The diagnosis of Type 2 diabetes does not have to be perceived with fatalism. If the results of a cluster-randomized study from Scotland are certain, the wheel can be turned back in many cases through high weight reduction and complete remission without the need for anti-diabetic medicines.
More and more people, that also younger, are developing type 2 diabetes. Current guidelines for its management focus primarily on good blood glucose control with lifelong blood sugar-lowering therapy and treatment of additional cardiovascular risk factors.
According to the results of the DiRECT study, this could be a mistake. A weight management program in family practices, in which one in four participants lost more than 15 kg in weight in the first year, led to complete remission of diabetes in almost half of the patients.
It is well known that type 2 diabetes is strongly associated with overweight and obesity. Excessive fat accumulations in the liver and pancreas, in particular, seem to play an important pathophysiological role. Previous studies have shown that a negative energy balance of 600-700 kcal/d can reduce insulin resistance in the liver and liver fat content within a few days - after eight weeks the pancreatic fat content and the primary insulin response also normalize. According to these pathophysiological studies, remissions of type 2 diabetes are possible. This has also been shown for bariatric operations. It was previously unclear whether this could also be achieved by weight loss in the outpatient sector in normal family doctor patients.
To verify this, a cluster randomized study was conducted in 49 family practices in Scotland and parts of England. Half of the practices were randomized to "intervention practices" in which patients participated in a weight management program (Counterweight plus) in addition to the usual treatment of type 2 diabetes. In the other half of the practices, patients received only standard therapy in accordance with the guidelines.
The intervention and control groups included 149 patients between 20 and 65 years of age who had been diagnosed with type 2 diabetes over the last six years. The BMI was between 27 and 45 kg/m2.
Exclusion criteria included:
The weight management program included a pure formula diet (825-853 kcal/d) over three months (extendable to five months if desired) - after that, a gradual return to a normal diet and the weight loss achieved was stabilized in the form of a structured program over the rest of the year. On day 1 of the weight management program, all antidiabetics and antihypertensives were discontinued and, if necessary, reapplied if certain criteria were met.
138 patients in the intervention group (86%) and 147 in the control group (99%) could be re-examined after 12 months. At this time, 36 patients (24%) in the intervention group had achieved a facial reduction of at least 15 kg, which was not the case in any patients in the control group (p<0.0001). On average, the weight had decreased by 10.0 kg in the intervention group and by 1.0 kg in the control group.
The significantly higher weight loss paid off for the patients: 68 patients in the intervention group (46%) were diagnosed with type 2 diabetes remission and were able to completely dispense with antidiabetic drugs. In the control group, only six patients (4%) achieved this goal. The remission rate showed a linear dependence on the weight loss achieved - 86% of patients who had lost more than 15 kg were free of the disease.
The complete remission of type 2 diabetes should therefore also be a primary goal in the GP's practice, the authors claim. It could also be a strong motivation for patients to lose weight if they are given the prospect of getting rid of their diabetes completely.
Michael Ej Lean et al; Primary Care-led weight management for the remission of type 2 diabetes (DiRECT): An open, cluster-randomized Study; Lancet (2017), online; DOI: http://dx.doi.org/10.1016/S0140-6736(17)33102-1