Low Calorie/Energy Restriction to Promote Type 2 Diabetes Remission - Is There Truth to This?
It was recently posted in U.K. university news
that the use of low calorie diets by individuals of South Asian ethnicity promoted weight loss, resulting in the remission of type 2 diabetes mellitus (T2DM). Similar postings about T2DM remission have been seen on various social networks, often relating to the DiRECT Trial
(Diabetes Remission Clinical Trial), as well as new related clinical practice guidelines in Canada (2). Remission is described differently across studies (1) with the 2022 European Association for the Study of Diabetes (EASD) conference describing remission as sustained metabolic improvements (e.g. blood glucose and A1C levels) that return to near normal levels after pausing the intake of glucose-lowering medications for a defined period of time (3). The PEN Team conducted a quick review of these studies to assess their application to dietetic practice.
What does the evidence say?
The PEN Team looked at two trials, both of which demonstrated T2DM remission in some individuals when weight loss occurred after following a weight management program:
- The DiRECT trial assessed if intensive weight loss/maintenance would help people living in the U.K. with T2DM experience diabetes remission (4).
- This open-label cluster RCT randomized 306 participants (20-65 years with T2DM ≤6 years not receiving insulin and a BMI of 27-45 kg/m2) from 49 general practices into two groups: a weight management program (intervention, n=149) or to receive standard care (control, n=149).
- The intervention included the withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (TDR) (825-853 kcal)/day formula diet for three to five months), stepped food reintroduction (two to eight weeks), and structured support to maintain long-term weight loss.
- At the end of 12 months, 36 (24%) of the participants in the intervention group had weight loss of 15 kg or more (a primary outcome); no participants in the control group achieved this weight loss (P<0·0001). Sixty-eight (46%) participants in the intervention group had diabetes remission (a co-primary outcome) and six (4%) of the participants had remission in the control group (OR 19.7, 95%CI 7.8 to 49.8, P<0.0001). Weight loss impacted remission. Seventy-six participants within the whole study population who gained weight did not achieve remission.
- Follow-up results at two years identified 17 (11%) of participants in the intervention group and three (2%) participants in the control group who had weight loss of 15 kg or more; 36% of participants in the intervention group and 5% of control participants had diabetes remission (adjusted OR 25.82, 95%CI 8.25 to 80.84) (5). This suggests that sustained remission can be achieved at two years in some participants and is related to sustained weight loss.
- A small proof-of-concept study, the STANDby study (6), is similar to the DIRECT Trial, with a focus on individuals with South Asian ethnicity.
- Participants (25 adults 18-65 years of South Asian ethnicity with T2DM for ≤4 years and a BMI between 25-45 kg/m2) were randomized into two groups. The intervention group (n=13) started a structured TDR (~850 kcal) immediately delivered by a dietitian. The control group (n=12) followed their usual nutrition management for three months and then started TDR.
- Using observational analysis of the combined groups (n=23) who followed TDR for three to five months, the authors found that eight of 23 (35%) participants lost over 10% of their body weight; T2DM remission was achieved in 10 of 23 (43%) of participants.
A review of the above studies (4-6), along with a closer look into PubMed related to this topic has revealed additional evidence and clinical guidance worth exploring (1,2,7). At a later date, the PEN Team will further analyze the evidence and add new content into the PEN System about the potential benefits of very low calories/energy restrictions to promote remission of T2DM in individuals with more recent diabetes diagnoses. For now, dietitians can continue to individualize nutrition care management with their clients, based on International Diabetes Guidelines
, to promote improvements in diabetic markers, including glycemic control.
See Additional Content:
- Jacob E, Avery A. Energy-restricted interventions are effective for the remission of newly diagnosed type 2 diabetes: A systematic review of the evidence base. Obes Sci Pract. 2021 May 15;7(5):606-18. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/34631138/
- MacKay D, Chan C, Dasgupta K, Dominy K, Gagner M, Jin S, et al. Remission in type 2 diabetes. Can J Diabetes. 2022; 46(2022):753-61. Available from: https://www.canadianjournalofdiabetes.com/pb-assets/Health%20Advance/journals/jcjd/JCJD_1609-1668176217383.pdf
- Joubert H. Remission From Type 2 Diabetes: myth or reality. Medscape. 2022 Dec. Available from: https://www.medscape.com/viewarticle/985111
- Lean ME, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. 2018 Feb;391(10120):P541-51. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/29221645/
- Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol. 2019 May;7(5):344-355. doi: 10.1016/S2213-8587(19)30068-3. Epub 2019 Mar 6. PMID: 30852132. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/30852132/
- Satter N, Welsh P, Leslie WS, Thom G, McCombie L, Brosnahan N, et al. Dietary weight-management for type 2 diabetes remissions in South Asians: The South Asian diabetes remission randomised trial for proof-of-concept and feasibility (STANDby). Lancet. 2022 Nov;9:1-15. Available from: https://www.thelancet.com/journals/lansea/article/PIIS2772-3682(22)00128-7/fulltext
- Churuangsuk C, Hall J, Reynolds A, Griffin SJ, Combet E, Lean ME. Diets for weight management in adults with type 2 diabetes: an umbrella review of published meta-analyses and systematic review of trials of diets for diabetes remission. Diabetologia. 2022 Jan;65(1):14-36. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/34796367/