Read Time: 9 mins

Early Recognition of Overweight Hyperglycaemia May Improve Clinical Outcomes in Type 2 Diabetes

Copy Link
Published Online: Mar 30th 2023 touchREVIEWS in Endocrinology. 2023;19(1):33-7 DOI:
Authors: Anand Chockalingam, Pandiyan Natarajan, Smrita Dorairajan, Uzma Khan
Quick Links:
Article Information

Diabetes is the ninth leading cause of death, directly accounting for 1.5 million deaths annually worldwide. Despite several breakthrough discoveries, little progress has been made in type 2 diabetes outcomes over the past 100 years. Younger age (below 60 years), a diet high in calories and processed food, and severe obesity (body mass index >35 kg/m2) may identify reversible beta cell dysfunction. Much of the clinical presentation pertains to flooding the body’s adaptive limits with overnutrition. Recognizing this as a global societal trend brought about by lifestyle changes, sedentary work, mental stress and unlimited access to caloriedense foods is crucial. Insulin resistance and genetic abnormalities cannot account for the dramatic increase in diabetes, from only 1% five decades ago to nearly 10% today. Obesity  and not insulin resistance  is at the core of the problem. As well as hyperglycaemia, end-organ damage can also be reversed with diet and weight loss in many affected individuals. We present the evolution of our understanding and compelling reasons to reframe diabetes in the severely obese to what it really is  overweight hyperglycaemia. This may shift societal perception, governmental funding, workplace reformations and individual engagement with healthy lifestyles. The objective of this review is to better understand global trends and the potential to improve outcomes by reframing the diabetes narrative towards remission. This may shift societal perception, governmental funding, workplace reformations and individual engagement with healthy lifestyles.


Diabetes, hyperglycaemia, insulin resistance, lifestyle, overweight hyperglycaemia, severe obesity, type 2 diabetes


Diabetes affects an estimated 537 million adults and was responsible for 6.7 million deaths in 2021, worldwide.1 The International Diabetes Federation estimates that 3 out of 4 adults with diabetes live in low- and middle-income countries.1 Southeast Asia alone accounts for 90 million patients, of whom only half are aware of their diabetes.2 Five decades ago, type 2 diabetes mellitus was a rare disease, affecting just 1% of the population.3 Most people with type 1 diabetes had autoimmune insulin deficiency and would die within weeks to months without insulin therapy.4 How has this disease increased several fold, to affect 1 in 10 adults worldwide within a few decades? This is despite 10 Nobel Prizes being awarded over the past 100 years for diabetesrelated scientific breakthroughs.4 With accumulating evidence for dietary interventions, more patients may prefer lifestyle modifications over gastric bypass surgery, for safe and effective diabetes remission.5,6 Plantbased whole food, lowcalorie diet and even gastric bypass surgery require holistic lifestyle changes to sustain the desired weight reduction. Are we focusing medical resources on management rather than remission or cure?7 Can we identify which individuals with diabetes will benefit most from holistic interventions?

Origins of type 2 diabetes

Excessive food consumption by the affluent has been directly linked to diabetes for thousands of years.8 In the 1930s when the prevalence of diabetes was <1%, only a fraction of these patients did not adequately respond to insulin injection and were considered insulin resistant. This observation opened the door to diagnosing type 2 diabetes. Since then, diabetes has been widely recognized as a chronic disease that occurs either when the pancreas does not produce enough insulin (type 1) or when the body cannot effectively use the insulin it produces (type 2 or insulin resistant).9 Our group has a strong interest in reframing this basic tenet and recently reviewed the evolution of the term insulin resistance.10 In later stages of the disease, all patients with diabetes manifest excess fatigue, urination and thirst as a result of insulin deficiency. In addition, longterm vascular complications and cardiac risk that accrue over decades are identical in both type 1 and type 2 diabetes. Thus, in 1930, with limited understanding of decades-long prediabetes, it made sense to place all the hyperglycaemic conditions under the diabetes umbrella.

