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By Joseph E. Scherger, MD, MPH
Vice President, Primary Care, Eisenhower Medical Center; Clinical Professor, Keck School of Medicine, University of Southern California, Los Angeles
Dr. Scherger reports no financial relationships relevant to this field of study.
SYNOPSIS: Type 2 diabetes is reversible (or can be put in remission) in a primary care practice with an intense low-carbohydrate weight management program.
SOURCE: Lean ME, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster randomized trial. Lancet 2017 Dec 4. pii: S0140-6736(17)33102-1. doi: 10.1016/S0140-6736(17)33102-1. [Epub ahead of print].
Type 2 diabetes is considered a chronic disorder that requires lifelong treatment. A group of investigators in Scotland enrolled 49 primary care practices to participate in an open-label trial of intensive weight management vs. routine care to achieve remission of type 2 diabetes. The patients were aged 20-65 years, had been diagnosed with type 2 diabetes within the past six years, had a body-mass index of 27-45 kg/m2, and were not receiving insulin. The intervention comprised withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (825-853 kcal/day formula diet for three to five months), stepped food reintroduction (two to eight weeks), and structured support for long-term weight loss maintenance. Measured outcomes were weight loss of ≥ 15 kg and remission of diabetes, defined as glycated hemoglobin (HbA1c) of < 6.5% (< 48 mmol/mol) after at least two months off all antidiabetic medications, within 12 months.
From 2014 to 2017, 306 individuals were recruited from 49 intervention (n = 23) and control (n = 26) general practices. At 12 months, a recorded weight loss of ≥ 15 kg occurred in 36 participants in the intervention group and no participants in the control group (P < 0.0001). Diabetes remission was achieved in 68 participants in the intervention group and six participants in the control group (P < 0.0001). Remission of type 2 diabetes varied with weight loss in the whole study population, with achievement in zero of 76 participants who gained weight, six of 89 participants who maintained 0-5 kg weight loss, 19 of 56 participants with 5-10 kg weight loss, 16 of 28 participants with 10-15 kg weight loss, and 31 of 36 participants who lost ≥ 15 kg. Mean body weight fell by 10.0 kg (standard deviation [SD], 8.0) in the intervention group and 1.0 kg (SD, 3.7) in the control group (P < 0.0001). Quality of life, as measured by the EuroQol 5 dimensions visual analogue scale, improved by 7.2 points (SD, 21.3) in the intervention group and decreased by 2.9 points (SD, 15.5) in the control group (P = 0.0012). Two serious adverse events (biliary colic and abdominal pain), occurring in the same participant, were deemed potentially related to the intervention. No serious adverse events led to withdrawal from the study.
Type 2 diabetes is not a life sentence. Although genetics plays a role, the dominant cause of type 2 diabetes is insulin resistance caused by lifestyle.1 At a certain weight, with excess body fat in the trunk, any person may become a type 2 diabetic. If insulin resistance can be reversed by loss of this fat, the disease should be reversible. Lean et al chose the term remission, suggesting the disease may return. This is true, but only if the underlying causes of the disease return. Long-term remission of type 2 diabetes should be considered as reversing the disease.
Clinics focusing on reversing type 2 diabetes are appearing across the country. We perform this work in my practice. Our method is a low-carbohydrate Mediterranean diet with intermittent fasting to achieve fasting insulin levels < 10. This method was developed by Jason Fung, MD, at the University of Toronto.2 Sarah Hallberg, MD, an internist at Indiana University, reverses diabetes as part of her weight management clinic. Eric Westman, MD, at Duke, recent president of the American Bariatric Society, uses low-carbohydrate nutrition to reverse type 2 diabetes.3 As Lean et al concluded, remission of type 2 diabetes is a practical target for any primary care practice.
Financial Disclosure: Internal Medicine Alert’s Physician Editor Stephen Brunton, MD, is a retained consultant for Abbott Diabetes, Becton Dickinson, Boehringer Ingelheim, Janssen, Lilly, Merck, Novo Nordisk, and Sanofi; he serves on the speakers bureau of AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, and Novo Nordisk. Contributing Editor Louis Kuritzky, MD, is a consultant for and on the speakers bureau of Amgen, Boehringer Ingelheim, and Shire. Peer Reviewer Gerald Roberts, MD; Editor Jonathan Springston; Executive Editor Leslie Coplin; and Editorial Group Manager Terrey L. Hatcher report no financial relationships relevant to this field of study.