1. Remission of Type 2 diabetes
Housekeeping

2. What is remission of Type 2 diabetes?

3. What is remission of Type 2 diabetes?
Remission means:
Maintaining blood glucose levels below the diabetes range without needing glucose lowering medications.
How is remission defined?
Differed criteria have been used in research and clinical practice.
Different organisations have developed slightly different criteria, including:
The American Diabetes Association
DiRECT trial

4. American Diabetes Association definition, 2009
Partial remission - HbA1c below 48mmol/mol (6.5%), fasting glucose between 5.6 and 6.9mmol/l, sustained over at least a year without any diabetes medication
Complete remission - HbA1c below 42mmol/mol (6%) and fasting glucose below 5.6mmol/l, sustained over at least a year without any diabetes medication
Prolonged remission - complete remission of at least 5years duration without diabetes medication

5. The need for consensus
The lack of an agreed definition risks causing confusion amongst healthcare professionals and people with diabetes.
Diabetes UK have helped establish an international group of experts with the purpose of agreeing an international consensus on the definition of Type 2 diabetes remission.
Including representatives from Diabetes UK, American Diabetes Association, European Association for the Study of Diabetes and other nominated experts from across North America and Europe.
The new guidelines are due to be published in the autumn.

6. Why is remission important?
Our increasing knowledge of remission is changing our understanding of Type 2 diabetes.
What we saw as a lifelong, progressive condition, does not have to be like this for everyone.
The possibility of achieving remission provides hope and motivation.
Remission can be life changing for those who achieve it.
The opportunity to stop taking diabetes medications and the need to manage diabetes on a day to day basis.
Lowering HbA1c can also reduce the risk of life changing diabetes complications.
Potential to be cost saving with reduction in medication use and diabetes related complications.
“Three years on, I’m not on any medication for my diabetes and it feels like such an achievement to have put my diabetes into remission”

7. Kathleen’s story

8. The routes to remission
The strongest evidence to date for achieving remission of Type 2 diabetes is with:
Bariatric surgery
A low-calorie based weight management programme
We know that remission is achieved mainly through weight loss, and weight loss in people with Type 2 diabetes can be achieved through other means.
There are also examples of people achieving remission through other approaches to achieve significant weight loss.

9. Diabetes Remission Clinical Trial (DiRECT)
The study tested if Type 2 diabetes can be put into long-term remission using a low-calorie based weight management programme.
The intervention was delivered entirely through GP practices, with practice nurses or dietitians providing support to patients.
The trial was only available to people who had been diagnosed with Type 2 diabetes for less than 6 years and who were overweight.

10. Weight management programme
3-5 months
Low calorie diet (around 850 cal per day, soups & shakes)
3 months
Reintroducing healthy food
18 months
Maintaining weight loss
Trial results: how many people in remission after 2 years?
3 years
Following participants

11. Results at 12 months…
Just under half (46%) of the participants were in remission after 12 months
Achievement of remission was closely linked to amount of weight loss
Nine out of ten participants who lost 15 kilos or more were in remission

12. Results at 24 months…
Over a third (36%) of the participants were in remission after 24 months
Of those in remission after one year, 70% stayed in remission.
Two thirds of those who lost 10 kilos or more were in remission after two years.

13. Other weight loss methods

14. Turning research into reality
The DiRECT results have generated a lot of excitement amongst people with diabetes, healthcare professionals and commissioners.
NHS England have announced that they will fund a Type 2 remission pilot programme for 5,000 people, involving a low calorie weight management programme.
The Scottish government have also announced funding for NHS Boards that can be used to deliver remission programmes.

15. Turning research into reality
Support for healthcare professionals and commissioners
Information Prescription
A consultation tool linked to primary care IT systems
DiRECT principles
The core elements to implementing a DiRECT intervention.
Lots of videos, case studies and information to share with your patients on our website

16. Turning research into reality – what can HCPs/CCGs/HBs do now?
Ensure that anyone achieving remission is being coded appropriately – do not use diabetes resolved, as people should remain on the register.
Ensure that anyone in remission continues to receive their annual review and 15 HCEs including retinal screening.
Review the policies and pathways in place for bariatric surgery and aim to increase uptake in line with NICE guidance.
Ensure equity of access to any services you provide – Meal replacement products should be provided by the NHS.
You can refer to our position statement on funding of meal replacement products for more info.

17. Questions still to be answered
The research to date has looked at achieving remission in people who are overweight or obese. ReTUNE is a new study Diabetes UK are funding which is looking at whether people with Type 2 diabetes can put their condition into remission.
The research studies have been carried out in areas with a predominately white population. We need to better understand the effects on people from BAME communities.
Diabetes UK are bringing together experts from across the UK to identify the key research questions that need to be answered to help make remission a reality for as many people with Type 2 diabetes as possible.

18. Support from Diabetes UK
Information prescription – consultation tool to help HCPs talk about remission.
DiRECT principles – the key elements to implement a DiRECT style intervention.
Information for commissioners – overview of the evidence around remission.
Helpline – support for people with diabetes, family members and friends.
Lots of resources for patients, including information about remission and inspiring stories from people who have achieved remission.

19. Thank you