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What clinical trials tell us about diabetes remission may not hold up in real-world settings, a new study argues. Image credit: Juan Moyano/Stocksy.
  • Type 2 diabetes is linked to obesity, and it can go into remission in people who lose weight.
  • A recent study of over 35,000 people with type 2 diabetes in Hong Kong has shown that while weight loss does increase the chance of remission, this is hard to achieve in real-world settings, and also to sustain.
  • Just 6.1% of people in the cohort saw their type 2 diabetes in remission at the 8-year landmark.

The number of people with type 2 diabetes rose nearly fourfold between 1980 and 2014, according to the World Health Organization (WHO).

Type 2 diabetes has many risk factors, including some genetic and environmental factors, but increased body weight and lack of exercise are both linked to the condition.

Diabetes is characterized by a chronic rise in glucose (blood sugar), due to insulin resistance in cells. Insulin is a hormone that allows the uptake of glucose by cells in the body, where it is used an as energy source.

Insulin is produced in response to increased glucose levels in order to facilitate this. However, some peoples’ cells become less responsive to insulin, meaning that their glucose levels rise.

Obesity can increase the risk of insulin resistance occurring, and can in fact trigger it. This may occur as some of the hormones and immune cells and molecules that play a role in insulin resistance are released by fat cells.

Obesity can also make it difficult to treat diabetes as some of the treatments that people with type 2 diabetes receive for their symptoms can cause weight gain, which can in turn worsen glucose control.

Weight loss can lead to remission of type 2 diabetes in some patients. This weight loss can be achieved via lifestyle changes or through weight loss surgery, as a study published in JAMA Surgery in 2020 shows.

A trial carried out in the United Kingdom, published in The Lancet in 2018, showed that 50% of people with type 2 diabetes who received support to lose weight through dietary changes were in remission a year later.

These studies involved significant intervention, whether they involved bariatric surgery for weight loss or lifestyle intervention, and were all based on clinical trials.

While they proved weight loss can be an effective way to achieve remission of type 2 diabetes, there is a lack of real-world data available about the likelihood, and sustainability of remission.

To remedy this, a group of researchers from the Chinese University of Hong Kong conducted an analysis of data for patients enrolled in the Risk Assessment and Management Programme for Diabetes Mellitus (RAMP-DM), which provides regular assessment of people with diabetes living in Hong Kong.

Their paper appears in PLOS Medicine.

The researchers looked at the data for 37,326 people with type 2 diabetes who were enrolled on the programme within a year of diagnosis between 2000–2017 and followed up until 2019. The researchers looked at weight loss, whether or not weight loss had been sustained, and blood glucose measurements.

Defining remission from diabetes as two consecutive measurements of a blood marker for high glucose, HbA1C, of under 6.5% at least 6 months apart, they looked at weight loss and remission over a period of an average 7.9 years. People with a body mass index (BMI) of under 15 or over 50 were excluded from the study.

The research team found that just 6.1% of people enrolled in the study remained in remission from type 2 diabetes at the 8-year landmark.

People who had lost 10% or more of total body weight in the year following diagnosis were over three times as likely to be in remission at the end of their follow-up compared to people who gained weight.

People who had lost between 5–9.9% of their body weight were over twice as likely as being in remission at the end of the follow-up compared to people who had gained weight.

Those who had lost up to 4.9% of their body weight had only a marginally better chance of being in remission than people who gained weight.

Thus, while weight loss did contribute to the chance that an individual would see their type 2 diabetes go into remission, this was lower for people who had lost less weight.

The risk of redeveloping type 2 diabetes after remission was 48% lower for people who had lost over 10% of their body weight compared to people who had gained weight, and 22% and 10% lower for people who had lost 5–9.99% and less than 4.9% of their body weight, respectively.

According to the authors, the study showed that while early weight loss did increase the chance of remission, achieving this in a real-world setting clearly came with challenges, as did maintaining remission.

Dan Gallagher, a registered dietician at Aegle Nutrition, who was not involved in the study, was not surprised that the results of clinical trials have been hard to replicate in real-world settings.

He told Medical News Today:

“Many studies will provide a dietary intervention specifically for the study without any consideration for the sustainability of said diet. If the diet isn’t easy to follow and doesn’t completely change the potentially harmful (in reference to one’s health) behaviors that caused the diabetes in the first place, then of course the patients aren’t going to keep the weight off.”

“Managing type 2 diabetes is completely attainable through diet changes, but you have to continue these changes in perpetuity. It’s not a 6-month change that will fix your blood sugar forever,” he cautioned.

“It’s a complete lifestyle change that you make and stick with or the diabetes will return. This is the fact that many people either completely miss or don’t understand when trying to change their diabetic status with diet,” added Gallagher.

Dr. Mir Ali, bariatric surgeon and medical director of MemorialCare Surgical Weight Loss Center at Orange Coast Medical Center in Fountain Valley, CA, who was also not involved in the research, advised MNT that “[b]ariatric surgery, for those who meet the criteria, has the highest success rate for weight loss and long-term remission of many medical conditions.”