Type 2 diabetes remission is possible. A 33-year-old Singaporean did it by losing 8kg and more – TODAY

Singapore
SINGAPORE — It is a commonly held notion that once diabetes takes root, the chronic disease is there for life even if it can be controlled with medication and treatments. However, a woman in her 30s managed to put the condition in remission.
Ms Sharon Lim (pictured) managed to achieve diabetes remission, motivated by her plan to have children.
SINGAPORE — It is a commonly held notion that once diabetes takes root, the chronic disease is there for life even if it can be controlled with medication and treatments.
For Ms Sharon Lim, who found out she had Type 2 diabetes at the age of 30 in 2019, she was not prepared to live with the medical condition even though she has a family history.
Over a year, by sheer commitment to losing weight, exercising and controlling her blood sugar, she then achieved what is still considered a very difficult goal for diabetic patients: She managed to put the condition in remission.
It is called remission because it is not a cure and the condition can still return.
However, for now, the 33-year-old’s blood sugar levels is back in the normal healthy range.
In her case, the strongest factors working in her favour were weight loss and that she had not had the condition for a long time.
Ms Lim lost around 8kg under her doctor’s supervision after being newly diagnosed. She was able to go off medications about a year after her diagnosis.
Speaking to TODAY, the assistant senior counsellor said that
her father, uncles, aunts and cousins all have the chronic disease, but they were diagnosed later in life.  
“I was shocked. I always thought that (Type 2) diabetes was more of an older person’s problem,” she said.
“I didn’t want to accept that I would need to take medications until I’m 80 or so. I’m still so young.”
She added: “Growing up and seeing my dad manage his diabetes, all I know about the condition was that one needs to be on medication for life, or else there’s a risk of (complications such as) limb amputation or going blind.”
The idea that a person can possibly strive to be rid of Type 2 diabetes — with blood sugar levels reverting to the normal range without medications — has been gaining attention. 
The Diabetes Remission Consensus, which is a consensus statement from an international group of experts last year, suggested that people with Type 2 diabetes should be considered in remission after sustaining normal blood sugar levels for at least three months or more without taking diabetes medication.
The group included the American Diabetes Association, the Endocrine Society, the European Association for the Study of Diabetes and Diabetes UK.
Your average blood sugar level over the past three months is measured through HbA1c or glycated haemoglobin.
It is made when glucose (sugar) in the human body sticks to red blood cells.
A high HbA1c means you have too much sugar in your blood.
The criteria for diabetes remission is an average blood sugar (HbA1c) level of less than 6.5 per cent for at least three months after stopping medication, the Diabetes Remission Consensus group said.
Doctors in Singapore who spoke to TODAY agreed that diabetes remission is possible but with several caveats:
Dr Ben Ng, an endocrinologist at Arden Endocrinology Specialist Clinic who handled Ms Lim’s case, said it is important to understand that diabetes is a continuum of rising blood sugars.
“Just because the patient is in remission and does not require treatment for now does not mean it will be like this permanently,” Dr Ng said.
“As we age, metabolic function declines and blood sugar can climb. Furthermore, if the individual adopts their old (unhealthy) lifestyle again, invariably, blood sugars will rise again.”
Senior consultant endocrinologist Tham Kwang Wei stressed that “the word ‘remission’ doesn’t mean that it is a cure”.
“For example, in cancer, when people say they are in remission, they know there is a possibility that the cancer may relapse. However, if remission is maintained in the long term, there is a potential for a cure,” Dr Tham said.
Dr Tham is the president of the Singapore Association for the Study of Obesity, which promotes the study of obesity in Singapore.
Dr Lee Yingshan, consultant at the department of endocrinology at Tan Tock Seng Hospital (TTSH), said that the longer the person has had Type 2 diabetes, the harder it may be to attain remission.
“But for patients who are recently diagnosed — for example, fewer than five years — diabetes remission is a worthy treatment goal,” Dr Lee said, adding that research has shown that this is achievable through a multidisciplinary team effort focusing on weight loss.
Around one in 12 people (7.9 per cent) in Singapore has diabetes, the National Population Health Survey 2020 showed.
Dr Lee noted that the highest prevalence is in the older age group of between 60 and 74, but the survey also found that more than half (56 per cent) of younger adults between the ages of 30 and 39 had undiagnosed diabetes.
Adults who are overweight have an 80 to 88 per cent risk of developing Type 2 diabetes; being overweight affects insulin responsive cells in the body and reduces insulin sensitivity, Dr Ng said.
Insulin is a hormone produced by the pancreas and released into body cells to convert blood glucose (sugar) for energy.
When someone has reduced insulin sensitivity, it means that more insulin is needed to bring the blood sugars down, Dr Ng said.
“Over time, if it continues, more and more insulin is required. This results in the pancreas becoming exhausted and hence, triggering the rise in blood sugars.”
