There are currently 37.3 million people (about twice the population of New York) in the United States living with diabetes, approximately 11.3% of the population, and 90% to 95% of those in this group are classified as living with type 2 diabetes (T2D). When people diagnosed with prediabetes are included, the group size increases by 96 million, thereby reaching 38% of the US population at risk for T2D and related sequelae.1 The economic burden associated with diabetes is staggering, accounting for $237 billion spent annually in direct medical costs and another $90 billion in reduced productivity for a price tag of $327 billion.2 Holistic care providers are rightly concerned about these costs and the magnitude of opportunity costs and quality-of-life concerns associated with diabetes in all its forms.
Patients living with T2D are often told by providers that their condition is chronic and likely progressive. Recent emerging research findings and evidence-based practice recommendations, including a consensus report published by the American Diabetes Association (ADA), offer a different and compelling case that supports the possibility of disease remission.3 These strategies are inconsistently shared with patients because many nurses and other health professionals are unfamiliar with new evidence or care advances. Holistic care providers are called to explore this science and include diabetes remission pursuit into patient treatment options when appropriate.
Pharmacological diabetes management may be the first choice for many patients, but it may not meet the needs of the patient seeking to discontinue medication use, utilize a drug-free holistic approach, or discharge themselves from what could realistically be a chronic and progressive condition. Medications do not come without risk, including the possibility of adverse events or predictable side effects. Many patients and providers are also concerned about the associated risks of drug-drug interactions and polypharmacy. Expense and insurance limitations associated with many T2D medications are also barriers to patient access.
Over the past decade, the national spending on glucose-lowering medications is estimated to have risen by 240% or $40.6 billion.4 Those most impacted by prescription costs are often those without health insurance or with high deductibles, potentially leaving the particularly expensive, often newest, medications out of patients' reach. The financial burden of T2D medication requires the holistic provider to acknowledge the consequences that expensive treatment options may pose to social justice and health equity. Medication management may be the desired option for many patients, but nurses interested in holistic care approaches must be aware of all evidence-based treatment options to support fully informed patient choice and empowerment.
Diabetes remission is defined by the ADA as achieving a hemoglobin A1c (HbA1c) of less than 6.5%, whether spontaneously or after the implementation of an intervention, for at least 3 months in the absence of glucose-lowering pharmacology.3 Published literature currently has identified 3 main modalities that may help patients move toward diabetes remission, including bariatric surgery, very low-calorie diets, and low carbohydrate diets (LCDs). Bariatric surgery is shown to offer high rates of T2D remission. Systematic reviews report an initial success postsurgery of up to 95%, with continuing remission of 36% to 51% at 10 and 12 years.5 This option, not without risk, is only available to patients with a qualifying body mass index. Bariatric surgical interventions may not be available to every interested patient related to out-of-pocket costs and insurance restrictions. Those patients seeking T2D remission via a lifestyle intervention are unlikely to consider bariatric surgery.
Very low-calorie diets have demonstrated positive T2D reversal results, with remission reported between 36% and 46% at 1 and 2 years.5 Very low-calorie diets may not be sustainable in the long run for many, plus nurses need to consider that not all patients living with T2D are candidates for weight loss. The LCD is a highly researched dietary intervention for T2D. One consensus report on nutrition summarized recommendations of eating patterns for persons living with T2D, noting that reductions in overall carbohydrate intake have the most evidence supporting glycemic control.6 LCDs demonstrate greater than 50% diabetes reversal rates and encouraging results on long-term sustainability, similar to outcomes related to bariatrics and very low-calorie diets.5,7
Definitions of an LCD vary, with some sources citing upward of 40% of daily calorie intake from carbohydrates. However, much published evidence points to lower targets of daily carbohydrate limits of no more than 30 g per day to achieve success with T2D medication reduction, diabetes reversal, and improved cardiovascular risk markers.5,7 LCDs revolve around real, whole foods; protein; and nonstarchy vegetables. Fat is usually not avoided on an LCD, and this helps increase satiety. LCDs can be customized to allow for patients' preferences and cultural considerations, even a vegan diet can be formulated to be lower in carbohydrates. LCDs can also be adjusted to meet the energy needs of patients living with T2D for whom weight loss is not a goal.
Best practice would ensure patients pursuing remission work under the supervision of their health care provider. Building a collaborative team to include a registered dietitian who supports the patient's intervention and goals may provide further benefit. Opportunities for continuing education exist for nurses and providers interested in increasing their knowledge of T2D remission and LCD. Dietdoctor.com, an evidence-based Web site led by physicians and registered dietitians, offers free, accredited continuing education modules, while organizations such as the Society for Metabolic Health Practitioners (https://thesmhp.org/) provide virtual and in-person conferences open to all health care professionals. Dietdoctor.com also offers patient education pertinent to LCD, including constructing a well-formulated LCD and many recipes and menu options for patients to enjoy. Content on Dietdoctor.com varies from free to an optional pay membership. Simple Web browser searches reveal other LCD planning resources and, for patients and family interested in meal delivery services, many for-profit meal delivery services offer LCD options. While not every patient may be suited for each option, health care provider knowledge of the possibility of remission remains key to the conversation and careful, respectful assessment will adjust the LCD plan in directions that are financially appropriate and interesting to the patient.
Shared decision-making is characteristic of holistic patient-nurse interaction. Health care providers should be open to all evidence-based treatment modalities because research findings support that providers' belief in intervention effectiveness can directly influence patients' beliefs and perceptions.8 When providers demonstrate greater empathy and belief in the treatment, patients reported perceiving greater benefits.8 Many treatment guidelines advocate for including a modified lifestyle approach. But after prescribing a trial of lifestyle change, providers frequently notice patients returning without improvement, thereby necessitating continuation or increase of pharmacological treatment. It may be that health care professionals are incorrectly or insufficiently coaching patients about potential opportunities of evidence-based lifestyle interventions as a path to diabetes remission.
Glucose management is the goal in diabetes management, but truly holistic practice requires responding to the whole person, including physical, psychological, spiritual, and emotional needs. This healing approach requires nurses to broaden their diabetes management practices. A well-informed conversation about the possibility of diabetes remission may empower interested patients and offer them an opportunity to become the drivers behind personal healing based on diet changes.
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