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Non-surgical treatments for type 2 diabetes

Metabolic surgery—sometimes called bariatric or gastric bypass surgery—is one of the interventions touted as a treatment option for type 2 diabetes, but is it right for you? Below, we discuss some of the available alternatives, and weigh up the pros and cons of each.
Laura Wolfe
3/11/2022
12
min read
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Quick summary

  • Medication can help lower blood sugar levels but weight loss has been shown to be one of the best ways to manage type 2 diabetes.
  • While there are surgical options available to achieve weight loss, they may not be suitable for everyone. 
  • For many people, changes in diet and exercise may be enough to keep blood sugar levels under control and can even result in enough weight loss to result in type 2 diabetes remission. 
  • Total diet replacement programmes have proven effective in achieving remission and carry significantly fewer long term risks than surgery.

‘Gastric Bypass: A Miracle Cure for Diabetes?’ With headlines like these,[1] anyone could be forgiven for thinking that surgery is the best, maybe even the only, treatment for type 2 diabetes. But while surgery might make sense for many people, particularly those who continue to struggle after making changes to diet and lifestyle, it’s important to understand the full range of options available before agreeing a type 2 diabetes treatment plan with your medical team.

Recent advances in the study of diabetes and nutrition have led to a more sophisticated understanding of how to develop and sustain the habits needed to support remission in type 2 diabetes patients, opening new, less invasive treatment possibilities for many.

What is type 2 diabetes remission?

Before we get started, it’s important to understand what we mean by ‘remission’ and ‘reversal’. While it’s not yet possible to cure diabetes in the sense of eliminating the condition, advances in our medical understanding of type 2 diabetes mean that many people with the condition can lower their blood sugars to within normal levels with the help of medications, such as metformin, as well as diet and lifestyle adjustments.

Studies have found that up to 60% of people can reverse type 2 diabetes with weight loss

Taheri et al, Lancet

A person in remission has not only lowered their blood sugar levels to below 6.5% (48mmol/mol) but maintained them at that level for at least 3 months without the aid of medication.[2] So, while a person managing type 2 diabetes through a combination of diet, exercise, and medication is doing an excellent job living with the condition, they’re not quite at the point of remission. If in the future, they no longer require medication and keep blood sugar levels down through lifestyle measures alone, then they will have achieved remission.      

The good news? Remission from type 2 diabetes is both possible and common. Scientific studies have found that up to 60% of people can reverse type 2 diabetes via weight management alone.[3]

What are common treatments for type 2 diabetes?

Metabolic surgery 

Surgical type 2 diabetes treatment involves altering the size of the stomach to reduce the amount of food entering the digestive system.[4] A limited food intake reduces the amount of fat that can build up around vital organs, such as the liver (it's this fat build-up that is thought to contribute to the development of type 2 diabetes) and also leads to significant weight loss, which is why you’ve likely heard it called “weight loss surgery”.[5] 

The two procedures most commonly performed are 'laparoscopic roux-en-Y gastric bypass' (called gastric bypass from here for simplicity) and 'laparoscopic sleeve gastrectomy (LSG). Gastric bypass surgery involves reducing the size of the stomach to a pouch about the size of an egg, which is then connected directly to the small intestine, bypassing the rest of the stomach and the first part of the small intestine that connects to the stomach (called the duodenum).[6] The LSG procedure, on the other hand, involves converting the stomach from a large pouch into a slim tube about the size of a banana, reducing its volume by about 80%.[7] 

While the cosmetic side-effects definitely have their appeal, it’s important to remember that metabolic surgery, like any other surgery, carries the risk of complications. Even assuming all goes well, however, patients recovering from metabolic surgery will need aftercare and follow up appointments.

While these treatments have produced positive results for many, it’s important to remember that their success depends on patients’ willingness to make significant changes to their diets and strictly limit intake to avoid damaging their new, much smaller stomachs. This is why the NHS requires anyone undergoing the procedure to commit to pre- and post-surgical nutritional counselling.[8] 

Medications

It’s very common for people with type 2 diabetes to be prescribed medication such as metformin at the point of diagnosis. Metformin keeps blood sugar levels down by helping the body process insulin and prevents the liver from releasing sugar into the blood.[9] Over time, your doctor may increase the dosage or add additional medications to your daily routine if your blood sugar levels continue to rise, or if you can’t tolerate the side effects of metformin.

