August 2018 - NON-MEDICATED LIFE
Remission of Type 2 Diabetes - PART TWO
By Dr. Paul E. Lemanski, MD, MS, FACP
Editor’s Note: This is the 84th in a series on optimal diet and lifestyle to help prevent and treat disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.
Medicines are a mainstay of American life and the healthcare system, not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death, while others may reduce certain types of cancer.
In the first 83 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals, many, if not most of the benefits of medications in the prevention and treatment of chronic medical conditions. Moreover, as a medical intervention they may accomplish such benefits with fewer side effects, may reduce the number and amount of medication, and may allow actual discontinuation of medication. However, in some cases, informed diet and lifestyle prove superior to medication. This is especially true for the prevention and remission of Type 2 diabetes mellitus. Part One (see Non-Medicated Life, June 2018) addressed the PREVENTION of Type 2 diabetes. Part Two, will address REMISSION of Type 2 diabetes.
As outlined in Part One, Type 2 diabetes is a disease characterized not by an insufficient amount of the hormone insulin, but by a resistance of body cells to its effects. One of the effects of insulin is to activate a pump on the surface of cells to transport sugar from the blood stream into body cells. In those with genetic predisposition to diabetes, (e.g., a blood relative with diabetes) and excess body weight, a condition called insulin resistance may develop and more insulin is required to transport sugar from the blood stream into cells. The cells in the pancreas that produce insulin, called islet cells, cannot increase their number to deal with the excess demand. Rather the increased insulin production taxes the existing islet cell population to work at greater than 100% capacity.
Over years, this excess insulin production overworks the islet cells causing them to burn out and die. By the time a diagnosis of Type 2 diabetes is made – by an elevated fasting blood sugar or elevated hemoglobin (HbA1c) – 50-70% of the islet cells may be lost to such burnout. Unfortunately, islet cells, once lost, cannot be replaced. What then is the evidence that diet and lifestyle may result in the remission of Type 2 diabetes and how may it work?
First, it is important to establish that Type 2 diabetes mellitus cannot be “cured” with informed diet, lifestyle, or for that matter, currently, by any other available means. Medications may control blood sugar and thus substantially reduce the consequences of Type 2 diabetes such as kidney failure, blindness, neuropathy, limb loss, heart attacks and strokes. Bariatric surgery (either roux en Y gastric bypass or gastric sleeve) may improve control of blood sugar, reduce reliance on medication, and may even get patients off of medications, but it does not result in an increase of pancreatic islet cell number.
Rather than a “cure” of diabetes, one speaks of a “remission” of diabetes, in which fewer pancreatic islet cells are able to produce sufficient insulin to control blood sugar, primarily because of dramatically reduced insulin resistance. Ostensibly, this reduced insulin resistance is a result of sufficient weight loss, although other hormonal factors may contribute – such as dietary composition and the physiological effects of exercise.
In 2009, the American Diabetes Association defined “complete remission” of diabetes as the condition achieved in individuals with a history of diabetes, who maintain normal glucose levels for at least one-year without medication. The ADA defined “partial remission” as glucose levels above normal, but below the threshold for diabetes for at least one-year without medication. In the DiRECT study, 24% of patients randomized to a weight management program maintained a weight loss of 33 pounds for one-year, although 46% were able to achieve remission. This included a few people with less than 10 pounds of weight loss, suggesting that weight loss alone is not always necessary to reduce insulin resistance.
Increasingly, short term use of a low carbohydrate diet (the so-called ketogenic diet), may rapidly lower blood sugar levels, as well as contribute to weight loss and sustained reductions in blood sugar in those with Type 2 diabetes, while reducing hunger. Such blood sugar reductions may require rapid reduction in diabetes medications, and in some, discontinuation. For those not interested in a ketogenic diet, a whole food, plant-based diet, emphasizing lower carbohydrate vegetables, may accomplish significant weight loss, lower insulin resistance, and also require reduction or discontinuation of medication.
It is important that those people with diabetes, who wish to try a low carbohydrate diet or a whole food, plant-based diet, first speak with their primary care physician or endocrinologist about medication adjustment – and the need for close monitoring to avoid the dangers of very low blood sugar or hypoglycemia. The help of a registered dietitian, who is a certified diabetes educator, is also critical to a safe and effective attempt at remission.
To date, while the most compelling data on diabetes remission is seen with bariatric surgery, the improvement in blood sugar in patients after surgery also is observed to occur before significant weight loss has been achieved. These results suggest, as with informed diet and lifestyle change, that it is correction of underlying insulin resistance, which leads to remission. Informed diet and lifestyle change is lower risk than surgery in the short term, and is decidedly less costly. For those interested in remission, the approach described above should be considered first.
In summary, the underlying cause of Type 2 diabetes is insulin resistance. Remission of diabetes, by either bariatric surgery or informed diet and lifestyle, may be achieved by reducing insulin resistance. A reduction in medication and actual discontinuation of medication is possible, but does require physician and dietitian oversight, and close monitoring. The longer the insulin resistant process goes on, the more islet cells are lost, and the less likely to achieve remission by any means.
This would argue for early intervention with diet and lifestyle to slow islet cell loss, both to prevent diabetes (as was shown in Part One), slow its progression and bring about remission (as has been shown in Part Two). In this way, informed diet and lifestyle as part of a Non-Medicated Life may be shown to prevent and treat one of the most significant threats to a healthy and quality life.
Paul E. Lemanski, MD, MS, FACP (firstname.lastname@example.org) is a board certified internist at Center for Preventive Medicine at Community Care Physicians in Albany. He is medical director of the Dept. of Community Medicine and Population Health at Community Care Physicians. Paul has a master’s degree in human nutrition, he’s an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.