In 2021, the American Diabetes Association, in collaboration with other organizations, defined type 2 diabetes mellitus remission as having an A1C lower than 6.5% measured at least three months after cessation of glucose-lowering pharmacotherapy.1,2 A 2022 umbrella review found that patients can achieve remission of type 2 diabetes with dietary changes alone.3 The American College of Lifestyle Medicine has published a position statement that supports this approach to reversing type 2 diabetes.4 Although meaningful weight loss requires resources and ongoing support, evidence shows that diabetes remission is achievable, especially for patients who have recently been diagnosed.5,6 Family physicians should share these findings and recommendations with patients.7,8
Motivational interviewing techniques are useful for exploring patients' interest and readiness to change their dietary habits.7,8 Family physicians can then explain the possibility of diabetes remission with diet change in patient-oriented terms: “You can achieve remission of your diabetes with diet and weight loss. I recommend that you see a dietitian as soon as possible to develop strategies for weight loss and hopefully achieve diabetes remission.”
The recent Diabetes Remission Clinical Trial (DiRECT) provides an evidence-based approach. The study recruited primary care patients with non–insulin-dependent type 2 diabetes diagnosed within the past six years.5,6 Participants were 20 to 65 years of age and had a body mass index of 27 to 45 kg per m2. The intervention group stopped all diabetes medications and followed a very low-calorie diet (approximately 850 kcal per day) that initially comprised a liquid meal replacement product. Solid foods were then gradually reintroduced. Participants were encouraged to engage in regular physical activity and had access to dietitians, cognitive behavior therapy, and regular follow-up with their primary care physician. After 12 months, 46% of participants in the intervention group had remission of their diabetes compared with only 4% of participants in the control group (odds ratio = 19.7; 95% CI, 7.8 to 49.8). The likelihood of remission increased with the amount of weight lost, with 86% of participants who lost at least 15 kg achieving remission.
Family physicians can and should be an integral part of supporting patients with recently diagnosed diabetes to work toward remission. We can monitor the patient monthly, noting progress and offering encouragement. We can facilitate ongoing contact with a dietitian and a therapist with expertise in cognitive behavior strategies. We can periodically monitor blood pressure and lipid, A1C, and transaminase levels to ensure safety of a very low-calorie diet, and we can help patients address social determinants using the EveryONE Project Toolkit (https://www.aafp.org/family-physician/patient-care/the-everyone-project/toolkit.html). Of note, glucagon-like peptide-1 agonists may also augment weight loss for patients who struggle to achieve meaningful weight loss with diet alone, although no evidence has linked this drug class with diabetes remission.
Given the negative effects of diabetes on patients, families, and communities, family physicians should counsel patients with a recent diagnosis about the benefits of a structured weight loss intervention, including diabetes remission.