With type 2 diabetes one of our biggest growing chronic conditions, doctors are trying to understand how it can be tamed, as Cathy O’Leary explains.
For years, a popular adage associated with type 2 diabetes was “once a diabetic, always a diabetic”. Apart from the language itself moving away from giving people labels, experts are now challenging whether type 2 diabetes is necessarily a ‘forever’ diagnosis.
Historically, type 2 diabetes mellitus was regarded as a permanent, progressive and chronic condition. Even if someone was able to get a good grip on their glucose levels, they were regarded as having “controlled diabetes”.
Until recently, there has been little in the way of clear clinical guidelines on the concept of diabetes remission, with most material explicitly focusing on managing obesity and keeping diabetes in check rather than achieving remission.
Now, however, the tantalising prospect of diabetes reversal and even remission have emerged as realistic goals, achieved largely through weight loss from dietary changes or bariatric surgery.
While official health advice to consumers and doctors has still been slow to reflect this shift in thinking, the number of type 2 cases is threatening to overwhelm the health system, so a circuit-breaker is sorely needed.
Television science journalist Dr Michael Mosley ignited debate late last year when he featured in a series on SBS which challenged traditional mantra that type 2 diabetes could not be reversed.
Recently diagnosed himself, Mosley claimed that rather than go on medication, he lost 9kg by putting himself on an intermittent fasting diet, resulting in his blood sugars returning to normal, without the need for medication.
However, some dietitians warned that while reversing diabetes and going off medication was possible, many people would be unable to achieve this and could end up feeling like failures.
Prominent eye surgeon and 2020 Australian of the Year Dr James Muecke also weighed into the discussion, arguing that putting people with type 2 diabetes on a low-carbohydrate diet could put their disease into remission.
And he claimed health authorities and advisory groups had been slow to acknowledge the growing body of science that proved type 2 diabetes could be halted.
Government nod
Significantly, the Federal Government released a new 10-year diabetes plan last November which, for the first time, recognised that type 2 could be reversed.
Diabetes WA says its educators have been regularly quizzed by consumers about the possibility of reversing type 2. There has been criticism of the group’s website and resources, including from the WA Parliament’s Education and Health Standing Committee following its inquiry into the prevention and management of type 2 diabetes.
Prompted by widespread confusion, the organisation last year carried out a survey of more than 2000 people with type 2 diabetes to gauge their understanding about remission.
It found that a lack of consensus among health professionals, even about the definition of remission, was contributing to the problem. Whether remission was possible divided health professionals, including GPs and endocrinologists.
“Two-thirds of consumers surveyed said they had been told by their health professional that diabetes remission was possible, while one-third were told it was not possible or their health professional was unsure,” the report said.
“Consumers often indicated the concept of diabetes remission had been endorsed by their GP, bariatric surgeon or their own lived experience of type 2 diabetes.
“It is hard to know why health care professionals said achieving diabetes remission is or is not possible. It could be because it would not be possible in a specific case, for example, if the patient had diabetes for a long time and the condition of their pancreas had deteriorated, or because they believed it was not possible in any case.”
Diabetes WA growth and innovation general manager Sophie McGough, who is a dietitian, diabetes educator and previous co-lead of the Diabetes Health Network, told Medical Forum that the organisation wanted to provide clearer information to consumers and health professionals.
“While statements about diabetes remission being possible for everyone are inaccurate, at the same time we have consumers and GPs who are seeing that remission is possible for some.
“So, we’re trying to marry those two worlds and find a happy medium so we can be clear for our consumers and health professionals.”
Ms McGough says that while they did not want to offer false hope, there were concerns that the use of the word ‘progressive’ was making people feel stressed or unmotivated.
“The word has been used to take away some of the blame and fear about people having to start insulin for their T2D, when it’s not their fault that their diabetes has progressed. Often on diagnosis, insulin deficiency has already started to occur, so the person will be less likely to achieve remission,” she said.
“But when we offered people the latest evidence-based definition of diabetes remission, we saw an increase in hopefulness.
“We want to avoid people with financial interests taking advantage of people with T2D with what they believe is a solution or magic bullet for everyone, but by the same token we want to be able to offer evidence-based paths for people.”
She said management guidelines for GPs did not give a lot of guidance about the concept of remission.
There was also confusion among consumers and health professionals about the difference between diabetes reversal and remission.
Remission vs reversal
A recently updated position paper by Diabetes Australia defines remission as a HbA1c of less than 6.5% (48mmol/mol) for at least three months after stopping glucose-lowering medication.
