Covid-19 has delivered another good reason to maintain a healthy weight and avoid - or reverse - diabetes using a breakthrough easy method. By Nicky Pellegrino, New Zealand Listener.
There are plenty of health-based reasons not to gain too much weight, and in 2020, we have encountered yet another compelling one. As world leaders Donald Trump and Boris Johnson now recognise, obesity increases your risk of dying from Covid-19.
Obesity causes the body to generate chronic inflammation, weakening our immune response. It's also associated with a higher likelihood of diseases such as diabetes, heart disease, and lung disease – all of which makes it a risk factor for severe Covid-19 cases.
A US study commissioned by the World Bank showed that obese sufferers of Covid-19 were 74 per cent more likely to end up in intensive care and 48 per cent more likely to die. Almost a third of deaths from the virus in the UK were among people with diabetes, according to one early study, and the older that people were, the higher the risk.
And that hoped-for vaccine, if it happens, is expected to have less benefit for obese people than for others – at least, that's what experts predict based on what they know from tests of the Sars and flu vaccines.
For US President Trump, his age (74) and sex were other risk factors increasing his susceptibility to Covid-19, but his body mass index of 33.3 puts him at the lower end of the obesity spectrum.
His British counterpart, Boris Johnson, aged 56, acknowledges that he was "way overweight" when he was hospitalised with the virus in April and has launched a campaign to reduce obesity that includes an expansion of NHS weight-loss services, restrictions on junk-food advertising, legislation requiring large restaurant businesses to put calorie counts on menus and rules around how unhealthy products are displayed in grocery stores. Johnson claims to have lost 12kg since then, thanks to healthier eating and runs with his dog, taking his BMI down from the obese zone to merely overweight.
Long before the Covid-19 crisis, Roy Taylor, a professor of medicine and metabolism at Newcastle University, started working on an answer to the problems of type 2 diabetes and our steadily increasing bodyweights. The solution he has come up with is elegantly simple and low-cost – it won't translate to huge profits for the pharmaceutical or slimming industries – and Taylor has the science to show that it works and how.
Nevertheless, he has had problems getting his ideas accepted into mainstream healthcare.
"It's been extremely difficult and that was inevitable. I've been unfortunate enough to be in this position more than once in my career where people say, 'No that won't work.' The only thing is to dig in and do more research," says Taylor, who experienced a sweet moment in August when NHS England announced it was rolling out his diabetes reversal programme to 5000 patients.
Diabetes occurs when there is too much sugar in the bloodstream. Levels naturally shoot up after a meal as the stomach breaks down food and releases glucose. The body deals with that by releasing insulin from the beta cells of the pancreas. If those cells are compromised in some way and fail to make enough insulin at the right time, then diabetes develops.
To make matters worse, with type 2 diabetes the body doesn't respond well to whatever insulin is on offer. Long term, this has devastating health consequences as the body's network of blood vessels is damaged, creating nerve problems that result in amputations and leading to sight loss, heart attacks, strokes and kidney damage.
What sufferers are offered is a steadily increasing amount of medication, some of which causes further weight gain, and eventually insulin injections. Diabetes has been seen as a lifelong condition and decline was believed to be inevitable.
The big breakthrough
Taylor's breakthrough was proving that diabetes is caused not by having lots of fat beneath our skin but by far tinier deposits of it in the liver and pancreas. As little as half a gram of fat inside the pancreas prevents the beta cells from manufacturing and releasing insulin. Initially it was believed that those cells had died, but what Taylor now knows is that the fat had merely put them to sleep. And, crucially, his studies have shown it is possible to revive those cells and put diabetes into remission purely by losing enough weight.
Taylor has been working with diabetes for decades. Everything changed for him in 2006 when he read a study that showed blood sugar plummeted within days in people with diabetes after they had bariatric surgery (a gastric bypass).
