COMMENTARY

How Diet Alone Can Achieve Remission in Diabetes

Cate Collings, MD

Disclosures

July 12, 2022

Cate Collings, MD

Every year, roughly 1.4 million US adults are diagnosed with type 2 diabetes. But when doctors discuss treatment options with newly diagnosed patients, they often fail to include an intensive whole-food and predominately plant-based dietary intervention as a potential strategy to achieve remission without medications or procedures.

That's a shame because remission should be the primary clinical goal of type 2 diabetes treatment, and evidence demonstrates that a person's diet is a significant driver of type 2 diabetes morbidity and mortality worldwide. But a lack of physician training, false assumptions that patients are not willing to engage in intensive interventions, and misguided quality measures that ultimately penalize successful outcomes through nutritional lifestyle interventions frequently result in treatment plans that approach type 2 diabetes more like an irreversible chronic illness.

Fortunately, the medical community is recognizing the need for change. In May, the American College of Lifestyle Medicine published an expert consensus statement "Dietary Interventions to Treat Type 2 Diabetes in Adults with a Goal of Remission" that was endorsed by the American Association of Clinical Endocrinology, supported by the Academy of Nutrition and Dietetics, and co-sponsored by the Endocrine Society.

Diet recommendations as treatment for diabetes generally focus on prevention and disease management. The expert panel behind the consensus statement focused on diet — without medications or procedures — as a primary means of achieving lasting remission of diabetes rather than its more common role as an adjunctive therapy.

This multidisciplinary expert panel (including representatives from seven other medical organizations) agreed on the effectiveness of a whole-food, plant-based diet and reduced calorie intake through reduced food volume, portion size, energy density, or a combination of the approaches over the standard US diet to promote remission of type 2 diabetes. A high level of consensus was also reached on the risk for significant adverse events associated with a very–low-carbohydrate diet.

The panel had consensus that remission should be defined as normal glycemic measures (normal A1c < 6.5% and normal fasting glucose) for at least 3 months without surgery, devices, or active pharmacologic therapy to lower glucose.

The publication delivers an empowering message. It can be argued that failure to present a food-as-medicine treatment option to individuals with type 2 diabetes is a failure of informed consent and shared decision-making. Numerous studies show that sufficiently intensive lifestyle interventions may result in type 2 diabetes remission, with a success rate similar to bariatric surgery but without the excessive costs of surgery or the potential complications. Nevertheless, patients are often steered to riskier and more invasive treatments before consideration of intensive lifestyle change.

The Critical Element of Dose

The expert consensus statement can help guide shared decision making but it is vital that clinicians who prescribe food as medicine develop the knowledge and skills to do so. Just as medication must be dosed correctly to achieve a desired result, intensive lifestyle interventions must be dosed sufficiently to achieve remission. For example, these interventions must be more intensive than those with the goal of prevention of type 2 diabetes. Many lifestyle medicine treatment plan failures are the result of incorrect dosing.

Example of a therapeutically dosed dietary regimen to achieve remission in type 2 diabetes.

Success of a whole-food, predominantly plant-based diet to achieve remission is, of course, largely dependent on a patient's readiness to adapt to intensive changes and adhere to them, which has been challenging for adults with type 2 diabetes.

Poor communication and lack of support from clinicians are frequent roadblocks. That is why it is important to receive treatment from a clinician who is trained in lifestyle medicine who can clearly support and prescribe appropriate dosing. The clinician must consider cultural differences and the social determinants of health and the influence they have on a patient's treatment plan.

Remission won't happen for everyone. Some studies suggest that the longer an individual has had diabetes, the less likely they are to achieve remission. More research is needed to determine how well food-as-medicine treatment can maintain remission for the long term. But through shared decision-making, patient by patient, it is possible to alter the rising trajectory of type 2 diabetes and be part of the solution to make lifestyle-first interventions the foundation of health and all healthcare.

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