You may remember I previously blogged about the HbA1c test whereby I discussed the diagnostic criteria for type 2 diabetes. As a reminder, type 2 diabetes is diagnosed at an HbA1c level of 48mmol/mol and pre-diabetes at a level of 42mmol/mol.
Most people suffering with diabetes will see this score vary over time. One question I commonly encounter is what does it mean if my HbA1c drops below diagnostic levels? Does this mean I no longer suffer with diabetes.
If your HbA1c drops below these values you no longer suffer with diabetes. There is currently a great body of work looking into this using very low calorie diets to help push type 2 diabetes into remission. The preliminary work looks promising but is not conclusive and is yet to be published.
The research focuses upon an 8 week 800kcal/day very low calorie diet. Currently, we do not know the long term management plan for those following such an intervention. 800kcal/day is a very low energy intake per day and is unlikely a realistic target for long term dietary management. Future research will likely focus on strategies for the best long term management strategies and whether we can achieve similar results with a higher and more sustainable calorie intake.
Where this research could be valuable is in those patients who want/require a drastic improvement in their control. This could then be balanced by adopting a more healthy lifestyle long term. That said, it will be interesting to see whether less drastic yet more sustainable calorie intakes e.g. 1500kcal/day can achieve similar results over a longer time period.
One should also exercise caution with dramatic reductions in their blood glucose levels because it can trigger complications similar to those seen with persistent high blood glucose levels i.e. retinopathy. This may not be true for those who are well controlled or newly diagnosed but it is certainly a consideration worth thinking about and I would advise speaking with your diabetes practitioner before commencing any drastic routines.
Those newly diagnosed (within 2 years) have the best chance of achieving remission. but before you get excited there are some things we need to cover.
First, your type of diabetes will be a big factor. Those suffering with type 1 produce no insulin of their own. Therefore, the disease has not manifested in the same way as type 2 diabetes. In type 1 diabetes, the body’s own immune system destroys the cells of the pancreas which produce insulin. Therefore, pushing your HbA1c level below 48mmol/mol does not cure the underlying cause of the disease. In fact, an HbA1c below 48mmol/mol does not produce any significant benefits compared to an HbA1c of 48-58mmol/mol and increases the risk of hypoglycaemic episodes. That said, if you are able to achieve levels below 48mmol/mol without hypoglycaemic episodes, it will translate into good control. However, your diabetes will not be in remission.
Type 2 diabetes on the other hand, is primarily the result of lifestyle factors and is specifically associated with carrying excess weight. Therefore, this disease is ideally placed for lifestyle interventions to help manage the disease.
With dietary changes and regular exercise alongside weight reduction, it is possible to push the type 2 diabetes into remission or at least significantly improve your control. An HbA1c of below 48mmol/mol in this scenario, especially if diet controlled, will be an indication of true remission. How long this will last for is unknown but if achievable it is certainly a goal worth aiming for.
Two scenarios where true remission may not be the case despite an HbA1c below 48mmol/mol is 1) if you completely cut out your carbohydrates without losing weight/improving your fitness and if 2) you are taking various medications to help reduce your HbA1c.
Lets start with diet. If cutting out carbohydrates and therefore your glucose intake your HbA1c will be towards the lower end of the scale and possibly below the 48mmol/mol diagnostic level. This would indicate your diabetes is in remission correct? Not necessarily. What you haven’t done is address the underlying cause of the disease which is the body’s resistance to your insulin. This typically is the result of carrying too much excess weight and/or being unfit. Therefore, by cutting out carbohydrates without improving your fitness or losing weight, the physiology of the body is not being altered. This may help to reduce long term complication risks but your body is still unable to manage it’s blood glucose levels effectively. If you were to eat carbohydrates, it is likely your blood glucose levels would spike beyond normal levels. In essence, you have plastered over the cracks.
Alternatively, your HbA1c level may drop below 48mmol/mol but you may remain on multiple therapies e.g. metformin, sitagliptin, empgliflozin and insulin. In this instance your diabetes is very well controlled but take away those medications and we may see a very different picture.
Therefore, it is always good to make lifestyle changes and assess the effect of these on your HbA1c independent of medication (especially if commencing a new medication). You may find over time your GP becomes satisfied enough to start reducing the medications but this may take time. Generally Metformin will be continued because it has some cardio protective effects and addresses the insulin resistance. True remission is when you are able to eat normal levels of carbohydrates without the need for multiple medications.
You can therefore make a huge difference to your diabetes control through diet and lifestyle changes and in some instances this may even result in your diabetes entering remission.