New study results are the first to show that people who can “reverse” type 2 diabetes through intensive lifestyle intervention — even if only temporarily — are less likely to develop heart and kidney disease in later life.
Reversal isn’t a medical term; doctors prefer to use the word remission, which, for type 2 diabetes, is defined as when a person’s A1C — a measure used to monitor blood sugar over a few months — falls below the diabetes range (<6.5 percent) without the use of blood sugar–lowering medication.
“There’s a lot of interest in the idea of remission of type 2 diabetes in the news these days. This is the first study to ask the questions ‘What happens after that? What happens after people achieve remission?’” explains lead author Edward W Gregg, PhD, professor at the School of Public Health, Imperial College, London.
“The main takeaway is that lifestyle-based efforts to achieve type 2 diabetes remission are associated with extended health benefits long beyond remission,” Dr. Gregg says.
Long-term complications that can result from living with type 2 diabetes for many years include damage to the heart, blood vessels, and kidneys and nerve damage that can affect eyesight and cause diabetic neuropathy.
In the study, called Look AHEAD, those who achieved diabetes remission had a 40 percent lower risk of cardiovascular disease and a 33 percent lower risk of kidney disease at the end of 12 years, according to the new report, published in Diabetologia.
This is most likely due to the results of weight loss, improvements in fitness, and lowering of A1C and low-density lipoprotein (LDL, or “bad”) cholesterol in the lifestyle intervention arm of the trial, says Gregg.
And the longer that people were able to maintain remission, the greater the benefit in terms of diabetes-related risk reduction, he stressed. Those who had evidence of at least four years of remission had 55 percent and 49 percent reductions in kidney and cardiovascular disease, respectively.
“This is the first study where we’ve shown the extended effects of remission on long-term diabetes complications. Our findings are very encouraging.”
Remission Isn’t Easy, but Even Temporary Reprieve Brings Benefits
The Look AHEAD study involved approximately 5,000 people with type 2 diabetes, around half of whom were assigned to an intensive lifestyle intervention segment. This consisted of weekly group and individual sessions in the first six months, to help participants reduce fat intake and total calorie intake by up to 1,800 calories per day, and to increase physical activity to around 175 minutes per week. The frequency of the sessions was reduced as the trial continued. By the end of the trial, participants attended training sessions only every two years.
The remaining half of the participants were given “diabetes education and support,” which consisted of three group sessions a year focusing on diet and physical activity goals.
Only 11 percent of the type 2 diabetes patients in the Look AHEAD study who were assigned to the intervention arm achieved remission one year into the study. Even fewer, 4 percent, were still in remission at 12 years, the study’s end. Participants with a short duration of type 2 diabetes, a low starting A1C, and a large magnitude of weight loss were most likely to experience remission.
Gregg stresses that remission isn’t easy; nor is it necessarily permanent.
“The majority of patients with type 2 diabetes are not going to achieve remission, but they can still gain these same health benefits through other means, such as managing risk factors well — blood pressure, glycemia (high blood sugar) and cholesterol, stopping smoking and things like that.”
“A healthy lifestyle is good at any point with type 2 diabetes. It’s going to have a benefit whether you achieve remission or not.”
As an illustration, Gregg notes that a few of the patients in the less intensive “diabetes, education and support arm” of Look AHEAD also achieved remission.
It Doesn’t Matter How Remission Is Achieved
Look AHEAD was started 15 years ago, when doctors first realized that bariatric surgery was able to put type 2 diabetes into remission, and they wanted to see if this was possible through lifestyle intervention alone.
In the years since, research has explored alternative methods of achieving diabetes remission. Other contemporary methods include very low-carbohydrate diets, meal replacement, such as the protocol for the ongoing DiRECT trial, or intermittent fasting.
It doesn’t really matter how remission is achieved, Gregg says, stressing that the goal is to remove use of all type 2 diabetes medications.
“[Look AHEAD is] the first intervention study to associate remission with reduction of diabetes-related complications, and this is encouraging news for those who can achieve remission from type 2 diabetes.”
And remission is still important even when only temporary, he says: “Our findings suggest any success with remission is associated with later health benefits.”
Can Ozempic and Mounjaro Create Diabetes Remission?
Asked whether the newer GLP-1 agonist drugs such as semaglutide (Ozempic) or tirzepatide (Mounjaro) should be counted when considering remission, Gregg is circumspect.
GLP-1 agonists appear to offer similar benefits to lifestyle interventions like those studied in the Look AHEAD trial. These drugs, which were first approved for type 2 diabetes for blood sugar reduction, can lead to a loss of up to 15 to 20 percent of body weight — approaching that achieved through bariatric surgery — and have also been shown to protect the heart and kidneys.
Technically, taking a GLP-1 agonist wouldn’t qualify for so-called type 2 diabetes remission because the goal of that is to remove all blood sugar–lowering medications, he explained.
And although people can now take GLP-1 agonists for obesity only, even if they don’t have diabetes, he quips, “I guess it’s a judgment call. Whether you call a GLP-1 agonist a diabetes medication or not.” But had GLP-1 agonists been available when Look AHEAD was conducted and a patient was taking one, “we would not have called that remission,” he concludes.
Gregg EW et al. Impact of Remission From Type 2 Diabetes on Long-Term Health Outcomes: Findings From the Look AHEAD Study. Diabetologia. January 18, 2024.