Type 2 diabetes is generally perceived as progressive and incurable. A new study led by Prof. Roy Taylor of the Newcastle University, UK, now indicated that it is possible to reverse the disease just by losing weight. Almost half of participants who followed a three-phased weight management program and attained an average of 10kg weight loss achieved remission and were off antidiabetic drugs at 12 months.1 These exciting results were presented at the International Diabetes Federation Congress 20172 and simultaneously published in the Lancet.1
It is well-known that weight gain, in particular the accumulation of excess fat within the liver and pancreas, is the dominant casual factor behind type 2 diabetes.1 Yet, the use of antidiabetic medications in attaining glycemic control remains to be the primary focus in current guidelines.1 Diet and lifestyle modifications are merely mentioned as part of efforts to better outcomes, and the potential of reverting disease state via this route is rarely discussed.3 DiRECT (Diabetes Remission Clinical Trial) provided the first piece of evidence from randomized trial that weight loss alone is sufficient to put short-duration diabetes into remission, and that the amount of weight loss is a pragmatic goal which can be achieved by many individuals under real-life, non-specialist community setting.1
In the study, 298 individuals aged 20 to 65 years who had been diagnosed with type 2 diabetes within the past 6 years, had a body mass index of 27 to 45kg/m2, and were not receiving insulin, were randomized to receive either intensive weight management (n=149) or usual care (n=149).1
The weight management program, delivered by practice dietitians or trained nurses, comprised of 3 phases: total diet replacement with a low-energy formula diet (≈850 kcal/day) for 3 months, followed by 2 to 8 weeks of structured food reintroduction and monthly visits for weight-loss maintenance. Antidiabetic and antihypertensive medicines were suspended in the intervention group at the onset of the study.1
The co-primary outcomes were weight loss of 15kg or more, and remission of diabetes, defined as glycated hemoglobin (HbA1c) of less than 6.5% at 12 months.1
After a year, just less than a quarter of participants in the intervention group achieved weight loss of ≥15kg (24% vs. 0% in the control group; p<0.0001), and almost half had remission of diabetes, off antidiabetic drugs (46% vs. 4% in the control group; OR=19.7; 95% CI: 7.8–49.8; p<0.0001).1 On average, participants in the intervention group shed 10kg of bodyweight compared to 1kg in the control group.1
Importantly, remission was found to be closely related to the degree of weight loss: 86% of those who lost ≥15kg, 57% of those who lost 10 to 15kg, along with 34% of those who lost 5 to 10kg, and only 7% of those who lost <5kg.1
“Our findings suggest that the very large weight losses targeted by bariatric surgery are not essential to reverse the underlying processes which cause type 2 diabetes. The weight loss goals provided by this program are achievable for many people. The big challenge is long-term avoidance of weight re-gain. Follow-up of DiRECT will continue for 4 years and reveal whether weight loss and remission are achievable in the long-term,” said Prof. Taylor.4
Meanwhile, he stressed that the study only addressed patients diagnosed relatively recently, and remission may be less likely to those with longer durations of disease. 1,5 “Initially, the [insulin-producing] cells slowly shut down, entering a so-called resting state. Those are the cells that weight loss can re-activate… as the disease continues, the cells start to die off and cannot be revived,“ he explained.5
In light of this, Prof. Taylor thinks it is critical to discuss with patients as soon as possible — when people are diagnosed with diabetes — the possibility of using diet and weight loss to treat their disease.5 “From the very clear data we produced in this trial, yes, this is a watershed moment for diabetes,” he said. “We can offer people hope from the start.” 5
1. Lean ME, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomized trial. Lancet. 2018; 391(10120): 541-551.
2. Lean M. The DiRECT trial: finding a practical management solution for primary care: the primary outcome results of DiRECT. International Diabetes Federation Congress 2017; Abu Dhabi, UAE. December 4-8, 2017.Abstract #193.
3. Standards of Medical Care in Diabetes-2017. American Diabetes Association 2017 (Accessed February 25, 2018, at http://care.diabetesjournals.org/content/diacare/suppl/2016/12/15/40.Supplement_1.DC1/DC_40_S1_final.pdf).
4. Weight management program can put type 2 diabetes into remission. Science Daily 2017. (Accessed February 25 2018, at https://www.sciencedaily.com/releases/2017/12/171205091651.htm).
5. Weight loss really can reverse diabetes, new study finds. Time 2017 (Accessed February 25, 2018, at http://time.com/5048653/weight-loss-diabetes-diet/?iid=sr-link1).