Insulin resistance, beta cell dysfunction, hyperinsulinaemia, and DiRECT

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travellor said:
I read it in detail at the time.
It was voluntary, and "128 (27%) of the practice population with T2D and 71 people with prediabetes had opted to follow a lower carbohydrate diet for a mean duration of 23 months".
So it was a biased group, already with incentive to improve their condition, and no great feedback on the actual food consumed, just a general diet sheet to follow, which originally did suggest limits on consumption.
But even hit or miss, it provides a good insight into the fact diabetes in reversible, or at least diet controlled in some cases.
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All study participants are volunteers. I have yet to hear of a conscripted research study.
 
travellor said:
Precisely, whereas the Direct trails were a much larger controlled study, hence maybe the confusion?
Either way, it all adds to the knowledge of what type 2 is.
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Control groups are easy to find.

About 9 months ago, I was invited to take part in a piece of research, relating to a condition (not diabetes, or Endo related) I live with. The study, testing and protocols looked fabulous, but there was a drug involved that I just didn’t fancy taking. I quipped I’d be very happy to be part of the study, provided I could be sure I got the placebo. I was politely reminded that’s not how it works.

Oh well. Another opportunity missed.

Nobody who doesn’t fancy participating in an active group in a trial is going to volunteer, are they. Or perhaps I’m just not philanthropic enough with my own body
 
Spathiphyllum said:
I've heard of some, but not in societies we would want to emulate ...
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OK. I get that.

I can sort of think of some circumstances where it might apply too, but in these litigious times, it'd be a brave researcher......
 
Having looked at the BMJ paper-- of course the authors recognise, explicitly, the limitations of this type of study! But it is still valuable, in showing what can actually be achieved by a GP practice in real life.

It does seem that weight loss, and keeping the weight off, is the key to remission; and the authors note that the low-carb diet may help simply by reducing hunger and reducing appetite: "A commonly reported patient finding was how surprised they were not to feel hungry on this diet."

But it's also clear that providing a lot of support, over a long period of time, is crucial for weight loss and keeping the weight off. (That may be expensive-- but the paper also shows how much money the practice saved the NHS through fewer prescriptions of Type 2 drugs.)

This links back to one of the Radio 4 programmes I mentioned, 'A Thorough Examination', both Series 1 and Series 2. For people who don't know the background: Drs Chris and Xand (short for Alexander) van Tulleken are genetically identical twins, both medical doctors-- but Chris has always been a healthy weight, whereas Xand became obese in his thirties. So they started exploring what it was about the difference in their environments which had made Xand obese but not Chris-- and of course whether they could change, and if so how.

'They' is a key word here, because it turned out Chris was part of the problem! They both had to make a lot of changes in their thinking and their behaviour. In the end, Xand loses weight, and in the best, most sustainable way-- he now actually *doesn't like* unhealthy food, or unhealthy amounts of food; he *enjoys* healthy food in healthy amounts, and he's got back to enjoying exercise-- and Chris and Xand have a much better relationship.

A lot of the information and tips they get from experts along the way are real eye-openers, and helpful for all sorts of problems. But probably especially helpful for people trying to overcome Type 2 themselves, or trying to support a loved one in overcoming Type 2.
 
Spathiphyllum said:
Having looked at the BMJ paper-- of course the authors recognise, explicitly, the limitations of this type of study! But it is still valuable, in showing what can actually be achieved by a GP practice in real life.

It does seem that weight loss, and keeping the weight off, is the key to remission; and the authors note that the low-carb diet may help simply by reducing hunger and reducing appetite: "A commonly reported patient finding was how surprised they were not to feel hungry on this diet."

But it's also clear that providing a lot of support, over a long period of time, is crucial for weight loss and keeping the weight off. (That may be expensive-- but the paper also shows how much money the practice saved the NHS through fewer prescriptions of Type 2 drugs.)