Type 1 diabetes is a true endocrine deficiency of a specific hormone  insulin – with specific symptoms and acute illness, centred around high glucose levels. On the other hand, type 2 diabetes is often due to relative overnutrition, with normal endocrine function and variable insulin levels. Homeostatic mechanisms are often intact for decades and attempt to compensate for the excess energy consumption from calorie-rich foods and drinks.6 Nature’s innate intelligence engages adaptive mechanisms to store lipids, causing weight gain over time. Insulin resistance is often secondary, variable and occurs only as cellular glucose uptake potential is saturated. Insulin injection may not elicit a sufficient reduction in blood glucose levels near the innate endocrine adaptive threshold. We recognize that there is significant individual variation in insulin sensitivity based on several genetic, environmental and age-related factors. However, recent diagnosis of type 2 diabetes, younger age (below 60 years), a diet high in calories and processed food, and severe obesity (body mass index [BMI] >35 kg/m2) may identify reversible beta cell dysfunction secondary to obesity.11

Overweight hyperglycaemia

Much of the world struggled for sufficient food until the end of World War II. Cyclical food scarcity was the norm and allowed utilization of stored fat reserves periodically. Thus, in 1948, type 2 diabetes was uncommon and most diabetes was type 1, and required insulin.12 The secure, abundant supply of food that we have experienced continuously since the 1950s in the West, and within the last 23 decades in many developing countries in Asia and Africa, is unprecedented in human evolutionary history.13 Type 2 diabetes has increased tenfold in the past five decades, tripling within 8 years in some populations, and now accounts for 95% of all diabetes worldwide.3,14,15 Extrapolating diagnostic thresholds from type 1 diabetes may not be ideal for individuals with type 2 diabetes who do not manifest symptoms for decades (Table 1). Targeted interventions to address lifestyle have not kept pace with sweeping changes in the workplace and global societal trends. Severe obesity (BMI >35 kg/m2) increased from 4% in 1980 to 13% in 2004, and accounts for half of all new diabetes cases in the USA.16 With severe obesity likely to reach 25% by 2030, the excess diabetes burden will affect especially women, black people and low-income groups.17 There could be significant health benefits for labelling type 2 diabetes in younger patients with severe obesity as what it really is – overweight hyperglycaemia (OH).

Table 1: Overview of challenges when applying the type 1 diabetes criteria ttype 2 diabetes and those with overweight hyperglycaemia (OH). Current severe obesityrelated differences and health implications unique to OH are highlighted

Type I diabetes

OH (BMI >35 kg/m2 and diabetes)

Type 2 diabetes

Reasons for 1930s nomenclature





Symptoms of excess urination, thirst, weight loss and fatigue


Asymptomatic for years to decades


Prevalence until 1960s

1% of adults, due to insulin deficiency


<0.25% of adults, typically in older individuals with obesity

Evolving understanding of overweight hyperglycaemia


insulin levels

Primary autoimmune endocrine disorder with insulin deficiency

Primarily a lifestyle issue; excess endogenous insulin secretion for decades

Several genetic and environmental factors contribute, variable insulin levels

Current prevalence


3035% of people with type 2 diabetes

>95% of all people with diabetes

Biological adaptive responses

Inadequate; thus, uniformly fatal within weeks to months if not treated

Intact; relative energy excess with weight gain for decades

Variable; declines with duration of diabetes, comorbidities and age

Symptom onset

At diagnosis

Delayed by decades

Delayed by years



Lifestyle and diet changes

Dietlifestyle and medication

Significant (>20%) weight loss

Need insulin therapy

Often may be able to discontinue all medication

Significant reduction in medication requirement


Lifetime disease management

High remission and cure potential


HALE impact with optimal management

Limited HALE impact

Significant HALE gains and cost savings

Modest HALE improvement

Healthcare expenses


Significant reduction following weight loss

Modest reduction following weight loss

BMI = body mass index;HALE = healthy life expectancy;OH = overweight hyperglycaemia.

OH is the overwhelming of the natural adaptive mechanisms, due to continued nutritional overload often encountered in sedentary individuals with severe obesity and recentonset hyperglycaemia. With intense lifestyle interventions targeting ideal body weight, this entity can be reversed, especially in younger people below 60 years of age.

