WHAT EXACTLY IS DIABETES REMISSION?

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Historically, a number of terms have been used to describe what is now known as type 2 diabetes remission, including ‘diabetes resolution’, ‘diabetes reversal’, and/or ‘cure’. Recently, a group of North American and European scientists recommended that ‘diabetes remission’ is the most appropriate term, as it strikes the right balance, noting that type 2 diabetes may not always be active and progressive, yet implying that a notable improvement may not be permanent (1). Remission retains the implication that there is susceptibility of a return of type 2 diabetes if substantial weight regain occurs, or simply due to advancing age.

The group also published what they consider to be the most appropriate definition of remission of type 2 diabetes based on our current understanding of the condition: Diabetes remission is when a person with confirmed type 2 diabetes has achieved a HbA1c (glycated hemoglobin – a long-term measure of average blood glucose levels) level less than 48 mmol/mol (or 6.5%) and that this result is maintained for at least three months, following the complete cessation of all glucose-lowering medications (1). Alternatively, a fasting blood glucose level less than 7.0 mmol/L (126 mg/dL) following the complete cessation of all glucose-lowering medications can also be used as a criterion for remission (1).

What’s the evidence?

Two recently published clinical trials provide compelling evidence that type 2 diabetes can be put into remission in certain people.

The first, described in this month’s Food for Thought, is DiRECT (Diabetes Remission Clinical Trial): a cluster randomised-controlled trial conducted in the United Kingdom (2). It included around 300 adults with type 2 diabetes of less than 6 years duration, who had an average weight of 101 kg (223 Pounds). For the control group, they used best-practice care by guidelines. For the intervention group, they used total diet replacements (3,450 – 3,570 kJ/day or 825 – 853 Calories/day) for 3-5 months, followed by stepped food re-introduction for an additional 2-8 weeks. In the total diet replacement group, the average reduction in body weight was 10 kg (~10% of initial body weight) at 12 months. Approximately 1 in 2 (46%) people achieved remission at this point in time and 36% (~ 1 in 3) achieved remission at 2 years. Importantly, remission was closely related to the degree of weight lost, with 86% of people who maintained at least 15 kg (i.e., ~15% of initial body weight) weight loss at 1 year, achieving remission.

The second was called DIADEM-I (Diabetes Intervention Accentuating Diet and Enhancing Metabolism). It was an open-label, parallel-group, randomised controlled trial conducted in Qatar (3). It included a total of 147 adults with type 2 diabetes of less than 3 years duration, with an average body weight of 100.6 kg (222 Pounds). People in the control group received usual medical diabetes care according to clinical guidelines. For the intervention group, they used total diet replacement (3,350 – 3,430 kJ/day or 800 – 820 Calories/day) for 3 months, followed by stepped food re-introduction for 12 weeks. The average reduction in body weight in the intervention group was 12 kg (~12% of initial body weight) at 1 year, and 61% (6 out of 10) achieved remission at this point in time, while in the control group, people lost an average of 4 kg (9 Pounds) and consequently, only 12% achieved remission.

In addition to these two clinical trials, a large observational study in Scotland provides supporting evidence for type 2 diabetes remission (4). It included 162,316 people aged 30+ years. Remission was defined as all HbA1c values <48 mmol/mol 6.5%) in the absence of glucose-lowering therapy for a continuous duration of ≥365 days before the date of the last recorded HbA1c. Most (64%) of the cohort had type 2 diabetes for at least 6 years. Over a 14 year period, 7,710 people (~5%) were in remission of type 2 diabetes.

In summary, remission of type 2 diabetes is possible in some – but not all – people with the condition. Early diagnosis of type 2 diabetes and ability to achieve and maintain significant weight reduction (ideally, 10-15% of initial body weight) are two key factors that should be considered when deciding whether it is an appropriate goal.

Read more:

1. Riddle and colleagues. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes. Diabetes Care. 2021.

2. Lean and colleagues. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018.

3. Taheri and colleagues. Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial. The lancet Diabetes & endocrinology. 2020.

4. Captieux and colleagues. Epidemiology of type 2 diabetes remission in Scotland in 2019: A cross-sectional population-based study. PLoS Med. 2021.

    

Dr Alan Barclay, PhD, is a consultant dietitian and chef with a particular interest in carbohydrates and diabetes. He is author of Reversing Diabetes (Murdoch Books), and co-author of 40 scientific publications, The Good Carbs Cookbook (Murdoch Books), Managing Type 2 Diabetes (Hachette Australia) and The Ultimate Guide to Sugars and Sweeteners (The Experiment Publishing).