I recently was asked about the latest research on the reversal of type 2 diabetes—both bariatric and non-bariatric solutions—and it made me wonder about the mechanisms of this possibility and what role being active may play in it. Each new year always brings a whole host of resolutions that people make focused on losing weight, getting more fit, and becoming healthier. Especially with all the COVID-related pounds I have heard about people gaining (1), I expect these resolutions to be out in full force at the start of 2022. But how effective will they be long-term, and is the reversal of type 2 diabetes a realistic resolution to make?
Getting blood glucose levels back to normal (to the point where it appears you no longer have type 2 diabetes) may be possible for many, but we also know that hyperglycemia can return if this “reversal” was accomplished through lifestyle improvements when people backslide into less favorable lifestyle habits. Complete remission may be harder to accomplish in people who have had type 2 diabetes for longer as they can permanently lose some of the insulin-making capacity of their pancreatic beta cells (2).
Research on diabetes reversal relying on bariatric surgery has been somewhat more optimistic, and bariatric surgery is now considered the most effective way to improve glycemic management and achieve diabetes remission long-term (3, 4). That said, pre- and post-operative lifestyle changes including regular physical activity are always recommended. Aerobic exercise training following surgery may further enhance weight maintenance, glycemic management, and insulin sensitivity (5-7), and resistance exercise done post-surgery may reverse muscle strength deficits frequently observed after bariatric surgery (8) and help prevent some bone loss (9, 10).
As for the reversal of type 2 diabetes without surgery, interventions appear to be focused on weight loss. In a recent study on remission of type 2 diabetes (the DiRECT study), adults ages 20 to 65 who had been diagnosed within the prior six years and not taking insulin followed a 12-month intervention that involved extensive dietary changes but not physical activity (11). In that trial, almost half of participants achieved remission (normal blood glucose and not taking any diabetes medications), with no remission among those who gained weight and the greatest success rate among those who lost the most (86% remission in the participants who lost 15 kg or more). In a two-year follow-up, remission was sustained for more than a third of them, with a remission rate of 64% among those who maintained at least a 10-kg weight loss (12). In my opinion, that is still not that great, especially since most of the success appeared to rely on being able to keep the lost weight off (and we all know how hard that is).
That brings me back to physical activity and its potential role. It appears that remission of type 2 diabetes—at least in those with a more recent onset—is most closely tied to abnormal fat deposits in the pancreas and in the liver (13). Here is where physical activity can play a dramatic role. Exercise training improves whole-body insulin sensitivity but, even more importantly, even just two weeks of exercise training improves beta-cell function in adults with prediabetes and type 2 diabetes and decreases pancreatic fat (14). Substantial weight loss at the time of diabetes diagnosis may work best to prevent loss of pancreatic beta-cell capacity (2), but staying in remission also likely requires maintenance of that lost weight, which we know is more readily accomplished by becoming and remaining physically active (15, 16).
Moreover, both aerobic and resistance training have been shown to reduce ectopic abdominal fat (i.e., visceral, liver, pancreatic, and other abnormal fat deposits) best (14, 17, 18), so why not get and stay more physically active this year? It is the best chance you have for accomplishing your 2022 resolution to get rid of your type 2 diabetes. If getting regularly active is not entirely successful in normalizing your blood glucose levels, at least it will get you closer, and you will have a healthier and happier year and life ahead. Just get up and get moving for the best results.
References:
1. Ruissen MM, Regeer H, Landstra CP, Schroijen M, Jazet I, Nijhoff MF, et al. Increased stress, weight gain and less exercise in relation to glycemic control in people with type 1 and type 2 diabetes during the COVID-19 pandemic. BMJ Open Diabetes Res Care. 2021;9(1).
2. Taylor R, Al-Mrabeh A, Zhyzhneuskaya S, Peters C, Barnes AC, Aribisala BS, et al. Remission of Human Type 2 Diabetes Requires Decrease in Liver and Pancreas Fat Content but Is Dependent upon Capacity for β Cell Recovery. Cell Metab. 2018;28(4):547-56.e3.
3. Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Capristo E, et al. Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial Lancet. 2021;397:293-304.
4. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes - 5-Year Outcomes. N Engl J Med. 2017;376(7):641-51.
5. Coen PM, Tanner CJ, Helbling NL, Dubis GS, Hames KC, Xie H, et al. Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity. J Clin Invest. 2015;125(1):248-57.
6. Dantas WS, Roschel H, Murai IH, Gil S, Davuluri G, Axelrod CL, et al. Exercise-Induced Increases in Insulin Sensitivity After Bariatric Surgery Are Mediated By Muscle Extracellular Matrix Remodeling. Diabetes. 2020;69(8):1675-91.
7. Mundbjerg LH, Stolberg CR, Cecere S, Bladbjerg EM, Funch-Jensen P, Gram B, et al. Supervised Physical Training Improves Weight Loss After Roux-en-Y Gastric Bypass Surgery: A Randomized Controlled Trial. Obesity (Silver Spring). 2018;26(5):828-37.
8. Oppert JM, Bellicha A, Roda C, Bouillot JL, Torcivia A, Clement K, et al. Resistance Training and Protein Supplementation Increase Strength After Bariatric Surgery: A Randomized Controlled Trial. Obesity (Silver Spring). 2018;26(11):1709-20.
9. Diniz-Sousa F, Veras L, Boppre G, Sa-Couto P, Devezas V, Santos-Sousa H, et al. The Effect of an Exercise Intervention Program on Bone Health After Bariatric Surgery: A Randomized Controlled Trial. J Bone Miner Res. 2021;36(3):489-99.
10. Murai IH, Roschel H, Dantas WS, Gil S, Merege-Filho C, de Cleva R, et al. Exercise Mitigates Bone Loss in Women With Severe Obesity After Roux-en-Y Gastric Bypass: A Randomized Controlled Trial. J Clin Endocrinol Metab. 2019;104(10):4639-50.
11. Lean ME, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018;391(10120):541-51.
12. Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol. 2019;7(5):344-55.
13. Petrov MS, Taylor R. Intra-pancreatic fat deposition: bringing hidden fat to the fore. Nat Rev Gastroenterol Hepatol. 2021 Dec 8. (Online ahead of print) PubMed PMID: 34880411.
14. Heiskanen MA, Motiani KK, Mari A, Saunavaara V, Eskelinen JJ, Virtanen KA, et al. Exercise training decreases pancreatic fat content and improves beta cell function regardless of baseline glucose tolerance: a randomised controlled trial. Diabetologia. 2018;61(8):1817-28.
15. Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR. Weight-loss maintenance for 10 years in the National Weight Control Registry. Am J Prev Med. 2014;46(1):17-23.
16. Friedenreich CM, Ruan Y, Duha A, Courneya KS. Exercise Dose Effects on Body Fat 12 Months after an Exercise Intervention: Follow-up from a Randomized Controlled Trial. J Obes. 2019;2019:3916416.
17. Honkala SM, Motiani KK, Eskelinen JJ, Savolainen A, Saunavaara V, Virtanen KA, et al. Exercise Training Reduces Intrathoracic Fat Regardless of Defective Glucose Tolerance. Med Sci Sports Exerc. 2017;49(7):1313-22.
18. Bacchi E, Moghetti P. Exercise for hepatic fat accumulation in type 2 diabetic subjects. Int J Endocrinol. 2013;2013:309191.