# Int'l consensus statement on definition of T2D "remission"



## Eddy Edson

__





						International experts outline diabetes remission diagnosis criteria – Diabetologia
					






					diabetologia-journal.org
				




Summary: Defines "remission" as HbA1c < 48 mmol/mol persisting for at least 3 months in the absence of meds. 

Given that this is the consensus of of the ADA, DUK, the EASD and the ES, I guess it is now the "official" definition.  



_People with type 2 diabetes should be considered in remission after sustaining normal blood sugar levels for three months or more, according to a new consensus statement from the Endocrine Society, the European Association for the Study of Diabetes (EASD), Diabetes UK and the American Diabetes Association, and co-published in Journal of Clinical Endocrinology & Metabolism, Diabetologia, Diabetic Medicine and Diabetes Care.  

About 10% of the U.S. population has diabetes, and these numbers continue to rise. People with type 2 diabetes can achieve “remission” by sustaining normal blood sugar levels for at least three months without taking diabetes medication. There is still a lot of uncertainty around how long remission will last and what factors are associated with a relapse. A person may require ongoing support to prevent a relapse or a hyperglycemic episode, and the long-term effects of remission on mortality, heart health and quality of life are not well understood.

“Our international group of experts suggest an HbA1c (average blood sugar) level of less than 6.5% [ie 48 mmol/mol]  at least three months after stopping diabetes medication as the usual diagnostic criterion for diabetes remission,” said statement author and Endocrine Society member Matthew Riddle of Oregon Health & Science University in Portland, Ore. Riddle is chair of the Diabetes Remission Consensus writing group that developed the statement. “We also made suggestions for clinicians observing patients experiencing remission and discussed further questions and unmet needs regarding predictors and outcomes.”

The authors developed the following criteria to help clinicians and researchers evaluate and study diabetes remission using more consistent terminology and methods:
_

_Remission should be defined as a return of HbA1c to less than 6.5% [48 mmol/mol] that occurs spontaneously or following an intervention and that persists for at least three months in the absence of usual glucose-lowering pharmacotherapy._
_When HbA1c is determined to be an unreliable marker of long-term glycemic control, fasting plasma glucose of less than 126 mg/dL (<7.0 mmol/L) or estimated HbA1c less than 6.5% calculated from CGM values can be used as alternate criteria._
_Testing of HbA1c to document a remission should be performed just prior to an intervention and no sooner than three months after initiation of the intervention or withdrawal of any glucose-lowering pharmacotherapy._
_Subsequent testing to determine long-term maintenance of a remission should be done at least yearly, together with the testing routinely recommended for potential complications of diabetes._
_“Diabetes remission may be occurring more often due to advances in treatment,” said Amy Rothberg of the University of Michigan in Ann Arbor, Mich. Rothberg represents the Endocrine Society as a member of the Diabetes Remission Consensus writing group. “More research is needed to determine the frequency, duration and effects on short- and long-term medical outcomes of remission of type 2 diabetes using available interventions.”_


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## Gwynn

Yahoo, I'm in remission!

But we knew that already.

Good to get a concensus though.


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## Kreator

Well, that's me too then! - Although from what I knew before it was 6 months which to be honest is more realistic - 3 months is not long enough in my opinion - T2 Remission should be regarded as a long term goal not a 3 month quick fix!

I'll stick with my 6 months and beyond thanks!


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## Leadinglights

I had always thought it would be below 42mmol/mol not 48 as above that would still be prediabetic, that will encourage people to take their eye of the ball too soon and end up back where they were. 
I have read of cases of that on here.


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## mikeyB

I agree,@Leadinglights, 42 is a far better level for the reasons you give. Then if you lapse to a degree, you will become prediabetic rather than diabetic.


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## Kreator

Leadinglights said:


> I had always thought it would be below 42mmol/mol not 48 as above that would still be prediabetic, that will encourage people to take their eye of the ball too soon and end up back where they were.
> I have read of cases of that on here.


That's a good point too - since being diagnosed, I always had in my mind to be below 42...forever! - I'd suggest this decision is based so that they can say look how many diabetics we have put into remission, only for a few months later for them all to be back in diabetic range!


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## Bruce Stephens

Kreator said:


> I'd suggest this decision is based so that they can say look how many diabetics we have put into remission, only for a few months later for them all to be back in diabetic range!


