In our previous blog, we discussed how type 2 diabetes comes about in the first place and considered its root cause. In this blog, the second of the two-blog series, we discuss whether type 2 diabetes remission can be achieved and how to achieve it.
Can type 2 diabetes remission be achieved?
Medications for type 2 diabetes work by primarily attempting to improve insulin resistance or increase insulin levels temporarily, among other mechanisms of action, but they do not address the root of the problem, because the root of the problem lies in the foods that we put into our mouths about three times a day for the duration of our lives—namely, excess intake of calories. To achieve remission of type 2 diabetes, an energy deficit is required, in order to remove fat molecules and resolve the lipotoxicity as explained in our previous blog, until remission is achieved. This is why certain diets do not work for the purposes of achieving type 2 diabetes remission, such as the type of so-called “ketogenic diet” that emphasizes low carbohydrates and high fat and high protein intake from animal foods (1), because they do not reverse excess caloric intake and lipotoxicity. This is a crucial point to understand, both for patients who wish to achieve type 2 diabetes remission and for physicians and clinicians who wish to help their patients achieve diabetes remission through a lifestyle intervention.
Insulin resistance and compromised ability of the beta cells of the pancreas to produce insulin, as discussed in our previous blog, constitute the primary root cause of type 2 diabetes. The important question is, can we reverse these changes? The short answer is, “Yes.” These physiologic impairments need not be permanent and can potentially be reversed, especially in earlier stages of the disease. In a study investigating patients with type 2 diabetes, published in the New England Journal of Medicine, researchers showed that weight loss itself (of about 18 percent) was associated with improved insulin sensitivity (the inverse of insulin resistance) and beta-cell function of the pancreas (2). Importantly, the study showed that it did not matter whether the weight loss was achieved through diet alone or through an invasive bariatric surgery (gastric bypass).
In an expert consensus statement published in 2022 by the American College of Lifestyle Medicine, endorsed by the American Association of Clinical Endocrinology, supported by the Academy of Nutrition and Dietetics, and co-sponsored by the Endocrine Society (3), a panel of diabetes experts agreed that “diet as a primary intervention for T2D [type 2 diabetes] can achieve remission in many adults with T2D and is related to the intensity of the intervention,” and that “diet as a primary intervention for T2D is most effective in achieving remission when emphasizing whole, plant-based foods with minimal consumption of meat and other animal products.” This means that by primarily making dietary changes, a person with type 2 diabetes can expect to achieve remission of diabetes. Furthermore, the intensity of the dietary intervention determines whether remission can be successfully achieved.
What does it mean to achieve type 2 diabetes remission? The panel of diabetes experts mentioned above defined remission of type 2 diabetes as achieving a hemoglobin A1c level (commonly referred to as “A1c”) of less than 6.5% for at least 3 months, without the use of any blood glucose-lowering medications, surgery, or devices (3). Most importantly, these experts agreed that remission is the optimal outcome for adults with type 2 diabetes, and that remission is a realistic and achievable goal for some adults with type 2 diabetes. An international expert group convened by the American Diabetes Association similarly defined diabetes remission as having an “A1c” of less than 6.5%, “measured at least 3 months after cessation of glucose-lowering pharmacotherapy” (4). In other words, a person who has achieved type 2 diabetes remission is no longer taking any blood sugar-lowering medications or receiving any blood sugar-lowering surgeries or device-based treatments for at least 3 months.
Clinical research has already shown that such remission of type 2 diabetes is very much possible and feasible. A randomized, controlled trial enrolling about 300 type 2 diabetics in the UK showed that a diet with intensive energy restriction led to diabetes remission after a year in almost half of the participants who received the study intervention, while only 4 percent of the participants in the control group had remission (5). The intervention package consisted of a total diet replacement (825-853 kcal per day formula diet) for 12-20 weeks, followed by structured food reintroductions for 2-8 weeks, and an ongoing structured weight loss maintenance program. Greater weight loss was associated with a greater proportion of participants who achieved remission. For example, 34 percent of the people who lost 5 - 10 kg (11 – 22 lb) achieved remission, while an impressive 86 percent of the people who lost 15 kg (33 lb) or more achieved remission. Not surprisingly, none of the people who gained weight achieved remission. Two years after the study began, 41 percent of the participants in the intervention group were still in remission, while only 3 percent of the control group was in remission (6). These results are all the more impressive when we keep in mind that the intensive energy restriction portion of the study’s diet only took place in the first 12-20 weeks of the study. It should be noted, however, that the use of a formula diet as used in the above study is not required in the real world to achieve diabetes remission and is, in fact, not practical for most people. As we will discuss shortly, a diet that involves whole foods is preferable and can certainly enable diabetes remission.
