Why Diabetes Remission is Possible in Type 2 Diabetes

And When It Is Less Likely To Occur

I first heard about diabetes remission over a decade ago from a few patients who claimed they had reversed their diabetes after undergoing intensive lifestyle changes. Diabetes occurs when the body cannot effectively regulate blood sugars resulting in hyperglycemia (elevated blood sugars). But not all diabetes is the same and there are quite a few different types. You’ve probably heard of Type 1 Diabetes and Type 2 Diabetes but there’s also Monogenic Diabetes which is due to a mutation in a gene that affects the production or function of insulin and there’s also LADA - Latent Autoimmune Disease in Adults which has characteristics of Type 1 and Type 2 so sometimes it’s referred to as Type 1.5 diabetes (more on these different types in a future post). The only diabetes where remission is possible with lifestyle interventions though is Type 2 Diabetes.

You may hear people say they have reversed their diabetes and while reversal is sort of used synonymously with remission, the preferred term in the medical community is diabetes remission because it acknowledges the ongoing nature of the condition and the possibility of relapse. Reversal implies that the condition is permanently cured but we know that maintaining normoglycemia (normal blood sugars) usually requires ongoing effort just like when someone loses weight - it is possible to gain back all the weight that was lost so if we want to keep the weight off, we need to put in effort (like not exceeding our daily maintenance calories).

Definition of Diabetes Remission
By definition, diabetes remission in Canada is an A1C below 6.0% for at least 3 months without the use of diabetes medications (e.g. remission to normal blood sugars). Diabetes Canada has ANOTHER definition which is remission to pre-diabetes levels - an A1C between 6.0% and 6.4% for at least 3 months without the use of diabetes medications. In the US, diabetes remission is defined as an A1C below 6.5% at least 3 months after stopping diabetes medications.

Also, the definition of pre-diabetes (for A1C anyway) in Canada is 6.0-6.4% whereas in the US, it is 5.7-6.4%. Why are they different? Honestly, it’s just a number and the thresholds are set by different health organizations. If someone is hovering around 5.7% to 5.9% in Canada, I still encourage them to think about what lifestyle changes can be implemented to lower their A1C.

To understand how diabetes develops and why remission is possible but also not possible in every individual, there are a few terms we need to know first:

Pancreas: this is the organ that produces and secretes insulin
Insulin: this is the hormone that is secreted and produced by the pancreas that helps the cells in our body (especially muscle, fat, and liver cells) take up sugar from the bloodstream
Hyperglycemia: elevated blood sugars

The Progressive Nature of Diabetes
Pre-diabetes generally precedes the diagnosis of diabetes by about 9-12 years and is the stage where blood sugars are elevated but not high enough to be classified as diabetes. In pre-diabetes, there could be impaired fasting glucose which is elevated blood sugars after fasting overnight and/or impaired glucose tolerance which is elevated blood sugars after eating.

When food is ingested, carbohydrates are broken down and absorbed, blood sugars rise triggering the release of insulin from the pancreas, insulin tells the body’s cells to take up sugar from the bloodstream and then, blood sugars go back down again. That is the usual cycle of the rise and fall of blood sugars following food ingestion. But in pre-diabetes or early diabetes, the cells are less sensitive to insulin and cannot efficiently use it so the sugar stays in the bloodstream causing hyperglycemia - this is called insulin resistance. Since blood sugar levels are still high, this feedback in turn goes back to the pancreas encouraging it to compensate by producing even more insulin. In pre-diabetes or early diabetes, this additional insulin will keep the blood sugars a little bit lower (hence usually mild hyperglycemia) and/or a slight delay in blood sugars returning to normal. Sustained activity like this where the pancreas needs to keep up a much larger production of insulin can eventually overwhelm and wear out the beta cells (ie. what produces insulin in the pancreas) resulting in beta cell dysfunction and consequently, insufficient insulin production to support the body’s needs. So as you can see, diabetes is a progressive condition overtime and starts with insulin resistance and/or some beta cell dysfunction (leading to reduced insulin production) followed by beta-cell failure (leading to little or no insulin production).

Why Remission is Possible in Pre-diabetes or Early Diabetes
This progressive course of diabetes is the reason why diabetes remission is very possible in pre-diabetes or early diabetes where insulin resistance is the main problem and pancreatic function is mostly preserved. Significant reduction in insulin resistance can induce diabetes remission and restore blood sugars to normal levels. As diabetes progresses, beta cells in the pancreas start to become dysfunctional and while lifestyle changes can restore some beta cell function, beta cells that were already lost cannot be recovered. In other words, if there is significant beta cell loss already from longstanding hyperglycemia, it is unlikely that lifestyle interventions can induce remission but they can still be helpful in improving insulin resistance, keeping blood sugars low and stalling the progression of diabetes.

What about Diabetes Medications?
If a diabetes medication is working well and glycemic targets are being achieved, will the diabetes eventually get worse? Yes, with time and if lifestyle interventions are not implemented. It is possible to start with 1 medication that works very well and keeps blood sugars in the target range and then eventually need a second or a third drug to achieve target blood sugars. Some drugs work by improving insulin resistance (eg. metformin, SGLT2 inhibitors) and others by enhancing insulin secretion (eg. DPP4 inhibitors, GLP1-RAs, Sulfonylureas). If there is significant beta cell loss and dysfunction, the drugs that enhance insulin secretion are less useful since they rely on functioning beta cells and the main course of treatment then becomes exogenous insulin. By the way, insulin will work at any stage of diabetes but it’s not usually necessary in early diabetes unless the blood sugar is extremely high at diagnosis which is suggestive of longstanding and untreated hyperglycemia and inadequate insulin production.

Lifestyle Interventions
What lifestyle interventions can be helpful in inducing remission then? There are a few:

• Low-carb diet

• Low-calorie diet

• Physical activity like aerobic exercise and resistance training

• Significant weight loss (like 5-15%) through the low-carb diet, low-calorie diet, or a combination of diet and physical activity

• Bariatric surgery

• Stress management (chronic stress raises cortisol levels, which increase insulin resistance and blood sugar levels)

• Sleep optimization (poor sleep disrupts insulin sensitivity and appetite regulation)
  

Nothing works!
If you have lost a significant amount of weight and implemented a number of lifestyle interventions but had little success lowering your blood sugars, it’s entirely possible you have a diabetes that isn’t Type 2. There are other forms of diabetes that are less common but present initially like Type 2 Diabetes like Monogenic Diabetes which is due to a gene mutation affecting insulin production or function and accounts for about 1-5% of all cases of diabetes. There’s also late onset Type 1 Diabetes and Latent Autoimmune Diabetes in Adults, both of which are autoimmune-related and affects the beta cells in the pancreas. Additional laboratory testing and investigation are needed to confirm the diagnosis of these other types of diabetes.

My Final Thoughts
I think lifestyle interventions are so incredibly important in the management of Type 2 Diabetes. Although remission is generally more likely to occur in pre-diabetes or early diabetes, these interventions can be very useful in improving insulin resistance, halting diabetes progression, maintaining and restoring pancreatic beta-cell function and reducing medication burden.