Reframing the lifestyle issue

Medicine is advancing in great strides, with numerous new therapies addressing specific molecular, genetic and viral diseases. Type 1 diabetes management has benefitted from the pioneering work of several scientists, and with evolving continuous monitoring devices, longterm outcomes are likely to keep improving. The same cannot be said for type 2 diabetes. Thus far, we have used these same diagnostic criteria for OH. The long-term cardiovascular risk is a continuum without a clear demarcation to justify prediabetes as a separate entity. Based on individual genetic and environmental factors, some people manifest metabolic syndrome characteristics, while others manifest hyperglycaemia in the diabetes range. Use of the term OH will help to shift the focus onto the lifestyle and societal transformations needed to regain health. Figure 1 outlines the framework of OH, the inconsequential role of insulin resistance, and the opportunity for lifestyle interventions aimed at remission/cure, rather than pharmacological chronic diabetes management and progressive endorgan damage and vascular complications.

Figure 1: Outline of overweight hyperglycaemia aetiology, the secondary phenomenon of insulin resistance and the potential of lifestyle interventions to achieve remission

Biological resilience

Clinicians have the opportunity and responsibility to educate individuals about the significant developments in the fields of ageing and resilience. Calorie restriction in all normalweight, healthy animal species increases survival by 20200% beyond usual life expectancy.18 Calorie restriction in rhesus monkeys, who share 93% of their DNA with humans, dramatically reduces the risk of diabetes and metabolic syndrome.19 Human resilience starts to decline by the age of 40 years.20 Until about the age of 70 years, we may be able to engage anti-ageing and cellular resilience pathways to reverse diabetes.20 Normalweight, healthy volunteers with a BMI of 25 kg/m2 demonstrated improved metabolic health through 20% calorie restriction.21 Insulin sensitivity and cardiometabolic risk appears optimal at a BMI of 22 kg/m2 for healthy humans.21 With life expectancy increasing globally, these studies suggest we may increase healthy life expectancy (HALE) by lowering daily calorie intake recommendations.22

Gastric bypass and fasting

Younger people with severe obesity may lose 10 years of life expectancy.23 Gastric bypass surgery improves diabetes control, yet the long-term physical, nutritional and psychological risks need further evaluation.24 When performed relatively early, between the ages of 30 and 50 years, bariatric surgery restores 3 years of life.25 Frailty may contribute to the significant drop in gastric bypass procedures in older patients, with surgery rates in younger people fortyfold higher than in those over the age of 65 years.26 Chronic conditions such as heart disease further reduce the suitability for bariatric surgery.27,28

Siddha‘, a traditional Tamil medicine used for several thousand years, recommends two meals day for maintaining good health, and prescribes further restriction to only one meal a day to aid healing. Unfortunately, especially within the past few decades, average meal frequency has increased to 56 meals a day.29 Autophagy research from Japan recently reaffirmed the therapeutic potential of fasting, with Dr Yoshinori Ohsumi being awarded the 2016 Nobel Prize in Physiology or Medicine.30–32 Our group encourages cardiac patients with cardiometabolic disorders to explore the Siddha mindful eating practice called Hunger Gratitude Experience, which combines mindfulness, gratitude, active relaxation and fasting to sustain holistic weight loss in the long term.33 When cardiac patients lose 2035% of body weight, they are often able to discontinue several diabetes medications.34 Independently of weight loss, the natural ketosis induced by fasting may result in pleiotropic metabolic, cardiac and cognitive benefits.35

Insulin resistance

Insulin deficiency and resistance are considered the central issues in type 2 diabetes, with novel pharmacological agents potentially addressing a dozen diseasespecific targets.36 However, insulin levels are often adequate in OH. Humans have evolved over millions of years to expect food scarcity several times in a lifetime. A constant supply of food is indeed a recent problem of plenty. In clinical practice, insulin levels and insulin resistance are seldom measured, and do not add value in severe obesity. Abnormal weight gain may occur within normal BMI range based on individual race, stress, activity level, age and body morphology. The global diabetes epidemic does not affect primitive tribes and people continuing to live traditionally in regions of the world with a high number of centenarians and elderly people without disease or chronic health problems.37 All people with type 2 diabetes have insulin resistance, which renders insulin testing redundant in patients with severe obesity.38 Several biological and hormonal factors have been linked to the increasing global prevalence of metabolic syndrome.39 Interestingly, insulin resistance resolves completely with 30% calorie restriction in rhesus monkeys.19 Emerging evidence for remission places obesity, instead of insulin resistance, at the centre of the type 2 diabetes paradigm.40 Healthcare would improve if providers shifted the focus from insulin resistance concerns to lifestyle modification and weight reduction. Redirecting resources first towards addressing lifestyle changes before exploring genetic testing and molecular therapies may better address global health equity.

