To reverse diabetes, weight loss and a low-carbohydrate diet must be combined. These are independent factors for reversing diabetes.

Weight loss can achieve diabetes reversal through decompressing (decongesting) the liver and pancreas, improving blood flow, and reducing adipocyte hormonal responses.

As the worldwide epidemic of obesity continues to worsen, the epidemic of type 2 diabetes follows, and 1 out of every 2 Americans born today is predicted to get type 2 diabetes. Clinically, we observe a progression of obesity to eventual type 2 diabetes through the lens of insulin resistance and metabolic syndrome.

In a recent study at Ohio State University, obese patients with metabolic syndrome ate a low-carbohydrate diet but maintained their weight. A four-week low-carb diet resulted in the reversal of the metabolic syndrome, even though there was no weight loss. Reversal of metabolic syndrome is key to reversing prediabetes and type 2 diabetes.

Parker N. Hyde, et al. Dietary carbohydrate restriction improves metabolic syndrome independent of weight loss. JCI Insight, 2019; 4 (12)

A low-carbohydrate diet can achieve diabetes reversal through reduced insulin requirements (reduced insulin production), a reduction in glycated lipids, proteins, and receptors, reduced lipid storage, and increased lipid mobilization

The clinical relevance of this is that patients can become rapidly insulin sensitive again, well before they have returned to normal weight. Explaining this to patients provides the encouragement they need to continue a long path to ultimate success. The only way we will know a patient’s insulin sensitivity is to actually check the insulin level.

Have you had your insulin level checked?

Insulin is misunderstood by many, including patients and even physicians. Most physicians think of insulin as a hormone that pushes glucose into the cell by opening a channel. However, the truth is that insulin is primarily a fat-storage hormone and shifts metabolism from fat use as energy to fat as storage. In the absence of insulin, the default is to use fat storage and convert it to usable energy, known as lipolysis. In the presence of insulin, lipolysis stops and lipogenesis starts, converting circulating glucose to lipid (fat) storage.

The higher your insulin, the greater you push circulating glucose to glycogen and then to fat stores. The circulating glucose capacity is approximately 5g. The glycogen storage capacity is 500g. Comparatively, the storage capacity for fat is limitless (exceeding 100,000g). As your fat storage depots fill, they release inflammatory cytokines.

There are two examples of this, both dealing with different types of diabetes. Type 1 diabetics, our first example, have an autoimmune dysfunction that destroys beta cells, stopping insulin production. Type 1 Diabetics produce little to no insulin and are thin until we give them insulin. Once they get excessive insulin, these patients gain weight. The insulin becomes excessive because our dietary guidelines encourage six snacks and meals per day with approximately 40% carbohydrates. We are chasing the blood glucose with insulin because we are overfeeding carbohydrates.

The second example relates to type 2 diabetes. Well over 90% of type 2 diabetics are overweight because they consume too much carbohydrate and produce chronically elevated levels of insulin to compensate. They then become progressively more overweight, and the glycation of the cellular structures leads to rapid aging. This excessive insulin causes excessive fat storage and inflammation as the fat cells swell and leech inflammatory cytokines.

To lose weight and process insulin most effectively, we must recognize some simple truths about ketosis and carbohydrates. Nutritional ketosis is the default human state, and consuming mostly carbohydrates is the preparatory stage for fat storage now, so you can be in ketosis later.

When you spend more time out of ketosis than in ketosis, you will develop insulin resistance. However, more ketosis is not better — you need just enough that you are predominately using fat as fuel.

The debate should be what combination of healthy food and activity is necessary to achieve a predominant state of ketosis. Once we get to this debate, 2/3 of our current chronic health expenditures will magically evaporate.

Nutritional ketosis has been found to improve metabolic and inflammatory markers, including lipids, HbA1c, high-sensitivity CRP, fasting insulin, and glucose levels, as well as aid in weight management. We discuss these findings and elaborate on potential mechanisms of ketones for promoting weight loss, decreasing hunger, and increasing satiety. Humans have evolved with the capacity for metabolic flexibility and the ability to use ketones for fuel. When we are eating low numbers of carbohydrates, insulin levels remain low and ketogenesis takes place. These conditions promote the breakdown of excess fat stores, sparing of lean muscle, and improvement in insulin sensitivity.

Curr Nutr Rep. 2018 Sep;7(3):97-106. doi: 10.1007/s13668-018-0235-0.

Insulin, the most popular pharmaceutical treatment for type 2 diabetes, was once used only sparingly in diabetes treatment, but today makes lots of money for the manufacturers. Thanks to pharmaceutical marketing and a lack of time, many physicians prescribe insulin rather than nutritional counseling or lifestyle management.

Prior to the 1920s, the mainstay of Diabetes treatment was aimed at controlling glycosuria (glycosuria occurs when the blood glucose level exceeds about 160–180 mg/dL and is easily measured). These dietary recommendations consisted of “meats, poultry, game, fish, clear soups, gelatin, eggs, butter, olive oil, coffee, tea” and contained 5% carbohydrates, 20% protein, and 75% fat. This is analogous to the Low Carbohydrate Ketogenic Diet (LCKD) . These recommendations were dramatically different from current low-fat, high-carbohydrate recommendations for patients with diabetes.  Also note that the feeding frequency rarely included breakfast, and manufactured snacks were not yet invented, resulting in 2 low-level glucose spikes, as opposed to today’s 5-6 spikes.  Also, vegetable oils were not routinely available before the 1940s and 1950s. .

