There has been much discussion around type 2 diabetes remission recently, with a brand new chapter in the Diabetes Canada Clinical Practice Guidelines dedicated to this topic.
As blogged previously, one of the concerns I raised about the concept of aiming for diabetes remisison, is that it may not be wise to stop medication that is also helping to treat obesity. The disconnect here is that, in my opinion, obesity is a medical condition that doesn’t generally go into remission. Let’s explore this statement.
Remission of a medical condition requires the non-detection of that condition after treatment. This terminology and definition is commonly used in the cancer field.
The diagnosis of diabetes is made based on blood sugars and related metrics (A1C). Thus, remission of type 2 diabetes is defined as normal sugars and A1C (ie, the diabetes can no longer be detected), on no treatment (specifically, after at least 3 months on no glucose lowering medication).
Now, let’s consider the definition of obesity: a chronic medical condition characterized by excess body fat that impairs health (metabolic, mechanical, mental, or quality of life).
Remission of obesity would thus be defined as the absence of obesity-related health issues, after treatment. (Note that the definition does not have a metric such as a target BMI, as the best weight is different for each individual. A ‘healthy’ range BMI target (18.5-25 by common definition) is not a treatment target.)
The trouble is, there is no ‘after treatment’ for obesity. Obesity requires ongoing active management for control. This is because of our natural human biology that ramps up our hunger hormone (ghrelin), suppresses our fullness (satiety) hormones, and decreases our resting energy burn, when we lose weight. All of these biological changes are engrained by evolution to defend our body weight, in order to find food and survive in times of food scarcity or famine. After weight loss with lifestyle changes, it is even harder work to keep the weight off, due to this natural biology.
Maintaining weight loss with ongoing weight management medication is challenging too, but easier than doing it with lifestyle alone, because obesity medications provide a defense against this natural biology by suppressing appetite and/or cravings. (and remember, people on medication are not in remission by definition)
Losing and maintaining weight with bariatric surgery is also challenging, but again, there is a defense put in place against this natural biology by changing gut hormones that favor reduction in appetite. Despite this defense, however, people who have had bariatric surgery are almost always continuing to treat their obesity actively with lifestyle measures, every day.
Are there exceptions?
A woman who develops obesity during pregnancy , but is able to successfully manage weight without lifestyle intervention after pregnancy, could perhaps be considered to have remission of obesity. (Note, however, that detangling obesity-related health issues in pregnancy like gestational diabetes from pregnancy-induced issues (independent of weight) is difficult. So, it may be hard to say whether a woman had obesity in pregnancy in the first place.)
A Hollywood star who gains 50lb for a role and develops hypertension, who loses weight after the movie and hypertension goes away, could perhaps be considered to have obesity in remission. But here, I am dubious if this person had obesity in the first place, as the weight gain was artificially driven, not driven by the natural biology that begets obesity for most people.
And finally, could childhood obesity go into remission? Some kids with obesity are actually very strongly genetically inclined towards obesity, and have a tougher road ahead than adult-onset obesity. Are there others where environmental factors are the dominant issue, and changing these could put obesity into remission? It’s a question that we need to explore.
BOTTOM LINE: In my opinion, obesity should not be thought of as a medical condition that goes into remission. People who are able to manage weight to resolve obesity-related health issues almost always need to continue to actively manage their weight for the rest of their lives, actively treating their obesity every day with important lifestyle measures.
(PS: On that note, one could challenge whether type 2 diabetes is in remission, if that person with normal sugars is continuing to treat/control sugars with lifestyle measures, as many would need to do in order to stay in ‘remission’. But we’ll leave that debate for another day.)
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