This links back to one of the Radio 4 programmes I mentioned, 'A Thorough Examination', both Series 1 and Series 2. For people who don't know the background: Drs Chris and Xand (short for Alexander) van Tulleken are genetically identical twins, both medical doctors-- but Chris has always been a healthy weight, whereas Xand became obese in his thirties. So they started exploring what it was about the difference in their environments which had made Xand obese but not Chris-- and of course whether they could change, and if so how.

'They' is a key word here, because it turned out Chris was part of the problem! They both had to make a lot of changes in their thinking and their behaviour. In the end, Xand loses weight, and in the best, most sustainable way-- he now actually *doesn't like* unhealthy food, or unhealthy amounts of food; he *enjoys* healthy food in healthy amounts, and he's got back to enjoying exercise-- and Chris and Xand have a much better relationship.

A lot of the information and tips they get from experts along the way are real eye-openers, and helpful for all sorts of problems. But probably especially helpful for people trying to overcome Type 2 themselves, or trying to support a loved one in overcoming Type 2.
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The paper certainly refers to saving, but doesn't actually explain the numbers.

"Norwood surgery had a T2D disease register of 473 people, of whom 186 (39%) chose the low- carbohydrate approach"
and
"average Norwood surgery spend was £4.94 per patient per year on drugs for diabetes compared with £11.30 for local practices. In the year ending January 2022, Norwood surgery spent £68 353 per year less than the area average."

Now that's a saving of £6.36 per person for 186 people. That's £1182.96.
So possibly the surgery already had a policy of not prescribing, as that's a big difference to £68353 per annum.

The other wrinkle is "the definition of remission; a glycated heamoglobin(HbA1c) <48 mmol/mol sustained for >3 months in the absence of diabetes medication"

Now I have seen many who actually follow low carb, as well as others, cry foul on this measurement, as it's still at the top of "prediabetic" not non diabetic for remission, and it's the minimum time for a meaningful hba1c to be effectively taken.

However as said right at the beginning of the paper, "remission induced by dietary weight loss" can only be a good thing, and the message is getting out there anyway it can.
 
travellor said:
The paper certainly refers to saving, but doesn't actually explain the numbers.

"Norwood surgery had a T2D disease register of 473 people, of whom 186 (39%) chose the low- carbohydrate approach"
and
"average Norwood surgery spend was £4.94 per patient per year on drugs for diabetes compared with £11.30 for local practices. In the year ending January 2022, Norwood surgery spent £68 353 per year less than the area average."

Now that's a saving of £6.36 per person for 186 people. That's £1182.96.
So possibly the surgery already had a policy of not prescribing, as that's a big difference to £68353 per annum.

The other wrinkle is "the definition of remission; a glycated heamoglobin(HbA1c) <48 mmol/mol sustained for >3 months in the absence of diabetes medication"

Now I have seen many who actually follow low carb, as well as others, cry foul on this measurement, as it's still at the top of "prediabetic" not non diabetic for remission, and it's the minimum time for a meaningful hba1c to be effectively taken.

However as said right at the beginning of the paper, "remission induced by dietary weight loss" can only be a good thing, and the message is getting out there anyway it can.
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Another spanner in the works concerning A1c thresholds is that the usual ones are not appropriate for older people. At age 75 I would become just prediabetic at A1c of 48 and full-blown diabetic at 57.
 
childofthesea43 said:
Another spanner in the works concerning A1c thresholds is that the usual ones are not appropriate for older people. At age 75 I would become just prediabetic at A1c of 48 and full-blown diabetic at 57.
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"the median (IQR) age at baseline was 63 (54, 73)"

BG increases with age as you say.
 
Burylancs said:
Was there actually a peer reviewed academic paper about the original 2017 Direct trial published at all ? Most of what I can find is a raft of claims and assertions about it unsupported by any evidence.

The daftest claim from Taylor is that he had T2s on a diet for three months in which they were getting up to 20% of their nutrition from Fresh Air ( 50% cals from carbs. 20-30% from fats and 10-20 % from protein).
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Maybe up to 20% calories from alcohol? I have a can of hard seltzer that says it has 27 calories per 100ml but 0g carbs, fat or protein....
 
