Type 2 Diabetes Remission: A Pharmacist’s Practical Guide
Hey there, folks, Cory Jenks here. It’s been a while since I’ve had the chance to contribute to tl;dr. You might remember me from such hits as Soft Skills for Pharmacists, 5 Steps to Being More Adaptable, and Healthcare Workers Need to Have Each Other’s Backs. If you want to connect, you can also find my LinkedIn here.
Today I am here to tackle something more…clincal. And something that impacts a lot of our patients: Type 2 diabetes. Most of my career has been spent tackling Type 2, and it has even inspired me to cohost a podcast on the subject of Type 2 diabetes remission (in case you wanted a non-tl;dr source from Apple, Spotify, or Youtube). Given my non-clinical posts in the past, you could say I look at pharmacy a little differently. Today we are putting a new lens on Type 2 physiology, treatment, and expectations. Let’s dive in.
Type 2 diabetes is a…problem. A big problem. And, in this pharmacist’s humble opinion, a reversible problem. But before we get there, a quick reality check on the scope of the problem:
Of the 40 million Americans with diabetes, it is estimated that 90-95% have Type 2 diabetes, specifically.
Over 50% of American adults have Type 2 diabetes or prediabetes (and for some sad context, about 1/3 of American kids have prediabetes).
Depressed yet? Great! Let’s cheer you up with some “good” news. Way back when I graduated pharmacy school in 2011, there weren’t cool medication tools like “SGLT-2 inhibitors” or “GLP-1 agonists that were only once a week and celebrities endorsed on Tik Tok.”
Hey fellow kids, that newfangled metformin XR has all the rizz, and glipizide is so mid, amiright?!
Of course, I am old, and back then Tik-Tok didn’t exist. (Image) We basically had insulin and a bunch of other oral options that have already been covered on tl;dr.
Oh, the “good” news: pharmacists now have more medication tools that actually help improve diabetes outcomes and prevent serious heart and kidney complications instead of just making your A1c look good so the doctor is happy.
Back to the bad news: even with all these fancy tools at our disposal, diabetes is still a massive problem. And it’s time to get a little uncomfortable, perhaps even a little awkward, and ask the question that gave my pharmacy career direction back in 2016:
Are we treating the symptoms of Type 2 diabetes… or the underlying pathophysiology driving the disease?
Don’t get me wrong, I don’t want a world of people with blood sugars in the 300s in whom we avoid medications because “welp, no point, it’s just the symptoms not the root cause!” I think there is room for medications as well as a discussion and PLAN to address the underlying problem to actually put Type 2 diabetes into remission. But to get there, there is, I know, yet another question to ask:
What if Type 2 diabetes is fundamentally a disease of total energy overload rather than simply high blood sugar?
That, my friends, is what is called a teaser. Because first, I want to dive into what Type 2 diabetes remission actually means. To do so, we’ll hit up our friends at the American Diabetes Association, whose definition of remission is:
“HbA1c below 6.5% for at least 3 months without glucose-lowering medications.”
Remission does not mean the disease has disappeared permanently. It means the underlying metabolic dysfunction has improved enough that blood sugar remains normal without pharmacologic support. In other words: the physiology has improved enough that medication is no longer required for blood sugar to be controlled.
Cool cool cool. We have defined the growing prevalence, acknowledged we have some better med tools to fight it, asked some tough questions, and defined Type 2 diabetes remission. Now, I’d like you to take what you have thought Type 2 diabetes is and throw it out the window. And if you could do me a favor, really break that window good, because it’s time to…totally reframe how we look at Type 2.
See what I did there? Window…reframe…window frame. Hehe.
Traditionally, Type 2 diabetes has been thought of as a glucose disorder. You know, check an A1c, see the glucose readings from fingersticks, maybe get lucky enough to have a continuous glucose monitor to track glucose trends.
The good news is overcoming INSULIN resistance is not futile.
In fairness, some of you intrepid readers may actually see Type 2 diabetes as a problem of insulin resistance that develops over years in people. Simply put, the insulin the pancreas produces no longer works as well as the body develops resistance to it, and blood sugar rises as a result. (Image)
The insulin resistance angle is not entirely wrong. But I want to reframe Type 2…even more.
My bold hypothesis is that Type 2 diabetes is primarily a muscle disease that manifests as a chronic energy storage problem. Let me build my case, then talk about how us pharmacists can help our patients get on the road to remission.
I want you to start thinking in terms of energy storage “tanks” in the body. Some store glucose in the form of glycogen, some store body fat. When humans consume energy in the form of carbohydrates (don’t worry, not gonna carb bash…too much) and there is an excess, it is first stored in the liver as glycogen, which capacity is 80-120 grams. Once our liver glycogen tank is full, the next place for any excess energy to go is the muscle. Here there is much more room for glucose to be stored as glycogen, as in 300-500 grams depending on muscle mass and training by the person. In our storage tank analogy, muscle is…much bigger.
And here’s another important distinction: the glycogen in the liver can be mobilized for the entire body. Muscle glycogen? It’s selfish and can only be used for the muscle itself.
If the glycogen “tanks” in the liver and muscle get full, but there is still extra energy floating around, the next stop for storage is subcutaneous fat once excess energy is converted into triglycerides. There is good news and bad news about storage in subcutaneous fat. The good news? It’s a “safe” place for excess energy to be. Unlike liver and visceral fat (we’ll tackle these in a moment), there is less danger in energy being stored here. The bad news? Excess weight in any place is not good for the overall health of the body.
The final storage tank for excess energy, and the one the body tries desperately to avoid filling, is ectopic fat. Here is where we can see fatty liver, as well as fat around the pancreas. All this leads to issues with insulin release as well as hepatic insulin resistance and excess glucose production.
An interesting, or more likely, frustrating aside. There is a concept known as the “personal fat threshold,” which basically says a person is genetically limited to how much subcutaneous fat they can store before it starts accumulating ectopically. While Type 2 diabetes is typically associated with being overweight or obese, that is not always the case. If you have ever had a patient frustrated with a Type 2 diagnosis or high blood sugar because they are “not overweight,” this could partly explain why. It can also explain why there are people who are morbidly obese with very normal blood sugars who can store excess energy more effectively in their subcutaneous fat tissue.
Returning back from our aside, if I had to summarize what Type 2 diabetes is in a single sentence, it would be: Type 2 diabetes develops when the body runs out of safe places to store energy.
Once all of the safe “storage tanks (hepatic glycogen, muscle glycogen, and subcutaneous fat)” fill up, then the “unsafe” ones fill up (ectopic fat). And at that point, we have full blown insulin resistance and energy (glucose and often, triglycerides) with no where else to go but the blood.
Ok, once we hit “energy storage overload,” insulin resistance develops, and blood sugar is high, things look pretty grim. But what if there were a secret weapon in the body that could help reverse all of this energy excess nonsense? An underused, underdeveloped, and underappreciated diabetes “drug”?
Good news, there is. And I have already mentioned it.
Hanz and Franz are excited I am about to pump you up - with diabetes advice.
Are you ready for me to pump you up…with strong blood sugar lowering advice? (Image)
Good, because I see Type 2 diabetes as a muscle disease. Why exactly? Because muscle is the largest storage “tank” in the body, accounting for 70-80% of post prandial glucose disposal. That means more muscle, more effective removal of glucose from the blood.
Think of our muscle system as a metabolic “sink” for blood sugar to drain. It is why, in this humble pharmacist’s opinion, that one of the risk factors for developing diabetes is age. Because as we age, we tend to lose muscle mass and thus, a major source of glucose regulation in the body.
Of course, this hypothesis runs contrary to the opinion that age-related diabetes risk is directly correlated to grandparents eating the leftover sugary sweets they give their grandkids.
