Author
Sarah McCorquodale MD, CCFP, FCFP (biography and disclosures)
Disclosures: No relevant financial disclosures for this work.
Acknowledgements: I would like to thank Dr. Jonathan Little, PhD (Professor, Centre for Chronic Disease Prevention and Management, UBC) for his thoughts and input on this article.
What I did before
Type 2 diabetes has always been a chronic, progressive disease that can be managed through lifestyle measures and pharmacotherapy but not cured or put in remission. My efforts at prevention of diabetes and management of early diagnosed diabetes were limited to advising about lifestyle changes but not helping them make the changes.
What changed my practice
Diabetes Canada released a new chapter in their Clinical Practice Guidelines, Remission of Type 2 Diabetes (view), wherein an expert panel of clinicians and diabetes researchers reviewed the emerging evidence that patients with early type 2 diabetes (less than 6 years) can achieve remission through weight loss interventions.1 They defined remission as being at least 3 months of a return to prediabetes HbA1c 6–6.4% or normoglycemia HbA1c <6.0% without the use of any antihyperglycemic medications. Sustained weight loss of ≥15 kg of initial body weight was associated with the greatest probability of type 2 diabetes remission. Patients with history of significant disordered eating or mental health concerns and those needing hypoglycemic medications for renal or cardiovascular protection would not be ideal candidates for this approach.
The expert panel assessed the impact and safety of a variety of weight loss interventions, including surgical, behavioral, pharmaceutical, and digital technology interventions in patients with type 2 diabetes. The following table outlines recommended interventions and evidence:
Table 1. Recommended weight-loss interventions for remission of diabetes
| Population | Intervention | Goal | Evidence | Remission rate2 |
| Nonpregnant adults with BMI >25 kg/m2, type 2 diabetes <10 yrs, A1C <9%, not using insulin | Behavioural intervention: structured physical activity 240–420 min/week over 5 days/week and calorie-restricted diet3 | ∼5–7% weight loss of initial body weight and remission of diabetes | Grade C
Level 2 |
25% after 2 years |
| Nonpregnant adults with BMI 27– 45 kg/m2, type 2 diabetes <6 years, A1C <12%, not using insulin | Behavioural intervention: low-calorie diet (~800–850 kcal/d) with meal replacements for 3–5 months then gradual reintroduction of food and increased physical activity to maintain weight loss4,5 | 15 kg weight loss and remission of diabetes | Grade A
Level 1A |
50% after 1 year and 33% after 2 years
|
| Nonpregnant adults with BMI ≥35 kg/m2 and type 2 diabetes | Surgical intervention: bariatric surgery | Weight loss and remission of diabetes | Grade A
Level 1A |
30–63% after 1–5 years (35–50% relapse after 8.3 years) |
What I do now
Having evidence that remission of type 2 diabetes is possible through weight loss in select people, I have changed my approach to prevention and management of type 2 diabetes. Care is individualized to recognize different needs, goals, and supports of each patient while being cognizant of the stigmata of weight and of a chronic disease diagnosis, and systemic biases towards certain demographics and medication prescriptions over health behaviour change.
For prevention (impaired fasting glucose or HbA1C’s 6–6.4% for any length of time) or for treatment within the first six years of diagnosis, I spend more time exploring the perceived meaning of their diagnosis, their current lifestyle habits, and the opportunity for change. This is no longer a conversation in passing but warrants a full visit and discussion using principles of motivational interviewing and health behaviour change. These patients can be recalled by a search in an EMR by lab parameters such as HbA1c 6-6.4% at any time or HbA1c >6.5% for up to 6 years.
There are two different frameworks that I find helpful for health behaviour change conversations with patients. This may be done over a couple of visits or with the help of a clinic nurse.
- The first is the 5 A’s.6 In a primary care visit, I will:
- assess their understanding, knowledge, and current behaviours;
- advise about risks and benefits of change including now the possibility that their diabetes could be put into remission; work together to
- agree on a personal action plan to set goals,
- assist them to identify and engage with their supports and overcome their barriers; and
- arrange connections to other allied health care providers and follow up to assess their progress, reinforce their interest in change, and celebrate any changes they have made.
- The second is brief action planning tools that provide a framework for agreeing on the action plan.7 The Brief Action Plan flow chart can be accessed from centrecmi.ca (download PDF) and can be summarized as:
- Develop a SMART behaviour plan — specific, measurable, achievable, relevant and time-bound.
- Elicit a commitment statement — How confident are you in carrying out your plan?
- In follow-up visits, check on progress and agree on the next steps.
Many patients benefit from working with other professionals in different areas of expertise. Having a network of nutritionists, kinesiologists, and trainers who embody healthy lifestyle habits can help patients find success in their efforts toward health behaviour change.
For patients with type 2 diabetes for longer than six years or who may already be on multiple medications, the chance of remission is less, although emerging research shows that reduction in medications and improved A1C may be possible in this cohort too.8 I now spend more time inquiring about lifestyle habits, advising about the benefits of weight loss, and asking them if they are interested in making any changes.
The maintenance of remission depends on the intervention and the ability of the individual to maintain weight loss. Once remission is achieved it is recommended to measure A1C every 6 months to monitor for progression of disease. Future studies will be needed to determine the effect of remission on morbidity and mortality.
Handout
View and download the conversation starters handout you can use in practice. Download PDF.
