Management of type 2 diabetes in real world with intermittent fasting: a report of two cases

¹Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria, ²Department of Community Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria

^&Corresponding author
Taiwo Hussean Raimi, Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria

Introduction    

Type 2 DM was thought to be a progressive and irreversible disease, but recent insights into its pathophysiology disprove this notion. Weight loss of over 10 kg is associated with durable recovery of β-cell function and restoration to non-diabetic glucose [1]. One of the ways of achieving weight loss is intermittent fasting (IF). Intermittent fasting means abstaining from food for a specific period, and then resuming food intake during specific hours of the days referred to as the window period [2]. Intermittent fasting has been shown to be beneficial for glucose homeostasis, resulting in decline in HOMA-IR index, fasting glucose and insulin, as well as glycosylated haemoglobin [2]. It also favors desirable weight, leptin and adiponectin profile [3]. These benefits imply that IF is an effective non-pharmacologic treatment for type 2 DM. Additionally, IF has favourable effects on blood pressure and lipid profile [4,5]. Effective DM treatment is out of reach for the majority of people living with DM in our environment. This novel therapy is desirable and important in an environment of scarcity and out-of-pocket health expenditure, like ours. Reports on IF for DM treatment in Nigeria is non-existent. We therefore report observations on two patients who achieved diabetes remission with IF. These cases are unique because they were managed in real world rather than research settings. Our main outcomes are change in weight, body mass index (BMI), waist circumference, premeal glucose, and HbA1c.

Patient and observation     

Patient 1

Patient information: a 66-year-old woman with T2DM of 14 years and systemic hypertension of 13 years, receiving treatment at our facility, had deterioration in her glycaemic control. Her diabetes and blood pressure medications include vildagliptin 100 mg/day, metformin 2000 mg/day, voglibose 0.6 mg/day, amlodipine 10 mg/day, valsartan 160 mg/day, and hydrochlorothiazide 12.5 mg/day (Table 1, Table 2).

Clinical findings: clinical evaluation revealed that she weighed 85 kg, had body mass index (BMI) of 34.0 kg/m², waist circumference (WC) of 97.5 cm, and her blood pressure (BP) was 150/90 mmHg.

Diagnostic assessment: her HbA1c increased from 7.0% (53 mmol/mol) to 7.9% (63mmol/mol). Similarly, her premeal glucose increased from 90-122 mg% (5.0-6.8 mmol/L) to 112-130 mg% (6.2-7.2 mmol/L), while her post-meal glucose increased from 116-154 mg% (6.4-8.6 mmol/L) to 146-195 mg% (8.1-10.8 mmol/L).

Diagnosis: type 2 diabetes mellitus, systemic hypertension, obesity

Therapeutic interventions: since she was unwilling to use insulin, counsel on IF was offered. She also had dietary advice. She fasted for 18 hours three times/week for three months and continued with 18 hours fast twice/week for 15 months before switching back to thrice/week fasting. The voglibose and vildagliptin were discontinued 3 and 6 months, respectively, after commencement of fasting.

After 18 months of fasting, she lost 14.0 kg; BMI was 28.4 kg/m²; WC, 93 cm; pre-meal glucose, 98-112 mg% (5.4-6.2mmol/L); post-meal glucose, 134-165 (7.4-9.1mmol/L); HbA1c, 6.1% (43 mmol/mol); and BP, 129/78mmHg (Table 2, Figure 1).

Patient perspective: "I have been having the diabetes disorder for many years. The dietary indiscipline on my part and poor management made the situation grow worse until I was referred. I was placed on intermittent fast three/four times per week, and my drugs were reviewed. I closely monitor my readings - fasting blood sugar, readings at breaking of the fast and 2 hours after food. This regime coupled with the right dietary control paid off tremendously as I began to record lower readings which invariably fell within the normal range after about three months of the start of the fast. Right now, my blood sugar is under control, so also my blood pressure. The doctor noticing this positive development had to review my drugs again. However, it should be noted that one has to exercise some degree of lifestyle change/discipline on foods and drinks. I´m happy to note now that my HbA1c and fasting blood sugar readings show that my diabetes is under good control."

Patient 2:

Patient information: a 53-year-old woman presented on account of fasting hyperglycemia of 252 mg% (14.0mmol/L). She was asymptomatic, save for nocturia. She had no visual complaints, intermittent claudication, angina or paresthesia. She was on amlodipine 5 mg daily and losartan 50 mg daily for systemic arterial hypertension. There is history of type 2 diabetes in the mother. Before presentation, she had commenced metformin 500 mg/day (Table 1, Table 2).

Clinical findings: clinical findings were significant for overweight (weight, 73 kg; height 1.6 m; BMI, 28.5 kg/m²), central obesity (WC, 89.6 cm), and blood pressure of 140/80mmHg. She had normal fundoscopic findings.

Diagnostic assessment: her HbA1c was >14% (>130 mmol/mol), and fasting plasma glucose 252 mg% (14.0 mmo/L). Other laboratory results were triglyceride, 0.20 mmol/l; total cholesterol, 4.56 mmol/l; LDL-cholesterol, 2.87 mmol/l; HDL-cholesterol, 1.60 mmol/l; AST, 17 IU/L; ALT, 09 IU/L. She had a normal urinalysis.

