COMMENTARY

Can Type 2 Diabetes Be Reversed? No, but Remission Is a Worthy Goal

Robert A. Gabbay, MD, PhD

Disclosures

September 15, 2022

Robert A. Gabby, MD, PhD

Diabetes poses one of the greatest health threats to in the United States. More than 37 million Americans are living with type 2 diabetes, which constitutes over 11% of the US population. Even more concerning is the increasing rise of diabetes and prediabetes combined: 38% of adults have prediabetes and 1.4 million Americans are diagnosed with diabetes every year. At the American Diabetes Association (ADA), we are laser-focused on what we can do to change these astronomical numbers.

Thankfully, many companies and health plans are aggressively working to curb diabetes within their own populations. As diabetes has taken greater hold within the benefits community, we have seen an increase in reference to "diabetes reversal." Understanding the appeal of such an outcome, it is important to take into account the physiologic nature of the disease itself as we work together to mitigate it.

To be clear, diabetes "reversal" is not recognized by the ADA or the endocrinologist community as a legitimate state of diabetes. In best-case scenarios, "remission" is a more accurate description of what can be achieved by people who have been diagnosed with type 2 diabetes. Similar to how the medical community refers to cancer remission when treatment is successful, we must use the correct term to define the state of disease — if for no other reason than to manage expectations about the potential return of the disease and the continued need to screen for the development of complications.

People with type 2 diabetes are considered to be in remission after sustaining normal blood glucose levels (A1c < 6.5%) for at least 3 months without taking diabetes medication. Note that the ADA identifies metformin as a diabetes medication, regardless of any other potential uses.

Diabetes Remission, Not Reversal

Claiming diabetes reversal is shaky ground. It ignores the progressive nature of the disease. Once a person has type 2 diabetes, they'll always have the propensity for the disease. People can achieve remission through healthy eating, carbohydrate restriction, and other avenues, but the underlying physiology of diabetes cannot be reversed at this time. The term "reversal" is particularly problematic when used to describe people who barely cross below the threshold of an A1c of 6.5% and may easily become symptomatic again. The human body is so intricate, so complex, that even the subtlest shifts can push a person back into a diabetic state.

Even after bariatric surgery, well established to be an effective treatment for people with type 2 diabetes and obesity, the medical community agrees only remission is possible. Type 2 diabetes seems to recur 3-15 years after surgery in 30%-50% of patients who initially experience remission after surgery. If a person lets their diet lapse and/or regains weight, their diabetes symptoms will reappear. 

Another reason why the term "reversal" is problematic is that it can lead people to believe they have beaten the disease. In reality, sustained remission requires continued adherence to a diabetes prevention program. After medications are no longer needed, a person will probably still need to maintain their nutrition plan, fitness regimen, and mental healthcare. If that person lets up their dietary guard and regains weight, the symptoms of diabetes will recur. This is why diabetes is considered a chronic condition.

People with diabetes should be continually monitored and supported for successful diabetes management. For those who achieve diabetes remission, subsequent testing should be done at least yearly to determine long-term maintenance and ensure they remain below the A1c threshold. Even when in remission, people with diabetes should undergo routine testing for potential complications of the disease. 

The mission to prevent and cure type 1 diabetes and to improve the lives of all people affected by diabetes remains top of mind within ADA's research programs. Each year, the ADA gathers the diabetes community to present the latest in innovations, prevention, and care. This summer, at the ADA's 82nd Scientific Sessions, we saw research showing that artificial intelligence offers significant rates of remission for type 2 diabetes.

We welcome the medical and technological innovations accomplished over the last two decades. People with diabetes are leading healthier, fuller lives as a result, and the drive to lessen prevalence is a goal shared by many healthcare organizations and companies nationwide.

The only way that we can decrease diabetes prevalence is by working together as a health community for a better tomorrow. This also means that we can't allow the clinical definition of reversal to be used in a relaxed manner. By using the correct term of "remission" of type 2 diabetes, we hope to emphasize the importance of adhering to long-term management practices, such as healthy eating, exercising, mental healthcare, and regular screenings to sustain remission — an accomplishment to be proud of and maintain.

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