Q&A: Plant-based diet intervention helps patients achieve type 2 diabetes remission

Key takeaways:

• The intervention led to decreases in BMI, HbA1c and fasting glucose.
• Physician interest and patient education on plant-based chronic disease management are crucial to the intervention’s success.

An intervention based on a plant-predominant diet and education helped patients with type 2 diabetes achieve remission, a study published in the American Journal of Lifestyle Medicine showed.

Gunadhar Panigrahi, MD, a cardiologist at Sentara Cardiology Specialists in Virginia, and colleagues wrote that with the incidence of diabetes among U.S. adults increasing from 2001 to 2020, “there is an urgent need for simple and accessible approaches to reverse this trend, including therapeutic lifestyle change.”

The researchers conducted a case series to demonstrate that a lifestyle-based intervention could reduce the need for medication and lead to remission among a cohort of patients with type 2 diabetes who were referred to a wellness clinic.

The intervention began with a 1-hour consultation visit to educate patients on the relationship between obesity and diabetes. Patients were then prescribed a plant-based diet that was high in fiber, low in fat and consisted of legumes, vegetables, seeds, nuts, fruits and whole grains.

A follow-up visit that consisted of progress monitoring and educational handouts occurred 6 to 12 weeks later, with further visits occurring every 3 to 6 months. A total of 59 patients with a mean age of 71 years underwent the intervention. Almost 60% were men.

The researchers found there were significant decreases in several outcomes following the intervention, including BMI (mean difference [MD] = –2.6; 95% CI, –4.8 to –0.3), HbA1c (MD = –1.3; 95% CI, –1.6 to –1) and fasting glucose (MD = –29.6; 95% CI, –41.8 to –17.5).

Ultimately, 37.2% of patients achieved type 2 diabetes remission.

Speaking to Healio, Panigrahi and study co-author Micaela C. Karlsen, PhD, MPSH, senior director of research at the American College of Lifestyle Medicine, discussed some of the study’s notable findings, the feasibility of implementing the intervention and more.

Healio: How feasible is the intervention to implement?

Panigrahi: The success will depend upon the following attributes:

• physician interest;
• investment of time in learning the principles of chronic disease prevention/management with plant-based diets and intensive education on plant-based nutrition and how to apply this in individual cases based on their particular need;
• working with patients where they are and supporting them in their learning process of the nutrition-based management of chronic diseases and applying them into their daily living; and
• educating [patients] on the facets of self-monitoring — daily weight, exercise and compliance with diet and blood pressure control — and understanding the results of blood chemistries [like] blood glucose, HbA1c, cholesterol levels, etc.

This is very time consuming, but at the same time very successful in preventing/reversing chronic diseases. In some cases, I have sent them to a dietitian who specializes in plant-based diets for chronic disease management (insurance covers this) and at times to a health coach who specializes helping them in meal planning, grocery shopping, label reading, etc.

To be broadly successful, it requires the participation of health care services, insurance companies and administrative support to compensate physicians based on a quality delivery model [rather] than the current work [relative value units (RVUs)] model based on time.

Healio: What would the cost be?

Panigrahi: There is no direct cost to the patients. The office visits are covered by their medical insurance. The initial visit as consult and the return visits are at the levels based on time spent with patient. These are according to the CMS guidelines (and most of the insurance companies reimburse based on these levels).

The teaching materials are prepared in-house using printers. So, my medical assistant helps me [with] printing these materials and putting them into folders, which I use for teaching/educating and give to the patients for free. This is absorbed to the practice overhead as a service (at no charge to the patient or insurance company).

There is a cost to me as a wellness provider because in my practice we are compensated based on work RVUs. My consult visits are 60 minutes, and return visits are 30 minutes. As a result of this, I see [a smaller] number of patients per day [and] generate less work RVUs, and the compensation is adjusted accordingly. But this has given me professional satisfaction, and my patients are appreciative of the extra time I give for education, meal planning, self-monitoring, etc. I acknowledge this is a limitation for implementing in the general practice as it stands now.

Healio: Did anything particularly stand out to you in the findings?

Karlsen: What stands out to me is the significance of seeing patients achieve type 2 diabetes remission by changing their diet — in this case, a whole food, plant-predominant, low-fat diet — without practicing severe calorie restriction.

Other examples of lifestyle interventions that have achieved remission include the DiRECT trial — an amazing clinical trial that did produce remission in about one-third of intervention participants — but they used liquid meal replacements and very low calorie intake (825 to 853 kcal per day formula diet for 12 to 20 weeks). It would not be possible to sustain that for the rest of someone’s life. Let’s be clear that DiRECT is an important and amazing study that was groundbreaking, but what we can see here is that we know that for at least some people, it is possible to achieve remission eating a diet that actually is feasible to maintain indefinitely.

The other type of remission research is on low-carb diets — and although it is possible for some individuals to make gains in glucose control or reduce diabetes medications, low-carb diets are usually high in saturated fat, and there are cardiovascular risks that come with this type of dietary pattern.

So again — what stands out to me is that the patients described here were able to eat a diet they can maintain, that is also heart healthy.

Healio: What are the implications for primary care physicians?

Karlsen: Patients deserve to be told that there is a chance they may be able to make meaningful improvements in glucose control and possible reductions in medication or even remission if they commit and are adherent to treatment. Not every patient will be interested, but every patient deserves to be informed and given the chance to try lifestyle approaches.

Healio: Where does research go from here?

Karlsen: This was a case series of success cases. We need to run randomized controlled trials to measure the effectiveness of this kind of intervention diet and lifestyle treatment quantitatively, and to compare outcomes across different levels of patient interest, across different levels of intensity and patient contact, and learn how many patients this will be effective for from the general population.

References:

• Lean MEJ, et al. Lancet Diabetes Endocrinol. 2019;doi:10.1016/S2213-8587(19)30068-3.
• Panigrahi G, et al. Am J Lifestyle Med. 2023;doi:10.1177/15598276231181574.