Can diabetes be reversed? Cutting carbs, exercising are key

Diabetes gate-crashed into Thomas Franco’s life in 2016 at a medical camp organised for senior bank employees in Chennai. The now-retired 64-year-old bank officer was invited to the gathering to inaugurate the camp by being the first person to get his blood glucose levels checked. Little did he realise that his life was about to undergo a total upheaval as it was revealed that his blood sugar level was extremely high at 380 mg/dl.

Back then Franco was convinced that he was as healthy as one could be at his age, and this came crashing down on him after this random blood sugar test.

“I had no clue about diabetes back then and was worried,” he said. “I did not waste more time and took a diabetologist’s appointment the next day. I was put on an insulin prescription of 12 units in the morning and 10 units at night, coupled with oral medications.”

He also told Happiest Health that he had almost consigned to leading an antidiabetic medicine-laden life until he bumped into a friend who had managed to bring his sugar levels under control by adopting a healthier lifestyle – mainly diet and exercise under a diabetologist’s supervision.

“He suggested that I should adopt a sort of Paleo Diet since it mainly focused on lean meat and egg with minimum carbs,” Franco said. “But I decided to research further as I was also told by someone about the harmful effects of such a diet.”

A customised diet and workout

Franco decided to keep an open mind and adopt a diet that had the best of almost all major diets. His key objective was to avoid carbohydrates as much as possible, especially rice, the staple diet in South India. He also included more fresh vegetables, fish and meat. As per this customised diet plan Franco used to have three entire eggs from a country chicken and sprouted grams for breakfast followed by a mid-day snack of a couple of nuts around 11 am.

“Lunch was mainly millet rice, lots of vegetables and meat or fish depending on availability,” he said. “At 5 pm I used to have some more nuts. I also completely quit drinking milk tea and coffee, and was having just black tea occasionally without sugar.” Franco’s dinner used to be just a serving of boiled vegetables.

Apart from the diet, Franco also took up an exercise routine comprising walking, yoga and a combination of breathing exercises.

“Once a week, I used a glucometer to check my blood sugar levels and noticed that they were slowly decreasing,” he said. “I gradually stopped taking insulin and other medications. I was on insulin for more than a year, and my diabetologist advised me to stop insulin in 2018.”

Remission of diabetes

Though Franco managed to put his diabetes in remission and get off his medications, diabetes once again popped up in his life during the pandemic as his daily workout routines and dietary restrictions went for a toss. He also had to restart his diabetes medication once again. Franco said in this second bout with diabetes, he is unable to follow his antidiabetic routine like he did in the past.

“I’m not always able to stick to my diet because I travel frequently,” he said. “Sometimes I eat whatever is available. I check my blood sugar levels, and if they rise, I take medication. As much as possible, I steer clear of carbs. My fasting blood sugar level is now between 140 and 150, and my HbA1c is 6.5.”

Franco’s case is a perfect example of how diabetes could be put into remission with sheer grit and a disciplined lifestyle coupled with intelligent food choices. Ironically, it is also a testimony to the persistence of diabetes – how it returns if the required lifestyle guidelines (mainly avoiding carbohydrates and sugar-rich food items) are not followed.

The ABCD of preventing complications of diabetes

Dr V Mohan of Dr Mohan’s Diabetes Specialities Centre, one of the premium diabetes care centres in India, tells Happiest Health that it is not just a disease of blood glucose levels, “but it affects all the metabolisms including the fats and the protein in addition to affecting the carbohydrate metabolism.” Diabetes is considered a vascular metabolic disease. “The reason why it is called vascular disorder is that diabetes affects the small blood vessels in the body – primarily the eyes, kidneys and the nerves and also the large blood vessels in the body, for example, the heart, the brain, and the peripheral arteries going to the feet,” he says.

To control the microvascular or the small blood vessel changes affecting the eye, kidney and nerves, if one keeps the sugar under good control and has an HbA1c of less than seven per cent, it may be possible to prevent these complications.

Dr Mohan talks about an ABCD mantra (slogan). “To prevent the macrovascular complications of diabetes, this mantra should be helpful: A is for A1c (HbA1c – average blood sugar level for the last three months) less than seven per cent, B for blood pressure less than 140/90, C for cholesterol, that is LDL cholesterol or bad cholesterol less than 100 and D that stands for discipline, which is all about healthy diet, physical activity, reducing stress, no tobacco in any form and no excess of alcohol.” Dr Mohan says that if all these are followed, then it is possible to prevent macrovascular complications.

Remission possible only in type 2 diabetes, not type 1

When it comes to the question of remission, Dr Mohan says the remission of diabetes is possible but only in those with type 2 diabetes.

