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Conquering Diabetes

with Michael Dansinger, MD

This blog has been retired. We appreciate all the wisdom and support Dr. Dansinger has brought to the WebMD community.

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Tuesday, June 30, 2009

What Is Diabetes Reversal? (Part II)

To fully understand the concept of diabetes reversal, it is important to understand how diabetes is detected, measured and monitored.

Measuring Diabetes
People with insulin resistance can eventually develop prediabetes which typically progresses to type 2 diabetes. In many cases people do not know they have prediabetes or early diabetes, until symptoms of diabetes occur, leading to medical attention and correct diagnosis. It is important to know that screening blood tests can detect the early stages of diabetes, or prediabetes, or insulin excess.

By measuring the levels of insulin, and glucose (sugar) in the blood, we can know whether someone has excess insulin levels, prediabetes, or diabetes. Eating a meal changes these levels, making them difficult to interpret, therefore clinicians often prefer to measure them while a patient has been fasting overnight or for 8 to 12 hours. The fasting levels of blood glucose may fluctuate widely from day to day, and no single measurement of blood glucose is a reliable indicator of the overall average blood sugar level.

Fortunately, we have a blood test that indicates the average blood sugar level, called the HEMOGLOBIN A1c. We often just shorten the name to “A1c”. This test measures how “sugar-coated” the blood cells are, and is an excellent reflection of the overall or average blood glucose control. The higher the A1c, the higher the average blood sugar, and the greater the risk of future diabetes complications. Knowing your A1c means knowing your risk of diabetes or diabetes complications. Normal healthy people have an A1c of less than 6%, meaning less than 6% “sugar coated”. In fact, at our hospital laboratory, normal is 5.8% or less, so greater than 5.8% means prediabetes or diabetes. Diabetes experts throughout the world are working together to achieve a consensus about how to use the A1c to define the official cutoff points for prediabetes versus diabetes. Obviously it is one continuum and the definitions or cutoff points are arbitrary. Lacking official cutoff points at this time, I believe it is fair to say that PREDIABETES is roughly an A1c of 5.9% to 6.4%, and DIABETES is roughly an A1c of 6.5% or higher. An A1c over 7% is considered insufficient control of the diabetes, and clinicians often consider increasing the intensity of the diabetes treatment when the A1c surpasses 7%. A1c’s in the 8%-10% range are considered poorly controlled diabetes, and A1c’s over 10% indicate very poor control, and if such levels are sustained over many years, there is especially high risk for diabetes complications, such as heart attack, stroke, sudden death, blindness or eye damage, foot infections or amputation, or kidney damage possibly leading to chronic dialysis.

Controlling Diabetes
We all recognize that healthy eating, exercise, and weight control are important for controlling diabetes. Doctors, dietitians, diabetes educators, nurses, and other health professionals agree that such lifestyle measures are crucially important. Nevertheless, medications are often used to help control the blood sugar levels. Some medications help reduce the insulin resistance, others stimulate the pancreas to make more insulin, some have a combination of effects.

Recent research studies have suggested that using multiple medications to reduce the A1c much lower than 7% may have little or no substantial advantage over just leaving the A1c at 7%. Unfortunately, there is risk of diabetes complications in all people with diabetes, despite A1c’s at or below 7%. In general, people with prediabetes progress to diabetes with gradually increasing A1c’s, despite a gradual increase in medication. Eventually, insulin delivered as injections or via a small “insulin pump” is used to replace or augment oral diabetes medications. All diabetes medications have side effects.

Reversing Diabetes With Surgery
Obesity surgery often reverses type 2 diabetes. Gastric bypass surgery, typically performed using the “minimally invasive” approach with a few small incisions, usually normalizes blood sugar within a few hours or days, allowing the elimination of diabetes medications for many years and possibly for one’s full life. The rapid rate of diabetes remission indicates that the weight loss is not the initial cause of the diabetes reversal. Rather, the change in the intestinal anatomy causes changes to the digestive process and hormonal balance that, combined with the change in food intake, result in diabetes reversal. The dramatic weight losses, often well over 80 pounds, clearly help sustain the long-lasting remissions. Alternatively, lap-band surgery, involving “minimally invasive” laparascopic placement of an adjustable band that constricts the stomach, results in more moderate weight losses, often in the 40-60 pound range, thereby leading to diabetes remission once a sufficiently low body weight has been reached. Most people with recently diagnosed type 2 diabetes can achieve remission with lap-band. More studies are needed to clarify the duration of remission and reversal rates according to age group, degree of obesity, duration of diabetes, and other factors that might influence the effectiveness of such surgery. Surgery for diabetes reversal or control seems like an extreme measure, however, as surgical techniques and post-surgical management of patients continue to improve, the attractiveness of such measures continues to increase, in my opinion. Still, it just seems “unnatural” to use surgery to reverse or control diabetes, and it is clearly not an ideal solution or anybody’s first choice. Personally, I favor it over medication, as a long-term solution for many people who simply can’t control their type 2 diabetes through diet and exercise.

Reversing Diabetes With Diet and Exercise
We know that weight loss, via healthy diet and exercise, can delay or possibly prevent the onset of type 2 diabetes in people with prediabetes. We also know that many people with prediabetes or type 2 diabetes have been able to restore normal blood sugar levels by improving their diet and/or exercising more. Unfortunately, such people are the exceptions, and most people do not achieve or sustain sufficient lifestyle changes to avoid progression of diabetes, once diagnosed. There are no published research studies that convincingly demonstrate the value of lifestyle change for achieving durable diabetes remissions in typical patients, at least not yet. Researchers around the world are working together to evaluate the effects of weight loss through diet and exercise, on diabetes control, and once those results are published, we will gain a better understanding of the relationship between weight loss and risk of diabetes progression and complications.

Meanwhile, I am convinced that reversing prediabetes and type 2 diabetes, as much as possible, through diet, exercise, and weight loss, is the best approach. Health care providers and patients have not done all they can to work together to use lifestyle methods to beat diabetes. Unhealthy lifestyle habits are the root cause of type 2 diabetes and reversing the underlying cause is the principal way to reverse diabetes. I do not use the word “cure” because the diabetes will re-emerge if the lifestyle changes are not sustained, and can even relapse despite ongoing adherence and weight loss. Whether patients can sustain remissions for decades remains to be seen.

Defining Diabetes Remission
There is no official definition for type 2 diabetes remission. The general concept is normal blood sugar levels without diabetes medication. However, if a person stops diabetes medication and has a few normal blood sugar readings, that is clearly not sufficient. Diabetes is officially defined as fasting glucose over125 mg/dL. Prediabetes involves fasting glucose levels in the
105-125 mg/dL range and A1c9s in the 5.9-6.4% range. Is getting into the prediabetes range considered remission? There is no official answer and therefore the topic is up for debate.

Lacking an official definition, I arbitrarily define DIABETES REMISSION as an A1c of 6.0% or less with no diabetes medications for at least 2 months, in a person formerly diagnosed with type 2 diabetes. One could use a different definition, but this one is mine. If someone has been diagnosed with type 2 diabetes, I do not use the term prediabetes to describe an improvement. I define DIABETES RELAPSE as an A1c of 6.5% or higher in someone who was previously in diabetes remission. I define PREDIABETES as an A1c of 5.9-6.4% in someone who has not met the definition of diabetes. I define REMISSION of PREDIABETES as an A1c of 5.8% or less in someone who has met criteria for prediabetes but not diabetes. RELAPSE of PREDIABETES is a return to A1c in the 5.9-6.4% range.

— Michael Dansinger, MD

Posted by: Michael Dansinger, MD at 7:28 pm

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