- By Rita Rubin
Most health care professionals will tell you that type 2 diabetes is a chronic, progressive and incurable disease (it’s the seventh leading cause of death in the United States).
But some small recent studies have raised the tantalizing possibility that diabetes could go into remission — at least partially, at least temporarily, at least in a subset of patients.
Thanks to the aging of the population and the increasing prevalence of obesity, both of which are risk factors for type 2 diabetes, the disease has been a growing public health problem in the United States. From 1980 through 2014, the number of Americans diagnosed with diabetes nearly quadrupled, from 5.5 million to 21.9 million, the vast majority of whom have type 2, according to the Centers for Disease Control and Prevention.
In people with type 2 diabetes, their bodies don’t use insulin properly, which is called insulin resistance. Early on, the pancreas makes extra insulin to compensate, but over time it can’t produce enough to maintain normal blood sugar levels.
Bariatric Surgery May Help
As a review article in the June issue of Current Diabetes Reports notes, however, weight-loss surgery provides a short-term cure for diabetes in more than seven out of 10 cases.
The non-surgical way to [reverse diabetes] is by going on a very low-calorie diet, which can remove fat that’s clogging the pancreas and blocking secretion of insulin.
— Dr. Roy Taylor, Newcastle University, U.K.
“It is extraordinarily effective in treating diabetes,” says Dr. Pankaj Pasricha, director of the Center for Neurogastroenterology at the Johns Hopkins University School of Medicine in Baltimore. “This is before they lose even a pound of weight.” In fact, many patients no longer need insulin by the time they’re discharged from the hospital after undergoing weight-loss surgery.
Obesity and type 2 diabetes are closely linked, although not all people with the disease are obese. A third of U.S. adults are at high risk of developing diabetes. If you’re one of them (you can take this American Diabetes Association test to help figure out if you are), losing as little as 5 percent of your body weight can greatly reduce your risk of the disease.
But what if you’ve already been diagnosed? Does surgery hold the only hope of remission?
Maybe not, although the likelihood of normalizing blood sugar without surgery appears to be extremely small.
Small Likelihood, But It Does Happen
“With current treatment, there isn’t much remission,” says Dr. Richard Hamman, a University Distinguished Professor of Epidemiology at the Colorado School of Public Health in Aurora. “In some studies we did years ago, we had a couple (of patients) who clearly had diabetes, and it went away.” (Hamman served as national vice chair of the Diabetes Prevention Program Outcomes Study, which found that the drug metformin or lifestyle changes, mainly losing 7 percent of body weight and increasing exercise to 150 minutes a week, could prevent or delay type 2 diabetes in people at high risk for the disease.)
In a study of 122,781 Kaiser Permanente patients with type 2 diabetes published in December 2014 in Diabetes Care, an American Diabetes Association journal, only .007 percent (or about eight people) went into complete remission for at least five years. Another 1.47 percent experienced partial remission, in which their blood sugar level fell to near-normal for at least a year, while another 0.14 percent experienced complete remission, or normal blood sugar levels for at least a year.
“We were surprised they were so low,” lead author Andrew Karter, a scientist with Kaiser Permanente of Northern California’s Division of Research, says of the remission rates. “We’ve heard people talk about remission. We just thought it would be higher. It was kind of disappointing.”
In Karter’s study, people who were over 65, African-American, less than two years out from their diagnosis and not on diabetes medication were more likely to have their diabetes go into remission. But that doesn’t necessarily mean that any of those factors caused their remission.
“Although rare, remission can also occur in individuals with more severe diabetes and those previously treated with insulin,” Karter and his coauthors added.
Reasons Are Elusive
Because he and his collaborators didn’t survey the patients about what might have contributed to their remission, though, “we can’t really answer the question ‘Why?’” Karter says.
Diabetes remission actually might be more common than studies would suggest, but doctors typically don’t test patients’ ability to control their blood sugar levels without medication, the scientists noted. Doing so could result in reduced adverse effects of diabetes medications and reduced health care costs as well as improved patient health, they wrote.
In other words, it would be reasonable for doctors to say to patients, “Your blood sugars are just great. Let’s try taking you off this medication and see how you do,” says Karter, who emphasized that he is a Ph.D., not an M.D., so he doesn’t take care of patients.
Doctor Pushes Different Tactic
One of the biggest proponents of the notion that type 2 diabetes is reversible is Dr. Roy Taylor of Newcastle University in the United Kingdom. “Diabetes reversal should be a goal in the management of Type 2 diabetes,” according to a paper Taylor coauthored in April 2013.
The non-surgical way to do that, Taylor says, is by going on a very low-calorie diet, which can remove fat that’s clogging the pancreas and blocking secretion of insulin.
In 2011, he coauthored a report in Diabetologia about a small pilot study of 11 type 2 diabetes patients, nine men and two women, who went on a 600-calorie-a-day diet — 510 calories from a liquid diet formula and the rest from three portions of non-starchy vegetables — for eight weeks.
After just one week, the patients’ fasting blood glucose fell to normal levels. MRI scans of their pancreas showed that the fat in the liver and pancreas had fallen from an elevated to a normal level. Three months after the study ended, seven of the patients were still free of diabetes.
“There is widespread skepticism, and this is entirely proper, as medicine as a whole must move forward on firm, mutually agreed upon foundations,” Taylor says.
In March of this year, Taylor coauthored a report in Diabetes Care about a study of 30 type 2 diabetes patients who stopped all diabetes medication and insulin before going on the very-low-fat diet for eight weeks. At the end of the eight weeks, patients gradually began to replace the diet shakes with solid foods. A dozen of the participants lowered their fasting blood glucose levels and experienced a remission of their diabetes for at least six months.
A total of 41 patients, however, is too few to support a paradigm shift in treating type 2 diabetes.
That is one reason Diabetes UK, the main diabetes charity in the United Kingdom, has awarded its largest grant ever to fund the DIRECT (Diabetes Remission Clinical Trial) study. Taylor is one of the principal researchers involved with the study.
About 30 primary care practices in the United Kingdom are recruiting a total of 280 type 2 diabetes patients age 20 to 65 to participate in DIRECT. They’ve all been diagnosed within the past six years and are being randomly assigned to the standard care for diabetes or an 800-calorie-a-day diet for 12 to 20 weeks. Their goal is to maintain the weight they lose while on the low-calorie diet.
Hamman, the Colorado School of Public Health professor, remains skeptical. “Lifestyle changes work, but nobody can maintain them,” he says. “The vast majority of people are going to have a very difficult time (restricting calories), short of surgery.”
The DIRECT study “is going to tell us a lot about the physiology of diabetes,” Hamman predicts, “but I don’t think it’s going to tell us a lot about remission.”
You’ll have to wait a couple of years until DIRECT results become available to see who’s right.