Is type 2 diabetes remission through diet sustainable?

Type 2 diabetes need no longer be a lifelong progressive condition as remission is possible through diet, medication or surgery. Focusing on the low-calorie diet approach, there was a lively debate on the motion ‘Is lasting remission of type 2 diabetes feasible in the real-world setting?’ at the 59th Annual Meeting of the EASD. Dr Susan Aldridge reports. 

Professor Roy Taylor of Newcastle University, who led the DiRECT low-calorie diet trials, put up a robust defence of the motion. “At one year, 46% of participants had achieved remission of type 2 diabetes and I would emphasise that this is in the real world because most type 2 diabetes is managed in primary care in the UK,” he said. At two years, remission rates had dropped to 36%. After five years, people were still over 6 kg lighter, which is remarkable in the context of dietary studies and 13% were still in remission. “So remission is feasible in the real world, though it is not necessarily easy or for everyone,” said Professor Taylor.    

So why might you recommend this approach to your patients? Quality of life improves quite early, with people reporting being able to chase their grandchildren or to do other things they hadn’t been able to do for a while. This happens within about two weeks of going on the low-calorie diet and this rapid weight loss is important to motivation. “It is also worth striving for if your patient wants to avoid a whole slew of adverse consequences, for the rate of serious adverse events over five years goes down from 70 to 40 per 100 patient-years,” said Professor Taylor. There is a big difference between those in the intervention and control groups in infections, renal failure was seen only in controls and there were no cancers in the intervention group compared with eight in the control group.

Maintaining remission

We live in an obesogenic environment, so how easy is it to maintain remission? “Inform people that the amount of food they eat will be 25% less once they’ve lost weight,” said Professor Taylor. “The reason is simple – it’s because they are smaller.”

He recommends weekly weighing at home with a written record and regular follow-up. The NHS remission programme, which is now well underway, is provided by a person with basic training, rather than a busy healthcare professional because people do need external agencies to assist them. Weight regain often follows a life event, but this can be dealt with using a relapse plan, which involves reverting to total diet replacement for one or more meals, depending on how much weight has been regained. 

The NHS remission programme aims for a 15 kg weight loss and, at 12 months, the average weight loss for 3,000 participants is already 10 kg. “This is quite remarkable and confirms what we were able to show in our independent psychology studies,” said Professor Taylor. “This method of weight loss depends on those who sign up for it and is not necessarily for everyone.” 

He then turned to look at the trajectory of someone passing through prediabetes, diabetes and remission. With diabetes, their QRISK is 14% and heart age 71. If you then go down to the glucose tolerance range, QRISK reduces to 7% and heart age to 56, and underlying pathophysiology is reversed. “The macrovascular risk associated with prediabetes is lipid and hypertension driven and, after weight loss, lipids are normal,” said Professor Taylor. “So don’t label this prediabetes – it’s post-diabetes. What patients are interested in is freedom from risk and this is a really potent point to make.”

Case studies

To demonstrate his point, Professor Taylor turned to two case studies of remission. The first was a man who, in 2013, had had type 2 diabetes for several years. His weight was 126 kg and HbA1c was 9.2%. He had a Charcot foot and the other foot was expected to be amputated. His sons made him take action and, in 2014, his weight had gone down to 94 kg and HbA1c was 6.2%. The year 2017 saw further improvements with weight at 83 kg and HbA1c at 5.7%. But during the Covid lockdown, he did get his diabetes back. The story has been written up by his sons and daughter-in-law in the book ‘Fixing Dad’.  

The second case history was Carlos who, in 2011, had already had a myocardial infarction, was on insulin and had a non-healing foot ulcer. His fasting blood glucose was 27 mmol/l and his weight 94 kg. He lost weight and his glucose went down but then he changed job and his diabetes returned. He changed job again and his weight went down again. He’s been in remission for nine years and the longest anyone has been in remission with this approach is now 18 years. “So, yes, remission is durable,” Professor Taylor said. “But it depends what you call lasting. Several years is lasting in my book for it will push back complications. It is not for everyone and it is not simple. But is it feasible, as in the wording of the motion? I would suggest it certainly is.”  

Against the motion

Kamlesh Khunti, Professor of Primary Care Diabetes & Vascular Medicine at the University of Leicester and part-time GP, made the case against the motion. “My view is based on the word ‘lasting’ and on the definition of remission,” he said. “It may be possible for a few, but we are talking here of a public health problem. We are looking at remission from two points of view. Roy is a world-class scientist while I am a pragmatic GP.”   