Previous studies had shown that lifestyle changes and weight loss reduced the incidence of diabetes, but what Taylor went on to prove with a small study involving 11 people was that rapid weight loss on a very low-calorie diet could reverse diabetes. Participants lost an average of 15kg. As the fat level in the liver fell, it became less insulin-resistant. And as the tiny amount in the pancreas disappeared, the beta cells woke up.
"When we first published that research in 2011, there was a huge influx of emails from people who were desperate for a way out of what they had believed to be the life sentence of diabetes," says Taylor.
A second study repeated those results and showed that when participants maintained the weight loss, the diabetes stayed away. And a subsequent much larger trial, known as DiRECT, run through GPs' surgeries, saw almost half of the participants reverse their diabetes and stopped having to take medication.
It didn't matter what diet people were on, but they restricted intake to 800 calories a day for two months. Taylor believes the simplest way to do this is by living on liquid meal replacement drinks supplemented with one serving of non-starchy vegetables a day for roughage. He claims that after 36 hours, people stop feeling so hungry.
Step two of his approach is a transition to proper foods. And the final step involves developing a new-normal way of eating, as less energy is required to fuel the body after the weight has been lost. If it starts creeping up again, a return to a period on 800 calories a day is necessary.
Not everyone who does this is going to achieve remission. "But if people lose 15 kilos within six years of being diagnosed, they've got a nine-out-of-10 chance of getting rid of their diabetes," says Taylor. "And if they lose 10 kilos, they've got about a two-thirds chance. Once you go beyond 10 years, it's not impossible, but it's much less likely that diabetes will be reversed."
Personal fat threshold
Taylor's work clarifies a baffling statistic. Although diabetes is known as a disease of obesity, about half of those who are newly diagnosed have a BMI under 30 and a significant number are in the healthy range and appear, at least from the outside, to not be carrying much excess fat at all.
"Every individual has their personal fat threshold," he says, "the point at which no more fat can be taken into the layer of cells under the skin. It has to go somewhere, so ends up not only inside the tummy cavity but inside the main organs of the body."
How early this happens is determined by genetics, and Taylor is pleased that it has taken some of the blame away from the weight debate.
"When I explain the personal fat threshold to patients in the clinic, I get this profoundly relieved reaction," he says. "I think it is something important to shout about. It explains the simplicity of what we're looking at."
Taylor has a photograph he likes to show people of a group of women standing on a street in his hometown of Newcastle back in the 1970s. Most of them are slim or only slightly overweight. Today, a shot of a similarly random group would look very different. We are heavier now than we were back then, and with the steady accumulation of kilos, more of us have crossed our personal threshold and become too fat for our own bodies, hence rates of diabetes have risen.
The rate of obesity in the UK since the photograph was taken has increased from one in 14 people to one in four (in New Zealand, the most recent statistics puts it higher, at one in three).
"We've got used to having the streets filled with people who are really quite large," he says. "An abnormal state has become normal."
It is easy to gain weight little by little over the years without obvious overeating, particularly in an environment where large portions and highly processed foods are served up everywhere. Just look at those huge banks of fridges containing sugar-sweetened beverages in every petrol station and dairy. Whole aisles of supermarkets are filled with low-nutrient, calorie-dense foods. The streets of every town feature takeaway bars and fast-food emporiums.
"It takes a surprisingly small amount – just a couple of mouthfuls too much a day – and that will have you gaining 10 kilos in 20 years. Then you're well on the way to setting the scene for diabetes, increased risk of cancer and all the other nasties, like Covid," says Taylor.
He is extremely lean, but he hasn't always been that way. "I was a chubby toddler. They used to call me Roundy Robin. The genes were there, but fortunately I just happen to enjoy exercise. There's no greater pleasure for me than to be out on my bike."
The exercise myth
Taylor doesn't recommend upping your exercise when trying to shed weight, however, because plenty of evidence shows it is counter-productive – one study from the University of Pittsburg showed that dieters using fitness trackers actually gained weight over a two-year period.
The problem, says Taylor, is compensatory eating. "In one of our exercise studies, I commented to a participant that it was interesting to see that she had got much fitter but not lost any weight, and she said: 'You don't understand, doctor. When you come back from a half-hour walk, you've only got one thought in your mind – I deserve that pie.'
