Need help navigating life with diabetes? You can always Ask D'Mine!

Welcome again to  our weekly Q&A column, hosted by veteran type 1 and diabetes author Wil Dubois.

Today Wil is looking at international differences in the way diabetes is treated and discussed, and whether type 2 diabetes can really disappear...

{Got your own questions? Email us at AskDMine@diabetesmine.com }

 

Michael, type 2 from the UK, writes:I am a 57-year-old UK male, recently diagnosed with type 2 diabetes in March 2018. My A1C was 8.5%, my weight, 343 lbs. Since then, I have lost weight by reducing white carbs, calories, and by taking a brisk walk daily. I have had two further A1C test results -- August 2018: 5.9%, December 2018: 5.6%. My weight is now 231 lbs. I have been told that my diabetes is in remission. I have never taken meds for my diabetes. Can you tell me what you think is now happening in my body with regard to liver, blood vessels, pancreas function, insulin and blood glucose control?

 

Wil@Ask D’Mine answers: Wow. Medicine sure is different on your side of the pond. But before I talk about that, and dig into your questions, let me take a moment to pin a medal on your chest. You’re my Diabetes Hero of the Month. In fact, I think I’ll just go head and give you the award for the whole year. You lost 112 pounds. In one year. That’s a third of your original body weight. In one year. That’s frickin’ amazing! And the results of that effort are sure paying off in your A1C improvements. 

But did it place your diabetes in remission? Hmmmm…. 

OK. Here’s the deal. Over here in the USA, "remission" is not a term we’ve really embraced for diabetes, for when it's seemingly stopped dead in its tracks by lifestyle change. Although we probably should. I like the term. It suggests the disease is currently a non-issue, but could come back. 

Instead, in State-side medical circles, we take the once-a-diabetic, always-a-diabetic approach. Patients with normalized blood sugar still carry a diabetes diagnosis with them. In fact, we don’t even have a diagnosis code for diabetes in remission. On the other hand, and to the opposite extreme, among patients you often hear the notion of “reversing” diabetes. Diabetes can’t be reversed. It can be slowed. It can be stopped where it is at. Blood sugars can be normalized, creating the illusion of reversal, but take away the damn you built across the river (by going back to your previous weight, eating, and exercise habits) and diabetes will come roaring back like flood waters. 

So, as I said, I like the word remission. And you Brits are actually the driving force for embracing the remission concept in diabetes, most notably with the recent DiRect Trial—which used weight management in primary care settings to treat diabetes and place it in “remission.” I hope the term catches on more widely. Of course, in fairness, back in 2009, the American Diabetes Association (ADA) published a consensus paper that tried to create a medical definitions of both “cure” and “remission.” In that paper the ADA established medical criteria for both partial remission and complete remission based on A1C and fasting glucose levels, and stipulated that those levels would have to be under the target levels for “at least one year’s duration in the absence of active pharmacologic therapy or ongoing procedures.” So under this rarely-used American definition of remission, you still haven’t been “clean” long enough to qualify. 

Not that I have any doubt that you will. 

But word choice isn’t the only thing about how your docs addressed your diabetes that’s different from what I’m used to. Your diagnosis A1C was right on the border of causing serious complications, and yet your medical team choose not to start even one single medication. That blows my mind. Completely. Using the American Association of Clinical Endocrinologists (AACE) treatment algorithm over here, you would have left the doctor’s office on at least two medications, and a good argument could have been made for starting insulin five minutes after your A1C test results came in.

Hey, I’m not medicine-happy, but I have a healthy sense of urgency when it comes to diabetes and its destructive capabilities when out of control. I don’t trust diabetes, and frankly, I don’t trust diabetes patients, either.

OK, that sounded bad. It didn’t quite come out the way I intended.

Here’s the deal: I’ve worked with literally hundreds of perfectly lovely people who have begged me to intervene with their doctors not to start any sort of medicine, offering up promises of ridiculous degrees of lifestyle change to avoid meds. These people meant well. And they thought they could do it. But, hey, lifestyle change is tough. I used to say it’s easier to change your gender than your diet, but that upset the trans-gender crowd. I honestly didn’t mean to diss anyone or bruise anyone’s feelings; rather I simply wanted to point out that for human beings, changing how we live is the hardest of all things. And I found through experience that we had better success when we medicated the tiger diabetes into submission, to ensure the patient’s safety, and then instituted lifestyle changes, in baby steps—reducing the meds as success dictated. 