If type 2 diabetes continues to worsen and blood sugar levels struggle to stay under control, your doctor may suggest insulin therapy. The main treatment for type 1 diabetes, insulin isn’t the first-line treatment for type 2 but rather a last resort. Up to 50% of people with type 2 diabetes eventually need to take insulin injections,[10] but this doesn’t happen straight away—before resorting to this treatment, your doctor will start you on tablets, adjust your prescriptions, and only when (if) they stop working, will insulin be an option.  

Added insulin works by helping lower the amount of glucose in the blood and can eliminate the risk of glucose spikes after eating.[11] It's important to receive appropriate training before starting this line of treatment as if misused, insulin can easily lead to dangerous ‘hypos’, which is when blood sugar levels drastically fall. Introducing synthetic insulin into the body can prompt the pancreas to stop producing it altogether, so it's not a recommended long term solution for people with type 2 diabetes unless other methods have been exhausted.[12] 

Your doctor will choose the specific medication and appropriate dosage for you depending on the severity of your condition, your general health, and your response to treatment. Always ask your doctor if you have any questions or concerns about your medication or side effects.

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Diet changes and weight loss

Before we go into the impact of diet and weight loss as a treatment for type 2 diabetes, let’s quickly recap the role of the liver and pancreas in blood sugar regulation—and the effect fat has on this finely tuned process. Internal fat deposits around the liver and pancreas interfere with normal blood sugar control. In the liver, these fat deposits cause the liver to become resistant to insulin. Normally, the liver produces glucose in varying amounts in response to insulin levels. Elevated blood sugar levels result in the release of insulin, which in turn tells the liver its time to stop producing glucose—as a result, blood sugar levels return to normal. When the liver becomes insulin resistant, it is unable to respond properly to the insulin and therefore carries on producing glucose, leading to elevated blood sugar levels.[13] The fat deposits in the liver can also be circulated in the blood, which is how they arrive in the pancreas. Here, the fat deposits are toxic to the cells that produce insulin meaning that little (or none at all) insulin is produced and blood sugar levels spike as a result.[13]

Changing the amount and nutritional quality of food can reduce the buildup of fat around the liver, resulting in improved insulin sensitivity

Taylor et al, BMJ

Although diabetes remission was first documented in patients who underwent gastric bypass surgery, subsequent research established that people with type 2 diabetes who commit to making lifestyle changes can also enter remission.[14] By altering the amount and nutritional quality of their food intake, these patients saw a reduction in fat accumulation around the liver, which led to increased sensitivity to insulin. Essentially, the weight loss triggered by eating a low-calorie, nutritionally dense diet included a loss of fat from around the liver. Without the unnecessary extra padding, the liver regained normal sensitivity to the level of glucose in the blood and stopped overproducing. As glucose levels normalised, so did insulin production by the pancreas. 

The extent of the weight loss required to naturally lower blood glucose levels will vary from person to person, as will the best diet to achieve it. Scientists have explored several options, including nutritional ketosis and intermittent fasting, but agree that total diet replacement (TDR) is the most effective option.[15-17] 

The term ‘total’ is what sets it apart from other types of meal replacements. TDR meals are nutritionally complete, meaning they contain all the nutrients your body needs to stay healthy while being low in calories (typically 200 calories per meal, with a daily calorie intake totalling 800). This means that it's possible to use TDR for a longer time period than other meal replacements, leading to safe and effective weight loss, and normalised blood sugar levels.

TDR can get a bad wrap, in part thanks to fad weight-loss schemes that have popped up since the 80s. Rest assured, TDR isn’t a crash diet but is in fact a scientifically proven weight loss tool that can help people with type 2 diabetes reach remission and when used in conjunction with habit change support (as scientifically advised), its an effective way of inciting sustainable change.[18,19] A TDR programme is not without its challenges but it does carry substantially lower risk than surgical interventions. It’s important to remember that starting TDR is a commitment to building a better, healthier life rather than a quick fix. 

