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Intensive weight loss can ‘reverse’ type 2 diabetes

Weight loss should be first aim of treatment – but prevention still primary goal overall

Louise Prime

Tuesday, 05 December 2017

More than a quarter of people with type 2 diabetes of up to six years’ duration are interested in using a practical weight management programme delivered by existing staff in primary care, and almost half of those undertaking it can achieve and maintain remission at 12 months, a UK primary care-based trial has shown. The authors of the DiRECT study,* published online today by The Lancet, said the dietary and lifestyle intervention used in their study has the potential for considerable personal and health-service-related benefits – and an expert commented that their results “indicate that weight loss should be the primary goal in the treatment of type 2 diabetes”.

Researchers recruited 306 men and women aged 20-65 years from 49 general practices in Scotland and Tyneside, all of whom had been diagnosed with type 2 diabetes within the previous six years, had a body-mass index (BMI) of 27–45 kg/m², and were not receiving insulin; they used no other specific eligibility criteria. They randomly assigned practices to be either control (23) or intervention (26) practices. Participants from the control practices received ‘best practice care by guidelines’, while those in the intervention practices were asked to follow the Counterweight-Plus weight management programme.

The Counterweight-Plus programme involves a total diet replacement phase using a low-energy formula diet (825–853kcal/day; 59% carbohydrate, 13% fat, 26% protein, 2% fibre) for three months (extendable up to five months if wished by participant), followed by structured food reintroduction of 2–8 weeks (about 50% carbohydrate, 35% total fat, and 15% protein), and an ongoing structured programme with monthly visits for long-term weight loss maintenance. This group discontinued all oral antidiabetic and antihypertensive drugs were discontinued on day one of the weight management programme, with standard protocols for drug reintroduction under national clinical guidelines, if indicated by regular monitoring of blood glucose and blood pressure (blood pressure rapidly decreases upon commencement of a low energy diet).

The study authors reported that at 12 months, they recorded weight loss of 15kg or more in a quarter (24%) of participants in the intervention group, compared with none in the control group. Close to half (46%) of patients in the intervention group, compared with just 4% of those in the control group, achieved diabetes remission by 12 months. In both groups, the likelihood of remission varied with weight loss – it occurred in none of the 76 participants who gained weight, 7% of the 89 who maintained 0-5 kg weight loss, over a third (34%) of the 56 participants with 5-10 kg loss, more than half (57%) of those with 10-15 kg loss, and 86% of those who lost at least 15kg or more. Mean bodyweight fell by 10.0kg in the intervention group, compared with 1.0kg in the control group.

They also noted that quality of life, as measured by the EuroQol 5 Dimensions visual analogue scale, improved by 7.2 points in the intervention group, and decreased by 2.9 points in the control group.

They commented: “A professionally supported intensive weight management programme is attractive to many people early in the course of type 2 diabetes. The programme allowed almost half of participants to revert to a non-diabetic state, off antidiabetic drugs at 12 months, and 68% stopped antihypertensive medications with no rise in blood pressure.” They said their findings suggest that even for people who have had type 2 diabetes for six years, putting the disease into remission is feasible.

The author of a linked editorial** said: “[These] results, in addition to those from other studies of type 2 diabetes prevention and some smaller interventions in this setting, indicate that weight loss should be the primary goal in the treatment of type 2 diabetes. … However, disease prevention should be maintained as the primary goal that requires both individual-level and population-based strategies, including taxation of unhealthy food items to tackle the epidemic of obesity and type 2 diabetes.”

The charity Diabetes UK has committed over £2.8 million to the DiRECT trial. Its director of research Dr Elizabeth Robertson said: “These first-year findings of DiRECT demonstrate the potential to transform the lives of millions of people. We’re very encouraged by these initial results, and the building of robust evidence that remission could be achievable for some people.”

* Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet, published online 5 December 2017.

** Uusitupa M. Remission of type 2 diabetes: mission not impossible. The Lancet, published online 5 December 2017.  

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