Type 2 diabetes mellitus (T2DM)

Last time I promised you a blog about frailty – so forgive me for changing my mind. This week’s blog is about that other health scourge of our times- Type 2 Diabetes (T2DM).  There is exciting new information about curing this pernicious and dangerous disease.

The Newcastle Study

In February 2022, I wrote about this study which looked at the ability of weight loss to cure T2DM. It was known as the DiRECT Study.

“The most successful RCT of lifestyle management of T2DM was reported from Scotland and Newcastle in 2018, with 298 obese diabetic patients receiving either intensive weight management or their usual care. The intervention group had their medication withdrawn and were given a carefully controlled diet, completely different from the one they usually ate, for a period of 12 weeks. This was followed by a 4-week food-reintroduction phase and a further weight-management phase lasting up to 2 years, using diet and exercise programmes to help to prevent them regaining weight. After one year, 46 per cent of the intervention group had remission of their diabetes compared with only 4 per cent in the control group. There was a reduction of an amazing 86 per cent in the incidence of diabetes among those who lost 15kg (about two stone) or more.”

As with many ground-breaking new approaches, the results are difficult to realise in the ‘real world’ scenario. A paper recently published in Lancet Diabetes and Endocrinology now shows the real-world effects of applying the Newcastle approach to a large group of diabetics in a realistic setting.

The soups and shakes diet

The study reports the results of “The NHS Type 2 Diabetes Path to Remission Programme”. This programme has been running since 2020 and so far more than 25,000 people have been enrolled. These subjects are adults aged 18 to 65 who have had their T2DM diagnosed within the previous six years with a Body Mass Index of over 27 if they are White or over 25 if they are from Black, Asian or other minority groups.

Eligible participants are offered low calorie, total diet replacement products including soups and shakes consisting of 800 to 900 kilocalories a day for 12 weeks. During this time, participants replace all normal meals with these products.

Alongside this, participants receive support and monitoring for 12 months including help to re-introduce food after the initial 12-week period. This support provides participants with the help and advice they need throughout every stage of the programme. The programme is fully funded by the NHS, therefore there is no cost to participants.

The Results

The Study reports on the outcomes for 7,540 people who took part in the programme between September 2020 and the end of 2022. 945 subjects completed full year of the programme. Of these, 32% had put their T2DM into remission – with an average weight loss of 15.9kg.

These results look great don’t they? – but a word or two of caution. The remission rate of 32% for those who completed the programme means that, of the total number enrolled, only 4% achieved remission. This is less eye-catching – and is very far from a (fat) maiden’s dream. 96% were left with their diabetes.

What else?

This trial shows that if the subjects stuck to the regime, one third achieved remission. The main problem was down to failure to adhere to the weight-losing regime.

Adherence to medical management is far more likely with pills than with lifestyle change – so how about the effects of weight-losing pills? I am, of course, referring to the GLP-1 agonists, like semaglutide (Wegovy, Ozempic) and tirzepatade (Mounjaro), both of which are given as weekly injections. These drugs influence the production and effectiveness of the body’s own insulin and were developed for the treatment of T2DM. Clinical trials have shown that about half of those taking semaglutide can lose the 15kg  which seems to give such a high rate of remission from T2DM.  For tirzepatide the success rate is even higher.

Conclusion

I am very uncertain about the merits of long-term use of drugs for weight control in obesity, but for overweight diabetics the benefits seem unarguable. There is work to be done on long-term side effects and the reduction of diabetic complications such as heart and kidney disease. But the future for diabetics seems much brighter and pills are going to be the main agents. I just hope that lifestyle changes such as exercise and diet are not ignored.