Of course, your docs took a different course when it came to starting meds, and they were proved correct in your case.

So, what about complications? A year from now, when both your docs and the ADA agree that you’re in remission, do you have a completely clean bill of health? Or is there permanent damage that can’t be undone? One thing everyone agrees on is that normalizing blood sugar stops old complications from growing and new ones from appearing. So that’s a good thing. But can any damage sustained from high blood sugars prior to remission improve? Can you return to the complete health you enjoyed prior to diabetes?

That’s controversial and not that well-researched yet. And it’s complicated by the fact that there are a lot of variables at play. The best way to think about this issue is to compare it to a thermonuclear bomb. BOOM. The bomb goes off. Buildings are flattened in the blast wave. People die in the fireball. But it doesn’t end there, does it?

‘Cause nukes have a side effect: Radiation. Some radiation accompanies the blast. Some drifts down in the fallout. And some permeates the blast site like some sort of evil mold that just can’t be scrubbed away. 

So too, high sugar affects cells in your body the same way, and linked with this is another issue: Some of the tissues in your body deal with damage better than others. Some can grow back if damaged. Others don’t seem to possess this same regenerative magic. And in sad point of fact, most complications—especially the big three — nephropathy, retinopathy, and neuropathy — are historically viewed as being cast in stone. Whatever damage is done prior to the sugars being controlled is with you for the rest of your life, sometimes not manifesting until years after the damage occurs. Did you have diabetes long enough for damage to happen? Most likely so. By the time of diagnosis, most type 2s have already suffered tissue damage from elevated blood sugars due to the fact that T2 diabetes is preceded by a looooooong period of pre-diabetes in which sugars are above normal, pouring the foundations for complications.

So where does that place us when it comes to your concerns in regard to liver, blood vessels, pancreas function, insulin and blood glucose control? At the moment, nothing new is happening. You sugar is now low enough that we can be pretty comfortable that there’s no new damage taking place. Whether you’ve sustained any damage in the interim, and, if so, whether that damage might improve, is a bit more complicated.

Starting with your liver: The main worry with the liver in T2 diabetes is fatty liver disease, which increases the risk of cirrhosis. Losing weight can fix the fatty part, but if cirrhosis has already started, that’s a tougher issue. This type of liver damage can’t be reversed—although like many other chronic conditions it can be treated, and isn’t necessarily a death sentence. 

Next, on to your blood vessels... 

Looking at studies of bariatric surgery patients, the best baseline for diabetes remission, blood vessel complication outcomes appear to be a real crap shoot. Many patients show improvements in both kidney function and in eye-related complications, while on the other hand, others don’t improve, and about a quarter—who had no complications prior to the procedure—develop microvascular complications in the five years following. This suggests a time-bomb like effect. 

What about the macrovascular complications? Initial evidence, also looking at bariatric surgery patients, suggests the same mixed bag.

Lastly, what about the complex dance between your pancreas, insulin, and blood sugar?

As a (former?) type 2, your body has been through a decades-long period of significant insulin resistance that led to your pancreas suffering some degree of burnout, ultimately leaving it unable to produce enough insulin to overcome the resistance, causing high blood sugar. Now that you’ve lost the weight, the insulin resistance is reduced and your insulin production is sufficient for you current needs. But has your pancreas recovered? I very much doubt that it has, or ever will. If you want to test that theory, eat a heavy dose of one of those white carbs you swore off and see what happens to your blood sugar. My bet is that you’ll experience a significant spike.

In active diabetes, insulin resistance gets worse over time, even when the diabetes is well-controlled. In pre-diabetes, when proactively addressed and “reversed,” the insulin resistance stabilizes and possibly improves. So what happens in remission? Will it stop advancing? Will it be frozen in place? Will dwindle and go away?

I don’t think anyone knows yet.

But one thing is certain: You’ve changed your life for the better. You’ve stopped all the evils under your skin from hurting your further. That’s wonderful. Will the sins of the past reap damage in the future? Possibly so. But it’s equally possible that your cells will re-group. Heal. Grow. And uncomplicate your life completely.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs (or partridges in pear trees). Bottom line: you still need the professional advice, treatment, and care of a licensed medical professional.