Diagnosis: type 2 diabetes; systemic hypertension; hypercholestorolaemia.

Therapeutic interventions: she was counselled on intermittent fasting, and opted for 16 hours fasting 3-4 days per week, and used metformin 500 mg on non-fasting days, but stopped about a month later. She maintained antihypertensives, but stopped amlodipine five (5) months later when the blood pressure improved. Clopidogrel 75 mg once daily was added to her medications, and was also counselled on diet and 150 minutes of exercise weekly.

Follow-up and outcome of interventions: sixteen (16) months later, she lost 11 kg. The BMI was 24.2 kg/m²; WC, 82 cm; HbA1c, 6.0% (42 mmol/mol) and BP, 130/68mmHg (Table 2, Figure 2). Lipid profile after nine (9) month of intervention revealed triglyceride, 0.6mmol/l; total cholesterol, 3.5mmol/l; LDL-cholesterol, 1.9mmol/l; and HDL-cholesterol, 1.31mmol/l.

Patient perspective: "I fasted intermittently for 16-18 hours 3-4 times a week. I drastically cut down on snacking and high-energy-dense drink. I don´t take food with raw sugar, but more of vegetables and fruits. The benefits are obvious - normalized glycemic values, normal blood pressure and normal BMI."

Informed consent: written inform consent was obtained from the patients.

Discussion     

In the cases above, both patients lost more than 10 kg, and when combined, this translated to 15.8% mean change in weight and BMI. Both of them also achieved with HbA1c of <6.5% (<48 mmol/mol). The mean change in HbA1c for the two patients was at least 44.7%. Our patients also had desirable changes in their waist circumference and blood pressure. Intermittent fasting helps to achieve durable weight loss due to its effect on hunger and satiety [3]. Our report is consistent with previous findings that weight loss of more than 10 kg was associated with improved beta-cell function and diabetes remission [1]. The second patient met the definition of remission proposed by Nagi et al. [6]. This definition has three components: (1) weight loss; (2) fasting plasma glucose 126 mg% (<7 mmol/L) or HbA1c <6.5% (<48 mmol/mol) on two occasions separated by at least 6 months; (3) the attainment of these glycaemic parameters following the complete cessation of all glucose-lowering therapies [6]. The first patient on the other hand was still on metformin. This may due to the fact that she had a long (14 years) duration of diabetes. Previous studies found that not all people with long duration of diabetes achieved remission. When diabetes duration is up to six (6) years or more, remission rates are about 50% [1,4]. This low rate is due to irreversible damage to β-cells of the pancreas [1]. Similar to our findings, some authors also reported improvement in anthropometry indices and blood pressure with IF [7,8]. Previous reviews also corroborated these [2,3,9,10].

The management of Type 2 DM is lifelong. This requires a combination of lifestyle changes (dietary/exercise) and medications. Combination of oral antidiabetic agents with different mechanisms of action are required, and in many cases as the disease progresses, injections such as insulin are needed. Despite the above, many patients fail to achieve glycaemic targets [11]. Overweight and obese patients are particularly difficult to manage due to associated insulin resistance, plus weight gaining effect of insulin and some oral medications. Bariatric surgery has been shown to be effective in the management of DM in an obese patient, but it is costly. Furthermore, there is need for follow-up with lifestyle adjustment for its benefits to be sustained. These modalities of treatments are out of reach for many patients with T2DM in Nigeria, and may result in catastrophic expenditure [12]. Any effective treatment for diabetes mellitus that costs little or nothing is highly desirable in our setting. Therapeutic fasting may be the answer.

IF need to be supervised, and continuous education and support are needed for its sustenance. This is because avoidance of weight regain is necessary to prevent recurrence of type 2 diabetes. Experience with one of the patients (case 1) showed this. She regained 3 kg, but fortunately, her HbA1c remained stable. During this period, she stopped IF, but resumed when she was counselled. The strength of our cases was the fact that they were managed in normal clinic and real-world scenarios. One of the patients was even managed remotely for 5 months due to the outbreak of COVID-19. This report is limited by the number of patients involved. And more people need to be studied to determine the usefulness of IF in our setting. Our cases highlighted the beneficial effects of IF in the management of Type 2 diabetes. The advantages of intermittent fast are that it is effective, free, simple, safe, and no special diet is required. Since IF results in reduction in pill and financial burden, it is hoped that this form of therapy will gain wide acceptance in our environment.

Conclusion     

The two patients presented achieved diabetes remission with intermittent fasting. These cases suggest that type 2 diabetes may be effectively managed with intermitted fasting in selected cases. This treatment modality is possible in real-world settings, and should be explored in developing countries, where catastrophic expenditure is common.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Taiwo Hussean Raimi and Oluremi Olayinka Solomon. Manuscript drafting: Taiwo Hussean Raimi. Manuscript revision: Taiwo Hussean Raimi and Oluremi Olayinka Solomon. All authors approved the final version of the manuscript.

Acknowledgements     

We thank the patients for granting consent to publish the cases.

Tables and figures     

Table 1: patient characteristics

Table 2: changes in glycaemic and anthropometric parameters from baseline to end of fast

Figure 1: change in glycosylated haemoglobin (HbA1c) while on fast for patient 1

Figure 2: change in glycosylated haemoglobin (HbA1c) while on fast for patient 2

References