Sorry, I am new to all this, please could you help me understand. If T2 produce too much insulin why has my husband been given a medication that encourages insulin production, Gliclazide. His HbA1c was 121. thank you.
 
Snapdragon said:
Sorry, I am new to all this, please could you help me understand. If T2 produce too much insulin why has my husband been given a medication that encourages insulin production, Gliclazide. His HbA1c was 121. thank you.
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The way it was explained to me (when I was misdiagnosed Type 2) was this. Insulin is released in response to eating a meal. In Type 2, the body loses its ability to use the insulin properly. So the body produces more and more insulin in response to eating. That’s where the over production of insulin occurs, and because the body only uses a fraction of this insulin, the rest is wasted. Insulin production then ceases til the next meal, leaving the body with too much unabsorbed glucose in the system. Gliclazide forces the pancreas to release insulin even when it hasn’t been stimulated by something being eaten. So it gets released all the time, and helps mop up some of the excess glucose sloshing around in the bloodstream.
There are various theories as to whether this is a good thing, or a bad thing. Some say forcing the pancreas to produce more and more insulin causes it to wear out, some say causing more production of insulin when the body isn’t using it properly is a waste of effort and won’t solve anything.
I think it’s fair to say that Gliclazide does work for some people, but not others, and it’s a case of seeing what results.
 
Snapdragon said:
Sorry, I am new to all this, please could you help me understand. If T2 produce too much insulin why has my husband been given a medication that encourages insulin production, Gliclazide. His HbA1c was 121. thank you.
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He doesn't produce 'too much' insulin, he doesn't produce enough to overcome the insulin resistance.

A normal pancreas can produce a lot of insulin, and a lot of people who have IR don't develop diabetes as their metabolism can cope with it.

In people with T2 diabetes it can no longer do so as beta cells have failed (There's actually a relationship between hba1c and the lack of insulin secretion/extent of failure). It's not that T2s produce 'too much' insulin, the insulin they produce is not being used and just builds up along with blood sugar and because the blood sugar is high it keeps producing it.

T2 diabetes drugs are designed to be used alongside lifestyle changes, as their effect is quite modest. Increasing insulin sensitivity can help use what is produced more effectively and lead to improved blood sugar levels.
 
harbottle said:
He doesn't produce 'too much' insulin, he doesn't produce enough to overcome the insulin resistance.
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I disagree. He is producing more insulin than should be needed if the insulin resistance wasn't there.
Therefore the insulin resistance needs fixing.
Forcing the poor pancreas to produce even more insulin is simply exacerbating the problem and treating the symptoms (high blood sugars) and not the underlying cause.
Intermittent fasting and ultra low carb should start to repair the problem without exhausting the pancreas and means the drugs would not be necessary. The root cause of the problem would be addressed.
 
Snapdragon said:
Sorry, I am new to all this, please could you help me understand. If T2 produce too much insulin why has my husband been given a medication that encourages insulin production, Gliclazide. His HbA1c was 121. thank you.
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We don't. I was the same initially.
I reversed my diabetes by losing weight, reversed my insulin resistance, and produce the right amount of insulin to maintain my BG correctly now.
 
I’m really happy for you travellor. My poor husband is very underweight, all the advice is to loose weight but I am trying to build him up a bit. We are eating a low carb diet and testing bloods regularly, fasting bloods 11.8 this morning.
 
Snapdragon said:
I’m really happy for you travellor. My poor husband is very underweight, all the advice is to loose weight but I am trying to build him up a bit. We are eating a low carb diet and testing bloods regularly, fasting bloods 11.8 this morning.
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I think it has been mentioned in your other thread that your husband may be Type 1 which would explain high blood glucose levels despite low carb.
You are right the emphasis for Type 2 is on losing weight and many menu plans are designed to do that.
 
Leadinglights said:
I think it has been mentioned in your other thread that your husband may be Type 1 which would explain high blood glucose levels despite low carb.
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If there is a suggestion that your husband may be T1 or LADA then it’s worth getting that checked - as Glic may not give the expected results if his betacell mass is reduced by autoimmune attack (rather than insulin resistant / signalling issues)?
 
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