like mentioned this is an option and lower carb diets, but not necessarily ketogenic for the sake of this kind of discussion, um, is that they had a book to sell. 

Leah

00:13:45 – 00:13:50

It’s always a little bit of a red flag. 

Aidan

00:13:50 – 00:14:40

It is in their interests, like I’m not being a sceptic or anything like that. But it’s like that is an outlier study in terms of compliance, um, jumping to ketogenic diets. They have shown great results when adhered to for two obvious reasons. One, as you said, like the mechanism carbs, glucose, insulin makes sense. Um, but the adherence rates are quite low, and there is even adherence rates kind of measured for people with Type two diabetes who would be more motivated to go down that route than the average person who was just looking to lose weight. For example, It seems like adherence rates are relatively high in those who have epilepsy and those who are athletes who believe that it’s going to improve their performance. Those adherents rats relatively high for almost every other group is here in. 

Leah

00:14:40 – 00:15:20

So it’s a really low, and I can definitely see why. It’s a very difficult thing to follow. Um, and you kind of think like, What is the impact on that individual’s quality of life like social events? Um, just generally being able to just enjoy food, like I can definitely see why people don’t want to be on this for a long, long time, because going back to remission versus management is this is more about management like that. This alone without weight loss is not going to put you into remission remission from the disease. So you’d likely if you’re not going to lose weight as well, you’d likely have to do this forever as your management. 

Aidan

00:15:20 – 00:16:03

I suppose that’s the second point that, low KJ, most people are going to lose weight on that. We’re going into a calorie deficit. But like there is that concept and, like touching on that even further is that if you have been low card for a long period of time, it seems like when you do introduce carbs your not as sensitive to insulin as somebody who had the exact same body composition and all other factors being equal who had had slightly more carbs for a significant portion of time. If somebody who’s done a cage yanked out for a year did the oral glucose tolerance test, it seems like they perform worse on that test than somebody who has all other factors being equal. But, yeah, it’s an argument in terms of like, people in the low carb diet community talked about this being like, I want to prove I’m in remission.

Aidan

00:16:03 – 00:16:33

How do I beat the oral glucose tolerance test? And they do talk about being like Okay, well, maybe you should choose cops for a little bit before you take the test, basically, just to, like, perform well on that test. Um, they’re interesting, Interesting topic, but yeah, as mentioned, like if you like jested low carb, that is for management. If you capture calories the same and stuff like that. And your body fat and stuff like that didn’t create it didn’t become more sensitive to insulin. But it is one option that, when adhered to, seems to have good outcomes. 

Leah

00:16:33 – 00:17:17

Quite well, the one of the last things we’re going to talk about before we move on to a more broad approach that we potentially take is plant based diets. Um, so I mean, you’d think that this is something that I’ve gone down the rabbit hole of, but actually haven’t. Um, so this is kind of the first time that I’ve gone a little bit down this rabbit hole. Um, in terms of using plant based diets for the management of type two diabetes. So there is a 2000 and nine study that did compare a low fat vegan diet to conventional diabetes management. Um, and on average, like when just talking about weight loss. The people on the low fat vegan diet lost about 4.4 kg whilst the control group lost about 3 kg. 

Leah

00:17:17 – 00:17:56

So not a really huge difference in those two groups, just from a weight loss perspective. So it’s not a crazy outcome. Um, but the vegan diet did improve the HbA1c more than the control, um, and dramatically outperformed in terms of cholesterol, which you would expect from a diet so low in saturated fat because it’s low and animal products. Um, I think the biggest point to make here is that something like this that is relatively high carbon nature, as a plant based diet usually is still provided better results than what most people see sometimes even with the standard attempting to follow or like even doing a low carb diet at some point.

Leah

00:17:57 – 00:18:13

So I just think if we’re it just highlights that overly focusing on carbs and low carb is definitely missing the bigger picture. And I think that’s probably what comes most from this discussion 

Aidan

00:18:14 – 00:18:44

I’m much just repeating your statement. But exactly that, like it is like highlighting that if you’re overly focusing carbohydrates, you’re missing other aspects as well. Like if and I say that because I spend time on Twitter reading low carb advocates kind of statements, but it’s kind of like if you bought too much into what they’re saying, you would think that this higher carbohydrate vegan diet would be a massive step back in the management of diabetes, not an improvement. 

Leah

00:18:44 – 00:19:00

Yeah, you would think if the best case scenario would be that it had no effect at all, you’d think it would be worse. But that’s just not the case that it in sometimes can actually improve the management of type two diabetes. So I think that’s very interesting, keeps things to consider.

Aidan

00:19:00 – 00:19:40

So the last thing we touch on is what I call a broad approach and some things that like, if I had Type two diabetes, it’s like, Well, what would I focus on? And I’m going to touch on some things that you can focus on without putting yourself into a box of being like low carb, plant based or any kind of box. And like these things are one exercise in terms of both building muscle, improving body composition, decreasing body fat um, the building muscle and, like improving insulin sensitivity and stuff like that, but also actually burning glucose like there is a start out there. That’s something along the lines of even 10 minutes or 30 minutes. 

Aidan

00:19:40 – 00:20:22

Don’t quote me on it because I can’t remember which one it is But even 10 minutes or 30 minutes of walking is the equivalent of metformin, which is the first line of diabetes management from a medication standpoint. And that’s just because you’re burning glucose as you’re walking. And like when I say in the equivalent of metformin, I mean the equivalent metformin in terms of like, what would happen to your blood glucose levels and H B and C and everything like that. So, like, that’s just 10 or 30 minutes of walking. What if you do more exercise than that? Like there’s a lot of factors to consider, and I often do wonder if, say, it’s 10 minutes just to keep this simple. If people opposed 10 minutes of exercise or first line medication for diabetes, which one would you prefer? 

Aidan

00:20:22 – 00:21:06

I feel like a lot of people might choose the 10 minutes of exercise not have, thus ensuring that. But like I, I feel like it’s worth being aware that that’s something to consider it as a factor. Another point that I go with personally is calorie deficit until as lean as desired. Um, that’s a bit of a nuanced one, because it’s kind of like you could even be in the healthy BMI range but still benefit from getting slightly leaner in terms of insulin sensitivity. That doesn’t make it a great idea for all other variables in life and whatever. But purely from a diabetes management perspective, that could be something that could help. 

Aidan

00:21:06 – 00:21:44

Personally, I would I would do the calorie deficit approach. Another variable is keeping protein relatively higher, partly from the muscle mass perspective and insulin sensitivity, but also the appetite management perspective and stuff like that, too, and also even keeping calories high enough for what I wanted without having to rely on carbohydrates or going excessively high fat in. In my case, that would be a personal preference. Another one is keeping fibre high, regardless of the style of diet chosen even if it’s low carb, whether it’s playing bass, whether it’s whatever keeping fibre relatively high is going to be a useful thing. That’s even something that you can think of in terms of being similar to going low glycemic because it’s kind of like it slows down the absorption of the carbohydrates and how quickly they turn into glucose in the blood. 

Aidan

00:21:44 – 00:22:11

And as another general thing, I would avoid going overly high in carbs, particularly in any individual occasion, meal or snack or whatever. Even though I personally would still like a flexible approach, I’d still avoid going overly higher in any individual occasion and probably avoiding or limiting reducing particularly high glycemic index carbohydrates. And all of those things can be done within the context of pretty much any approach. 

Leah

00:22:12 – 00:22:24

Basically, this has been Episode 33 of the ideal nutrition podcast. Thank you for tuning in.