Or they can see that actually, getting under 48 for three months is a good predictor for being under 48 for much longer, so is about as useful as using 42?


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## Kreator

Bruce Stephens said:


> Or they can see that actually, getting under 48 for three months is a good predictor for being under 48 for much longer, so is about as useful as using 42?


I guess that's a fair point - I for example for 3 years was controlled with Metformin being between 52-45, but it didn't really do me any favours really until I came off Metformin, went on a Low Calorie Diet, changed my whole thinking around food etc. etc. - my latest level was 42 a couple of months ago (No Meds) - next HbA1c in 2 weeks time - if it's not in the mid 30's by then, I have more work to do - but I still even then need to keep it up as I'm still suseptable to going back up again if I'm not mindful...

My point really is that making it 3 months and bingo you're in remission doesn't quite send the right message...


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## Bruce Stephens

Kreator said:


> My point really is that making it 3 months and bingo you're in remission doesn't quite send the right message...


I agree, but maybe they have evidence that it's fine really? Or maybe they're OK with having remission often being just temporary.


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## AndBreathe

Personally, I feel the fairest way to judge remission is on sustainability.  I'm not necessarily suggesting 10yrs of HbA1c <42, but perhaps 12 or 24 months.   I fear a single <48 HbA1c might lead to yo-yo diagnosis, just like yo-yo dieting.


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## everydayupsanddowns

I was reading this Diabetes UK position statement on how the consensus was put together a couple of days ago.

There’s a more person-with-diabetes-friendly version which explains things here too 





						Diabetes remission
					

Diabetes remission in people with Type 2 diabetes means that your blood sugar levels are below the diabetes range without needing to take diabetes medication any more. Here we’ll explain what aiming for diabetes remission could mean for you.




					www.diabetes.org.uk


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## Eddy Edson

everydayupsanddowns said:


> I was reading this Diabetes UK position statement on how the consensus was put together a couple of days ago.
> 
> There’s a more person-with-diabetes-friendly version which explains things here too
> 
> 
> 
> 
> 
> Diabetes remission
> 
> 
> Diabetes remission in people with Type 2 diabetes means that your blood sugar levels are below the diabetes range without needing to take diabetes medication any more. Here we’ll explain what aiming for diabetes remission could mean for you.
> 
> 
> 
> 
> www.diabetes.org.uk


The DUK position statement is well worth reading.


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## Eddy Edson

It's a bit interesting that the position statements don't say anything about weight loss meds.  

Recent large semaglutide trials show "remission"-type HbA1c outcomes in T2D, driven just by weight loss, with far greater proportions of people hitting and maintaining 15%+ weight loss targets than you find in lifestyle programs. 

Would achieving normoglycemia via semaglutide-induced weight loss count as "remission" and if not, is there actually a useful reason why not? I suppose the expert groups are considering this kind of question.


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## Kreator

From my own personal standpoint being diagnosed with T2 over 3 years ago knowing at that point I could aim for remission, found that until I was invited onto the NHS 5000 Pilot Low Calorie Diet Program my GP/DN aims were for good control with meds - fine, but that advise was only going to lead one way...down...more meds, eventually insulin etc...

I had good control and was doing well - but in my mind wanted better and better results - to the point of asking my DN to come off the Metformin only to be told late last year that they don't like to do that...! - I asked 'how can I achieve remission then?' - No answer...

...Until the NHS Pilot came along...

Meds stopped a month before starting the pilot and no meds since including statins...in 15 weeks lost 15Kg, totally changed my thinking and behabiour around food, and bacame much more active....

I know from daily Glucose testing (Fasting/Post Prandial/after exercise) it's working - I am finally becoming normal if you like - But....I also know that after 30 years of abuse my body can't recover that quickly - my Liver perhaps, but my Pancreas has still a way to go, so I don't intend relaxing any time soon...

So the point of <48 with no meds for remission is a start and a line has to be drawn somewhere, but T2 remission is much much more than this...and from my experience <48 with meds was not remission, and I doubt 47 without meds would be much different in terms of day to day glucose levels - although I can see it might offer a glimmer of hope for people going forward so long as it's emphasised that it's a long term strategy and not a quick fix...


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## Gwynn

Just read the diabetes Uk position statement and agree with it completely.

I have acheived remission from T2 with a HbA1c now of 34. 

I fitted the bill. Obese, terrible diet, no exercise. Diagnosed. Shoved on meds. Turned all that around, came off meds and got into remission nine months down the line. 

