Research shows that it is possible for some people with type 2 diabetes to achieve type 2 diabetes remissionⁱⁱⁱ.

We define type 2 diabetes remission as an HbA1c of under 6.5% (48mmol/mol) for at least three months without the need for glucose-lowering medications.

The most common ways people have achieved remission is by achieving substantial weight loss following very intensive dietary changes or through bariatric surgery.

Remission is not achievable for everyone with type 2 diabetes. In all studies of intensive dietary modifications, less than half of participants were able to achieve remission after one year.

Remission does not mean type 2 diabetes is cured or reversed – it simply means that people have blood glucose levels below the type 2 diabetes levels. It is important that people in remission continue to access regular diabetes monitoring at least annually and keep up their Annual Cycle of Care health care checks. Ongoing monitoring is required as some of the macrovascular and microvascular damage which cause long term complications has already begun.

People with type 2 diabetes who want to attempt diabetes remission need to do so in close consultation with their diabetes healthcare team, as intensive dietary and weight changes need careful management, monitoring and support.

People who do not achieve or sustain remission should not feel that they have ‘failed’. The health benefits of weight loss and a reduction in HbA1c are significant even if remission does not occur, as these reduce the risk of developing diabetes-related complications and may lead to reducing or stopping glucose-lowering medications.

How is remission achieved

For people who have overweight or obesity, remission of type 2 diabetes usually requires substantial weight loss. While any amount of weight loss is usually beneficial, people are more likely to achieve remission if they lose around 10% – 15% of their body weight. Weight loss may be achieved through intensive dietary change (e.g. very low energy diet) and other healthy behaviour modification, or bariatric surgery.

Intensive dietary changes

While several approaches to weight loss may help a person with type 2 diabetes achieve remission, there has been considerable recent focus on particular dietary interventions including very low energy and ketogenic diets. The major studies investigating intensive dietary interventions include DiRECT, DIADEM-1 and a study by technology company Virta Health (see table below).

Major studies investigating dietary interventions

Study	Intervention	Remission Definition	Remission at 1 year	Remission at 2 year
DiRECT Study (United Kingdom) N=306	Meal replacement (e.g. shakes) – followed by a gradual reintroduction of food before entering a weight maintenance phase.	No glucose-lowering medication HbA1c <6.5% Duration ≥ 2 months	I: 46% 5 C: 4%	I: 36% 6 C: 3%
DIADEM Study (Qatar – involving people from the Middle East and North Africa) N=147	Meal replacement (e.g. shakes) – followed by a gradual reintroduction of food before entering a weight maintenance phase.	No glucose-lowering medication HbA1c <6.5% Duration ≥ 3 months	I: 61% 7 C: 12%	–
Virta Health (United States) N=349	Ketogenic (‘keto’) diet	No glucose-lowering medication HbA1c <6.5% Duration not stated	25% (I) 8	17.6% (I) 9 2.4% (C)

A recent systematic review and meta-analysis reported that rates of people achieving type 2 diabetes remission (HbA1c less than 6.5% (48mmol/mol) with no glucose-lowering medications) by following a low or very low carbohydrate diet were not higher than the rate of remission achieved by people following
other dietary approaches. ¹⁰

Bariatric surgery

Bariatric surgery refers to several surgical procedures designed to reduce the size of a person’s stomach and the amount they need to eat to feel full. A range of studies have shown that people with type 2 diabetes have achieved remission following bariatric surgery with the median duration of remission being about eight years.¹¹

Remission from bariatric surgery occurs more often in younger people and in people recently diagnosed with type 2 diabetes.

The largest studies that have looked at the impact of bariatric surgery on type 2 diabetes remission include the Swedish Obesity Study (SOS)¹², the Longitudinal Assessment of Surgery-2 (LABS-2)¹³ and the Scandinavian Obesity Surgery Registry.¹⁴ All three studies show a significant percentage of people achieved longterm type 2 diabetes remission. In particular in the SOS study, 38% of participants were still in remission after 10 years, while in LABS-2 46% of participants were in remission after seven years.

Bariatric surgery is a significant commitment. Once the surgical procedure has been completed, it cannot be undone easily. Despite significant weight loss and improvements in physical health, research shows that emotional and mental health problems may remain.¹⁵

Diabetes Australia supports bariatric surgery as a treatment option for people with type 2 diabetes with a body mass index of at least 30, where dietary, physical activity and medical interventions for obesity or diabetes have not been successful.¹⁶ Appropriate clinical and psychological support needs to be made available.

Defining surgical procedures

Gastric band (or lap band)

» A small silicon device is surgically implanted around the top portion of the stomach creating a small pouch that can only hold a small amount of food.

Gastric sleeve

» Some of the stomach is removed including the part of the stomach that makes the hormone that makes you hungry.

Roux-en-Y bypass (RYGB) or gastric bypass

» A pouch is created from the stomach and then connected directly to the small intestine.

More information

To read more Diabetes Australia has developed a position statement on diabetes remission to help people with diabetes and health professionals make informed choices.

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[iii] Lean, M. E., Leslie, W. S., Barnes, A. C., Brosnahan, N., Thom, G., McCombie, L., Peters, C., Zhyzhneuskaya, S., Al-Mrabeh, A., Hollingsworth, K. G., Rodrigues, A. M., Rehackova, L., Adamson, A. J., Sniehotta, F. F., Mathers, J. C., Ross, H. M., McIlvenna, Y., Stefanetti, R., Trenell, M., & Welsh, P. (2018). Primary care-led Weight Management for Remission of Type 2 Diabetes (DiRECT): an open-label, cluster-randomised Trial. The Lancet, 391(10120), 541–551. https://doi.org/10.1016/s0140-6736(17)33102-1‌

5 Lean M, Leslie W, Barnes A, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet, 2018; 391(10120): 541-551.

6 Ibid.

7 Taheri S, Zaghloul H, Chagoury O, et al. Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol 2020; 8: 477-489.

8 Hallberg S, McKenzie A, Williams P, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, nonrandomized, controlled study. Diabetes Therapy, 2018 9(2): 583-612.

9 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. Frontiers in Endocrinology, 2019; 10: 348. doi: 10.3389/fendo/2019/00348.

10 Goldenberg J, Day A, Brinkworth G, et al. Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and metaanalysis of published and unpublished randomized trial data. BMJ, 2021; 372 m4743

11 Rubino, F, Nathan D, Eckel R, et al Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care, 2016; 39(6): 861-877.

12 Sjöström L, Peltonen M, Jacobson P, et al. Association of Bariatric Surgery With Long-term Remission of Type 2 Diabetes and with Microvascular and
Macrovascular Complications. JAMA, 2014; 311(22): 2297.

13 Purnell J, Dewey E, Laferrère B, et al. Diabetes Remission Status During Seven-year Follow-up of the Longitudinal Assessment of Bariatric Surgery Study. The
Journal of Clinical Endocrinology & Metabolism, 2021; 106(3):774-788.

14 Jans A, Näslund, I, Ottosson, J, Duration of type 2 diabetes and remission rates after bariatric surgery in Sweden 2007–2015: A registry-based cohort study. PLOS Medicine, 2019; 16(11): .e1002985.

15 Jumbe S, Hamlet C and Meyrick J. Psychological Aspects of Bariatric Surgery as a Treatment for Obesity. Current Obesity Reports, 2017; 6(1): 71-78.

16 Australian Diabetes Society. (2016) The Australian Obesity Management Algorithm. Retrieved (11 October 2021) from https://diabetessociety.com.au/
documents/ObesityManagementAlgorithm18.10.2016FINAL.pdf