There’s currently quite a bit of interest in type 2 diabetes remission as the long-term consequences are devastating to health. Fortunately, I feel equipped to tackle this subject: I was pre-diabetic in my late 20s/early 30s but have spent the last 10 years free of it. At 44, my hemoglobin a1C is 4.9% and has been that or lower for the whole time.
My initial approach centered around a low carbohydrate diet. In college and shortly thereafter, I had great success with losing weight with an Atkins diet. I’m simply not hungry on a low carbohydrate diet.
I started the Paleo diet in 2010 because the story behind it resonated with me. I wasn’t dropping carbs as low as the intro stage to Atkins or the current iteration of the Keto diet. But, it was enough to get my A1c into the healthy range.
The problem with the low carb lifestyle is it isn’t a long term solution for me. I like carbs, and avoiding them long term is no bueno. Some people can stay low carb forever, but I like variety in my diet. I’m also more comfortable with the long term data on the Mediterranean diet.
So oddly enough, when I increased my carbs, I started teetering near pre-diabetes again. After much research, I learned my perspective on type 2 diabetes was wrong.
Why I wasn’t in type 2 diabetes remission
My myopic view of type 2 diabetes back in the late 2000s was that it was simply an artifact of a highly processed, high carbohydrate diet. Why else would my prediabetes go into remission so rapidly on a low carbohydrate diet?
Well, for one, I wasn’t in remission. My low carbohydrate diet was fantastic at managing postprandial(After meal) blood glucose spikes. As a result, over time, my A1c came within the healthy range. Great, problem solved!
But then, I bought a blood glucose meter and began measuring fasting glucose and doing oral glucose tolerance tests. Despite a fantastic A1c(5.1%), my fasting glucose was still in the prediabetes range(104mg/dL). Then came the oral glucose tolerance tests…
An oral glucose tolerance test measures your response to a 75g load of glucose in liquid form. This is a great way to get a reading on how insulin sensitive you are with little investment. A healthy response to an OGTT has your glucose rise no higher than 140mg/dL and return back to fasting levels within 2 hours.
My responses were always above 180mg/dL. So while I was successfully managing my blood glucose levels with a low carb diet, I clearly wasn’t in remission. My fasting glucose and OGTT were proof of this.
The Personal Fat Threshold and type 2 diabetes remission
Type 2 diabetes is a complex metabolic problem. While there is a lot of focus on blood glucose levels, no one pays much attention to what’s going on under the hood with triglycerides. This is unfortunate, as they are as much a problem as glucose, if not worse.
In type 2 diabetes, individuals may have normal fasting triglycerides, but postprandially they are a mess. Consequently, their daily exposure to elevated triglycerides is much higher than healthy controls even though they have similar fasting levels.
This is a big problem. The Personal Fat Threshold theory of type 2 diabetes posits that each of us has a unique fat(Aka triglyceride) storage capacity. When we exceed this capacity, we start storing excess triglycerides in our organs, specifically the liver and pancreas.
As a result, this impairs the ability of each to properly manage blood glucose levels. It causes the liver to pump out more glucose. In the pancreas, it puts the beta cells that produce insulin into a sleep mode which decreases insulin production.
This creates a gradual “Twin Cycle” where the liver converts excess glucose into triglycerides to store or release into the blood. The circulating triglycerides get stored in the pancreas and inhibit insulin production, which causes glucose to elevate further. This excess glucose is converted into triglycerides and stored in the liver or released in to the blood. And so on, and so on…
As a result, there is a gradual degradation of blood glucose management. Removing carbohydrate from the diet is a way to manage this, but weight loss is essential for remission. Those triglycerides in the liver and pancreas are preferentially burned when energy is restricted in the diet.
When the excess fat in the liver and pancreas is lost, the organs resume healthy function.
Where low carb diet gurus get it wrong
Low carb diets are fantastic for managing blood glucose levels. Dietary carbohydrate is a substantial driver of postprandial glucose excursion. So by limiting them, you manage your blood glucose levels better and see a drop in A1c.
Despite improvements in A1c, this doesn’t mean you’re in remission, even if A1c is normal. Fasting glucose may still be out of whack, as would an OGTT. That’s because you’ve reduced the work the liver and pancreas have to do to manage glucose. But if you don’t reduce the excess triglycerides in both they aren’t working better, they just don’t have to work as hard.
But what is the natural substitute for carbohydrates when you remove them from your diet? Triglycerides. If eating at your energy needs, you won’t burn the triglycerides in your liver or pancreas because you’ll just burn the ones from your diet.
Despite improvements in glucose regulation, you’re no better off. In fact, there’s an argument you’re worse off.
