Do I need to take medicine if I have type 2 diabetes?

Do I need to take medicine if I have type 2 diabetes?

Author: Zhong Juan, The Second Affiliated Hospital of Hunan University of Chinese Medicine

Instructor: Guan Yan, The Second Affiliated Hospital of Hunan University of Chinese Medicine

Image drawing: Yang Xi

For a long time, the traditional public perception has been that type 2 diabetes (T2DM) is an incurable lifelong disease that requires long-term treatment with hypoglycemic drugs.

However, a large number of research results in recent years have shown that lifestyle intervention , drug therapy, and metabolic surgery can promote the remission of type 2 diabetes patients with overweight and obesity , allowing patients to avoid the use of hypoglycemic drugs for a longer period of time [1]. What is the principle behind this? Can all people with type 2 diabetes do this? Let's talk about it today.

What is remission?

In the absence of hypoglycemic drug treatment, blood sugar can still be maintained at the target or normal level.

So, what is the standard for judging whether or not the disease is remitted? In the consensus report on "Definition and Interpretation of Remission in Type 2 Diabetes" released by the American Diabetes Association (ADA) in 2021, it was proposed that a blood test of glycated hemoglobin (HbA1c) <6.5% should be used as the diagnostic standard for remission of type 2 diabetes after at least 3 months of discontinuation of hypoglycemic drugs . When glycated hemoglobin cannot reflect the actual blood sugar level, fasting blood glucose (FPG) <7.0 mmol/L or estimated glycated hemoglobin (eA1c) <6.5% calculated by dynamic glucose monitoring can be used as an alternative standard for diagnosing remission of type 2 diabetes [2].

What is the mechanism of mitigation?

Correct pancreatic beta cell dedifferentiation, correct insulin resistance, correct obesity, correct fatty liver and fatty pancreas.

Patients with type 2 diabetes who have been suffering from it for less than 5 years still have a certain number of pancreatic beta cells in their pancreas. Through certain interventions, the "dormant pancreatic beta cells" can resume synthesis and secretion of insulin. Under the action of insulin, the body's blood sugar level is reduced and reaches a balanced state.

Among newly diagnosed type 2 diabetes patients, hyperinsulinemia accounts for 50%. However, as diabetes progresses, pancreatic β-cell function is impaired, making type 2 diabetes impossible to reverse. If insulin resistance is corrected, pancreatic β-cell function can be significantly improved.

Overweight and obese patients with type 2 diabetes often have fatty liver. In patients with fatty liver, fat overflows from the liver into the pancreas, leading to fat deposition in the pancreas (fatty pancreas), which may lead to abnormal function of pancreatic β cells [5].

What is the core of mitigation?

Weight loss is central to the management of type 2 diabetes associated with being overweight or obese.

Overweight/obese patients with type 2 diabetes have increased visceral fat. As weight is reduced, fat deposits in organs such as skeletal muscle and pancreas are reduced, and the insulin secretion function of β cells is also significantly improved. Therefore, weight loss is the core goal and means for overweight/obese patients with type 2 diabetes to achieve clinical remission. According to the Diabetes Remission Clinical Trial (DiRECT) study, the diabetes remission rate of patients with diabetes and obesity within 5 years after weight loss was 46%, and the more weight they lost, the higher the diabetes remission rate. When the body weight was reduced by more than 15 kg, the complete remission rate could reach 86% [8].

People with type 2 diabetes and obesity are advised to lose at least 10 kg (preferably 15 kg) or more of their body weight [1]. However, please note that long-term extremely low-energy (<800 kcal/d) nutritional therapy is not recommended [3]. So, how much energy do adult diabetic patients with different physical activity levels need in a day? Please refer to the following table [3]

Daily energy intake for diabetic adults with different physical activity levels [KJ/Kg (kcal/kg)]

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①Standard weight:

Male = [height (cm) - 100] x 0.9 (kɡ);

Female = [height (cm) - 100] x 0.9 ( k ɡ) - 2.5 ( k ɡ);

② Body mass index:

Body mass index (BMI) = actual weight (kg) / height (m)2

≤18.5 k ɡ/m2 is considered underweight, 18.6-23.9 k ɡ/m2 is considered normal weight, 24.0-27.9 k ɡ/m2 is considered overweight, and ≥28.0 k ɡ/m2 is considered obese.

What methods can provide relief?

Metabolic surgery, lifestyle intervention, drug therapy

According to research, metabolic surgery has the highest remission rate among these methods, but not everyone can undergo it and must undergo various evaluations. Surgery is an invasive treatment method and complications may occur during and after the operation. Insulin intensive therapy in drug treatment has a good remission rate, but it is complicated to operate and has low patient acceptance. Therefore, considering the comprehensive remission rate, acceptance, compliance, etc., lifestyle intervention therapy is the most suitable and promising method among all remission methods.

In terms of mitigation strategies, it is recommended that lifestyle intervention with diet therapy as the main intervention measure be preferred . In terms of dietary pattern selection, it is recommended to mainly eat low-calorie and high-satisfaction diets such as coarse grains and vegetarian foods .

