Some new healthcare companies claim to “reverse diabetes” with a lifestyle intervention that primarily focuses on the blood glucose and hemoglobin A1c level. That claim may be a clever marketing ploy, but it has little to do with the latest science on diabetes.
Although their intervention reduces carbohydrate and sugar intake dramatically and it does lower blood glucose. The problem is that it does not address the core issue in Type 2 diabetes.
The definition of Type 2 diabetes
Type 2 diabetes is defined by a blood glucose of 126 or higher or a hemoglobin A1c of 6.5 or higher. If you introduce sugar and carbohydrate restriction and cause weight loss, the glucose and hemoglobin A1c levels will fall below those numbers and so, by that definition, diabetes is “cured.” The patient no longer meets the criteria for a diabetes diagnosis.
But this premise ignores fundamental and important realities. High glucose levels cause changes in gene expression that persist after the glucose returns to normal causing atherosclerosis and other complications. This well-known phenomenon is called metabolic memory.
Metabolic memory is a critical concept that points to the broader reality of people living with Type 2 diabetes. The high glucose levels found in people with the condition are only one part of the complex molecular biology that causes diabetic complications.
The cardiovascular complications of diabetes begin in the fetus and even in the lifestyle choices of prior generations. Overfeeding or underfeeding in the parental generation can produce infants that are too small or too large based on inappropriate activation or inactivation of genes (epigenetics). That inappropriate switching on or off is persistent and many genes are involved causing hypertension, diabetes, and cardiovascular complications in adults.
Patients may themselves switch these genes on or off later in life by gaining weight or smoking. These genes cause diabetes by killing insulin-producing cells in the pancreas and increasing insulin resistance leading to high glucose which further increases oxidative particles and switches on additional genes that cause diabetic complications.
These genes remain switched on even when the glucose is lowered. Therefore, it is very important to continue to take medications that interfere very specifically with the signaling that these genes generate.
Promoting the message that cardiometabolic medication should be stopped when the glucose falls below the diabetic level is not in keeping with the latest science and contrary to diabetic guidelines.
The American Diabetes Association (ADA) guidelines recommend metformin use even in prediabetic patients who have a BMI of 35 or greater, have a history of gestational diabetes, or an increasing fasting glucose or hemoglobin A1c. That is because metformin reduces progression to diabetes by about 31%.
Roughly half of prediabetic patients will progress to diabetes despite weight loss. Even patients in the later stages of prediabetes may have lost 70-80% of their insulin-producing function.
These prediabetic patients should not stop metformin when they have lost weight and their glucose improves. There is a tendency for diabetes to reappear with age. Certainly, metformin should not be stopped in patients who already have diabetes regardless of their glucose level.
How metformin works
Metformin reduces diabetic complications by interfering with signaling that has nothing to do with blood glucose levels. It inhibits the same master metabolic switch as the active ingredient in the drug-eluting coronary artery stent.
The increased risk of major cardiovascular events does not disappear with diet and weight loss, however, metformin directly reduces that risk. Type 2 diabetics lose about 10 years of life. If they are on metformin, they live a bit longer than normal people. Metformin is safe and costs only about $4 a month. It is dangerous to recommend “stopping diabetic medications once the glucose is controlled by lifestyle interventions.”
Controlling glucose levels has beneficial effects on microvascular events like retinopathy, neuropathy, and kidney damage but it does not reduce the problems that cause most serious cardiovascular complications, death, disability, and costs. Most diabetics die of cardiovascular disease.
Lowering the glucose with lifestyle or any medication approved for the purpose does NOT reduce cardiovascular events. In fact, aggressive glucose lowering with medication and lifestyle caused more people to die.
This is especially important because cardiovascular event incidence and other complications can be dramatically mitigated with a comprehensive solution that brings to bear lifestyle management and medications that interfere with the molecular biology that causes cardiometabolic complications.
Lowering the glucose by any means below the diabetic level, stopping the medication, and expecting complications to fall makes sense, but that idea is not supported by the evidence.
