Remission, Not Reversal: Experts Agree to Define Ultimate Type 2 Diabetes Success

Type 2 diabetes can be considered “in remission” if patients can maintain non-diabetic blood glucose levels (<6.5% A1c) for 3 months without medication, according to an international panel of experts.

On August 30, the American Diabetes Association joined the Endocrine Society, the European Association for the Study of Diabetes, and Diabetes UK in co-authoring a consensus statement on “the definition and interpretation of remission in type 2 diabetes.” Here’s a press release, and here’s the full statement.

Remission is Becoming More Common

Type 2 diabetes remission has always been rare – a 2014 survey concluded that fewer than 2% of adults with diabetes experienced any level of remission without bariatric surgery – but in recent years, it has become more common.

The increasing prevalence of diabetes reversal owes partially to the rise in bariatric surgery, but is also likely due to the proliferation of new weight loss and diabetes management techniques. Although diabetes rates continue to rise unabated throughout the world, experience and understanding of the disease have led to superior treatment strategies, allowing a minority of patients to return their blood glucose levels to non-diabetic levels.

Now there are even companies, such as Virta Health, that have based their entire business strategy on the belief that diabetes “reversal” is within the reach of millions of adults with the condition.

With so much attention paid to diabetes remission, the world’s major diabetes authorities decided that the phenomenon of diabetes remission or reversal needed to be properly addressed, named, and described. The consensus statement should help guide study of the phenomenon, and give doctors and patients a framework for understanding just what remission really means.

What’s in a Name?

The experts seem to have given very careful consideration to what word doctors should use to refer to the achievement of regaining non-diabetic blood sugar levels. Many in the diabetes world use words like “reverse” or “correct” or even “cure” to refer to this phenomenon, each of which has its own implications. To speak of a “cure,” for example, is to imply that the disease has left and will never return; in the case of a patient that needs to keep up with dramatic lifestyle adjustments to keep their blood sugar at non-diabetic levels, this is a plainly inaccurate label. “Reversal” and “resolved” likewise suggest similar shades of meaning.

The panel decided,

that diabetes remission is the most appropriate term. It strikes an appropriate balance, noting that diabetes may not always be active and progressive yet implying that a notable improvement may not be permanent.

The term also accounts for the fact that while patients with diabetes may have achieved normal glycemic levels, they may still suffer from insulin resistance and/or deficiency, factors that may mean that they need to continue keeping a careful watch on their blood sugar management.

An earlier statement from the American Diabetes Association on type 2 remission categorized patients into different types of remission – partial, complete, and prolonged. These categories have been discarded as unhelpful.

Diagnosing Remission

Type 2 diabetes remission is now defined “as a return of HbA1c  to < 6.5% (<48 mmol/mol) that occurs spontaneously or following an intervention and that persists for at least 3 months” without the use of insulin or glucose-lowering medications. (The statement also allows for some other manners of diagnosing remission, such as using fasting blood glucose, in cases where HbA1c may be unreliable.)

The 3- month time parameter helps weed out both fluke A1c results and the lingering effect of medication, which can last for months after it’s been discontinued. Lifestyle interventions (changes to diet and exercise) and surgery (especially gastric bypass) can precipitate diabetes remission.

At the moment, the experts advise that patients in remission should have their A1c, as well as any potential diabetic complications, checked annually.

By definition, patients with type 1 diabetes cannot achieve remission (except under perhaps under unique and extraordinary circumstances), given their lifelong reliance on exogenous insulin

How to Achieve Remission

The most reliable way of creating type 2 diabetes remission is through bariatric surgery: nearly half of the patients in a Swedish cohort experienced lasting remission.

Bariatric surgery, however, is a very intense and expensive operation, and it comes with its own risks and complications; most patients with type 2 diabetes will not be considered good candidates. For the rest, weight loss, however it may be achieved, appears to be the best path to remission. Experts additionally debate the efficacy of specialized eating patterns, such as low-carbohydrate diets and therapeutic fasting.

