From the Guidelines
The most effective protocols for achieving type 2 diabetes remission are intensive weight loss interventions, particularly very low-calorie diets (VLCDs) and bariatric surgery, as demonstrated by the DiRECT trial and other studies 1.
Key Findings
- VLCDs typically involve restricting caloric intake to 800-900 calories per day for 8-20 weeks, followed by a structured food reintroduction and maintenance phase.
- The DiRECT trial demonstrated that this approach can achieve remission rates of approximately 46% at one year and 36% at two years, with greater success in those who lose more weight (>15kg) and those with shorter diabetes duration (<6 years) 1.
- Bariatric surgery, especially Roux-en-Y gastric bypass and sleeve gastrectomy, has shown even higher remission rates of 60-80% lasting several years 1.
- Programmes with a 'total diet replacement' induction phase were the most effective dietary approach for type 2 diabetes remission (up to 61% of participants at 1 year) 1.
Recommendations
- For optimal results, these approaches should be implemented early in the disease course and combined with regular physical activity (150+ minutes weekly), ongoing support, and monitoring.
- While medications like GLP-1 receptor agonists (semaglutide, tirzepatide) can support significant weight loss and improve glycemic control, they typically don't achieve the same remission rates as VLCDs or surgery when used alone.
- The American Diabetes Association recommends referring adults with overweight or obesity at high risk of type 2 diabetes to an intensive lifestyle behavior change program to achieve and maintain a weight reduction of at least 7% of initial body weight through healthy reduced-calorie diet and 150 min/week of moderate-intensity physical activity 1.
From the Research
Protocols for Type 2 Diabetes Remission
The protocols that have resulted in the highest rates of type 2 diabetes remission include:
- Intensive lifestyle interventions, such as customized integrated intensive lifestyle modifications, including a vegan diet, exercise, and psychological support 2
- Multidomain lifestyle interventions, including expert-guided educational and nutritional counseling combined with a personalized physical exercise prescription 3
- Lifestyle intervention alone (LSI-alone), which can induce remission in both newly diagnosed and established type 2 diabetes, with predictors of remission including 10% weight loss and higher BMI, lower A1C, and shorter type 2 diabetes duration at enrollment 4
- Intensive weight-loss interventions, which have been associated with a greater likelihood of partial remission of type 2 diabetes compared with diabetes support and education 5
Key Components of Successful Protocols
The key components of successful protocols for type 2 diabetes remission include:
- Dietary changes, such as a vegan diet or low-calorie meal replacement 2, 4
- Exercise and physical activity, such as personalized physical exercise prescriptions 3
- Psychological support and counseling, such as expert-guided educational and nutritional counseling 3
- Weight loss, with a goal of 10% weight loss or more 4
Remission Rates
The remission rates achieved with these protocols vary, but include:
- 20% remission rate among participants with prediabetes and 12% among those with type 2 diabetes after a 12-month multidomain lifestyle intervention 3
- 11.5% remission rate at year 1 and 7.3% at year 4 with an intensive lifestyle intervention 5
- 9.2% continuous, sustained remission for at least 2 years, 6.4% for at least 3 years, and 3.5% for 4 years with an intensive lifestyle intervention 5