Conference Coverage

How to reverse type 2 diabetes with a crash diet: the DiRECT approach

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A new approach

M. Alexander Otto

Dr. Alvin Powers

This study really proposes a new approach to people who have recent-onset type 2 diabetes. Our current approach is to recommend reduced caloric intake, exercise, and medication. It’s usually viewed as a progressive disease, with some individuals eventually requiring insulin. These remarkable results were obtained in the real world of clinical practice, not in a research study.

Alvin Powers, MD, is director of the diabetes center and a professor of medicine at Vanderbilt University, Nashville. He moderated the presentation and had no relevant disclosures.



Patients had diabetes for less than 6 years and were not insulin dependent. The baseline mean body mass index was 35 kg/m2, mean age 54 years, mean hemoglobin A1c 7.6%, and mean duration of disease 3 years; 176 subjects were men.

Diabetes drugs, anti-hypertensives, and diuretics were stopped in the weight loss group; the program consisted of three Optifast meal replacement shakes or soups per day – Optifast is one of many commercially available options – for a daily intake of 825-853 kcal. There was no other food, and alcohol was not permitted. The weight loss goal was 33 pounds or more over 3-5 months; almost 90% of the intervention group made it. The protocol did not include exercise.

Next came a 2-8 week stepped reintroduction to normal food, followed by counseling and other supportive care out to 2 years, plus some extra packets of Optifast, just in case.

“People [had] panic attacks when they [went] back into the kitchen, but that’s marvelous: we [had] a blank slate on which to write new dietary habits, building up knowledge of portion size and what to eat.” Dr. Taylor said.

At 1 year, 68 (46%) of the intervention participants were in remission off all drugs, and 36 (24%) had maintained at least a 33-pound weight loss. At 2 years, 53 (36%) were in remission, and 17 (11%) had maintained. Percent remission was linked to the extent of sustained weight loss.

Strokes, heart attacks, and other serious adverse outcomes were less common in the diet group, versus standard care, at both 1 and 2 years.

Among those who went into remission, the rapid initial response to a glucose bolus came back to near normal soon after food reintroduction, and “was sufficient to get nondiabetic blood glucose control,” with a mean hemoglobin A1c of 6% at 2 years. “We [also] saw, quite remarkably, was a slow steady return to almost completely normal” maximum beta cell capacity over the first 12 months, Dr. Taylor said.

The most likely explanation is that beta cells are overwhelmed and shut down in a milieu of too much fat and glucose, but are able to reconstitute their specialist function and come back online once it’s addressed, he added.

The study was funded by Diabetes UK. Dr. Taylor reported financial relationships with Self, Wilmington Healthcare, Lilly Diabetes, and Novartis AG.

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SOURCE: Zhyzhneuskaya SV et al., ADA 2019 abstract 66-OR


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