Mitchel L. Zoler, PhD
November 18, 2021
Roughly 5% of adults with type 2 diabetes achieve remission of their disease, often unbeknownst to the patient and without aggressive weight-loss interventions, according to a new analysis of data from more than 160,000 people in a national diabetes registry in Scotland.
"One of our key new findings is that a reasonably large proportion of people [with type 2 diabetes] were able to achieve remission in routine care, without undergoing bariatric surgery and prior to the introduction of very-low-calorie interventions in routine care," said Mireille Captieux, MBChB, lead author of the report, in an interview.
In her analysis, two of the strongest correlates of remission related to weight loss.
First, a history of bariatric surgery, which included a scant 488 people (0.3% of the study cohort), was associated with a 13-fold increase in the rate of remission compared with those who did not undergo bariatric surgery. Second, weight loss of 15 kg (33 lb) or more at the time of remission detection in 2019, in comparison with their weight at initial diabetes diagnosis, was linked with a greater than fourfold increase in the rate of remission compared with those who did not have this amount of weight loss.
But "even losing a small amount of weight increased the chances of remission," highlights Captieux. "This finding offers a counterbalance to the pessimistic assumption that almost all people find it very difficult to lose weight."
Hopeful Message, but Which People Achieve Diabetes Remission?
"What's encouraging here is that you have people who probably did not do anything radical and yet they went into remission. The next step is to find out who these people are and what they did to go into remission," commented Julia Lawton, PhD, a professor of health and social science at the University of Edinburgh whose research focuses on how patients with diabetes manage their disorder.
"If we can understand who the patients are who can achieve remission without taking extreme measures, it could help people in the health professions get beyond their presumptions about who is, or is not, a good candidate for achieving diabetes remission," said Lawton, who was not involved with the new study.
The message from this study is "very hopeful," Lawton said in an interview. "How can we make this opportunity [for diabetes remission] available to more people? What can we learn from these patients that we could then apply to other patients?"
Captieux agrees. Given her findings, an important next step is to find out more about the population in remission to better understand "their perspectives on the challenges and benefits of supporting weight loss.
"Obesity is a complex issue, and therefore weight loss interventions that target individual actions and behaviors are much more likely to be effective if they are accompanied by multiple interventions at different levels," Captieux said.
In addition, "more evidence is needed to assess the sustainability of diabetes remission and the effect of different durations of remission for a clinically relevant definition."
Better Defining Diabetes Remission
Captieux noted that the new international consensus definition of type 2 diabetes remission - which specifies a minimum 3-month duration of glycemic control to qualify as remission - means that people with diabetes "may frequently oscillate" between remission and active disease.
This makes it important to better define the effect of duration of diabetes remission regarding various diabetes complications.
Another issue raised by the new findings is the importance of distinguishing people who lose weight because of a healthier diet and increased activity from those who lose weight because of chronic illness or frailty that's followed by long-term adverse outcomes.
If these two populations are not distinguished in an observational cohort study - such as the one run by Captieux and her associates - then the people with chronic illness might appear to have worse outcomes following diabetes remission.
Captieux and her co-authors used data collected in the Scottish Care Information–Diabetes registry, which includes almost all people diagnosed with diabetes in Scotland. They focused on people with diabetes who had first been diagnosed with diabetes during 2004–2018, who were at least 30 years old at the time of their initial diagnosis, and who had received care in the national health system during 2019.
This yielded a study cohort of 162,316 people, of whom 7710 (4.8%) were identified by the researchers as being in remission in 2019.
Patients in remission were defined as those whose A1c level was less than 6.5% at their index reading in 2019 and whose A1c level could be documented as being lower than 6.5% for at least 1 year prior to the 2019 measurement.
In a primary logistic regression analysis, the authors identified five variables that were significantly linked with remission: age of at least 65 years (the association was even stronger for age older than 75 years), a lower A1c level at the time of initial diabetes diagnosis, weight loss, prior bariatric surgery, and no prior treatment with a glucose-lowering therapy.
The strongest association was with having had no prior treatment with a glucose-lowering therapy in 2019. People who met this criterion were nearly 15 times more likely to be in remission in 2019 compared with those who had received at least one of these agents.
The study received no commercial funding. Captieux and Lawton have disclosed no relevant financial relationships.
PLoS Med. Published online November 2, 2021.
Mitchel L. Zoler is a reporter with Medscape and MDedge based in the Philadelphia region. @mitchelzoler.