Early findings from the NHS Type 2 Diabetes Path to Remission Programme: a prospective evaluation of real-world implementation

Early weight loss, diabetes remission and long-term trajectory after diagnosis of type 2 diabetes: a retrospective study

AIMS/HYPOTHESIS

Weight loss can improve glycaemic management in individuals with type 2 diabetes, but its long-term effects on remission, cardiovascular risk factors and complications remain unclear. We investigated clinical outcomes following non-interventional ≥10% body weight loss in people with newly diagnosed type 2 diabetes in a routine care setting.

METHODS

We retrospectively analysed two cohorts of people with newly diagnosed type 2 diabetes. After exclusions, cohort 1 included 1934 individuals followed for up to 25 years; cohort 2 comprised 13,277 individuals followed for up to 10 years. Participants were categorised into two groups based on whether or not they lost at least 10% body weight. In a sensitivity analysis, a group of participants with intermediate weight loss (5% to <10%) was also considered. Outcomes included HbA1c, diabetes remission, cardiovascular parameters and chronic complications.

RESULTS

Participants (58% male) had a mean age of 62 years and a mean diabetes duration of <2 years at inclusion; mean baseline HbA1c was 57-64 mmol/mol (7.4-8.0%) and mean BMI was ~30 kg/m2. Weight loss ≥10% was obtained in 15.9% (n=308) of participants in cohort 1 and in 8.8% (n=1167) in cohort 2. In cohort 1, weight loss ≥10% was associated with a sustained reduction in HbA1c (mean difference 2.1 mmol/mol; 0.19%) and a higher remission rate than in the <10% weight loss group (20.2% vs 5.5%; HR 4.2). These findings were confirmed in cohort 2, with remission rates of 13.2% and 4.1% (HR 2.6) in the ≥10% and <10% weight loss groups, respectively. Weight loss ≥10% improved systolic BP and HDL-cholesterol and triglyceride levels. Participants with weight loss of 5% to <10% (28.2% in cohort 1 and 17.4% in cohort 2) had marginal improvements in HbA1c, lipids and remission rates compared with participants with weight loss <5%, and such results were inferior to those achieved with weight loss ≥10%. In cohort 1, compared with weight loss <5% (reference), the HR for remission was 5.2 with weight loss ≥10% vs 1.7 with weight loss 5% to <10%. Weight loss ≥10% was not associated with a reduced incidence of complications. On the other hand, remission was independently associated with a significantly lower rate of new-onset microangiopathy (adjusted HR 0.84; 95% CI 0.73, 0.97; p=0.019).

CONCLUSIONS/INTERPRETATION

Early weight loss of ≥10% in type 2 diabetes was associated with sustained glycaemic improvements, increasing by three to four times the rates of diabetes remission. Remission, in turn, more than weight loss was associated with a reduced risk of complications.

Anthocyanin-rich black wheat as a functional food for managing type 2 diabetes mellitus: a study on high fat diet-streptozotocin-induced diabetic rats

Background: Type 2 Diabetes Mellitus (T2DM) is associated with insulin resistance, hyperglycemia, and hyperlipidemia. Anthocyanins, which are natural antioxidants, have been reported to manage T2DM-related complications. However, the potential of anthocyanin-rich black wheat as a functional food for managing diabetes remains unexplored. Aim: This study aimed to investigate the effects of anthocyanin-rich black wheat on glucose metabolism, insulin sensitivity, lipid profile, oxidative stress, inflammation, and organ protection in high fat diet-streptozotocin (HFD-STZ) induced T2DM rats. Methods: T2DM was induced in rats using HFD-STZ. The rats were fed with either white wheat or anthocyanin-rich black wheat chapatti. Glucose metabolism, insulin sensitivity, lipid profile, antioxidant enzymes, inflammatory markers, and glucose transporters were assessed. Histopathological analysis of the liver, kidneys, and spleen was performed. Results: Compared to white wheat chapatti, black wheat chapatti exhibited higher α-amylase and α-glucosidase inhibitory activities. Black wheat chapatti consumption significantly reduced blood glucose and HbA1c levels, and improved insulin sensitivity, oral glucose tolerance, and insulin tolerance. Antioxidant enzyme (superoxide dismutase and catalase) activities were enhanced. Atherogenic dyslipidemia was attenuated, with improved high-density lipoprotein cholesterol levels. Inflammatory markers (TNF-α, IL-1β, leptin, resistin and cortisol) were reduced, while adiponectin (Acrp-30) levels increased. Black wheat chapatti activated adiponectin-AMPK and PI3K-AKT pathways, upregulating glucose transporters (GLUT-2 and GLUT-4). Histopathology revealed protective effects on the liver, kidneys, and spleen. Conclusions: Anthocyanin-rich black wheat chapatti ameliorates insulin resistance and associated complications in HFD-STZ-induced T2DM rats. It modulates key signaling pathways and glucose transporters, demonstrating its potential as a functional food for managing T2DM and its complications.

