Health

Achieving Remission for Type 2 Diabetes

Type 2 diabetes nearly killed Anthony Wilson before he had even been diagnosed.

One morning in 2012, his wife Sheila woke up for work to see that her husband had dark circles under his eyes and his skin looked gray. She knew something was seriously wrong, and that she had to get him to the hospital immediately. He resisted, but she persisted and prevailed, he recalls.

“She walked me down the stairs at home, and the next thing I remember was when I woke up in the ICU,” says Wilson, now 54, who lives in Virginia Beach. Tests revealed Wilson’s blood sugar was multiple times higher than the threshold needed to diagnose Type 2 diabetes, a chronic condition where the body doesn’t use insulin properly, allowing blood sugar to rise unchecked.

So intense was the strain on Wilson’s body that his organs were failing. His doctors were talking about putting him on dialysis because of kidney failure, and they had to shock his heart twice to get it back into rhythm because his diabetes had exacerbated an under-lying heart condition, Wilson says.

Once he was stabilized, a doctor told Wilson he had Type 2 diabetes and would need to take insulin for the rest of his life. But not only was he able to come off insulin within months of his diagnosis, he can also now keep his blood sugar in a normal, healthy range with no diabetes medication at all.

After losing 60 lb. in 2020—thanks to diet changes and regular exercise—Wilson, who’s an EMS operations manager and volunteer for the American Diabetes Association (ADA), achieved what’s considered the holy grail in Type 2 diabetes management by bringing it into “remission.”

“I’m the type of person who wants to be in control of my health,” says Wilson, who continues to be vigilant about monitoring his blood sugar. “I share my story with anybody who will listen, in hopes that it can make a difference.”

Diabetes ‘reversal’ by another name

The concept of Type 2 diabetes remission, which is getting increasing attention from researchers and doctors, also goes by other names, including diabetes “reversal,” “resolution,” and even “cure.” But a consensus of experts led by the ADA last year agreed on the term remission as being most accurate.

“The reason we use the word remission is because if someone were to think that they were cured or reversed, the challenge is they may then not feel like they need to have anything checked,” says Dr. Robert Gabbay, ADA’s chief science and medical officer.

In simplest terms, the expert panel defined Type 2 diabetes remission as having a blood-sugar level below the established threshold for a diabetes diagnosis for at least three months without taking diabetes medication. That would be below, for example, 6.5% A1c, for the blood test that’s used to get a three-month average of blood sugar.

But a lot still remains unclear—like how long remission generally lasts, because it varies. And experts stress that continued follow-up with health care providers—not only to monitor blood glucose but also to check for diabetes complications—is important because the impact of diabetes remission (fleeting or long-lasting) on things like heart health and death rate isn’t yet well understood.

Something to strive for, or a rare phenomenon?

Advances in the treatment of Type 2 diabetes may put remission within reach for more people with the disease, especially those who have been more recently diagnosed. “The most common place we see [diabetes remission] is with bariatric surgery where there’s significant weight loss,” Gabbay says.

In addition to the pounds dropped, he adds that there may be secretion of hormones as a result of the surgical reconfiguration of the gastrointestinal tract that makes remission more likely. Some research suggests that after gastric-bypass surgery is performed, certain gut hormones stimulate the production of insulin in the body, including what’s called glucagon-like peptide-1 (GLP-1) and peptide tyrosine-tyrosine (PYY), which drive down blood-sugar levels.

But although remission is strongly associated with bariatric surgery, prominent research shows that significant weight loss alone—without surgery—can be enough to put Type 2 diabetes into remission. A closer look reveals that weight loss can cut fat levels inside the liver and pancreas, letting those organs function normally and allowing them to better regulate blood–glucose levels.

And remission isn’t accessible just to a select few.

The DiRECT trial published in the Lancet in 2018 found that nearly half (46%) of 149 participants studied—who had been diagnosed with Type 2 diabetes within six years and who weren’t on insulin—were able to achieve remission through an evidence-based weight-loss program. The research was carried out in primary-care practices—not specialized weight-loss centers-—over a period of a year. Those who lost 33 lb. or more were most likely to achieve remission.

Follow-up research, published in The Lancet Diabetes & Endocrinology in 2019, found that one-third of participants remained in remission at the two-year mark. Sustained remission was linked to keeping the weight off.

The biggest factor in whether a person can lower blood sugar below diabetic levels and keep it there without medication is the amount of time that has passed since diagnosis, according to Dr. Roy Taylor, professor of medicine and metabolism at Translational and Clinical Research Institute at Newcastle University upon Tyne in the U.K. Taylor was the co–chief investigator and co–senior author of the DiRECT trial.

There’s growing acceptance that remission is possible for a wider group of patients than previously thought, Taylor says, and that’s supported by research. But he expressed frustration that many doctors still don’t approach it this way with patients—at least giving them the option to pursue this goal, should they choose to do so.

