Evidence-Based Responses to Type 2 Diabetes Reversal
“Are we selling something to folks that isn’t a long-term solution? Knowing the health and emotional impact of weight stigma, severe calorie restriction and the biological realities of weight and diabetes: are these studies ethical?” asked Megan Muñoz, RN, MSN, CMSRN, CDCES, during her presentation on evidence-based responses to type 2 diabetes reversal. Acknowledging that discussions surrounding reversal are everywhere and a hot topic for people with type 2 diabetes (T2D), Muñoz delved into several high-profile studies that have broached the issue. She segmented each study into the following:
- Calorie Restriction – DIRECT Trial
- Diet-Specific Studies – Virta Health
- Surgical – Swedish Outcomes Studies
Here’s what we know about T2D Reversal and commonalities found across each of those studies.
- Near Target A1C
- Early in Diagnosis
- Minimal use of medication/few insulin users
- Interventions reintroduced if moving out of remission or weight increase
- Lower body mass index (BMI) qualifications for surgical interventions
- Overall there’s a general fix on weight loss as a means to remission
Reversal vs. Remission
Reversal and remission are often used interchangeably when referring to one’s progress in managing type 2 diabetes, however, the terms are not the same.
Reversal: a turning or changing to the opposite direction as of a process, disease, symptom, or state—a complete turnaround, this condition no longer exists.
Remission: Abatement or lessening in the severity of the symptoms of a disease, but the disease still exists. Diabetes is a progressive disease, which is why remission is used in literature and among medical professionals. People with diabetes who experience remission still have type 2 diabetes.
The Threshold for Diabetes Remission
Muñoz noted there are guidelines from a Diabetes Remission Clinical Trial Expert Consensus report that lists the different kinds of remission and their criteria:
Partial Remission: A1C <6.5 and off medication for a year
Complete Remission: A1C <5.7 and off medication for a year
Prolonged Remission: <5.7 and off medication five years
However, she mentioned it’s important to know that some studies may not go by the consensus or follow the same standards when conducting their trials, which is why the consensus report is useful when discussing remission.
Look Beyond the Surface
However, because there’s a large focus on weight loss, Muñoz emphasized it’s important to look carefully at the statistics to understand just how many people are experiencing remission and if it’s partial, complete, or prolonged. Comparing the intervention with the control can give more context to just how effective the interventions are. For example, Muñoz cited the Look AHEAD trial, which showed in the first year of the trial, 37 percent of patients lost more than 10 kg (22 lbs) and in the second year, 23 percent lost that amount. However, when looking at the difference between the intervention and control group was just a 2.2 kg (5 lb) difference. She also noted that weight loss interventions are repeated throughout the study in the event a patient was falling out of remission or experiencing weight gain, they were put on weight-loss medicines or put back on a restricted diet. In other words, there wasn’t a “one-stop-shop” on the path to diabetes remission, but instead, multiple attempts to help participants reach their goals.
She also encouraged people to look at the total number of participants compared to the dropout number of participants and how data is reported over time. For example, in the Swedish Outcomes Study on bariatric surgery, initially, over 2000 people had weight loss surgery, but in years 2 and 15, the numbers of people who had remission were much smaller than how the data was reported. Still in all of the studies Munoz mentioned, patients regained weight over time.
Muñoz gave tips on other ways to look beyond the surface when reading literature:
- Look at the data being collected and reported over time. Patients can drop out of studies over the years, which can skew the data.
- Important to remember these studies had participants who were highly motivated, had repeated intervention, restricted diets monitored by providers and had endless resources and access to medical professionals.
- These studies are controlled and don’t account for real-world barriers and scenarios.
Remission declines year over year because diabetes is progressive. Remission is less likely depending on:
- Having a longer duration of T2D
- Having a higher A1C at the beginning of these studies
- If one uses insulin
Muñoz said this is further evidence diabetes is progressive, rather than can be “reversed.”
If a person has been living with T2D for 10 years and is on insulin, remission is less likely. But it’s important to understand why a patient asks about diabetes remission. Some reasons include:
- Diabetes burnout
- Frustration with blood glucose levels
- Fear of complications
According to Muñoz, other ways this research can be stigmatizing is because it limits diabetes to a simplistic condition that develops mainly due to weight or body size. Diabetes, instead, is a complex condition that requires looking beyond health habits and body size. She also pointed out the complexity of type 2 diabetes is obvious due to the different types of medication approved to treat it.
A major point Muñoz made is that type 2 diabetes has links to disordered eating and the focus on weight promotes weight stigma, which contributes to:
- Weight gain
- Chronic stress
- Nutrition intake
- Higher mortality
- Lower physical activity
- Mental health and wellbeing from post-bariatric surgery had two to three times higher issue of mental health issues, 40 percent had no history of mental illnesses.
- Cost of intensive treatment replicating these kinds of studies in the real world include:
- Supplements, including high-quality protein shakes
- Lost work hours
- Gym membership or workout equipment
- Social and environmental resources:
- Many US adults don’t have a PCP/general practitioner.
- Diabetes has an inverse relationship to poverty, hence why diabetes research on remission can’t be limited to just “weight” and “body size.”
Muñoz also gave more context to diet-specific remission studies, saying that weight cycling episodes also cause changes in insulin resistance, muscle mass and lipids. She explained weight cycling increases the odds of poor cardiovascular health, especially those with existing CVD conditions. She also said many people are trying to mimic these high-fat, low-carb keto-like diets without medical guidance and may have different interpretations of what those diets consist of. She also noted they can have a negative impact on kidney health.
In regards to gastric bypass studies, she noted these trials tend to be smaller in size, remission depends on the type of procedure performed, have increased mental health struggles and have different caloric needs such as long-term usage of vitamins and supplements.
“We need to normalize the imperfection and make discontinuation of extreme behaviors okay.” Muñoz ended her presentation by encouraging developing a well-rounded diabetes care routine and advocated for the use of consensus group guidelines to define remission to limit confusion and reduce the sense of failure when someone experiences an increase in A1C.