Aetiology of type 2 diabetes: an experimental medicine odyssey

This review describes a prolonged research endeavour to test the twin cycle hypothesis that type 2 diabetes is caused by fat-induced dysfunction of the liver and pancreas, guided by the happenstance of clinical practice. Testing of the personal fat threshold hypothesis, that individuals exhibit different levels of tolerance to intra-organ fat accumulation, is also described. Both hypotheses predict that type 2 diabetes is potentially reversible by weight loss. The results of the Counterpoint study supported the twin cycle hypothesis, leading to a second study which determined that short-duration diabetes was more likely to remit following the 10-15 kg weight loss. It also confirmed that remission was durable over 6 months on an isoenergetic, normal diet. Subsequently, it was shown that weight loss caused an immediate decrease of pancreas fat only in people with type 2 diabetes and also that postprandial incretin spikes after bariatric surgery had no role in normalising fasting plasma glucose. DiRECT, a 2 year randomised controlled study, demonstrated clinical utility, observing functional beta cell capacity to return almost to normal over 12 months. A small group of participants regained weight and redeveloped type 2 diabetes, allowing observation that the underlying pathophysiological mechanisms during onset of diabetes were as postulated by the twin cycle hypothesis. Major clinical benefit was demonstrated after a further 3 year follow-up in routine care, halving the incidence of serious adverse effect compared with the standard treatment control group. In answer to the question of whether individuals have a personal fat threshold for tolerance of fat, stepwise weight loss in people with type 2 diabetes and BMI in the range 21-27 kg/m2 resulted in remission in 70%, with a wide range of fat thresholds. Type 2 diabetes can be regarded as a condition of homogenous aetiology in genetically heterogenous individuals.

The latest evidence and guidance in lifestyle and surgical interventions to achieve weight loss in people with overweight or obesity

BACKGROUND

The prevalence of obesity and related co-morbidities has reached epidemic proportions. Effective evidence-based treatment approaches are therefore important. Lifestyle intervention remains the mainstay of the treatment strategy to manage obesity. Increased evidence has also emerged regarding the efficacy of metabolic bariatric surgery (MBS) to induce significant and sustained weight loss while also reducing the progression of obesity-related co-morbidities for people living with obesity.

AIMS & METHODS

This article aims to bring together current evidence, guidance and best practice for the prevention and management of people living with overweight or obesity by means of lifestyle and behavioural intervention, as well as by MBS.

RESULT

Lifestyle intervention encompasses dietary strategies, physical activity and behavioural intervention. Discussion on MBS will focus on current indications, comparison between different MBS procedures, novel endoscopic techniques, potential complications and pre-operative management.

PLAIN LANGUAGE SUMMARY

The number of people living with excess weight and complications associated with being overweight is alarmingly quite high. Effective treatment approaches that are supported by clinical studies are therefore important. Lifestyle changes remain very important to manage excess weight. Increased evidence has also shown the benefits of weight loss surgery to produce significant weight loss which could be sustained, while also reducing the risk of developing medical conditions associated with excess weight. This article aims to bring together current evidence, guidance and best practice for the prevention and management of people living with excess weight by means of lifestyle and behavioural changes, as well as by weight loss surgery. Lifestyle intervention encompasses dietary strategies, physical activity and behavioural intervention. Discussion on weight loss surgery will focus on current criteria for suitability, comparison between different weight loss surgery procedures, new techniques, possible complications and appropriate management prior to weight loss surgery.

The Twin Cycle Hypothesis of type 2 diabetes aetiology: From concept to national NHS programme

The development of magnetic resonance methods for quantifying intra-organ metabolites has permitted advances in the understanding of fasting and post-prandial carbohydrate and lipid handling in people with and without type 2 diabetes. Insulin resistance in the liver was shown to be related to excess intra-organ fat and was able to be returned to normal by weight loss. The practical effect of having muscle insulin sensitivity in the lower part of the wide normal range resulted in the obligatory shunting of carbohydrates via de novo lipogenesis into saturated fat. These observations provided the basis for the Twin Cycle Hypothesis of the aetiology of type 2 diabetes. Subsequent studies on people with type 2 diabetes confirmed the postulated pathophysiological abnormalities and demonstrated their reversibility by dietary weight loss of 10-15 kg. Overall, the fundamental understanding of the mechanisms causing type 2 diabetes has bridged physiological and clinical perspectives. Large population-based randomised controlled trials confirmed the practical clinical application of the method of achieving substantial weight loss, and an NHS programme is now in place offering potential remission to people within 6 years of diagnosis.

