In our previous blog post: The Realities of Type 2 Diabetes Remission, Part 1 Physiology, I outlined some of the human physiology (body) processes that keep blood sugar at usual levels. When food is eaten, digestive systems start the process to breakdown, absorb, and metabolize those nutrients into energy and into components of the body needed for health such as the blood and immune system, while the endocrine systems release hormones to allow for transport of key nutrients in or out of cells.
What Causes Type 2 Diabetes?
Which came first: the chicken or the egg? When it comes to type 2 diabetes, it isn’t always clear what starts the process of blood sugar dysregulation for each individual. Is it genetic, lifestyle or both? There is a strong genetic component but there are also people with no history of diabetes in their family who develop type 2 diabetes. Our current food supply with its abundance of heavily refined, low-nutrient and low-cost options places an increased burden on our bodies ability to process those calories and some believe that that burden starts the cascade of the pathway to type 2 diabetes. Our bodies have adapted over thousands of years to the physical requirements of hunting and gathering that were required for basic living and survival. Our high-tech world of gadgets simplify many of the manual tasks that we all used to do each day and leaves many of us sitting for long periods of time. That adaptation has not led to an increasingly sedentary lifestyle over the past 50 years.
When we look at diabetes rates, Diabetes Canada statistics tells us that between 5 and 15% of the population in Canada lives with diabetes. Those rates are projected to increase to as high as 30% of the population by 2030 but the flip side tells us that currently more than 70% of the population does not ever develop diabetes. There are many unanswered questions, and it is likely the causes of type 2 diabetes are multifactorial for each person.
The Problem Areas of Type 2 Diabetes
In the Diabetes Manager University (DMU) training program delivered by Diabetes Training 101 Inc., we aim to explain diabetes pathophysiology to the participants to help health care providers assess and identify an individual’s problem areas in diabetes. In almost all cases, the problem area/pathophysiology is related to the response of one of four systems: the liver, the muscle and/or fat, the pancreas, and/or the incretin system.
Here we aim to simplify the problem areas of type 2 diabetes. If we want to be able to discuss diabetes remission with our clients we have to understand ways that remission would even be possible.
For remission to be possible, these altered systems have to go back to working as they used to, as they did before the individual developed type 2 diabetes. Previously our approaches (medicines, lifestyle) addressed only one problem area at a time and sometimes also led to other additional problems such as weight gain. That left the individual living with diabetes taking multiple pills and or insulin to control their blood sugar levels while also experiencing other side effects that made managing more difficult.
There has always been a small number of people diagnosed with type 2 diabetes who were able to change their lifestyle drastically enough, increase their activity substantially, and improve their eating to a mostly whole food approach that have been able to achieve diabetes remission. For true remission to happen though, those individuals have to be able to make enough insulin to match the amounts of food needed to promote health. Food is our medicine and food guide and land foods do promote health, so there will always be a need for insulin in the body.
Measuring an individual’s insulin levels is not a lab test that we can commonly do. It is a specialized and expensive test that is not a part of routine lab screening. We can use finger poke or CGM glucose testing to understand how well an individual makes their own insulin, and that can be helpful to assess whether remission is a possible for the individual in front of us.
Game Changer: Semaglutide
In 2018 a new diabetes medicine, an incretin hormone called semaglutide/Ozempic was approved for use in Canada and it completely changed diabetes management. We also had other versions of incretins/GLP-1 including Byetta, Victoza and Trulicity. These injectable medications are all GLP-1 RA’s (Glucagon Like Peptide 1 Receptor Agonists) and the are replicas of intestinal hormones called incretins. When the previous versions of incretins were compared head-to-head against semaglutide, semaglutide proved to be superior and given it was given once a week. Patients were very happy that there was less treatment burden as injecting once a week is less stressful than once or twice a day.
Why is Semaglutide Different?
Talking about the health and diabetes benefits of semaglutide is something that I could cover in a webinar or a few hours of discussion, so I will attempt to briefly share with you some of the key reasons why it is different and point you to some literature that you can read.
When it was looking like semaglutide was showing very positive results, researchers put it in head-to-head trials (research studies) against the other diabetes treatments. These series of trials were called the SUSTAIN trials and all trials showed superior and sustained blood sugar control and weight loss over the compared treatment in the over 8000 participants in the studies. In addition to significantly improved blood sugar control and weight loss, participants reported a reduced appetite and reduced craving for food. Many reported a decrease preference for fatty and energy dense foods. Further to that and equally as important as the above-mentioned positive effects, semaglutide significantly decreased the cardiovascular events compared to placebo and that protection was seen rather quickly and has shown this class of drugs to offer cardiovascular protection. Because people living with diabetes have significant cardiovascular risk (risk for heart disease and stroke), the effects of this drug proved to be a game changer in diabetes care and management, and has since changed our clinical practice guidelines to a focus of protect the heart and blood vessels with our treatments.
Commonly Seen Benefits of Semaglutide
- Stops hepatic glucose release. Stops “Leaky Liver”.
- Tells the body to release insulin only when food is eaten. This differs from other diabetes medications which raise insulin levels all day. High levels of circulating insulin in the body are related to increased appetite, weight gain, increased blood pressure and blood cholesterol, and also increase an individual’s risk of hypoglycemia or low blood sugar. Semaglutide allows the body to release insulin similarly to how it would if the body did not have diabetes. Improves “Pooped Out Pancreas”
- Slows digestion which decreases after meal blood glucose rise. This allows the body to better handle glucose from food and keep blood sugars lower after meals. This leads to improved blood sugar control.
- Signals fullness in the brain. Individuals report decreased appetite increased fullness, earlier satiety, nausea which tends to make people not want to eat, a reduced preference for salty or fatty foods, and some report a reduced interest in alcohol. This almost always leads to weight loss, less insulin resistance and improved insulin sensitivity. This addresses the issues of insulin resistance and low incretin levels.
- Semaglutide has different doses and individuals start at a lower dose and work their way towards a higher dose. So weight loss varies between individuals with a usual weight loss between 5 and 40 lbs.
- Improves beta cell function, decreases beta cell dysfunction and death, and promotes an increased in beta cell numbers. That translates to improved ability of the body to make its own insulin.
- As the research shows, semaglutide is linked to rapid and significant cardiovascular protection. It protects you against major adverse cardiac events such as heart attacks and stroke.
Semaglutide has been a game changer in diabetes management. It addresses multiple body systems and offers hope in an individual’s ability to make insulin again or better use the insulin they have. This is key to diabetes remission. In Part 3 of this three-part blog series, I will discuss briefly Diabetes Canadas position on diabetes remission and why we will eventually see pharmacological remission included in the clinical practice guidelines.
Thank you for reading. Your comments are always welcomed here or in our Certified Diabetes Educators Community of Learning on Facebook.
References
- Diabetes Training 101 Inc Blog
- Diabetes Canada https://www.diabetes.ca/advocacy—policies/advocacy-reports/national-and-provincial-backgrounders/diabetes-in-canada
- Aroda, VR et al Comparative efficacy, safety, and cardiovascular outcomes with once-weekly subcutaneous semaglutide in the treatment of type 2 diabetes: Insights from the SUSTAIN 1-7 trials https://pubmed.ncbi.nlm.nih.gov/30615985/