Explore your alternative type 2 diabetes treatment options

Tempting though it may be to think of metabolic surgery as a silver bullet solution to type 2 diabetes, it’s just one of several pathways to remission. Lifestyle changes, such as a TDR-based programme, not only produce similar outcomes as surgical interventions but involve significantly less risk to and stress on the body. Before committing to a single type 2 diabetes treatment plan, talk to your doctor about your options depending on your health, lifestyle, and budget. 

References

[1] Gastric Bypass: A Miracle Cure for Diabetes? Discover Magazine. Retrieved 21 February 2022. Accessible here.

[2] Remission in adults with type 2 diabetes. Diabetes UK. Retrieved 21 February 2022. Accessible here

[3] Taheri, S., Zaghloul, H., Chagoury, O., et al. (2020) Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group randomised controlled trial. Lancet 8(6):477-489. Accessible here.

[4] Rubino, F., Schaur, P., Kaplan, L., et al. (2010). Metabolic Surgery to Treat Type 2 Diabetes: Clinical Outcomes and Mechanisms of Action. Annual Review of Medicine 61:P393-411. Accessible here.

[5] Bariatric (Weight Loss) Surgery for Treating Diabetes. The Cleveland Clinic. Retrieved 21 February 2022. Accessible here

[6] Gastric Bypass Surgery. University of California - Los Angeles School of Medicine Center for Obesity and Metabolic Health. Retrieved 21 February 2022. Accessible here

[7] Gastric Sleeve Surgery. University of California - Los Angeles School of Medicine Center for Obesity and Metabolic Health. Retrieved 21 February 2022. Accessible here

[8] Weight Loss Surgery. NHS. Retrieved 21 February 2022. Accessible here.

[9] Metformin. NHS. Retrieved 21 February 2022. Accessible here.

[10] Turner, R.C., Cull, C.A., Frighi, V., et al. (1999). Glycemic Control With Diet, Sulfonylurea, Metformin, or Insulin in Patients With Type 2 Diabetes Mellitus. JAMA 281(21):2005-2012. Accessible here

[11] Insulin Basics. American Diabetes Association. Retrieved 21 February 2022. Accessible here.

[12] Swinnen, S., Hoekstra, J., DeVries, J.H. (2009). Insulin Therapy for Type 2 Diabetes. Diabetes Care 32(2):P253-259. Accessible here

[13] Taylor, R. (2008). Pathogenesis of type 2 diabetes: tracing the reverse route from cure to cause. Diabetologia 51(10):1781-1789. Accessible here.

[14] Taylor, R., Ramachandran, A., Yancy, W., et al. (2021). Nutritional Basis of Type 2 Diabetes Remission. BMJ 374:n1449. Accessible here.

[15] Hallberg, S., McKenzie, A., Williams, P., et al. (2018). Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Therapy 9(2):583-612. Accessible here.

[16] Furmli, S., Elmasry, R., Ramos, M., et al. (2018). Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. Case Reports bcr-2017-221854. Accessible here

[17] Brown A., Dornhorst, A., McGowan, B., et al. (2020). Low-energy total diet replacement intervention in patients with type 2 diabetes mellitus and obesity treated with insulin: a randomized trial. BMJ Open Diabetes Research and Care 8(1):10.1136/bmjdrc-2019-001012. Accessible here.

[18] Churuangsuk, C., Hall, J., Reynolds, A., et al. (2021). Diets for weight management in adults with type 2 diabetes: an umbrella review of published meta-analyses and systematic review of trials of diets for diabetes remission. Diabetologia 65:14-36. Accessible here.

[19] Astbury, N.M., Aveyard, P., Nickless, A., et al. (2018). Doctor referral of overweight people to low energy total diet replacement treatment (DROPLET): pragmatic randomised controlled trial. BMJ 362:K3760. Accessible here.

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