As the afternoon sun beats down on the coastal village of Veli in Thiruvananthapuram, William Pereira, 57, sits down to lunch. His plate is a canvas of colours, with a generous serving of fruit and vegetable salad, a modest portion of rice, sambar and fish curry. His food was not always this colourful, varied and measured.
Pereira is a loco pilot with the Indian Railways. He started his career as an assistant loco pilot at the age of 25 in the Madras division. Over the years, he has held various positions, including goods train driver, yard shunter and passenger train driver before becoming a loco pilot of express trains. “The nature of my job is such that if one day it is night duty, the other day it is day duty,”says Pereira. “It is not a nine-to-five job. As assistant loco pilot, you have to work on all sorts of trains. In goods trains, you may have to spend 96 hours or more. Owing to the nature of this job, having nutritious meals on time has been a challenge.”
But his body, like the trains he manoeuvred, worked like clockwork. That is until July 2020. Pereira was at home owing to the pandemic-induced lockdown, and his body started showing signs that all was not well. “I was thirsty always, and I frequented the toilet to pee,”he says. “Then I spoke to [diabetologist and researcher] Dr Sreejith N. Kumar, who was my classmate at Government Model School, Thiruvananthapuram. He asked for details of any history of diabetes in the family. My mother was diabetic. So, he asked me to check the blood sugar level, and meet him with the results.”
A fasting blood sugar level of less than 100mg/dL is considered normal, and after food normal is less than 140mg/dL. Pereira’s test results showed a fasting blood sugar of over 500mg/dL and after food sugar level of 700mg/dL. Pereira did not want to take lifelong medication or insulin injections. “I took metformin and glimepiride for a year,”he says. “However, within a year, I was able to stop these medications by following a lifestyle intervention and weight loss programme devised by Kumar.”At the heart of the programme is the slogan “platil paathi pachakari (half the plate for vegetables)”. Not only did it help stop his diabetes medication, it also brought down his hypertension medication from 50mg twice a day to 25mg once a day.
Diabetes in remission: A possibility?
Type 2 diabetes was considered to be a lifelong condition for a long time. However, in 2008, UK-based diabetologist Roy Taylor introduced ‘the twin-cycle hypothesis’. In subsequent years, he published groundbreaking studies that showed that the disease could go into remission through lifestyle interventions. The most crucial in this regard was the Diabetes Remission Clinical Trial aka DiRECT study, published in 2016, which showed that a primary care-led weight management programme can induce remission of type 2 diabetes. This study was conducted in Scotland and involved 306 participants who were diagnosed with type 2 diabetes and had a BMI of 27 or higher. The study found that a low-calorie diet (around 800 calories per day) could result in significant weight loss and remission of type 2 diabetes in almost half the number of participants.
“Earlier we thought insulin resistance and insulin deficiency, caused by eight factors―ominous octet―such as lack of physical activity, chronic inflammation and poor diet, led to diabetes. And we thought it was invariably progressive,”says Kumar. “But with the publication of the DiRECT study and other studies correlated with it, it became clear that diabetes can be reversed even in ordinary [primary-care] settings with lifestyle interventions.”
Taylor’s twin-cycle hypothesis emerged from a work he had been doing to understand how the body, in particular the liver, was controlling the glucose level in the blood. When a person eats, his body breaks food into sugar and sends it to the blood. Insulin, produced in the pancreas, then helps the body to move the sugar from the blood to cells. The sugar that enters the cells would be either used immediately as fuel for energy or may be stored for later use. In the case of a person with type 2 diabetes, the body’s cells do not respond to insulin properly, and this condition is called insulin resistance. When the blood sugar levels are high, the pancreas would secrete more insulin to make up for it. However, over time, pancreas would find it harder to create so much insulin to keep the blood sugar at normal levels.
“We found that the fat in the liver makes it resistant to insulin, and glucose production is far too high in type 2 diabetes [patients],”Taylor told THE WEEK. “But then we found that if we reduce the amount of fat in the liver, the insulin sensitivity would go back to normal and, I said, ‘Well, that is fascinating’. I thought that if fat in the liver is causing this, then type 2 diabetes has to be a simple condition―it is associated with putting on a little bit more weight than ideal.”
Taylor then put two and two together―what is happening in the liver with what is happening in the pancreas. He observed that it was not only insulin resistance, but also pancreas not producing enough insulin rapidly after eating that was causing the blood sugar levels to shoot up. “As I played with these ideas on a piece of paper and drew arrows between the things, I could see it all work as two vicious cycles,”he said. “One vicious cycle in the liver would cause a steady buildup of fat in the liver. But then that fat is going to be exported. That is what the liver does; it just gives fat to the rest of the body.
