Michael Collins relied on mainstream medicine to manage his type 2 diabetes for nearly 20 years — during which time he became morbidly obese as the illness became severe and increasingly uncontrolled. “My doctor would tell me to lose weight. I tried every diet and nothing worked.”
The drugs he was prescribed to control his blood sugar were no longer working and he was told he would need daily insulin shots. “I had severe heart and leg problems and couldn’t get my breath,” he recalls.
The 52-year-old mental health services manager lives in Boaz, Alabama — a state with a 39 per cent adult obesity rate in 2020, the third highest in the US. Indeed, across the US diabetes affects one in 10 (or 37mn) people, with the vast majority (95 per cent) of these cases being type two, according to the Centers for Disease Control and Prevention (CDC). Genetic factors raise the risk of developing the disease along with being overweight and inactivity.
The problem is global too. Obesity has tripled around the world since 1975, according to the World Health Organization. In 2016, some 39 per cent of adults over the age of 18 were overweight, while 13 per cent were obese. In 2014 there were 422mn people across the world living with diabetes, it notes.
Many people with the disease live normal lives by controlling it with medication. But one in two — like Collins — live with a raised risk of premature death, stroke or heart attacks. Long-term hazards include blindness, kidney failure and amputations.
In 2017, diabetes in the US cost $327bn, according to The American Diabetes Association. Some $237bn of this was medical costs, it notes, while $90bn was due to lost productivity. So it is no surprise that there is growing interest among employers about tackling type two, strengthened by growing evidence — acknowledged for the first time in clinical consensus reports published last year — that lifestyle changes can bring the disease into remission.
In October 2019, Collins opened his work email to find an invitation from his employer, the State of Alabama, to sign up for free virtual treatment and nutritional coaching aimed at reversing his type two diabetes. The Virta Health programme, accessed through an app, partners participants with a coach offering round-the-clock contact. Collins says his coach quickly became his best friend.
“I love my bread and french fries. But with my coach’s help, I could see from daily blood tests that these were my enemies,” says Collins. He saw that carbohydrates — which he believed were an essential part of his diet — raised his blood sugar levels, causing insulin levels to spike and worsening the disease. But he also discovered he could eat his fill of “the Southern cuisine we all love, the bacon and greens of our native Alabama”.
Evidence of the benefits of a low carbohydrate diet for people with type two diabetes has also emerged from a doctor’s surgery in north-west England. Dr David Unwin, a general practitioner for the NHS, has published studies in the British Medical Journal detailing his success in enabling 128 of his patients, nearly one in three of his practice population with type two diabetes, to follow a diet that replaces carbohydrates such as pasta and bread with healthy fats and vegetables. Of these, 46 per cent achieved drug-free remission from the disease.
The achievement has been widely recognised. In 2018 the Royal College of General Practitioners launched an online training programme for NHS doctors about the approach, written by Unwin. But he himself acknowledges that bringing about lifestyle change is time-consuming for GPs already struggling to manage the disease. Just over half of people diagnosed with type 2 diabetes in the UK get the recommended once-a-year check-ups, according to the 2020 National Diabetes Audit.
This explains why the new digital protocol — reducing rather than adding to the workload of primary care clinicians — is proving easier to roll out.
Virta Health was launched publicly in the US in 2017 with $37mn in funding and now works with more than 250 customers including employers, government entities and health insurance companies. Its latest peer-reviewed data shows that 54 per cent of patients remain below the diagnostic threshold for type 2 diabetes while eliminating all their anti-diabetic medications after two years of their bespoke remote counselling service, according to a study published in 2019 in the Frontiers in Endocrinology journal.
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Collins lost weight rapidly — eventually shedding 68kg in 18 months. Doctors, employed by Virta and working remotely, guide participants in the delicate task of reducing diabetes medication safely as their health improves.
This sort of medical intervention via workplaces is still in its infancy — and could raise concerns about privacy for some employees. Virta points out that while employers make the first connection with employees and pick up the bill, they are never told which employee has accepted the invitation.
In any case, says Unwin, such concerns miss the point. “In nine years of offering patients the alternative of lifestyle medicine or life-long medication, I’ve not had a single patient who opted for the drugs,’’ he says. “It’s just sad that so few people are offered this choice.”
Now a lifestyle advocacy group, Public Health Collaboration, which includes Unwin as vice chair of its scientific advisory board, is preparing to launch a new service, The Lifestyle Club (TLC). It offers an eight-week health coaching service and ongoing support for lifestyle behavioural change. The service will be promoted to employers once it is established in GP practices, explains TLC operations manager, Helen Gowers.
“The NHS is very good at acute medical intervention,” she explains. “Our mission is to inspire healthier lifestyles including wellbeing in the workplace.”
Swiss Re, one of the world’s largest reinsurance companies, is also encouraging its clients to “incentivise policyholders via their insurance to live healthier lives”. Its latest underwriting manual includes diabetes in remission as a lifestyle factor that could attract a lower premium. “It’s all the more important as we emerge from the pandemic,” says John Schoonbee, Swiss Re’s global chief medical officer.
In Alabama, Collins has joined a gym, enjoys spending time with his grandchildren and beat a “nasty” episode of Covid in January 2022. He has also had two promotions at work — “which I wasn’t even looking for”.