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Weightloss with diabetes

NIHR Signal Losing weight following type 2 diabetes diagnosis boosts chance of remission

Published on 21 November 2019

doi: 10.3310/signal-000841

People who lose at least 10% of their body weight in the first year after being diagnosed with type 2 diabetes increase their chances of being in remission after five years, compared with those whose weight remains stable. Losing this achievable amount of weight over the next four years also makes remission more likely.

In this study of 867 people, 257 (30%) achieved remission at five-year follow-up. The participants had been taking part in a trial but had not received intensive lifestyle interventions or been put on extremely calorie-restricted diets.

This NIHR-funded study strengthens the evidence that healthy behaviour change and weight loss can result in remission of type 2 diabetes. This finding may help to motivate people to lose weight soon after a diabetes diagnosis ─ setting realistic and achievable targets can make a difference in the longer term.

Share your views on the research.

Why was this study needed?

Around 1 in 10 adults over 40 in the UK have been diagnosed with type 2 diabetes. This has been fuelled by the rise in obesity rates. Diabetes UK estimates that in addition to the 3.8 million adults who have been diagnosed with type 2 diabetes, a further one million have the disease without knowing it. Diabetes and its complications, including kidney failure, loss of sight and lower limb amputations, cost the NHS £6 billion per year.

Previous studies have shown that remission of type 2 diabetes, without medication or surgery, is achievable through intensive low-calorie diets and behaviour change in those who have lived with diabetes for some years. Many of these studies have also been relatively short.

The present study looked at whether a more moderate approach could achieve remission over the longer term, and whether a window of opportunity exists following diagnosis when weight loss interventions may be both effective and acceptable.

What did this study do?

This was a prospective cohort study of 867 people, aged 40 to 69, newly diagnosed with diabetes. Participants had been enrolled in the ADDITION-Cambridge randomised controlled trial, from 49 East of England GP practices between 2002 and 2006. The trial randomised participants into an intervention group, who received additional support, or the control ‘usual care’ group. This cohort study pooled data from both groups to look at who achieved remission during five years of follow-up.

Participants’ weight, physical activity, diet and alcohol consumption at baseline and one year were assessed. At five-year follow-up, 730 people (84%) had weight and HbA1c (long-term blood sugar measurement) measures taken. The participants were predominantly white.

What did it find?

  • Diabetes remission, defined as an HbA1c level of less than 48mmol/mol (6.5%) in the absence of any diabetes medication or bariatric surgery, was achieved in 257 participants (30%) at five-year follow-up.
  • People who lost at least 10% of their body weight in the first year after diagnosis of diabetes were more likely to achieve remission at five years compared to those with stable or increased weight (risk ratio [RR] 1.77, 95% confidence interval [CI] 1.32 to 2.38).
  • Similar trends were observed in those who had more modest weight loss of 5 to 10% over the first year after diagnosis, but this was not statistically significant.
  • In the subsequent four years (i.e. between the end of the first year and the end of the five-year study), achieving at least a 10% weight loss was associated with more than double the chance of remission at five-year follow-up (RR 2.43, 95% CI 1.78 to 3.31).
  • In this period weight loss of 5 to 10% was also associated with an increased likelihood of remission (RR 1.43, 95% CI 1.03 to 1.98).

What does current guidance say on this issue?

NICE’s guideline (NG28 updated in 2019), states that people diagnosed with type 2 diabetes should receive personalised and ongoing dietary advice. This should be integrated within a personalised diabetes management plan that includes other lifestyle modifications, such as losing weight and becoming more physically active.

The guideline states that for overweight adults diagnosed with type 2 diabetes, an initial body weight loss target of 5 to 10% should be set. NICE notes that lesser degrees of weight loss may still be beneficial and that a larger degree of weight loss in the longer term will have advantageous metabolic impact.

What are the implications?

This was a reasonably large cohort study whose findings should be generalisable to wider UK diabetes populations. The findings support the current guidelines around patient education and setting weight loss targets. Healthcare professionals and people newly diagnosed with type 2 diabetes will welcome the finding that relatively achievable weight loss in the first year after diabetes diagnosis or within five years can lead to disease remission.

Further studies to confirm findings in more diverse populations, such as black and ethnic minority groups who are at significantly greater risk of developing type 2 diabetes, would be helpful.

