Clinical pathways are changing to incorporate support and appropriate follow-up for people to achieve remission of type 2 diabetes, but there is limited understanding of the prevalence of remission in current practice or patient characteristics associated with remission.
Methods and findings
We carried out a cross-sectional study estimating the prevalence of remission of type 2 diabetes in all adults in Scotland aged ≥30 years diagnosed with type 2 diabetes and alive on December 31, 2019. Remission of type 2 diabetes was assessed between January 1, 2019 and December 31, 2019. We defined remission as all HbA1c values <48 mmol/mol in the absence of glucose-lowering therapy (GLT) for a continuous duration of ≥365 days before the date of the last recorded HbA1c in 2019. Multivariable logistic regression in complete and multiply imputed datasets was used to examine characteristics associated with remission. Our cohort consisted of 162,316 individuals, all of whom had at least 1 HbA1c ≥48 mmol/mol (6.5%) at or after diagnosis of diabetes and at least 1 HbA1c recorded in 2019 (78.5% of the eligible population). Over half (56%) of our cohort was aged 65 years or over in 2019, and 64% had had type 2 diabetes for at least 6 years.
Our cohort was predominantly of white ethnicity (74%), and ethnicity data were missing for 19% of the cohort. Median body mass index (BMI) at diagnosis was 32.3 kg/m2. A total of 7,710 people (4.8% [95% confidence interval [CI] 4.7 to 4.9]) were in remission of type 2 diabetes. Factors associated with remission were older age (odds ratio [OR] 1.48 [95% CI 1.34 to 1.62] P < 0.001) for people aged ≥75 years compared to 45 to 54 year group), HbA1c <48 mmol/mol at diagnosis (OR 1.31 [95% CI 1.24 to 1.39] P < 0.001) compared to 48 to 52 mmol/mol), no previous history of GLT (OR 14.6 [95% CI 13.7 to 15.5] P < 0.001), weight loss from diagnosis to 2019 (OR 4.45 [95% CI 3.89 to 5.10] P < 0.001) for ≥15 kg of weight loss compared to 0 to 4.9 kg weight gain), and previous bariatric surgery (OR 11.9 [95% CI 9.41 to 15.1] P < 0.001). Limitations of the study include the use of a limited subset of possible definitions of remission of type 2 diabetes, missing data, and inability to identify self-funded bariatric surgery.
In this study, we found that 4.8% of people with type 2 diabetes who had at least 1 HbA1c ≥48 mmol/mol (6.5%) after diagnosis of diabetes and had at least 1 HbA1c recorded in 2019 had evidence of type 2 diabetes remission. Guidelines are required for management and follow-up of this group and may differ depending on whether weight loss and remission of diabetes were intentional or unintentional. Our findings can be used to evaluate the impact of future initiatives on the prevalence of type 2 diabetes remission.
Why was this study done?
Feasibility of diabetes remission has been demonstrated in research settings and after bariatric surgery, but we do not know how many people in the general population achieve remission of type 2 diabetes.
Informed decisions need to be made about which people are most likely to achieve and maintain remission; to do this, we need to better understand the characteristics of people who are currently in remission.
Estimating the prevalence of remission of type 2 diabetes in Scotland in 2019 creates a baseline to evaluate the impact of future initiatives to support remission and for future studies of duration of remission and effect on risk of complications of diabetes.
What did the researchers do and find?
We calculated how many people were in remission of type 2 diabetes in 2019 in Scotland from a national type 2 diabetes register. This register contains 99% of people with diabetes in Scotland.
We described the characteristics of people who were in remission of type 2 diabetes compared to people who were not in remission and created a mathematical model that shows the probability of achieving remission in 2019 based on these characteristics.
We found that about 1 in 20 of people with type 2 diabetes in the study population were in remission of type 2 diabetes.
Compared to people who did not achieve remission, people in remission of type 2 diabetes tended to be older; have a lower HbA1c at diagnosis; have never taken any glucose-lowering medication; have lost weight since the diagnosis of diabetes; and have had bariatric surgery.
What do these findings mean?
There is a sizeable proportion of people who achieve remission of type 2 diabetes outside research trials and without bariatric surgery. These people should be recognised and coded appropriately so they can be supported by their clinicians. The clinical progress of these people can now be followed by researchers.
People who have not yet been prescribed drugs to treat diabetes may be the most appropriate group for clinicians to initiate discussions around remission and weight management options.
Guidelines for supporting people who achieve remission of diabetes must recognise differences between people that lose weight intentionally and those that lose weight because of severe illness. Clinicians also need greater clarity on how to manage older or frailer people who achieve remission criteria.