Improving eating disorder care for underserved groups: a lived experience and quality improvement perspective

Improvements to eating disorder (ED) care are urgently needed in the United Kingdom (UK) and around the world. Informed by my lived experiences, independent research, and involvement in the underappreciated field of quality improvement (QI), I have written this article to offer ideas on how to improve individuals' access to and experiences of ED care. As I live in the UK, my lived and QI experiences are of the UK's National Health Service (NHS). However, much of this article's content can be applied broadly to healthcare providers around the world, as similar ED care improvements are needed internationally. Furthermore, this commentary is informed by the latest international research.In this paper, I will identify and discuss 12 groups of individuals whom I believe are more likely to be underserved in ED care. The 12 'underserved groups' (USGs) are as follows: [USG. 1] People with longstanding EDs and/or older-age ED sufferers; [USG. 2] Younger children/preadolescents; [USG. 3] People with under-recognised/underappreciated EDs; [USG. 4] People with higher weights; [USG. 5] People with comorbidities; [USG. 6] People with neurodevelopmental conditions (neurodiverse people); [USG. 7] Digitally excluded people; [USG. 8] Socioeconomically and/or sociogeographically disadvantaged people; [USG. 9] Ethnic/racial minorities; [USG. 10] Sexual and gender-diverse people; [USG. 11] Males; [USG. 12] Caregivers/loved ones.ED sufferers/caregivers are also an underserved group as a whole in general mental health care, so broader considerations for improving ED care will be explored in a future publication; these include stigma, research biases, inadequate clinical monitoring and diagnosing, poor-quality treatments, disorganised service transitions, systemic problems/inefficiencies, and underfunding/under-resourcing. Specific recommendations for USGs 1-12 must be considered alongside these and other broader issues. Throughout both articles, I advocate a humanistic care model/approach based on the inexpensive principles of compassion, hope, empathy, appreciation (of identity), and patience ('CHEAP').

Remotely delivered weight management for people with long COVID and overweight: the randomized wait-list-controlled ReDIRECT trial

Long COVID (LC) is a complex multisymptom condition with no known disease-modifying treatments. This wait-list-controlled open-label trial tested whether a remotely delivered structured weight management program could improve respective LC symptoms in people living with overweight. Adults with LC (symptoms >12 weeks) and body mass index >27 kg m-2 (>25 kg m-2 for South Asians) were randomized (n = 234, 1:1) to control (n = 116, usual care) or the remotely delivered structured weight management (n = 118, total diet replacement (850 kcal per day) for 12 weeks, followed by food reintroduction and weight loss maintenance support) via minimization and randomization (80:20) to balance dominant LC symptom, sex, age, ethnicity and postcode-based index of multiple deprivation between groups. The control group received the intervention after 6 months. Participants selected the dominant LC symptom they would most like to improve (fatigue, breathlessness, pain, anxiety/depression or other) as the prespecified respective primary outcome. Individual symptoms were assessed using validated questionnaires and a visual analog scale for those without prespecified scales. At 6 months, the primary outcome improved in the intervention group (change -1.16 (s.d. 1.42), n = 97 analyzed) compared with the control group (change -0.83 (s.d. 1.14), n = 117 analyzed) with a treatment effect of -0.34 (95% confidence interval -0.67 to -0.01), with no excess of serious adverse events. International Standard Randomised Controlled Trial Number Registry registration: ISRCTN 12595520 .

Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants

BACKGROUND

Diabetes can be detected at the primary health-care level, and effective treatments lower the risk of complications. There are insufficient data on the coverage of treatment for diabetes and how it has changed. We estimated trends from 1990 to 2022 in diabetes prevalence and treatment for 200 countries and territories.

METHODS

We used data from 1108 population-representative studies with 141 million participants aged 18 years and older with measurements of fasting glucose and glycated haemoglobin (HbA1c), and information on diabetes treatment. We defined diabetes as having a fasting plasma glucose (FPG) of 7·0 mmol/L or higher, having an HbA1c of 6·5% or higher, or taking medication for diabetes. We defined diabetes treatment as the proportion of people with diabetes who were taking medication for diabetes. We analysed the data in a Bayesian hierarchical meta-regression model to estimate diabetes prevalence and treatment.

