An update on development of guidelines for diabetes remission – remission possible!

Posted On: 3rd May 2022

On 12th April, TDMR Europe’s online seminar brought together speakers from Scotland, England and Cyprus to focus on weight maintenance and diabetes remission maintenance after weight loss with total diet replacement.

The webinar was opened by Professor Mike Lean, Professor of Human Nutrition at the University of Glasgow who reviewed research evidence including the DiRECT trial of Total Diet Replacement (TDR) weight loss with behavioural and lifestyle guidance followed by weight maintenance to achieve diabetes remission in people with type 2 diabetes.  Prof Lean also reviewed the extent to which current guidelines refer to the evidence for diabetes remission and forthcoming plans for further guidelines later in 2022.

Introducing the webinar TDMR Europe chair Professor Anthony Leeds said ‘European countries face levels of obesity and diabetes that will overwhelm capacity for healthcare provision. Weight loss has been recognised as the key component for diabetes prevention and key to effective diabetes prevention. All European countries require effective programmes for diabetes prevention, diabetes remission and obesity prevention and reduction and diabetes remission programmes based on the DiRECT research results may help contribute to this.’

TDMR Europe’s online seminar brought together industry stakeholders, academics and others and showed the potential role of TDR in contributing to diabetes remission and prevention and considered the issues relating to weight maintenance, including whether or not dietary glycaemic index and glycaemic load could play a part.

The recording of the webinar will is available here.

More information on TDR is available here.

Professor Mike Lean is a principal investigator of the DiRECT study, chair of the department of human nutrition at the University of Glasgow, visiting professor at Otago University and visiting professor at the University of Sydney. He is a keen fiddle-player and climbs mountains.

FUNDING – The DiRECT trial was funded as a Strategic Research Initiative by Diabetes UK and Cambridge Weight Plan donated all formula diet products.


An update on development of guidelines for diabetes remission – remission possible!

Professor Mike Lean, University of Glasgow, Scotland

Until very recently, ‘remission ‘ of type 2 diabetes (T2D) was an unknown concept.  Results from the UK Diabetes Remission Clinical Trial (DiRECT), supported by near-identical findings from DIADEM-1 in Qatar, have challenged and changed the old paradigm of T2D being a permanent condition, treatable by life-long glucose-lowering drugs, an inconvenience of ageing.  The new evidence reveals T2D as a very serious life-shortening and disabling disease, part of the disease-process of ‘obesity’ in genetically predisposed people, but preventable and reversible at an early stage.

DiRECT included people with T2D up to 6 years from diagnosis. A structured dietary programme (Counterweight-Plus: Total Diet Replacement for 12 weeks, transferring to a food-based maintenance diet with about 50% energy from carbohydrate) achieved remission (HbA1c <48mmol/mol (<6.5%) for 46% of all participants randomized to the intervention, with mean 12m weight loss 10kg.  Those who maintained >15kg loss had over 80% remissions at both 12 and 24 months, and >10kg loss brought remissions for over 70%.

With slightly younger participants and shorter diabetes duration, using similar total Diet Replacement and food-based maintenance, DIADEM-1 achieved 61% remissions at 12m.

These are the only randomized controlled trials of diet interventions reporting remissions of diabetes.  Several observational studies have employed low-carbohydrate diets, but while some have led to good weight losses, the remission rates are rather lower.  The large VIRTA-Health study in US achieved 13kg weight loss, but only 19% remissions. A failure to withdraw glucose lowering drugs may have obscured some more remissions, but these results are in, one with evidence that lower carbohydrate diets are associated with higher, not lower HbA1c.

Criteria for remission of T2D entail (1) a cut-off of HbA1c to denote freedom from diabetes, and (2) a duration of non-diabetic HbA1c without glucose-lowering medication.  There are now internationally agreed criteria, by ADA, EASD, Diabetes UK, the Endocrine Society, and the Diabetes Surgery Summit (2021): HbA1c <48mmol/mol (6.5%), >3 months without glucose-lowering medication.

Following publication of DiRECT, the wishes of people with T2D seeking freedom from the disease have been important in stimulating adoption of remission programmes, for local services, in national Clinical Guidelines (eg Australia, New Zealand) and from international organisations such as forthcoming 2022 evidence-based Guidelines from the Diabetes Nutrition Study Group of EASD.

An Update On Development Of Guidelines For Diabetes Remission PPT Slides


  1. Churuangsuk C., et al Diets for weight management in adults with type 2 diabetes: an umbrella review of published meta-analyses and systematic review of trials of diets for diabetes remission. Diabetologia (2022) 65, 14–36
  2. Lean MEJ, et al,. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet (2018) 391(10120) 541-551
  3. Thom, G. et al. (2021) Predictors of type 2 diabetes in the Diabetes Remission Clinical Trial (DiRECT). Diabetic Medicine, 38(8), e14395. (doi: 10.1111/dme.14395) (PMID:32870520)
  4. Riddle M, et al; Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes. Diabetes Care 1 October 2021; 44 (10): 2438–2444.