Type 2 Diabetes

Lifestyle changes are the most important treatments for type 2. Many patients can decrease or even eliminate medications within days to weeks.

In the US alone, over 37 million people are living with type 2 diabetes, that's more than 11% of the US adult population living with a preventable chronic disease (CDC, 2022). Globally, type 2 diabetes cases are increasing at an alarming rate, figures already surpassed 245 million in 2017 and are expected to reach 629 million people in 2045 1

Prediabetes is the state where your blood glucose levels are elevated, but they are not (yet) at the threshold to clinically be considered type 2 diabetes. The statistics for prediabetes are even more shocking, with 96 million people ages 18 or older having prediabetes - 38% of the adult US population. Over 50% of US adults aged 65 have prediabetes (CDC, 2022). Some of the complications associated with type 2 diabetes, such as organ damage, can actually start in prediabetes, so it’s a state to be avoided at all costs 2

There’s a relatively simple solution to this spiraling problem. Most of these cases can be prevented, and reversed, with a whole-food plant-based lifestyle. 

What causes type 2 diabetes? 

Type 2 diabetes is defined by insulin resistance. When we eat food, we break down carbohydrates into glucose, which is needed by our cells, such as our muscle cells, for fuel. Glucose isn’t able to let itself into our cells, it first requires an invitation. This invitation is insulin, which is secreted by pancreatic beta-cells. Insulin molecules bind to their receptors on the surfaces of cells, which allows glucose to enter the cells. This takes glucose out of the bloodstream and keeps blood glucose levels within their normal range (normoglycemia). 

When we eat too many calories and become overweight, the body starts to store the excess fat  in tissues where it shouldn’t really be. This includes the liver, pancreas, and muscle tissue. This stops cells being able to function properly, interfering with insulin’s ability to allow glucose out of the bloodstream and into our cells. Our stuffed-full fat cells start to secrete more hormones, meanwhile oxidative stress and inflammation is increasing 1. Insulin receptors and pancreatic-beta cells become damaged, so less insulin can bind to its receptors, meaning glucose receives fewer invitations into the cells where it is required. The liver, muscle, and fat cells no longer respond well to insulin. This is insulin resistance. More insulin is then produced to try and get glucose into the cells where it is needed. However, the body cannot continue to produce high levels of insulin, so this eventually results in insulin deficiency. Gradually, less glucose is able to get into the cells, so more hangs around in the blood, which leads to diabetes 3. Genetic factors can also increase an individual’s risk of developing Type 2 diabetes 4

Symptoms

The elevated levels of glucose in the blood causes a range of long term health-problems for individuals with type 2 diabetes via damage to blood vessels and organs. Diabetes is a leading cause of vision loss (diabetic retinopathy), renal failure, nonalcoholic fatty liver disease, stroke, and leg amputation 5. Diabetes considerably increases the risk of cardiovascular disease 6. Diabetes does not just impact physical health; it is also considered one of the most psychologically demanding chronic conditions and can leave patients with poor psychological well-being. Depression is three times as common in individuals with diabetes 7

Diagnosis

Hemoglobin is a protein within our red blood cells. When it joins with glucose in the bloodstream, it becomes glycated hemoglobin. 

Glycated hemoglobin is also known as HbA1c, or hemoglobin A1c. The HbA1c test measures the amount of glucose attached to hemoglobin and is often used to diagnose diabetes. It gives an idea of average blood glucose levels over several weeks, instead of just one moment in time. 

The results are as follows:

  • Normal - below 5.7% 
  • Prediabetes - 5.7% to 6.4%
  • Diabetes - 6.5% or higher on two separate tests

Treatment 

Current treatment options mostly focus on slowing the progression of the disease, not on remission. They focus on reducing blood glucose levels, which is a symptom of diabetes, rather than addressing the route cause, damage to insulin pathways and the pancreatic beta-cells. High blood glucose is a symptom of type 2 diabetes, insulin resistance and deficiency is the disease itself. 

Metformin is the first-line treatment for most type 2 diabetes patients, which lowers blood glucose by improving the way your body handles insulin. However, as with most medications, beta-cell function and mass still declines which means disease state is still worsening underneath the surface 3.  

