Is diabetes progressive?

[Teadance]

Good morning everyone, at my most recent diabetic check in August, I was surprised and upset to find my HbA1c had increased despite my best efforts, (mostly!!) There were two diabetic nurses in the room, one was under the guidance of the other. After asking if I could account for the increase, one looked at the other and said, ‘…..progression of the disease?’ I presume the other nodded, but I wasn’t looking.

Now, my understanding was that if you controlled your diabetes well, it no longer needed to be considered progressive. In fact I’ve based all my efforts on believing that ‘fact’. I admit I ‘chose’ to believe it because I wanted to feel I could directly influence the diabetes through my own efforts. This recent increase makes me despondent, thinking, will it progress inspite of anything I do? I want to believe I can influence it for the better, otherwise what’s the point of all this effort?

I have a repeat test, at my request, in early December, and am doing all I can to bring the numbers down, but I was doing that before!!!

Thanks for reading.

 

[Sharron1]

Alas, I was under the impression it can be progressive however hard one maintains the diet etc. But the progression can take years and doesn't happen to everyone. Hence a reason for annual checks.

 

[Martin.A]

Good morning everyone, at my most recent diabetic check in August, I was surprised and upset to find my HbA1c had increased despite my best efforts, (mostly!!) There were two diabetic nurses in the room, one was under the guidance of the other. After asking if I could account for the increase, one looked at the other and said, ‘…..progression of the disease?’ I presume the other nodded, but I wasn’t looking.

Now, my understanding was that if you controlled your diabetes well, it no longer needed to be considered progressive. In fact I’ve based all my efforts on believing that ‘fact’. I admit I ‘chose’ to believe it because I wanted to feel I could directly influence the diabetes through my own efforts. This recent increase makes me despondent, thinking, will it progress inspite of anything I do? I want to believe I can influence it for the better, otherwise what’s the point of all this effort?

I have a repeat test, at my request, in early December, and am doing all I can to bring the numbers down, but I was doing that before!!!

Thanks for reading.

My understanding is that it is currently considered to be a progressive disease although I have read that this is being questioned by some, especially those promoting what they call 'reversal' programmes. Lifestyle changes, medication, and diabetes self-management strategies are intended to help prevent, treat, manage, and slow the progression. Of course, if we do nothing to manage our BG then I suspect that progression is inevitable.

 

[rebrascora]

Can I ask how much your HbA1c has increased and what dietary changes you have made to manage it? Just wondering if you are following NHS dietary advice or some other more up to date thinking?

Many people who mostly follow the NHS advice will find that their diabetes will be progressive because they still eat more carbs than their system can cope with, albeit, the supposedly healthy wholegrain ones. It is also possible that you may not be a typical Type 2 diabetic and possibly a slow onset Type 1 or possibly Type 3c or some other Type or subset, which was why I went back through your previous posts to find more information and ended up posting on a 2 year old post where you mentioned your levels rising not long after your Covid and Flu vaccines so this clearly isn't a very recent issue.
If you can give us an idea of what a typical day's menu looks like for you then it might give us an idea of whether there is much room for dietary adjustment or if this genuinely may be progressive. I think there are probably more sub types of diabetes than are known or categorized. I also think that the NHS is a bit behind the curve with both their thinking and advice and many GPs are still of the opinion that Type 2 diabetes is progressive, so it doesn't surprise me that 2 nurses might think so and indeed some diabetes is progressive. Those of us with Type 1 have no hope of remission but it doesn't mean that we shouldn't manage it as well as we can and thereby remain healthy, so I don't think you should consider your previous dietary and exercise efforts as being in vain and they will be an important part of managing your diabetes going forwards whether your particular diabetes may be progressive or not.

 

[everydayupsanddowns]

Some members over the years seem to settle into a sort of ‘stasis’ with their diabetes management - where as long as their weight remains stable, and they stick to the menu they have found works for them, their diabetes seems to potter along year after year.

Some spot rises in their levels / A1c, and realise things have perhaps slipped a little, and then go back to basics for a bit of a reset.

Still others seem to find that things change from time to time, and that what was once sufficient to keep glucose levels under control seems currently to not be working so well, and they need to make further adjustments, or perhaps add or tweak some medication to get things back on track.

I think this variation in experience might partly be because of the fairly wide variation of diabetes sub types that seem to be gathered under the T2 umbrella. So different people’s experiences can be very different.

Roy Taylor and Mike Lean’s work on the DIRECT trial has shown that for some people getting below a ‘personal fat threshold’ can hold the key to effectively rebooting the metabolism, and restoring proper metabolic function. Their published papers say that diabetes no longer needs to be considered inevitably progressive for everyone, and that some people can hold diabetes in remission for extended periods of time.

