Aug. 22, 2024 – Lauren O’Hagan received a message on her phone on May 1 that caused her to pause. With a gastric bypass pre-operation appointment looming – a procedure that she really didn’t want to go through with – she was being offered a different option: A spot in an experimental program that aims to send type 2 diabetes into remission.
Run by the United Kingdom’s National Health Service, the yearlong Type 2 Diabetes Path to Remission Programme kicks off with “total diet replacement,” where people swap meals for low-calorie soups, milkshakes, porridges (a breakfast dish similar to oatmeal), and snack bars for the first 12 weeks. They are limited to between 800 and 900 calories per day. After the meal replacement phase, they get personalized coaching as they start reintroducing a nutritious, balanced diet for the rest of the program.
A third of people who completed the program put their diabetes into remission, and some lost up to 38 pounds, according to a recent report in the journal The Lancet Diabetes and Endocrinology. In the spring, NHS England announced plans to double the capacity of the program. Those taking part must be between the ages of 18 and 65; have a BMI over 27 if they are White and 25 if they are Asian, Black, or another ethnicity; and have been diagnosed with type 2 diabetes within the last 6 years.
O'Hagan, 27, canceled the gastric bypass surgery, is currently in the total diet replacement phase of the program, and has already lost almost 28 pounds.
“I would be lying if I say it has been easy,” said O’Hagan, who works as a human resources assistant. “Definitely cried a few times within the first week as you are getting used to not having as much sugar and things like that, but it just gets easier as time goes on.”
She enjoys both a cappuccino shake and a summer fruit shake (which O’Hagan said tastes like a strawberry milkshake) each day, along with porridge twice a day. People in the program are also offered a fiber supplement made of psyllium husk, which O’Hagan often mixes with her porridge.
When she noticed her blood sugar getting unusually low, O’Hagan discovered that she had developed hypoglycemia due to the low-calorie diet, coupled with taking Mounjaro (tirzepatide), which is a GLP-1 weight loss medication.
“This is why it's so important to do this diet under medical supervision, because you have a care team around you with Counterweight (who makes the meal replacement products) and with the NHS,” O’Hagan said. “They are constantly monitoring you, and you get given a blood glucose monitor, as well, so that you can be self-sufficient.”
Her doctor decided to take her off tirzepatide, and her blood sugar re-stabilized.
Total diet replacement for weight loss could be a good jump-start for patients on their health journeys, as short-term studies have found calorie restriction can be an effective tool for shedding pounds and lowering your blood sugars, according to Kunal Shah, MD, an endocrinologist and assistant professor at Rutgers Robert Wood Johnson Medical School in New Brunswick, NJ.
“But they’re short-term studies for a reason," he said. “Countless studies show that these sorts of really low-calorie, restricted diets are just very, very difficult to adhere to.”
The effectiveness of meal replacement diets can also depend on the patient, said Sue Decotiis, MD, a medical weight loss doctor in New York City.
“If a patient has a very unhealthy lifestyle and they're eating poorly – lots of processed, low-fiber foods and not a lot of vegetables – then [meal replacement products] can be helpful because you're kind of reining in their food intake,” Decotiis said. “But for someone that knows how to eat well, and perhaps they just have a slow metabolism, then I don't think that I would start someone on meal replacements because they are used to eating healthy food.”
Meal replacements are often missing key nutritional ingredients, such as vitamins, antioxidants, and a good mix of healthy fats and proteins, said Shah, who also helps lead the Rutgers Center of Metabolic Health and Weight Management. Maintaining muscle mass through eating enough protein is particularly important for patients with type 2 diabetes, Decotiis said.
“When somebody is really insulin resistant, sometimes they go on a low-calorie diet and they actually gain weight because their metabolism is going down, and that can be very upsetting and frustrating,” she said. “So, we have to make sure they're getting enough protein.”
When you take in very few calories, your body can often go into “energy conservation mode,” Shah said. “The amount of caloric output, or our basal metabolic rate, goes down, and what ends up happening is people tend to lose a lot of weight early on, but then as their caloric output goes, that sort of caloric deficit that people talk about actually decreases and people tend to plateau.”
Very low-calorie diets could also cause hormonal changes. Your body has hormones for both fullness, or satiety, and for hunger. Shah cited a 2010 study in The New England Journal of Medicine that studied effects of a low-calorie diet – around 800 calories – for 8 weeks.
“They did a long-term follow-up, and what they found is that hunger hormone levels were still very, very high, even though people had stopped doing that caloric diet and satiety hormones were very low,” Shah said.
O’Hagan said that one of the toughest parts of this program has been watching others eat normally. She stressed the importance of family and friends walking alongside you in your efforts to live healthier.
“Being open and transparent about what you're going through, what you're thinking about doing, and what the program entails is a big part of it, so that they can support you along in the journey, as well,” she said.
For example, her partner pushes the more unhealthy foods to the back of the kitchen cupboard, so they are out of sight and less distracting.
Total diet replacement has given O’Hagan a “much needed and long overdue break from food.”
“Before starting the program, my relationship with food was really unhealthy and very full of comfort eating and emotional eating,” she said.
While putting normal foods back into her diet is slightly daunting, O’Hagan feels positive about the food reintroduction phase of the program, particularly with the support of her doctor and her personal health coach.
“I feel like I have a new appreciation for food now,” she said. “I am being taught all about the nutrition of food and what to prioritize: like fiber, protein, and just a healthier way of living all round.”
Before she started the National Health Service program, O’Hagan’s blood sugar levels were above normal. At her last health check, her blood sugar was completely normal. If it stays that way, her diabetes will officially be in remission.