Drugs that block epigenetic signaling
Take a look at the diagram below. Type 2 diabetes occurs mostly in patients with extra abdominal fat caused by poor diet. Increased nutrition and fat switches genes on/off that increase angiotensin II, aldosterone, HMG CoA Reductase, and mTOR activity.
Angiotensin receptor blockers (ARBs), spironolactone, statins, and metformin interfere directly with the molecular signaling cascades that these genes activate. Blocking angiotensin II with an ARB, aldosterone with spironolactone, HMG CoA reductase with a statin, and mTOR with metformin dramatically reduces cardiovascular events in multiple settings. The genes involved are switched on before diabetes develops.
In fact, these elements contribute to diabetes development. Increased mTOR activity directly increases insulin resistance. Blocking mTOR with metformin reduces progression to diabetes.
Blocking HMG Co A reductase with a statin actually increases the incidence of diabetes but has a powerful impact on cardiovascular events and other outcomes. Even that can likely be explained by a hard look at the molecular biology. Blocking HMG CoA reductase with a statin does lower LDL cholesterol but it also reduces Coenzyme Q10 production. Coenzyme Q10 is a powerful antioxidant and it is important for mitochondrial function. Impaired mitochondrial function may be important in the modestly increased risk of diabetes in patients who take statins.
Type 2 Diabetes Treatment
The best treatment for type 2 diabetes is not a matter of either lifestyle or medication. Effective treatment requires best practice implementation of lifestyle measures along with medications that interfere with the molecular biology causing disease. For most patients, medical treatment will include metformin, statins, and angiotensin receptor blockers.
It is important to move beyond a medical system focused on risk factors and organ systems.
There is a very complex interplay in the molecular biology that causes hypertension, diabetes, high cholesterol, and related complications. Reversing diabetes with weight loss and dietary interventions makes perfect sense but improving cardiovascular outcomes and reducing costs to the fullest extent requires a more comprehensive solution. We can treat chronic disease with precision medicine and molecular biology now.
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William H. Bestermann, Jr., MD
William H. Bestermann Jr., MD is a board-certified internist who has practiced preventive cardiology for more than 20 years. His core expertise is consistently producing optimal medical therapy (OMT) for cardiovascular and related conditions. He does this by using evidence-based care processes consistent with best practices.
He looks at OMT as a product. He understands how health care organizations can combine new systems, new science, and new payment models to produce that product much more consistently. That combination can be standardized, scaled, and industrialized. These new systems combine teams, protocols, population health tools, clinical/financial analytics, and provider training. Certain clinical interventions reduce clinical events more than they impact the target risk factor.
Dr. Bestermann has developed integrated protocols that combine those interventions which maximize impact on weight reduction, minimize drug interactions, and reduce side effects. When these systematic interventions are combined, they dramatically reduce the cost of care, prolong life, and delay cardiovascular events.
Dr. Bestermann wrote the first article on a systematic, integrated approach to the metabolic syndrome. He collaborated later with multiple academics and community leaders in a more detailed article on metabolic syndrome science and treatment. He proposed a new mechanism of action for metformin explaining its impact on cardiovascular, events, cancer, and aging.
He supervised an advanced medical home team within Holston Medical Group for cardiometabolic conditions that contained an ambulatory care residency for PharmDs. The team managed high-risk diabetic and hypertensive employees of Eastman Chemical Company.
He is also a senior clinical advisor for the Quality Blue Primary Care initiative at BCBS of Louisiana. That effort reduced hospital admissions, length of stay, and specialty referrals while lowering per member per month costs. He has personal experience producing OMT in multiple medical settings.
He has become convinced that only evidence, data, and transparency can deliver us from the low-value healthcare that prevails across the United States. There are many vendors making claims regarding their clinical and financial success. Most of those claims are not valid. Almost no one is consistently applying optimal medical therapy to patients with cardiovascular and related conditions in a way that prolongs life, delays cardiovascular events and reduces costs. Dr. Bestermann submitted his approach to the Validation Institute and received their stamp of approval.
In addition to being a contributing author for The Doctor Weighs In, Dr. Besterman also serves on the TDWI Editorial Board, where he medically reviews articles submitted for publication.