Nutritional basis of type 2 diabetes remissionBMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1449 (Published 07 July 2021) Cite this as: BMJ 2021;374:n1449
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Per my paper in progress, Unified Physiology of Obesity and the Metabolic Syndrome, I submit this simplified counter-analysis:
Cutting calories usually entails cutting carbs.
Human evolution expects almost all glucose to be released little by little from the liver, just as needed. So blood glucose never rises very much or very fast and your beta cells are never overtaxed. But, dietary carbs make blood glucose rise massively and quickly, requiring massive and quick insulin secretion. And overstuffed glucose storage in the liver and muscles further aggravates this by requiring even more insulin to force in even more glucose. This threatens the very survival of our beta cells.
When something goes wrong with a cell, which happens all the time, apoptosis destroys that cell, ensuring that our bodies are composed of properly functioning cells. The main trigger of apoptosis is failure of a cell to perform its function. But requiring beta cells to massively and quickly secrete insulin tempts them into failure and triggers apoptosis. When most of your beta cells have suffered apoptosis, you have diabetes; that is diabetes.
If, eight hours after eating, your pancreas is unable to supply enough insulin to push your fasting blood glucose below 90, you must have few surviving beta cells - and each of those few survivors now is asked to secrete even more insulin. Thus an avalanche effect, fewer beta cells, more asked from each cell, faster apoptosis - worsening diabetes. This is why diabetes is a progressive disease.
Early in diabetes you face a choice. You now have three classes of beta cells. Some are working, supplying insulin to control your blood glucose. Others are not working, but can be rescued by no longer exceeding their design limits.. The rest are dead, irredeemably.
You can continue to overtax and kill your remaining beta cells by eating carbs. Or, you can stop eating carbs and hope that your remaining beta cells, relieved of unnatural stress, can survive - keeping your blood glucose within healthy bounds.
Competing interests: No competing interests
Acceptability of low energy diet - reference query
A reference provided in the article (23) claimed that acceptability of low energy diets was up to 6 months. I wonder how that could be possible, as the reference article refers to interviews conducted after 8-week diet? Participants recorded hunger, not surprising for a calorie restricted diet. I think this reference is inappropriate to claim a recorded 6-month acceptance of a starvation diet.
Low carbohydrate diets have reported up to 24 months' follow up with high adherence and, obviously, acceptability. (1) This is not surprising for an ad libitum diet. (2)
1- Athinarayanan SJ, Adams RN, Hallberg SJ, Mckenzie AL, Bhanpuri NH, Campbell WW, et al. . Long-term effects of a novel continuous remote care intervention including nutritional ketosis for the management of type 2 diabetes: a 2-year non-randomized clinical trial. Front Endocrinol. (2018) 10:348.
2- Wheatley SD, Deakin TA, Arjomandkhah NC, Hollinrake PB, Reeves TE. Low Carbohydrate Dietary Approaches for People With Type 2 Diabetes—A Narrative Review. Frontiers in nutrition. 2021:415.
citing - "available evidence does not support the assertion that LCDs are more difficult to follow than other dietary approaches. In the Virta Health trial, for example, where participants were highly motivated and self-selected the diet, adherence was 83% at 1 year (130) and 75% at 2 years (38). "
Competing interests: No competing interests