People newly diagnosed with type-2 or adult-onset diabetes, which affects roughly 7·7% of all adults in India, over the past five years now have a chance of reversing the disease using very-low calorie diet or a low-carbohydrate ketogenic diet to lower body weight and improve glucose control.
Being overweight is the biggest risk factor for diabetes among Indians. For every 100 overweight adults in the country, 38 have diabetes, compared with the global average of 19 adults with diabetes for every 100 overweight person in 2016, found the first district-level analysis of disease trends in India published in The Lancet in September 2018. With India’s overweight population ages 20 years and above more than doubling from 9% in 1990 to 20·4% in 2016, diabetes prevalence will continue to rise unless low-cost prevention and early management interventions such as dietary restrictions are promoted.
Diabetes till now regarded as an incurable, chronic disease that required lifelong management through medication and insulin. “Till a few years ago, it was believed that lifestyle changes and medication could at best slow progression and prevent complications. New scientific evidence demonstrates type-2 diabetes remission is possible through substantial weight loss in the initial stages of the disease using very-low calorie diets or bariatric surgery for weight loss,” said Dr Anoop Misra, chairman, Fortis C-DOC Centre of for Diabetes, Metabolic Diseases and Endocrinology in New Delhi.
Diabetes remission is defined as partial when glycated haemoglobin test (HbA1c) is <6.5 without diabetes medication for one year; and complete when HbA1c <5.7 without medications for one year. The haemoglobin A1c is an indicator of the average glucose over the past two to three months. A healthy number is below 5.6%.
The community-based UK-funded DiRECT (diabetes remission clinical trial) study of overweight (BMI of 27–45 kg/m²) in the UK with type-2 diabetes (HbA1c ≥ 6.5%) demonstrated that 36% people remained in remission two years later. Remission is closely linked to weight loss, with 64% of patients who lost more than 10 kg remaining at remission at two years. Body mass index (BMI) is a measure of healthy weight and calculated by dividing a person’s weight in kg by the height in metres squared. The healthy range is 18.5 and 24.9 kg/m².
A low-carbohydrate diet usually restricts total carbohydrates to less than 130 gm a day, while a very low-carbohydrate or ketogenic diet restricts carbohydrates to 20–30 grams per day. Protein accounts for around 20% of total food intake, with the remaining energy met and non-starchy vegetables with some six to eight nuts, some dairy, and some fruit.
The World Health Organisation 2016 global report on diabetes added a section achieving diabetes reversal through weight loss and calorie restriction, and both the American Diabetes Association and the European Association for the Study of Diabetes recommend the short-term use of low calorie diet of up to 800 calories day for at least two months, followed by a 1,000 calories a day diet for at least another four months. A ketogenic diet is a very low-carbohydrate, high-fat diet similar Atkins Diet that replaces carbohydrate with fat to push the body into a metabolic state called ketosis, where it starts burning fat for energy, leading to rapid weight loss.
But very low calorie and keto diets are not without risks, including micronutrient imbalances, high cholesterol and hypoglycaemia. “It needs close medical monitoring. People with type 1 diabetes, underweight diabetics with a BMI <18kg/m2, people with diabetes for more than a decade, pregnant women, people with heart, kidney or liver disease or any other advanced organ dysfunction, and young children are unsuitable for diabetes remission interventions,” V Mohan, chairman of Dr Mohan’s Diabetes Specialities Centre, which has 50 centres across India.
Tough to follow
Agrees Dr Misra: “A very low calorie diets are theoretically very effective in the short term but are practically very difficult to follow. Except one, 15 of my patients who tried a very low calorie diet abandoned it within a month or two. A 20-year-old woman, who weighed around 90-95 kg, followed it for three months, but stopped when her weight reduced to 78 kg and her blood sugar control improved.”
Despite counselling and motivating patients to reverse diabetes, most patients in India drop out. “Low calorie diets are difficult to follow in India, with ketogenic diets that require replacing carbohydrates with protein and fats being untenable to vegetarians,” said Dr Misra.
“The short-term results are good no doubt, with obese people losing 10-15kg in a few months, but it cannot be called a cure because long-term studies are needed to rule out re-occurrence. Unlike in bariatric surgery where people do not put on weight again, most people on very low calorie diet have to restrict food, which is very difficult over the long term, which makes scaling up at the community level a challenge,” said Dr Mohan.
He advises patients to take the middle path, like The Buddha. “You must adopt a sustainable healthy diet that is low in carbohydrates and high in proteins and vegetables,” said Dr Mohan.