I am glad that the NHS are waking up to better acheivable possibilities for T2s and to the hope advice and support on remission can give. 

I got zero advice and zero support but at least they didn't try to stop me trying. But, and its a big but, I had to learn for myself how to do it. Of course this forum pointed me in all the right directions.


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## AndBreathe

@everydayupsanddowns (I only tag you as I understand you are a member of Diabetes UK staff - apologies if this isn't the case) - Whilst most of those diagnosed with T2 will be carrying some additional weight, that doesn't cover everyone.  My concern with the Diabetes UK statement on remission is its focus on weight loss:

".... 
How can you put diabetes into remission?​The strongest evidence we have suggests that diabetes is mainly put into remission by weight loss. ...."

Surely T2 is put into remission by reducing the blood glucose scores?  Dietary changes, resulting in weight loss may be a mechanism for doing that, but the fact there are slim and even skinny T2s suggests there's more to diabetes than love handles.

Yes, the statement states mainly, but it could be taken, by those don't understand T2 well, to be discouraged, simply because they don't carry much, if any, excess weight.


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## Eddy Edson

AndBreathe said:


> @everydayupsanddowns (I only tag you as I understand you are a member of Diabetes UK staff - apologies if this isn't the case) - Whilst most of those diagnosed with T2 will be carrying some additional weight, that doesn't cover everyone.  My concern with the Diabetes UK statement on remission is its focus on weight loss:
> 
> "....
> How can you put diabetes into remission?​The strongest evidence we have suggests that diabetes is mainly put into remission by weight loss. ...."
> 
> Surely T2 is put into remission by reducing the blood glucose scores?  Dietary changes, resulting in weight loss may be a mechanism for doing that, but the fact there are slim and even skinny T2s suggests there's more to diabetes than love handles.
> 
> Yes, the statement states mainly, but it could be taken, by those don't understand T2 well, to be discouraged, simply because they don't carry much, if any, excess weight.


 Just because you have a "normal" BMI doesn't mean you won't get to T2D remission by losing weight. Eg: I had a BMI of 25 point something at DX and zapped my T2D by losing 10kg.  There are plenty of other anecdotes along the same lines, and the delayed ReTUNE study of weight-loss remission amongst slimmer T2D's hopefully reports soon.

The model doesn't depend on how much fat you're carrying, rather on where that fat is stored and how your individual make-up responds to it. Pack too much visceral fat for your "personal fat threshhold" and you may develop T2D, regardless of your BMI.    https://www.ncl.ac.uk/media/wwwncla...onancecentre/files/fat-threshholds-slides.pdf



Of course there are people for whom a weight-loss approach won't work. But I'd say that the "weight loss but only if you need to lose weight" kind of messaging you see may well be more problematic, because it might lead somebody with a "healthy-ish" BMI to conclude that the weight-loss approach wouldn't work for them, when it most likely would.


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## everydayupsanddowns

Yes I spotted that too @AndBreathe

I wasn’t involved in the position statement, but I would imagine that much of the research data that underpins the statement comes from the ongoing and pivotal DIRECT trial, which has made important discoveries about some of the weight-related drivers behind T2 diabetes (or at least the majority of T2 cases), and how these can be put in remission by significant weight loss.

If you are interested I can ask the Information Team for details?


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## Burylancs

mikeyB said:


> I agree,@Leadinglights, 42 is a far better level for the reasons you give. Then if you lapse to a degree, you will become prediabetic rather than diabetic.


No you won't, you will still be diabetic. A diagnosis of T2 is for life. What's this fad for 'remission' all about, what was wrong with 'good control'? It seems to be feeding denial and implying that T2s shouldn't be taking meds. Both highly irresponsible.


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## AndBreathe

everydayupsanddowns said:


> Yes I spotted that too @AndBreathe
> 
> I wasn’t involved in the position statement, but I would imagine that much of the research data that underpins the statement comes from the ongoing and pivotal DIRECT trial, which has made important discoveries about some of the weight-related drivers behind T2 diabetes (or at least the majority of T2 cases), and how these can be put in remission by significant weight loss.
> 
> If you are interested I can ask the Information Team for details?



Yes, I'd be interested please.  I'd be very disappointed if the stance was created purely based on the DiRECT trial, or indeed solely on trials funded by Diabetes UK.


