A computer-controlled algorithm connects the CGM and insulin pump so they communicate. As the CGM detects high blood sugar, the pump knows to provide a specific amount of insulin. The goal is to provide the patient with more normalized and ideal blood sugar management without the constant hassle of decisions by the patient who is presumably allowed to live a more normal life.
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Chronic exposure of β-cells to triacylglycerol or fatty acids either in vitro or in vivo decreases β-cell capacity to respond to an acute increase in glucose levels (57,58). This concept is far from new (59,60), but the observations of what happens during reversal of diabetes provide a new perspective. β-Cells avidly import fatty acids through the CD36 transporter (24,61) and respond to increased fatty acid supply by storing the excess as triacylglycerol (62). The cellular process of insulin secretion in response to an increase in glucose supply depends on ATP generation by glucose oxidation. However, in the context of an oversupply of fatty acids, such chronic nutrient surfeit prevents further increases in ATP production. Increased fatty acid availability inhibits both pyruvate cycling, which is normally increased during an acute increase in glucose availability, and pyruvate dehydrogenase activity, the major rate-limiting enzyme of glucose oxidation (63). Fatty acids have been shown to inhibit β-cell proliferation in vitro by induction of the cell cycle inhibitors p16 and p18, and this effect is magnified by increased glucose concentration (64). This antiproliferative effect is specifically prevented by small interfering RNA knockdown of the inhibitors. In the Zucker diabetic fatty rat, a genetic model of spontaneous type 2 diabetes, the onset of hyperglycemia is preceded by a rapid increase in pancreatic fat (58). It is particularly noteworthy that the onset of diabetes in this genetic model is completely preventable by restriction of food intake (65), illustrating the interaction between genetic susceptibility and environmental factors.
It’s fairly standard practice for physicians to encourage, if not prescribe, a healthy diet for most of their patients, especially those with type 2 diabetes. But dietary guidance has not traditionally been the focus of treatment for diabetes and similar conditions. “Rather than addressing the root cause, management guidelines for type 2 diabetes focus on reducing blood sugar levels through drug treatments. Diet and lifestyle are touched upon, but diabetes remission by cutting calories is rarely discussed,” Taylor told The Guardian.
Together with evidence of normalization of insulin secretion after bariatric surgery (84), insights into the behavior of the liver and pancreas during hypocaloric dieting lead to a hypothesis of the etiology and pathogenesis of type 2 diabetes (Fig. 6): The accumulation of fat in liver and secondarily in the pancreas will lead to self-reinforcing cycles that interact to bring about type 2 diabetes. Fatty liver leads to impaired fasting glucose metabolism and increases export of VLDL triacylglycerol (85), which increases fat delivery to all tissues, including the islets. The liver and pancreas cycles drive onward after diagnosis with steadily decreasing β-cell function. However, of note, observations of the reversal of type 2 diabetes confirm that if the primary influence of positive calorie balance is removed, then the processes are reversible (21).
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Scientists are cautious, and research is continuing, but evidence is growing that the diet can indeed remove the symptoms of type 2 diabetes. The question for researchers, who are now working on identifying the type of diet that can keep diabetes at bay after reversal, is once we've beaten the condition, how do we improve our lifestyle so it doesn't return? Watch this space.
Benari doesn’t want to remain an outlier, though. And perhaps surprisingly, many doctors and surgeons are starting to agree that surgery should be considered more than a last-resort remedy for weight loss. Instead, it should be seen as a crucial aspect of diabetes care, and quite possibly the best tool we have against the chronic, often worsening condition.
The prevalence of prediabetes is also on the rise, as it’s estimated that almost 34 million U.S. adults were prediabetic in 2015. People with prediabetes have blood glucose levels that are above normal but below the defined threshold of diabetes. Without proper intervention, people with prediabetes are very likely to become type 2 diabetics within a decade.
But is John “free of diabetes”? This is where the lines become blurred. Medically speaking, the term “cure” is usually associated with acute disease—a temporary medical condition, such as bacterial pneumonia, that can be cured with antibiotics. For diabetes, which is a chronic disease, it may be more accurate to use the term “remission” rather than cure. Particularly when considering the pathology associated with diabetes and the individual’s genetic predisposition, relapse is always possible. In a consensus statement issued by the ADA, the term remission is defined based on the following definitions:2
According to the National Center for Complementary and Alternative Medicine, there is still not enough good evidence to support the use of herbal supplements as effective type 2 diabetes treatments. While many of these supplements show promise, until results from additional studies come out, do not take herbal supplements to treat type 2 diabetes without first consulting with your doctor. Herbal supplements have side effects and can interfere with other medications.
Some of the above drugs are available in compound form, and there are many patients taking three to four of them to control their blood sugar. But again, "the most common duo is metformin and a sulfonylurea,” says Arti Bhan, MD, division head of endocrinology at Henry Ford Health System in Detroit. “Metformin makes the body utilize insulin more effectively, and the sulfonylurea works on the pancreas to make more insulin in response to food consumption. Another common combination is metformin and insulin.”
At Diabetes Daily, we prefer using the word remission over cure because far too often the state of diabetes returns even with people’s best efforts. Regardless of the definition of a cure, finding a way to live with little to know highs or lows is a worthwhile endeavor. Long-term studies show that even a few years of great blood sugars significantly reduces your long-term risk of complications.
Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates you have diabetes. A result between 5.7 and 6.4 percent is considered prediabetes, which indicates a high risk of developing diabetes. Normal levels are below 5.7 percent.
Despite these encouraging results, Vulksan cautions that it's too early for diabetic patients to rely on ginseng. Herbs sold in this country are not standardized, he says, so it's difficult to know for certain what you're buying and impossible to ensure consistent dosages. Besides, his study looked only at American ginseng, and he's not certain the results would hold true for the seven other varieties. What's more, researchers haven't conclusively identified ginseng's active ingredients.
In type 2 diabetes, even though insulin resistance is what leads to the condition, injections of insulin are not the first resort. Instead, other drugs are used to help boost insulin production and the body’s regulation of it. Insulin resistance occurs when the body’s cells don’t respond properly to insulin, which is a hormone made in the pancreas that’s responsible for ferrying glucose to cells for energy.
The NIH National Institute of Diabetes and Digestive Diseases and Kidney Diseases says it, “currently supports studies that are working toward obtaining FDA licensure to reclassify islet allo-transplantation as therapeutic. In other countries, such as Canada and Scandinavia, islet allo-transplantation is no longer considered experimental and is an accepted therapy in certain patients.” It adds that “Some patient advocates and islet researchers feel that islet allo-transplantation is close to having a therapeutic label.”
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