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 1. Home
 2. Health Information
 3. For Health Professionals
 4. Diabetes Discoveries & Practice Blog
 5. Achieving Type 2 Diabetes Remission through Weight Loss

Diabetes Discoveries & Practice Blog


ACHIEVING TYPE 2 DIABETES REMISSION THROUGH WEIGHT LOSS

Sept. 30, 2020 4 Comments
 * Obesity and Weight Management

Studies have shown that significant weight loss, through either metabolic (also
known as bariatric) surgery or calorie restriction, may lead to remission in
some people who have type 2 diabetes.

William T. Cefalu, MD, director of the NIDDK’s Division of Diabetes,
Endocrinology, and Metabolic Diseases, discusses type 2 diabetes remission,
including recent research into strategies and mechanisms by which people who
have diabetes can achieve remission.

Q: What is remission of type 2 diabetes? How do health care professionals define
remission and know when a patient has achieved it?

A: People with type 2 diabetes who do not have adequate glycemic control have an
increased risk for diabetes complications. Glycemic control is monitored by
measuring both blood glucose and blood markers assessing antecedent glycemia
such as hemoglobin A1C, which reflects average glucose over the previous months.
We define type 2 diabetes remission as having the condition revert to a
nondiabetic range as assessed with blood glucose levels or blood glucose markers
and staying in that range for at least 6 months when a person isn’t taking any
diabetes medications.

It’s important for both health care professionals and people who have type 2
diabetes to realize that significant weight loss either from lifestyle
intervention (i.e., diet and exercise) or from certain procedures can result in
blood glucose levels decreasing into the nondiabetic range, and that achieving
remission can minimize or prevent future complications.

Q: Why do health care professionals use the term “remission” rather than “cure”
when discussing type 2 diabetes? What happens to a person’s diabetes when he or
she relapses?

A: We don't use the word “cure” when we refer to blood glucose levels reverting
back to levels below the threshold used for diagnosis, as you could argue “cure”
means completely alleviating the condition. For example, an acute condition seen
with infectious diseases such as bronchitis may be considered to be cured with
antibiotics. However, in type 2 diabetes, because blood glucose levels are on a
continuum and are significantly associated with weight, it is observed that when
weight regain occurs, the glucose levels may increase back to the range
associated with diabetes diagnosis. So, the correct term is “remission.”

Type 2 diabetes is a progressive disorder, and, at one time, we didn’t think
that weight loss or other interventions could allow people with type 2 diabetes
to lower their blood glucose levels into the nondiabetic range and to stay there
for an extended period of time without medication. However, we now understand
that people with type 2 diabetes who lose significant weight and improve other
factors related to diabetes can achieve remission.

With sustained weight loss, people may stay in remission for quite some time.
However, if they begin to put on weight, their blood glucose levels can increase
and return to the diabetic range. They may need diabetes medications or even
insulin with weight regain depending on the severity of their type 2 diabetes
and their glucose control.

Q: What strategies can lead to remission of type 2 diabetes?

A: The most important factor in achieving remission is weight loss, and two
techniques—metabolic surgery and lifestyle changes that restrict calories on a
daily basis to achieve weight loss—have been shown to induce remission.

Some studies, dating back many years, have observed that metabolic surgery leads
to high rates of type 2 diabetes remission. Recently, the Diabetes Remission
Clinical Trial (DiRECT) NIH external link, conducted in primary care practices
in the United Kingdom, examined type 2 diabetes remission rates in participants
who lost weight, starting with a very low-calorie diet and sustaining the weight
loss over time. DiRECT found high rates of type 2 diabetes remission among
people who lost a significant amount of weight—more than 10 kg (about 22
pounds)—and sustained the weight loss over 12 to 24 months.

Q: What research is being conducted on remission of type 2 diabetes?

A: Studies have sought to understand the mechanisms of remission. A lot of
current research focuses on not only total fat in the body, but also where the
fat may be located, referred to as “ectopic fat” (e.g., fat in the liver and
pancreas) that may affect normal physiologic function. This research has led to
some very interesting observations about potential mechanisms. Weight loss may
improve pancreas function, with better insulin secretion and type 2 diabetes
remission.

Q: Are some people with type 2 diabetes more likely to achieve remission than
others?

A: Three factors that seem to predict success in achieving remission are
significant weight loss, baseline pancreatic function, and diabetes duration.

Significant and sustained weight loss—for example, in the range of 10 kg (about
22 pounds) as shown in some studies—is the most important factor. Studies in
which participants lost small amounts of weight have shown lower rates of type 2
diabetes remission. However, studies in which participants lost a significant
amount of weight—such as DiRECT or studies of metabolic surgery—have shown
higher remission rates.

Studies of weight loss through restricting calories or metabolic surgery have
found that people with type 2 diabetes who start with greater pancreatic
function at baseline, prior to the intervention, are more likely to undergo
remission. People who have had shorter diabetes duration are also more likely to
undergo remission. Type 2 diabetes is a progressive disease, and, after a long
time with diabetes, pancreatic function may decline over time. Thus,
observations suggest that after having diabetes for a long period of time,
significantly improving pancreatic function and achieving remission may prove to
be more difficult, compared to achieving remission early in the natural history
of the disease.

Q: How and when should health care professionals talk with patients who have
type 2 diabetes about remission? How can health care professionals help patients
achieve remission and sustain it over time?

A: First and foremost, you should emphasize the importance of managing blood
glucose levels to minimize the complications of type 2 diabetes whether the
patient is or is not on medications. Glycemic control is incredibly important in
reducing the risk of complications, and you need to discuss glycemic control and
a goal with the patient. In most cases, this means advising patients to keep
their A1C level at 7 percent or below to prevent eye, kidney, and nerve
complications. While we have very effective medications to lower blood glucose
levels, lifestyle interventions (nutrition and exercise) are a cornerstone of
managing diabetes. A balanced diet that achieves weight loss not only improves
blood glucose levels but also may reduce cardiovascular risk factors.

Patients should also know that obesity contributes to increased blood glucose
levels due to insulin resistance and that the more weight patients put on, that
may mean they need more medication. It is important that they know if they lose
weight and improve their body’s efficiency, they may require less medication.
Let your patients know that if they lose enough weight, particularly during the
early phases of type 2 diabetes, they will significantly lower their blood
glucose, have less risk for diabetes complications, and may be able to achieve
remission.

Overall, with significant weight loss through restricting calories or other
strategies, patients have a high likelihood of achieving remission, particularly
if they have a greater baseline pancreatic function and have had diabetes for a
shorter time.

How do you talk with patients about type 2 diabetes remission? Tell us below in
the comments.


ABOUT THE EXPERT

William T. Cefalu, MD, is director of the Division of Diabetes, Endocrinology,
and Metabolic Diseases at the NIDDK, and has had a 35-year career as a
scientist, a health care expert, and a physician. His clinical and basic science
research has focused on interventions to improve the metabolic state of people
with insulin resistance and type 2 diabetes, and on the cellular mechanisms for
insulin resistance.

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