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## everydayupsanddowns

I will ask the question! 

Though to be fair to DUK, DiRECT is a large, ongoing, and respected piece of work and I think it would be viewed as important whoever had funded it


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## Kreator

everydayupsanddowns said:


> I will ask the question!
> 
> Though to be fair to DUK, DiRECT is a large, ongoing, and respected piece of work and I think it would be viewed as important whoever had funded it


Hi @everydayupsanddowns I'd also be interested please - I agree DUK & DiRECT are hugely important pieces of work - I wouldn't be able to participate in the NHS Pilot if it wasn't for both!

The main issue I have is that I'm finding personally that true 'remission' is well below 48 or even 42 - I would say 48 - 42 range is more like well controlled...

To me, 'Remission' means my body is starting to work properly again slowly but surely, which could come back if I slip into old ways...?


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## everydayupsanddowns

Kreator said:


> The main issue I have is that I'm finding personally that true 'remission' is well below 48 or even 42 - I would say 48 - 42 range is more like well controlled...



Yes, reading the DUK position statement, I think it was quite difficult to come to an agreement, and I suspect there were a variety of views and opinions to balance.


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## AndBreathe

everydayupsanddowns said:


> I will ask the question!
> 
> Though to be fair to DUK, DiRECT is a large, ongoing, and respected piece of work and I think it would be viewed as important whoever had funded it



To be clear, I'm not suggesting the DiRECT trial is shady or in any way inappropriate, but I would like to think they looked at other ways of achieving remission, and other dietary approaches.

I'm afraid for me asking people to give up what I consider to be proper food (shakes haven't ever been part of my life, and for now, I can't ever seeing them feature), the learning what they have to do to maintain any losses achieved doesn't make sense.

I feel that all those changes are more likely to lead to a revolving door situation in terms of weight regain and potential re-crossing the diagnostic threshold.


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## everydayupsanddowns

Thought this thread, and the paper it quotes, was interesting in the context of this discussion



			https://forum.diabetes.org.uk/boards/threads/dietary-strategies-for-remission-of-type-2-diabetes-a-narrative-review.95671/
		


It specifically mentions the effectiveness of low-carb approaches, but recognises that some people can find these hard to maintain, plus the importance of being able to maintain either the weight loss, or the balance of macronutrients which have been involved in achieving the remission.

I have read before that low carb approaches seem to struggle in some clinical trials - part of me wonders whether it makes a difference whether low carb is an approach that you discover for yourself, vs one that you are told you have to do by a Dr?


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## Burylancs

Eddy Edson said:


> __
> 
> 
> 
> 
> 
> International experts outline diabetes remission diagnosis criteria – Diabetologia
> 
> 
> 
> 
> 
> 
> 
> diabetologia-journal.org
> 
> 
> 
> 
> 
> Summary: Defines "remission" as HbA1c < 48 mmol/mol persisting for at least 3 months in the absence of meds.
> 
> Given that this is the consensus of of the ADA, DUK, the EASD and the ES, I guess it is now the "official" definition.
> 
> 
> 
> _People with type 2 diabetes should be considered in remission after sustaining normal blood sugar levels for three months or more, according to a new consensus statement from the Endocrine Society, the European Association for the Study of Diabetes (EASD), Diabetes UK and the American Diabetes Association, and co-published in Journal of Clinical Endocrinology & Metabolism, Diabetologia, Diabetic Medicine and Diabetes Care.
> 
> About 10% of the U.S. population has diabetes, and these numbers continue to rise. People with type 2 diabetes can achieve “remission” by sustaining normal blood sugar levels for at least three months without taking diabetes medication. There is still a lot of uncertainty around how long remission will last and what factors are associated with a relapse. A person may require ongoing support to prevent a relapse or a hyperglycemic episode, and the long-term effects of remission on mortality, heart health and quality of life are not well understood.
> 
> “Our international group of experts suggest an HbA1c (average blood sugar) level of less than 6.5% [ie 48 mmol/mol]  at least three months after stopping diabetes medication as the usual diagnostic criterion for diabetes remission,” said statement author and Endocrine Society member Matthew Riddle of Oregon Health & Science University in Portland, Ore. Riddle is chair of the Diabetes Remission Consensus writing group that developed the statement. “We also made suggestions for clinicians observing patients experiencing remission and discussed further questions and unmet needs regarding predictors and outcomes.”
> 
> The authors developed the following criteria to help clinicians and researchers evaluate and study diabetes remission using more consistent terminology and methods:
> _
> 
> _Remission should be defined as a return of HbA1c to less than 6.5% [48 mmol/mol] that occurs spontaneously or following an intervention and that persists for at least three months in the absence of usual glucose-lowering pharmacotherapy._
> _When HbA1c is determined to be an unreliable marker of long-term glycemic control, fasting plasma glucose of less than 126 mg/dL (<7.0 mmol/L) or estimated HbA1c less than 6.5% calculated from CGM values can be used as alternate criteria._
> _Testing of HbA1c to document a remission should be performed just prior to an intervention and no sooner than three months after initiation of the intervention or withdrawal of any glucose-lowering pharmacotherapy._
> _Subsequent testing to determine long-term maintenance of a remission should be done at least yearly, together with the testing routinely recommended for potential complications of diabetes._
> _“Diabetes remission may be occurring more often due to advances in treatment,” said Amy Rothberg of the University of Michigan in Ann Arbor, Mich. Rothberg represents the Endocrine Society as a member of the Diabetes Remission Consensus writing group. “More research is needed to determine the frequency, duration and effects on short- and long-term medical outcomes of remission of type 2 diabetes using available interventions.”_



