Transcription: Caroline Trapp, DNP, ANP-BC, CDCES, on Achieving Remission of Type 2 Diabetes Through Lifestyle Medicine
Jessica Bard: Hello everyone, and welcome to another installment of "Podcast 360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.
According to the Centers for Disease Control and Prevention, about 34 million people or 10.5 percent of the population in the United States had diabetes in 2018.
Dr. Caroline Trapp is here to speak with us about remission of type 2 diabetes through lifestyle changes. Dr. Trapp is the director of diabetes education and care at the Physicians Committee for Responsible Medicine, and an adjunct faculty member at the University of Michigan School of Nursing in Ann Arbor, Michigan.
Thank you for joining us today, Dr. Trapp. Please give us an overview of your poster presented at ADCES21, targeting remission of type 2 diabetes with lifestyle medicine.
Dr Caroline Trapp: This poster is a labor of love. I have to tell you that so much of what I understood about how to provide care to people who have diabetes has really changed over the years. In my work as a nurse practitioner in primary care and as a certified diabetes care and education specialist, I would say that the goals of care had always been tight control: A1c reduction and good glucose numbers.
It was all about management and prevention of complications, and those are worthwhile goals. But, in my clinical experience, in the primary care setting, we treated diabetes really aggressively. Ours was a primary care practice that used insulin pumps early on, made those available to patients, we used a lot of insulin, we used a lot of medications to get numbers lower. But what I saw in my practice was that even people in good control often develop complications. With good numbers, they weren't immune from suffering from heart attacks, or losing their vision, or having kidney disease.
I was really concerned about that, of course. I have come to recognize that the route to lowering A1c is critically important. That lower blood glucose numbers with medication doesn't get at the underlying problem of type 2 diabetes. It doesn't always prevent vascular disease, micro or macrovascular disease. There has to be a different route.
Through my work with the Physicians Committee, I've become an expert in the science of plant‑based nutrition. I have seen that work effectively with my own patients to help them turn their diabetes around as well as experience all kinds of other benefits that a conventional diet for diabetes didn't do.
I've seen people get off a blood pressure medication, lower their cholesterol, lose weight if they're overweight, and experience other improvements in things like arthritis and migraine headaches. There seemed to be all these additional benefits of a plant‑based diet.
I was really excited when the American College of Lifestyle Medicine published a paper in November of 2020 called, "Type 2 Diabetes Remission and Lifestyle Medicine." This is their position paper.
The goal of my poster presentation is to share this information with other diabetes educators with the hope that our interactions with our patients can be around this new idea that it's not about control. It's not about slowing the progression to complications, but that it's possible to put type 2 diabetes into full remission.
Jessica: Let's dive a little bit deeper here on remission. Define partial and full remission of type 2 diabetes. How can it be achieved? I know we talked a lot about diet, but dive a little bit deeper there for us, please.
Listen to the podcast here.
Dr Trapp: Sure. Let me start with the numbers. I'm going to use the definition of remission that American College of Lifestyle Medicine used in their position paper.
This comes from use in 2009 Diabetes Care. They defined remission as an A1c in the normal range, so less than 5.7 percent. Fasting glucose less than 100 milligrams per deciliter without any medication for at least one year.
They also defined partial remission. This would be sub‑diabetic hyperglycemia, an A1c of less than 6.5 percent. Fasting glucose between 100 and 125 milligrams per deciliter. That's for a year.
It's helpful to know what are the numbers that we're looking at. The British Diabetes Association uses the same numbers, but they say six months is their target.
There are different routes to remission Research has shown that significant weight loss can lead to remission. Fasting and fasting‑mimicking diets are a route, bariatric or metabolic surgery is a route. The route that I think is important for us to focus on is intensive lifestyle modifications.
Jessica: Let's talk about those modifications. How does a certified diabetes care and education specialist identify type and intensity of lifestyle modifications required for significant metabolic improvements and intervention?
Dr Trapp: First of all, I want to list the areas for lifestyle modification that have been recognized by the American College of Lifestyle Medicine as being therapeutic. They include physical activity, stress management, healthy relationships, quality sleep, and avoiding risky substances like alcohol into their health, and then healthful eating is the sixth.