Remission may not be a realistic goal for everyone, and researchers don’t yet have a solid understanding of why some patients are better able to reset their metabolic health than others.

We have an entire article on diabetes remission – originally published using terminology that is now officially out of step with mainstream practice: What You Need to Know About Reversing Type 2 Diabetes.

Going Forward

There’s an awful lot we still don’t know about remission. To date, diabetes remission has not attracted much attention from researchers, possibly because it was considered such a rarity. But with that changing, the diabetes authorities behind the consensus statement recognized a need to guide the questions of researchers.

The statement includes a laundry list of areas where future study is required, including:

  • How often patients in remission need to be re-evaluated
  • Whether or not patients in remission could still benefit from metformin and other drugs
  • Whether other metabolic parameters (such as cholesterol levels) need to be monitored
  • How long remission can be expected to last
  • What impact remission has on longterm health outcomes

Having finally named and described the phenomenon, the panel hopes to spur research into the reality of the condition so that it may be better understood.

 

Source: diabetesdaily.com

Imagine 288 Fingersticks a Day: The Power of CGM

This content originally appeared on diaTribe. Republished with permission.

By Michael Hattori

Michael writes about his diagnosis with type 2 diabetes, and how he used a CGM to put his type 2 diabetes into remission

My name is Michael, and I have type 2 diabetes. In remission. This means that my body no longer experiences unusually high blood sugar levels, and I don’t have to take diabetes medications.

Diabetes remission would not have been possible for me without the help of a miraculous tool called a continuous glucose monitor (CGM). Let me tell you how and why.

I have been a nurse for almost 22 years. Although most of my time has been in the operating room, I started my career taking care of people with diabetes, most of whom were faced with complications from diabetes. I realized early on how immensely complex and challenging diabetes is – I never imagined that I would be diagnosed with type 2 diabetes.

Well! About six months ago, my weight had reached 200 pounds (I’m 5’3”), my appetite was growing, I began experiencing extreme thirst. The huge amounts of water I was drinking seemed to do nothing but drive me to the bathroom seemingly every five minutes. Now, as a nurse, I knew exactly what was happening. But it couldn’t be happening to me!

At first I thought, “Oh, this will go away. It’s temporary.” But after several weeks of symptoms, I realized I needed to do something. I asked one of my colleagues at work to check my blood sugar, and it was 298 mg/dl. I could not believe it. We checked again, and it was 300 mg/dl. Lab tests a few day later showed a fasting glucose of 305 mg/dl and A1C of 10.5%. I had diabetes.

Now, you may be thinking, “You’re a nurse, for crying out loud! How could this happen to you?” But the fact is, I’m also a human being, just like you. Having worked outside of diabetes care for over 18 years, I was as uninformed as most people, and just as frightened.

One of the general surgeons I work with was standing next to me, and I asked him what he thought I should do. He was genuinely shocked, and said, “I think we need to get you on metformin, an SGLT-2 inhibitor, and a DPP-4 inhibitor.” Fortunately, my friend and colleague, Jennifer, immediately interjected, “No! You have to try this CGM first!”

I had no idea what a CGM was, but I soon found out. And it changed my life – saved my life, really.

Jennifer said, “This [CGM] is the greatest thing ever! It measures your blood sugar every five minutes, 24 hours a day, and you don’t have to stick your finger to see the results!” I was intrigued, as I had heard rumors of such devices (and also hated sticking my finger). She said that it had become her “best friend” and that it helped her mother, who had type 2 diabetes for 20 years, to manage her blood glucose. The next day I spoke with my primary care provider, and one day later I had a Freestyle Libre CGM sensor on my arm and the determination to manage my type 2 diabetes with diet and exercise alone.