While the volume of muscle affects glucose regulation, skeletal muscle has another trick up its bulging bicep-y sleeve. Because while we were all taught insulin needs to be around to open the “gate” for glucose to enter our bodies’ cells, muscle has a secret side door.
GLUT-4.
Cool name. Even cooler effect. Because GLUT-4 allows for glucose to leave the blood and enter muscle cells independent of insulin secretion…provided the muscle contracts.
That means lowering blood glucose even in a setting of insulin resistance or impaired beta cell function. Indeed, muscle is one of the only tissues that can clear glucose from the blood without insulin.
Is your mind blown?
With that knowledge in your back pocket, let’s start constructing that roadmap to Type 2 diabetes remission.
I said THREE levers, not 311 levers. Sorry if you got All Mixed Up.
I like the simple things: 90’s alternative rock, adding guacamole to my Chipotle order, and keeping lists in groups of three. Which is why I am going to give you the three simple levers for diabetes remission. (Image)
Diabetes Remission Lever #1: Muscle
You just got the reasons why muscle is so important for blood glucose regulation as it is our bodies’ largest glucose storage tank. It can even remove glucose from the blood without needing insulin. Why’s are great, but how can we encourage the people we care for to actually implement muscle building. The simple answer is resistance training, but the more complicated answer is “how much, which kind, where, and do I need to spend lots of hours in the gym?”
Uncle Rico talks a big game, but can he give you 30 minute total a week total body muscle workout?
The internet, your local gym, and your Uncle Rico (no, not the one who could throw a pigskin a mile) all have lots of opinions on resistance training protocols. (Image) I lean towards a simple protocol that is just 15 minutes twice a week.
That’s right, 15 minutes twice a week. It sounds like a scam, but the evidence backs it up (actually, this study showed how going to muscle failure once a week worked too). If you’d like a book on the subject, 15 Minutes to Fitness by Dr. Ben Bocchicchio is the place to nerd out. I typically just send my patients to one of the many videos where the 7-8 movements are described. The trick to getting these done in such short order is that each rep is done sloooooowly so that if you pick the right resistance, you get to muscle failure in 60-90 seconds.
I’ll admit my bias, but I like this protocol as a “minimum effective dose” of strength training to put it in pharmacist language. Personally, I follow this protocol due to the time constraints of three very young, needy, and often loud children and have been very upset by it. Only because I spent years doing hours of exercise but didn’t get the same strength gains as this workout.
This workout will build muscle to help lower sugar, not take a ton of time, and can be done at home with resistance bands. It’s basically a perfect workout for anyone who says, "I don't have time to workout." And the low reps and slow movements are great for minimizing injury risk.
But if you think 15 minutes twice a week is ALL you have to do to reverse Type 2 diabetes, let me introduce you to Lever 2.
Diabetes Remission Lever #2: Smart Movement
Let me preface this by saying any kind of movement someone with diabetes can do is better than none. But we are tl;dr for a reason: work smarter, not harder. While volume of movement is good, what if we could time things in a targeted way to get the most blood sugar lowering bang for the buck. Because many patients have exercise framed in a way that is doomed to failure, like “exercise 30-45 minutes a day.”
I don’t know about you, but life is chaotic. To get a chunk of time even as small as that EVERY day would be a challenge for many. But if we can encourage smaller bouts of exercise with better timing, we can help people incorporate movement into their lives that is doable, sustainable, and actually helpful for lowering blood glucose.
To that end, we want to focus on a couple of action items:
Move when glucose is **typically** highest
Move throughout the day periodically (aka exercise snacks)
First, timing of movement around elevated glucose. This could mean going for a walk after meals for just 5-10 minutes. This can help with post meal glucose spikes. And if after a meal doesn’t work, going before can be useful in glucose lowering too.