Shooting the messenger

OH, like prediabetes, remains asymptomatic because of adaptive weight gain over decades. Therefore, unlike type 1 diabetes where patients develop severe hyperglycaemia and catabolic symptoms, individuals with OH may appear well with no symptoms for many years. Often organ damage with cardiac or renal failure brings OH to medical attention. If there are no symptoms and patients can reverse to normal metabolism, then the hyperglycaemia of type 2 diabetes may just be an epiphenomenon. We diagnose cardiac, hepatic or renal pathology based on troponin elevation, hyperbilirubinemia and uremia, respectively. We do not attempt to reduce or control these serum biomarker levels. Instead, we identify and manage the underlying aetiology of organ injury to reduce longterm damage. OH manifests hyperglycaemia as a disease marker decades before normal adaptive mechanisms are overwhelmed. The underlying pathology needing management is sedentary lifestyle, mental stress, unhealthy and inappropriate diet, and overnutrition. Therapies focusing on controlling hyperglycaemia are shooting the messenger without addressing the underlying problem, and are unlikely to improve outcomes. We miss the window of opportunity to address the social, nutritional and lifestyle problems, and thereby fail to correct the underlying relative overnutrition.

Management and outcomes

Lifestyle changes are recommended for people with prediabetes to prevent diabetes. This is welcome and central for public health. However, people with OH are considered in the chronic disease category, even though a majority would benefit significantly from changes to lifestyle.41–44 Insulin as well as oral antidiabetic agents reduce blood glucose levels but fail to reverse the disease or improve survival. Gastric bypass reverses OH, giving us the evidence we need that this is indeed a metabolic problem.45 Importantly, lifestyle interventions may offer all the metabolic benefits of gastric bypass with adequate calorierestricted weight reduction.46 Many patients with longstanding diabetes showed reversal of metabolic abnormalities and could discontinue diabetic medications following a 20% weight reduction.40

Lowincome countries

Lowincome Southeast Asian, African and Latin American countries have limited resources to manage diabetes. Much of the developing world uses Western standards without validating normal ranges for cardiometabolic risk predictors. Developing countries may not have developed the genetic tolerance to overnutrition, developing diabetes decades earlier and at lower BMI compared with Western populations.47 Thus, a BMI of >23 kg/m2 may represent overweight and >25 kg/m2 may denote obesity, causing diabetes and other metabolic derangements.48 Limited resources and challenges accessing therapies in developing countries often result in premature cardiovascular mortality.49 Thus, it is vital to deliver appropriate education to providers and patients about lowcost, sustainable lifestyle and dietary interventions to optimize metabolic health in lowincome countries.

Future directions

OH is a lifestyle disease with some genetic predisposition. The pace of modern life, competition and mental stress are likely to contribute significantly to sympathetic activation and insulin resistance. Furthermore, mental stress may predispose to unhealthy comfort food choices and emotional eating behaviour patterns with cumulative risk over a lifetime. The role of social media in adding and aiding stress and influencing behavioualso needs closer scrutiny.

Mindbody methods that can address the root causes of OH in sustainable and meaningful ways are required. Integrative approaches that incorporate local cultural fasting traditions may offer solutions. Appropriate food (diet) is central to achieving meaningful weight loss. Research into sustainable lifestyle changes, diet and physical activity are needed to improve HALE, minimize frailty and optimize compliance.50 OH may contribute to the USA and India having the lowest HALE within their income categories.51

Public health policy and corporate workspace design should account for the basic human requirement of physical activity and movement. Improving OH requires the major health challenge of obesity and mental stress to be addressed. Real solutions may be years away, but first we must acknowledge that the problem has burgeoned well beyond the scope of medical solutions. Labelling diabetes with severe obesity as OH may allow a broader societal reckoning. Individuals can and should be identified as early as possible, and should be fully informed that OH is much more likely to be due to overnutrition than insulin resistance or a genetic defect. For the 35% of people with type 2 diabetes and OH, and the 34% of all adults dealing with prediabetic conditions globally, it is crucial to emphasize that they can regain their health by reducing weight to a targeted ideal body weight. Calorie counting, exercise time and glycosylated haemoglobin are only intermediateterm goals. Reaching ideal body weight will soon become a sustainable reality with advances in lifestyle medicine. Then, the persistence of hyperglycaemia after achieving normal body weight will be needed to diagnose type 2 diabetes.


