The risk-reversal diet

Unless we are willing to rethink our beliefs about food and sickness, Minnesota is headed for an accelerated worsening of health, with bills that will grow, grow and grow, crowding all other needs from our lives.

As noted in our recent down-ranking from the United Health Foundation, Minnesota just experienced a double-digit rise in the percentage of residents with diabetes, the vast majority being cases of so-called "adult onset" or type 2 diabetes. Though it is lower than the national average, the percentage of Minnesotans with diabetes jumped 11 percent in 2017, to 8.4 percent of all adults, according to the report. For perspective, in 2000 this figure was just over 4 percent, according to the Minnesota Department of Health.

So that's a doubling in the prevalence of what is essentially a food-borne illness, in less than two decades.

For even more perspective, in 1960 fewer than 1 percent of Americans had diabetes.

The exponential rise in type 2 diabetes in our lifetime has become part of the backdrop, normalized via waste bins full of sharps, television ads for glucose monitors and A1c-lowering pills (the top-selling drugs in the country) and the proliferation of strip-mall-based chain-dialysis centers, whose numbers now surpass those of all Target and Best Buy stores combined, according to the trade journal NEJM Catalyst.

These little signposts all around us make the spread of type 2 diabetes seem like the common cold. They allow us to forget the disease's dramatic social cost — its characteristically high dependency on the health care system, and how even when "managed" with medications and the standard advice about diet, type 2 diabetes can progress to amputation, infection, blindness, kidney and liver failure. Lesser complications include reflux, erectile dysfunction, hair loss, mood disorders, sleep apnea and insomnia — your basic shortlist of the ills keeping America popping pills.

Not surprisingly, it's also breaking our bank. With 30 million Americans meeting the diagnosis and another 83 million "prediabetic," or on the verge, over half the country either is diabetic or positioned to get there. This costs Americans $237 billion in direct charges annually, according to "Economic Cost of Diabetes in the U.S. in 2017," a publication of the American Diabetes Association, or one in every four dollars spent on health care.

Nearly 340,000 Minnesotans have diabetes, ringing up $3.5 billion in direct costs each year, according to the same ADA data. That's enough to fund the entire state transportation budget. According to the Institute for Alternative Futures Diabetes Forecasting Model, by 2030, if we are anything like the rest of the country, Minnesota can look forward to spending $6 billion each year on diabetes. That's enough to buy free college for everyone.

Now, zoom out for a moment. These are just the costs of treating diabetes. Insulin resistance is also a risk factor for heart disease, hypertension, dementia and many forms of cancers, suggesting a shared underlying disease process linking nearly every major category of illness that is killing us.

So if there's a preventable illness that deserves our attention more than diabetes, it's hard to imagine what that is. And yet our imagination when it comes to identifying the source of the illness is impoverished. Officeholders demand more "access to health care" (from the political left), or "freedom to choose your doctor" (from the political right). Few ask why we need so much diabetes care in the first place. Not to mention why "your doctor" doesn't seem to have the tools to arrest diabetes.

A solution, however, may be closer than we think. We now know it's possible to not simply manage diabetes, but to reverse and possibly eradicate it as a public health crisis. The method in question, moreover, is cheap, available to all and requires no surgery, caloric deprivation, hours of prescribed exercise or lifelong dependency on expensive medications.

In an especially apt detail, this unheralded pathway to reversing diabetes entails a return to dietary practices last deemed acceptable in the comparatively diabetes-free 1960s. The one (substantial) obstacle is cultural, not medical. It is the stubbornness of our beliefs about food and health.

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So here, then, is our lucky break, if we can live with it: LCHF puts diabetes into remission.

What does that mean? According to dozens of peer-reviewed findings — the most persuasive being a recent long-term controlled dietary trial out of Indiana — it has become apparent that shifting diabetic patients toward a calorically-unrestricted low-carbohydrate, high-fat dietary pattern known as "nutritional ketosis" can safely and sustainably reverse diabetes.

As reported last year in the journal Diabetes Therapy by lead investigator Sarah J. Hallberg of Indiana University Health and the dietary coaching firm Virta Health, the physician-directed, app-delivered LCHF intervention reversed diabetes in 60 percent of patients.

That's not a typo. At a one-year mark in the venture capital-funded study, 60 percent of 262 rural, obese, long-term diabetic patients who were coached on how to eat LCHF dropped and remained below the diagnostic threshold for diabetes. They ate as many calories as they wanted.

Thanks to dietary coaching based on digital monitoring of the ketone blood markers confirming the absence of dietary carbohydrates, they likely ate a lot of once-forbidden foods like eggs, cheese, butter, full-fat dairy and yogurt. The subjects were coached to eat only a normal amount of protein, but all the non-starchy vegetables, greens, berries and dietary fat they desired. Calorically, that breaks down to 10 percent or fewer calories from carbohydrates, 10-20 percent from protein, and 70 percent from fat. Though it may give some pause, the fats helpful in this quest include unlimited amounts of coconut and olive oil, dairy fat and the most marbled cuts of meat — every kind of fat except for that which is used to hold together carbohydrates. This allowed the participants to feel full while keeping their total daily carbohydrate intake under 30 grams a day, or roughly the amount of three slices of bread.

Because you're wondering about this next part, they lost over 12 percent of their body weight in the process, for an average of 30 pounds, with the weight loss sustained at one year. More importantly, by following close medical guidance, they rapidly titrated downward their diabetes drugs, and by necessity at that, since an acceptable dose of glucose-lowering medications and insulin can quickly become dangerous in the absence of dietary carbohydrates.