Sulfonylureas, which were previously used as second-line agents, were found to increase the risk of heart attack, all cause mortality, and drop to severe low blood sugar levels when they were used for treatment alone 8. Some newer diabetes medications that increase spillage of glucose from the kidneys into the urine promote bacterial growth and urinary tract infections, which then results in further treatments 3

Bariatric surgery is recognized as an effective way of achieving type 2 diabetes remission, because it results in significant weight loss which subsequently reduces insulin resistance. However, surgery is accompanied by risks and the weight can be regained 9

Intensive lifestyle changes can produce the same rates of remission as bariatric surgery, and does not come with the same risks 10. Which would you rather go through to achieve the same outcome? 

There is a need for diet and lifestyle change to control the rising number of diabetes cases and bring people into remission by treating the root cause of this condition, instead of trying to control the symptoms.  

Role of western diet and lifestyle in causing diabetes 

Most cases of type 2 diabetes are preventable, yet over 37 million people are living with this chronic condition. 

How and why have we reached this point? 

Consider the average western diet. These diets contain high amounts of processed foods and animal products, saturated fat and sugar, and contain harmful substances that are known to contribute to insulin resistance. We are eating ourselves into this chronic disease state. Lifestyle behavior, mainly poor diet, is the most influential factor for the development of type 2 diabetes 7

Here are some of the ways meat and processed foods promote insulin resistance and diabetes 11 1:

  1. Haem iron - is a pro-oxidant meaning it contributes to the formation of reactive oxygen species (ROS) and increased oxidative stress. Oxidative stress can prevent insulin binding, reducing insulin sensitivity. ROS can also damage pancreatic beta-cells, the cells that produce insulin in the first place. If they are damaged and cannot secrete enough insulin, less glucose can be taken into the cells. 
  2. Nitrates and nitrates - these are found in processed meat and get converted to nitrosamines in the stomach. They contribute to DNA damage and oxidative stress. Nitrosamines are toxic to beta-cells in the pancreas thus impairing insulin response.
  3. Advanced glycation end-products (AGEs) - We produce some AGEs in the body daily, however dietary AGEs, along with those from tobacco, are the biggest source. They increase levels of oxidative stress in the body and are associated with insulin resistance. AGEs are produced during the cooking of red and processed meat. A study found that limiting dietary AGEs intake in patients with diabetes saw a decrease in oxidative stress and inflammation, and an improvement in insulin sensitivity. 
  4. Increased levels of branched chain amino acids in the blood - amino acids make up protein, those that are branched such as leucine, isoleucine and valine, have negative effects on insulin signaling and are associated with insulin resistance and raised blood sugar 
  5. Increased consumption of saturated fat - meat has a high energy density, excess fat is stored in muscle and liver cells, and increases oxidative stress, contributing to insulin resistance 
  6. Choline and carnitine - choline gets transformed by the intestinal microbiota to trimethylamine (TMA), which the microbiota then metabolize to TMAO. TMAO has been associated with a reduced tolerance to glucose and increased insulin resistance. 
  7. Excessive fructose - results in an increased production of triglycerides, contributing to obesity where excess fat is stored in muscle and liver cells, contributing to insulin resistance  
  8. Sodium - processed meat contains high levels of sodium, some studies have implicated sodium as a risk factor for developing type 2 diabetes 

Overall, these substances are associated with increased risk of diabetes by contributing to pathways including oxidative stress, inflammation, and weight gain. Obesity is a well-established cause of diabetes. However, vegetarians are still less likely to develop type 2 diabetes even after adjusting for BMI 1. This suggests that the reduction in diabetes risk associated with lower meat consumption does not just stem from a reduction in BMI, but also from reduced exposure to the compounds mentioned above. 

How can plant-based nutrition prevent type 2 diabetes?

  1. Evidence supporting plant-based diets for the prevention of type 2 diabetes 

Most cases of type 2 diabetes are preventable with a healthy diet and lifestyle. Many robust studies now show that a plant-based diet is the best way to achieve this, which has outperformed the standard diabetes diet in several head-to-head studies 12 13.

