February 2018, Dr Chee L Khoo
It’s frustrating isn’t it when managing patients T2D. Patients adhere to diet and lifestyle the best they can, the HbA1c is “on target” but yet we have to keep layering more tablets or injections over time to maintain the constantly deteriorating glycaemic control. Can we do better than accepting without question the “progressive nature of T2D”?
We have all heard about treating the symptoms but not the disease. Is that what we are doing in T2D? I mean, hyperglycaemia really is the “symptom” of the metabolic disease, isn’t it? Yes, current multi-modal management attempts to reign in the hyperglycaemia in diabetes and there are increasing number of medications which we layer on as we treat the hyperglycaemia. But are we still just treating the symptoms?
Is dietary and lifestyle intervention with the aim of achieving remission in patients with T2D possible in primary care? The DiRECT trial is a pragmatic trial done under real-life, primary care conditions in a sample of people with type 2 diabetes. 306 individuals with T2D diagnosed in the preceding 6 years were recruited from 46 general practices from Scotland and the Tyneside region of England. There were many exclusion criteria, one of which was treatment with insulin.
The co-primary outcomes were a reduction in weight of 15 kg or more and remission of diabetes, defined as HbA1c less than 6.5% after at least 2 months off all anti-diabetic medications, from baseline to month 12. Patients in the intervention group were asked to follow a weight management program consisting of three months of low energy meal replacement diet. Following food re-introduction, physical activity was also increased. Nothing fancy. Just diet and then increased physical activity.
At 12 months, for participants who lost ≥ 15 kg, 86% achieved diabetes remission, for participants who lost 10-15kg, 57% achieved diabetes remission, for participants who lost 5-10kg, 34% went into remission and for participants who lost 0-5kg, 7% achieved remission. Not unexpectedly, none of the participants who did not lose any weight achieved remission. Lipid-lowering, anti-hypertensive and other medication prescriptions were significantly lower in the intervention group at 12 months. Quality of life also significantly improved in the intervention group at 12 months.
Franz et al’s meta-analysis showed an average weight loss of 10kg at 12 months with low calorie diets. In the Look AHEAD trial, a mean weight loss of 8.6kg were achieved in a heavily supported programme in specialist centres although diabetes remission was not the primary outcome. DiRECT differs from previous studies in that it was done under real life primary care conditions delivered by local nurses and dietitians (rather than specialist staff) with a primary outcome objective of diabetes remission.
Diet and lifestyle measures are often used in conjunction with pharmacotherapy to control glycaemia in T2D but often we are not aggressive enough to utilise these measures to achieve diabeteS remission. Bariatric surgery can achieve diabetes remission, especially where the duration of diabetes has not been long. Only a small proportion of patients could or would undergo this procedure.
Patients with T2D are still dying decades earlier than the general population and have 2-3 time the risk of cardiovascular events. We are still not treating the elephant in the room. Instead of treating to failure, should we not aim to get all T2D into remission? The DiRECT study has shown that weight loss resulting in diabetes remission is possible in general practice.
Access abstract here
Michael EJ Lean*, Wilma S Leslie, Alison C Barnes et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet. Published Online December 5, 2017 http://dx.doi.org/10.1016/S0140-6736(17)33102-1
Franz M, Vanwormer JJ, Crain L et al. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1 year follow up. J Am Diet Assoc 2007; 107: 1755–
Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the look AHEAD study. Obesity 2014; 22: 5–