Citation and Funding

Dambha‐Miller H, Day AJ, Strelitz J et al. Behaviour change, weight loss and remission of Type 2 diabetes: a community‐based prospective cohort study. Diabet Med. 2019; Sept 3. doi: 10.1111/dme.14122. [Epub ahead of print].

This project was funded by the NIHR Health Technology Assessment Programme (project number 08/116/300) as well as the Wellcome Trust (grant number: G061895), the Epidemiology Unit programme (MC_UU_12015/4), and the National Health Service R&D support funding.

Bibliography

MRC Epidemiology Unit. ADDITION. Cambridge: MRC Epidemiology Unit; accessed 2019.

NHS England. Type 2 diabetes and the importance of prevention. London: Department of Health and Social Care; updated April 2018.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; updated August 2019.

Why was this study needed?

Around 1 in 10 adults over 40 in the UK have been diagnosed with type 2 diabetes. This has been fuelled by the rise in obesity rates. Diabetes UK estimates that in addition to the 3.8 million adults who have been diagnosed with type 2 diabetes, a further one million have the disease without knowing it. Diabetes and its complications, including kidney failure, loss of sight and lower limb amputations, cost the NHS £6 billion per year.

Previous studies have shown that remission of type 2 diabetes, without medication or surgery, is achievable through intensive low-calorie diets and behaviour change in those who have lived with diabetes for some years. Many of these studies have also been relatively short.

The present study looked at whether a more moderate approach could achieve remission over the longer term, and whether a window of opportunity exists following diagnosis when weight loss interventions may be both effective and acceptable.

What did this study do?

This was a prospective cohort study of 867 people, aged 40 to 69, newly diagnosed with diabetes. Participants had been enrolled in the ADDITION-Cambridge randomised controlled trial, from 49 East of England GP practices between 2002 and 2006. The trial randomised participants into an intervention group, who received additional support, or the control ‘usual care’ group. This cohort study pooled data from both groups to look at who achieved remission during five years of follow-up.

Participants’ weight, physical activity, diet and alcohol consumption at baseline and one year were assessed. At five-year follow-up, 730 people (84%) had weight and HbA1c (long-term blood sugar measurement) measures taken. The participants were predominantly white.

What did it find?

  • Diabetes remission, defined as an HbA1c level of less than 48mmol/mol (6.5%) in the absence of any diabetes medication or bariatric surgery, was achieved in 257 participants (30%) at five-year follow-up.
  • People who lost at least 10% of their body weight in the first year after diagnosis of diabetes were more likely to achieve remission at five years compared to those with stable or increased weight (risk ratio [RR] 1.77, 95% confidence interval [CI] 1.32 to 2.38).
  • Similar trends were observed in those who had more modest weight loss of 5 to 10% over the first year after diagnosis, but this was not statistically significant.
  • In the subsequent four years (i.e. between the end of the first year and the end of the five-year study), achieving at least a 10% weight loss was associated with more than double the chance of remission at five-year follow-up (RR 2.43, 95% CI 1.78 to 3.31).
  • In this period weight loss of 5 to 10% was also associated with an increased likelihood of remission (RR 1.43, 95% CI 1.03 to 1.98).

What does current guidance say on this issue?

NICE’s guideline (NG28 updated in 2019), states that people diagnosed with type 2 diabetes should receive personalised and ongoing dietary advice. This should be integrated within a personalised diabetes management plan that includes other lifestyle modifications, such as losing weight and becoming more physically active.

The guideline states that for overweight adults diagnosed with type 2 diabetes, an initial body weight loss target of 5 to 10% should be set. NICE notes that lesser degrees of weight loss may still be beneficial and that a larger degree of weight loss in the longer term will have advantageous metabolic impact.

What are the implications?

This was a reasonably large cohort study whose findings should be generalisable to wider UK diabetes populations. The findings support the current guidelines around patient education and setting weight loss targets. Healthcare professionals and people newly diagnosed with type 2 diabetes will welcome the finding that relatively achievable weight loss in the first year after diabetes diagnosis or within five years can lead to disease remission.

Further studies to confirm findings in more diverse populations, such as black and ethnic minority groups who are at significantly greater risk of developing type 2 diabetes, would be helpful.