In the Adventist Health Study 2, vegans had a 49% risk reduction in diabetes compared to non-vegetarians. Ovo-lacto vegetarians had a 46% reduced risk, followed by pesco-vegetarians with a 30% reduced risk and even semi-vegetarians had a 24% reduced risk of type 2 diabetes. The authors concluded that increased adherence to a vegetarian diet increased protection against type 2 diabetes, even after taking BMI and lifestyle factors into account 14

In the EPIC-Oxford study people consuming low or meat-free diets had a lower risk of hospitalization or death from diabetes, partly attributable to lower BMI, than regular meat eaters. Those avoiding meat had around a 50% reduced risk of diabetes compared to regular meat eaters 1. That is a huge risk reduction to come from avoiding just one dietary component. Results from a large cohort also found that plant-based diets are associated with a significantly lower risk of developing type 2 diabetes. This was especially true for plant-based diets that emphasized the consumption of high-quality plant foods 15

One study measured adherence to a plant-based diet over time and the associated risk of diabetes. The researchers found that each additional 10% adherence to an overall and healthful plant-based diet index over 4 years was associated with a 7-9% lower risk of developing type 2 diabetes. Unhealthful plant based diets were not associated with the same reduction in disease risk, which emphasizes the importance of eating healthy plant-foods, and not just considering any vegan diet healthy enough to reduce the risk of disease. Decreased adherence to a plant-based diet had the opposite effect, and was associated with a 12-23% increased risk of diabetes 16

Plant-based diets were found to be the most effective diet in reducing energy intake, resulting in significant weight loss, compared to four other dietary patterns. This is a really important factor for reducing the risk of type 2 diabetes, as we discussed above obesity and excess calorie consumption is a huge risk factor for developing type 2 diabetes 17

  1. Mechanisms behind the role of plant-based diets for diabetes prevention 

The benefits of a plant-based diet are two-fold. Firstly, it leads to the elimination or reduction of harmful substances such as cholesterol and saturated fat, whilst simultaneously increasing the intake of important nutrients via an increased consumption of plant foods such as whole grains, fruits, vegetables, and legumes. The reduced risk of diabetes found in low-meat eating, vegetarian, and vegan populations across several studies is likely a combination of these effects, along with a reduced BMI 1

Plant foods contain high levels of fiber, antioxidants, phytochemicals, polyphenols, vitamins and minerals and are associated with lower fasting glucose levels, lower insulin concentrations, and increased insulin sensitivity 18 19

These components offer high protection against diabetes due to their anti-inflammatory and antioxidant effects. Vitamins C and E, for example, have been shown to increase beta-cell proliferation, inhibit AGE production, and reduce oxidative stress 5. Plant based foods are low-fat and high-fiber which is what makes them so effective. Fruit and vegetables have a high water content, a low energy density, and a low glycemic index 20

The American College of Lifestyle Medicine emphasizes the importance of fiber in plant-based diets for diabetes management. A high fiber diet has been shown to reduce blood glucose concentrations; fiber is only found in plant-foods 20. Fiber binds glucose and slows the absorption into the bloodstream, contributing to a lower rise in glucose after a meal 19 5. It also increases bile acids which contribute to improved glycemic control. Partly due to the fiber, plant-based diets also improve the gut microbiome. Fiber causes an increased production of short-chain fatty acids by bacterial fermentation which has beneficial effects on glucose and energy homeostasis 5

Plant protein, compared to animal protein, contains less saturated fat, cholesterol, and branched chain amino acids. It has been associated with improved glycaemic control and insulin sensitivity, and total and LDL cholesterol, compared to meat protein. Plant proteins have been inversely associated with diabetes risk 21 22

Plant-based diets for type 2 diabetes remission

Complete remission of type 2 diabetes is considered as the return to normal measures of glucose metabolism, with normal HbA1c less than 6.5% and normal fasting glucose 20.

The evidence for plant-based diets in type 2 diabetes reversal is now so strong that in 2022 the American College of Lifestyle Medicine (ACLM) published a Consensus Statement on the use of a whole-foods plant-based diet as the sole primary intervention for diabetes remission. This solidifies everything we have discussed and the utter importance of diet for achieving type 2 diabetes remission 20. Diet is most effective at achieving remission when emphasizing whole, plant-based foods with minimal consumption of meat and other animal products, and processed foods. This is endorsed by the American Association of Clinical Endocrinology (AACE), and supported by the Academy of Nutrition and Dietetics (AND). To reverse T2D or achieve remission the lifestyle modifications need to be more intense than those aimed at just preventing it, but there is so much evidence to show this is possible, especially with the right support.  

