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Spotlight on diabetes
By Jennifer Baird
Type 2 diabetes has always been considered an irreversible condition, but groundbreaking research from Glasgow suggests this need not be the case.
Around 6% of the UK, 10% of the USA and up to 20% of Middle Eastern populations have type 2 diabetes – the most common form of the disease – and its prevalence has more than doubled in the last 20 years. Globally, the number of cases is expected to exceed half a billion by 2025.
Diabetes appears in a range of forms. Type 1 is an autoimmune disease, triggered by genetic or environmental factors, where the body’s immune system destroys the cells that produce insulin. It’s more commonly diagnosed in younger people and usually requires daily injections of insulin. Type 2 diabetes, which makes up around 90% of cases, is more often diagnosed in adults and obesity is its major risk factor. These main types account for around 98% of sufferers – a small number have rarer forms of the disease.
The human cost
In the UK the burden of diabetes to the NHS is overwhelming. It costs an estimated £14 billion every year, and almost 80% of the money is spent not on the disease itself, but on treating its many complications, the most common of which are eye, kidney, nerve and heart disease.
Mike Lean (left), Professor of Human Nutrition at Glasgow, is a medical specialist in diabetes. He is stark about the effects of type 2 diabetes. “It’s not a mild disease,” he says. “It’s an awful disease that destroys your body and your mind. By the time it’s done its complications, they are irreversible. The disabilities it brings are ghastly.”
Glasgow Professor of Metabolic Medicine Naveed Sattar agrees. “High sugar damages blood vessels because it sticks to proteins in a process called glycation and disrupts the function of various body systems – for example, the blood vessels that supply oxygen to the eye. So you get eye disease.”
The key factor
The overriding factor which affects your chances of acquiring type 2 diabetes is your weight. “And it doesn’t matter how you put on weight,” says Mike. “Even if you have minimal sugar in your diet, if overweight, you’re still eating excessive calories.”
DiRECT action
But there is good reason for optimism. A pioneering weight-loss trial has demonstrated that it’s no longer inevitable that someone diagnosed with type 2 diabetes will have the condition for life.
The conclusions of DiRECT – the Diabetes Remission Clinical Trial – are game-changing.
The 2016 study, funded by Diabetes UK and conducted by researchers at Glasgow and at the University of Newcastle, had volunteers follow a low-calorie meal replacement diet for between 12 and 20 weeks. A year later, 46% of subjects were experiencing remission from their diabetes, and 70% of these were still in remission after two years. “Some of the GPs we spoke to were initially very sceptical,” says Mike, who was co-lead investigator on the trial.
“But as soon as they started to see the results, they were saying, ‘Oh, hang on, we’ve got a few more patients!’”
Further findings showed that a huge 73% of people can achieve remission if they succeed in losing more than 10kg. At 15kg lost, almost nine out of ten patients regained normal function in their pancreas. And two years after beginning the programme, over a third of participants are still in remission from type 2 diabetes.
THE DIET IN DETAIL
The meal substitute programme, known as Counterweight Plus, works by giving participants a total diet replacement of nutritionally balanced soups and shakes, totalling around 800 to 850 calories per day, for 12 to 20 weeks. Diabetes medication is simultaneously withdrawn. At the end of that period, normal meals are reintroduced gradually, over several more weeks. Support is then offered for many months afterwards to help subjects maintain their weight loss, and continued physical activity is strongly encouraged. The "magic figure" which has been observed as putting diabetes into remission is 15kg, although this of course varies between patients.
When Isobel Murray from Largs was recruited for DiRECT, she weighed 15 stone. She lost 25% of her body weight thanks to the meal replacement diet and has now been in remission for almost five years. "My life has changed for ever," she says. "I was completely overjoyed to be told I was in remission." Although feeling hungry at times during the programme is expected, she feels she was one of the lucky ones: "The DiRECT trial regime was really easy to follow – the only difficulty was adjusting to no solid food."
DiRECT trial
Why does it work?
“The diet gets rid of the excess fat from their liver and pancreas,” explains Naveed, “and improves the function of those organs so the sugar goes down again.”
And it’s not only significant, intensive weight loss that helps in the fight against type 2 diabetes. “Several trials show that small lifestyle changes of about 2 to 3 kilograms can delay diabetes for a few years,” says Naveed. “For some people, small but sustained lifestyle changes can delay it for ever.”
A no-brainer
In Scotland, 11 out of 14 health boards are now on board with the DiRECT approach, and getting ready to offer their patients the meal replacement programme. NHS Scotland has been allocated £42m as part of the programme to put this into place, with the expectation that this upfront cost will lead to considerable savings in the future.
“This intervention is relatively inexpensive when compared to managing type 2 diabetes,” says Glasgow Professor of Health Economics Andrew Briggs, “and we anticipate that there will be cost savings further down the line. If people can stay in remission and therefore reduce their chances of developing diabetes complications, the cost savings to the NHS could be substantial.”
With diabetes numbers continuing to rise, there are still plenty of challenges ahead. But there’s no doubt that real hope is on the horizon.
What can you do?
Mike and Naveed give their top tips to help you reduce your risk of developing type 2 diabetes
Are you at risk?
Professor Naveed Sattar’s internationally recognised research has defined novel risk factors for diabetes. His findings, some of which have helped shape clinical guidelines, have also shown the extent to which diabetes influences life expectancy and the risk of heart disease.
Naveed has a personal interest. “I grew up eating Frosties and drinking Irn Bru every day, even though I had a family history of diabetes. I was overweight when I graduated and in an early-career research project, when they took insulin levels of 300 people, mine was the highest, signifying that my pancreas was having to work hard to keep my sugar levels down.”
Factors affecting your chances of developing type 2 diabetes include
• being overweight, particularly with a large waist measurement
• lack of activity
• being older – over 40 if you’re white or over 25 if you’re African-Caribbean, Black African, or South Asian
• having a close relative with the condition
• high blood pressure
• a diet high in processed foods and low in fibre
• stress
• smoking
• drinking heavily
• lack of sleep.
Mike: "The one thing that really matters is to avoid putting on weight. The best thing is to be an ideal body weight and that comes down to nutrition – calories in, calories out. Have a real old-fashioned diet, which some people would consider boring because there's no silver paper or coloured wrappings. Don't drink things out of cans. The right sort of diet is often close to what you might have enjoyed with your granny, without the sweeties!"
Naveed: "Eat plenty of fruit and veg – they protect against type 2 diabetes by reducing both dense calories and glycation, the process by which sugar becomes sticky and adheres to the insides of arteries. Cut sugary drinks and replace with diet drinks or water. Increase fibre intake. Cut alcohol intake, because alcohol is associated with weight gain."
Mike: "We talk about 150 minutes of activity a week but I want to try and change that phraseology and say, even if you manage an extra 1,000 steps of walking a day, that's a great start – an extra ten minutes of walking. As you build up strength, increase in stages by another 1,000 brisk steps, another ten minutes a day if possible until you are averaging 15,000 steps."
This article was first published September 2019.