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

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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.

 

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