Making Sense of Diabetes Remission
By Andrew Briskin
The latest advances in diabetes care have led to several new tools to help people with type 2 diabetes lower their glucose, lose weight, and prevent complications. From medications to virtual care to more effective diets, experts discussed these tools in diaTribe’s Musings panel “Reimagining Approaches to T2D: Is Remission Possible?”
Research over the last decade has led to remarkable new interventions to help people with type 2 diabetes live healthier and happier lives. These interventions make it possible for some people with type 2 to lower their blood glucose to pre-diabetes levels and lose weight, while simultaneously reducing the medications they need.
However, reaching this goal is no easy task. Experts on type 2 diabetes medication, diet, and clinical care discussed these tools, the meaning of diabetes “remission,” and more at diaTribe’s Musings panel “Reimagining Approaches to T2D: Is Remission Possible?” You can watch the full panel discussion below, or on YouTube.
The panel discussion was moderated by Dr. Alan Moses, chair of diaTribe’s board of directors, and former chief medical officer and current member of the board of trustees at Joslin Diabetes Center. Speakers on the panel included:
Dr. Vanita Aroda, associate professor of medicine at Harvard Medical School and director of diabetes clinical research at Brigham and Women’s Hospital
Dr. Leonard Glass, vice president, Lilly Diabetes Global Medical Affairs
Dr. Bob Ratner, advisor and former chief medical officer at Virta Health
The panel started with a discussion about the changing approaches to care for type 2 diabetes, which, in recent years, has gone beyond managing glucose levels.
“In the past, [American Diabetes Association] practice guidelines were entirely focused on glucose [management],” said Aroda. “Now with the tools we have, we have medications that can address both glucose and weight, probably at equal levels. The evolution of the guidelines is now saying that no two patients are alike, so let’s put the person at the center and consider their own glucose and weight goals, while reducing cardiovascular risk. This is really a more holistic picture.”
Panelists elaborated on the tools available to treat type 2 diabetes from several different angles, including weight, glucose management, and limiting complications. Some of these tools include:
Lifestyle interventions – new programs and virtual platforms support people with type 2 diabetes in changing their daily diet and exercise routines.
Ratner advocated for a shift toward continuous, virtual care to better support people with diabetes. “[Clinicians] spend maybe 40 to 50 minutes a year with our patients. That just doesn’t work for a chronic disease like diabetes,” he said. “Having a continuous remote care model for diabetes allows health coaches, nutritionists, and providers to interact much more frequently with their patients.”
Bariatric surgery – procedures that alter the anatomy of the stomach and small intestine so that food bypasses part of the intestines, and therefore the body absorbs fewer calories.
Medications – these include a class of glucose-lowering medications called GLP-1 receptor agonists, that also support weight-loss and provide protection against cardiovascular (heart) complications.
Along with GLP-1 receptor agonists, Mounjaro (tirzepatide) is a medication in a new drug class called a GIP/GLP-1 receptor agonist, or dual agonist. The drug is a single molecule that activates the body’s receptors for two hormones, GIP and GLP-1, as opposed to just one. The drug has shown significant effects on glucose management and weight loss.
“Tirzepatide is not yet approved for weight loss, but we are conducting a large clinical trial program called SURMOUNT, where we are looking for a weight loss indication,” said Glass. “We released data from the SURMOUNT-1 trial recently at ADA and were very excited about the data we saw. We continue to have conversations with the FDA on how to move that program forward.”
The availability of these tools has made it increasingly possible for people with type 2 and their providers to target a goal of diabetes remission. Though there are varying definitions for this term, Aroda said that “in the international consensus to define type 2 diabetes remission [which involved the ADA], the term was defined as having an A1C of less than 6.5% for at least three months without any therapy [glucose-lowering medications].”
Some panelists, however, cautioned that this definition may not be ideal. Many glucose-lowering medications that contribute to weight loss have also shown positive effects on protecting the heart and kidneys. Experts mentioned that for some, the goal of eliminating all medications may not be the best course of action to limit the progression of complications long-term.
“Remission as a term is complicated, because we want people to achieve normal blood glucose and weight to prevent the complications of diabetes,” said Glass. “At this point, we cannot stop therapy and expect patients to maintain their blood glucose and weight long-term. Our goal should be to allow people to achieve a healthy lifestyle, and if you have to do that with medication, that’s still a very good goal if the risk-benefit of the medication is positive.”
Still, for some people with type 2, it is possible to eliminate the need for medications by modifying their diet. Ratner said that while clinical trial evidence demonstrates how many people can successfully reach remission through dieting, people must enjoy the diet, see the benefits, and be able to stick to it in their daily lives.
“Sustainability and durability are what differentiates [Virta Health’s] approach from other diets that are not as sustainable,” said Ratner. “One of the issues with other lifestyle interventions is that people don’t see the effects very quickly, so they stop the program. Individuals with a well-formulated ketogenic [very low-carb, high fat] diet are seeing falls in glucose on day 2. They are seeing decreases in medication on day 1 or 2. They are seeing falls in weight after the first week. People see the beneficial effects, so they stick with it.”
Finally, panelists discussed the effects of stigma on weight management, and how new treatments have impacted how individuals experience living with type 2 diabetes.
“There is a perception in society that excess weight is ‘the patient’s fault.’ We now know that is not the case,” said Ratner. “We know that there are [brain] signals, inflammatory responses, and other factors [outside the individual’s control] that affect metabolism. People who have struggled with weight management will have tried a thousand different diets, and none of them worked. If they can find something that works, their whole personality begins to change, since they’ve found success, as opposed to this perception of failure.”
“Over time, we’ve had improvements to therapies, including surgeries and medications,” said Glass. “We’ve been able to identify new targets and therapies that deliver significant improvements in weight, which provide more tools to address that weight stigma. At the end of the day, we want the patient to achieve a healthy metabolic state,” he added.
“I hope that with the tools we have today that weight can be treated as an objective factor, as one biomarker in the bigger picture,” said Aroda. “Weight is an important factor, but there are so many historical, social, and cultural issues that affect weight. I hope the tools we have allow us to have more holistic conversations with patients that we should have been having this whole time.”
Overall, panelists were very optimistic about the future of type 2 diabetes treatment and the tools available that might allow some people to achieve diabetes remission. “The key is to start treatment early,” said Moses, the panel moderator, in his closing remarks. “You have the best chance of achieving a good outcome, sustaining that outcome for a long time, and impacting long term complications over a lifetime. The tools are there; it’s an exciting time in diabetes, both for the science, and the translation of that science, into clinical care for people living with diabetes.”
To learn more about diabetes remission and the strategies and tools available to reach this goal, read: