Diabetes remission with lifestyle intervention - have we learned anything?

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In a continued quest to employ dietary strategies to help people with type 2 diabetes achieve remission (ie make blood sugars go back to normal), the English National Health Services has established a real world 1-year behavioral support program, built on evidence from randomized controlled trials including the DiRECT trial (blogged previously several times, start here). They have recently reported remission rates of type 2 diabetes in their program.

To help participants achieve diabetes remission by losing weight, the program includes a 3-month diet replacement program, food reintroduction, and weight maintenance support, with a minimum of 20 sessions over a year.

Of the 1740 people who had the opportunity to undertake the entire 1-year program, only 960 (55%) completed the program (defined as having a weight recorded at 1 year). They report diabetes remission in 190 people out of 710 (27%) who had two A1c measurements recorded – but this is only 10.9% of the 1740 people they started with. The average weight loss was 8.3%.

While the authors conclude that remission of type 2 diabetes is possible in the real world, they acknowledge that the rate of remission achieved is lower than what was seen in the 1-year data from the randomized controlled trials.

I would take it a step further to say that these real-world data show that for most people, it is difficult and not pragmatic to use lifestyle changes alone to achieve diabetes remission. Only half of people completed the program, likely in large part because trying to lose weight with lifestyle alone goes against our natural human biology which vigorously defends our weight. This can be discouraging, leading to stopping the program. Remember (in the words of my wonderful friend and colleague, obesity psychologist Dr Michael Vallis): People don’t fail diets – diets fail people.

Further to that, diabetes and weight management both require long term interventions. The DiRECT trial 5 year results were poor, showing that while 46% were in diabetes remission at 1 year, only 7% of people in the initial trial were in diabetes remission at the 5 year mark. So even for those who do have success at a year, this is very unlikely to be sustained over the longer term.

I also question the ‘real world’ nature of having a 1-year program with 20 sessions over the course of the year. Many health care systems and clinics cannot support this.

BOTTOM LINE: I come back once again to the futility of recommending lifestyle alone for most people with type 2 diabetes. I have continued concerns about recommending lifestyle for diabetes remission in guidelines, as the interventions recommended are not feasible in most real-life scenarios, are effective for few, set people up for a sense of failure, and are not successful strategies in the long term.

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