Recent research suggests that only a very small number of patients with type 2 diabetes (T2D) can achieve and maintain diabetes remission through weight loss alone.
Of the more than 37,000 people with type 2 diabetes in Hong Kong, only 6% achieved and maintained diabetes remission through weight loss alone up to 8 years after diagnosis. Of those who initially achieved remission, 67% developed hyperglycemia after 3 years.
Individuals who lost the most weight in the first year after diagnosis (10% of their body weight or more) had the greatest likelihood of achieving sustained remission.
„The study has helped confirm the low rate of diabetes remissions and the high rate of relapse into hyperglycemia in practice,“ said Dr. Andrea Luk of the Chinese University of Hong Kong, as reported in Medical News from Medscape. „Over 80% of diabetes remissions occurred within the first 5 years after the diabetes diagnosis. This is consistent with our understanding that beta-cell function gradually declines over time, making diabetes remission even more difficult, even with weight reduction.“
The study was published on January 23, 2024, in PLOS Medicine.
Early Weight Management Works
Recent clinical studies have shown that T2D remission can be achieved through sustained weight loss from bariatric surgery or lifestyle interventions, the authors noted. This study examined the relationship between weight changes one year after diabetes diagnosis and the long-term incidence and sustainability of T2D remission in real-world settings using data from the nationwide Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM).
A total of 37,326 individuals with newly diagnosed T2D who were enrolled in the RAMP-DM between 2000 and 2017 were included in the study and followed until 2019.
At the start of the study, the average age of the participants was 56.6 years, the mean body mass index (BMI) was 26.4 kg/m2, and the mean HbA1c was 7.7%. Sixty-five percent were taking glucose-lowering drugs (GLDs).
T2D remission was defined as two consecutive measurements of A1c < 6.5% taken at least 6 months apart without current or recent GLD use.
During a mean follow-up period of 7.9 years, 6.1% of people achieved remission, with an incidence rate of 7.8 per 1000 person-years. The percentage was higher among those with greater weight loss: 14.4% of people who lost 10% or more of their body weight achieved remission, compared to 9.9% of people with 5-9.9% weight loss and 6.5% of people with 0-4.9% weight loss. 4.9% lost weight and 4.5% gained weight.
After adjusting for age at diagnosis, gender, assessment year, BMI, other metabolic indices, smoking, alcohol consumption, and medication use, the hazard ratio (HR) for diabetes remission was 3.28 for persons with weight loss of 10% or more within one year of diagnosis, 2.29 for 5-9.9% weight loss, and 1.34 for 0-4.9% weight loss compared to weight gain.
The incidence of diabetes remission in the study was significantly lower than in clinical trials, which may be due to study participants engaging in structured programs involving intensive lifestyle interventions, regular monitoring and feedback, and the strengthening of a holistic approach to diabetes treatment, the authors noted. In real-world situations, such interventions may be present or absent.
Further analyses showed that within a mean follow-up period of 3.1 years, 67.2% of people who achieved diabetes remission developed hyperglycemia again – an incidence rate of 184.8 per 1000 person-years.
The adjusted HR for return to hyperglycemia was 0.52 for people with 10% or more weight loss, 0.78 for those with 5-9.9% weight loss, and 0.90 for those with 0-4.9% weight loss compared to weight gain.
In addition, diabetes remission was associated with a 31% (HR: 0.69) reduced risk of overall mortality.
The study „provides evidence to policymakers for the development and implementation of early weight control measures“ for people diagnosed with T2D, the authors concluded.
Physicians also play a role, added Luk. „At the first encounter with a person newly diagnosed with type 2 diabetes, physicians should emphasize the importance of weight loss and guide the individual on how this can be achieved through adopting a healthy lifestyle. Pharmacotherapy and metabolic surgery for weight control may be considered in appropriate individuals.“
Overall, she added, „Physicians should be informed that the likelihood of achieving and maintaining diabetes remission is low, and patients should be advised accordingly.“
Similar to US Experience
Mona Mshayekhi, MD, PhD, assistant professor of medicine in the Division of Diabetes, Endocrinology, and Metabolism at Vanderbilt University Medical Center, Nashville, Tennessee, commented on the study for Medical News from Medscape.
„These results very much reflect the clinical experience in the US,“ she said. „We know that sustainable weight loss without the use of medication or surgical interventions in practice is extremely difficult due to the hormonal factors of obesity combined with socioeconomic challenges.“
The study was conducted before newer weight management strategies like glucagon-like peptide-1 receptor agonists were widely available, she noted. „This actually underscores the realization that weight loss without routine use of drugs has a variety of benefits, including diabetes remission and reduced overall mortality.“
However, she added, „I suspect that future studies with more modern cohorts will show much higher rates of diabetes remission when using newer medications.“
„Our ability to help our patients meaningfully lose weight was limited until recently,“ she said. „With the new tools in our arsenal, physicians must take the lead and help patients address and treat obesity and combat the stigma that prevents many from even discussing it with their doctors.“
The study was not funded. Luk received research grants or contracts from Amgen, AstraZeneca, Bayer, Biogen, Boehringer Ingelheim, Eli Lilly, Junshi, Lee Pharmaceutical, MSD, Novo Nordisk, Roche, Sanofi, Shanghai Junshi Biosciences, Sugardown, and Takeda, as well as travel grants and speaking fees from AstraZeneca, Boehringer Ingelheim, Eli Lilly, and MSD. Mshayekhi reported no conflicts of interest.