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Primary care weight-management intervention leads to sustained type 2 diabetes remission
Adults with type 2 diabetes and obesity assigned to a structured weight-management program in a primary care setting were more likely to achieve sustained disease remission at 2 years compared with adults assigned to usual care, according to findings published in The Lancet Diabetes & Endocrinology.
“Every person diagnosed with type 2 diabetes should be informed that their condition is likely to be entirely reversible if they lose 15% body weight,” Roy Taylor, MD, FRCP, professor of medicine and metabolism at Newcastle University in the United Kingdom and honorary consultant physician at Newcastle upon Tyne Hospitals NHS Trust, told Endocrine Today. “Using an effective method of achieving — and then maintaining — weight loss, every person with established type 2 diabetes can potentially escape from the clutches of the disease; however, the chance of achieving this depends upon duration since diagnosis. In the first 6 years, nine of 10 people who lose 15 kg in body weight became free of diabetes. In the randomized controlled trial, 70% of those who achieved remission at 1 year were also in remission at year 2. Those who put on weight were not.”
Taylor and colleagues analyzed data collected between July 2014 and August 2016 from 298 adults with type 2 diabetes for less than 6 years who were not prescribed insulin therapy. Participants were assigned to a structured weight-management program (n = 149) or to usual care (n = 149) as part of the Diabetes Remission Clinical Trial (DiRECT), an open-label, cluster-randomized controlled trial conducted at 49 primary care practices in Scotland and the Tynesdale region of England.
The weight-management intervention included the withdrawal of any antidiabetes or antihypertensive therapies, total diet replacement (825-853 kcal per day formula diet for 12 to 20 weeks), stepped food reintroduction for 2 to 8 weeks and then structured support for weight-loss maintenance. The intervention was delivered within the primary care setting by a trained dietitian or nurse. Control participants continued with usual care and no changes to diet, medications or exercise advice. Coprimary outcomes were weight loss of at least 15 kg and remission of diabetes, defined as an HbA1c of less than 6.5%, at 24 months.
At 24 months, 17 intervention participants (11%) and three control participants (2%) sustained weight loss of at least 15 kg (adjusted OR = 7.49; 95% CI, 2.05-27.32), and 53 intervention participants (36%) and five control participants (3%) had diabetes remission (aOR = 25.82; 95% CI, 8.25-80.84).
“Type 2 diabetes is reversible in up to one-third of people for at least 2 years after an initial low-calorie diet,” researcher Naveed Sattar, MD, professor of metabolic medicine at the BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, told Endocrine Today. “The key to sustained remission is to keep the majority of the weight off after the initial 3- to 5-month rapid weight loss. Such weight loss was accompanied by better lipid levels, improved well-being and good blood pressure control, all of which bode well for long-term cardiovascular risk reduction.”
In a post hoc analysis of 45 participants who maintained at least 10 kg weight loss, 29 (64%) achieved diabetes remission.
“It is critically important to understand that this is not merely ‘good control of diabetes,’” Taylor said. “The substantial weight loss achieves normalization of the grossly elevated liver fat levels typical of type 2 diabetes, and this allows the high intrapancreatic fat pool to decrease, in turn permitting the beta cells to re-differentiate.”
As a result of the normalization of fat delivery from the liver to the rest of the body, Taylor said, serious adverse events were lower in the intervention group in the second year vs. controls, including a decrease in major vascular events.
“Notably, there were five weight-related cancers in the control group, yet none in the intervention group,” Taylor said.
Sattar said more work is needed to better understand how to help people better avoid weight regain after the initial weight-loss phase is finished and participants return to normal diets.
“The DiRECT trial methods were good at preventing weight regain, but we can and must find ways to better help people,” Sattar said. “This area deserves urgent research.” – by Regina Schaffer
For more information:
Naveed Sattar, MD, can be reached at the BHF Glasgow Cardiovascular Research Centre, University of Glasgow, University Avenue, Glasgow, G12 8QQ, Scotland; email: naveed.sattar@glasgow.ac.uk.
Roy Taylor, MD, FRCP, can be reached at the Newcastle Magnetic Resonance Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE4 5PL, United Kingdom; email: roy.taylor@newcastle.ac.uk.
Disclosures: Sattar reports he has served as a consultant for Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Janssen, Novo Nordisk and Sanofi. Taylor reports he has received educational lecture fees from Eli Lilly and Novartis and advisory board fees from Wilmington Healthcare. Please see the study for the other authors’ relevant financial disclosures.