In his essay ‘Scotoma: Forgetting and Neglect in Science’, the late Professor Oliver Sacks notes that science and medicine evolve when people ‘confront both anomalies and deeply held ideologies’, with open debate central to progress (Sacks, 1997). In this context, it is perhaps worth considering a mounting evidence base that challenges the idea (ideology?) of type 2 diabetes (T2D) being irreversible. For example, Rasouli (2020) observes: ‘T2D has been considered a chronic, progressive disease with expected worsening of glycemia due to steady decline in -cell function over time. However, recent studies have suggested that T2D diabetes could be a reversible condition in specific settings.’
If so, the potential savings in both human and economic terms could be huge, given that in the UK around one million people have undiagnosed T2D; 57% of people with type 1 diabetes and 42% with T2D do not receive annual health checks; one third of those diagnosed with T2D have a microvascular complication at the time of diagnosis; and the NHS spends at least £10 billion a year on diabetes, equivalent to 10% of its budget, with 80% spent on treating complications (Whicher et al, 2019).
Following their evaluation of 99 original articles related to diabetes reversal or remission, Hallberg et al (2019) found evidence that T2D reversal is achievable using bariatric surgery, low-calorie diets, or carbohydrate restriction. However, Kassem et al (2017) point out that hypoglycaemia following bariatric surgery is a serious complication, particularly ‘when patients develop life-threatening neuroglycopenia with loss of consciousness and seizure. The avoidance of this adverse event may be achieved by strict dietary modification including a restriction on carbohydrates…’
How much easier it might be to address the diabetic challenges posed by the UK's current dietary predicament (Whicher et al, 2019) if the risks of bariatric surgery could be obviated by recourse to lifestyle-related solutions that reverse – or better still, prevent – the insulin resistance that can lead to the onset of T2D. Hallberg et al (2019) identify a need to educate healthcare providers on reversal options ‘so they can actively engage in counselling patients who may desire this approach to their disease.’ And as far as Van Ommen et al (2017) are concerned, T2D should be reversible and curable by changing dietary habits and physical activity. However, implementing a change of lifestyle to effect a cure needs personalised and sustained lifestyle adaptations, which can only be achieved by a systems approach, including aspects such as ‘personalized diagnosis and diet, physical activity and stress management, self-empowerment, motivation, participation and health literacy, all facilitated by blended care and e-health’ (Van Ommen et al, 2017).
In this respect, pharmacists have an important role to play, with Feinmann (2019), for instance, detecting a growing view that low-carb advice is a job for pharmacists, not GPs, and citing GP Dr Campbell Murdoch, medical officer for www.diabetes.co.uk. Murdoch emphasises the importance of a team approach, commenting: ‘Pharmacists are smart; they are critical thinkers and not mired in dogma’ (Feinmann, 2019). One such critical thinker is Graham Phillips, superintendent pharmacist at Manor Pharmacy Group in Hertfordshire, whose use of continuous glucose monitoring, allied to dietary, exercise and lifestyle advice (www.prolongevity.co.uk) won the Health Initiative of the Year Award 2020 (Chemist & Druggist, 2020).
Meanwhile, the diverse effects of diabetic remission continue to be recorded. For example, Chandrasekaran and Rani (2020) describe the case of an obese 40-year-old woman with T2D who had unstable proliferative diabetic retinopathy with extramacular tractional retinal detachment (TRD) in the left eye. After she adopted a coconut oil-rich ketogenic diet, she lost 25 kg body weight concomitant with apparent reversal of diabetes (HbA1C of 5.3% without insulin) and ‘there was complete resolution of macular detachment due to TRD in the left eye with stable vision. This was attributed to the impactful ketogenic diet’ (Chandrasekaran and Rani, 2020). And when Hamada et al (2015) considered (albeit) three cases of kidney transplantation from diabetic donors to non-diabetic recipients, they found that ‘early diabetic changes found at the 1-hour and 1-month protocol biopsies were reversed and improved at the 1-year biopsy.’
It seems reasonable to speculate – and hope – that this year will see an acceptance by health professionals that diabetes need not be a lifelong, progressive condition.