When a diabetic no longer needs medication and has normal blood sugars – do we call it remission or do we call it a cure?

Assume for a moment that you’re a diabetic.  Your fasting blood sugar is 214.  Your hemoglobin A1c – the component of hemoglobin to which glucose is bound – is an unhealthy 7.9.  You are taking nine pills per day in an effort to control your blood sugar, but it does not seem to be working.  This means you are a poorly controlled type 2 diabetic, and your risk of experiencing the deadly effects of unchecked diabetes – heart attacks, strokes, dementia, blindness, kidney failure, loss of sensation in your extremities and amputations – is significantly elevated.

Now, let’s consider a different scenario.

You are a patient at Longevity Medical Clinic. Since we started treating your type 2 diabetes, we have restored your hormone balance to that of a 25-year-old.  Your immune system is more robust and competent than it has been in decades.  Your body fat has dropped from 30% to 15%.  You are lean, strong, and fitter than you were in high school.  You eat a near ideal diet and workout regularly 3 to 5 times per week.  Your fasting blood sugar is now 85, and your hemoglobin A1c is a healthy 5.3.  You are maintaining these great blood sugar levels and yet are taking no diabetic medications whatsoever. The big question: what do we call you?  Are you in remission, or are you cured?

This is the current state of debate in medicine.  A large percentage of type 2 diabetics still make perfectly adequate amounts of insulin.  The problem is that they have developed significant insulin resistance.  If we correct the insulin resistance, their diabetes will essentially disappear.  There are at least two ways to accomplish this.  The first, called bariatric surgery, is more invasive and brings higher risk; nevertheless, this surgery will correct insulin resistance in about 85% of surgery patients.  The less risky path to overcoming insulin resistance, combining aggressive hormonal treatments with significant lifestyle changes, can potentially eliminate symptoms of diabetes in roughly 70% of people.

In 2009, the International Consensus Committee decided that it was probably most appropriate to refer to a diabetic whose robust good health has been restored as “in remission” – not “cured.”  Their reasoning is that most people will eventually return to the old lifestyle that caused the disease in the first place, creating a high probability that they will once more become diabetic.  This reasoning makes sense, based on the behavior of all too many people. But this same committee admitted that the “remission” versus “cure” debate is mostly a matter of opinion, not really based on objective science.

My view is simple. Instead of resting on opinion, preferences, or social and political pressures, I prefer to use the term “cure.” If a person has normal blood sugar and normal insulin levels and is not taking any diabetes medications, I am hard pressed to consider them a diabetic.  But at the same time, I certainly agree that any patient who returns to the lifestyle that caused the diabetes in the first place will almost certainly cause it to recur. Let me give you an analogy from my own experience. Several years ago when I was skiing (in my usual less than cautious manner), I took a nasty fall and broke my left hip.  Today, other than some bony callus at the site of healing, and some scarring on the bone, I have no current evidence of a fractured hip.  I run, I jump, I leap and cavort, and I also continue to ski in a less than cautious manner!  That means I am certainly at risk of fracturing my hip a second time.  Am I cured, or am I in remission? I would say that my hip fracture has been cured, but using the reasoning of the medical community my fracture would be in remission, since my lifestyle might cause me to break my hip again at some time in the future. Sounds like silly reasoning, doesn’t it?

To sum up: the vast majority of people with type 2 diabetes make plenty of insulin.  Their blood sugar is high because they have developed severe insulin resistance.  We know how to correct insulin resistance and to restore patients to health.  The big question that we are now arguing about is not so much whether it can be done, but what we should call it when we have done it.  Some people seem outraged when we suggest that some type 2 diabetics can be cured.  I sincerely don’t want to upset them, so if they prefer, they can substitute the words “in remission” for cured.  I frankly don’t care what we call it.  What I do care about is helping those people with high blood sugars, high insulin, and a high risk of devastating consequences to overcome their problems and lead a longer, healthier life. That’s what we’re working to do every day at Longevity Medical Clinic.

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