Diabetes Remission- A new direction for the future

According to a 2021 report by the International Diabetes Federation, 537 million people globally, or 1 in 10, had diabetes mellitus. This figure is anticipated to rise by 2045, to 783 million, and by 2030, to 643 million. More than 75% of diabetic people reside in low- to middle-income nations. The increasing trend of Diabetes is mainly related to insulin resistance due to obesity and South Asian ethnicity in countries like Sri Lanka.

Diabetes is known as a silent killer. Even though, deaths directly related to high blood glucose is minimal, micro and macrovascular complications can cause significant morbidity and mortality. Diabetes caused 6.7 million deaths in 2021, equivalent to one death every five seconds. Though Diabetes is currently not a curable disease. We have the next best option which is Diabetes Remission. A phenomenon known as legacy effect describes that initial control of hyperglycemia can have long term benefit in reduction of complications even though stringent control is not maintained during the course of the disease.

Pathophysiology of Type 2 Diabetes

When pathophysiology is concerned mismatch between energy intake and expenditure plays a significant role in insulin resistance.Excess calories are transformed into fatty acids and stored in the liver, which exacerbates insulin resistance (IR). Higher basal insulin levels are necessary to regulate hepatic gluconeogenesis as a result of IR, particularly during fasting times. The liver produces more fatty acids as a result of this elevated insulin demand. Very low-density lipoproteins (VLDL), which are accumulated in peripheral adipose tissue, are the result of the secretion of these excess fatty acids. Fatty acids start to build up in ectopic locations, including the pancreas, when the storage capacity of adipose tissue is surpassed. Pancreatic beta cell dysfunction brought on by this ectopic fat buildup affects the insulin response to postprandial glucose, leading in chronic hyperglycemia.

How to achieve remission

However, remission can be achieved with lifestyle modification, metabolic surgery and pharmacotherapy. Very low calory diet of around 850 kcal per day can significantly reduce fatty liver improving insulin resistance.  Dietary changes along with exercises can reduce body weight, however it is important to maintain these lifestyle changes to avoid reversing back to hyperglycemia state.

For obese individuals’ metabolic surgery can be advantageous to reduce body weight. Bariatric surgery can be helpful in attaining 60-80% of a remission rate in a short duration. However, the long- term maintenance of bariatric surgery effect depends on the type of the surgery, patients’ commitment to the post- surgery lifestyle changes including dietary control, exercise, presence of comorbidities and pancreatic reserve.

To be considered as diabetes remission patient needs to be off hypoglycemic medication for at least three months. Early studies show that short intensive insulin therapy at the initial stage reverse glucose toxicity improving beta cell function resulting in decrease insulin resistance. Recently included incretin-based therapies such as GLP-1 receptor agonists such as liraglutide and semaglutide , GLP-1 receptor agonists with GIP receptor agonists terzepatide. These medications promote weight loss and achieve glycemic control.

For the current global epidemic of diabetes and obesity, diabetes remission is a great tool to handle mortality and morbidity and health care expenses related to diabetes. However, to achieve the complete impact of remission, long-term maintenance of good lifestyle is mandatory. With low calorie diet, exercise and proper follow-up remission is an achievable goal.