It's intriguing that the four bodies deciding this are Lobby/Pressure Groups. There doesn't seem to be any official medical body involved in it.  This makes this definition of so-called 'remission' a . political decision rather than a medical one ? It's disappointing that it ignores all the other aspects of Type 2 and just focusses on the HbA1c. That plays into the narrative that T2s don't need to test because the A1c will decide everything. But according to this feeble definition of 'remission'  a T2 could  be taking a statin to combat their Diabetic Dyslipidemia or a  blood pressure tablet to get their bp in the range for diabetics or an Ace Inhibitor for kidney problems and  they would be said to be in 'remission'  because they weren't taking metformin. Absurd tunnel vision. This definition seems to ignore the Metabolic Syndrome - the Four Horsemen of the Apocalypse that ride together and exacerbate each other - Hypertension , Hypercholesterol, Overweight and Type 2 Diabetes. This definition of 'remission' seems to be 'golfing with one club'.


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## Eddy Edson

Burylancs said:


> It's intriguing that the four bodies deciding this are Lobby/Pressure Groups. There doesn't seem to be any official medical body involved in it.  This makes this definition of so-called 'remission' a . political decision rather than a medical one ? It's disappointing that it ignores all the other aspects of Type 2 and just focusses on the HbA1c. That plays into the narrative that T2s don't need to test because the A1c will decide everything. But according to this feeble definition of 'remission'  a T2 could  be taking a statin to combat their Diabetic Dyslipidemia or a  blood pressure tablet to get their bp in the range for diabetics or an Ace Inhibitor for kidney problems and  they would be said to be in 'remission'  because they weren't taking metformin. Absurd tunnel vision. This definition seems to ignore the Metabolic Syndrome - the Four Horsemen of the Apocalypse that ride together and exacerbate each other - Hypertension , Hypercholesterol, Overweight and Type 2 Diabetes. This definition of 'remission' seems to be 'golfing with one club'.


Oh, I agree. BP, lipids, kidneys are generally way more important than BG once you get down to 48-ish (or higher) mmol/mol HbA1c levels. People stressing about whether they score sub 48 or sub 42 or whatever, where the exact number makes sod all difference for health outcomes, are not doing themselves a service if it means they're ignoring the other markers.  

On the other hand, reducing weight is generally a pretty effective tool (not perfect, obviously) for handling all of these issues, in particular, cutting through the metabolic syndrome nexus. That's certainly been my experience.


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## Burylancs

everydayupsanddowns said:


> I will ask the question!
> 
> Though to be fair to DUK, DiRECT is a large, ongoing, and respected piece of work and I think it would be viewed as important whoever had funded it


You can understand them not wanting to get involved in Taylor's simplistic fat shaming version of Type 2 especially as his experiment wasn't all that successful. And as Eddie Edspn keeps reminding us the benefits of the Newcastle diet's short sharp shock wash out over time as the reality of the condition, chiefly Insulin Resistance, re-assert themselves.