Diabetes remission is considered possible for people who have been diagnosed with type 2 diabetes in the past six years and are overweight. The best chance of diabetes remission is with weight loss of more than 10kg in a short amount of time, such as 8-12 weeks.
Ms McGough says reversal is more about good management of diabetes, such as improved glucose control, where people might come off their medications or regress back to earlier medication.
“Reversal and remission tend to be used interchangeably but they are not the same thing. Reversal is what everyone is trying to achieve, which is all about improvements.
“We’re also concerned that a lot of diabetes management is focused on glycaemic control, but it’s also about cardiovascular risk, because that’s what causes the serious complications from diabetes.
“Unfortunately, consumers and even health care professionals aren’t seeing the link between diabetes and cardiovascular risk.”
Endocrinologist Dr Greg Ong, who co-authored the Diabetes WA report on remission, said it gave hope to people with type 2 diabetes.
“We need to support our health professionals to actively consider remission as a treatment goal in appropriate circumstance, and have productive conversations about this with consumers,” he said.
Diabetes Australia has called for bariatric surgery to be more widely available for people with type 2 diabetes who meet the criteria.
It also warns that remission does not mean that type 2 diabetes is cured, as over time glucose levels can return to levels indicating diabetes.
UWA endocrinologist Professor Tim Davis agrees, and says dramatic weight loss in the overweight or obese can improve both insulin resistance and pancreatic beta cell function, but a diagnosis of type 2 diabetes implies significant beta cell loss, a lot of which may be irreversible.
‘When people in remission are stressed, such as with a severe infection, they can have temporarily very raised blood glucose levels, as there is a limited insulin secretory reserve in the presence of high levels of counter-regulatory hormones,” he told Medical Forum.
And people who do not achieve or sustain remission should not feel that they have failed because the health benefits of weight loss and a reduction in HbA1c are significant even if remission does not happen.
“One intermediate beneficial outcome for some patients between staying on current therapy and not requiring treatment for diabetes is coming off insulin,” Professor Davis says.
“Although this may not mean oral blood glucose-lowering therapies can also be stopped, freedom from the burden of regular injections is viewed as a worthwhile goal for many patients even if they do not achieve remission.”
Making it real
Professor Davis says more research is needed to understand the real-world experience of remission, because there is a lack of longitudinal studies that have assessed its sustainability, whether remission is achieved through lifestyle changes, pharmacotherapy or bariatric surgery.
As with many diseases, type 2 diabetes has an earlier window of opportunity to turn back the clock, while a person is at a pre-diabetes level with raised blood glucose levels.
Edith Cowan University professor of nursing research Lisa Whitehead says setting goals such as a 10% weight reduction not only helps patients control diabetes, it can help them avoid it in the first place.
But appointments with doctors are often short, so motivating people to adopt healthy behaviours and ultimately a healthy lifestyle is a major challenge, she says.
“There is evidence that goals set with a health practitioner and regular review of those goals is important, because weight loss is probably the most important thing to focus on in prediabetes,” she said.
“If you lose weight, you’re far more likely to naturally achieve better glycaemic control, and we know that even a 5% weight loss can make a huge difference, regardless of what weight someone starts at.”
Professor Whitehead says many people with prediabetes will eventually go on to develop type 2, and not enough is being done in Australia to intervene.
“We have different methods for assessing if someone has raised glycaemic levels or not, and there are different definitions around the world as to what constitutes prediabetes,” she says.
“It’s something we really need to be talking about more here, and supporting GPs and nurses to recognise it as an important area.
“Anecdotally, some people at the prediabetes stage are told to go away and come back in six months for another blood test, when there are many important things that they could be doing to stop them progressing on to T2D.”
Diagnosis snap
Professor Whitehead says that for most people getting a diagnosis of prediabetes is a light-bulb moment.
“A lot of the people we’ve interviewed in our studies say it was a real shock, even if diabetes ran in the family,” she says.
“There’s a bit of mixed literature out there about whether you should give someone a diagnosis of prediabetes – is it useful or does it stigmatise them – but when we looked at that in our studies, everyone said they would much rather have had the diagnosis than not being told.”
Professor Whitehead believes ongoing support from nurses is critical for people with prediabetes.
“Patients will see their GP but then having follow-ups with a nurse every three months or so, to touch-base with them and talk through issues and adapt their plans and goals, means they don’t lose interest and give up.
“We found that having that regular support from a nurse made people feel accountable, in a positive way. We’re not talking rocket science – it’s just about someone talking to them about their blood sugars, weight and BMI, because that can make a big difference.
“They can also reinforce that setbacks are normal, because we’re not robots, we’re human, and sometimes you need mini-goals and a reminder that you don’t have to accept putting on more and more weight.”