Can we reverse diabetes with diet?

Recently, a 40-y-old man asked me, “doctor, can I reverse (permanently eliminate/cure) diabetes?” I stated, “reversal is a definitive word, let us just stick to remission (normalisation of blood glucose without use of medicines with no guarantee of permanent reversal)”. I further told him “I will now explain whether or not it can be applied to you.”
A decade earlier, reversal of diabetes was considered the ‘holy grail’ of medicine. Physicians dreamt about it but could not achieve it. Behind this failure was inadequate knowledge about physiology of diabetes. As research progressed, we started getting more insights about the role being played the liver in generating and sustaining diabetes. When a person eats a lot of saturated fats and calories, liver fat cells rapidly increase in numbers, and when the liver is full of fat, it starts to leak creamy substances (known as free fatty acids) in the blood. Such cream has a great tendency to get deposited in muscle, pancreas, and heart arteries as well. Deposition in pancreas impairs functioning of vital insulin producing cells, thus critically decreasing in insulin levels in the body. The blood sugar rises and does not go down easily.
Having known this cascade of events now, the next big question was how to remove this creamy layer from various organs? Simple solution is take away the hand that feeds the cream! A nice experiment in the UK made it look all so easy and started the ball rolling for ‘reversal of diabetes’. Ten years ago, 12 patients with diabetes were given very low calorie liquid meals (less than half of the calories that we require daily) for eight weeks under controlled conditions. Investigators were immensely surprised when blood sugar of all patients normalised within a couple of days. Half of the fat and cream from liver and pancreas rapidly disappeared in 4 to 6 weeks. Patients remained without medications for a short period of time.
An important question was if such remarkable results could be duplicated in free living people over a long period of time. Another study from the UK, carried out in patients living in community, employed the same principles of diet over one year. First participants were given severely restricted calories for 12-20weeks, followed food reintroduction, and then long-term weight loss maintenance. An interesting observation was that those who lost 10-15 kg weight normalised their blood glucose. Further, in some people this remission disappeared in about a year, and they were back to diabetic state. Since then, other experiments (and massive weight loss after bariatric surgery) have supported these observations.
Based on these studies elsewhere, many commercial clinics in India are offering “reversal of diabetes” to all patients with diabetes. This is an incorrect practice. An apt person for remission of diabetes diet and lifestyle is the one who has been recently diagnosed, is clearly obese and willing for difficult and rigorous diet and lifestyle practices over long periods. Those with longstanding diabetes, with complications of diabetes, type 1 diabetes and pregnant women should not attempt such modalities.
Overall, about 10-20% of patients of diabetes may be good candidates for remission.
What are the modalities? Diet alone could be used as has been stated. It could be a very low calorie diet, or low calorie, low carbohydrates, high fat, or high protein diets. The primary aim is to lose a considerable amount of weight. Bariatric surgery is a remarkable modality because if patients are chosen carefully, there is 80-100% changes of remission after major weight loss. Currently, with incredible progress in antidiabetic medications, we have drugs and non-insulin injections which can produce substantial weight loss and remove fat/cream from organs, thus demonstrating potential for remission of diabetes.
Science has given us this great research, which must be applied judiciously; counselling to my patient continues. After evaluating his clinical profile, I considered him to be a correct candidate for attempting remission of diabetes. Then I tell him; “in this remission protocol the most crucial fact has not yet been written that your strong will to achieve, and then maintain this goal is the most important driver”. That, unfortunately, is not the case with many individuals.