Pre-diabetes and Type 2 Diabetes are reversible for the vast majority of people according to multiple randomized intervention trials and this has recently been popularized by Roy Taylor's and Mike Lean's work from across the pond.
But who can reverse their Type 2 Diabetes and is it too late for some?
Reversal verses Remission. What is the difference?
In 2021 an international panel of experts on diabetes published a statement in the American Diabetes Association (ADA) press to update the consensus definition on diabetes remission (2).
"Our international group of experts suggest an HbA1c (average blood glucose) level of less than 6.5% at least three months after stopping diabetes medication as the usual diagnostic criterion for diabetes remission,” said statement author and Editor in Chief of the ADA’s Diabetes Care, Matthew Riddle of Oregon Health & Science University in Portland, Ore. Riddle is chair of the Diabetes Remission Consensus writing group that developed the statement. “We also made suggestions for clinicians observing patients experiencing remission and discussed further questions and unmet needs regarding predictors and outcomes.” (2)
Their definition of remission is the absence of clinical evidence of active Type 2 Diabetes, meaning that someone has achieved an A1c of less than 6.5% without the assistance of medication for a set period of time (3 months minimum) (2). While that might sound like reversal, technically it is. The goal of referring to this as remission appears to be the concern that it can come back if we regain the weight and return to our old habits. This is why it is still recommended that we check an A1c once a year to screen, especially if our weight creeps back up. We know from Roy Taylor's work on the personal fat threshold that there does appear to be a metabolic tipping point that is specific to each one of us, but that's an article for another day.
Having been formally trained by the American College of Lifestyle Medicine (ACLM), passing their board exam and completing their course spanning Reversal and Remission of Type 2 Diabetes and Prediabetes, I've spent the past 2 years of my career working in primary care to help patient's do just that. And I've seen it work. With adequate weight loss through dietary change, people can lose weight and keep it off.
The position of the ACLM, informed by current best research evidence, is that (1) sufficiently intensive lifestyle modifications are capable of producing significant clinical improvements in patients with T2D and (2) that the optimal treatment to bring about remission (defined below) includes a whole food, plant-based (WFPB) dietary pattern coupled with moderate exercise. A WFPB diet emphasizes fruits and vegetables, legumes, and whole grains, and includes nuts and seeds while eliminating or minimizing animal foods such as red and white meat, poultry, fish, eggs, and dairy, as well as refined foods that include added sugars and oils. ACLM is in agreement with the position stated by the group who conducted the Counterpoint Study on the reversibility of T2D, “Diabetes reversal should be [the] goal in the management of Type 2 diabetes." (3)
With sufficient weight loss (typically 15+ kg), up to 80% of people living with type 2 diabetes for less than 8 years can achieve reversal (1). This is important for people to know -- we can do something about this!
So how do we determine who can reverse this?
There's really no better way than to try an intensive therapeutic lifestyle intervention aimed at losing the weight. That said, there are ways that we can attempt to quantify how well our body is making insulin and how much insulin resistance we have.
We know from the CARDIOPREV-DIRECT trial that the likelihood of reversal rests on two metrics which often correspond with the length of time that we've been living with diabetes (4). If our insulin producing cell are functioning well and our insulin resistance is low then we have the highest chances of reversal (4).
How do we quantify this for you specifically? For example, how do we know how well your beta cells are functioning and how much insulin resistance you have?
When we work together, we'll use a tool called the HOMA-IR which can be used to estimate both pancreatic function and liver insulin resistance. This involves 2 blood tests called a c-peptide and a plasma glucose taken at the same time.
The HOMA-IR is a great way to monitor progress and gather feedback on the dietary changes we are making, especially if we are taking the slow and steady approach to changing what we eat.
Can't we just follow the dietary advice from the American Diabetes Association?
Remission and reversal of Type 2 Diabetes is very unlikely to occur if we follow the advice of the American Diabetes Association (ADA) where the focus is on management (not reversal).
(image source: a presentation by Professor Mike Lean, the study author)
The blue line in the graph above shows remission rates for patients following the control diet, in this case, the American Diabetes Association (ADA) diet. This low remission rate with the ADA diet is why I do not use this dietary pattern to reverse Pre-Diabetes and Type 2 Diabetes, because it simply doesn't work for most people. Adequately dosed therapeutic lifestyle interventions aimed at significant weight loss is our best option for those of us looking to reverse this.
So what do I recommend.... Learn more about therapeutic lifestyle intervention and the chances of Type 2 Diabetes Reversal in the FREE online Course: Reversing Pre-diabetes and Type 2 Diabetes. The course is free as a public service offered through Lifestyle Medicine Maine.
References
(1) Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lean et al. The Lancet (2017). https://doi.org/10.1016/S0140-6736(17)33102-1
(2) International Experts Outline Diabetes Remission Diagnosis Criteria. ADA Press Release. (2021). https://www2.diabetes.org/newsroom/press-releases/2021/international-experts-outline-diabetes-remission-diagnosis-criteria
(3) Type 2 Diabetes Remission and Lifestyle Medicine: A Position Statement From the American College of Lifestyle Medicine. Kelly et al. American Journal of Lifestyle Medicine. (2020). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7692017/
(4) Beta cell functionality and hepatic insulin resistance are major contributors to type 2 diabetes remission and starting pharmacological therapy: from CORDIOPREV randomized controlled trial. Roncero-Ramos et al. Journal of Translational Research. (2021). https://doi.org/10.1016/j.trsl.2021.07.001
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