Want to know about Type 2 diabetes remission?

Dr Angela Murphy looks at how Type 2 diabetes remission can be achieved and how anyone living with Type 2 diabetes can aim for this.

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Receiving a diagnosis of Type 2 diabetes can be distressing. It is a chronic condition that truly invades into daily life. The aim is to keep it controlled to prevent and avoid any future complications. Could you do even better than control? Could you, in fact, reverse Type 2 diabetes?

To achieve diabetes remission, or reversal, certain criteria need to be met. According to the American Diabetes Association these criteria are:

Full diabetes remission – Fasting blood glucose (FBG) < 5.56mmol/L and HbA1c < 6.0% on no diabetes treatment.

Partial diabetes remission – FBG is 5.56-6.9mmol/L and HbA1c 6.0 -6.5% on no diabetes treatment.

Classification of Type 2 diabetes

New research has suggested that there may be four subtypes of Type 2 diabetes. This is important to be aware of as it will influence attempts to reverse diabetes.

1. Severe insulin-deficient diabetes (SIDD) – Diagnosed at a younger age, lower body mass index (BMI), and early need for insulin therapy.
2. Severe insulin-resistant diabetes (SIRD) – Higher BMI and features of insulin resistance.
3. Mild obesity-related diabetes (MOD) – Younger age at diagnosis with high BMI and moderate insulin resistance
4. Mild age-related diabetes (MARD) – Older age with ‘mild’ diabetes in that very little medication is used to control glucose levels.

Interventions

Currently, interventions to achieve diabetes reversal are aimed at weight loss and kilojoule restriction. These interventions are not appropriate for the MARD person who may develop significant muscle loss and worsen overall health. The intervention may not be adequate for the SIDD who even with weight loss doesn’t have enough endogenous insulin production. However, most people with Type 2 diabetes are overweight or obese and will benefit. The accepted interventions are:

1. Dietary

In 2011, the Counterpoint Study showed that extreme kilojoule restriction could normalise blood glucose levels in a group of people with Type 2 diabetes. The 11 study volunteers were given a liquid shake (Optifast – available in South Africa) and non-starchy vegetables totalling 2510,4kJ per day.

After the first week blood glucose levels dropped on average from 9.2mmol/L to 5.9mmol/L and remained there for the duration of the eight-week study. All diabetes medications were stopped. There was a significant improvement in insulin sensitivity in the liver and pancreas. This meant that the production of glucose in the liver decreased, and the pancreatic beta-cells could do their work again to control blood glucose. The average weight loss to achieve these changes was 15% of initial body weight.

The Counterbalance Study published in 2016 showed similar results in a larger group of patients with Type 2 diabetes who achieved normal blood glucose values for up to six months.

The DiRECT Trial, conducted in a general practice setting in the United Kingdom, showed diabetes remission in 46% of patients after a year and 36% of patients were still in remission after two years.  This showed that a kilojoule-controlled diet could induce diabetes remission.

There is similar evidence for the use of a low carbohydrate diet as a dietary intervention to induce diabetes remission. There is still some debate whether it’s the low carbohydrate intake per se or the associated overall drop in total kilojoules that produces the benefit. In my experience, I like patients to follow diets they prefer as reducing kilojoules is always hard work.

2. Surgery

Bariatric surgery has been used to treat obesity for many years. The sleeve gastrectomy, Roux-en-Y-gastric bypass, and biliopancreatic diversion are the three main procedures.

The Swedish Obese Subject study followed several hundred patients with Type 2 diabetes who underwent bariatric surgery for over two decades. At the end of the second year 72.3% of patients were in remission. This number decreased to 30.4% at 15 years post-surgery which is still significant.

We now talk about metabolic surgery which is defined as gastrointestinal surgery with the intent of treating diabetes and obesity. The improvement in glucose control post bariatric surgery occurs within days so it’s not entirely dependent on actual weight loss. The significant drop in kilojoules decreases the fat in the liver and pancreas, restoring normal function in these organs.

In addition, the levels of the gut hormone glucagon like peptide 1 (GLP-1) increase. These changes lower insulin resistance and increase insulin production which decreases blood glucose. Many medical and scientific societies now endorse bariatric surgery as an effective treatment for Type 2 diabetes and a means to achieve diabetes remission.

Factors that predict diabetes remission include:

• Age: Younger is more likely to experience remission.
• Duration of diabetes: A shorter history of diabetes is more likely to experience remission.
• Weight loss: Losing 10% or more of body weight in the year after diagnosis is a strong predictor of remission.
• Baseline glucose control: A lower HbA1c at time when weight loss is started is a predictor of remission.
• Baseline BMI: Higher baseline BMI is a predictor of remission.
• Baseline medications: Less medications, particularly insulin, at baseline is a predictor of remission.
• Triglyceride and gamma-glutamyl transferase levels (liver function tests): Lower baseline levels of these are predictors of remission.
• Quality of life: Reporting better quality of life with less anxiety or depression is a predictor of remission.

Takeaway message

Not all people given a diagnosis of Type 2 diabetes will be able to achieve diabetes remission. This may be due to the subtype of diabetes or the difficulty succeeding with extreme dietary changes, significant weight loss, or access to bariatric surgery.

For some people with Type 2 diabetes aiming for remission is a realistic goal and they should be given the information and access to care they need to achieve this.

Bariatric surgery offers an excellent chance of diabetes reversal, but it’s expensive, and it requires specialised units not necessarily available in every area. Lifestyle intervention should be a simpler option, but the kilojoule restriction is significant and for many people difficult to sustain. This is where newer medications, such as the GLP-1 receptor agonists (liraglutide, dulaglutide, and semaglutide) and the soon to be available, dual action tirzepatide, may help in the long-term use of very low-kilojoule diets.

However, if weight is successfully lost and normal glucose levels achieved while using these medications, we can’t call this diabetes remission. For the exact diagnosis of remission, no medications can be used.

It’s realistic for some people with diabetes to aim for remission. However, it’s extremely beneficial also to aim for good diabetes control which then decreases the risk of diabetes complications.

It’s much more beneficial to achieve a low HbA1c with diabetic medications than fail at attempts to reverse diabetes and end up with poor control. To achieve diabetes remission is possible but not easy. To achieve diabetes control is possible and usually easier.

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