We have not made meaningful progress in addressing type 2 diabetes since its first description in the 1930s. Nature is better adapted to cope with undernutrition than overnutrition. This fact is painfully felt as metabolic disorders surge just as human life expectancy is increasing. This is an opportune moment to realize that the latest scientific discoveries cannot overcome sedentary habits and overnutrition. We may find solutions for this when we reframe the entity as a lifestyle issue. While this may seem to state the obvious, healthcare providers have the responsibility to present to society the daunting issues around obesity and metabolic disorders. Low-income countries and the underprivileged are dealing with food insecurity and obesity simultaneously. The challenges are regionspecific and complex, but innovative social and lifestyle solutions will emerge. Biology is innately intelligent. When well informed, people with OH may find intuitive lifestyle solutions to reduce food consumption, eat healthily and increase their activity levels, rather than accepting the inevitable progression of diabetes and/or waiting for the next miracle cure pill for type 2 diabetes to be discovered.

Learning points

  1. Doctors must recognize the curative potential in OH in younger people with diabetes and severe obesity.

  2. Doctors must recommend lifestyle and food modification for substantial weight reduction.

  3. Lifestyle changes in younger people engages innate resilience to reverse OH.

  4. HALE may improve, particularly for the USA and India, if we address OH.

Article Information:

Anand Chockalingam is founder of, a non-profit online self-help tool aimed at improving cardiac health and resilience through self-inquiry, and author of Seeking HUNGER, a book encouraging self-inquiry for holistic health. He is also an advisor at the Cardiac Wellness Institute, Chennai, India. Pandiyan Natarajanb, Smrita Dorairajanc and Uzma Khan have no financial or non-financial relationships or activities to declare in relation to this article.

Compliance With Ethics

This article involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors.

Review Process

Double-blind peer review.


The named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published.


Anand Chockalingam, Division of Cardiovascular Medicine, University of Missouri – Columbia, Five Hospital Drive, CE306, Columbia, MO 65212, USA. E:


No funding was received in the publication of this article.


This article is freely accessible at © Touch Medical Media 2023

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analysed during the writing of this article.




1. International Diabetes Federation. Diabetes facts & figuresAvailable (accessed date10 March 2023)

2. International Diabetes Federation. Diabetes in South-East AsiaAvailable (accessed date10 March 2023)

3. CDCLong-term trends in diabetes2017Available (accessed date14 March 2023)

4. Polonsky KSThe past 200 years in diabetesN Engl J Med2012;367:133240DOI10.1056/NEJMra1110560

5. Kelly JKarlsen MSteinke GType 2 diabetes remission and lifestyle medicine: A position statement from the American College of Lifestyle MedicineAm J Lifestyle Med2020;14:40619DOI10.1177/1559827620930962

6. Rosenfeld RMKelly JHAgarwal Met alDietary interventions to treat type 2 diabetes in adults with a goal of remission: An expert consensus statement from the American College of Lifestyle MedicineAm J Lifestyle Med2022;16:34262DOI10.1177/15598276221087624

7. Khan MABHashim MJKing JKet alEpidemiology of type 2 diabetes – global burden of disease and forecasted trendsJ Epidemiol Glob Health2020;10:10711DOI10.2991/jegh.k.191028.001

8. Karamanou MProtogerou ATsoucalas Get alMilestones in the history of diabetes mellitus: The main contributorsWorld J Diabetes2016;7:17DOI10.4239/wjd.v7.i1.1

