There are two things that I remember being taught about diabetes when I was in medical school. Firstly what is now known as type 2 diabetes was called “mature onset diabetes”. They had to change the name as younger and younger people were being diagnosed with the condition. The second thing I was told is that type 2 diabetes is a “chronic progressive disease” requiring ongoing life medication.
Regarding the second point, there is now ample evidence that type 2 diabetes does not have to be a “chronic progressive disease” and that it is possible to put diabetes into remission.
What do we mean by type 2 diabetes remission?
There have been a lot of discussions recently about the definition of remission and the different types of remission/reversal/cure. The diagnosis of type 2 diabetes is usually made based on your HbA1c levels, with a fasting blood HbA1c of 6.5% (48 mmol/mol) or greater being defined as type 2 diabetes. Therefore it’s logical to consider reducing your HbA1c to less than 6.5% as showing remission. However, it is not that simple!
For those with an HbA1c of less than 6.5%, there are three scenarios: 1. off all medication, 2. on metformin only, and 3. on other anti-diabetic medication(s). A recent consensus report published on behalf of The Endocrine Society, the European Association for the Study of Diabetes, Diabetes UK and the American Diabetes Association has recommended the term “remission” be confined to those with an HbA1c of less than 6.5% and who were no longer taking any medication. Diabetes Australia has also adopted this definition.
Other groups suggest using the term “diabetes reversal” for those who have reduced their HbA1c but continue to take metformin (often for reasons other than lowering blood sugar). I would argue that even those whose HbA1c is less than 6.5% and who continue to take anti-diabetes medication should also have another category, as improving glycemic control is likely to be positive for their health.
What evidence is there to support type 2 diabetes remission?
Now that we have defined diabetes remission, what is the scientific evidence for achieving it? Three scientifically proven ways of putting T2D into remission are bariatric surgery, low-calorie diets, and carbohydrate-restricted eating.
- Bariatric surgery and type 2 diabetes remission
Bariatric surgery, which includes procedures such as gastric banding, gastric bypass and sleeve gastrectomy, can lead to remission of type 2 diabetes in many patients. However, as with any surgical procedure, there are associated complications, especially as patients often have other medical conditions. There is also significant discomfort following the procedure and a relapse rate of around 35% at 5 years¹ and 60% at 10 years².
- Low calorie diets and type 2 diabetes remission
Very low calorie diets (VLCD) associated with significant weight loss are an effective way of putting type 2 diabetes into remission. The classic study is the DiRECT (Diabetes Remission Clinical Trial), conducted by Professor Roy Taylor of Newcastle, UK, which achieved a 46% remission of type 2 diabetes at 1 year and 36% at 2 years³. Participants ‘ate’ a total liquid diet replacement (825–853 kcal per day) for 3–5 months, with food gradually reintroduced after 6–8 weeks, with structured weight-loss maintenance support. If the subjects regained weight during the maintenance phase, they were offered a “rescue package” of liquid meals. Almost half of the intervention group required this additional intervention.The DiRECT trial demonstrated that diabetes remission was associated with reduced fat content in the pancreas, restoration of the pancreas to its normal shape and size, and restoration of β-cell function⁵ – in other words, the pancreas can again produce insulin.The problem with all low calorie diets is, of course, sustainability. Restricting calories to around 800 cals/day is almost impossible in the medium to long term due to hunger. People on a restricted diet are “hangry” – hungry and angry. Hence the high rate of relapse and subsequent yo-yo dieting.
Professor Taylor has suggested that the mechanism for this weight loss-associated remission was due to reduced fat deposits in the liver, and particularly the pancreas, thus enabling the body’s insulin response to food to return to normal⁴. b
- Low carb and type 2 diabetes remission
The pioneer of the restricted carbohydrate approach to managing type 2 diabetes is Dr David Unwin, a GP from Southport, UK. He stumbled across this regime by accident and has subsequently transformed the lives of those with type 2 diabetes in his general practice. In a paper published recently, he reported that in a group of 186 individuals, 97% of type 2 diabetes patients who adopted a low-carbohydrate diet saw improvements in blood sugar control, and 94 patients (51%) showed sustained remission, achieving HbA1c levels below the remission rate for more than 3 months. Of those who followed a low carb approach in the first year after diagnosis, 77% achieved remission⁶.
