After recently reading this paper about the natural history of diabetes remission using Kaiser Permanente data, Just Read: Predicting Risk of Diabetes Progression, and Incidence of Remission in Usual Care â€“ data from Kaiser Permanente, I had the opportunity to walk and talk with one of its authors, Shantanu Nundy, MD (@DrNundy) who framed the work in a completely different way than I had.
I came away with the impression that diabetes remission is a rare event in today’s state of the art care. Shantanu relayed the story behind the piece, with this clue in the acknowledgements that also caught my eye when I read it:
Acknowledgments. S.N. dedicates this study to his mother, Anju Nundy, who has type 2 diabetes.
I asked him to provide the story for me and he did, with permission to publish here:
What inspired to write this paper was actually a patient of mine: a mid-40 year old African-American living on the South Side of Chicago. He had had type 2 diabetes for years and previously on insulin, but more recently had lost over 20 pounds and stopping taking his medications due to insurance reasons. When I saw him, he had just re-gained insurance but was excited to get back on his meds. But once I checked his initial A1c, it was below 5.7%. To which he asked, “Doc, does that mean I’m cured of diabetes?” Initially I was tempted to retort “Of course not!”, but in truth, I didn’t know the answer to his question. I told him I’d have to get back to him and then rushed back to my research group at the University of Chicago to think. To my surprised, the idea of “remission” had actually been contemplated a panel of diabetes experts who defined it in a prior Diabetes Care paper. Their primary motivation was patients with gastric bypass surgery, not patients like mine. I wondered how many more patients like mine were out there.
The primary motivation for writing this paper was hope. I suspected if remission existed in patients with type 2 diabetes and no gastric bypass surgery it would be rare. But knowing that remission was at least possible could bring hope to the hundreds of thousands of people around the world diagnosed with type 2 diabetes each year. I knew for a fact that for my mom, who was diagnosed 20 years ago, and who I dedicated this paper to, it would have given her hope and perhaps motivated her to make the lifestyle changes needed to achieve it.
For me, the upshot of what we found was “remission in type 2 diabetes is possible [without surgery]”. Even today, most endocrinologists (let alone patients) do not think that it is. And for every patient we found in remission, I wonder how many more might already be in remission, if only their physicians gave them a therapeutic trial off their medication (like my patient did unknowingly when he stopped his medication for insurance reasons).
Our paper isn’t a reflection of the state of type 2 diabetes care and certainly isn’t a reflection of the quality of care (or lack thereof) at Kaiser Permanente. We simply used the best dataset available to show the world that my patient was right to ask, full of hope, “Doc, does that mean I’m cured of diabetes?”
Listening to the stories behind peer reviewed research
I’ve remarked previously on this blog that the process of peer review tends to remove the essence of many research publications, in a way that matters.
I realize I read the paper with the bias that came with my 20th Century medical training (and still in much of medicine) that diabetes is an unremitting, progressive disease. We are now learning that this depiction is a mental model, like so many others created in the last century about patients and their ability to heal and be healthy.
In an era of changing the way we think about conditions like diabetes (and HIV, and transgender person medicine, etc., etc., etc.), social media has made a huge difference (Just Read: Does Hyperinsulinemia cause obesity, and academic discourse on Twitter (finally)).
Many of the authors in this field are taking the time to tell the story behind their peer-reviewed pieces in parallel. Ryan Lowery, PhD(c) (@RyanLowery14) and Jacob Wilson, PhD (@TheMusclePhd) are examples of the new generation of the social scientist (see: Just Read: The Ketogenic Bible: The Authoritative Guide to Ketosis, by Dr. Jacob Wilson and Ryan Lowery, PhD(c))
Giving credit also: The people we serve inspire us
With this new frame, I now read the author contributions section in the paper differently as well.
Notice what the article says and compare it to the narrative above:
S.N. conceived the study; contributed to the study design, the analysis and interpretation of the data, and the critical review and revision of the manuscript; and drafted the original manuscript.
The story behind this sentence values and gives credit to the patient-physician relationship for causing us to ask “why?”
The medical profession doesn’t always have the answers; the people we serve are our allies, too. We are therefore better off when a talented primary care physician takes the time to listen, which is what happened here.
Physicians are uniquely suited (and it’s their role) to (a) bring the patient story into every conversation (b) support patients in leading the conversation themselves.
It has always been important to go beyond the abstract and read the whole paper. Now that’s not enough either, and that’s okay. We’re here to understand what’s best for the health of the people we serve. My/our curiosity is boundless.
That this process may involve a walk in the most gorgeous capital city is low carbohydrate icing on the kale 🙂 .