9. WHODiabetes2022Available (accessed date2 March 2023)

10. Chockalingam ANatarajan PThanikachalam PPandiyan RInsulin resistance: The inconvenient truthMo Med2021;118:11921.

11. White MGShaw JATaylor RType 2 diabetes: The pathologic basis of reversible β-cell dysfunctionDiabetes Care2016;39:20808DOI10.2337/dc16-0619

12. Valabhji JSpotlight on diabetes2018Available (accessed date2 March 2023)

13. Hall KDDid the food environment cause the obesity epidemic? Obesity (Silver Spring)2018;26:113DOI10.1002/oby.22073

14. Xu GLiu BSun Yet alPrevalence of diagnosed type 1 and type 2 diabetes among US adults in 2016 and 2017: Population based studyBMJ2018;362:k1497DOI10.1136/bmj.k1497

15. Burke JPWilliams KGaskill SPet alRapid rise in the incidence of type 2 diabetes from 1987 to 1996: Results from the San Antonio Heart StudyArch Intern Med1999;159:14506DOI10.1001/archinte.159.13.1450

16. Gregg EWCheng YJNarayan KMVet alThe relative contributions of different levels of overweight and obesity to the increased prevalence of diabetes in the United States: 1976–2004Prev Med2007;45:34852DOI10.1016/j.ypmed.2007.07.020

17. Ward ZJBleich SNCradock ALet alProjected U.S. state-level prevalence of adult obesity and severe obesityN Engl J Med2019;381:244050DOI10.1056/NEJMsa1909301

18. Mair WDillin AAging and survival: The genetics of life span extension by dietary restrictionAnnu Rev Biochem2008;77:72754DOI10.1146/annurev.biochem.77.061206.171059

19. Colman RJAnderson RMJohnson SCet alCaloric restriction delays disease onset and mortality in rhesus monkeysScience2009;325:2014DOI10.1126/science.1173635

20. Scheffer MBolhuis JEBorsboom Det alQuantifying resilience of humans and other animalsProc Natl Acad Sci U S A2018;115:1188390DOI10.1073/pnas.1810630115

21. Kraus WEBhapkar MHuffman KMet al2 years of calorie restriction and cardiometabolic risk (CALERIE): Exploratory outcomes of a multicentre, phase 2, randomised controlled trialLancet Diabetes Endocrinol2019;7:67383DOI10.1016/S2213-8587(19)30151-2

22. NHSWhat should my daily intake of calories be? Available (accessed date14 March 2023)

23. Lung TJan STan EJet alImpact of overweight, obesity and severe obesity on life expectancy of Australian adultsInt J Obes (Lond)2019;43:7829DOI10.1038/s41366-018-0210-2

24. Lim RBeekley AJohnson DCDavis KAEarly and late complications of bariatric operationTrauma Surg Acute Care Open2018;3:e000219DOI10.1136/tsaco-2018-000219

25. Carlsson LMSSjöholm KJacobson Pet alLife expectancy after bariatric surgery in the Swedish obese subjects studyN Engl J Med2020;383:153543DOI10.1056/NEJMoa2002449

26. Iranmanesh PBoudreau VRamji Ket alOutcomes of bariatric surgery in elderly patients: A registry-based cohort study with 3-year follow-upInt J Obes (Lond)2022;46:57480DOI10.1038/s41366-021-01031-w

27. Nor Hanipah ZPunchai SKaras LAet alThe outcome of bariatric surgery in patients aged 75 years and olderObes Surg2018;28:1498503DOI10.1007/s11695-017-3020-z

28. Brathwaite BMHowell RSPetrone PBrathwaite CEMSafety of bariatric surgery in patients with congestive heart failure: Results of an 11-year retrospective studyAm Surg2022;88:1195200DOI10.1177/0003134821991975

29. Paoli ATinsley GBianco AMoro TThe influence of meal frequency and timing on health in humans: The role of fastingNutrients2019;11:719DOI10.3390/nu11040719

30. de Cabo RMattson MPEffects of intermittent fasting on health, aging, and diseaseN Engl J Med2019;381:254151DOI10.1056/NEJMra1905136

31. Bagherniya MButler AEBarreto GESahebkar AThe effect of fasting or calorie restriction on autophagy induction: A review of the literatureAgeing Res Rev2018;47:18397DOI10.1016/j.arr.2018.08.004

32. Hornyak TProfile: Yoshinori Ohsumi: The rise and rise of a biology superstarNature2017;543:S19DOI10.1038/543S19a

33. Chockalingam ADorairajan SAnand KHigher consciousness through self-inquiry can improve cardio metabolic outcomes, mental health, and resilienceMo Med2021;118:97102.