Citation and Funding

Dambha‐Miller H, Day AJ, Strelitz J et al. Behaviour change, weight loss and remission of Type 2 diabetes: a community‐based prospective cohort study. Diabet Med. 2019; Sept 3. doi: 10.1111/dme.14122. [Epub ahead of print].

This project was funded by the NIHR Health Technology Assessment Programme (project number 08/116/300) as well as the Wellcome Trust (grant number: G061895), the Epidemiology Unit programme (MC_UU_12015/4), and the National Health Service R&D support funding.

Bibliography

MRC Epidemiology Unit. ADDITION. Cambridge: MRC Epidemiology Unit; accessed 2019.

NHS England. Type 2 diabetes and the importance of prevention. London: Department of Health and Social Care; updated April 2018.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; updated August 2019.

Behaviour change, weight loss and remission of Type 2 diabetes: a community‐based prospective cohort study

Published on 5 September 2019

H. Dambha‐Miller A. J. Day J. Strelitz G. Irving S. J. GriffinH. Dambha‐Miller , A. J. Day , J. Strelitz , G. Irving , S. J. Griffin

Diabetic Medicine , 2019

Aim To quantify the association between behaviour change and weight loss after diagnosis of Type 2 diabetes, and the likelihood of remission of diabetes at 5‐year follow‐up. Method We conducted a prospective cohort study in 867 people with newly diagnosed diabetes aged 40–69 years from the ADDITION‐Cambridge trial. Participants were identified via stepwise screening between 2002 and 2006, and underwent assessment of weight change, physical activity (EPAQ2 questionnaire), diet (plasma vitamin C and self‐report), and alcohol consumption (self‐report) at baseline and 1 year after diagnosis. Remission was examined at 5 years after diabetes diagnosis via HbA1c level. We constructed log binomial regression models to quantify the association between change in behaviour and weight over both the first year after diagnosis and the subsequent 1–5 years, as well as remission at 5‐year follow‐up. Results Diabetes remission was achieved in 257 participants (30%) at 5‐year follow‐up. Compared with people who maintained the same weight, those who achieved ≥ 10% weight loss in the first year after diagnosis had a significantly higher likelihood of remission [risk ratio 1.77 (95% CI 1.32 to 2.38; p<0.01)]. In the subsequent 1–5 years, achieving ≥10% weight loss was also associated with remission [risk ratio 2.43 (95% CI 1.78 to 3.31); p<0.01]. Conclusion In a population‐based sample of adults with screen‐detected Type 2 diabetes, weight loss of ≥10% early in the disease trajectory was associated with a doubling of the likelihood of remission at 5 years. This was achieved without intensive lifestyle interventions or extreme calorie restrictions. Greater attention should be paid to enabling people to achieve weight loss following diagnosis of Type 2 diabetes.

Expert commentary

Type 2 diabetes is a global epidemic and is associated with microvascular and macrovascular events. There has been recent interest in the potential to cure type 2 diabetes (to achieve “biochemical remission”) with low-calorie diets. However, most of these studies are short term.

The present study conducted a secondary analysis of the ADDITION Europe trial to determine weight changes at the population level and their association with remission in routine clinical practice over a five-year follow-up. The study found that weight loss ≥10% within the first year after diagnosis was associated with an increased likelihood of remission compared to those who did not lose weight. These are important findings as many people are reluctant to go onto a low-calorie diet and motivation to lose weight through behaviour change in the real-world setting could potentially have similar benefits.

Further research is required to identify the proportion of people and those likely to benefit from such behaviour change programmes.

Professor Kamlesh Khunti, Head of Department and Professor of Primary Care Diabetes and Vascular Medicine, University of Leicester; Co-Director of the Leicester Diabetes Centre

The commentator declares no conflicting interests

Expert commentary

Intensive weight loss programmes are highly successful in reversing type 2 diabetes. Questions remain about their generalisability and whether a less restrictive diet would achieve similar outcomes.

This study showed that 30% of people who are newly diagnosed with diabetes achieved remission at five years through a less intensive weight loss programme. Those achieving remission at five years had a lower baseline HbA1c but similar baseline weight.

Early weight loss in people who are newly diagnosed with type 2 diabetes should be strongly encouraged, whether through intensive or less intensive weight loss programmes.

Dr Rustam Rea, Consultant in Diabetes and Acute General Medicine, Oxford University Hospitals NHS Trust

The commentator declares no conflicting interests