Experts urge caution against overemphasis on type 2 diabetes remission

Current thinking around type 2 diabetes remission needs to be re-examined to improve patient outcomes, researchers behind a ground-breaking new report have said.

An international team of diabetes experts say that viewing type 2 diabetes remission as a “static endpoint” carries potential risks and creates a false sense of security among both patients and healthcare professionals. 

Instead, the concept of type 2 diabetes remission should be viewed as a spectrum with “more nuanced understanding”, with the team saying a globally coordinated effort is needed to redefine remission in type 2 diabetes.

The review, which examines the current definitions of type 2 diabetes remission and its limitations, was led by Professor Kamlesh Khunti CBE and Dr Dimitrios Papamargaritis from the Diabetes Research Centre at the University of Leicester, and funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) East Midlands.

An international consensus report in 2021 defined type 2 diabetes remission as HbA1c below 6.5% (48 mmol/mol), sustained for a specified period after starting a lifestyle intervention or undergoing bariatric surgery, or after stopping usual glucose-lowering medications. HbA1c is a person’s average blood glucose (sugar) levels for the last two to three months, and an HbA1c equal or more than 6.5% is one of the diagnostic criteria used for type 2 diabetes.

However, the new paper published in The Lancet Diabetes & Endocrinology highlights how type 2 diabetes remission is a new concept “with many unanswered questions” and that its definition is “contentious, given that it could occur for as little as three months”. 

The team points out that type 2 diabetes remission, typically attained through weight loss, appears to be temporary, with most people experiencing weight regain and relapse of the condition.

The current definition of remission is primarily glycaemia-focused, the report also outlines, and does not fully reflect the broader goals of care for type 2 diabetes, such as sustained weight loss and improving cardiovascular risk factors.

Professor Kamlesh Khunti, who is also Director of NIHR ARC East Midlands, said: “The concept of type 2 diabetes remission requires a paradigm shift towards patient-centred care, with an emphasis on holistic disease management and evidence-based interventions.

“By re-evaluating current definitions, acknowledging the progressive nature of type 2 diabetes, and embracing individualised approaches to glycaemic control, remission can be redefined as a dynamic continuum rather than a static endpoint. 

“Ultimately, this shift promises to herald a new era in personalised medicine, where the unique needs and goals of each patient are at the forefront of type 2 diabetes management, ultimately leading to improved health outcomes for people with the disease.” 

The researchers say that while there are benefits to the focus on remission, the risks in doing so could compromise health outcomes. This could include patients in remission receiving less attention, leading to inadequate support for maintaining remission and inadequate monitoring of diabetes-related complications. 

A study of over 2.8 million people with type 2 diabetes in England revealed that those classed as in remission were less likely to receive essential care processes, such as HbA1c measurements, blood pressure monitoring, and kidney function tests, than people with type 2 diabetes not classed as in remission. The label of remission can also cause patients and clinicians to view the condition as fully resolved, the researchers say.

Dr Papamargaritis added: “Type 2 diabetes remission could be viewed as a spectrum, from medication-supported to drug-free states. This more flexible and inclusive approach would better reflect real-world care and make remission a more relevant outcome in both clinical practice and research. 

“Sustained control of hyperglycaemia, along with reducing adiposity [body fat] – whether through surgical, medical, or lifestyle interventions – could be more relevant than remission itself.”

NIHR ARC East Midlands funds vital work to tackle the region’s health and care priorities by speeding up the adoption of research onto the frontline of health and social care. The organisation puts in place evidence-based innovations which seek to drive up standards of care and save time and money. 

NIHR ARC East Midlands is hosted by Nottinghamshire Healthcare NHS Foundation Trust and works in collaboration with the Health Innovation East Midlands. It has bases at the University of Leicester and the University of Nottingham.