Sustained Weight Loss: A Key to Diabetes Remission

Written by Ahmed Zayed Helmy, MD, on July 14, 2021

Diabetes is a condition indicated by high blood glucose (blood sugar) due to insufficient insulin production or because the body can’t use the insulin it produces. As a lifelong condition diabetes can lead to a number of health complications if not managed adequately. Maintaining weight in a healthy range or weight loss is an important part of diabetes management. In fact, it is the key to diabetes remission. Why? Read on to learn more about this subject.

Diabetes Prevalence

According to the CDC, 34.2 million Americans have diabetes. In other words, just over one in 10 people in the U.S. have this condition. Of these, 34.1 million people with diabetes were adults ages 18 and older. These figures indicate that 13% of all U.S. adults have diabetes.

Many people aren’t even aware they have diabetes. In fact, 7.3 million U.S. adults meet the criteria for diabetes diagnosis but are unaware of their condition. This means that 2.8% of all U.S. adults have undiagnosed diabetes or 21.4% of all persons with diabetes in the United States (1).

At the same time, 88 million American adults or one in three people have prediabetes. While the percentage of adults with prediabetes who were aware of their condition increased between 2005 and 2016, most people remain to be unaware (2).

But this condition doesn’t affect adults only; children and adolescents can also develop this lifelong illness.

Who Is At Risk?

Generally speaking, everyone can develop diabetes. Some people are at a higher risk, though. The most notable risk factors for diabetes include (3):

Excess weight
Sedentary lifestyle
Family history of diabetes
Advancing age
Having had gestational diabetes
Polycystic ovary syndrome
Hypertension (high blood pressure)
Abnormal cholesterol and triglyceride levels

What is Diabetes Remission?

Diabetes remission means the blood sugar levels remain below the diabetes range without the need for diabetes medication. Basically, blood glucose stays at a healthy and normal point during remission. Generally speaking, remission is when HbA1c, a measure of long-term blood glucose levels, remain below 48mmol/mol or 6.5% for at least six months.

Many people use the term “reversing diabetes” to talk about this situation, but it’s not correct since diabetes may come back (4). While the concept of remission may seem too good to be true event, it’s an entirely realistic goal. To achieve remission and maintain it, you need strong willpower and effort to change your lifestyle. Weight loss is considered the most significant factor in diabetes remission.

Excess Weight and Diabetes

Before we discuss the role of weight loss in diabetes remission, it’s necessary to address the impact of excess weight on the risk of developing diabetes.

Excess weight is associated with a higher risk of diabetes. Moreover, even moderately elevated BMI can increase the likelihood of diabetes complications (5). So, not only does excess weight increase the risk of this condition, but it can also worsen it in persons who have diabetes.

Overweight and obesity are correlated with type 2 diabetes because excess weight is the most important culprit of insulin resistance which appears early in the disease and is primarily compensated by hyperinsulinemia (too much insulin).

Excess weight may contribute to the onset of diabetes through impaired microbiome balance. Proper gut health requires a balance of good and bad bacteria that reside in the gut microbiome. Overweight and obesity disrupt that equilibrium which may lead to unsealing of the intestinal barrier. The increased gut permeability results in leakage of lipopolysaccharides into the bloodstream, consequently inducing chronic inflammation.

You see, chronic inflammation is characteristic both of obesity and insulin resistance associated with type 2 diabetes (6).

The reality is that multiple mechanisms are implicated in the link between excess weight and obesity. Yet another mechanism could be the surplus stress on the cells in the body.

A quick reminder first; in persons with diabetes, the body produces insulin but the cells become resistant to the salutary action of the hormone. Blood sugar can’t enter cells without insulin. This leads to high blood sugar levels.

Now back to the subject. Being overweight or obese stresses the insides of individual cells. More precisely, overeating stresses the endoplasmic reticulum (ER). The ER is the membranous network inside of cells. When the ER has more nutrients to process than it can handle, it sends out signals telling the cell to dampen insulin receptors located on the cell surface. This leads to insulin resistance and persistently elevated blood sugar levels (7).

Weight Loss and Diabetes Remission

Diabetes remission is an achievable goal and weight loss seems to be the key factor in its accomplishment. When it comes to type 2 diabetes remission itself, with weight loss it is entirely possible and especially in persons who sustain more weight loss, those who are younger, and in people who have had diabetes for a shorter time. You see, it’s not enough to slim down. It’s also necessary to maintain results.

One study aimed to determine the rate of remission of recently diagnosed type 2 diabetes in overweight or obese subjects with a six-month program of weight loss and exercise. The study included 12 subjects who were sedentary and unfit but also recently diagnosed with diabetes. The mean HbA1c value was 6.8%. After the exercise program, results showed that 80% of subjects went into partial type 2 diabetes remission. Additionally, HbA1c decreased to 6.2%. Scientists confirmed that a lifestyle program (exercise and weight loss) resulted in remission in six months, but emphasized the importance of new studies to evaluate long-term effects (8).

Diabetes remission with weight loss is possible, but various approaches may work. For instance, in the Look AHEAD randomized trial overweight/obese subjects with type 2 diabetes engaged in an intensive lifestyle intervention focused on weight loss through a combination of physical activity and healthy eating. At one year, 11% of the intervention group achieved complete or partial diabetes remission compared to only 2% from the control group. Four years later, 7.3% of subjects from the intervention group achieved complete or partial diabetes remission as opposed to 2% from the control group (9).

