Words Matter – Why You Can’t Reverse Type 2 Diabetes

Don't Say "Reverse Diabetes"
It Makes My Hair Catch on Fire!

I feel constantly bombarded with claims that Type 2 diabetes can be reversed and prevented.  I even hear absurdities about how Type 2 diabetes can be cured.  I expect these things from the scams that we all see in our email inboxes and across the web.  But what really sets my hair on fire is the use of these words by people who should know better.  Medical professionals and our government should know better.  And unfortunately when the leaders of the conversation send out a confused message our entire society follows them down the wrong path.  So why does it matter?  It matters because these words communicate meaning and concepts and when these concepts are inaccurate and misleading they can be harmful.  It can leaves people with diabetes confused about their condition, encouraged to pursue bad goals, feeling blame and shame that they “didn’t do it right” and full of false hope.  Today, I'm going to focus on the phrase "Reversing Diabetes" and end with a plea that we stop using the term "reversing" and use the term "remission."  Nobody has ever shown that once you have Type 2 diabetes that you can reverse the condition to become non-diabetic.  All we can do is slow or stop the progression.  Let's start using the term remission when we successfully manage the symptoms of diabetes, we all know that our diabetes is still there and can and will rear it's ugly head if we stray from our treatment.

The phrase "Reversing Diabetes" is Inaccurate:

So let’s examine the definition of the word "reverse" in the medical sense.  Here is a medical definition of reverse (from this standard dictionary): A turning or changing to the opposite direction, as of a process, disease, symptom, or state.

So in the medical sense if we talk about reversing diabetes we need to talk about the reversal of the disease itself.  This is different than reversing the symptoms of diabetes.  Symptoms of diabetes (according the WHO) are of course hyperglycemia, increased urination, thirst, hunger and unexplained weight loss and we also consider the comorbidities of obesity, hypertension and abnormal cholesterol as symptoms of diabetes.  Clearly if one normalizes blood sugars and all these symptoms improve or normalize to what is seen in a healthy state we would say that someone has reversed the symptoms of their diabetes.  But have they really reversed their diabetes?  I don't think so.

Well this is where things have gone awry.  For reasons that are beyond me the medical profession has decided to define reversal of diabetes as reversing the symptoms.  According to webmd:

"The term 'reversal' is used when people can go off medication but still must engage in a lifestyle program in order to stay off," says Ann Albright, PhD, RD. She's the director of diabetes translation at the CDC.

By medications, we obviously mean medications which address hyperglycemia.  I think it is totally absurd to consider medication as a treatment and that lifestyle is not a treatment. 

And it doesn't mean that your insulin resistance, insulin deficiency or other factors which impair the blood sugar response is improved.  It only means that your blood sugar isn't measured as being outside of a defined "norm."  And it doesn't mean that you have addressed the other symptoms of diabetes (lipids, hypertension, weight gain etc).   And what do we mean by "normalize," depending on the guidelines that is either an A1c < 6.5% or and A1c < 7%.  In my little twisted part of the world, this is not normal.  So here we have medical professionals using the term reversing diabetes to mean controlling hyperglycemia to mediocre levels without medication.  Not normalizing all the symptoms and even the ones that are controlled aren't normal.

Could we really look ourselves in the mirror and tell ourselves that we have “reversed” our condition when by any measure we still have an abnormal blood sugar, perhaps all the rest of the symptoms and actually still have diabetes there ready to rear it's ugly head if we stop our diet and exercise treatment.

The phrase "Reversing Diabetes" is misleading:

A patient who has gotten themselves off of medications and can manage their condition with lifestyle has done a great job.  But have they done what is best for the health in managing their condition?  What is the goal?  Should our goal be to achieve the best health outcomes or to simply not take medications?  I think simply getting off medications is a misleading goal and it would be better to work towards the best outcomes.  Calling it "reversed diabetes" leaves us with the belief that we have normalized our condition. If you still have abnormal blood sugars and you still have to watch everything you eat and exercise all the time how in the world is that normalized?  That is really not telling us the truth.  And the sad thing is that we have an insane focus on obesity.  Sure, losing weight can improve blood sugar control and help manage diabetes.  It works for both Type 1 and Type 2.  But weight is not the cause of diabetes and losing weight doesn’t stop diabetes.  If you have been diagnosed with diabetes or pre-diabetes it doesn’t matter, diabetes has already happened.  You can manage it, but you will never return to a condition in which diabetes never exists.  Even if you totally manage the symptoms without medication you can never expect to go back to your previous lifestyle without diabetes rearing its ugly head.  So saying that diabetes has been reversed is just misleading.  It causes patients to have an incorrect understanding of their condition.

The phrase "Reversing Diabetes" is harmful:

And in the end the most difficult thing to understand is that the use of these terms is harmful to patients.  If you tell a patient that they have reversed their diabetes they may think that they no longer have diabetes and can simply go back to their old lifestyle.  And repeating this phrase gives patients hope that is just not realistic.

Unfortunately efforts to truly reverse Type 2 diabetes that bring patients back to a full healthy state have all utterly failed.  The most costly and concentrated effort to prevent and reverse diabetes (the Diabetes Prevention Program (DPP)) was only able to show that you could slow or halt the progression of diabetes.   None of the patients were shown to have gone back to a non-diabetic state.  Halting the progression is not reversing. So when a some is led to believe that they have reversed the condition, that maybe the lost weight and had better blood sugars, they can be vulnerable to making bad decisions.  Very bad decisions.  They may stop watching what they eat, exercising, skip medications, stop checking their blood sugar and stop going to their doctor.  Bad things can happen.  All because they have been misled.

The use of the phrase reversing diabetes also can leave patients with a sense of blame for their condition when they don't achieve the goal of getting of medication.   What about those who cannot get normalized blood sugars without medication.  Did they fail?  And what about those that have short term success but still have their diabetes progress to requiring medication.  Did they fail?  Holding out a false concept that you can reverse diabetes can lead to a sense of failure and blame when you can't live up to achieving the impossible.

And finally I ask whether the current definition of "reversing diabetes" is even an appropriate goal.  If we want the best health outcomes, how would we achieve that.  Compare two patients, one who has "reversed" their diabetes, takes no medication and has an A1c of 6.9%.  The other takes an oral medication and has achieved an A1c of 5.5%.  Who is better off, the patient who has reversed their diabetes or the patient with full blown diabetes on a medication.  And wouldn't we think a patient with an A1c of 6.9% would have their diabetes progress faster than a patient with an A1c of 5.5%.  Personally I'd rather have a normal blood sugar even if it meant I had to take a medication.   "Reversing diabetes" is the wrong goal and it leads patients to not make the best choices of good health outcomes.

So what should we say instead?  I would argue that we should use terms that are accurate, convey the proper meaning and don’t harm patients.  David Mendosa has argued that we should use the term “remission.”  And I agree with him.  That term is much better.  As David quotes, remission is “abatement or disappearance of the signs and symptoms of disease.”  And that is what everyone refers to when they say reversal.  I would urge everyone to use the term "Remission" and to work to eliminate the term "Reversing Diabetes" from the medical lexicon.  Words matter.

ps. And please, anyone who has achieved remission of their diabetes without needing medication, you are my heroes.