 

[Teadance]

Thanks for your replies,

I do understand that if someone is diagnosed with type 2 diabetes and makes no changes, would of course find their diabetes progressing. I was diagnosed some years ago with an HbA1c of 51, reduced it to 49 and eventually to 40. In August it was 53. A typical breakfast is avocado with cottage cheese or avocado and a boiled egg. I add 2 Paterson’s oat biscuits. Lunch is usually soup (often homemade) or an omelette with mushrooms and/or ham. Dinner is usually salmon stir fry, homemade turkey burgers with veg. and sometimes new potatoes. Puddings are blueberries with Total yoghurt or plain kefir. If I snack I have nuts, or if I’m hungry I may have a couple of oat biscuits with almond butter. I eat apples. If I feel like indulging I have veg crisps or the Kind seasalt and nut bar. I like cream on blueberries occasionally. I’ve been known to have chocolate occasionally. I rarely eat bread.

My question is, if you divest the liver of fat (getting below your personal fat threshold) thus restoring proper metabolic function, why would the disease progress?

Many thanks.

 

[rebrascora]

My question is, if you divest the liver of fat (getting below your personal fat threshold) thus restoring proper metabolic function, why would the disease progress?

That assumes that fat in and around your liver and pancreas was the cause of your particular diabetes and that may not be the case for everyone, which is why we talk about sub types and may be the reason why so many people have different experiences of diabetes.

Your diet seems to be genuinely low carb, so I don't think there is much more you can do there although when you say you eat apples, I am hoping that doesn't mean more than 1 a day as apples are moderate carb. I tend to have half an apple most days with a nice chunk of cheese, but I wouldn't eat a whole one every day within my carb allowance.

 

[Teadance]

Thanks rebrascora,

I must admit I thought all type2 diabetes was related to too much fat in the liver. I don’t really know anything about the sub types.
I only eat apples occasionally and I’m definitely not perfect (are any of us?). I DID have a Bailey’s yesterday, but any ‘treats’ I have are only occasional. I can’t think they’re enough to cause an increase in my HbA1c over the period between tests. I‘m usually pretty strict.

Again, I thought if you divested the liver of fat, (assuming that’s the reason I have diabetes), I couldn’t see why it would progress. Perhaps it’s a lot more complicated than I thought!

 

[Martin.A]

Again, I thought if you divested the liver of fat, (assuming that’s the reason I have diabetes), I couldn’t see why it would progress. Perhaps it’s a lot more complicated than I thought!

Fat around the pancreas is another risk factor:-

Removing fat from pancreas can reverse type 2 diabetes, study finds - Diabetes

Fat stored around the pancreas is far more important in determining the development of type 2 diabetes than overall body fat, according to new research. The study, conducted at Newcastle University, indicates that less than half a teaspoon could be enough to cause – or reverse – the development...

www.diabetes.co.uk

 

[Proud to be erratic]

Thanks rebrascora,

I must admit I thought all type2 diabetes was related to too much fat in the liver. I don’t really know anything about the sub types.
I only eat apples occasionally and I’m definitely not perfect (are any of us?). I DID have a Bailey’s yesterday, but any ‘treats’ I have are only occasional. I can’t think they’re enough to cause an increase in my HbA1c over the period between tests. I‘m usually pretty strict.

Again, I thought if you divested the liver of fat, (assuming that’s the reason I have diabetes), I couldn’t see why it would progress. Perhaps it’s a lot more complicated than I thought!

I have become intrigued by this thread, @Teadance, partly because I spent several years assisting my late brother who returned to UK, after over 30 yrs living in Africa, as a medical emergency because of his diabetes. He surrendered a leg to his T2 within a month and 12 months later surrendered his other leg. Since joining this forum it has become increasingly apparent to me that there seems to be many varieties or sub groups of T2. So I've just done a quick Google search and among a number of technical articles this one below is recent (August 2020) and appropriate from a Symposium sponsored by the American Diabetes Association:

Subtypes of Type 2 Diabetes Determined From Clinical Parameters

Type 2 diabetes (T2D) is defined by a single metabolite, glucose, but is increasingly recognized as a highly heterogeneous disease, including individuals w

diabetesjournals.org

Fairly early on in the paper the authors remark:
"T2D is thus clearly a multifactorial disease with multiple underlying etiologies that results from the combined effects of numerous genetic and environmental risk factors"

and start the conclusion by saying:
"Easily measurable clinical parameters can be used to subclassify individuals with T2D into five groups with differing characteristics and disease progression. These clusters have been shown to be stable and reproducible in several populations."

There is a lot of detail in between, not surprisingly! But there is also a considerable amount of research and collation that demonstrates T2 is a great deal more complex than is too frequently assumed by the media. Also sometimes by the casual way it seems to have been diagnosed and treated - judging by some of the experiences related from members of this Forum.