Dr Tham said: “In the most effective of therapies using bariatric and metabolic surgery, diabetes remission is seen in up to 80 per cent of patients at one year after surgery. 
“However, around 30 to 50 per cent of patients who attain remission experience a relapse of their diabetes in five to 10 years, illustrating the chronic nature of diabetes and obesity.”
Bariatric or metabolic surgery is performed on the digestive system to help patients lose weight and improve medical conditions linked to obesity such as Type 2 diabetes.
It may also be possible to put Type 2 diabetes into remission without surgery by shedding a significant amount of excess body fat. 
Citing the Direct study published in the Lancet medical journal in 2018, Dr Tham said that 46 per cent of participants who underwent rigorous medical intervention over a year for weight loss — losing an average of 11 per cent of their weight — were able to achieve diabetes remission.
Those who lost 15kg or more were most likely to achieve remission.
From 46 per cent for the first year, though, the proportion of participants who achieved remission at two years dropped to 36 per cent.
Dr Jaideep Raj Rao, senior consultant surgeon at JR Surgery in Mount Elizabeth Novena Hospital, said that excess weight can be lost by changing one’s diet and lifestyle, and by the use of medications that induce weight loss along with controlling diabetes.
However, more than 95 per cent of individuals with obesity are unable to lose adequate weight with those methods. 
Dr Ng said that reducing the intake of refined sugar and saturated fat have been shown to significantly reduce blood sugar levels and improve the odds of remission. Increased physical activity also improves overall sugar metabolism.
“With regards to weight reduction, at this time, we are fortunate to have numerous medications that can potentially help, such as GLP-1 analogues that can reduce blood sugars and result in significant weight reduction.
“Many patients who have diabetes and want to start to lose weight can consider these medications as an add-on therapy to their current lifestyle and dietary intervention,” Dr Ng added.
Dr Lee from TTSH said that consistency is key.
“Patients who achieve remission are often able to establish a set of routine that works well for them for a prolonged period of time.”
While researching about diabetes management, Ms Lim discovered the concept of diabetes remission. Enlisting the help of her doctor, she felt that there was nothing to lose by trying it.
Apart from the fear of getting diabetes-related complications, her main motivation was the desire to be in better health to start a family.
Ms Lim has a high body mass index (BMI) since young and had trouble losing weight, despite exercising.
“There was a time when I used to hit the gym six times a week and I managed to lose 10kg over four to five years. The moment I stopped the intense exercise routine, I’d put on weight again,” she said.
“My diabetes diagnosis gave me closure because I finally knew why (likely due to impaired insulin sensitivity) I could not lose weight despite trying so hard for so many years.”
Reduced insulin sensitivity can make it harder for people to lose weight and more likely to develop Type 2 diabetes.
In a bid to achieve remission, Ms Lim went on a complete diet overhaul and exercised two to three times a week. She also took medication that helped induce weight loss while controlling her blood sugar.
Her weight dropped from 87kg to 79kg from 2019 to 2020.
“As much as I hate needles, I pricked and tested my glucose levels daily, up to eight times a day — on my own accord. I wanted to learn how different types of food affected my blood sugar level and eliminate those that spike it,” Ms Lim said.
She gave up all of her favourite foods, opted for zero-sugar beverages and prepared her meals using high-protein recipes she found online.
“Mango sticky rice, glutinous rice, porridge, grapes, durian and refined carbohydrates like white rice, noodles and white bread — all went out (of her diet) even though I absolutely love carbs. It was extremely difficult at the beginning but over time, it got easier,” she said.
For people aiming for remission, Dr Ng said that it is essential to work with their doctors.
“There are many methods to potentially reduce blood sugars. Even if you do not achieve remission, your blood sugar levels can be maintained with less medication,” he added.
Now focused on starting a family, Ms Lim still tracks her blood sugar readings every six months.
“I feel it’s important for people to identify their motivation – that will be their greatest push,” she said.
“My diagnosis happened a year before I was to get married, which made it more anxiety-provoking since we wanted to start a family. Without the thought of family planning, I might not have pushed myself to this level.”
Dr Ng cautioned that even after losing weight, not every patient goes into remission.
Yet, this does not mean that the person has “failed”.
Dr Tham said what is more realistic are the baby steps taken to lose and sustain weight loss in a sustainable manner.
She pointed out that blood sugar levels can improve with weight loss of just 3 to 5 per cent — and with it, an improvement in other aspects of health and well-being, and a reduced risk of complications linked to diabetes and obesity.
“People with diabetes don’t necessarily have to go into remission to say they’ve done well. It’s not ‘all or nothing’,” Dr Tham said, adding that patients who achieve remission will still require long-term monitoring and follow-up with their doctors.
Dr Lee said: “I can speak from experience that patients who establish a change in their lifestyle habits — including changes in food options, meal timings, better sleep, increased physical activity — will almost always see their diabetes markers improve, and beyond that, improvements in their physical and psychosocial health.”
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