In people who have had long-standing type 2 diabetes (for example, 8 years or more), remission may be harder, though not impossible, to achieve, if there is a greater loss of beta-cell function in the pancreas. In this scenario, witnessing good recovery of beta-cell function (which can be estimated from blood tests) in the course of dietary intervention is a good indication that success in achieving remission is more likely (1).
Using food as medicine to achieve remission from pre-diabetes and diabetes
According to the panel of diabetes experts that published the consensus statement mentioned above, dietary intervention is the primary way by which type 2 diabetes remission can be achieved. A review article published in the Lancet summarized research evidence showing that in people with diabetes, diets that are rich in whole grains, legumes, vegetables, fruits, nuts, and seeds, and low in red or processed meats and refined carbohydrates, improve blood sugar control and cholesterol levels (7). Beyond simply improving blood sugar control, a safe and effective dietary intervention that can accomplish type 2 diabetes remission would minimize the use of harmful foods, maximize the consumption of healthful foods rich in micronutrients and antioxidants (important in any healing process), and facilitate weight loss without having to restrict the volume of foods eaten. Dietary interventions that fulfill these qualities invariably emphasize a whole-food, plant-centered dietary pattern, which enables the greatest reduction in fat intake and the greatest increase in foods that are lower in energy density, and prevents consumption of excess calories.
These qualities of such a dietary intervention address the underlying root cause of type 2 diabetes as we discussed previously—namely, excess caloric intake resulting in “lipotoxicity” of cells and consequent insulin resistance and reduced pancreatic beta-cell function. In clinical practice, such a dietary approach is reported by experienced healthcare practitioners to be associated with the greatest success in achieving type 2 diabetes remission (1).
A brief word of caution about using low-carbohydrate diets (such as varieties of so-called ketogenic diets that emphasize higher consumption of animal fats) in the treatment of diabetes. The diabetes expert panel mentioned above did not agree on using low-carbohydrate diets as a short-term or long-term intervention for type 2 diabetes, because of potential negative cardiovascular and metabolic effects of such diets (8), and such low-carbohydrate, high-fat diets have failed to reverse insulin resistance in animal studies (3). Therefore, a quick takeaway is to not use low-carbohydrate diets that incorporate higher consumption of animal fats for the purpose of achieving type 2 diabetes remission at this time. However, it should be noted that the quality of the fat is more important than the quantity of the fat in the diet, as along as the quantity consumed does not result in an energy (calorie) excess, of course. As re-iterated by authors of the Lancet review article cited above, “The quality of fat is more important than total fat intake, and diets that favor plant-based fats over animal fats are more advantageous [in diabetes] (7).”
The importance of dosing or intensity of the dietary intervention
One important and common reason that dietary interventions do not achieve the expected result of type 2 diabetes remission is that the dosing is inadequate. For example, it is easy to understand that taking an antibiotic at a dose that is too low will not result in the cure of an infection. This is a point that is often missed when it comes to dietary interventions. Often, people attribute the failure of a diabetic dietary intervention to the inherent lack of efficacy of the diet and subsequently become convinced that the management of their type 2 diabetes must, therefore, rely on the chronic use of medications. What many people do not realize is that the lack of success is due to an inadequate dosing of the dietary change. In other words, making only some dietary changes (for example, simply eating more vegetables, eating less sweets, or eating less meat), rather than the full extent of the required change, will not result in type 2 diabetes remission, although some improvement in the blood sugar control can still be seen. Research has shown that a lifestyle intervention that is dosed sufficiently intensively will result in type 2 diabetes remission in half or more of the participants (1). Those with a shorter duration of type 2 diabetes generally have a higher success rate of remission. Equally important to the success of achieving remission is the type of intervention used, because not all lifestyle interventions result in remission (1).
