Sustained weight loss, not diet type, key to diabetes remission

ByMichael Monostra

Type 2 diabetes remission with weight loss is possible and most likely for individuals who sustain more weight loss, who are younger and who have had diabetes for a shorter time, according to a speaker.

“We can no longer talk and tell our patients that diabetes is a chronic disease,” Ebaa Al Ozairi, BMSc (Hons), MD, MRCP, CCT, ABPN, FACN, Chief Medical Officer at the Dasman Diabetes Institute in Kuwait, an American Board of Physician Nutrition specialist, and a Fulbright Scholar at Harvard Medical School, said during a presentation at ObesityWeek Interactive. “We have to give them the hope that we know today that diabetes remission is not a myth and is actually a reality. We really need to rethink treatment of type 2 diabetes, so if it is treated early, we can achieve remission.”

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Al Ozairi defined diabetes remission as reaching either euglycemia (HbA1c 5.7%) or prediabetes glycemic level (HbA1c 5.7%-6.4%) with no diabetes medication for at least 1 year.

Approaches to diabetes remission

Different dietary approaches can help individuals with type 2 diabetes achieve remission, according to Al Ozairi. In the Look AHEAD randomized trial, participants with type 2 diabetes and overweight or obesity engaged in an intensive lifestyle intervention focused on weight loss through a combination of healthy eating and increased physical activity. At 1 year, 11% of the intensive lifestyle intervention group achieved complete or partial diabetes remission vs. 2% of a non-intervention control group. At 4 years, 7.3% of the intensive lifestyle intervention cohort had complete or partial remission, while the control group remained at 2%.

Two trials that centered on a low-calorie liquid diet combined with an intensive lifestyle intervention also showed evidence of diabetes remission. In the DiRECT randomized controlled trial in the U.K., 149 participants who had type 2 diabetes for less than 6 years and did not use insulin were randomized to either an intensive weight loss intervention group or a control group. After 12 months, 68% of participants in the intervention group achieved remission compared with 4% of the control group. At 24 months, the prevalence of diabetes remission in the intervention group was 36% compared with 3% for controls.

The DiRECT researchers found that diabetes remission was correlated with the amount of weight lost. Of 36 participants who lost 15 kg or more during the study, 86% achieved diabetes remission. About 57% of the 28 individuals who lost between 10 kg and 15 kg had diabetes remission, 34% of participants who lost 5 kg to 10 kg achieved remission, and remission decreased to 7% in the group who lost 5 kg or less.

Participants in the DIADEM-I randomized control trial, conducted in primary care practices in Qatar, also followed a low-calorie diet and intensive lifestyle intervention. The trial enrolled participants 50 years or younger with early type 2 diabetes, with individuals randomized to the intensive lifestyle intervention or control group. In the intervention group, 61% achieved diabetes remission and 33% reported normoglycemia for at least 3 months, compared with a 12% diabetes remission rate and 4% normoglycemia in the control group.

The Virta Health study combined a ketogenic diet with a continuous care model. Participants ate a low carbohydrate diet and maintained ketosis by monitoring beta-hydroxybutyrate in their blood. Participants had access to continuous care, including home monitoring of weight, blood glucose, beta-hydroxybutyrate and BP and online coaching and group support. Of 218 participants who completed 1 year of the study, 72% reached diabetes remission with no diabetes medications or taking only metformin. Of 194 who completed 2 years, 63% achieved remission. There was a 13.8 kg mean weight loss at 1 year and 10 kg weight loss at 2 years.

Diabetes remission predictors

Al Ozairi said the studies revealed several common factors for diabetes remission, with sustained weight loss and beta-cell function and duration of diabetes all determinants. Individuals with the greatest weight loss have the best chance for remission, while weight gain may lead to diabetes relapse. Additionally, those who had type 2 diabetes for a shorter duration have higher odds for remission than someone with long-term diabetes.

“It’s the increase in the liver fat disposition that will lead to overspill in the blood stream, and then the disposition of the pancreatic fat that will lead to the beta-cell damage,” Al Ozairi said. “The earlier we can reverse it by lowering the liver fat, and thus reducing the pancreatic fat, that will put the beta cell in surviving mode. What’s really important is when you have weight regain, it will cause the regain of the pancreas fat and the return of diabetes. All you need is 0.5 grams of pancreatic fat that will lead to the development of type 2 diabetes.”

When identifying individuals with type 2 diabetes who might achieve remission, Al Ozairi said providers should focus on younger individuals who recently developed type 2 diabetes and who are not on insulin and have not yet lost beta-cell reserve.