If it is too much fat in the liver, maybe too much fat is coming out of it as well and settling in the pancreas and other places where it should not be. And then that would cause blood sugar to go higher, and that will make more fat in the liver. So, we have two vicious cycles, which are interacting. So that was the twin-cycle hypothesis and it carried the vital prediction that if we reduce the amount of fat in the organs, everything should go back to normal.”
Those who participated in the DiRECT trial received a dietary intervention. “In the trial, it was observed that if the people had lost more than 15kg, 86 per cent of them had their diabetes in remission―and, after one year they did not require any drugs,”says Kumar. “Seeing its impact, we decided that we should also try to implement a lifestyle intervention programme.”Based on a lot of trial-and-error methods, in 2018, he came up with a programme called the Structured Lifestyle Intervention Method or SLIM with a specific focus on the Indian population.
Kumar’s method involves a dietary intervention along with other strategies such as increased physical activity, exercises and behavioural changes. “In SLIM, we follow something called ‘my plate method’or a ‘food plate method’,”says Kumar. “This was a method developed in the west, which prescribes the right distribution of carbohydrate, protein and fat [in a plate]. [A lot of people have a diet that has] an excess of calories and carbohydrates. So, what we are trying to do is, we are encouraging our patients to eat between 1,000-1,400 calories a day so that there is a calorie restriction and a carbohydrate restriction. We ask them to consume less than 50 per cent of calories from carbohydrates, 20 per cent from proteins and 30 per cent from fat. This means filling half your plate with vegetables and fruits, especially low glycaemic index (GI) fruits (which are high in fibre, protein and healthy fats, and low in carbohydrates and sugar), one quarter with proteins and the other quarter with cereals. So, when we translate this, it becomes plenty of vegetables, some amount of low GI fruit, coupled with some proteins. Protein brings satiety and does not increase sugar. But we have to be mindful of the calories. So, a limited amount of protein.”
Dr Vijaya Sarathi H.A., an endocrinologist with Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, claims to be the first in India to start a programme that aims at reversing diabetes. In 2017, he along with three other researchers published a study that observed high remission rates in young Indian diabetics who were newly diagnosed and were put on an intensive lifestyle therapy of low-calorie diet and brisk walking for an hour. The study observed that the remission rates at three months, one year and two years were 75 per cent, 75 per cent and 68.75 per cent, respectively.
Sarathi’s method of dietary intervention is very similar to the one devised by Kumar. “We encourage our patients to go for a more complex, but more balanced [diet] with protein and fat,”says Sarathi. “My focus was more on the patient’s ability to sustain the diet. I typically give a low-calorie, low-carbohydrate diet. And this is working very well. I have many patients who have reversed diabetes within a period of one month to three months.”
According to Kumar, a patient’s journey to reverse diabetes starts with his passion for the process. “We cannot force them, so one has to be passionate to be involved in the intervention programme,”he says. “We then train them.”First comes a comprehensive evaluation, along with which the participants receive practical and academic training. The practical training, says Kumar, involves giving participants a model breakfast that follows the concept of the healthy food plate method after they give their fasting blood sample. “After this model breakfast, we give them a lecture,”says Kumar. “And, their after-food sugar levels are checked.”
In 2019, Kumar and his team conducted an independent study with 250 patients who had the model breakfast and 250 patients who had a usual breakfast. “We found that the difference between the fasting and after-food sugar levels in those who had our breakfast was only 16mg/dl on average, whereas it was 75mg/dl in the other one. So, they can straightaway see the benefit, and get convinced of our method. And that is a huge motivation. In fact, we observed that one-third of the patients would have lesser after-food sugar levels than fasting levels. And on the day of the testing, we ask them to reduce their medicine dosage by half. So, in spite of halving their dose, when they get the substantial result in their after-food blood sugar, they get convinced about the power of our method.”
This initial session on dietary intervention is followed by a session on exercise. “We get a spectrum of patients for SLIM. As a general rule, we ask patients to walk for 45 minutes to one hour,”says Dr Unnikrishnan Ramachandran, a consultant physiatrist from Thiruvananthapuram. “Those who would like to take other forms of aerobic exercises such as jogging, swimming or cycling are also encouraged to do so. We prescribe only less injury-prone exercises to our patients. We also give 12 sets of exercises that cover most of the major muscles in the body. These include exercises performed with dumbbells and elastic bands, as well as those utilising your own body weight. These are simple things that are known to everybody. But when we give them in a systematic way, people are motivated to stay on the SLIM path.”