The other is small amounts of movement throughout the day, also known as exercise snacks. This can mean those walks around meals, but it can also mean fitting in 10 bodyweight squats every hour, or taking 2 minutes an hour to go up and down the stairs. Anything to break up sitting and sedentary behavior throughout the day can help lower glucose and improve insulin sensitivity. In fact, one study found that doing those intermittent squats throughout the day lowered glucose better than one continuous 30 minute walk.
So we grow some muscle and contract it regularly throughout the day, and blood sugar will improve. But we can’t ignore that diabetes may still stick around if energy intake is still too high. Which brings us to…
Diabetes Remission Lever #3: Satiety-Driven Nutrition
“Too many calories and not enough nutrition.”
This is the line I have given to countless patients. And I’ll explain what I mean in a second. But before I do, I’d like to make an (another) aside.
If you have ever given diet advice, read about diet advice, or turned on the TV or internet to learn more about nutrition, you have probably seen some form of The Diet Wars. And like Star Wars, there seems to be a sequel every week.
Paleo
Plant Based
Keto
Low Fat
Mediterranean
I am going to plant my flag in the “no more diet wars” camp and provide a framework that is diet camp agnostic. Because it works for any approach to eating that…works for better blood sugar. And all of those approaches, like the ones I listed, reduce overall energy intake.
The approach I recommend for Type 2 reversal is a satiety-based approach that helps people naturally regulate food intake and can be adapted to nearly any dietary preference. That is, other than the “Standard American Diet” which…is not conducive to controlled blood sugars.
The framework is a “Nutrient to Energy” ratio. The leap I am taking here is that our bodies regulate appetite primarily through protein and nutrient intake, not calorie intake. As I said earlier, I often tell people suffering with high blood sugar that they eat too much energy (calories) and not enough food (nutrition).
Modern processed foods are:
High energy (lots of fats and carbohydrates)
Low satiety (don’t make you feel full)
Easy to overeat (hello my friend, the old bottom of a bag of chips)
It would not be beyond someone, like myself, to eat 1000 calories of tortilla chips and still feel hungry. But a 1000 calories of broccoli…good luck.
The goal is to consume more “nutrient dense” foods that are less “energy dense". For example:
Higher protein foods
Meat
Fish
Eggs
Greek yogurt
Lower energy density foods
Vegetables
Fruits
Some whole food carbohydrates
When people increase protein and nutrient density, total energy intake (calories) from fats and carbohydrates often falls naturally. And the good news is that we can all join hands and sing kumbaya because this “maximum nutrition with minimal energy” approach works for all sorts of different dietary approaches.
No fights about diet required.
So now you, intrepid pharmacist, are armed with the three pronged approach to help your patients with Type 2 diabetes reverse course and set sail onto the Sea of Remission.
And because you see these patients so often: in your clinics, at your counters, and at the family barbecue while Uncle Frank won’t stop asking why his copay went up 3 dollars, you have the power to help them.
You can educate on the importance of muscle, smart movement, and a fight free approach to eating that will help them build a better capacity for handling glucose, utilize it more effectively, and stop overfilling their bodies with energy.
Lest we forget, you are, in fact, a pharmacist with vast medication knowledge. So remember that on the road to Type 2 diabetes remission, there are certain classes of medications that can be used as supportive tools.
GLP-1s can improve satiety to reduce energy intake.
SGLT-2 inhibitors can help rid the body of excess glucose.
Metformin can improve insulin sensitivity.
Sulfonylureas can burn out their pancreas and cause dangerous hypoglycemia. (Can you tell I am no fan of sulfonylureas?)
Remember that medications treat the symptoms, but fixing the underlying physiology treats the root cause of Type 2 diabetes. And lifestyle will determine if patients continue accumulating excess energy or begin reversing the problem.
I hope you now realize that Type 2 diabetes doesn’t have to be a lifelong progressive disease. When we treat muscle as medicine and prioritize satiety, remission becomes a realistic outcome for many patients.