We package triglycerides into chylomicrons in our gut and deliver them to peripheral tissues and the liver. The liver converts all excess calories into triglycerides and packages them into VLDL particles, which can be further converted in to LDL particles.
This is important because all 3(chylomicrons, VLDL, and LDL) contain apoB. All apoB-containing particles promote atherosclerosis, not just LDL-C. (Yes, even the big fluffy LDL)
Consequently, your plaque burden will likely increase, even if you bring carbs down to below 50g. Your A1c is great, but if you don’t metabolize the fat in the liver and pancreas, postprandial triglycerides will continually circulate in apoB-containing lipoproteins and promote atherosclerosis.
Get below your personal fat threshold for type 2 diabetes remission
It doesn’t really matter how you do it, but burning more energy than you take in decreases fat in the liver and pancreas. You can do that with low carb, low calorie, low fat, you name it.
Ultimately, you need to eliminate the fat in your liver and pancreas by getting below your personal fat threshold. This allows both to properly manage your blood glucose levels.
It also allows you to overeat from time to time without doing too much damage. Freeing up space in your fat tissue prevents storage in the liver and pancreas. It also allows triglycerides to get shuttled into storage rather than circulating for too long and causing damage.
Sure, you can decrease the load on your liver and pancreas by cutting dietary carbohydrate. But that doesn’t fix either, and it ignores the negative effects of elevated triglycerides.
This doesn’t mean a low carbohydrate diet is ineffective for type 2 diabetes remission. It simply means that without weight loss, a low carb diet doesn’t lead to remission. It’s great for managing glucose, but it’s not a cure.
This was my experience. Back in 2010, when I first addressed blood glucose management by doing low carb Paleo. I dropped from ~215lbs to 205lbs. But my fasting glucose and OGTTs didn’t turn around until I dropped below 200lbs. I’m currently sitting at 185lbs with the same A1c, but while consuming a bit over 300g of carbs per day.
It’s important to point out that the Personal Fat Threshold is different for everyone. In this regard, having a genetic propensity to lay down subcutaneous fat is beneficial because you have a higher threshold of body fat you can put on before it impairs blood glucose regulation.
This is why we see lean-looking individuals with type 2 diabetes. They are the so-called TOFI phenotype: Thin outside, fat inside.
Other important factors
Diet is simply one lever you can pull for type 2 diabetes remission. Physical activity and exercise are other factors you can use to help build better insulin sensitivity and manage a healthier weight.
Simply walking more helps manage blood glucose levels by tapping into liver glycogen and emptying out those fat stores. There’s also evidence that it plays an important role in managing triglycerides in the blood. So if you decide to low carb it, walking more can mitigate some of the risk from the higher postprandial triglycerides.
Strength training also helps. Muscle is a glucose sink, pulling glucose from the blood to fuel exercise. Having more muscle mass and frequently using that muscle is another important factor for increasing carbohydrate tolerance.
Sleep is another important factor that people often ignore. One study found that 7 days of getting 5 hours of sleep led to a substantial decrease in insulin sensitivity in healthy men.
As you can see, you don’t simply have to eliminate carbohydrates from your diet if your goal is healthy blood glucose regulation. A healthy person should be able to tolerate a carbohydrate load with their meals just fine.
If your goal is type 2 diabetes remission, it’s important to understand how the disease develops. Furthermore, it’s important to understand all the tools you have at your disposal.
Though type 2 diabetes is often thought of as a blood glucose problem, it’s actually a disease of energy excess. This is why people with the disease have elevated glucose AND triglycerides.
According to the best supported hypothesis, each of us has a personal fat storage threshold that, once exceeded, causes us to lay down fat in our internal organs. This is referred to as ectopic fat, and when it floods the liver and pancreas, it impairs our ability to manage blood glucose levels.
A low carbohydrate diet is useful for managing blood glucose levels because dietary carbohydrate at meals raises blood glucose. But cutting carbohydrates doesn’t really correct the problem unless it leads to weight loss that taps into and removes fat in the liver and pancreas.
Eliminating carbohydrates from your diet doesn’t really correct the problem, it’s more akin to symptom management. You’ll see improvements in A1c, but not in an OGTT or possibly your fasting glucose. It’s an important distinction, because many people believe that since their A1c is better, that the problem is solved.
A low carbohydrate diet in and of itself is no more a cure for type 2 diabetes than avoiding exercise is a cure for exercise intolerance. Any diet that removes fat from the liver and pancreas works for remission, and other tools such as walking, strength training, and good sleep hygiene can help as well.
Use all these tools to achieve type 2 diabetes remission. You don’t have to fear teh carbz!