In type 1 diabetes, reversal of diabetes is not possible. But for achieving type 2 diabetes remission, Dr Mohan reminds us of certain principles. “ABCDE Principle: A that stands for A1c (glycated hemoglobin). If the A1c level is below nine per cent, then there will be better chances of achieving remission. B stands for body weight or BMI. The higher the body weight, the more difficult it is to manage diabetes. C is about C-peptide, which is an index of insulin secretion. The better the insulin secretion, the greater the chance of inducing remission. D for the duration of diabetes. In those with a very long duration, 15-20 years, reversing the effects of diabetes becomes very difficult. E is all about enthusiasm. A motivated person can manage diabetes because it needs continuous control of diet and exercise for months or years which many people will not be able to follow.”

However, Dr Mohan says that ‘remission’ of diabetes is a better term to use than ‘reversal’  when it comes to diabetes management. “It also implies that at any time, remission can go away and diabetes can come back again. Reversal on the other hand implies that it is a total cure of the condition; such a thing very rarely happens, as diabetes is usually a progressive condition,” he says.

In type 2 diabetes, the form of diabetes affecting over 90 per cent of people with diabetes, the main processes that define the body are a decrease in insulin secretion from the beta cells of the pancreas and insulin resistance which is a decreased efficiency or action of insulin which can be in the liver, the muscles or the fat cells (adipose tissue).

Going by B, one of the major factors of the ABCDE principle, a study conducted on obese people with type 2 diabetes found that a low-calorie diet (LCD) and gastric bypass surgery were equally effective in achieving weight loss and improving glucose levels and HbA1c levels in the short term.

Dr Sreejith N Kumar, diabetologist, Diabetes Care Centre, Thiruvananthapuram, says that type 2 diabetes has long been regarded as one that is inevitably progressive, and as one that requires an increasing number of oral drugs and insulin. Noting that diabetes can be halted, Dr Kumar says type 2 diabetes can be understood as a potentially reversible metabolic state precipitated by the single cause of chronic excess fat stored deep inside the belly, wrapped around the organs, including the liver and intestines.

Carbohydrates: The starting point of trouble

“It all starts with excess carbohydrate intake, which leads to an increase in lipogenesis (the conversion of fatty acids and glycerol into fats), which leads to fat accumulation in the liver. This fat accumulation causes resistance to insulin suppression of hepatic glucose production. There is an increase in fasting plasma glucose level, and increased basal insulin, which again produces more lipids (lipogenesis.) Thus, there is more fat in the liver and there is a vicious cycle of hyperinsulinemia and blunted suppression of hepatic glucose. So, what happens is that there is the export of VLDL Triglycerides (very-low-density lipoprotein; the liver makes VLDL and releases it into the bloodstream) to all tissues including islets of the pancreas, and fat in the pancreas increases impaired acute insulin secretion in response to ingested food and produces postprandial hyperglycaemia. This hyperglycaemia further increases insulin secretion, more fat in the liver and more fat in the pancreas. These two twin cycles – the cycle of the liver and the cycle of the pancreas contribute to the development of diabetes. All these start with excess carbohydrates,” Dr Kumar says, decoding the process of diabetes.

In a study from the United States, 4,503 adults with a body mass index of 25 or higher with type 2 diabetes were grouped into an intensive lifestyle-based weight loss intervention (ILI) and Diabetes Support and Education intervention (DSE). In what was called an intensive lifestyle intervention, the study says the participants of ILI were seen losing weight significantly more than DSE participants. The ILI group was significantly more likely to experience any remission (partial or complete). (ILI included weekly group and individual counselling in the first six months, followed by three sessions per month for the second six months, and twice-monthly contact and regular refresher group series and campaigns in years two to four).

Multiple studies indicate that type 2 diabetes is reversible by lifestyle modification and that not only normalises blood glucose levels but also decreases blood pressure and serum lipids and improves the quality of life.

Excess fat in the liver and the pancreas is driving the whole mechanism of a decrease in beta-cell function and insulin resistance.

“But beta-cell function can be restored if liver fat is reduced through weight loss and this cycle reverses,” says Dr Kumar, adding that what is called partial remission is retaining HbA1c to 6.5 for more than one year without any medication. “Complete remission is maintaining the fasting blood sugar of less than 100 decilitres for one year without any medication. The prolonged remission conventionally lasts for five years without any diabetes medication,” Dr Kumar notes.

The population growth and ageing in the world’s largest countries — including China and India — are leading to an absolute increase in the number of people with diabetes, says the Global Burden of Disease Study by the Institute for Health Metrics and Evaluation, an independent global health research centre at the University of Washington. According to the International Diabetes Federation, 537 million adults across the world had diabetes in 2021 and this is expected to be around 783 million in 2045. India has 74.2 million adults with diabetes in 2021 – a number that is projected to go up to 124.9 million in 2045.