 

[childofthesea43]

The theme of this thread has also been my preoccupation for three years. Is T2D truly complex, multi-factorial and manifested in many subtypes? Are carbs really fundamental in causation or mitigation? Not according to Taylor and Lean with whom I have had several exchanges on this very topic. So far -so far - their view is that if you clear the fat away quite soon into the disease state then your prospect of true reversal is over 80% at least, and if you then rigorously maintain the new weight then the prospect of maintaining your reversal is near 100 per cent. And indeed all those initially reversed candidates in Direct who kept their weight unchanged over 5 years also kept their reversed state. Well, so far… we need bigger and much longer trials to see whether this holds true. Some researchers think that although one has rebooted the beta cells and got them back to apparent full health they will have been subtly weakened by the earlier insult and will not thrive as well long term as if one had never become diabetic. Moreover some people have five times as many of these cells as others at start of life.

 

[everydayupsanddowns]

Moreover some people have five tines as many of these cells as others at start of life.

That’s very interesting, and might explain some of the variation we see in tolerance to different sources and amounts of carbohydrates in various forum members.

Can you remember where you got that snippet of information from?

 

[rebrascora]

Diabetes is incredibly complex. The problem is that there really hasn't been enough study done to establish the cause(s) of Type 2 diabetes and that is assuming you are definitely Type 2 for which there is no specific test What we can see here on the forum is that not everyone's diabetes responds the same

 

[childofthesea43]

That’s very interesting, and might explain some of the variation we see in tolerance to different sources and amounts of carbohydrates in various forum members.

Can you remember where you got that snippet of information from?

I am not sure of my original source stating that the variability was about 5:1, but this paper gives an estimate of 4:1: https://www.sciencedirect.com/science/article/abs/pii/S221385872030022X

 

[childofthesea43]

Diabetes is incredibly complex. The problem is that there really hasn't been enough study done to establish the cause(s) of Type 2 diabetes and that is assuming you are definitely Type 2 for which there is no specific test What we can see here on the forum is that not everyone's diabetes responds the same

And yet we have Taylor firmly stating over and over again "We now understand that T2D is very simple". Perhaps the truth is that there is a great swathe of T2D that is indeed very simple but also some remaining species of T2D that are not so.

 

[grovesy]

I thought that the researchers at Exter had said they had identified over 40 differnt types at around the time Taylors study first imerged.

 

[harbottle]

This paper (from 2013) has a lot of information about the then current knowledge of beta cells by looking at the research that been done up to that point:

Diabetes mellitus and the β-cell: the Last Ten Years

Diabetes is a major global problem. During the past decade, the genetic basis of various monogenic forms of the disease, and their underlying molecular mechanisms, have been elucidated. Many genes that increase type-2 diabetes (T2DM) risk have also been ...

www.ncbi.nlm.nih.gov

Some interesting stuff here:

- Mass of beta cells can be reduced to 40% with the surviving cells still being able to keep control of glucose levels to some degree. (As seen in people who've had partial removal of the pancreas)
- Loss of functionality seems to be more important than mass.
- Potentially a lot of genetic implications that break pathways.
- Fat in the pancreas is linked to reduced insulin secretion (And in times when diet has been restricted, incidence of T2 diabetes has been lower - such as during wars when food is rationed.)
- By product of glucose metabolising causes beta cell dysfunction, and this leads to a vicious cycle in which ever increasing levels lead to more dysfunction (I believe Oxford University published a paper showing the pathway for this a few years ago.)

When this paper was published there had been very few studies on weight loss and diet, apart from this one... from Newcastle University... with R Taylor as a co-author, which I believe pre-dates the Direct trial:

Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol

Type 2 diabetes is regarded as inevitably progressive, with irreversible beta cell failure. The hypothesis was tested that both beta cell failure and insulin resistance can be reversed by dietary restriction of energy intake.Eleven people with type 2 ...

www.ncbi.nlm.nih.gov

 

[childofthesea43]

This paper (from 2013) has a lot of information about the then current knowledge of beta cells by looking at the research that been done up to that point:

Diabetes mellitus and the β-cell: the Last Ten Years

Diabetes is a major global problem. During the past decade, the genetic basis of various monogenic forms of the disease, and their underlying molecular mechanisms, have been elucidated. Many genes that increase type-2 diabetes (T2DM) risk have also been ...

www.ncbi.nlm.nih.gov

Some interesting stuff here:

- Mass of beta cells can be reduced to 40% with the surviving cells still being able to keep control of glucose levels to some degree. (As seen in people who've had partial removal of the pancreas)
- Loss of functionality seems to be more important than mass.
- Potentially a lot of genetic implications that break pathways.
- Fat in the pancreas is linked to reduced insulin secretion (And in times when diet has been restricted, incidence of T2 diabetes has been lower - such as during wars when food is rationed.)
- By product of glucose metabolising causes beta cell dysfunction, and this leads to a vicious cycle in which ever increasing levels lead to more dysfunction (I believe Oxford University published a paper showing the pathway for this a few years ago.)

