Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial

A very low calorie diet is changing the way we look at treating Type 2 Diabetes (T2D)1. A recent study, funded by Diabetes UK aimed to find an effective and accessible way to put T2D into remission2. Led by Professor Roy Taylor from Newcastle University, Prof Taylor wanted to address the ‘root cause’ of diabetes rather than just treat the symptoms3. “Diet and lifestyle are touched upon but diabetes remission by cutting calories is rarely discussed,3” he said.

Type 2 Diabetes is a chronic illness that is characterised by high blood sugar levels and insulin resistance within the body. T2D requires lifelong treatment of various kinds including lifestyle interventions5, which ideally should be first line treatment. This study looked at the impact of a very low calorie dietary intervention delivered through primary care practices.

Patients were randomised into two groups: a control group receiving best-practice care by guidelines, and a weight management (with meal replacement) program, known as the Cambridge Weight Plan4. Diabetes remission was achieved in 68 (46%) participants in the intervention group and six (4%) participants in the control group after 12 months1. Remission was even observed in patients who had the disease for six years4. “Our findings suggest that even if you have had type 2 diabetes for six years, putting the disease into remission is feasible”, says Prof Michael Lean from the University of Glasgow. “In contrast to other approaches, we focus on the need for long-term maintenance of weight loss through diet and exercise and encourage flexibility to optimise individual results4.”

This is important and timely research in light of Australia’s rising T2D prevalence. According to Diabetes Australia, diabetes is the epidemic of the 21st century and the biggest challenge confronting Australia’s health system5. Approximately 1.7 million Australian’s live with diabetes, type 2 accounting for 85% of this and increasing5. The total annual cost to Australia’s healthcare system is estimated to be $14.6 billion and growing5.

This study confirms and adds to what we already know about lifestyle intervention for remission of T2D. The Dr Dean Ornish Reversing Heart Disease program is one such example, demonstrating that patients with diabetes were able to follow the ‘intensive’ program, achieving the same improvements in coronary risk factors and quality of life as those without diabetes. Patients showed statistically significant decreases in their HbA1c, and many were able to reduce their diabetes medication6.

Another excellent example is CHIP, the Complete Health Improvement Program, with a similar research pedigree to the Ornish program. Likewise, the Stanford Chronic Disease Self-Management Programs (CDSM), now called the Self-Management Resource Centre, are heavily backed by good quality research demonstrating a wide range of conditions can successfully be treated with lifestyle intervention.

You can find more information about these programs at:

Programs such as these have been reversing T2D and other chronic conditions for decades and the link between excess weight and T2D is well known. But this new research could be one of the first studies to demonstrate remission primarily through a very low calorie diet. Importantly, publication of this study in the Lancet with the conclusion, “Remission of type 2 diabetes is a practical target for primary care,” will shine the spotlight on the common assumption that once T2D is established, it is irreversible and the patient will be on ‘medication for life’. It also raises the question whether sufficient creativity, time and resources are being employed in primary care to ensure lifestyle intervention is actually being promoted, made available and being delivered to diabetic patients, especially those recently diagnosed or classed as pre-diabetic, an opportune intervention window.

In related research, ASLM’s own Profs John Stevens and Garry Egger (the founder of Gutbusters) are currently conducting a trial of ‘Programmed Shared Medical Appointments (pSMAs) for Obesity through eight medical centres in the South Eastern NSW Primary Health Network. This is a structured series of facilitated group medical visits utilising the benefits of peer support with pre-determined content, online resources for participants, and also utilising meal replacement to assist with calorie reduction. Early indications are that the pSMA trial will also demonstrate meaningful weight loss and improvement in disease markers for participants.

Finally, some limitations of lifestyle programs have been accessibility, affordability and scalability. Enter the health tech startups, utilising technology to bridge the gap. Some notable examples include:

And coming soon from some of ASLM’s own team members,

It’s great to see the relationship between weight loss and remission of type 2 diabetes so clearly demonstrated using the Cambridge Weight Plan, but it’s also important to note the large body of research already supporting lifestyle change programs for a host of conditions of lifestyle, society and environment.

ASLM aims to promote awareness and uptake of ‘real world’ programs, which means they need to operate effectively in the social context of our daily lives, especially programs that are accessible, cost effective and scalable. With this year’s announcement of ASLM’s Endorsement framework for programs that exemplify the principles of Lifestyle Medicine, we aim to be a clearing house for programs that work in everyday life.