In my experience, the success or failure of a functional medicine and lifestyle medicine-based treatment for type 2 diabetes remission depends heavily on ensuring the adequacy of the dosing of the dietary intervention, elucidating misconceptions about the proper lifestyle changes necessary to achieve remission, and having access to support and educational reinforcement from a physician or clinician who can model the proper dietary change through personal, first-hand experience with such a change.
Diabetes experts agree that when diet is used as a primary intervention to promote type 2 diabetes remission, it can also improve cholesterol levels and lower the risk of cardiovascular diseases such as heart attacks and strokes (3). This is the power of a whole-person approach to healing through integrative medicine and functional medicine: An effective intervention promotes a therapeutic outcome in not just one organ but the whole person, and in not just one disease but many diseases and overall health. The therapeutic use of the diet in achieving type 2 diabetes remission is one of the prime examples of prescribing “food as medicine.”
Cautions and caveats
If you are already on one or more diabetes medications that lower blood sugar levels, you should only start dietary changes under the oversight and guidance of your physician or a lifestyle medicine physician, who can promptly reduce your medication dose and de-prescribe your medication(s) as necessary. This is crucially important because, as you make dietary changes, your blood sugar levels may drop too much, resulting in hypoglycemia (low blood sugar level), a potentially dangerous situation if not monitored and corrected immediately. Generally speaking, a more intensive lifestyle intervention requires swifter “de-escalation” or “de-prescribing” of blood-sugar-lowering medications. If you have diabetes or other medical conditions, consult your physician before making dietary changes or any changes to your medical treatment.
The diabetes expert panel agreed that the physician’s knowledge, experience, and ability for supportive, empathic communication to type 2 diabetes patients are essential qualities to successfully achieve diabetes remission (3).
Another important point to keep in mind is that once remission is achieved, continued monitoring is important, because high blood glucose can recur. Reasons for the recurrence of diabetes include reverting to a diet that promotes high blood glucose, weight gain, stress from other illnesses, and side effects from medications, such as steroids and certain antipsychotic medications. HgbA1c should be measured at least once a year, if not more often. Of course, continued active engagement in a healthful dietary and lifestyle pattern is crucial to maintaining diabetes remission.
A hope for the future of medicine
The fact that remission of type 2 diabetes is possible and achievable, without the use of blood glucose-lowering drugs or surgeries, may come as a surprise to many people even in 2023, but this should not be the case. Public education is needed. While new drugs garner wide attention because of the proprietary interest behind the marketing of such drugs, the effectiveness of a dietary intervention such as we discussed here, powerful as it may be, does not enjoy similar widespread marketing campaigns because no single commercial entity stands to gain monetarily from them. However, the value of such non-patented treatments to each and every individual with type 2 diabetes is priceless. So please share this newfound knowledge of yours with others, or share this post. The fact that research continues to show possible ways to reverse chronic diseases, such as type 2 diabetes, gives me hope for the future of medicine. Let us, clinicians and healthcare consumers alike, continue to work together to make disease remission a reality for all.
References
1. Kelly J, Karlsen M, Steinke G. Type 2 Diabetes Remission and Lifestyle Medicine: A Position Statement From the American College of Lifestyle Medicine. Am J Lifestyle Med. 2020 Jun 8;14(4):406-419.
2. Yoshino M, et al. Effects of Diet versus Gastric Bypass on Metabolic Function in Diabetes. N Engl J Med. 2020 Aug 20;383(8):721-732.
3. Rosenfeld RM, et al. Dietary Interventions to Treat Type 2 Diabetes in Adults with a Goal of Remission: An Expert Consensus Statement from the American College of Lifestyle Medicine. Am J Lifestyle Med. 2022 May 18;16(3):342-362.
4. Riddle MC, et al. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes. J Clin Endocrinol Metab. 2022 Jan 1;107(1):1-9.
5. Lean ME, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018 Feb 10;391(10120):541-551.
6. Lean MEJ, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol. 2019 May;7(5):344-355.
7. Ley SH, et al. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet. 2014 Jun 7;383(9933):1999-2007.
8. Smith SR. A look at the low-carbohydrate diet. N Engl J Med. 2009 Dec 3;361(23):2286-8.