When this paper was published there had been very few studies on weight loss and diet, apart from this one... from Newcastle University... with R Taylor as a co-author, which I believe pre-dates the Direct trial:

Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol

Type 2 diabetes is regarded as inevitably progressive, with irreversible beta cell failure. The hypothesis was tested that both beta cell failure and insulin resistance can be reversed by dietary restriction of energy intake.Eleven people with type 2 ...

www.ncbi.nlm.nih.gov

Yes, many of the papers I’ve read agree with your point that although the amount of beta cell mass is certainly significant to T2D outlook after reversal, it is their degree of recovered secretory and response function that dominates in the issue of durability.

 

[Drummer]

Thanks for your replies,

I do understand that if someone is diagnosed with type 2 diabetes and makes no changes, would of course find their diabetes progressing. I was diagnosed some years ago with an HbA1c of 51, reduced it to 49 and eventually to 40. In August it was 53. A typical breakfast is avocado with cottage cheese or avocado and a boiled egg. I add 2 Paterson’s oat biscuits. Lunch is usually soup (often homemade) or an omelette with mushrooms and/or ham. Dinner is usually salmon stir fry, homemade turkey burgers with veg. and sometimes new potatoes. Puddings are blueberries with Total yoghurt or plain kefir. If I snack I have nuts, or if I’m hungry I may have a couple of oat biscuits with almond butter. I eat apples. If I feel like indulging I have veg crisps or the Kind seasalt and nut bar. I like cream on blueberries occasionally. I’ve been known to have chocolate occasionally. I rarely eat bread.

My question is, if you divest the liver of fat (getting below your personal fat threshold) thus restoring proper metabolic function, why would the disease progress?

Many thanks.

I concentrate on the carbs.
I do not eat oats or any grain, I do not snack, I eat twice a day, I might eat a few apples off the trees in the garden, but most are given away, I chose berry mixtures with the lowest carb content, yoghurt is full fat Greek from Lidl or Tesco, but I eat any sort of meat or fish, eggs, cheese, and salad, stir fry and mushrooms all feature, but no more than 40gm of carbs a day. I do eat small amounts of high cocoa chocolate.
I regard myself as a very ordinary type 2 and regard those who do not find that diet alone is sufficient as more complex versions under the same name but needing more than diet can do.
My liver has shrunk down drastically during the last few years, so I don't have a 'bay window' at waist level these days - plus I've had to remake and remodel my clothes, or buy smaller every year or so since diagnosis. I have had problems with carbs all my life, though, plus when I became an adult the ceaseless yammering of those telling me carbs are healthy and I was a very bad person for finding that not true at all. and as for daring to put on weight - that was an awful thing to do. Just don't eat low carb and lose a Kg a day and then laugh at your GP for thinking that it was a trick.

 

[Teadance]

I have become intrigued by this thread, @Teadance, partly because I spent several years assisting my late brother who returned to UK, after over 30 yrs living in Africa, as a medical emergency because of his diabetes. He surrendered a leg to his T2 within a month and 12 months later surrendered his other leg. Since joining this forum it has become increasingly apparent to me that there seems to be many varieties or sub groups of T2. So I've just done a quick Google search and among a number of technical articles this one below is recent (August 2020) and appropriate from a Symposium sponsored by the American Diabetes Association:

Subtypes of Type 2 Diabetes Determined From Clinical Parameters

Type 2 diabetes (T2D) is defined by a single metabolite, glucose, but is increasingly recognized as a highly heterogeneous disease, including individuals w

diabetesjournals.org

Fairly early on in the paper the authors remark:
"T2D is thus clearly a multifactorial disease with multiple underlying etiologies that results from the combined effects of numerous genetic and environmental risk factors"

and start the conclusion by saying:
"Easily measurable clinical parameters can be used to subclassify individuals with T2D into five groups with differing characteristics and disease progression. These clusters have been shown to be stable and reproducible in several populations."

There is a lot of detail in between, not surprisingly! But there is also a considerable amount of research and collation that demonstrates T2 is a great deal more complex than is too frequently assumed by the media. Also sometimes by the casual way it seems to have been diagnosed and treated - judging by some of the experiences related from members of this Forum.

A very interesting article. Begs more questions than it answers, inevitably. And yet we do read about people who’ve lost weight and put their diabetes into remission. Glad to see research is ongoing though. How very complicated it is!