Remission of type 2 diabetes (T2D) is a practical target for primary care, according to a recent study that showed that almost half of participants with T2D achieved remission to a non-diabetic state and off antidiabetic drugs through primary care-led weight management. The open-label, cluster-randomized trial (DiRECT) took place at 49 primary care practices, which were randomly assigned 1:1 to provide either a weight management program or best-practice care by guidelines (control). 306 individuals aged 20 to 65 years who had been diagnosed with T2D with the past 6 years, had a body mass index (BMI) of 27-45 kg/m2, and were not receiving insulin, were recruited. Researchers found:
- At 12 months, weight loss of ≥15 kg was recorded in 36 (24%) participants in the intervention group and no participants in the control group.
- Diabetes remission was achieved in 68 (46%) participants in the intervention group and 6 (4%) in the control group (OR, 19.7).
- Remission varied with weight loss in the entire study population.
- Quality of life improved by 7.2 points in the intervention group and decreased by 2.9 points in the control group.
Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster-randomized trial. [Published online ahead of print December 5, 2017]. Lancet. doi:10.1016/S0140-6736(17)33102-1.
This remarkable study shows that lifestyle modification can be effective at achieving remission of diabetes. The obvious challenge, of course, was finding patients who are willing and able to comply with an extremely restrictive regimen that only allowed for 825–853 kcal/day of a formula diet for 3–5 months, after which stepped food reintroduction was allowed over 2-8 weeks. The authors state that their “findings confirm that type 2 diabetes of up to 6 years’ duration is not necessarily a permanent, lifelong condition. Weight loss sufficient to achieve remission can be attained in many individuals by use of an evidence-based structured weight management program delivered in a non-specialist community setting.”
The challenge for those of us in practice is to figure out the correct behavioral interventions and programs that support and encourage our patients to carry out lifestyle changes, and to decide which patients benefit most from emphasis on lifestyle modification and which benefit most from medications, with of course most patients benefiting optimally from both used together. —Neil Skolnik, MD
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