We need to talk more about reversal of type 2 diabetes
In 2011, a landmark study demonstrated that it is possible for people to reverse type 2 diabetes by lifestyle change. Six years later, many people have reversed their diabetes, yet many health professionals and diabetes organisations maintain the line that it is a progressive permanent condition. Meanwhile, the huge global growth in type 2 diabetes continues unabated.
A transformational change in our understanding
For many years, I worked as a Consultant Diabetologist, responsible for delivering diabetes care for the area around Bournemouth, on the South Coast of the UK. Type 2 diabetes was considered to be an inexorably progressive disease, fraught with risk of complications and ill health and requiring ever more intensive treatment. And this is what people were told when they attended the education programme set up for those newly diagnosed with type 2 diabetes. While many people responded to the lifestyle advice provided, the overall message was often perceived as negative, devoid of hope for the future, and demotivating, especially to those that found lifestyle change difficult.
In 2011, the Counterpoint study was published. This established that type 2 diabetes is not inevitably progressive. It is a condition that can be reversed by lifestyle change and weight loss. To me this transformational research revolutionised our understanding of type 2 diabetes. I felt that everyone with the condition, and especially everyone at diagnosis, should know that it could be reversed, and furthermore that the goal of treatment should shift from mere ‘control’ to ‘reversal’. To me, it was a message of hope, that would have a positive effect on motivation of individuals to change their lifestyles. A message that everyone should hear when they attended an education programme. However, when I suggested this, I was met with scepticism; I was told this was not a priority. It was as if there was a belief that ‘most people’ would not be able to maintain the lifestyle changes necessary to achieve reversal, and therefore we should not introduce unrealistic expectations.
Learning from cancer - focus on the positive
The following year, my father was diagnosed with chronic lymphocytic leukaemia. This is a relatively common condition in the elderly and generally does not cause serious health problems. Unfortunately, he had a rare and aggressive form of the condition that did not respond to standard treatment. However, his specialist explained that there was a different treatment that he could have, that it was complex and had side-effects but it had a chance of taming his disease. I could tell from the tone of the doctor’s voice that it was serious and that the chances of success were slim. However, I was struck by the focus on the possibility of a positive outcome. And that positivity had a deep and encouraging effect on my father, as well as the family around him.
He was admitted to the cancer unit for treatment on Christmas Eve in 2012. On Christmas day, as the family shared a bottle of Champagne with him at his bedside, I was struck by how ill he looked and I was clearly worried. One of the nurses could see that in my face, and she said to me, very gently and very kindly ‘there is always hope’. That focus on the positive, on the hope, was a great source of strength, even though just a few days later it was confirmed that his condition had become so aggressive that there was no effective treatment. He died, a very peaceful and dignified death less than two weeks later. Arguably the hope for a person with type 2 diabetes is so much greater – yet I rarely experience anything approaching the level of hope amongst diabetes professionals as I did at the cancer unit.
At that time, I was writing a book to support the self-management of people with type 2 diabetes. I wanted the focus to be one of hope and of the positive outcome that can be achieved. I felt that everyone with type 2 diabetes should know that reversal is at least possible. Hence the title of the book – Reverse your diabetes - should carry that message of hope. The book did not make claims to guarantee reversal, but focused on the lifestyle changes that could maximise the chances of reversal. The most critical lifestyle change is a diet in which carbohydrates are significantly reduced, even though this is counter to the prevailing wisdom, namely that everyone with diabetes – as with the general population - should base their meals on carbohydrates. It is however very similar to the diet that was recommended for people with diabetes a hundred years ago.
The message of hope is gaining ground amongst people with diabetes
When the book was published in 2014, the concept of reversal of type 2 diabetes was still largely met with scepticism, and I came in for criticism from some of those in the higher echelons of my profession. Since then, however, the notion of reversal has slowly gained acceptance. This has occurred as a result of people with diabetes, rather than health professionals, embracing it. There is the compelling story of the Whitington family, as charted in the film and book ‘Fixing Dad’. This is the story of a 62 year old man, at risk of a foot amputation as a result of diabetes, who was guided, encouraged and at times cajoled by his sons into making the changes to his lifestyle that reversed his diabetes and saved his foot.
Then there is the story of the TV director, Eddy Marshall, who despite a very negative outlook from his own GP, managed to reverse his type 2 diabetes by losing 50lb in weight. He has now set about making a documentary on the subject and with his wife has set up courses in his area to support others to reverse their type 2 diabetes.
Reversal has also been highlighted by the pioneering work of people like Dr David Unwin, whom I visited recently. Four years ago, he was challenged by a patient who reversed her diabetes by ignoring the standard advice and by adopting a low carbohydrate diet. Dr Unwin was so struck by the change in her quality of life that he started advising low carbohydrate diets routinely to his patients with diabetes, with remarkable results. He has since published details of his experience, that has seen many people reverse their diabetes, and at the same time generated savings of tens of thousands of pounds a year as a result of people coming off medication.
But some seem to want to ration hope
Despite this, I have seen influential figures in the NHS saying that reversal isn’t for everyone and we should not raise hopes; in a recent radio interview, a spokesperson for Diabetes UK said that we shouldn’t use the word ‘reversal’ but ‘remission’ of type 2 diabetes, because if one reverts to an unhealthy lifestyle, the diabetes will return. I felt like screaming out loud when I heard that. Why the focus on failure? What about the message of hope?
Remission is something that happens to someone. Such as would have been the case if my father’s treatment had been successful. Reversal, on the other hand, is a process that precisely describes what happens to the pathological changes that cause type 2 diabetes, when someone changes their lifestyle. Unlike with cancer treatment, this is not as a result of drugs. The diabetes is reversed as a direct result of actions by the individual to change their lifestyle.
Yes, it is still early days; yes, we still do not know the best route to achieving reversal, or the extent to which an individual can reverse their diabetes. It is likely to be different for different people. But let us not use this uncertainty to deny people the knowledge that type 2 diabetes can be reversed, and that lifestyle changes are effective in achieving it. And please, let us not shy away from using the term reversal. Above all, let’s bring hope to our approach to type 2 diabetes. Even if the chances for an individual are slim, should we not focus on the hope of even a small chance of a positive outcome?
It makes good economic sense too
There is also a compelling economic argument to promote reversal. The traditional model, that treats type 2 diabetes as an illness that requires medication, often without addressing the lifestyle factors that contributed to it, is failing to improve the outcome for many individuals affected. This is despite billions of healthcare dollars and pounds and euros being spent every year on diabetes, money that most health systems can ill afford. Adopting lifestyle approaches to prevention of type 2 diabetes is cost-effective and often cost-saving; the accumulating evidence that lifestyle approaches enable people to reverse their diabetes and stop taking medications suggests this too will be cost-saving. There is no doubt that medications will still be needed by many, but their effectiveness will be so much greater if they are used to enhance the effect of lifestyle change rather than as a substitute for it.
So, if you have type 2 diabetes, please consider what lifestyle changes you can make to help reverse it. If you are a health professional that manages people with type 2 diabetes, please consider adopting reversal as the preferred goal of treatment. And if you have a role in public health, please consider the benefit to public health and health finances, of striving for reversal of type 2 diabetes. And let us all start talking about it.
Please support us in our efforts to help all people with type 2 diabetes live longer, healtheri and haqppier lives.