Other studies also showed the benefits of lifestyle modifications. A great example is the DiRECT randomized controlled trial in the UK which enrolled 149 subjects with type 2 diabetes for less than six years and didn’t use insulin. Participants were randomized to either an intensive weight loss intervention group or a control group. The intervention focused on an evidence-based weight management program Counterweight-Plus, which is a low-calorie liquid diet program. After 12 months, 46% of subjects in the intervention group achieved diabetes remission compared to 4% of their counterparts from the control group. Results after 24 months revealed that the prevalence of diabetes remission in the intervention group was 36% and in the control group only 3%. This extensive research confirmed that remission of type 2 diabetes is a practical target for primary care (10).

Researchers from the DiRECT study found that diabetes remission correlated with the amount of weight the subjects lost. For example, 36 participants lost 15kg (33lbs) or more during the study, 86% went into remission. Also, 28 subjects lost 10-15kg (22-33lbs) and 57% of them achieved diabetes remission just like 34% of subjects who lost 5-10kg (11-22lbs). Therefore, the greater the weight loss, the better the results are.

Besides DiRECT, other studies focused on calorie restriction to achieve weight loss and diabetes remission. We’re talking about the DIADEM-I randomized control trial carried out in Qatar. Subjects in this study were randomly allocated either to an intensive lifestyle intervention group or the control group. The intensive lifestyle intervention included a diet replacement phase wherein the subjects received formula low-energy diet meal replacement products alongside gradual food reintroduction. The participants also had to exercise. The intervention group also had a weight loss maintenance phase and structured lifestyle support.

The number of subjects in the intervention group was 70 and 77 in the control group. Results showed that between baseline and 12 months, the mean bodyweight in subjects from the intervention group decreased by 11.98kg (26lbs) compared with 3.98kg (8lbs) in the control group. About 61% of subjects from the intervention group achieved diabetes remission compared to 12% of participants from the control group. The results also showed that 33% of intervention group subjects had normoglycemia (normal blood sugar levels) as opposed to 4% of the control group participants (11).

One study took a different approach by combining the ketogenic diet (well-known keto diet) with a continuous care model. A total of 218 subjects completed 12 months of the study and 72% went into diabetes remission without having to take medications. Moreover, 194 subjects completed 24 months of the study and 63% achieved remission. During the first year of the study, participants lost about 13.8kg (30lbs) on average and 10kg (22lbs) during the second year (12). Basically, this study found that dietary modifications in the form of the keto diet could help promote weight loss and achieve diabetes remission.

Factors That Influence Diabetes Remission

What we can learn from these studies is that different approaches lead to weight loss and subsequent diabetes remission. These findings only confirm that weight loss is the crucial factor to achieve remission and stick to it.

Although weight loss is the most important approach for diabetes remission, it is also worth mentioning other predictors such as (13):

Duration of type 2 diabetes
Glycated hemoglobin
Fasting glucose levels
Absence of insulin therapy
Short duration of diabetes (the time after receiving diabetes diagnosis)

The biggest chance of achieving diabetes remission occurs with the most significant weight loss. On the flip side, weight gain leads to diabetes relapse. For this reason, you need to maintain your weight loss once you achieve it. That way, you could also maintain diabetes remission (14).

How to Maintain Weight Loss?

It’s easy to say you need to maintain weight loss to achieve diabetes remission, but this is a challenging process. Many people with diabetes struggle to maintain their weight loss and even a modest weight regain could make diabetes come back.

What we need to bear in mind is that lifestyle modifications to slim down and get into diabetes remission shouldn’t stop with weight loss. A common mistake that many people repeat generally is that they stop eating a healthy diet or exercising once they slim down. This mistake is fixable and it’s particularly important for persons with diabetes.

The solution to weight loss maintenance could be a low-carbohydrate, high-protein diet. A dietary pattern that provides 20-30% of its calories from carbs and 30% from protein can lower blood glucose levels in people without type 2 diabetes without weight loss. This amount of carbs is just less than half of the carbohydrate intake a person consumes on average, and double the protein. The rest accounts for fat intake. Keep in mind we’re talking about healthy fat here, not trans fats.

A higher intake of protein than usual could work by helping beta-cells produce more insulin as you eat. Amino acids that make protein up are insulinogenic i.e. they stimulate the production and release of insulin (15).

Besides dietary adjustments, weight loss maintenance also requires regular physical activity. In fact, a healthy diet and regular exercise should come hand in hand as the body needs both for weight maintenance. This is especially the case after you achieve desired weight loss.

Surgery for Diabetes Remission

For persons with high BMI that indicates overweight and obesity, bariatric surgery could help achieve diabetes remission. Bariatric surgery is a weight loss procedure that involves making changes to the digestive system to promote weight loss. This procedure results in diabetes remission in 78% of patients who undergo the surgery. In one study, 72% of people who underwent bariatric surgery were in transmission for two years following the procedure and 30% were in remission for 15 years post-op (16).

Bariatric surgery is not for every person with excess weight. Doctors recommend it to persons who meet specific criteria. But, this also shows how important weight loss is for diabetes remission and its maintenance.

Can Everyone Achieve Diabetes Remission?

As seen above, certain factors predict the likelihood of achieving diabetes remission. The longer you have diabetes, the less likely you are to achieve diabetes remission. Over time, beta cells in the pancreas burn out and lose their ability to produce insulin. After a certain timeframe, it may be too difficult to restore the normal production of insulin.

What we can learn from this is that a proactive approach to diabetes diagnosis can make a huge impact on your effort to achieve remission.

Conclusion

Diabetes remission may seem like a fairytale for many, but it can be a reality. Many call it diabetes reversal, but it’s a wrong term since diabetes can relapse. The most important factor in achieving remission is weight loss. Various approaches can serve this purpose including the keto diet, calorie restriction, among others. You should not make significant diet modifications without consulting your doctor first. Your healthcare provider can give you valuable input.