Don’t count on starving diabetes away

Hey there, time traveller!
This article was published 27/12/2023 (981 days ago), so information in it may no longer be current.

The “remission diet” for Type 2 diabetes remains a controversial topic that’s worth revisiting and reflecting upon.

The 2022 update to the Diabetes Canada clinical practice guidelines showcased an article on remission of Type 2 diabetes in which Type 2 diabetes can essentially be treated following the remission diet, a diet that can only be defined as another fad and throwback to the SlimFast era. The article was published without any long-term data to support its success and undermines the established role of medication in managing diabetes. It devalues a holistic approach to nutrition in weight and diabetes management, emphasizes a quick fix to a complex condition with sociopolitical roots, and may in fact unintentionally cause disordered eating behaviours in an already at-risk population.

About 90-95 per cent of those living with diabetes have Type 2 diabetes, a chronic condition in which the body’s pancreas cannot produce enough insulin or utilize insulin effectively to keep blood sugars in target. As of this year, this equals a conservative estimate of about 15 per cent of the Manitoba population, a figure that only continues to grow. Thus, there is an urgent need for innovation with respect to managing Type 2 diabetes through a population health approach, not another fad diet.

In Canada, Type 2 diabetes remission is defined as achieving a Hemoglobin A1c (average blood sugar over the last three months) of less than six per cent without any blood sugar lowering medications for a minimum of three months. Those more likely to find success in remission are folks who have been living with Type 2 diabetes for less than six years, who are overweight or obese, whose blood sugars “are not that elevated” and who are not on insulin. For this narrowed pool of Type 2 diabetes candidates, remission may be achieved through a three-phase low-calorie diet approach under the guidance of a “specialized clinical health-care team.”

In Phase 1 (total dietary replacement), patients are expected to consume a limited 800-900 calories per day by drinking only liquid meal replacements for three to five months with the aim of losing 10 to 15 kilograms (22 to 33 pounds). This is a far cry from the approximate 2,000 calories per day recommended for the average Canadian adult.

After three to five months, Phase 2 (food re-introduction) continues with the strict 800-900 calorie per day goal, provided as meal replacements and “one complete real-food meal,” followed by Phase 3 (Weight Maintenance and Relapse Management) where patients are weighed weekly and if there is weight regain of more than 2kg (4.4lbs), the meal replacements are brought back to “get back on track.” The remission recommendations are based on a handful of behavioural interventions, most notably the DiRECT trial, in which 68 participants remained in remission after one year and only 11 after five years. While the authors tout this as a success, in reality it showcases the difficulty of maintaining remission, and the high plausibility of relapse.

We’d be hard-pressed to believe that the remission diet doesn’t raise some red flags even for the general population. Not only are Health Canada’s eating guidelines non-existent within the recommendations, but the diet itself contradicts Health Canada’s guidelines for fad diets and healthy eating. Health Canada warns Canadians how to spot a fad diet. Is the diet low in calories? Yes. Will it be hard to fit into your lifestyle? Likely. Could you follow it long term? No. Does it promise fast weight loss? Yes. Do you need to buy special foods or supplements? Sure do. Do you have to cut out foods you love forever? Most likely.

And it’s not without additional costs.

Post pandemic consumers have unequivocally felt the pressure of rising food costs and inflation. Food insecurity is a growing concern for many families with rates near 20 per cent in Manitoba. Feeding a family of four costs approximately $900 a month. Now add on the extra costs for these liquid meal supplements ($240-$785/month depending on the recommended supplement purchased) for three to five months. For food-insecure households, this just isn’t feasible.

Food preoccupation is a risk factor for developing disordered eating patterns and potentially full-blown eating disorders. The Type 2 diabetes remission guidelines insist all patients be screened for mental health and eating disorders before starting; however, there is no mention of ongoing monitoring of disordered eating during the remission journey. Therefore, long-term outcomes have yet to be determined.

What is well established is that people with an increased body mass index (BMI) are at greater risk for developing mental health conditions such as major depressive disorder and eating disorders/disordered eating. According to Diabetes Canada’s 2023 update on mental health and diabetes, up to 20 per cent of those living with Type 2 diabetes have an underlying eating disorder, a value that is up to 3.5 times higher than the general population. This extremely restrictive, non-individualized approach will only further perpetuate weight-based stigma within the health-care setting and increase mental health concerns for this population.

Eighty per cent of people with Type 2 diabetes die of heart disease, and Type 2 diabetes is a leading contributor to kidney failure, requiring dialysis. The remission guidelines state all medications indicated for Type 2 diabetes must be stopped, yet there is well established evidence of the heart, kidney, and weight loss benefits of many diabetes medications.

Among health-care team members, only physicians can prescribe and de-prescribe medications. The authors state that the outcome of the remission diet is based on one’s access to a specialized clinical team (endocrinologist, family doctor, dietitian, pharmacist, nurse, physical activity trainer, and “social support” system). The grim reality is that one in six Canadians don’t even have a family doctor, let alone access to a specialized team. For the majority of with Type 2 diabetes, this level of care just isn’t feasible. Geographically, we also must consider that many northern communities are fly-in only, with at best a nursing station, never mind specialized team.

Thus, as our new provincial government works to fix our health-care crisis, we advocate for actions that move away from reactive treatments that target individual behaviours and support people living with chronic diseases using a population-based approach. First and foremost, this must begin by improving widespread access for all to basic health care. Second, we need to examine structural determinants that give rise to population health outcomes. The remission model discriminates against the majority of individuals living with Type 2 diabetes and gives little to no weight to health equity and socioeconomic and structural barriers driving chronic diseases such as Type 2 diabetes.

Rather, it focuses on the elite few who can access and afford this way of life.

So, for now, our question remains: who is the remission diet for, and who is benefiting? At best, we simply don’t know. But the answer cannot be an acute treatment for a chronic disease.

Nikki Webb, Tiffany Augustine, and Ermina Vasilescu are all practising Registered Dietitians and Certified Diabetes Educators within the Winnipeg Regional Health Authority.