A comprehensive plan accompanied by other lifestyle changes (such as exercise, etc.) is more beneficial than dietary intervention alone . In terms of exercise, aerobic exercise is the best exercise to reduce fat, and it can reduce body fat. It is recommended to do at least 150 minutes of moderate-intensity aerobic exercise per week. At the same time, resistance exercise should be performed at least twice a week. You can refer to the table below.

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When exercising, be sure to choose the exercise method, intensity, exercise environment and equipment that suits you, and monitor the effects at any time to avoid injuries during exercise.

When weight loss is too fast, fatigue and motor function decline, it is appropriate to reduce the amount of exercise. On the contrary, when weight change is not obvious, it is appropriate to increase the amount of exercise to accelerate fat loss.

Which relief method is suitable for you? It is recommended that you ask your doctor to conduct a comprehensive assessment before formulating a personal relief plan. This will be more effective and safer.

Which people with diabetes are likely to experience remission?

Comprehensive evaluation from the following four aspects [1]

1. Antibodies: Glutamic acid decarboxylase antibodies and other type 1 diabetes-related antibodies are negative. This means that the patient does not have an immune response that destroys his own pancreatic islets.

2. Body mass index ≥ 25 kg/m2 (or waist circumference > 90 cm for men and > 85 cm for women)

3. Fasting C-peptide ≥ 1.1 μg/L and 2 hours after meal C-peptide ≥ 2.5 μg/L indicate that the patient still has a certain pancreatic β cell function and has the basis for alleviating type 2 diabetes.

If you have cardiovascular disease and severe retinopathy, you should have a cardiopulmonary function assessment and avoid high-intensity exercise to prevent accidents.

4. Short course of disease. Clinical evidence shows that patients with type 2 diabetes with a course of disease ≤ 5 years have a higher chance of remission after intervention.

For patients with type 2 diabetes who have a long course of disease, severe complications, and poor islet function (fasting C-peptide <1.0 μg/L when blood sugar reaches the target), there is no clinical evidence that diabetes can be alleviated in this population.

Is there a golden period for remission?

Pre-diabetes, within 5 years of onset

During these two periods, the patient's pancreatic function is relatively less damaged. In the early stages of abnormal glucose metabolism in patients with type 2 diabetes, in the context of insulin resistance, the body's β cells compensatorily secrete more insulin in order to maintain normal blood sugar levels. However, after a long period of "high load", β cell function declines, insulin secretion is relatively insufficient, and blood sugar levels can no longer be maintained, leading to diabetes [4]. In addition, as the disease progresses, β cell function further declines or even becomes exhausted, and type 2 diabetes can no longer be reversed [7].

Therefore, the golden period that everyone is concerned about is nothing more than "early". Early detection and early intervention and treatment can restore the function of pancreatic beta cells early, so that blood sugar can still be in a standard or normal state without hypoglycemic drug treatment.

If you have type 2 diabetes, you don’t have to take medicine. For those who meet the remission conditions, scientific intervention treatment can help patients avoid using hypoglycemic drugs for a longer period of time, slow down the progression of the disease, and reduce the risk of lifelong complications.

However, please also note that this state of diabetes remission is not permanent. It is not that you can ignore it after a normal test. It is best to test glycated hemoglobin once every 3 months and no longer than 1 year .

So far, there is no evidence that type 2 diabetes can be cured. After remission, even if the measures to induce remission are still maintained, the blood sugar levels of some patients may rise again to a level that requires the use of hypoglycemic drugs. Therefore, regular follow-up is very necessary, and long-term strict lifestyle management also needs to be adhered to.

References:

［1］Expert Committee for Compilation of “Chinese Expert Consensus on Remission of Type 2 Diabetes”. Chinese Expert Consensus on Remission of Type 2 Diabetes[J]. Chinese General Practice, 2021, 24(32): 4037-4048. DOI: 10.12114/j.issn.1007-9572.2021.01.105.

[2] RIDDLE MC, CEFALU WT, EVANS PH, et al. Consensus report: definition and interpretation of remission in type 2 diabetes［J］. Diabetologia, 2021. DOI: 10.1007/S00125-021-05542-Z.

[3] Chinese Medical Association Diabetes Branch. Guidelines for the prevention and treatment of type 2 diabetes in China (2020 edition) [J]. Chinese Journal of Diabetes, 2021, 13(4): 315-409. DOI: 10.3760/cma.j.cn115791-20210221-00095.

[4] Weir GC, Bonner-Weir S. Five stages of evolving beta-cell dysfunction during progression to diabetes［J］． Diabetes, 2004, 53 Suppl 3: S16-21.

[5]Wagner R, Eckstein SS, Yamazaki H, et al. Metabolic implications of pancreatic fat accumulation［J］． Nat Rev Endocrinol, 2022, 18(1): 43-54．

[6] Lean MEJ, Leslie WS, Barnes AC, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-yearresults of the DiＲECT open-label, cluster-randomised trial［J］． Lancet

Diabetes Endocrinol, 2019, 7(5): 344-355．

[7] Alejandro EU, Gregg B, Blandino-Rosano M, et al. Natural history of β-cell adaptation and failure in type 2 diabetes［J］． Mol Aspects Med, 2015, 42(4): 19-41.

[8] LEAN ME, LESLIE WS, BARNES AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial [J]. Lancet, 2018, 391 (10120): 541-551.