Practice point: The concept of diabetes remission
Diabetes ‘remission’ is often stated as one of the measured outcomes of clinical trials of weight loss interventions, usually defined as a reduction or cessation of the use of glucose-lowering agents by participants for a minimum of three months.2
However, the period that normalisation of glycaemia can be sustained for varies in the long term, according to study length, intervention methods and time to follow-up.5–9 Periods beyond 12 months report lowered efficacy in maintaining remission with interventions across different populations.
Remission of type 2 diabetes is often linked to sustained weight loss for people who have been overweight or obese, but requires significant weight changes. People have a higher chance of achieving remission if they lose around 10–15% of their body weight. This may be achieved through multiple and complementary approaches, such as intensive dietary change (eg very-low-energy diet) and other healthy behaviour modification, pharmacotherapy or bariatric surgery.2
Close consultation with their diabetes healthcare team is required to support people with type 2 diabetes who want to attempt diabetes remission because intensive dietary and weight changes need careful management, monitoring and support. Less than half of all people with type 2 diabetes who attempt remission through intensive dietary changes will achieve it at one year, and only one-third will sustain it over two years.2
Evidence supporting practice
- In the Look AHEAD study, an intensive lifestyle intervention resulted in remission in 11.5% and 7.3% of individuals at one and four years, compared with 2% at both time points in the control group.10
- The UK DiRECT study, which randomised people with type 2 diabetes into a weight management program, including a low-calorie meal-replacement diet followed by stepped food reintroduction and supportive follow-up, reported that 46% of participants were in remission after one year and 36% after two years.6 A one-year remission rate of 86% was reported in participants who lost 15 kg or more.6
- The DiRECT-AUS study in Australia used a 13-week low-energy total diet replacement with structured introduction of foods and demonstrated remission in 56% of 155 participants, with an average weight loss of 8.1% at 1 year.11
- The DIADEM-1 study from Qatar, which replicated the DiRECT approach in people with type 2 diabetes from the Middle East and North Africa, found that 61% of participants were in remission after one year.12
- Therapeutic carbohydrate restriction diets have medium to low level evidence for diabetes remission in people who can adhere to low- or very-low-carbohydrate diet approaches for at least six months.7,13–15 Longer-term studies are still required to support the persistence of remission,
- Metabolic surgery16 is indicated for people with type 2 diabetes and a BMI ≥35 kg/m2. The optimal procedure is an individually negotiated process involving the person and their management team. A review of diabetes remission rates after bariatric surgery reported remission in over 75% of people 2 years after Roux-en-Y gastric bypass that persisted in 30% of people at five years and in 25% of people at 10 years.17
Healthcare professionals should provide consistent, evidence-based information to a person with type 2 diabetes about the potential for remission as a goal of treatment, at the time of diagnosis and in the first few years following diagnosis. Encourage active participation in available services.18 Type 2 diabetes remission may not be realistic for everyone. Nor is it desirable for some people to stop taking certain glucose-lowering medications because they have benefits beyond the management of blood glucose levels, such as cardiovascular and kidney disease risk reductions (sodium–glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonist classes).2