Exogenous insulin for the treatment of Diabetes was introduced in the 1920s, which began the switch to controlling diabetes through pharmaceutical management instead of lifestyle management, to the point that many type 2 Diabetic patients now consume excessive carbohydrates knowing they can chase it with insulin.  Unfortunately, these patients already have a high insulin level, and the extra insulin only makes the insulin resistance worse. Additionally, the fat storage action of insulin, makes the metainflammation worse as well as the patient’s obesity.  This is like a fat dog chasing its tail.  The glucose is the tail, the mouth is the insulin, and the fat dog is the metabolic derangement.

 

Several recent studies have re-examined the effect of carbohydrate restriction on type 2 Diabetes and revalidated the safety and efficacy of the Low Carbohydrate Ketogenic Diet (LCKD).  These studies confirmed that hemoglobin A1c improved to a greater degree over one year with a low-carbohydrate diet compared with a low-fat, calorie-restricted diet.  Specifically, the participants had greater improvement in glycohemoglobin while on the low-carbohydrate diet than when on a eucaloric low-fat diet.  Because LCKD can be very effective at lowering blood glucose, patients on diabetes medication who use this diet should be under close medical supervision or capable of adjusting their medication.

 

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So, we know that patients with type 2 diabetes have the symptom of too much glucose, but their actual disease process is excessive Insulin, with the cells being insulin resistant; yet, we treat them with more insulin.  This begs the question, why and who benefits? (This is in no way to be construed as suggesting insulin is bad; insulin is a lifesaving drug.  It’s meant to suggest that patient therapy should be first geared to lifestyle changes, and insulin should be the rescue drug.)

Making lifestyle changes and counseling patients takes time and energy, which most healthcare providers lack.  As the one of the key decision makers, physicians remain a primary focus of pharmaceutical company sales success. The pharmaceutical industry employs numerous marketing and promotional efforts to influence prescribing patterns, starting early in medical school, even in the preclinical years of study. These marketing strategies continue throughout a physicians’ career.  Drug company marketing strategies include gifts and benefits ranging from low-cost gifts to expensive trips and grants, which leads to suboptimal prescribing practices and promotes more expensive medical treatment. One could postulate that most physicians are simply a marketing tool used by the pharmaceutical companies to get their products sold; they are an indirectly paid sales team.

Often, the pharmaceutical companies launder their education endeavors through patient advocacy groups that on the surface appear to be trusted authorities, such as The American Diabetes Association.

It is obvious that Big Pharma will not be likely to support studies that reduce the utilization of their products over non-compensable lifestyle changes.  Evidence-based academic research is also unlikely to be performed by academicians who are funded by these same interests.  The entire health delivery industry seems to be geared towards medicalization of treatment rather than lifestyle improvement, which would radically disrupt the status quo.  Big Pharma is so prevalent in the academic world of policy and thought leaders that it is no longer considered a “conflict of interest” to recommend a pharmaceutical that compensated that policy or thought leader. It is now simply considered a “duality of interest.”

Why do we care so much about food and diet and its impact on your health? We own and operate chronic care health-related companies, but also own and operate restaurants.  We have been fascinated with the intersection of health, dietary intake, and lifestyle. We view nutrition as a program, or a subroutine, that informs and instructs the body to specific action.  A corrupted program leads to a corrupted outcome.

Our clinics evaluate and treat several thousand patients per year for chronic and acute pain, in an urban setting where access to high-intensity healthcare is readily available through several large academic centers as well as government-sponsored outreach clinics.  Unfortunately, despite the availability of cutting-edge medical treatment, the health of individuals and populations continues to decline year over year. Over 90% of our patients have untreated metabolic syndrome, and over 80% have undiagnosed prediabetes or diabetes type 2.  The symptom of pain is the final common pathway for the human body to signal impending tissue damage, and most patients avoid contact with the health delivery system until they develop a symptom that they can no longer ignore. Unfortunately, our clinical practice is not unique. Pain is the leading reason for patients seeking medical care and is one of the most disabling, burdensome, and costly conditions in the US. Overall, pain care/treatment and lost productivity costs $635 billion per year. The commonality in metabolic syndrome and chronic pain is the hyperinflammatory state or metainflammation.

As we have treated this patient population over the last 20-plus years, we have discovered some common threads that trouble us.  About 80% of the patients have either obesity, prediabetes or diabetes, with the vast majority remaining undiagnosed.  More than half of these patients go on to have significant expensive complications and about 20% eventually require dialysis. By 2026, the Medicare system will be so overwhelmed with the diseases of metainflammation that it will literally run out of money.  We must engage individual patients in improved health outcomes in order to change the community.  We have fewer than seven years.

We are passionate about returning this patient population to health, and avoiding bariatric surgical procedures, which are costly and carry significant risks of organ injury, death, and long-term disability.  We have found that academic institutions avoid this population until extraordinary and expensive complications set in, requiring hospitalization.  It is our opinion that there is a fundamental cultural disconnect between the ivory tower of the institutions and the actual communities where these patients reside. This cultural disconnect prevents patient engagement in lifestyle changes.  Additionally, the Medicaid system does not reimburse for lifestyle and dietary modification for obesity but does reimburse for bariatric surgery. The overwhelming marketing from processed food manufacturers targets the urban minority communities with disingenuous messaging, suggesting health benefits for obesogenic foods.  This combined with supplemental nutrition benefits and game theory promotes the hyper-consumption of farmer-subsidized high fructose corn starch as well as industrial seed oils.  It is our opinion that the overconsumption of hyperpalatable, nutritionally deficient food is a major contributor to reduced academic success, reduced employment opportunities, increased incarceration rates, and progression of metabolic dysfunction.  It is a root cause of the social and economic disparity.