Resources
- User’s guide — remission of type 2 diabetes. Diabetes Canada Clinical Practice Guidelines Expert Committee. Includes the guideline, video presentation, presentation slides, downloadable PDF, and summary of recommendations. (View)
- Jin, S. Remission of Type 2 Diabetes — User’s Guide. YouTube. 2022. (View video)
- 5As of obesity management for adults.
- Rationale and strategies for implementing the Five As from Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-84. doi:10.1016/s0749-3797(02)00415-4 (View with UBC)
- Obesity Canada (View)
- Practitioner guide PDF (View PDF)
- Motivational interviewing free online module. UBC CPD. 2.0 Mainpro+/MOC Section 3 (View)
- Brief action planning:
- The Centre for Collaboration, Motivation & Innovation.
- Brief Action Planning Flow Chart (View PDF)
- The Brief Action Planning Guide (View PDF)
- Brief action planning example – rheumatoid arthritis. YouTube. (View video)
- Brief Action Planning Professional Network
- Brief action planning example. YouTube. (View video)
- Cole SA, Jadotte YT. BAP-MI: a novel stepped-care integration of brief action planning and motivational interviewing to optimize outcomes. AJPM Focus. 2023;2(3):100108. May 15, 2023. (View)
- The Centre for Collaboration, Motivation & Innovation.
References
- MacKay D, Chan C, Dasgupta K, et al. Remission of type 2 diabetes: Diabetes Canada clinical practice guidelines expert working group. Can J Diabetes. 2022;46(8):753-761. doi:10.1016/j.jcjd.2022.10.004 (View)
- Jin S, Bajaj HS, Brazeau AS, et al. Remission of type 2 diabetes: user’s guide: Diabetes Canada clinical practice guidelines expert working group. Can J Diabetes. 2022;46(8):762-774. doi:10.1016/j.jcjd.2022.10.005 (View)
- Ried-Larsen M, Johansen MY, MacDonald CS, et al. Type 2 diabetes remission 1 year after an intensive lifestyle intervention: a secondary analysis of a randomized clinical trial. Diabetes Obes Metab. 2019;21(10):2257-2266. doi:10.1111/dom.13802 (View PDF)
- Taheri S, Zaghloul H, Chagoury O, et al. Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): An open-label, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2020;8(6):477-489. doi: 10.1016/S2213-8587(20)30117-0 (View with UBC)
- Lean M, Leslie W, Barnes A, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster-randomised trial. Lancet. 2018;391(10120):541-551. doi:10.1016/S0140-6736(17)33102-1 (View with UBC)
- Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-84. doi:10.1016/s0749-3797(02)00415-4 (View with UBC)
- Cole S, Gutnick D, Davis C, Riems K. Brief Action Planning Flow Chart. Centre for Collaboration Motivation and Innovation. 2016 Aug 8. 2023 July 2. (View PDF)
- Durrer, C., McKelvey, S., Singer, J. et al. A randomized controlled trial of pharmacist-led therapeutic carbohydrate and energy restriction in type 2 diabetes. Nat Commun. 2021; 12(1):5367. doi:10.1038/s41467-021-25667-4 (View PDF)
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It would have been useful to mention the Lifestyle Rx program which is available to all BC residents, and is covered by MSP. It is an in depth 12 week program supporting all the changes you have mentioned.
Karen Nishio
I took a course at UBC on low carb eating approaches to reverse diabetes a few years ago. “Eat less, exercise more” does not work. I’m surprised that the article suggests this paradigm with evidence against it. Nutritional ketosis has clear evidence, presented by UBC, for diabetes remission. Advocating unsupported, outdated advice does more harm than good.
Great article thank you.
This is a wonderful article. Thanks for summarizing everything I do in BC, it was right on point. We struggle across Canada to establish evidenced based weight management clinics with a functioning business model concurrently. However, despite this, many clinics use your approaches to Obesity and DM2 management. So it was a critical article for general MDs to read in BC. Thanks again. DEH.
This is a great article! I am so happy to share with my clients that remission may be possible. This may also help mitigate some of the diabetes distress so many people with diabetes face. Many of my clients are used to providers chasing A1C numbers and this gives back some of the control to the patient. Thank you.
Response to Joanne Parker:
Thank you for sharing your thoughts. In this article, I focused on the evidence that diabetes remission is possible through weight loss rather than specific ways to lose weight. Though I did cite evidence of calorie restriction and increased physical activity being an effective means of weight loss to achieve remission of diabetes, it is not the only way. The evidence tells us that sustainable weight loss is more nuanced than simply eat less and exercise more. Whether and how people attempt to lose weight is very much an individualized discussion dependent on the available evidence, the person’s resources and their desired outcome, and collaboration with the health care team.
Great article Dr. McCorquodale!
I would resonate with your response to Dr. Parker, and add to it – the evidence is also extremely clear that without calories burned in excess of total intake there is no change in weight and likely other metabolic parameters. I have a deep love and respect for ketogenic approaches as a therapeutic modality, but it is quite possible to gain weight on a LCHF diet if out of caloric balance. “Eat less, move more” is can certainly be poor advice as a basic counsel, but when paired with an appropriate behaviour change strategy and a nuanced understanding of the physiology underpinning a patient’s current metabolic state, I would argue it still serves as a foundation of what we aim to achieve with patients by one strategy or another.