Lifestyle modifications remain the mainstay of therapy for patients with type 2 diabetes, but are rarely successful in daily practice. At the same time, highly effective medical therapy options are available. Should health professionals just stop advising people to eat less and be more active and instead prescribe one of the increasingly powerful drugs? Expert opinion is widely divided on this issue, as the Diabetes Congress in Berlin, Germany demonstrated.
Diets Promote Remission
Stephan Martin, MD, of the West German Diabetes and Health Center in Düsseldorf, Germany, is convinced that lifestyle modification is indispensable for the treatment of type 2 diabetes. “It is the opportunity to overcome type 2 diabetes simply through a change in your daily habits.”
Low-calorie meal replacements have been shown to be particularly effective. The effect of these liquid meals was investigated in the Diabetes Remission Trial (DiRECT) in a general population of 306 overweight and obese diabetic patients. Of these patients, 24% achieved a weight loss of more than 15 kg, and for 46%, the patients’ diabetes went into clinical remission. Clinical remission was defined as an A1c value less than 6.5% after 12 months without taking antidiabetic medication.
“On average, patients had type 2 diabetes for 4 years and had been taking sometimes two or three medications before the study. All of these medications could be stopped because the HbA1c value was below 6.5%,” he said. Martin.
New diagnoses, good prognosis
Of the patients who lost at least 15 kg in the study, 86% achieved remission. “This means that if someone is newly diagnosed with diabetes, they probably have almost a 100% chance of going into remission, and also of clear weight loss,” Martin said.
Among patients with type 2 diabetes, postprandial insulin production is reduced. But the DiRECT study suggested that if patients lose weight, normal postprandial insulin secretion can be achieved within 8 weeks.
wake up beta cells
“For type 2 diabetes, this depends on whether the beta cells are broken or if they’re in hibernation,” Martin said. During “hibernation,” beta cells shift because the liver has reached its fat-storage capacity and fat is now deposited in the pancreas, the DiRECT study group hypothesized.
“A radical change in diet causes the liver to lose that fat, even though nothing else happens to subcutaneous adipose tissue, for example,” Martin explained. The task force assumes that if fat is lost from the liver, fat from the pancreas is also lost.
Individual fat threshold
“For a long time, it was thought that to fight type 2 diabetes you had to lose a lot of weight,” Martin said. “But that’s clearly not the case. Even massively overweight patients just need to drop below their individual fat threshold.”
With 306 participants, the DiRECT study was quite small. However, other studies have confirmed the results. In the DIADEM-1 study, carried out by Katar with 147 patients, 61% achieved clinical remission. A comparable study in Canada, conducted in pharmacies, used a low-calorie meal replacement with reduced carbohydrate content. With this diet, 35% of all participants were able to discontinue their diabetes medication after 1 year.
Patients become treatable again
The TeLiPro study, which took place in Germany, included telemedical training in addition to a low-calorie, reduced-carbohydrate liquid diet. The 200 patients in the study had had type 2 diabetes for an average of 11 years. The intervention was associated with positive effects on A1c, weight, blood pressure, body mass index, hunger, and insulin requirement. “Patients become treatable again, even if they have had diabetes for many years,” Martin said.
There is no truly good predictor of which patients will respond to an extremely low-calorie liquid diet and achieve remission. “This means we have to offer it to patients to see if it works, and most manage it,” Martin said. “These patients still have type 2 diabetes; they are not cured and they still have to move on. They are not taken out of the disease management program.”
Type 2 diabetes doesn’t have to be a one-way street, Martin said. “There is a way to get healthy again. But for this to happen, we also have to demand something from our patients.” Low-calorie meal replacement is suitable for this, as it can lead to rapid and visible success, which in turn strengthens the motivation of patients.
cardiovascular-renal disease
Stephan Jacob, MD, a diabetologist in the Prevention and Therapy Practice at the Cardiometabolic Institute in Villingen-Schwellingen, has a much more pessimistic outlook on the potential of lifestyle intervention. “Type 2 diabetes is more than hyperglycemia. It is cardiovascular and kidney disease that begins long before the first diagnosis of abnormally high blood sugar.”
Studies show that atherosclerotic changes develop mainly at a time when the blood sugar level is not abnormally high. “Forty percent of patients have already developed some microvascular changes at the time of diagnosis,” said Jacob. “And more than 80% of type 2 diabetics have metabolic syndrome.”
Prevention of cardiovascular events
People with type 2 diabetes are “absolute risk patients who don’t live longer because of a blood sugar correction,” Jacob said. Improving a factor such as blood pressure or blood sugar is only beneficial if cardiovascular and renal events are prevented as a result and survival is prolonged.
The evidence that lifestyle modification can do this is extremely limited. In the Diabetes Prevention Program (DPP) study, beneficial effects were seen on A1c, blood pressure, and weight after 18 years, but no effects on cardiovascular effects or mortality.
Thirty-year data from the Da Qing Diabetes Prevention Outcomes Study show a reduction in major cardiovascular events and a reduction in mortality in the lifestyle group. “But first you have to live that long to get the benefit,” Jacob commented.
Even the study with the highest expectations, the LookAHEAD study, failed to demonstrate any improvement in major cardiovascular endpoints after intensive lifestyle intervention.
Clear successes of pharmacotherapy
In stark contrast to this are the success stories of pharmacotherapy. “For patients with type 2 diabetes, SGLT2 inhibitors and GLP-1 receptor agonists have been successful in preventing serious cardiovascular events, even in primary prevention,” Jacob said.
“In light of the clear data for medical intervention, we should not deny our patients evidence-based therapy.” Gone are the days when patients were first advised to go on a diet.
However, it may not be possible to get this kind of clear data for lifestyle interventions, Martin explained. “For many, the required evidence simply doesn’t exist, that’s true. But we won’t get this evidence either.” And he added: “Evidence-based medicine criteria used in drug studies cannot be transferred to lifestyle studies.”
Analysis of “soft parameters”
Martin also questioned why “only prevention of heart attack and prolongation of survival” matters. He recommended that much more importance be attached to “soft parameters.” “If I help a patient lose weight through a lifestyle intervention, I give them the chance to move more again, maybe avoid knee surgery. That’s much more important to the patient than living 2 years.” more after 30 years.”
This article was translated from the German edition of Medscape.
Source: www.medscape.com