Lowering Blood Sugar Without Weight Loss | Dr Nicola Guess

Simon Hill (0:04)

You've done a lot of work on what's described as calorie-independent dietary approaches to type 2 diabetes. And I read a review, a kind of framework that you put forward in 2022 on this. And then I saw that that thesis has been sort of since supported by other groups and people that have shown that pre-diabetes remission is possible without weight loss, for example. And this is where I want to start our conversation today.

Why have calorie-independent approaches to managing type 2 diabetes and preventing type 2 diabetes perhaps been such a focus of your research?

Nicola Guess (0:46)

It really comes from patient-centered. It's what patients have told me. And like I said, I am an academic researcher, but I do that part-time, but I also see patients. And what became abundantly clear, seven, eight years ago, when remission started being possible, it started being a thing, that really captured the imagination of patients. Patients with type 2 diabetes, they want remission. And if they can't achieve complete remission, they at least want to come off their meds.

But to achieve that, you're talking 10 kilograms of weight loss.

For lots of people, they don't want to do that. It might not be clinically appropriate for them. So that's what I was hearing from patients. And I thought to myself, well, what can I do as a dietician to help this become a reality? So I began a series of studies which manipulated carbohydrate and protein concentrations, keeping weight constant, keeping calorie constant, to see if we can improve glucose. And so what that has shown, and this is confirmed by others' research, is that if you have type 2 diabetes, and you follow a high-protein, low-carbohydrate diet, by high-protein, I'm talking 30% of calories from protein, so it's quite a lot, you can lower your glucose by more than medications.

So postprandial glucose in some of the studies come down by 4 millimole per liter. That's, I can't do the math in my head, but it's about 75 milligram per deciliter. Huge, without weight loss. So this is really exciting, and I've actually recently got funding from NIHR, who are a big funder here in the UK, to develop a program actually for patients. And the idea is, the largest group of people who are type 2 diabetes are the over 60, over 65-year-olds. They don't want to lose 10 kilograms. So the idea is, with this diet, we can help people improve their diabetes without having to lose weight.

Simon Hill (2:34)

Right. And we're hopefully going to get into the specifics of that and what that looks like in practice for an individual as this episode unfolds. You alluded to the fact that the last 10 years, there's been a lot of research looking at remission and the possibility of remission.

So has this been a big paradigm shift in diabetes care? So before that, was there a time where once you were diagnosed with pre-diabetes or type 2 diabetes, people thought that was it, you just had that for the rest of your life and you'd go on medications and potentially deal with the complications as they come up?

Nicola Guess (3:11)

100%.

When I was a dietician back in 2008 in the NHS, I mean, you would just manage it. So you would give advice to reduce risk factors to the extent that you could. But the idea that your job as a dietician was to help people come off medication just wasn't anything that entered my head. And then we had the bariatric surgery data that showed actually people could get remission of type 2, the question then became, is it weight loss, is it something else? So it all came from there, but 100%.

I think though, I would say, we need to be really careful with how we define things and the words we use. Remission is a really good way of describing it, because it means you don't have diabetes at the present time, but it could come back. And I think we do need to be very honest with patients about the durability of remission. It does involve for lots of people, significant weight loss and maintenance of that weight loss, which is really tough. But there are some people that have achieved remission and they still don't have diabetes based on a hemorrhoid A1c test now.

Simon Hill (4:15)

Is there a formal definition of what remission actually means?

Nicola Guess (4:19)

We do have one and it will probably change. I mean, they're all glycemic, which is understandable, but it's interesting. So basically, it used to be if you had a normal A1c, actually it's not even normal, it's just under 48 millimole per mole. So if you had a non-diabetic A1c and you weren't on medications, that was remission.