Over the next six weeks, I came to rely on my CGM as my personal blood sugar “GPS.” It allowed me to see how every single thing I did affected my blood sugar, and not only during waking hours, but also while I was asleep. I kept a log of everything I ate; the CGM helped me to see how it affected my blood sugar, both immediately and over many hours. Can you imagine how powerful a tool that is for people with diabetes? To see in real time what effect food has? And not for just one point in time, like a fingerstick, but every five minutes after you eat. Imagine, if you are taking insulin, how valuable that information would be to help with dosing. No more guessing – incredible!

I had also heard about intermittent fasting but was skeptical until I started reading and found agreement that it is not only effective in helping to manage blood sugars and lose weight, but that there are other long-term health benefits. Jennifer had been doing intermittent fasting for over a month and was very positive about it, so I decided to give it a try. One of the main reasons I was willing to try it was because I had my friend, the CGM, as my guide. Being able to check my blood sugar at any time provided me with the safety net I needed to try something as radical (to my mind, at least) as fasting. And guess what, it worked!

I am now a huge advocate of intermittent fasting. But– and this is a big but – it is not for everyone. Anyone using insulin or medications that might cause low blood sugar (hypoglycemia) must consult with their healthcare professional, and also preferably a diabetes care and education specialist, before starting any kind of fasting program.

Along with helping me with my diet, the CGM gave me immediate feedback on exercise. I knew that exercise would help manage my diabetes, but I had no idea just how big a difference it could make. I’m not talking about hours of hard, furious sweating and exhaustion; all I did at the beginning was walk. The diabetes care and education specialist who led my class told us that even a 10-15 minute walk after a meal can bring your blood sugar down significantly. Many of the people in the class were skeptical, but she made us promise to walk at least ten minutes after every meal, and to check our blood glucose before and after the walk. Everyone was amazed at how much it really did bring down blood sugars.

For those of us with CGM, we could monitor our blood glucose throughout the walk, without any fingersticks. For me, a 20-minute brisk walk after dinner would often bring my blood sugar down 60 points or more. It was so gratifying to be able to watch my blood sugar go down and down. It motived me to make walking part of my daily routine – I still try to walk at least ten minutes after every meal, especially dinner.

Having so much CGM knowledge at my fingertips 24 hours a day gave me the power to make informed decisions about exactly what and how much to eat, to experiment with favorite foods, and to see, in real time, the benefits of exercise. How could you ask for a better tool? Within a month, I was able to get my fasting blood sugar down from over 300 mg/dl to less than 150 mg/dl. After three months it was under 120 mg/dl, and after four months under 100 mg/dl, with an A1C of 5.2%. I lost 35 pounds and still plan to lose 20 more.

I don’t think I could have achieved this without a CGM. My CGM gave me the equivalent of 288 fingersticks a day! A CGM puts that huge amount of information right at your (now not sore) fingertips. Of course, it’s up to you to use that information. But as they say, knowledge is power, and this gives you the power to manage your diabetes, and not the other way around. The CGM is the ultimate tool to show you just how your behavior affects your blood sugar, all day long.

Michael Hattori

Image source: diaTribe

Diabetes was a wake-up call for me to improve my lifestyle, and the CGM was the tool that allowed me to do so quickly and effectively. I am now in remission and intend to stay that way.

I am now on the path to becoming a certified diabetes care and education specialist, so that I can share my story and help others understand and manage their diabetes. Surprisingly, the CGM is not available to all people with diabetes. I can’t imagine a single person with diabetes who wouldn’t benefit from this amazing technology: it is like going from seeing through a tiny pinhole to having a full 360-degree view. And the view is incredible!

Source: diabetesdaily.com

Type 2 Diabetes Remission: What Is It and How Can It Be Done?

This content originally appeared on diaTribe. Republished with permission.By Emma Ryan and Jimmy McDermott Learn about three ways that may put type 2 diabetes into remission: low-carbohydrate diets, low-calorie diets, and bariatric surgery Type 2 diabetes is traditionally described as a progressive disease – without major lifestyle changes, A1C levels will gradually increase over time, […]
Source: diabetesdaily.com

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