Healthful eating is the area of lifestyle change that has probably the most robust research and has been shown to have the most dramatic improvement in care of people who have diabetes and many other chronic diseases. It's a whole‑food plant‑based diet that has been identified as per dietary approach of American College of Lifestyle Medicine.
I would also point out that a whole‑food plant‑based diet has been the diet recommended by AACE, the American Association of Clinical Endocrinologists, for several years. Plant‑based or vegan/vegetarian diet is within the guidelines of the American Diabetes Association.
This is not completely a new information but unfortunately, a lot of clinicians are not aware of it. It certainly isn't something that has been taught in many medical, nursing, even dietetic programs, and that's changing.
Here, where I am in Michigan, Wayne Medical College now is including plant‑based nutrition across the four‑year curriculum for medical students. There are other health professional education programs that are also teaching this dietary approach.
Jessica: When considering the goal of our mission, what are potential changes certified diabetes care and education specialist can make to their roles and responsibilities?
Dr Trapp: The first thing I would recommend is that diabetes educators learn about this approach. Come at it with an open mind. I know from myself that I really thought plant‑based ‑‑ or as we called it back in the day, a vegan diet ‑‑ was really extreme and too hard for most patients, and something that I never thought would be anything doable for most people.
Now, there's so much good research and there are continuing medical education programs and entire conferences devoted to whole‑food plant‑based diets for diabetes and other associated chronic conditions. The first step is certainly learning about it. I'll be happy to talk to you about some good resources to where diabetes educators can get good evidence‑based information on plant‑based diet.
The second piece is talking to our patients about this approach, letting people know that this is effective and it's doable. That there are great resources to help people make the shift.
Within ADCES there is a plant‑based community of interest. It's been around for, I think, five years now. We have over a 450 members, so it is the largest or one of the largest communities of interest within ADCES. The web page for the group...We all have kinds of great resources including a toolbox for DSMES programs that is available at no cost that people can use to incorporate information about plant‑based eating into their recognized diabetes education programs.
For me, in primary care, what I would do with patients is ask, "Are you familiar with plant‑based diets?" "What do you know about plant‑based diets and diabetes?" and, "Would you like to learn more about it?"
I love to share stories of success that my patients have had with making this diet change, and how they've achieved weight loss and the ability to get off a blood pressure medications. But the thing that I'm the most excited about is I see that blood sugars drop like a stone within a short time when they make this change.
Another thing that I think is important for diabetes educators to have is a number of different resources.
People learn differently. Some people like to read. Maybe educators want to recommend "Dr Neal Barnard's Program for Reversing Diabete," a great book. Other people love to watch movies, and especially, they want to bring this information to their family members who maybe aren't in the class or aren't in my clinic.
They want to share a movie, a documentary, like, "Forks Over Knives," or "The Game Changers" to get others involved and excited about this approach.
Of course, having access to some resources like cooking classes: The Physicians Committee has a program called Food for Life. These are live and online cooking classes that people can take on.
There's one specific to diabetes. There's a cancer‑survivors' class. There's a weight‑control class. There's an employee‑wellness class. They can go to http://www.fflclasses.org for Food for Life classes to find classes in their area or virtual classes. Often these are available at a very low cost. It's a great way to learn some of the cooking skills and to try out some delicious plant‑based recipes.
Jessica: That must be extremely rewarding to see those positive outcomes in your patients, I can imagine. We can list some of those additional resources on consultant360.com with this podcast, too. What's next for research in this area?
Dr Trapp: There's a lot of different areas. One area of research that I find interesting is identifying those people who have type 2 diabetes, who are candidates for full remission.
We know that the underlying problem in type 2 is insulin resistance. We also know that some people over time are not making adequate insulin. Being able to identify those people outside of the research setting using C‑peptide test, using HOMA‑IR. Those might be tests that become
There may be other ways that people can be identified before they make these lifestyle changes so that we can target this approach to those who will be successful with it. I will also say that partial and full remission should be the goal.
There are so many other health benefits to implementing significant lifestyle changes that I feel that a whole‑food plant‑based dietary pattern is something that should be offered to all of our patients.
