Mr X had parked his car in a narrow parking area near his house yesterday. Today, he started the car and switched the vehicle into reverse gear. After the successful reversal of his car, he drove to his office.
Mr Y was diagnosed with type 2 diabetes in 2016. His doctor advised a weight loss diet, exercise, stress reduction, and medication. As his lifestyle changes began to take effect, his doctor stopped medications but asked him to regularly monitor his blood glucose. After a few months of maintaining good glucose control, he stopped going to the doctor. Over the next two years, the blood glucose levels remained normal. However, in 2019, his diabetes was back and he regained the weight that he had lost. Indeed, his friends told him that he had a relapse of type 2 diabetes, and advised him to go back to his doctor. Simply put, the word relapse meant a return of illness after a temporary pause.

Mr Z had been diagnosed to have a cancer of the thyroid gland in the neck, which had spread to several nearby areas of his body. After surgery and radioactive iodine treatment, scans showed the disease was no longer detectable. His doctor told him that his cancer had gone into remission. The word remission, the doctor carefully mentioned, meant that the disease had got better temporarily – but that it could come back later and might have to be treated again. The word remission was a better word than reversal, said the doctor and added that the term remission would send a subtle signal to both the patient as well has healthcare providers about the need for long-term surveillance and close monitoring to see if the disease returns.

Friends, RRR was one of the most successful Indian movies of all time, and had some glorious scenes. In the movie, which I enjoyed tremendously (yes, I did see it!) RRR stood for the Rise Roar Revolt! In contrast, my diabetes version of RRR is a less flamboyant, yet equally important one – and stands for Reversal, Relapse and Remission, as explained above.

Putting a car into reverse gear is of course, simpler than trying to reverse diabetes. Nevertheless, our internet and newspapers are always abuzz with stories of what they call the “reversal of diabetes”. Not all of them are true, and not all of them are false. Firstly, let us get the facts right. Most of these stories pertain to type 2 diabetes, the commoner form of diabetes in the world. Type 1 diabetes, which occurs due to the permanent destruction of insulin-producing beta cells, cannot be cured or reversed by any means and requires insulin treatment for blood glucose control.

Clinical and Scientific Evidence on Remission
It is true that many people with type 2 diabetes are able to stop medications by diet control and other lifestyle changes, and still maintain good glucose control. It is false that this control of glucose is always permanent in every person. Many patients, after successfully controlling their blood glucose, are lulled into a false sense of security. They feel that they have “reversed” their diabetes. However, slowly, either because such restrictive lifestyle changes are not sustainable, or because the disease biology has progressed (worsening of beta cell death or increasing ineffectiveness of insulin), eventually, type 2 diabetes makes a comeback. They soon go back to their doctors because of rising blood glucose levels. Do note that type 1 diabetes is due to permanent destruction of the insulin-producing beta cells, and that these subjects cannot be considered for reversal/remission as their lives depend on insulin injections.

In order to acknowledge the possibility that people with type 2 diabetes can achieve good glucose control via purely lifestyle measures, but at the same time, to prevent them from going into a sense of complacency provided by words like “reversal”, experts now suggest the word “remission”. The word remission of type 2 diabetes, while imparting a sense of positivity by acknowledging that the problem has gone away, continues to emphasize the need to focus on lifestyle modifications and monitoring, because the disease could make a comeback.

The best clinical trials of achieving a remission of type 2 diabetes come from studies led by Prof Roy Taylor and his colleagues from the United Kingdom. His studies show the importance of nutritional interventions in achieving remission of type 2 diabetes and clarify that this remission could be successfully sustained over a period of time in primary healthcare settings in the United Kingdom. Weight loss and a personal fat threshold – i.e. the concept of a very individualized fat loss plan seem to be good predictors of achieving success in remission, according to these studies. Many studies, including one conducted by our team in Pune, have shown that there is a possibility of remission in Indian subjects with type 2 diabetes as well.

How is type 2 diabetes remission defined?
If people with type 2 diabetes are able to stop medications with good glucose control and good health for 6 months, then we say that type 2 diabetes is in remission. However, there are some caveats. Firstly such people should not have associated diabetic complications like kidney disease. During kidney disease, the blood glucose levels come under control because the kidneys are now not able to produce glucose, and also because people with kidney failure cannot eat due to nausea and vomiting – such lack of eating can improve blood glucose levels and is not an example of remission. Also, people with some illnesses like anorexia – where intake of food becomes extremely low as they are starving – are not in good health and cannot be considered to be in remission. Finally, people who have undergone some special diets, and have a good HbA1c level – if they are feeling tired, exhausted and have become frail due to loss of muscle mass cannot be considered to be in remission.