Weight loss with a plant-based diet has been demonstrated in an endless list of studies. Vegetarian diets are associated with reduced energy intake which improves glycaemic control. Part of the reason vegetarian diets reduce energy intake is because they reduce total fat intake. As we have discussed above, fat stored in the muscle (intramyocellular lipid accumulation) is strongly associated with insulin resistance. Vegetarian diets reduce the percentage of calorie intake from fat and likely reduce intramyocellular lipid accumulation which reduces insulin resistance 23. A plant-based diet is a sustainable way to lose weight and, most importantly, keep the weight off. Often where people struggle is when calorie counting and following restrictive diets. Plant-based diets allow you to eat a plethora of foods with no calorie counting, as plant foods are nutrient dense and low in calories, you can eat a larger volume of food and still lose weight . Studies that put individuals on a vegetarian diet without limiting portion sizes or calories have also demonstrated an association with lower body weight. Weight loss can be achieved without patients feeling like they are being deprived or constantly hungry, surely that’s the ideal scenario!

The ACLM states that diet can achieve T2Ds remission even for adults who have a normal BMI, demonstrating it is not only the weight loss aspect of a plant-based diet that contributes to T2D remission 20 . Plant-based dietary patterns have outperformed the conventional diabetes diet for improvement in diabetes markers in several studies. A low-fat vegan diet can improve glycemic control and reduce the need for medication and insulin without using portion control or calorie counting better than the conventional american diabetes diet 12. In another study, an amazing 43% of the vegetarian group reduced diabetes medication vs only 5% of the control group. Bear in mind this study used a vegetarian diet, and not a completely whole-food plant based approach, which is likely to have an even bigger effect 20. The vegetarian group saw a significantly larger increase in insulin sensitivity, and a significantly larger reduction in body weight and visceral and subcutaneous fat. They also saw an improvement in markers of oxidative stress. The combination of these improvements is what likely led to reduced insulin resistance. Exercise training further augmented improvements seen in the vegetarian group, which is an important part of lifestyle medicine 13

One study found that a low-fat vegan diet can restore beta cell function and insulin sensitivity in non-diabetic overweight adults 24. A meta-analysis found that glycated hemoglobin (HbA1c) significantly improved in those following a vegetarian and vegan diet pattern 23.

How can Mora help? 

The research shows that lifestyle medicine interventions, primarily the adoption of a plant-based diet, is enough, in many cases, to achieve diabetes remission and live healthy. By reducing your consumption of animal and processed foods, and eating more whole foods, your body can heal itself. We recognise that it can be hard to make these changes without adequate support and guidance. Lack of communication and support from healthcare providers has been identified as a key barrier to sticking to these changes 3. This is why it’s important to work with trained lifestyle medicine physicians to get the education, support, and guidelines required to succeed with these changes. Here at Mora our team of experienced physicians are here to help you do just that, succeed with these changes and improve your health for good. 

Type 2 diabetes remission is achievable without invasive surgeries or pills, with intensive lifestyle interventions. Once you unlock the power of a plant-based diet, you won’t look back. 

References

1. Papier, K. et al. Vegetarian diets and risk of hospitalisation or death with diabetes in British adults: results from the EPIC-Oxford study. Nutr. Diabetes 9, 7 (2019).

2. Baranowska-Jurkun, A., Matuszewski, W. & Bandurska-Stankiewicz, E. Chronic Microvascular Complications in Prediabetic States—An Overview. J. Clin. Med. 9, 3289 (2020).

3. Kelly, J., Karlsen, M. & Steinke, G. Type 2 Diabetes Remission and Lifestyle Medicine: A Position Statement From the American College of Lifestyle Medicine. Am. J. Lifestyle Med. 14, 406–419 (2020).

4. Ali, O. Genetics of type 2 diabetes. World J. Diabetes 4, 114 (2013).

5. Salas-Salvadó, J., Becerra-Tomás, N., Papandreou, C. & Bulló, M. Dietary Patterns Emphasizing the Consumption of Plant Foods in the Management of Type 2 Diabetes: A Narrative Review. Adv. Nutr. 10, S320–S331 (2019).

6. Martín-Timón, I. Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength? World J. Diabetes 5, 444 (2014).

7. Toumpanakis, A., Turnbull, T. & Alba-Barba, I. Effectiveness of plant-based diets in promoting well-being in the management of type 2 diabetes: a systematic review. BMJ Open Diabetes Res. Care 6, e000534 (2018).

8. Douros, A. et al. Sulfonylureas as second line drugs in type 2 diabetes and the risk of cardiovascular and hypoglycaemic events: population based cohort study. BMJ k2693 (2018) doi:10.1136/bmj.k2693.

9. Velapati, S. R. et al. Weight Regain After Bariatric Surgery: Prevalence, Etiology, and Treatment. Curr. Nutr. Rep. 7, 329–334 (2018).

10. Yoshino, M. et al. Effects of Diet versus Gastric Bypass on Metabolic Function in Diabetes. N. Engl. J. Med. 383, 721–732 (2020).

11. Barnard, N., Levin, S. & Trapp, C. Meat Consumption as a Risk Factor for Type 2 Diabetes. Nutrients 6, 897–910 (2014).

12. Barnard, N. D. et al. A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial. Am. J. Clin. Nutr. 89, 1588S-1596S (2009).

13. Kahleova, H. et al. Vegetarian diet improves insulin resistance and oxidative stress markers more than conventional diet in subjects with Type 2 diabetes: Vegetarian diet in Type 2 diabetes, a randomized study. Diabet. Med. 28, 549–559 (2011).

14. Tonstad, S., Butler, T., Yan, R. & Fraser, G. E. Type of Vegetarian Diet, Body Weight, and Prevalence of Type 2 Diabetes. Diabetes Care 32, 791–796 (2009).

15. Satija, A. et al. Plant-Based Dietary Patterns and Incidence of Type 2 Diabetes in US Men and Women: Results from Three Prospective Cohort Studies. PLOS Med. 13, e1002039 (2016).

16. Chen, Z. et al. Changes in Plant-Based Diet Indices and Subsequent Risk of Type 2 Diabetes in Women and Men: Three U.S. Prospective Cohorts. Diabetes Care 44, 663–671 (2021).

17. Turner-McGrievy, G. M., Davidson, C. R., Wingard, E. E., Wilcox, S. & Frongillo, E. A. Comparative effectiveness of plant-based diets for weight loss: A randomized controlled trial of five different diets. Nutrition 31, 350–358 (2015).

18. Kahleova, H. et al. Effect of a Low-Fat Vegan Diet on Body Weight, Insulin Sensitivity, Postprandial Metabolism, and Intramyocellular and Hepatocellular Lipid Levels in Overweight Adults: A Randomized Clinical Trial. JAMA Netw. Open 3, e2025454 (2020).

19. Olfert, M. D. & Wattick, R. A. Vegetarian Diets and the Risk of Diabetes. Curr. Diab. Rep. 18, 101 (2018).

20. Rosenfeld, R. M. et al. Dietary Interventions to Treat Type 2 Diabetes in Adults with a Goal of Remission: An Expert Consensus Statement from the American College of Lifestyle Medicine. Am. J. Lifestyle Med. 155982762210876 (2022) doi:10.1177/15598276221087624.

21. Chiu, T. H. T., Pan, W.-H., Lin, M.-N. & Lin, C.-L. Vegetarian diet, change in dietary patterns, and diabetes risk: a prospective study. Nutr. Diabetes 8, 12 (2018).

22. van Nielen, M. et al. Dietary Protein Intake and Incidence of Type 2 Diabetes in Europe: The EPIC-InterAct Case-Cohort Study. Diabetes Care 37, 1854–1862 (2014).

23. Yokoyama, Y., Barnard, N. D., Levin, S. M. & Watanabe, M. Vegetarian diets and glycemic control in diabetes: a systematic review and meta-analysis. Cardiovasc. Diagn. Ther. 4, 373–382 (2014).

24. Kahleova, H., Tura, A., Hill, M., Holubkov, R. & Barnard, N. A Plant-Based Dietary Intervention Improves Beta-Cell Function and Insulin Resistance in Overweight Adults: A 16-Week Randomized Clinical Trial. Nutrients 10, 189 (2018).

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