Question: Multiple trials have shown short-term reversal of diabetes through diet and/or exercise. Are these reversals durable?
Takeaway: The results of the DiRECT trial, and others like it, indicate durable diabetes reversal without medication or surgery is possible. The diabetes community is beginning to shift away from viewing the condition as chronic and progressive and toward understanding it as treatable.
This short, March 2019 commentary, published alongside the two-year results of the DiRECT trial (1), argues there is now sufficient evidence to target diabetes treatment (i.e., reversal), not just symptom management, within the general population.
The DiRECT trial placed 149 diabetic adults on a “total replacement” diet for 3-5 months until specific weight loss targets were achieved (2). All food was replaced with 825-853 calories per day in meal replacement shakes, supplements, and other artificial food sources — all designed to minimize caloric intake while preventing nutrient deficiencies.
All subjects discontinued medication at the beginning of the intervention (3). At one year, 46% of subjects had achieved diabetes remission, defined as an HbA1c < 6.0% (4). At two years, 36% of subjects maintained remission. Only 3% and 4% of control subjects achieved remission at one and two years, respectively.
The authors note the likelihood of diabetes remission increased with greater weight loss and argue weight loss is the driver of remission. This conclusion is not necessarily true, however, as a third factor (e.g., improvements in organ-specific or whole-body insulin resistance) may directly cause both these visible, clinical improvements.
The DiRECT trial, this commentary notes, would be difficult to scale. Patients were offered 30 minutes each month with a dietitian or clinician for the entire two-year trial. The average U.K. resident sees a primary care nurse for 12.8 minutes each year (5); thus, the DiRECT approach would require a substantial increase in available nurse and dietitian time. One in 12 adults worldwide is currently diabetic (6). Reaching this enormous population will require interventions that are effective, simple, and straightforward (i.e., they would need to support consistent adherence with minimal education and oversight), or that can be delivered and overseen by individuals outside the traditional medical infrastructure.
This commentary indicates there is a specific opportunity for community-based diet and lifestyle interventions with demonstrated effectiveness to reverse diabetes at scale. As the diabetes community continues to recognize diabetes is in fact a reversible disease and not necessarily a chronic, progressive condition, these interventions may have an opportunity to play an increasingly prominent role in diabetes prevention and treatment.
Notes
- Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial
- Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label,cluster-randomized trial
- This is common in trials of highly restrictive diets, as maintaining medication alongside severe calorie or carbohydrate restriction can lead to hypoglycemia.
- How do we define cure of diabetes?
- Clinical workload in UK Primary care: A retrospective analysis of 100 million consultations in England, 2007 – 2014
- World Health Organization: Global Report on Diabetes
Type 2 Diabetes: Treating Not Managing