FINDINGS

In 2022, an estimated 828 million (95% credible interval [CrI] 757-908) adults (those aged 18 years and older) had diabetes, an increase of 630 million (554-713) from 1990. From 1990 to 2022, the age-standardised prevalence of diabetes increased in 131 countries for women and in 155 countries for men with a posterior probability of more than 0·80. The largest increases were in low-income and middle-income countries in southeast Asia (eg, Malaysia), south Asia (eg, Pakistan), the Middle East and north Africa (eg, Egypt), and Latin America and the Caribbean (eg, Jamaica, Trinidad and Tobago, and Costa Rica). Age-standardised prevalence neither increased nor decreased with a posterior probability of more than 0·80 in some countries in western and central Europe, sub-Saharan Africa, east Asia and the Pacific, Canada, and some Pacific island nations where prevalence was already high in 1990; it decreased with a posterior probability of more than 0·80 in women in Japan, Spain, and France, and in men in Nauru. The lowest prevalence in the world in 2022 was in western Europe and east Africa for both sexes, and in Japan and Canada for women, and the highest prevalence in the world in 2022 was in countries in Polynesia and Micronesia, some countries in the Caribbean and the Middle East and north Africa, as well as Pakistan and Malaysia. In 2022, 445 million (95% CrI 401-496) adults aged 30 years or older with diabetes did not receive treatment (59% of adults aged 30 years or older with diabetes), 3·5 times the number in 1990. From 1990 to 2022, diabetes treatment coverage increased in 118 countries for women and 98 countries for men with a posterior probability of more than 0·80. The largest improvement in treatment coverage was in some countries from central and western Europe and Latin America (Mexico, Colombia, Chile, and Costa Rica), Canada, South Korea, Russia, Seychelles, and Jordan. There was no increase in treatment coverage in most countries in sub-Saharan Africa; the Caribbean; Pacific island nations; and south, southeast, and central Asia. In 2022, age-standardised treatment coverage was lowest in countries in sub-Saharan Africa and south Asia, and treatment coverage was less than 10% in some African countries. Treatment coverage was 55% or higher in South Korea, many high-income western countries, and some countries in central and eastern Europe (eg, Poland, Czechia, and Russia), Latin America (eg, Costa Rica, Chile, and Mexico), and the Middle East and north Africa (eg, Jordan, Qatar, and Kuwait).

INTERPRETATION

In most countries, especially in low-income and middle-income countries, diabetes treatment has not increased at all or has not increased sufficiently in comparison with the rise in prevalence. The burden of diabetes and untreated diabetes is increasingly borne by low-income and middle-income countries. The expansion of health insurance and primary health care should be accompanied with diabetes programmes that realign and resource health services to enhance the early detection and effective treatment of diabetes.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), and US Centers for Disease Control and Prevention.

A Systematic Review and Meta-Analysis of the Effect of Caloric Restriction on Skeletal Muscle Mass in Individuals with, and without, Type 2 Diabetes

BACKGROUND

Severe caloric restriction interventions (such as very-low-calorie diets) are effective for inducing significant weight loss and remission of type 2 diabetes (T2DM). However, suggestions of associated significant muscle mass (MM) loss create apprehension regarding their widespread use. We conducted a systematic review and meta-analysis to provide a quantitative assessment of their effect on measures of MM in individuals with, or without, T2DM.

METHODS

EMBASE, Medline, Pubmed, CINAHL, CENTRAL and Google Scholar were systematically searched for studies involving caloric restriction interventions up to 900 kilocalories per day reporting any measure of MM, in addition to fat mass (FM) or body weight (BW).

RESULTS

Forty-nine studies were eligible for inclusion, involving 4785 participants. Individuals with T2DM experienced significant reductions in MM (WMD -2.88 kg, 95% CI: -3.54, -2.22; p < 0.0001), although this was significantly less than the reduction in FM (WMD -7.62 kg, 95% CI: -10.87, -4.37; p < 0.0001). A similar pattern was observed across studies involving individuals without T2DM. MM constituted approximately 25.5% of overall weight loss in individuals with T2DM, and 27.5% in individuals without T2DM. Subgroup analysis paradoxically revealed greater BW and FM reductions with less restrictive interventions.

CONCLUSIONS

Our review suggests that caloric restriction interventions up to 900 kilocalories per day are associated with a significant reduction in MM, albeit in the context of a significantly greater reduction in FM. Furthermore, MM constituted approximately a quarter of the total weight loss. Finally, our data support the use of less restrictive interventions, which appear to be more beneficial for BW and FM loss.