The ability for diabetes to reverse itself into remission is a fairly novel concept that recently received considerable backing by clinical research.
Diabetes remission
Diabetes UK (2023), together with the American Diabetes Association and the European Association for the Study of Diabetes, defines remission as HbA1c levels remaining below 48 mmol/mol or 6.5% for at least 3 months, while free from medications used to treat diabetes. Remission is more appropriate than the term reversal as there is always a chance levels may rise.
For remission to occur, weight loss is key. According to Diabetes UK (2023), losing 15 kg promptly but safely following a diabetes diagnosis leads to the strong possibility for remission. However, the charity raises the point that insulin or sulphonylurea should be stopped prior to weight loss. Further, it is advised that people who are of healthy weight, have an eating disorder, are under 18 years old, pregnant or breastfeeding should avoid this approach as it could cause them harm. However, the majority of people with newly diagnosed diabetes usually have problems with their weight and this approach may be effective for a large number of people living with the disease.
The research
Unwin et al (2023) conducted a longitudinal study across an 8-year period. This general practice service evaluation of a lower carbohydrate diet with weight loss in turn helped to ascertain predictors of diabetes remission. They published the results of their study in the BMJ Nutrition (Unwin et al, 2023). The authors note that sustained remission of type-2 diabetes in particular is now well established. However, it is not yet routinely practised, despite its recognition in blood test results.
Methods
The team used Norwood surgery to examine patients eating a low-carbohydrate diet or following a low carb programme that hoped to achieve diabetes remission for patients following the diet since 2013. The scheme involved routinely offering advice on how to follow the programme between 2013 and 2021. The practice was home to 9800 patients and conventional one-to-one GP appointments were used to implement the advice, alongside group consultations and personal phone calls, as necessary. Participants were computer-coded for ongoing audits so that baseline and follow-up parameters could be compared.
A total of 186 patients chose the low-carbohydrate approach, 39% of the type-2 diabetes registered patients.
Health outcomes
Following an average of 33 months, the average weight of the patients on the low carb diet fell from 97 kg to 86 kg, amounting to an average weight loss of 11 kg. The average HbA1c level fell from 63 to 46 mmol/mol. In less than one year, 77% of type-2 diabetic patients achieved remission (Unwin et al, 2023). However, this fell to 20% for a duration greater than 5 years. In total, 51% achieved remission by the end of the study. Unwin et al (2023) reported that the mean low-density lipoprotein cholesterol decreased by 0.5 mmol/l, mean triglyceride by 0.9 mmol/l and mean systolic blood pressure by 12 mmHg.
Cost savings
The researchers reported substantial prescribing savings, with accounts showing that the average Norwood surgery spending for diabetic drugs was £4.94 per patient per year, compared with £11.30 for local practices. By the end of January 2022, Norwood surgery spent £68 353 less per year than the area average. These findings indicate that this may be a valid method to achieve better health for those living with the condition, while making significant financial savings.
Conclusions
Overall, the researchers agreed that a low-carbohydrate-diet achieved major weight loss with substantial health and financial benefits and that and this approach was most impactful for those who had been diagnosed with type-2 diabetes less than 1 year ago.
This is an important window of opportunity for achieving drug-free remission of diabetes, thus indicating new diagnosis requires very prompt action to achieve remission (Unwin et al, 2023). The approach can also give hope to those with poorly controlled type-two diabetes who may not achieve remission, as this group showed greatest improvements in diabetic control, as represented by their HbA1c results.
Weight loss
Unwin et al (2023) discussed the weight-loss element of their study, stating that the low-carbohydrate approach had sometimes shown little benefit in other research where weight did not fall so significantly. This indicates that the low-carbohydrate approach is only beneficial for remission if significant weight loss is achieved with it. The authors noted that the approach was effective as it was given by a trusted health professional, who was frank with their communication on the matter, with consistent long-term management to sustain remission being achieved by the primary care team.
Collaborative support
A collaborative approach between professionals is essential. Simply giving advice and recipes will get a patient to change, but motivation to do so may come frommay come from interactions with trusted health professionals over time. These professionals provide knowledge, but also support, which is essential when facing big changes to daily life.
Emotional eating
There can be an emotional aspect to eating that contributes to many cases of being overweight. This is also important to address to sustain weight loss and motivate positive change. The authors note that food can be an addiction, requiring long-term support to manage.
Psychology of eating
The team found that addressing the psychological aspect of eating could help patients to better understand their relationship with food to better understand their relationship with food, helping them notice their thinking and behaviour and to start to change it. Achieving remission becomes a lifestyle, as one patient reported (Unwin et al, 2023). Part of this lifestyle involved pre-planning for holiday periods that are inevitably filled with by adverts for food and meals out or dinners at home with family and friends, often with high-sugar desserts, and many of carbohydrates. As with recovery from any addiction, pre-planning is essential.
Low-carbohydrate diet
The team noted noted that their approach resulted in a remission rate of type 2 diabetes that has improved every year since 2017. A low-carbohydrate diet may both increase energy expenditure and reduce appetite, both of which can increase ease of weight loss. The team reviewed multiple studies examining the pathophysiology of mechanisms of remission in relation to weight loss, and found that the physiological changes that underlie remission show considerable liver fat reduction is associated with weight loss.
The role of the liver
Decreasing liver fat can reverse the liver insulin resistance that causes fasting hyperglycaemia and can also result in a sharp reduction in exported triglyceride from the liver to all ectopic sites, including the pancreas. The decrease in pancreatic fat supply allows relief of the metabolic stress that causes beta cell dysfunction (Unwin et al, 2023). However, the authors highlight that weight loss by any method is likely to induce remission.
Summary
Overall, this research provides insight into diabetes remission and its link to weight loss for those living with type two diabetes, and encourages those who are overweight to work with their healthcare provider to promote remission of their diabetes. Further studies would be required to confirm the generalisability of these results and to examine other diet methods, which may have the greatest efficacy. The study also describes the potential for considerable financial savings for the NHS while helping to transform lives—aims that are desperately needed in the current climate of the NHS.