In terms of other research, my focus in this poster presentation has been with type 2 diabetes. The Physicians Committee for Responsible Medicine is about to launch a study on diet and type 1 diabetes. We know that people with type 1 experience vascular disease diet is certainly involved in the development of vascular disease. While we don't expect that people with type 1 will eliminate the need for insulin, we suspect based on the clinical experience of many people, that we may be able to significantly reduce the amount of insulin needed as well as reduce progression to various complications.
Jessica: To sum it all up, what are the overall take‑home messages from this poster?
Dr Trapp: The primary take‑home message of this poster is that remission is possible for people who have type 2 diabetes. We can do more than just control this disease or manage this disease. It can be turned around.
A really important distinction that diabetes educators should be aware of is the dose of the intervention. We're used to thinking of the dose in relation to medications. "How much insulin? How much of these different pills should a patient get?" Lifestyle can also be dosed.
There are therapeutic doses and sub‑therapeutic doses. In my poster and in the ACLM position paper, they make the distinction between these two quantities of dose as those who achieved remission, and those who didn't.
The difference in their literature review of studies that achieved remission was the amount of the weight loss. Those studies that showed people were able to achieve remission at a mean weight loss of about 20 pounds in comparison to those that didn't achieve remission patients only lost an average of about eight pounds.
In the studies where they achieved only about eight pounds weight loss, those patients were instructed to reduce their caloric intake by about 500 calories. Oh my goodness, when I read that, it hit me so hard.
Isn't that what diabetes educators are taught? That we should teach people who are overweight to take in about 500 less calories a day and that will help them get control of their diabetes. However, perhaps not going far enough to achieve full remission.
In the studies that achieved 20 pounds of weight loss and showed remission, many of these studies used low‑calorie diet, 600 to 1,100 calories per day. While that's one approach, the American College of Lifestyle Medicine suggests that that's not the only way to achieve that much weight loss.
We routinely see in studies where people adopt a whole‑food plant‑based diet they lose 20 pounds or more with a whole‑food plant‑based diet. The takeaway here is that our recommendation to switch from whole milk to skim milk or to take the skin off the chicken or look at different ways to cut calories a little bit, doesn't go far enough.
We now have better evidence to suggest that we need to intensify our lifestyle interventions to the point where they get at the underlying problem. One more point that I want to leave people with, is this idea of a good understanding of why a plant‑based diet is effective.
In my poster, I can hear potential mechanisms. I look at what are the problems with foods from animals along with what are the benefits of plant foods.
We know that foods from animals are high in saturated fat and cholesterol. Plant foods have no cholesterol at all. Most of them have very little to no saturated fat.
Fat intake is really important. We know that excess dietary fat gets inside muscle cells, liver cells, pancreatic cells, and interferes with the body's ability to make insulin and to utilize insulin. Fat content is just one of the really important considerations in comparing foods from animals to plant foods.
There's an important term for diabetes educators to know, it's intramyocellular lipid. This is the fat that accumulates in muscle cells, and leads to insulin resistance. When people shift to whole‑food plant‑based diet, they're taking in less fat in their diet, and intramyocellular lipid dissolves and disappears. Insulin resistance goes away. Insulin sensitivity improves.
Understanding this underlying mechanism is an important concept for diabetes educators, and one that we can share with our patients to understand why we're recommending a plant‑based diet.
The other benefits of plants are things like antioxidants and phytochemicals that have been shown to reduce the risk of cancer, which people with diabetes are not immune from. Another really important piece is only plant foods are high in fiber.
Foods from animals have no fiber at all. We know that fiber helps to keep blood glucose levels steady, and also lower the risks of many types of cancers.
I'll stop there. [laughs] You can see that there are...Although this poster has the word remission in the title, the really important concept that I want to share is the route to remission I think is critical. Lowering A1c by piling on more and more medications may get better numbers but does not cure the disease whereas lifestyle medicine offers us the opportunity to help our patients achieve remission.
Jessica: This poster is so jam‑packed with important information. That was great. Is there anything else you would like to add at all that you think we missed?
Dr Trapp: You are so kind to ask that question after I have gone on and on. I want to make sure I really emphasize that our community of interest is an active community within the American Association of Diabetes Care & Education Specialists. I hope diabetes educators will know that it's free with their membership and will check it out because there's a lot of great resources there.
Jessica: Fantastic. Thank you so much, Dr Trapp. We really appreciate your time today.