Are you an ideal candidate for remission?
People with type 2 diabetes, with excess body fat – who are either clearly obese or who have excess abdominal fat, are excellent candidates for remission. Even people who look normally built (that is, neither thin or fat) could have excess abdominal fat and may be good candidates for remission. Loss of weight via loss of body fat is an ideal strategy for remission. People who have end-stage diabetic complications like advanced heart or kidney disease are generally considered unsafe candidates for a remission strategy. Likewise, pregnancy, where adequate maternal and foetal calories are a must – is NOT a situation where remission programs can help. Generally speaking, type 2 diabetes is due to two defects: lack of insulin production and lack of efficacy of insulin action (insulin resistance). Subjects with predominant insulin resistance (usually due to obesity) are excellent candidates for type 2 diabetes remission diets. However, subjects with type 2 diabetes who have a failure of insulin production are not good candidates for remission. Usually, with a combination of clinical assessment and appropriate testing, doctors can make out which defect is predominant in a particular patient with type 2 diabetes.

How does remission occur?
Type 2 diabetes is characterized by high glucose levels and glucose is a carbohydrate. Generally, carb reduction either via a specific reduction of food containing carbohydrates - or via a general reduction in calories – is the key to reversal. A reduction in carbohydrates means that glucose is not available to be converted to fat in organs such as the liver and pancreas. In fact, many such tissues may actually burn up the fat during such a remission program. A reduction in fat in the liver, muscle and other organs results in better insulin action and weight loss. Over time, some of these people develop a reduction of fat deposits in the pancreas as well- the pancreas now works better to make more insulin efficiently, and this paves the way for more sustainable remission. However which patient will relapse into type 2 diabetes and which patient will undergo a lasting remission – is a subject of intense scientific debate. It is safe to say that people who follow a strict diet and continue to be physically active for a longer time have a greater chance of remaining in remission.

Which is the ideal diet for remission?
There are several dietary pathways to type 2 diabetes remission. At present there is insufficient evidence to recommend one over the other. Some of these remission diets include.
Low carbohydrate diet: A selective lowering of carbohydrate, the source of glucose
Low-calorie diet: Reduction of overall food intake to reduce overall energy consumption.
Keto diet: Drastic and severe reduction in carbohydrate, with high fat intake
Vegan diet: Purely plant-based diet, avoiding meat, fish and dairy. The diet is not only free of the guilt of animal cruelty, but proponents also suggest that it is good for combating climate change.
Intermittent fasting: Eating at less frequent intervals, for example only eating for 8 hours and fasting for 16 hours. For example, skipping breakfast – or eating just 2 meals a day, as the case may be. Another option is to eat only 5 days/ week.
There are many such type 2 diabetes remission diets, and I have mentioned only a few. It is important to note that extreme dieting is never the answer. A diet that is balanced, and which provides all the good nutrients, vitamins and minerals, and which at the same time offers taste, variety and satisfaction along with health -is an ideal diet. From that perspective, a balancer low-calorie or low-carb diet seems acceptable to most. While the food intake can be reduced significantly in the first 2 or 3 months of a remission diet to initiate the remission process, the food intake can be increased later on to help sustain the diet. Using a continuous glucose monitor or measuring glucose early on can help prevent low glucose events and facilitate medication reduction, the focus must be on diet and not on the technology per se.

Exercise is an excellent tool for maintaining remission. However, According to Dr Roy Taylor’s research from the UK, intensifying exercise early on can lead to difficulties in dietary control. This is because exercise-induced food intake can overcome dietary restrictions early on. But in the long run, exercise helps to maintain weight loss and also keeps diabetes in remission. Hence while subjects are advised moderate exercise early on in the remission program – but later on, during the maintenance phase they are encouraged to augment the exercise program.
In the future, a combination of genetics, health science, and artificial intelligence could together help bring biology and behaviour together to suggest who could benefit from which diet – till then we must wait for more research.
Some concluding thoughts
Clearly, the concept of type 2 diabetes has now moved from that of an inevitably progressive disease to that of a disease that can, via lifestyle changes, be put into remission and halted in its tracks. However, the science is evolving.
The goal of diabetes treatment is not a simple reversal of blood glucose- the goal is to reach a healthy state. The goal of diabetes treatment is not a control of medicines or injections, it is the control of blood glucose and an abnormal metabolic state. To this end, people must be wary of unscientific agencies that promise “reversal” of diabetes that is merely a short-term reduction in blood glucose and where blood glucose rises to very high levels in a jiffy after the intervention. Such a short-term change in glucose is fairly simple to achieve – but soon fails because of the inability to follow regimented diets. Also, it is not worthwhile to hold up a normal blood glucose level with a starvation diet – but the patient is left with a frail thin, emaciated and aged body type.
Finally, remember diet and exercise are the key to better diabetes control. But other interventions like avoiding alcohol in excess, stopping smoking and reducing stress- along with regular glucose monitoring are also important. For people at high risk of heart failure and kidney disease, it is important to remember that today many diabetes medicines do not merely control blood glucose but also, in addition to glucose control, offer additional cardiac and kidney protection. It is important to talk to your healthcare provider prior to choosing a strategy and to measure the chances of success using the scale of scientific evidence. 
(Dr AG Unnikrishnan is the CEO and Chief of Endocrinology, Chellaram Diabetes Institute, Pune)

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