"Exercise is good for you. But the amount of energy spent during exercise is smaller than people imagine."
If the aim is to prevent weight gain, his advice is that being moderately active for a long period is better than intense bursts in the gym. But for those trying to lose weight, the priority is to consume fewer calories – boosting the appetite with an exercise session won't help.
It's a challenge to stick with any diet, particularly such a low-calorie one, but in all Taylor's studies, his participants were strongly motivated to improve their health. If they committed to the diet and were supported by their families, the excess fat did come off.
In the first week alone, the average weight loss was 3.5kg. Not only did blood- sugar levels drop, but the successful participants had fewer heart attacks and cancers.
"We've forgotten how much ill health is caused not by obesity but by a person being a bit heavier than is ideal for their own body. They've exceeded their personal fat threshold and that is such an important concept."
Taylor doesn't stand to get rich from any of this. He isn't launching his own range of liquid-diet meals, and royalties from the English language editions of his book, Life Without Diabetes, are going to the charity Diabetes UK, which funded his research.
In that book he debunks a lot of myths, or, as he calls them, "evidence-free ideas" – the notion of superfoods, the idea that the types of foods you eat are more important than the quantity. The most important myth his work has disproved is that medication is the only answer.
"The evidence-based medicine movement has rumbled along focused on drugs," says Taylor. "Everyone wants there to be a magic bullet. What we've shown is stopping all the drugs that we've developed at the cost of billions and fixing the problem with the body allow people to go back to normal."
Iinterest in ethnicity
The expertise that Taylor and his team have developed to manage the tricky business of scanning the pancreas for fat has been shared with researchers at the University of Auckland who are working on the High Value Nutrition Project and looking at the underlying causes of type 2 diabetes, how to diagnose risk earlier, and the optimum diet to prevent it.
Sally Poppitt, a professor of human nutrition, and her team are particularly interested in how ethnicity may play a role. They have scanned almost 200 people so far – a mix of European and Asian Chinese – looking at abdominal fat and then going deeper to seek out fat in the liver and pancreas.
"When we do that, with people who are the same height, weight, age and gender, the Asian Chinese are the most at risk of having worse blood glucose and fat in their pancreas," says Poppitt.
Participants in this study are healthy, but potentially at risk of developing diabetes, and the hope is to identify biomarkers in the blood that will signal early on that there is a problem in the pancreas and it is time to intervene. In the meantime, says Poppitt, the advice to remain lean is particularly important for those in the higher risk ethnic groups – Asian Chinese and Asian Indian – and anyone with a family history of type 2 diabetes.
"We hope that in a few years' time there might be a blood test," says Poppitt. "And we're also now looking at dietary intervention, what we can do to help the pancreas – that's one of our big interests."
As for Taylor, he has now managed another breakthrough. "Some experts say this isn't a remission: the diabetes is still there, it's just under good control," he says. "But we've been working on a paper that I hope will make a difference.
"We've shown that in type 2 diabetes, the whole pancreas is small and shrunken – about two-thirds the size of a normal pancreas. And we've demonstrated that in those people that get remission, the small pancreas gradually expands back towards normal over two years. It's real, there are scans to prove it and you can't argue with that."
Taylor's top tips for curtailing the kilos
1. The speed of weight loss isn't important, but most people find it easier to do it faster.
2. Only eat at mealtimes – no snacking.
3. Avoid sweetened drinks of all kinds.
4. Alcohol is liquid fat – don't drink it at all if you are trying to lose weight.
5. Write down your weight every week. If it rises by more than 3kg, take immediate action and decrease your daily amount of food.
6. If you have been diagnosed with pre-diabetes, losing 10kg – or 10% of your weight if you are under 80kg – should take you out of the category.
7. Once the weight loss part of the programme is over, you are likely to need only about three-quarters of what you used to eat.
8.You aren't what you eat – you are how much you eat.