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## Eddy Edson

Burylancs said:


> You can understand them not wanting to get involved in Taylor's simplistic fat shaming version of Type 2 especially as his experiment wasn't all that successful. And as Eddie Edspn keeps reminding us the benefits of the Newcastle diet's short sharp shock wash out over time as the reality of the condition, chiefly Insulin Resistance, re-assert themselves.


No, in the studies remission "washes out over time" if you stack the fat back on again, not otherwise (over the 2 year follow-up). Maintaining the weight loss is the hard thing.


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## Burylancs

Eddy Edson said:


> No, in the studies remission "washes out over time" if you stack the fat back on again, not otherwise (over the 2 year follow-up). Maintaining the weight loss is the hard thing.


Yes, the short sharp shock hasn't done anything tp address the underlying problem. Its Insulin Resistance that's causing the weight gain.


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## Eddy Edson

Burylancs said:


> Its Insulin Resistance that's causing the weight gain.


No. The model I know of which says something like that is sometimes called the "carbohydrate insulin" model and a series of experiments by Kevin Hall & others have pretty much put a fork in it, I would say. https://www.niddk.nih.gov/about-niddk/staff-directory/biography/hall-kevin/publications

What's causing the weight gain amongst some of the trial participants (certainly not all)  is starting to eat too much again.


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## Kreator

Eddy Edson said:


> No. The model I know of which says something like that is sometimes called the "carbohydrate insulin" model and a series of experiments by Kevin Hall & others have pretty much put a fork in it, I would say. https://www.niddk.nih.gov/about-niddk/staff-directory/biography/hall-kevin/publications
> 
> What's causing the weight gain amongst some of the trial participants (certainly not all)  is starting to eat too much again.


Exactly...

From what I can see the absolute 'key' to this is the individual person's drive & determination...long term...

I was really concerned when I started food re-introduction that I'd put all the weight back on and then some - It's no good thinking 'I've lost 15Kg and I'm in Remission' only to take your eye off the ball and go back to where you started...

The weight loss is a mechanism rather than a strategy - and you have to understand what's happenning during this process to be able to move on - the strategy is then living a healthy lifestyle once the weight is off...

For certain, I won't be able to eat what I did before, but why would I want to?! - It was altogether far too much for me to handle long term hence diagnosis of T2D in the first place...


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## Docb

Interesting discussion.  I'll chuck in my usual comment that dumping everything into one box and calling it T2 diabetes tends to confuse the issue.  I keep coming back to the idea that there should be, to start with, two sub groups.  IRT2 -T2 due to insulin resistance and IIT2 - T2 due to insulin insufficiency.  

The idea that losing weight and then eating any old diet that maintains that weight loss works well for those with IRT2 caused by excess fat around the body.  Keep the weight down, a good idea for all sorts of reasons, and the diabetes is no longer a problem no matter what you eat and that is something that can be called remission.

When it comes to IIT2 things are a bit different.  In that case, there is a limit to the amount of glucose the system can deal with and any old diet is not going to work.  If you do not limit carb intake when your body weight is OK then your blood glucose will rise whilst your weight stays the same.  To me that is not remission, it is best described as control.

Personally I consider myself in the second category. BMI fine, HbA1c well below diagnosis level but I reckon a slice of flapjack would give me a double figure spike and readjusting my diet to double the carb intake without a calorie boost would soon put me over the diagnosis level without any weight increase.  It's a guess, and would need a trial to confirm, but it is one experiment I am not going to do.

One of the things I find most frustrating is that once T1 is ruled out, no effort is made to identify the underlying reason for high blood glucose for any individual.  Casting the runes seems to be the order of the day and how you get on has more to do with the luck of the rune caster than objective science.  You also get analysis heavily influenced by opinion and prejudice, and that may have something to do with the origins of this discussion.


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## adrian1der

everydayupsanddowns said:


> I was reading this Diabetes UK position statement on how the consensus was put together a couple of days ago.
> 
> There’s a more person-with-diabetes-friendly version which explains things here too
> 
> 
> 
> 
> 
> Diabetes remission
> 
> 
> Diabetes remission in people with Type 2 diabetes means that your blood sugar levels are below the diabetes range without needing to take diabetes medication any more. Here we’ll explain what aiming for diabetes remission could mean for you.
> 
> 
> 
> 
> www.diabetes.org.uk


I'm confused - the top says three months but the link says six?