Two interesting features of restricted carbohydrate eating in type 2 diabetes are that blood sugar levels improve early and before significant weight loss⁷. Secondly, even if prescribed to the participants with no obligation to restrict calorie intake, a spontaneous calorie restriction is often seen⁸,⁹.
Achieving remission with a low carb approach
The VIRTA Health program in the US is a low carb approach to manage type 2 diabetes. For 5 years, they’ve run a study into their program’s efficacy, publishing the results annually.
They used a low carbohydrate diet to induce nutritional ketosis (when your body burns fat for energy instead of sugar) in patients with type 2 diabetes. They compared this group to type 2 diabetes patients receiving routine care. At 1 year, the HbA1c decreased by 1.3% in the restricted carbohydrate group, with 60% of completers achieving an HbA1c of below 6.5% without medication (not including metformin). Overall, medications were significantly reduced, including the complete elimination of sulfonylureas (an antidiabetic drug) and the reduction or elimination of insulin therapy in 94% of users¹⁰. The 2-year results of this trial showed sustained improvements in blood sugars, with 54% of completers maintaining an HbA1c below 6.5% without medication or only on metformin¹¹.
The best level of evidence is a systematic review (a review of all available research). A recent systematic review by Goldenberg et al. examined 23 scientific trials involving 1357 participants. It found that following a low carbohydrate diet for 6 months was associated with higher remission rates among people with type 2 diabetes¹² compared to low fat diets.
Can you cure type 2 diabetes?
So there is clear evidence that it is possible to put type 2 diabetes into remission. Does that mean it can be “cured”? No. If you remove the treatment that has brought about the remission, you will likely develop type 2 diabetes again.
What, then, is the best means of achieving remission? As mentioned above, all three treatments can achieve type 2 diabetes remission. Still, bariatric surgery is a drastic step with significant side effects, while a low calorie diet is difficult to sustain in the medium to long term. This leaves restricted carbohydrate eating as the most practical and sustainable means of achieving and maintaining diabetes remission.
2. Sjostrom L, Peltonen M, Jacobson P, et al. Association of bariatric surgery with long-term remission of T2DM and with microvascular and macrovascular complications. JAMA 2014;311:2297–2304. doi:10.1001/jama.2014.5988
3. Lean MEJ, Leslie WS, Barnes AC, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol 2019;7:
5 Al-Mrabeh A, Hollingsworth KG, Shaw JAM, et al.. 2-year remission of type 2 diabetes and pancreas morphology: a post-hoc analysis of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol 2020 Dec;8(12):939-948. doi: 10.1016/S2213-8587(20)30303-X.
6 Unwin D, Delon C, Unwin J, et al What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutrition, Prevention & Health 2023;e000544. doi:10.1136/bmjnph-2022-000544
7 Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of T2DM at 1 year: an open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583–612. doi:10.1007/s13300-018-0373-9
8 Brehm BJ, Seeley RJ, Daniels SR, D’Alessio DA. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab 2003;88:1617–1623. doi:10.1210/jc.2002-021480
9 Nordmann AJ, Nordmann A, Briel M, et al. Effects of a low-carbohydrate vs. low-fat diets on weight loss and cardiovascular risk factors. Arch Intern Med 2006;166:285–293. doi:10.1001/archinte.166.3.285
10 Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: An open-label, non-randomized, controlled study. Diabetes The. 2018;9:583–612. doi: 10.1007/s13300-018-0373-9
11 Athinarayanan SJ, Adams RN, Hallberg SJ, et al. Long-term effects of a novel continuous remote care intervention including nutritional ketosis for the management of Type 2 diabetes: a 2-year non-randomized clinical trial. Front Endocrinol 2019;10:348. doi: 10.3389/fendo.2019.00348
12 Goldenberg J Z, Day A, Brinkworth G D, et al. Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data. BMJ 2021; 372 :m4743 doi:10.1136/bmj.m4743