The “DiRECT” path to remission of type 2 diabetes?

Many of you will be aware of the DIRECT trial. First published in 2017, a UK primary care based trial funded by Diabetes UK, DiRECT was a major catalyst in initiating the conversation around remission of Type 2 diabetes.  At the Diabetes UK conference in April, the research team announced their 5 year follow up data.

The original trial, based in 49 practices across Scotland and the North of England investigated the approach of a very low calorie diet (VLCD) for people recently diagnosed with type 2 diabetes (within the last 6 years). The participants enrolled in the intervention arm received 3-5 months of 750 calories per day full meal replacement plan, followed by supported food reintroduction. After 12 months, 46% of the participants were in remission from their type 2 diabetes (HBA1c in the normal range, off all diabetes medications), and of those whom had lost at least 15kg in weight, 86% achieved remission.

Two year data subsequently showed some weight regain and some return to type 2 diabetes, but 36% of all participants remaining in remission after 2 years.  The cost effectiveness data was very convincing and led to many pilots across the NHS.

There have been many subsequent publications looking who is most likely to achieve remission, and the mechanisms behind remission, with a fascinating focus on the rapid reductions seen in liver fat deposition especially with rapid weight loss seen in the VLCD approach. 

At the Diabetes UK Professional conference during April in Liverpool, Professors Mike Lean, Roy Taylor and team announced their 5 year follow up data.  This is an extension to the original trial with 85 of the original participants involved, of whom 48 were in remission at the start of the extension. During this 3 year period, if participants gained >2kg they received further intervention, with a 3-4 week period of time back on the VLCD with support.  Of those who were in remission at the end of the original 2 years, 23% were in remission after 5 years (11 / 48).  Those who were still in remission had an average weight loss of 8.9kg at 5 years. 

The data supports the discussion around remission of type 2 diabetes with all of our patients newly diagnosed.  This trial has changed the conversation I have with patients from “you have type 2 diabetes, this is a progressive condition”, to “you have type 2 diabetes, I know it is difficult but if you can lose 10-15% of your body weight in this next year, you have a high chance of achieving remission”. 

The VLCD approach will certainly not suit all, and I feel strongly that people should be able to choose the diet which best suits them, which they are able to afford and sustain. Evidence continues to emerge of the cardiometabolic benefits for a plethora of different dietary approaches.  Many people will need professional support which we know can be lacking or has long waiting lists to access. 

Achieving remission of type 2 diabetes, even for a few years, will have multiple beneficial effects. However, this data also clearly reveals that people who do achieve remission of their type 2 diabetes must receive annual HBA1c recalls as they are at high risk of re-entering the criteria for a diagnosis a few years down the line. Our coding of “remission” rather than “resolved” type 2 diabetes is important, ensuring that people remain on their annual recalls.

If you would like to top up your current knowledge of Diabetes in Primary Care, do come along to our online Diabetes Course on 8^th July with myself and my Consultant Diabetes Nurse colleague Su Down for a full day update on everything you need to know from diagnostic dilemmas in diabetes to safe use of insulin.