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## Burylancs

Docb said:


> Interesting discussion.  I'll chuck in my usual comment that dumping everything into one box and calling it T2 diabetes tends to confuse the issue.  I keep coming back to the idea that there should be, to start with, two sub groups.  IRT2 -T2 due to insulin resistance and IIT2 - T2 due to insulin insufficiency.
> 
> The idea that losing weight and then eating any old diet that maintains that weight loss works well for those with IRT2 caused by excess fat around the body.  Keep the weight down, a good idea for all sorts of reasons, and the diabetes is no longer a problem no matter what you eat and that is something that can be called remission.
> 
> When it comes to IIT2 things are a bit different.  In that case, there is a limit to the amount of glucose the system can deal with and any old diet is not going to work.  If you do not limit carb intake when your body weight is OK then your blood glucose will rise whilst your weight stays the same.  To me that is not remission, it is best described as control.
> 
> Personally I consider myself in the second category. BMI fine, HbA1c well below diagnosis level but I reckon a slice of flapjack would give me a double figure spike and readjusting my diet to double the carb intake without a calorie boost would soon put me over the diagnosis level without any weight increase.  It's a guess, and would need a trial to confirm, but it is one experiment I am not going to do.
> 
> One of the things I find most frustrating is that once T1 is ruled out, no effort is made to identify the underlying reason for high blood glucose for any individual.  Casting the runes seems to be the order of the day and how you get on has more to do with the luck of the rune caster than objective science.  You also get analysis heavily influenced by opinion and prejudice, and that may have something to do with the origins of this discussion.


Perhaps you are being unnecessarily frugal in allowing only 2 types of T2. When I was dxed in 1992 it was commonplace to hear that Type 2 Diabetes was a label covering half a dozen different conditions with a common symptom. In the late 1990s we heard a lot about about Amylin, that excess amylin was the major problem for some T2s. It was seriously proposed by some authorities that up to 10-15% of T2s should be redxed as 'Amylinotics' but that would mean testing newbies for amylin levels which is never going to happen. And of course investigations have shown that between 20 and 30% of T2s have malformed insulin without the tethers needed to tether themselves to the insulin receptor port on the cell wall. That's the cause of their Insulin Resistance. Again are they going to test the insulin of every new T2 ? No way, even though that research suggests  that up to 30% of T2s just need insulin injections from the get go to replace their wonky stuff.


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## grovesy

Some researchers have identified many Types of Diabetes, but it has not received as much publicity as the Newcastle findings.


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## Burylancs

grovesy said:


> Some researchers have identified many Types of Diabetes, but it has not received as much publicity as the Newcastle findings.


Diabetes UK has invested too much time, money and emotional capital in Direct trial. And that inappropriate term  'remission', is seductive and beguiling newbies into believing they can return to 'normal' with a quick shake of Sooty's Magic Wand.


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## Docb

Burylancs said:


> Perhaps you are being unnecessarily frugal in allowing only 2 types of T2.


Quite agree @Burylancs but you have got to start somewhere.  My underlying point is that the more precise the information, the better the decisions made on the basis of it.  All too often more effort is spent arguing about the meaning of limited information than would be spent getting better data.


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## everydayupsanddowns

adrian1der said:


> I'm confused - the top says three months but the link says six?



Good spot Adrian - I hadn’t noticed that!

The position statement says ‘at least 3 months’, which could suggest maintaining it through 2x HbA1cs, usually 3months apart?



			https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-08/DIABETES%20UK%20UPDATED%20POSITION%20STATEMENT%20ON%20REMISSION%20IN%20ADULTS%20-%20FINAL_0.pdf


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## adrian1der

everydayupsanddowns said:


> Good spot Adrian - I hadn’t noticed that!
> 
> The position statement says ‘at least 3 months’, which could suggest maintaining it through 2x HbA1cs, usually 3months apart?
> 
> 
> 
> https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-08/DIABETES%20UK%20UPDATED%20POSITION%20STATEMENT%20ON%20REMISSION%20IN%20ADULTS%20-%20FINAL_0.pdf


Makes a difference to me - I had an HbA1c three months after coming off metformin. So by one definition I'm in remission by the other I will have to wait for my next test


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## everydayupsanddowns

AndBreathe said:


> Whilst most of those diagnosed with T2 will be carrying some additional weight, that doesn't cover everyone.  My concern with the Diabetes UK statement on remission is its focus on weight loss:
> 
> "*How can you put diabetes into remission?*
> The strongest evidence we have suggests that diabetes is mainly put into remission by weight loss. ...."
> 
> Surely T2 is put into remission by reducing the blood glucose scores?  Dietary changes, resulting in weight loss may be a mechanism for doing that, but the fact there are slim and even skinny T2s suggests there's more to diabetes than love handles.