Despite study results like those from the DiRECT trial, many doctors contend that such weight loss is difficult for patients to achieve and then maintain. They stress that diabetes control—not remission—remains a primary goal.

It’s very challenging for people to lose the amount of weight necessary to achieve remission, says Dr. Jill Crandall, professor of medicine and chief of endocrinology at Albert Einstein College of Medicine and Montefiore Health System in the Bronx. “It may be that we’re overlooking an opportunity to really motivate patients for that weight loss by introducing the notion of remission. But I think it’s not first in the mind of most clinicians who are treating people with diabetes.”

Others say it should be.

“I used to feel like I was handing out a life sentence when I diagnosed a patient with diabetes. I now work with my patients to reverse their disease,” says Dr. Stephenie Lucas, an endocrinologist at Beaumont Health, which is based in the Detroit area. “Many patients with Type 2 diabetes can go into remission and not require medication to maintain normal glucose levels.”

One thing that’s more universally accepted: regardless of whether a patient is in remission, continued vigilance is key.

“There is no permanent cure for diabetes, because the cells that produce insulin have been damaged and the underlying genetic factors remain,” Lucas says. “The patient does maintain an increased susceptibility to recurrence of diabetes, so lifestyle interventions must be continued.”

Giving patients a choice

Doctors stress that patients should be supported in making diabetes management a priority—however they choose to do so—regardless of whether the aim is remission.

The majority of patients don’t achieve remission, but the goal is to keep their blood sugar under good control, says Dr. Gwendolyne Jack, endocrinologist and clinician-educator at Weill Cornell Medicine in New York City. To achieve this, she says, some patients will continue to need lifelong medication, including insulin. “That’s OK. That is not a failure on their part,” Jack says.

But the impact of a diagnosis on patients—and the desire many patients have to control blood sugar without medication or insulin—shouldn’t be ignored, Taylor and others emphasize. Survey results published in Diabetic Medicine in February 2018 show this is the No. 1 question patients want researchers to answer about the disease: “Can Type 2 diabetes be cured or reversed, what is the best way to achieve this, and is there a point beyond which the condition can’t be reversed?”

Taylor acknowledges that many people with the chronic condition see it as something the doctor will deal with; patients often get help with controlling blood sugar, but their goal isn’t remission. “However, at least 40% of people with Type 2 diabetes hate their condition and would go to lengths to get rid of it,” he says. “They describe the moment of diagnosis as a hammer blow. Many doctors do not understand that.”

For those who wish to work toward remission, Taylor suggests leaning into that motivation:

  • Write down your reasons, so you can come back to them later.
  • Discuss your plans with those you live, work, and socialize with to gain support and understanding.
  • Once you’re ready, decide when to start—and prepare meticulously. “This is not a crash diet,” Taylor says.
  • Understand that your chances of remission are best the closer you are to diagnosis, but it’s still possible even up to 10 years after diagnosis. It’s less common beyond that; waiting makes the goal harder to attain.
  • Weight loss and maintenance, diet adherence, and activity are key to improving chances of remission.

Whether your aim is remission or to improve blood-sugar control through lifestyle changes in addition to taking diabetes medication or using insulin, you’ll want to make it clear to your endocrinologist. And together, carefully parse out a dietary approach in advance of implementing changes to what you eat to ensure it’s safe and that you’re getting all the nutrients you need.

Wilson said it was important for him to see a physician who was as dedicated to his goals around diabetes as he is.

He has other conditions that his Type 2 diabetes could exacerbate, including high blood pressure and supraventricular tachycardia, for which he needs a pacemaker. He also has risk factors—like a family history of kidney disease—that diabetes could exacerbate. So Wilson wants to make sure his A1c remains well under 6.5% and has worked hard to ensure it’s easily within the normal, healthy range.

The longtime medic wasn’t messing around when he decided to try to reverse his Type 2 diabetes in 2020. So he went to his endocrinologist, who put him on a strict 1,200-calorie-per-day diet, which Wilson followed closely. He ate lean proteins, drank plenty of water, limited carbs, cut sugar, decreased serving sizes, and stayed active. These steps helped him drop 60 lb. Although there’s no single diet that’s recommended to achieve remission, low-calorie and low-carb plans have been found to help with weight loss, and shedding significant pounds can increase one’s chances of achieving remission.

Wilson credits his wife Sheila with supporting him throughout his Type 2 diabetes journey. She exercises with him and helps him maintain a healthy diet. “We still have to hold each other accountable,” says Wilson, adding that he uses the ADA as a resource and volunteers with the organization to support others. “I feel pretty good knowing that with hard work, you can accomplish a goal, and I’ve done that with the help of my family.”

He’s also careful not to grow complacent. That’s something experts say is critical to not only achieve but—more important—maintain Type 2 diabetes remission.

Wilson is prepared to continue his hard work. “I didn’t work this hard to lose the weight to go back to the way it was,” he says.

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