He noted that there are multiple definitions of remission, which suggests a problem, with the latest being HbA1c less than 6.5% three months after cessation of glucose-lowering therapies. “Why 6.5%?” asked Professor Khunti. “If you look at data, you should be going lower, below the diabetes range. The increases in risk starts at HbA1c of 5.5%.” 

Turning to the various weight-loss trials, he noted that people tend to regain weight and fall out of remission, despite support. One example is the Look AHEAD trial, which involved intensive lifestyle intervention in people with type 2 diabetes and obesity or overweight, where remission rates were down to only 4% after four years, despite an average of 10 kg being lost in the first year. 

“Adherence to diet-induced weight loss is difficult because of hormone changes that increase appetite, hunger and preference for energy-dense foods,” he said. “But surgery and GLP-1 receptor agonists target some of these.” To back up his argument, he cited a review of 21 studies, which showed only 5% maintenance of weight loss in the long term. These low numbers are likely to be because it is an extremely demanding task to follow participants for extended periods of time and to maintain sufficient numbers in the programme. 

“One of the worries I have is collateral fattening, which is excess fat deposited as result of body’s attempt to counter a deficit in lean mass through overeating following dieting,” he said. “For instance, in the Minnesota Starvation Experiment – carried out in 1944/45 to investigate the impact of severe food restriction – participants gained more fat mass on refeeding.” 

And there are other options for achieving remission, such as intensive insulin therapy, tirzepatide or semaglutide, but these wouldn’t be proper remission because people are still on medication. There is also the option of metabolic surgery. The Swedish Obese Subjects study shows that 30% are still in remission at 14 years. However, surgery is not appropriate on a large scale and is associated with morbidity and complications, but does offer benefit in terms of reducing the risk of microvascular and macrovascular diabetes complications. “I note that the EASD/ADA consensus on managing type 2 diabetes has a section on metabolic surgery and GLP-1 receptor agonists, but nothing on remission by calorie restriction,” Professor Khunti concluded.

Challenges in clinical practice

Professor Khunti went on to consider the problems of recruitment and retention for lifestyle studies. “Getting people onto these behavioural change programmes is difficult,” he said. For instance, in the NHS Diabetes Prevention Programme, 1.9 million factsheets and 4.6 million brochures were distributed in order to recruit 3,234 participants. “No-one tells you this,” he added. And, in a similar study in Finland, recruitment took five years.  

Meanwhile, there is also remission that people achieve on their own. A study of over two million people in England with type 2 diabetes showed that only 1.7% went on to meet the criteria for remission. “These were mainly people with lower HbA1c who had had diabetes for less than a year,” said Professor Khunti.  

In the view of healthcare professionals, people in remission are not offered the support they need to stay in remission. Instead, they are considered as people who no longer need so much attention. “This is the worrying data that I have – people are being given false reassurance,” warned Professor Khunti. “Those who had remission coded in their notes were less likely to receive their care processes. For example, there was a 24% reduction in foot exams. We may lose these patients and they may then come back with complications.” 

What is remission anyway?

A key point in Professor Khunti’s rejection of the motion is the word ‘remission’. “Remission is wrong,” he said. “It gives false hope to the patient. I think we should call it remission of hyperglycaemia – that is, euglycaemia with or without glucose-lowering therapy.”

A problem with the current definition is that it takes a glucocentric approach and does not include longer-term outcomes. We should be looking for longer-term weight loss maintenance and reduced micro- and macrovascular outcomes. The very low-calorie diet approach does not, as yet, have data on this or on cancer. “People with type 2 diabetes want to live a long and happy life,” concluded Professor Khunti. He does not believe that remission through rapid weight loss is the way to ensure this. 

Rebuttal and voting

Professor Taylor disagreed, from his own evidence, that people do not want to take part in behavioural change programmes. While it is true that surgery is very effective in achieving and maintaining remission, this is meant for a population that is very obese. And we can now bring medications like semaglutide to bear in helping to maintain weight loss in an obesogenic environment. Finally, when it comes to the word ‘remission’, this is used all the time in cancer and people are advised that it does not mean their cancer has gone away. So there is no reason why remission can’t be used in the same way in type 2 diabetes. “Lasting remission of type 2 diabetes in a real-world setting is feasible, although it is not easy,” he concluded.

“To me, the word ‘lasting’ means for the rest of someone’s life,” replied Professor Khunti. “Let’s give patients what they want – a long life with no restrictions.” 

Earlier, only five people in the audience voted that they’d be willing to go on a very low-calorie diet to achieve remission. On reflection, they were clearly won over by Professor Taylor’s argument and voted in favour of the motion by a large majority.

To learn more, enrol on the EASD e-Learning course ‘Lifestyle intervention’.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.