Diabetes in Remission
What are the evidence based interventions available to achieve and maintain remission of type 2 diabetes?
- (1) Bariatric surgery
- different remission rates have been reported depending on the procedure used, criteria for defining remission among other factors (1)
- an international consensus statement endorsed by 45 international diabetes associations including Diabetes UK and the ADA reported that Type 2 diabetes remission occurs in about 30–63% of people following surgery (2,3)
- median diabetes-free years for people with Type 2 diabetes undergoing surgery is about eight years, depending on the procedure and available data suggest an erosion of remission over time
- available data suggest an erosion of diabetes remission over time: 35–50% or more of patients who initially achieve remission of diabetes eventually experience recurrence.
- the median disease-free period among such individuals with Roux-en-Y gastric bypass (RYGB) is 8.3 years
- with or without diabetes relapse, the large majority of patients who undergo surgery maintain substantial improvement of glycemic control from baseline for at least 5 to 15 years
- a cohort of 217 patients with T2DM who underwent bariatric surgery between 2004 and 2007 and had at least 5-year follow-up were assessed. Complete remission was defined as glycated hemoglobin (A1C) less than 6% (42 mmol/l) and fasting blood glucose (FBG) less than 100 mg/dL (5.5 mmol/l) off diabetic medications (4)
- demonstrated that 24% of all patients and 31% of gastric bypass patients achieved long-term complete remission with an A1C less than 6.0% and that 27% of the gastric bypass patients sustained that level of glycemic control off medication continuously for more than 5 years
- as seen in other studies this study demonstrated that (Roux en Y gastric bypass) RYGB had a higher long-term rate of diabetes remission than restrictive procedures
- (2) The introduction of short term major caloric reduction, with total diet replacement and a stepped food re-introduction - clear that significant weight loss is a pre-requisite to achieving remission of type 2 diabetes, but shorter duration of diabetes is also an important factor associated with successful recovery of residual beta cell function (1)
- remission through lifestyle interventions appears more likely in people newly diagnosed with Type 2 diabetes and those with lower baseline HbA1 c (3,5)
- Very Low Calorie Diet or VLCD (800 calories/day)
- evidence on how to achieve remission is based on the DiRECT study which was published in 2017
- in this study, 46% the people who went on an 800 calorie Very Low Calorie Diet achieved remission at one year and 36% remained in remission at 2 years
- nearly 86% of people who lost more than 15kg were in remission at one year -- weight loss was the greatest predictor of "remission" from diabetes in this study
- remission varied with weight loss in the whole study population, with achievement in none of 76 participants who gained weight, six (7%) of 89 participants who maintained 0-5 kg weight loss, 19 (34%) of 56 participants with 5-10 kg loss, 16 (57%) of 28 participants with 10-15 kg loss, and 31 (86%) of 36 participants who lost 15 kg or more
Why is this significant to achieve (1):
- development or progression of microvascular complications is unlikely below the threshold for diagnosing diabetes, and indeed this was a major part of the original ADA and WHO reasoning to adopt this diagnostic criterion
- macrovascular risk is sharply decreased by weight loss, as indicated by 10 year cardiovascular risk (QRISK) decreasing from 23% to 7% after 6 months steady weight following diet-induced remission of type 2 diabetes
- this remarkable health gain is explained by the improvement in lipid status as well as mean blood pressure and weight
- both microvascular and macrovascular risk has been shown to decrease sharply after bariatric surgery induced remission, and microvascular complications regress after pancreas transplantation
Definition of diabetes in remission:
- Type 2 Diabetes Remission can be confirmed if a person has achieved all of the following criteria (1):
i) Weight loss - ii) Fasting plasma glucose or HbA1c below the WHO diagnostic threshold (<7mmol/l or <48mmol/mol) on two occasions separated by at least 6 months
- iii) The attainment of these glycaemic parameters following complete cessation of glucose-lowering therapies
However, remission is a fluid state and relapse can occur in various circumstances, especially if weight is regained. Patients need to continue to have regular monitoring at least annually.
Partial Remission of Type 2 Diabetes:
ADA has previously proposed (5) the terms:
- Partial remission: i.e. return of glycaemia below diagnostic threshold for type 2 diabetes for at least one year
- Complete remission, where glucose tolerance is normal at least for one year
- in both scenarios, these thresholds must be achieved without need for pharmacological treatments
ABCD and PCDS strongly recommend that “diabetes resolved” clinical codes should not be employed in clinical practice but that “diabetes in remission” codes should preferentially be adopted.
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