Case Study – Remission of Diabetes

Interesting study of a woman who went into remission of her Diabetes (Case Study: Remission of Type 2 Diabetes After Outpatient Basal Insulin Therapy).

However, a few studies have demonstrated that drug-free glycemic control can be achieved in type 2 diabetes for 12 months on average after a 2-week continuous insulin infusion.

They felt that her instance was a one-off.

Here, we describe an unusual case of a 26-month drug holiday induced with outpatient basal insulin in a patient newly diagnosed with type 2 diabetes.

She was in a bad way when diagnosed. I have never seen a A1C value this high:

A 69-year-old white woman (weight 72.7 kg, height 59 inches, BMI 32.3 kg/m2) was diagnosed with type 2 diabetes in June 2011. She presented with an A1C of 17.6% (target <7%) and a fasting blood glucose (FBG) of 452 mg/dL (target 70–130 mg/dL).

What comes next is interesting.

She reported recently initiating a cinnamon supplement and switching her beverage intake from sugar-sweetened products to water and diet soda. Although the majority of her fasting SMBG values were controlled (80–110 mg/dL), she had experienced six hypoglycemic episodes (FBG 13–64 mg/dL). All values were objectively confirmed in the patient’s glucose meter, and the meter was replaced in case of device error.

So she added cinnamon and dropped sugar sodas and got fine. The doctors discounted most of that as you read on.

Another data point was:

During the drug-free period of March 2012 to May 2014, the patient maintained her lack of sugar-sweetened beverage consumption. However, she reported having difficulties purchasing healthy food options because of financial constraints.

The conclusion was entertaining:

The purposeful remission of diabetes is not widely attempted or generally considered possible.


Tighter Blood Sugar Control Is Harmful

A study by Mayo Clinic doctors on Blood Glucose control (Glycemic Control for Patients With Type 2 Diabetes Mellitus: Our Evolving Faith in the Face of Evidence). The study:

We sought to determine the concordance between the accumulating evidence about the impact of tight versus less tight glycemic control in patients with type 2 diabetes mellitus since the publication of UKPDS (UK Prospective Diabetes Study) in 1998 until 2015 with the views about that evidence published in journal articles and practice guidelines.

They noted the fact that:

There is also no significant effect [of tight control of glucose] on all-cause mortality, cardiovascular mortality, or stroke; however, there is a consistent 15% relative-risk reduction of nonfatal myocardial infarction.

They concluded:

Discordance exists between the research evidence and academic and clinical policy statements about the value of tight glycemic control to reduce micro- and macrovascular complications. This discordance may distort priorities in the research and practice agendas designed to improve the lives of patients with type 2 diabetes mellitus.

Metformin and the Fatty Liver

A study (Metformin in patients with non-alcoholic fatty liver disease: A randomized, controlled trial).

Forty-eight patients with biopsy-proven non-alcoholic fatty liver disease (NAFLD) were randomized to treatment with metformin (n=24) or placebo (n=24) for 6 months.

The study concluded that:

Treatment with metformin for 6 months was no better than placebo in terms of improvement in liver histology in patients with NAFLD.


Another new hero?

Dr Gerard Reaven of Stanford Medicine, may be my new hero. Dr Reaven:

Jerry is credited with developing the insulin suppression test, the first quantitative method to measure insulin-mediated glucose uptake in humans. Using this technique, he established the importance of insulin resistance in human disease, and importantly, in type 2 diabetes.


Dr. Reaven challenged the then prevailing theory that defective insulin secretion adequately explained the hyperglycemia of T2DM, postulating that insulin resistance might be as, or more, important.

He is a prolific writer of studies. Here’s just one (All obese individuals are not created equal: insulin resistance is the major determinant of cardiovascular disease in overweight/obese individuals) of his papers.

Bucking the Trend

There is one study that looks bad for LCHF. It looks bad mostly based on the name of the study rather than the science (High-Fat, Low-Carbohydrate Diet and the Etiology of Non-Insulin-dependent Diabetes Mellitus: The San Luis Valley Diabetes Study).

The study (1990) suggests that High Fat diets are associated with onset of non-insulin dependent diabetes mellitus.

The findings support the hypothesis that high-fat, low-carbohydrate diets are associated with the onset of non-insulin-dependent diabetes mellitus in humans.

The problem is that, at least in the abstract, there’s no evidence that the people were on anything at all related to a Low Carbohydrate diet. That was inferred based on the High Fat. But you don’t need to go any farther than your local McD’s to know that french fries are both high in fat and high in carbs.


Fat Adapted Athletes

Here’s a great study on fat adapted athletes (Enhanced endurance in trained cyclists during moderate intensity exercise following 2 weeks adaptation to a high fat diet).

The study looked at five cyclists and compared them on a High Carb vs a High Fat diet.

Despite a lower muscle glycogen content at the onset of MIE [32 (SEM 7) vs 73 (SEM 6) mmol · kg −1 wet mass, HIGH-FAT vs HIGH-CHO, P < 0.01], exercise time to exhaustion during subsequent MIE was significantly longer after the HIGH-FAT diet [79.7 (SEM 7.6) vs 42.5 (SEM 6.8) min, HIGH-FAT vs HIGH-CHO, P<0.01]

Looks like they have an almost 2x advantage when it comes to endurance.

How long did it take to convert these athletes from Carb Adapted to Fat Adapted?

These results would suggest that 2 weeks of adaptation to a high-fat diet would result in an enhanced resistance to fatigue and a significant sparing of endogenous carbohydrate during low to moderate intensity exercise in a relatively glycogen-depleted state and unimpaired performance during high intensity exercise.

Only two weeks!

One Week Off Insulin

I’ve been off Insulin for a full week now.

So why am I still alive? After all, I needed 100 units a day on the average just one month ago. But here I am. Still Alive!

So did I just decide to ignore my Blood Glucose levels and am I on the edge of dying? Hardly. I’m still checking multiple times a day – mostly now in disbelief at how well my blood sugar is being regulated by my body. My high today was 124 and my low so far today is 109. I never got numbers like that before day after day on Insulin.

For dinner last night I took the kids out to Five Guys Burgers and Fries. I skipped the fries. I ate a bunch of peanuts and more importantly had my burger “bunless”. The choice to replace the bun with lettuce was a good one since it took away about 40 grams of carbs and left about 1 gram. The fat ratio was good and the jalapenos, etc didn’t add much to the carb count but they did add to the flavor.

All of that made my Blood Sugar at 103 around bedtime.

Addendum : Still taking Metformin. Not out of the T2D woods yet.