34. Gajagowni STarun TDorairajan SChockalingam AFirst report of 50-day continuous fasting in symptomatic multivessel coronary artery disease and heart failure: Cardioprotection through natural ketosisMo Med2022;119:2504.

35. Chockalingam AKumar SFerrer MSet alSiddha fasting in obese acute decompensated heart failure may improve hospital outcomes through empowerment and natural ketosisExplore (NY)2022;18:71418DOI10.1016/j.explore.2021.12.003

36. Galicia-Garcia UBenito-Vicente AJebari Set alPathophysiology of type 2 diabetes mellitusInt J Mol Sci2020;21:6275DOI10.3390/ijms21176275

37. Marston HRNiles-Yokum KSilva PAA commentary on blue zones®: A critical review of age-friendly environments in the 21st century and beyondInt J Environ Res Public Health2021;18:837DOI10.3390/ijerph18020837

38. Reaven GMRelationships among insulin resistance, type 2 diabetes, essential hypertension, and cardiovascular disease: Similarities and differencesJ Clin Hypertens (Greenwich)2011;13:23843DOI10.1111/j.1751-7176.2011.00439.x

39. Saklayen MGThe global epidemic of the metabolic syndromeCurr Hypertens Rep2018;20:12DOI10.1007/s11906-018-0812-z

40. Yska JPvan Roon ENde Boer Aet alRemission of type 2 diabetes mellitus in patients after different types of bariatric surgery: A population-based cohort study in the United KingdomJAMA Surg2015;150:112633DOI10.1001/jamasurg.2015.2398

41. Gong QZhang PWang Jet alMorbidity and mortality after lifestyle intervention for people with impaired glucose tolerance: 30-year results of the Da Qing diabetes prevention outcome studyLancet Diabetes Endocrinol2019;7:45261DOI10.1016/S2213-8587(19)30093-2

42. Lean MELeslie WSBarnes ACet alPrimary care-led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster-randomised trialLancet2018;391:54151DOI10.1016/S0140-6736(17)33102-1

43. Lean MEJLeslie WSBarnes ACet alDurability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trialLancet Diabetes Endocrinol2019;7:34455DOI10.1016/S2213-8587(19)30068-3

44. Taheri SZaghloul HChagoury Oet alEffect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): An open-label, parallel-group, randomised controlled trialLancet Diabetes Endocrinol2020;8:47789DOI10.1016/S2213-8587(20)30117-0

45. Lin CYeong TJJLim WHet alComparison of mechanistic pathways of bariatric surgery in patients with diabetes mellitus: A Bayesian network meta-analysisObesity (Silver Spring)2022;30:138090DOI10.1002/oby.23453

46. Castagneto-GisseyLCasella GMingrone GEffect of diet versus gastric bypass on metabolic function in diabetesN Engl J Med2020;383:23934DOI10.1056/NEJMc2030030

47. Misra AGopalan HJayawardena Ret alDiabetes in developing countriesJ Diabetes2019;11:52239DOI10.1111/1753-0407.12913

48. Verma MRajput MKishore KKathirvel SAsian BMI criteria are better than WHO criteria in predicting hypertension: A cross-sectional study from rural IndiaJ Family Med Prim Care2019;8:2095100DOI10.4103/jfmpc.jfmpc_257_19

49. Wolf RMNagpal MMagge SNDiabetes and cardiometabolic risk in South Asian youth: A reviewPediatr Diabetes2021;22:5266DOI10.1111/pedi.13078

50. GBD 2017 DALYs and HALE CollaboratorsGlobal, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: A systematic analysis for the global burden of disease study 2017Lancet2018;392:1859922DOI10.1016/S0140-6736(18)32335-3

51. WHOLife expectancy and healthy life expectancy data by country world health organizationAvailable at (accessed date27 March 2023)

Further Resources

Share this Article
Related Content In Diabetes
  • Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72