Some crucial observations from the study of SLIM subjects in the last few years were presented by Kumar at the International Diabetes Federation’s World Diabetes Congress 2019, held in Busan.
“In the first 50 patients enrolled in SLIM, 86 per cent could lose some weight and 76 per cent could either reduce or stop medicines within three months,”says Kumar. “A majority of them only reduced their medicine dosage. But one thing was certain―none of them had to increase their medicine dosage.”
Thiruvananthapuram resident Sailaja Kumari, 65, a retired Kerala Water Authority employee, used to take 1,000mg of glutformin before she followed the SLIM regimen. “Kumar later reduced the dosage to 500mg and eventually stopped it altogether,”she says. “Additionally, my weight decreased from 78kg to around 70kg, and I noticed significant improvements in my sugar levels. I diligently followed the prescribed food plan, ensuring that a significant portion of my plate consisted of vegetables. I also reduced my cereal intake significantly.”
By 2022, Kumari says she completely stopped taking medicines for diabetes, and could maintain it for many months.
But then something unexpected happened―she had a tumour in the uterus, for which she had surgery. Her exercise and diet went for a toss, and her sugar levels shot up. “I had to be back on medicines,”says Kumari. “Post surgery I started taking 1,000mg. But within months, by being back on a good diet and exercises, I could bring it down to 500mg. I hope that soon I will be able to avoid medicines completely.”
Kumar, who authored the book Prameham Maaran Nalla Bhakashanam (Good Food to Reverse Diabetes), later did a study on 55 patients on SLIM who could completely stop medicines between 2019 and 2022. Of these patients, three were initially only on lifestyle intervention. Twenty-six patients were on insulin and oral drugs―they could stop insulin intake. And, 26 patients were on oral drugs alone and they could stop all oral drugs. All patients continue to be on lifestyle intervention. The study was presented at World Diabetes Congress 2022, held in Lisbon last December.
“Our study was not to find out how many people reversed diabetes in a particular amount of time, but to know the profile of those who had reversed diabetes. We had two criteria: duration of diabetes and the weight loss [achieved during SLIM],”says Kumar. “We found that for those with less duration of diabetes, the tendency for reversal was much higher, which is reported across the world, including in the DiRECT study.”The fat in the pancreas is reversible to a large extent in the initial stages, and that is why the chance for reversal is high in the initial stages, according to the researcher.
“But more importantly, we found that people who had a very long duration of diabetes, even ten years, could stop drugs,”says Kumar. “We also found that people who were taking insulin for a smaller duration had more chances to stop insulin. Even people who had been taking insulin for more than 15 years could stop it.”
The third and most important question that Kumar’s study dealt with was about how much weight one needs to lose to achieve desirable results. “A majority of the patients lost only between 1kg to 5kg [to reverse diabetes],”says Kumar. “So, it is not an unachievable goal. Some had lost only less than 1kg. Very few patients lost more than 5kg. Whatever results we were getting, we were getting it from actual day-to-day life. There was no extra intervention after our initial sessions, though they undergo some routine consultation. That is why we say this is a practical day-to-day method. This reversal of diabetes was achieved not in test conditions.”
Doctors caution that diabetes patients should not take the ‘so-called’reversal for granted, and should sustain the lifestyle changes that helped them lower their blood sugar. “One fine day, all these people may have diabetes again, because what they undergo is a transient reversal,”says Sarathi. “So, there is a debate whether we should call it remission rather than reversal of diabetes.”Also, there is a chance of recurrence in patients with low insulin secretion, even if they follow a strict diet and exercise regimen. “Insulin secretion is something that is dependent on genetics,”says Sarathi. “We cannot regulate that, though the calorie restriction may slightly increase insulin secretion, as shown by Taylor. This insulin secretion, as a natural course for type 2 diabetes patients, may eventually go down. With calorie and carbohydrate restrictions, a person could reduce insulin resistance and make the insulin work in the body better. Even if they maintain the same insulin sensitivity, as the insulin secretion goes down after five years or ten years, they won’t be able to maintain normal glucose levels.”
A lifestyle for all
It is estimated that for every diabetic in India, there is a pre-diabetic. “So even if someone has a normal sugar level, he may have other lifestyle diseases like high cholesterol or high blood pressure,”says Kumar. “The Indian Council of Medical Research recommends a waist circumference of less than 80cm in women and less than 90cm in men. If this is increasing, that is an indication of increased body fat. And that is an indication that this person is going to have lifestyle diseases and cardiovascular complications such as cardiovascular disease, which is heart attacks or strokes. The method which we are suggesting―though diabetic patients are more willing to listen―is a method for everyone in the society to adopt.”