We’re continuing our roundup of the biggest research news from the biggest gathering of diabetes scientists.
We’ve already taken a look at highlights from the virtual American Diabetes Association (ADA) Scientific Sessions on future treatments to cure or prevent diabetes. Now it’s time for type 2 diabetes remission.
What’s the best way to get there?
Remission in people with type 2 diabetes means that your blood sugar levels are healthy without needing to take any diabetes medication. We heard from researchers who are leading the way and uncovering the best approaches to get there.
So far, the strongest evidence is behind a low-calorie diet to help people with type 2 diabetes lose weight and go into remission. This comes from our DiRECT trial. The findings showed that over a third of people who took part in the weight management programme were in remission two years later.
DiRECT researchers Professor Roy Taylor and Alison Barnes were on hand to update the ADA community on their ground-breaking work. While a low-calorie liquid diet isn’t the only route to weight loss and remission, they ran us through why it’s a good option.
- By restricting calories internal fat that sits around the liver and pancreas can be ‘used up’ really quickly. And shedding this fat is key to going into remission.
- Ensures people get all the right nutrients they need, while keeping calories down
- Removes the need for people to make decisions about their meal options
- Can create a blank slate that helps people break unhealthy eating habits and make longer term lifestyle changes
- Can act as a good motivator to lose weight quickly.
The researchers also told us more about what happens when people go into remission. They’ve discovered that remission depends on the capacity of insulin-producing beta cells to recover. For some people, despite losing weight and shedding internal fat, their beta cells weren’t able to pull through. But for those who were able to go into remission their beta cells rebooted and started to release the right amount of insulin the body needs. What we don’t yet understand is why this is only possible in some people and not others, but the researchers think it could be related to the length of time you’ve lived with type 2 diabetes.
The DiRECT researchers also looked at what happened to the size of the pancreas with remission. Professor Taylor explained that the pancreas in people with type 2 diabetes is around 25% smaller than people without the condition. Could it return to normal size with remission? “You bet it did,” Professor Taylor told us.
He described how these insights make it clear we’re not just seeing people with type 2 diabetes managing to bring their blood sugars down to a healthy range. Weight loss through a low-calorie diet is able to reverse biological processes that cause the pancreas to fail in type 2 diabetes. But Professor Taylor flagged that if people put weight back on type 2 diabetes will come back. They’ve seen this is a small group of people who took part in DiRECT. After regaining weight and regaining internal fat, beta cells – which are already susceptible to type 2 diabetes – started failing again. Keeping weight off is essential to stay in remission.
A low-carb diet is another possible route to remission. Dr William Yancy explained that the majority of low-carb studies have looked at how helpful the diet is for weight loss, rather than reporting on remission. So there’s less robust evidence so far. But the findings we do have suggest a low-carb approach can be effective.
A trial from 2018 studied over 1,000 people with type 2 diabetes who took part in an online programme that gave advice on how to reduce carbohydrate intake. Of those who completed all the sessions, 26% were in remission after a year. In this study, the researchers define remission as healthy blood sugar levels (a HbA1c of less than 6.5%) whilst either stopping all diabetes medication or just taking metformin alone.
Dr Yancy also ran us through his work on the Jump Start study. It involved 236 people with type 2 diabetes. Half were given diabetes education and a more intensive medication regime to treat their condition, and the other half received a low-carb diet weight loss intervention.
Over 11 months, Dr Yancy found both groups reduced their HbA1c by 1% on average. But the low-carb group lost more weight and 11% were in remission, compared to 0% in the medication group. They also used a definition of remission here that includes people who were still taking metformin.
From what we know so far Dr Yancy highlighted that in low-carb studies, as with low-calorie approaches, a greater amount of weight loss appears to increase the chance of remission. He also stressed that we need to make sure people maintain changes to their diet, so they can keep weight off. So finding out what works best for the individual is vital to achieve sustainable lifestyle changes.
Weight loss surgery
Diets aren’t the only way people with type 2 diabetes have gone into remission. Professor Franceso Rubino at King’s College London is a pioneer of weight loss (or bariatric) surgery to treat type 2 diabetes. He told us the evidence on its long term benefits is compelling. After gastric bypass surgery, 75% of people who had type 2 diabetes were in remission two years after the procedure, after six years 62% and 51% were still in remission at 12 years.
When it comes to predicting who will go into remission after surgery, duration of type 2 diabetes is the most important factor. It’s more likely in people more recently diagnosed. But Professor Rubino explained that remission is possible at any time.
And even if people don’t go into remission following surgery there are still real benefits. Along with weight loss, bariatric surgery can reduce the need for diabetes medications, lower risk of heart problems and improve quality of life.
It could also tell us something about the root causes of type 2 diabetes. In the previous talks, researchers shone a light on the importance of weight loss to bring about remission. But when it comes to bariatric surgery Professor Rubino doesn’t think that the weight loss it triggers alone can explain why people go into remission. The effects on blood sugars levels are often seen almost immediately after surgery, long before any significant weight loss kicks in. This indicates that something else is at play, and the gut seems to be a likely candidate. We know that bariatric surgery can change how the hormones in the gut work, which in turn affects how the body makes insulin. Professor Rubino believes this points to the gut as playing a major role in causing type 2 diabetes, and its remission.
The ins and out of how remission happens is a hot topic of debate. And we still have a lot to learn about the different routes to support people to get there. But we know remission is changing people’s lives right now. As evidence continues to build, the sense of hope for people with type 2 diabetes builds too.
The psychology of keeping weight off
We know maintaining weight loss is the most important thing to achieve lasting remission. But making sustainable and long-lasting lifestyle changes is by no means easy. Professor Colin Greaves from the University of Birmingham has theorised why people might regain weight.
He thinks that there’s a tension between maintaining weight loss and our physical, psychological and social needs. These needs include things like hunger, stress and acceptance from peers. This tension is what draws people back into old habits and can cause them to regain weight.
Professor Greaves wanted to find a way to stop this tension developing and promote a more sustainable approach to weight loss. He devised a toolkit, called Skills for Weight Loss Maintenance (SKIM). It teaches people to:
- Make realistic changes you can live with
- Use cognitive behavioural techniques to help gain control over impulses
- Pinpoint what drives your unhealthy lifestyle habits, then come up with a plan on how else to address that need
- Focus on the long term – think ten years rather than one.
He tested this toolkit with 100 people who were trying to lose weight over a 12 month period. He found that SKIM helped people develop more positive self-beliefs and reduced tension in weight loss maintenance. In turn, the results suggested reduced tension could predict maintained weight loss.
This was a very small initial study. Professor Greaves next plans to develop his tension theory and build on the SKIM intervention, before testing its effectiveness in larger trials. But the findings do suggest making use of psychological techniques to change thinking and behaviours could form an important part of future remission programmes.