R M Cullen
MD MSc MFM BA DipStats DipProfEthics
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Reversal or cure?
If your A1c level was 55 but is now 37, is it fair to claim that your diabetes has been 'cured'?
'Cure' is a term that is increasingly falling into disuse. With the advent of antibiotics, it was common to alk about curing infectious disease. All the bacteria responsible for the infection had been killed. However, there is a sense in which we all expect 'cure' to mean 'gone and never to return'. If your diabetes is reversed it is not cured in the sense that you will never ever have an A1c of 50 or more in the future.
Dr Cullen sees type 2 diabetes as something triggered by problems in the walls of cells acting as glucose gates or filters. This problem leads to insulin resistance and the requirement for elevated serum glucose levels in order to have the same amount of glucose pass into cells.
Although, in general, Beta cells can increase in number quickly enough to deal with the requirements of more body cells (through growth or fat storage) they are often overwhelmed by the steeper increase in workload that the development of insulin resistance can impose. The result is excess Beta cell death and a cycle where more and more is demanded from fewer and fewer Beta cells.
Diabetes reversal is nothing more than restoring to your Beta cells the ability to manage their current workload. There is no guarantee that a future workload increase will not tip you back into a situation of excess Beta cell death.
Reversal vs control?
If you are successful in reversing your type 2 diabetes, then your A1c level should continue to be checked, perhaps every three months if you have other blood tests regularly, perhaps annually if you have no need to see a doctor more often.
If you elect 'good control' then you are committing to a lifetime not only with the label 'diabetic' along with whatever employment or driving limitations accompany the diagnosis, but also with the pressure not to eat this and so on.
'Intensive management' of diabetes, aiming for sustained 'good control' can be dangerous. The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial was stopped early because there was an increase in both cardiovascular and all cause mortality in the intensively managed group. The aim in this trial was to reduce HbA1c levels to 42 or below i.e effectively to reverse diabetes. However, the methods of intensive control are quite different to the methods of reversal.
This article from NZ's BPAc is worth reading.
What are my chances?
If you were diagnosed with diabetes more than ten years ago, have never had good control (A1c consistently above 65), and already have one of retinal disease due to diabetes, impaired kidney function, or reduced sensation in your feet, then your Beta cell mass is probably already under 60% of what it once was. Diabetes reversal is about, first ending excess Beta cell death, and then increasing Beta cell mass by 2.5-5.0 per-cent per year. It will take a while, five years or more, to reverse your diabetes if this can be done at all. We need good control as a starting point. You should be on metformin, insulin (which may not be needed permanently), an ACE inhibitor, and aspirin.
At the other extreme, if your A1c is somewhere in the 43-46 range, reversal of your pre-diabetes can be expected. Remember that an A1c of 48 is diagnostic of diabetes in the USA!
What is the evidence?
Doctors have known for years that bariatric surgery (loosely speaking stomach stapling) reverses diabetes within a few days of the surgery, well before any significant weight loss has occurred.
A team from Newcastle university has developed the theory that fat storage cells around the liver and pancreas in some way poison the pancreatic Beta cells, and that in a very low calories diet these fat storage cells are the first to be removed. They have found a short-term very low calorie diet effective in reversing type 2 diabetes. One man's story can be found here.
There have been a number of studies with the goal of lowering HbA1c to below 48 in at least some patients (the 'intensive intervention' group). This was achieved in some patients.
The evidence that type 2 diabetes can be reversed is strong. What is unclear is what is the minimum effective intervention.