Prevention and remission of type 2 diabetes (SIGN)
Early in the course of type 2 diabetes, it is possible for some people to achieve remission from the condition through weight loss. Remission is defined as HbA1c remaining below 48 mmol/mol or 6.5% for at least three months, without diabetes medication.52 Achieving remission reduces complications from type 2 diabetes and allows people to experience a greater quality of life.
Remission of type 2 diabetes is directly related to the amount of weight lost, with clinical trial data showing that the vast majority (85%) of trial participants who lost more than 15 kg achieved remission.53
The following is adapted from recommendation 5 (page 759) of Diabetes Canada clinical practice guideline on remission of type 2 diabetes.53
Low-calorie (~800 to 850 kcal/day) diets with meal replacement products for 3 to 5 months aimed at achieving >15 kg body weight loss, followed by structured food reintroduction and increased physical activity for weight-loss maintenance, and with behavioural support, should be considered for type 2 diabetes remission in non-pregnant adults.
The combination of weight loss and optimisation of lifestyle interventions is the primary intervention. Low-calorie diet, which has been well researched, is only one method of weight loss; other methods may be more appropriate. More research is required on the contribution of physical activity (which offers other physical and mental health benefits) to remission.
Behavioural and psychological support underpins delivery of a structured programme. Be aware of other conditions (such as eating disorders, see SIGN 164: Eating disorders) and screen and assess appropriately before starting an intensive weight-management programme.42
The aim is to achieve remission as soon as possible after diagnosis. Many people can achieve remission without a structured evidence-based programme if signposted to effective methods of weight loss. However, the additional support and professional input may be more beneficial for some. It is critical to understand individual motivations and social and personal circumstances, including other clinical conditions and access to services.
It is important to support individuals who enter a structured programme but do not achieve remission by emphasising the multiple benefits gained through clinically significant weight loss. This includes the positive effects of metabolic recovery; reduced blood pressure, blood lipids, polypharmacy and quality of life gained. Any weight loss should be considered a successful outcome. Equally, the importance of weight loss should be emphasised to individuals who do not wish to participate in a structured NHS programme.
Health boards across the NHS in Scotland currently deliver the Counterweight Plus structured type 2 diabetes remission programme, which was implemented as part of the Framework for the prevention, early detection and early intervention of type 2 diabetes and underpinned by guidance in the Public Health Scotland standards for weight management.42, 43
A review by SHTG found that interim results from studies and large-scale pilots of digital-delivered programmes (with asynchronous messaging, educational content and health tracking) in NHS England suggest that both digital and in-person programmes can lead to similar levels of weight loss and remission and that type 2 diabetes programmes are cost effective to the NHS. Digital programmes have the potential to provide wider access to treatment and be more convenient to those particiipating.54
Maintaining weight loss is critical to sustain remission.
Use standards for the delivery of tier 2 and tier 3 weight-management services for adults as a basis for design and delivery of structured weight-management programmes that include type 2 diabetes remission programmes (see Figure 3 in Components of an effective diabetes prevention programme).
Liaise with the primary care provider and local diabetes teams as appropriate to adjust both glucose-lowering and blood pressure lowering medication as part of the medicines management protocol in a type 2 diabetes remission programme.
Upon achieving remission, ensure the patient is coded in primary care systems correctly as being in remission of type 2 diabetes (Read code C10P1 Type II diabetes mellitus in remission). Patients should remain on the diabetes register for annual review, so retain the original type 2 diabetes code (C109-2). Do not use the code ‘diabetes resolved’. It is reserved only for misdiagnosis or diabetes due to a secondary factor that has since been removed, such as acute steroid use.