I’ve asked Diabetes UK for some feedback on your questions @AndBreathe 

Diabetes UK understands that not everyone with T2 is overweight or living with obesity, but for those who are, research over the years has shown that weight loss is the primary goal to managing blood glucose levels and reducing the risk of diabetes complications​​The position statement is based on published research, and research to date shows that remission of type 2 diabetes occurs in people living with obesity, or who are overweight, when they lose weight. We do not currently have research to show how type 2 diabetes remission can occur in people without weight loss which is why the statement emphasises on weight loss to reflect the research evidence.​​There is research underway to see if the same concept of remission by weight loss can help people with type 2 diabetes with lower BMI. This would involve people aren’t usually advised by their doctors to lose weight https://www.diabetes.org.uk/research/our-research-projects/northern-and-yorkshire/retuneing-type-2-diabetes-remission. Until more research results are available, Diabetes UK can only rely on the published research which shows that type 2 remission is mainly achieved through weight loss in people who have obesity or overweight​
Interestingly the idea of achieving remission with a low carb approach that @Eddy Edson shared includes some similar language:

_• Based on evidence from clinical trials, *maintenance of weight loss appears to be the main driver of continued remission*, and this therefore needs to be a key focus of the planning and delivery of all services designed to achieve remission.
If a diet low in carbohydrate is sustainable to the individual, normoglycaemia may be maintained in the absence of weight loss, *although evidence is limited and loss of remission is likely to occur if carbohydrate restriction ceases*.
• Total dietary replacements (TDR) and low carbohydrate diets have been demonstrated as being effective in facilitating weight loss and remission of T2DM. Evidence of effectiveness beyond 2 years is limited. The dietary approach should be one which the individual can maintain for the long term._

(emphasis added)


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## Burylancs

adrian1der said:


> Makes a difference to me - I had an HbA1c three months after coming off metformin. So by one definition I'm in remission by the other I will have to wait for my next test


The goalposts keep moving. The original Lancet article about this in 2017 says 2 months ....
'Co-primary
outcomes were weight loss of 15 kg or more, and remission of diabetes, defined as glycated haemoglobin (HbA1c) of
less than 6·5% (<48 mmol/mol) after at least 2 months off all antidiabetic medications.'


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## AndBreathe

everydayupsanddowns said:


> I’ve asked Diabetes UK for some feedback on your questions @AndBreathe
> 
> Diabetes UK understands that not everyone with T2 is overweight or living with obesity, but for those who are, research over the years has shown that weight loss is the primary goal to managing blood glucose levels and reducing the risk of diabetes complications​​The position statement is based on published research, and research to date shows that remission of type 2 diabetes occurs in people living with obesity, or who are overweight, when they lose weight. We do not currently have research to show how type 2 diabetes remission can occur in people without weight loss which is why the statement emphasises on weight loss to reflect the research evidence.​​There is research underway to see if the same concept of remission by weight loss can help people with type 2 diabetes with lower BMI. This would involve people aren’t usually advised by their doctors to lose weight https://www.diabetes.org.uk/research/our-research-projects/northern-and-yorkshire/retuneing-type-2-diabetes-remission. Until more research results are available, Diabetes UK can only rely on the published research which shows that type 2 remission is mainly achieved through weight loss in people who have obesity or overweight​
> Interestingly the idea of achieving remission with a low carb approach that @Eddy Edson shared includes some similar language:
> 
> _• Based on evidence from clinical trials, *maintenance of weight loss appears to be the main driver of continued remission*, and this therefore needs to be a key focus of the planning and delivery of all services designed to achieve remission.
> If a diet low in carbohydrate is sustainable to the individual, normoglycaemia may be maintained in the absence of weight loss, *although evidence is limited and loss of remission is likely to occur if carbohydrate restriction ceases*.
> • Total dietary replacements (TDR) and low carbohydrate diets have been demonstrated as being effective in facilitating weight loss and remission of T2DM. Evidence of effectiveness beyond 2 years is limited. The dietary approach should be one which the individual can maintain for the long term._
> 
> (emphasis added)



Thanks for asking for me.  I appreciate it.


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