For many decades, study after study have consistently shown that rapid weight loss in patients with type 2 diabetes can massively improve long-term glycaemic control and insulin sensitivity. Whether it can be considered remission or cure, weight loss produces a very high percentage of symptom-free individuals.
For a newly diagnosed type 2 diabetic patient, the standard medical procedure is all too often the immediate prescription of drugs. These drugs frequently lead to an increase in body weight with subsequent worsening of the diabetes.
Type 2 diabetes is not trivial; a high percentage of patients will suffer cardiovascular problems and early death. The benefits of weight loss to diabetic patients have been published by many different groups with diverse agendas: groups advocating weight-loss drugs, groups promoting bariatric surgery, and by very low calorie diet programmes worldwide. Whatever the route to rapid and reliable weight loss, it is imperative that weight management be included in treatment protocols for type 2 diabetes.
Very low calorie diets (VLCD) and bariatric surgery are demonstrably the most effective weight loss methods for diabetic patients. Ultimately, it is the loss of the excess weight that will lead to the long term improvement in insulin sensitivity and blood sugar control. However, the rapid weight loss by VLCD or surgery share a common feature which augments the benefit. In both cases, there is an immediate substantial reduction in the oral consumption of either carbohydrates or substances that can be readily converted to carbohydrates. As a result, the metabolic response is rapid. Circulating glucose and mobilised glycogen stores are rapidly consumed and are generally depleted within about 3-4 days, resulting in normal glucose levels. This reduction is so dramatic that it is crucial to stop the administration of oral hypoglycaemic agents prior to the start of a VLCD programme.
Weight loss and diabetes control
Weight loss, regardless of how it is achieved, will usually put diabetes into long term remission although rapid weight loss confers better long term glycaemic control than the same loss achieved more slowly. The combined effect of the rapid initial normalisation of blood sugars and the subsequent loss of excess body weight yields impressive clinical results. Blood sugar levels and HbA1c levels become normal and there is improvement in insulin sensitivity. With reasonable long term weight management these parameters remain normal.
The current situation regarding the use of drugs for weight loss is not very encouraging. In recent years, rimonabant, sibutramine, fenfl uramine and dexfenfl uramine have all been withdrawn from the market. As a result, since the value of orlistat, the one drug remaining available, is quite limited, there are no truly effective drugs available to achieve the necessary weight losses. Whether this situation will continue is unknown, despite a massive pharmaceutical search for an effective and safe drug. Bariatric surgery is usually effective, but even if the problematic morbidity and mortality associated with surgery could be reduced, the substantial costs and vastly inadequate number of surgical opportunities (compared to the millions of people in need of weight loss in the UK alone) conspire against a total reliance on surgical solutions.
Very low calorie diets remain the safest, most practical and demonstrably effective means of weight management, yet they are repeatedly rejected as ‘extreme diets’ or ‘fads’. Ridiculous and unfounded suggestions of metabolic harm are attributed to their use. Thirty years of scientific study resulting in an overwhelming body of literature and massive worldwide use has consistently validated the safety and utility of a properly formulated VLCD. There is no loss of muscle – either heart or skeletal – and there are no real, negative, long term outcomes from the use of these nutrient complete formula foods. These formulations are based upon substantial nutritional science. In fact, the nutritional quality of proper formulations is far superior to the nutrition provided by most standard meals. And there is no other treatment method that can deal with the problem of food abuse.
Tackling food abuse
While not every person who consumes beer or wine becomes an alcoholic, clearly some do; alcohol addiction is correctly recognised as a serious problem. In a similar way, many people are able to eat and at times overeat without becoming overweight or obese. Like alcoholism, food abuse (by a significant percentage of the overweight population) is now recognised as sharing the biological characteristics of other addictions. We have to assume that it is as difficult for many obese people to reduce their dietary excesses as it is for alcoholics to stop drinking.
No one would expect an alcoholic to simply cut down to a unit or two of alcohol a day. To deal with addictive behaviour it is generally understood that the individual must first discontinue the substance of abuse. This means that for a large segment of the overweight and obese population it is futile to expect them to sustain a dietary regime that essentially amounts to a food-addict’s equivalent of one or two alcohol units a day. They need to stop the substance of abuse – completely.
The dilemma, however, is that while abstinence from alcohol or tobacco or drugs is possible, this is not true of food. The total absence of food necessarily leads to nutritional deficiencies that will of course become fatal in a very short time. Providing the essential nutrients however, in a properly formulated enteral food, solves this problem. It permits the total cessation of traditional foods while providing essential nutrition with absolutely minimal calories and the result is weight loss and – perhaps more importantly – a disruption of the addictive process. While occasionally there still can be recidivism, an effective follow on maintenance programme keeps this to a minimum.
Although diabetes is perhaps the most closely linked serious health consequence from excess weight, there are many others. VLCDs are effective for weight loss. Even though high blood sugar levels, evidence of diabetes, disappear within a week, weight loss continues. Standard weight loss methods commonly falter after achieving the relatively easy loss of glycogen and its associated water weight. Fat weight loss requires considerably greater calorie deficits and in many cases is not achieved. Even if there is some subsequent weight regain after VLCD, the diabetes usually remains in remission and substantial fat loss is generally sustained.
Many of the pharmacists running the VLCD programmes have kept their patient records on tracker software and their audits prove efficacy. Ignoring the weight loss option, which is arguably the most logical initial treatment option for weight related illnesses, will cost the health service considerable money without as much benefit. Recent reports estimate that the NHS is spending about £9 Billion a year on diabetes alone.
The RPSGB amongst other pharmacy bodies are pressing for evidence of efficacy of pharmacy services. Howard Foundation Research have responded to this by developing the Lipotrim Patient Tracker software which has enabled collation of weight loss and maintenance evidence from detailed audits of individual pharmacies, surgeries, or groups with thousands of patients.
By S.N Kreitzman, V. Beeson and S.A. Kreitzman of Howard Foundation Research Ltd