By the end of one year, 57 percent of the study subjects had all of their prescriptions discontinued save for the drug metformin, with drug costs halved for the entire group and the use of insulin, a medication currently the subject of shortages and price gouging, either eliminated or halved. The vast majority were able to stick to the LCHF program. There were no adverse events attributable to the change in diet. The intervention improved biomarkers for heart disease, hypertension, kidney disease, liver disease and cancer. It was an unqualified success.

And if we consider how type 2 diabetes occurs, the only part of this story that should seem at all surprising is that this cheap, easy, highly successful intervention is not the current standard of care. After all, diabetes arises when dietary glucose hits elevated levels long enough to wear out the body's system to correct the problem.

Carbohydrate-rich foods like bread, pastry, pasta, potatoes, juices and sugar send glucose into the bloodstream. The arrival of this glucose triggers the body to release insulin, our hormone for clearing excess glucose and storing it for later use within fat cells. But that energy cannot be used as long as insulin remains in the bloodstream, and with insulin high, dietary energy is locked away, leading to endless cycles of carbohydrates followed by hunger. In this way, carbohydrates make patients simultaneously fatter, disregulated and malnourished.

The more refined the carbohydrate, the more insulin is released, but even high-fiber, so-called "healthy carbs" like brown rice, grains, fruit and whole-grain breads will cause insulin to enter the bloodstream. Protein, for its part, causes only a modest release of insulin, while dietary fat causes virtually no insulin to enter the bloodstream.

But there's no need to take this on faith. By monitoring blood sugar with continuous glucose monitors, diabetic patients can now see their glucose rising after differing meals in real time, enabling them to discover that while watermelon may be a "healthy whole fruit" it is causing the body to release insulin, prolonging the cycle of diabetes.

It will come as a surprise for many to learn that there is no penalty to eating unlimited saturated fat in the absence of carbohydrates, and that there is nothing unnatural or unhealthy about utilizing the body's system for burning ketone bodies in the absence of carbohydrates. It was once believed that saturated fat causes clogged arteries, obesity and diabetes — and as the proliferation of skim milk and skinless chicken breasts all around us makes clear, this will remain the hardest dietary myth to shake off if we are to embrace LCHF as a first-line treatment for diabetes. But no fewer than eight systematic reviews of random controlled trials have found no association between these so-called "bad fats" and disease. It's quite possible they are beneficial.

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Longer, larger trials are needed to confirm that LCHF produces reductions in heart attacks, amputations, blindness and early death, even if the standard of care has failed to produce proof of these outcomes for the diets we are told to follow today. It's also vital that parties with no financial interest in the outcome replicate the Indiana finding.

But let's not lose sight of the significance of this moment. Previously, we have been told to accept that diabetes is chronic and progressive, with remission possible only through improbably low calorie eating (400-900 calories a day) and bariatric surgery.

For everyone else, there's always been only the standard of care. It advises glucose control, exercise and either the Mediterranean, so-called DASH, or plant-based diet. All options include plentiful levels of carbohydrates, the food that triggers the release of the diabetes-promoting hormone insulin. All options include the admonishment to avoid animal and dairy fat, safe, satisfying whole foods necessary to cut carbohydrates from the diet in the American dietary environment. And it's been a bust.

Though profitable for drugmakers, chain dialysis firms, blood labs and endocrinology wards, the standard of care places diabetic patients in remission just 0.1 percent of the time. Which is to say, never.

As if to confirm this story of unmet expectations, during the Indiana trial, an 87-person control group received the standard of care. They experienced no reversal of diabetes, no reduction in medication, no loss of weight. For some, use of insulin went up.

How did we get here? We embraced ideas about diabetes that aligned with our sense of righteousness — the virtue of physical activity and salads, the supposed decadence of satisfying foods eaten during the unenlightened past. We got detoured by conceptual errors, pairing diabetes with obesity, for instance, when obesity is largely benign other than as a symptom of diabetes. We learned to approach hypertension, heart disease, dementia and common forms of cancer as separate classes of disease, when their common metabolic signature and rise in time as a cluster suggest they share a dietary exposure making us diabetic.

Lately, we have witnessed the assertion that the urgency of combating climate change and protecting animal welfare can guide our approach to treating diabetes. We are told this as if starting with a preferred, often vegetarian or vegan answer to a medical question, then moving backward in search of supporting evidence is a sensible method to take on the public health crisis of our time.

We formed moral positions about diabetes, telling patients to stop being "noncompliant" in the face of their providers' complex, ever-expanding treatment regimens, a special kind of cruelty that is the subject of the small, bracing manifesto "Why We Revolt," by Mayo Clinic diabetes specialist Dr. Victor Montori.

We told harried, manual-labor-performing diabetic patients to join the gym, eat smaller portions, less red meat or more plants, as if diabetes had been traced to cultural villains like sloth, overeating or beef, instead of being the maladaptation of the body's system for regulating energy that we know it to be.

Our problem was always just diabetes. Find a cure for that, we failed to remember, and we become America of the 1950s, an era when less than 1 percent of the country had insulin resistance, health care did not gobble up all new economic gains and doctors could stick to what doctors do best: treating infections, delivering babies and setting broken bones.

Schoolchildren are advised to eat diabetes-promoting foods like dinner rolls, unbuttered produce, skinless chicken and low-fat milk. The halls of our hospitals are lined with diabetes-promoting candy, soda and juice machines, even as savvy doctors have learned to push the kaiser roll to the side.

These are just the easy targets. After all, you don't have to be dining on Skittles to develop type 2 diabetes. The founder of Virta Health, a 30-something tech billionaire and endurance athlete, was racing in triathlons when he learned that his blood glucose had reached the level designating him as prediabetic. He was the picture of health.

He was also drinking fruit smoothies and eating five bowls of oatmeal a day.

Paul John Scott is a writer in Rochester.