Diabetes Reversal ? Yes, it is POSSIBLE

Diabetes is known as greatest threat of the society in 21^st century. India is considered as capital of diabetes in the whole world being at second rank after china in terms of prevalence of diabetes. Looking at increasing number of diabetes cases in India, it is predicted that in near future we may beat china in this matter. Also now diabetes is seen in more younger age and more complications are there, which also progresses very fast in our country.

 

Good news is that Diabetes Type 2 can be reversed. It is being evident through bariatric surgery, very low calorie diet and low carbohydrate diet that diabetes type 2 can be reversed. But still confusion is there what to considered as Diabetes Reversal. And above mentioned strategies are not practical for all diabetes patients. So here we have defined the clinical journey of reversal in diabetes. To understand diabetes reversal we must know why and how diabetes develops. We all know that we require energy to survive which is produced in our cells primarily from glucose. We get glucose through food. But when we fast (we fast daily for around 6-8 hours when we are sleeping) still our all cells get glucose, which produced mainly in liver. Glucose production of liver is governed by our central nervous system and insulin. Now whatever glucose comes into blood through food or liver, it is sensed by our brain and it commands our pancreas to produce insulin from beta cells. Also when food enters our gut, there is production of hormones known as Incretin which stimulates glucose dependent insulin production. Insulin helps glucose to get entered into the cells for energy production. After utilisation of glucose for energy production, if gets converted into glycogen and even if more glucose remains it is stored as fat in body. In spite of that if there is excess glucose remains in blood, it gets excreted out in urine through our kidney governed by our brain. This whole process is also governed by one’s immune system. If any person develops high blood sugar there must some fault at one or more level which may be

• Increased calorie intake
• Increased liver glucose production
• Decreased pancreatic insulin production
• Decrease insulin action
• Abnormal signalling into brain
• Decreased kidney glucose excretion
• Abnormal immune system

 

Out of all these the hallmark of type 2 diabetes is at least some reduction in pancreatic insulin production. The available treatment works on one or more aspects of these malfunctions, based on which we can classify diabetes treatment into five groups:

• Insulin Provider: it includes insulin itself or medicine which increases insulin production overall. (sulfonylurea and glinides)
• Incretin Enhancer: it includes medicines which help to increase Incretin hormone action. (DPP4 inhibitors and GLP1 receptor agonists)
• Glucose Excretor: they help to excrete out excess glucose into urine.
• Insulin Sensitizers: they improves insulin action and reduces insulin demand in body.
• Glucose Restrictors: it stops glucose absorption through intestine. It acts in gut.

 

Based on requirement of the medicines we can classify the reverse journey into diabetes into following stages:

	A1C *	MEDICATION	DURATION
Control	< 7.0	Any	≥ 3 months
Reversal Stage 1	< 6.5	IE/IS/GE/GR	≥ 3 months
Reversal Stage 2	< 6.5	IS, GE, GR	≥ 3 months
Reversal Stage 3	< 6.5	IS	≥ 3 months
Remission	< 6.5	No	≥ 3 months

*atleast two HbA1c three month apart

 

• Diabetes in control: when we are able to achieve the glycemic target. In general recommended target HbA1c is < 7%. (HbA1c is measure of around last three months average blood glucose, HbA1c ≥6.5% is diagnostic of Diabetes). Once the glucose control is achieved, patient should be motivated for lifestyle modification in terms of diet, exercise and healthy habits we may be able to reduce and stop the insulin or insulin provider drugs.
• Reversal Stage 1: when glycemic target is maintained below diagnostic range (HbA1c < 6.5%) without use of insulin provider class of medicines it is called stage 1 of diabetes reversal. It is considered as the first step into reverse journey of diabetes. With continue motivation and positive behaviour we can then stop Incretin enhancer drugs.
• Reversal Stage 2: when a person in reversal stage 1 is able to maintain glycemic target below diagnostic range (HbA1c < 6.5%) without use of Incretin enhancer class of medicines it is called stage 2 of diabetes reversal. In around 70% of the patients who achieves target glycemic control ate able to reach stage 2 of diabetes reversal.
• Reversal Stage 3: With more counselling and education of positive behaviour in lifestyle modification a stage may come in person in stage 2 diabetes reversal that there is no excess glucose into blood to get excreted in urine and we may be able to stop glucose excretor group of drugs and patient is only on insulin sensitizer group of drugs. It is known as stage 3 of diabetes reversal. This is most difficult stage to achieve, but it is possible with healthy dietary habits.
• Remission: It is the final stage into diabetes reversal, where patient is able to achieve and maintain glycemic value as per non-diabetes range (HbA1c < 6.5%). It is possible through more improving physical activity more particularly muscle strengthening exercise regularly and improving muscle mass and reducing fat mass of the patient. If a person has lose weight of at least 10-15 kg or reduces fat mass up to 10 % we may stop insulin sensitizer drugs. When a person in stage 3 reversal is able to maintain glycemic value as per non-diabetes range (HbA1c < 6.5%) even after stopping insulin sensitizer drugs for at least three months or more it is known as diabetes into remission. There is always a chance of relapse and constant monitoring is advised.

To summarise, there are plenty of evidence suggests that Diabetes type 2 is potentially reversible condition when

• Duration of disease is ≤ 5 years, preferably < 2 years
• Sufficient pancreatic β cell reserve
• No associated permanent irreversible diabetes complications
• Age < 60 years

 

As majority of type 2 diabetes patient are on some medical management and if they are able to maintain the glycemic target it is advisable to de-intensify the therapy with continue effort to improve lifestyle.