May 25, 2022
Many adults can achieve remission of type 2 diabetes with a primary intervention consisting of a diet that emphasizes whole, plant-based foods, according to a new publication from the American College of Lifestyle Medicine (ACLM).
The document was developed to assist clinicians treating adults with type 2 diabetes, with the goal of remission using diet as a primary intervention. A panel of 15 experts from seven societies reached consensus on 69 statements.
"A healthy diet is a foundational component of current lifestyle guidelines for treatment of type 2 diabetes, but it is often overlooked because of the lack of physician training and patient awareness," Felice A. Caldarella, MD, MBA, who is president of the American Association of Clinical Endocrinology (AACE), said in a press release from ACLM.
"The consensus statements produced by this panel of experts are invaluable in bringing awareness to the value of diet for diabetes remission in addition to management," he summarized.
The initiative was co-sponsored by the Endocrine Society, endorsed by AACE, and supported by the Academy of Nutrition and Dietetics. The expert panel also included representatives from the American College of Cardiology, the American Heart Association, and the American Academy of Family Physicians. It was published in the American Journal of Lifestyle Medicine.
Amy E. Rothberg, MD, PhD, Endocrine Society representative on the panel, said: "I think many patients would do the challenging work of making lifestyle modifications if it meant remission of [type 2 diabetes] and sparing them the burden and cost of medications or surgery."
"By changing the course of the disease, ie, if in remission, they are unlikely to get the complications related to [type 2 diabetes]," Rothberg, professor of nutritional sciences, School of Public Health, University of Michigan, Ann Arbor, told Medscape Medical News in an email.
Also invited to comment, Yehuda Handelsman, MD, who coauthored a 2020 type 2 diabetes management algorithm by AACE and the American College of Endocrinology, and was not involved with the current initiative, agrees with the importance of lifestyle in the management of type 2 diabetes but takes issue with a few points.
Consensus on 69 Statements
The panel used a modified Delphi process to develop the consensus statement. They identified 49 articles from the literature regarding dietary interventions in adults with type 2 diabetes. They reached consensus on 69 statements that cover seven topics: definitions and basic concepts; diet and remission of type 2 diabetes; dietary specifics and types of diets; adjuvant and alternative interventions; support, monitoring, and adherence to therapy; weight loss; and payment and policy.
Rothberg identified six key areas:
- Definition of remission: Type 2 diabetes remission is defined as A1c < 6.5% for at least 3 months with no surgery, devices, or active pharmacologic therapy for lowering blood glucose, consistent with the diabetes remission timeline published in 2021 by the American Diabetes Association. Remission does not exclude the possibility of recurrence. Remission is a realistic and achievable goal for some adults with type 2 diabetes.
- High-intensity diet, short duration of diabetes: Patients are more likely to attain remission with a high-intensity diet (eg, high level of restrictions plus frequent patient contact or counseling) accompanied by physical activity and if the patient has had diabetes for 4 years or less. A high-fiber diet is essential.
- Fewer calories, focus on plant-based foods: Calorie reduction could be achieved by reducing food volume, portion sizes, or energy density, or by using liquid meal replacements, or by a combination of these approaches. It should mainly include whole, plant-based foods (whole grains, vegetables, legumes, fruits, nuts, and seeds) and avoid or minimize meat and other animal products, refined foods, ultra-processed foods, and foods with added fats.
- A very low energy diet as initial intervention is optional: There was consensus that this approach can achieve remission, but there was not agreement that low calorie content was essential for achieving remission, Rothberg noted.
- Beyond type 2 remission: Diet as a primary intervention can also lower the risk of cardiovascular disease and improve lipoprotein profile.
- Self-management, support, and monitoring: The group recognizes the importance of patient education and support. "This can play a vital role and should be part of any comprehensive lifestyle treatment," said Rothberg. The diet and lifestyle strategies should be acceptable to most patients, easy to adhere to, accommodate patient preferences and values, and be culturally sensitive.
Intensive Lifestyle Change Can Equate to Bariatric Surgery
Most clinicians and experts do not believe that diabetes can be reversed, as such, only controlled, Handelsman, medical director of the Metabolic Institute of America, Los Angeles, California, noted.
However, most patients do not adhere to diet modifications by 6 months and especially by 1 year, which has led to universal recommendations to add medication to lifestyle from inception, he continued.
Most clinicians have not been trained in lifestyle modalities. And many patients with type 2 diabetes are not adherent to medications, which "led to the relative success of bariatric surgery leading to remission (at least for 3-5 years)."
"Remission, which in broad terms implies the disappearance of signs and symptoms, should be a top priority for individuals with type 2 diabetes," the consensus statement authors write.
"While [bariatric surgery] can induce remission in 25% to 80% of targeted patients, it carries risk and its effectiveness wanes as subjects regain lost weight," and "more dramatic and intensive [lifestyle] change produces remission rates equivalent to bariatric surgery," they note.
Need for More Randomized Trials
Handelsman also stressed that remission may be temporary. "Three months or 6 months cannot be a measure of success. We must have at least 1 year," he added. "In fact, there are data to show that remission requires 3 years."
Nevertheless, the consensus statement does highlight the importance of lifestyle in remission of diabetes, he agreed.
The expert panel also noted that patients can benefit from a healthy lifestyle, even if they do not attain remission, Rothberg pointed out.
Moving forward, the statement concludes that "there is ... an ongoing need for additional randomized controlled trials to assess sustainable plant-based dietary interventions with whole or minimally processed foods, as a primary means of treating [type 2 diabetes] with the goal of remission, as well as factors that lead to successful patient adherence and effective dissemination and implementation of such interventions."
This study was supported by the Lisa Wendel Memorial Foundation. Rothberg has disclosed being the medical director of Rewind, a virtual platform created for weight control with the goal to "defeat" type 2 diabetes, and a consultant for a study for which Nestle provides product. Handelsman has disclosed receiving research grants and consultant and speaker honoraria from Amarin, Amgen, Applied Therapeutic, AstraZeneca, Bayer, Boehringer Ingelheim, Corcept, Esperion, Ionis, Mankind, Merck, Merck-Pfizer, Novartis, Novo Nordisk, Regor, Sanofi, and Vertis.
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