Defining type 2 diabetes remission: KISS goodbye to confusion?

Abstract

The concept that type 2 diabetes can revert to glycaemic levels below the diabetes threshold without diabetes medications (type 2 diabetes remission) is increasingly appreciated. Metabolic surgery results in a substantial proportion of people having type 2 diabetes remission, although the proportion reduces over time. 1 Sjostrom L Peltonen M Jacobson P et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA. 2014; 311: 2297-2304 Crossref PubMed Scopus (628) Google Scholar Randomised clinical trials incorporating a low energy total diet replacement phase have shown that, with maintained weight loss of at least 10 kg, type 2 diabetes remission is possible in a significant proportion of people. 2 Lean MEJ Leslie WS Barnes AC et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol. 2019; 7: 344-355 Summary Full Text Full Text PDF PubMed Scopus (258) Google Scholar , 3 Taheri S Zaghloul H Chagoury O et al. Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2020; 8: 477-489 Summary Full Text Full Text PDF PubMed Scopus (59) Google Scholar In one trial, 3 Taheri S Zaghloul H Chagoury O et al. Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2020; 8: 477-489 Summary Full Text Full Text PDF PubMed Scopus (59) Google Scholar which included younger patients (aged 18–50 years) with short duration of diabetes, 43 (61%) of 70 participants had type 2 diabetes remission at 12 months (defined as HbA1c <6·5% [48 mmol/mol] for ≥3 months). Substantial weight loss is associated with reduced liver and pancreatic fat, and with restoration of pancreatic morphology and β-cell insulin secretory capacity. 4 Al-Mrabeh A Hollingsworth KG Shaw JAM et al. 2-year remission of type 2 diabetes and pancreas morphology: a post-hoc analysis of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol. 2020; 8: 939-948 Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar , 5 Taylor R Al-Mrabeh A Sattar N Understanding the mechanisms of reversal of type 2 diabetes. Lancet Diabetes Endocrinol. 2019; 7: 726-736 Summary Full Text Full Text PDF PubMed Scopus (80) Google Scholar Carbohydrate restriction can also result in glycaemic levels below the diabetes threshold through a combination of weight loss and reduced carbohydrate intake. 6 Brown A McArdle P Taplin J et al. Dietary strategies for remission of type 2 diabetes: a narrative review. J Hum Nutr Diet. 2021; (published online July 29.)https://doi.org/10.1111/jhn.12938 Crossref Scopus (3) Google Scholar Younger age, early-stage disease, lower number of diabetes medications, and greater weight loss are indicators for type 2 diabetes remission for both surgical and non-surgical interventions. The greatest challenge to sustaining type 2 diabetes remission is maintenance of weight loss and lifestyle change.