The world is beginning to talk about remission: What do we know so far?

4 September 2018

While we still have a lot to learn about the concept, there’s definitely hope. Let’s sum up what we know so far.

Remission means…

Remission is when you’ve got normal blood glucose levels, without using any diabetes medications, for the long term. The DiRECT trial defined remission as having blood glucose levels at least under the threshold for diagnosing Type 2 diabetes (HbA1c of 6.5%). Other experts have defined remission differently, so we’re working on getting a consistent definition for GPs.

We use the term ‘remission’ because Type 2 diabetes might come back, so it’s really important that people in remission continue to get regular check-ups. This way, any signs of returning Type 2 or complications can be spotted early. In the future, we might find out that people in remission don’t need as regular check-ups, but it’s too early to tell.

How do people go into remission?

To answer this question, we need to look at how Type 2 diabetes develops.

If someone’s carrying extra weight around their middle, fat can build up around important organs, like their liver and pancreas. This makes it more difficult for those organs to work properly, leading to Type 2 diabetes.

Not everyone who develops Type 2 diabetes is overweight. There are other factors, like age, ethnicity and family history that play a role in our risk too. These factors influence how well the liver and pancreas work, and also where we store our fat.
We can’t change those things, but we can usually change our weight. That’s why weight becomes such an important topic – and a focus of research.

Just as storing fat around the liver and pancreas is important in the development of Type 2, so is losing fat for remission.
Not everyone who loses fat will go into remission. But the good news is that remission aside, losing weight – sometimes as little as 5% of your body weight – improves blood glucose levels too.

So if weight loss is the key, how do we do it?

Option 1: diet or lifestyle

Three studies have reported people with Type 2 diabetes going into remission using lifestyle changes:
1. Look Ahead: an American study using a low fat diet alongside some meal replacements. 7% of people were in remission after four years (around 1 in 13).
2. An Italian study used a low-carb Mediterranean diet. 5% of people were in remission after six years (or 1 in 20).
3. DiRECT: an ongoing study we’re funding, testing a low calorie diet alongside weight loss support from a healthcare professional. At the end of year one, just under half of people were in remission (around 1 in 2).
You can’t really compare the three studies because they were done in different ways with different numbers of people. And DiRECT was the only study that set out to look specifically at remission. But they all point to remission being a feasible outcome for some.
At the moment, there are no NHS services available to specifically help people put their Type 2 diabetes into remission. And that’s because we need more evidence: what are the long-term effects of a ‘lifestyle programme’ and how much would it cost?

Option 2: surgery

But diets aren’t the only way people have gone into remission – some have had bariatric (or weight loss) surgery. Interestingly, their blood glucose levels begin to improve before they lose any weight. This suggests that weight loss isn’t the sole benefit of the surgery, but there’s something else at play as well.

Whatever the explanation, 30-60% of people who have bariatric surgery go into remission. And there’s one encouraging report of some staying in remission for up to 15 years.

Surgery isn’t something to take lightly, and is definitely no quick fix, but it should be an option for those who want it. At the moment, it can be really difficult to get a referral. So we’re working to try and make bariatric surgery more accessible for those who are eligible.
Each of the approaches above have been successful for some people, and hopefully as more evidence builds, more people will have access to an option that works for them.

No two people are the same

All this talk of remission is exciting, but it’s not going to be achievable for everyone.
Evidence points to weight loss being the key to remission – around 15kg significantly increasing your chances of remission. Alongside this, it appears to be more likely in people newly diagnosed and who start off with lower blood glucose levels.

Lots of people on DiRECT lost enough weight but didn’t go into remission. And the latest DiRECT results suggest that this is because some people’s insulin-producing cells in the pancreas wouldn’t ‘reboot’ after weight loss.

We know some people will be able to lose this weight on their own, and we’re already hearing incredible stories from those who’ve managed it. But safety is a number one priority, and results from DiRECT point to support from a healthcare team being absolutely key.

Results are also based on people who aren’t using insulin. Trying a low-calorie diet comes with risks if you’re taking insulin or other medications, so it’s vital to speak to a doctor first.

Importantly, losing excess weight is good for us – whether remission is at the end of the rainbow or not. It can mean fewer medications, better blood glucose levels, and a lower risk of complications. All of these are important for a long and healthy life, so good news all round.

What next after remission?

We don’t yet have the evidence to say that remission will definitely lead to fewer complications in the future, but it’s an exciting prospect. Lower blood glucose levels, better blood pressure and better cholesterol reduce the risk of complications – and remission ticks all three boxes.

We’re optimistic, but let’s stay cautious until we’ve got the evidence. In the meantime, people in remission should still get their regular check-ups, including eye screening.

For now, we’ve got a few questions we want answers to, like:
1. Lots of research so far has focused on people with Type 2 diabetes who are overweight – will we need a different approach for people who aren’t? Luckily, Prof Roy Taylor’s ReTUNE study is looking at this.
2. How can we make sure people stay in remission – what support do they need?
3. Does remission reduce the risk of diabetes complications down the line? All of them, or specific ones?
4. Although rare, children also develop Type 2 diabetes. Is remission an option here too?

While we’re waiting for evidence to build, we can start having important conversations now. Watch out for the latest results from DiRECT. And ask your healthcare team if they’ve heard about research into remission too. You could also ask to see a dietitian who can support you to lose weight. This way, you could work to improve your blood glucose levels and increase your chances of remission now.
Importantly, we’re about to see a shift in how we talk about Type 2 diabetes. It’s still a very serious condition – but one where remission could be a realistic goal for some. And that’s exciting.

Authors: Douglas Twenefour and Emily Burns

Acknowledgement: Diabetes UK