SAN FRANCISCO — Diabetologists in recent years have been forewarning people with newly diagnosed type 2 diabetes they have a progressive condition that will eventually require insulin therapy. But one expert believes his latest research supports a different approach.

"We can say, 'If you stay your current weight, or even put on weight as some people do, you will follow the track of slowly going downhill," said Roy Taylor, MB, professor of medicine and metabolism, Newcastle University, Newcastle upon Tyne, UK. "And don't worry, we can look after you and give you pills, but we're going to be supervising your demise. So that's one choice."

"On the other hand, you might want to do this, admittedly, challenging thing and escape." The path to that "escape" is weight loss, pure and simple, Taylor told Medscape Medical News.

And although that message may not seem new, tying it to the potential for diabetes remission makes it more enticing, he says, pointing to the "extraordinary" 28% response rate he and his UK team got to recruiting letters for the Diabetes Remission Clinical Trial (DiRECT).

"There is a possible way back even after type 2 diabetes has been diagnosed," Taylor told a press briefing here. "This is very good news for people with diabetes."
Remarkable Results Achieved in the Real World

Moderating the press briefing, Alvin C. Powers, MD, director of the division of diabetes and endocrinology, Vanderbilt University School of Medicine, Nashville, Tennessee, said: "Diabetes is considered a progressive disease. These are remarkable results achieved by Taylor [and colleagues] in the real world."

The DiRECT study found rapid weight loss that is maintained can lead to remission of type 2 diabetes at 2 years in patients with early disease.

"We had a really representative group of people with real-life diabetes," said Taylor, presenting the findings here at the American Diabetes Association (ADA) 2019 Scientific Sessions for a US audience, having previously reported them at the Diabetes UK Professional Conference (DUPC), at which time they were also published simultaneously in Lancet Diabetes & Endocrinology.

"The [patients] want to get rid of their diabetes and get rid of the pills. So there's a big motivation that we, as doctors in diabetes, have not really spotted before," Taylor told Medscape Medical News.
"But then we haven't been able to say to people [before], 'Look, it's possible to escape this.'"
In the UK, where DiRECT was conducted, pilot studies are currently underway but more investment is needed for a national rollout.

Insulin-Producing Beta Cells Dormant, Not Dead

In the DiRECT study, patients with recently diagnosed type 2 diabetes received a calorie-restricted liquid diet (800 calories/day) for 3 to 5 months followed by gradual food reintroduction and a weight loss maintenance program.
Diabetes remission was defined as maintaining an HbA1c < 6.5% and fasting plasma glucose levels < 126 mg/dL without the use of drugs.
Overall, 36% of patients attained diabetes remission and sustained it for 24 months.

Achieving remission was tied to several factors, most notably weight loss. Of those participants who lost more than 10 kg (about 22 pounds), 64% achieved remission at 2 years.
But because not all of those who lost that much weight achieved remission, the researchers set out to differentiate between "responders" and "nonresponders."

One factor associated with being a responder was the mean time since diabetes diagnosis, Taylor explained.
Responders were diagnosed on average 2.7 years before the study, whereas nonresponders were diagnosed on average 3.8 years prior.

The thinking, he said is that — although the destruction of insulin-producing beta cells is a hallmark of progressive type 2 diabetes — responders had some beta cells that were dormant and the weight loss and associated reduction in metabolic stress enabled insulin production to "restart."
"By taking the 'stress' away [of a toxic food environment], the specialist function of the beta cell comes back," he told journalists.

Further study is nevertheless required to tease out the factors that determine whether significant weight loss can lead to diabetes remission, Taylor emphasized.
"We all have our own pancreas and it does its own thing," he said, responding to questions from delegates about whether genetics plays any role.

"The clues are there," he said, adding, "This is the beginning of the story, not the end."
Taylor has disclosed no relevant financial relationships.

ADA Scientific Sessions. Presented June 7, 2019. Abstract 66-OR

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