A fairly novel concept, which now has considerable backing by clinical research, relates to the ability for diabetes to reverse—that is, to go into remission. According to Diabetes UK (2023), remission is defined by the HbAlc remaining below 48 mmol/mol (6.5%) for at least 3 months, free from medications used in the treatment of diabetes. Remission is more appropriate than the term ‘reversal’, as there is always a chance the levels may once again rise.
For remission to happen, weight loss is the key. In fact, by losing l5 kg safely and promptly following a diabetes diagnosis, there is a strong possibility of remission (Diabetes UK, 2023). However, insulin or sulphonylurea should be stopped prior to weight loss (Diabetes UK, 2023). Furthermore, those who are of healthy weight; have an eating disorder; are under 18 years; pregnant or breastfeeding; should avoid this approach as it could cause significant harm to them. Nonetheless, the majority of people with newly diagnosed diabetes do have problems with their weight and therefore, this approach may be effective for a large number of people living with the disease.
Unwin et al (2023) carried out a longitudinal study across an 8—year period of general practice (GP) service’s evaluation of a lower carbohydrate diet with weight loss, which in turn helped to ascertain what predicts diabetes remission. The researchers have now published their results in the British Medical Journal (BMJ) Nutrition, Prevention and Health.
The team used Norwood surgery to examine patients eating a low-carbohydrate diet. The team hoped to achieve remission for patients following this diet since 2013. The scheme involved routinely offering advice to those with type 2 diabetes between 2013 and 2021. The practice was home to 9800 patients. Conventional one-to-one GP appointments were used to implement the advice, alongside group consultations and personal phone calls, as deemed necessary. Those agreeing to their participation were then computer-coded for ongoing audit in order to be able to compare their baseline and latest follow-ups for the relevant parameters. There were 186 patients who chose the low-carbohydrate approach, which amounted to 39% of the type 2 diabetes register of patients. Following an average of 33 months, the average weight fell from 97 kg to 86 kg. This amounted to an average weight loss of 10 kg. With this, the average HbA1c fell from 63 to 46 mmol/mol. In less than 1 year, the approach led to a total of 77% of type 2 diabetic patients achieving remission (Unwin et al, 2023). However, this fell to 20% for a duration greater than 5 years. In the cohort, 51% achieved remission by the end of the study.
Mean low-density lipoprotein cholesterol decreased by 0.5 mmol/l, mean triglyceride by 0.9 mmol/l and mean systolic blood pressure by 12 mmHg. The researchers reported substantial prescribing savings, with accounts showing that the average Norwood surgery spend for diabetic drugs was £4.94 per patient per year, compared with £11.30 for local practices. By the end of January 2022, Norwood surgery spent £68 353 per year less than the area average. This provides hope for those living with the condition and their practitioners that there is a way to achieve better health through such remission, while making significant financial savings.
The authors highlighted that sustained remission of type 2 diabetes is specifically well-established; however, it is not yet routinely practised despite its recognition in blood test results (Unwin et al, 2023). Overall, the researchers agreed that a low-carbohydrate diet-based approach was able to achieve major weight loss with substantial health and financial benefits. It was found that recent diagnosis of type 2 diabetes (<1 year) was the most important factor and an important window of opportunity for achieving drug-free remission of diabetes (Unwin et al, 2023). Thus, new diagnosis requires very prompt action in order to achieve remission. The approach can also give hope to those with poorly controlled type 2 diabetes who may not achieve remission, as this group showed the greatest improvements in diabetic control as represented by their HbA1c results.