IS diabetes remission with lifestyle change a realistic long term goal?

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Guidelines currently recommend lifestyle change as a strategy to achieve diabetes remission. Remission gives people freedom from disease, and by definition, freedom from treatment, including medication. Recent data also suggest that diabetes remission is associated with a reduction in diabetes-related health complications. But is diabetes remission with lifestyle change alone a realistic long term goal?

A recent analysis from the LOOK AHEAD study was conducted, which was a study of intensive lifestyle intervention versus standard diabetes care in people with type 2 diabetes. The intensive lifestyle group received a program of reduced calorie intake and increased exercise, while the standard care group received usual diabetes care and lifestyle support. Data were examined on almost 4,500 people with type 2 diabetes and overweight or obesity who participated in the trial. They looked at whether diabetes remission was associated with improvement in kidney or cardiovascular disease risk. They found that people who achieved diabetes remission at any time point during the 12 year follow up had a 33% lower risk of kidney disease and a 40% lower risk of cardiovascular disease, compared to those who did not achieve remission. For those who had achieved at least 4 years of diabetes remission, the risk reduction was even greater (55% and 49% respectively).

That all sounds great – but – diabetes remission was achieved at any time point during the study by only 12.7% of participants. In the intensive lifestyle group, only 11% of people in the intervention group achieved remission at one year, and this number had decreased to 4% by the 8 year mark.

In real world studies, the data on sustained remission rates of diabetes are even worse. In the UK national diabetes audit, remission was only 1% in the overall population with diabetes. In a recent observational study in Hong Kong, which included over 37,000 people with newly diagnosed type 2 diabetes enrolled in a risk assessment and management program, people who experienced diabetes remission had higher survival rates than those who did not. However, only 6.1% of people achieved diabetes remission during a median follow up of 7.9 years. During a median follow up of 3.1 years, over two thirds of people who had achieved diabetes remission had relapsed.

There are studies that show higher diabetes remission rates, at least initially. In the DIADEM-1 study, diabetes remission was 61% at 1 year. In the DiRECT study, remission of diabetes was 46% at 1 year , and 36% at 2 years. However, at 5 years, the data presented (not yet published) show that only 7% of people in the original treatment arm were still in remission at 5 years. It’s important to note that both DIADEM-1 and DiRECT employed total diet replacement with calorie intake of 800-850 calories per day; the higher DM remission rates in these studies was likely related to this more dramatic lifestyle intervention.

For all of these studies, a theme that is consistent is that the likelihood of diabetes remission, and sustained remission, is greater with greater weight loss. At least 10% weight loss seems to give the best chance of diabetes remission.

Taking all these data into consideration, I find myself coming back to the futility of recommending lifestyle alone to people with type 2 diabetes, in hopes that they will enjoy sustained diabetes remission. Ok, if we employ an intensive treatment strategy with meal replacements and lots of support, a substantial proportion of people will go into remission, for a while. And yes, even a shorter duration of diabetes remission appears to have health benefits, which is great. But given that intensive lifestyle intervention is difficult to reproduce in the real world, given that 10% weight loss is extremely difficult to achieve and sustain with lifestyle changes, and given that remission (if it happens) is unlikely to be sustained, doesn’t it make sense to employ a treatment approach that has a better likelihood of giving more sustained success? Not to mention that most people who battle elevated weight have done so for years and have usually already tried managing with lifestyle many times, before going on to develop diabetes. Sending that person home from the clinic to ‘try again’ with lifestyle alone may also be setting that person up for a sense of failure if they do not achieve enough weight loss to get to diabetes remission.

BOTTOM LINE: Diabetes remission is good for health, even if it’s sustained only for a short term. However, few are able to achieve diabetes remission with lifestyle alone in the real world or usual clinical practice, and even fewer are able to sustain it for the longer term. Read more on other strategies for diabetes control or remission strategies here.

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