Introduction
A new consensus report from an expert panel made up of representatives from the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), and Diabetes UK [1,2,3] has proposed a standard definition for remission of type 2 diabetes. This article outlines the different factors involved in that definition, as well as the proposed cut-offs.
Evolution of the Definition of Remission
As outlined in a previous article, in 2009, the American Diabetes Association defined partial remission, complete remission, and prolonged remission of type 2 diabetes as follows [4];
Partial remission is having blood sugar that does not meet the classification for Type 2 Diabetes; i.e., either HbA1C < 6.5% and/or fasting blood glucose 5.5 — 6.9 mmol/l (100—125 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.
Complete remission is a return to normal glucose values i.e. HbA1C < 6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.
Prolonged remission is a return to normal glucose values (i.e., HbA1C < 6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 5 years while not taking any medications to lower blood glucose.
In 2019, the Association of British Clinical Diabetologists and the Primary Care Diabetes Society [5] defined remission of type 2 diabetes as follows;
“Remission of type 2 diabetes can be diagnosed when a person with confirmed type 2 diabetes has achieved all three of the following criteria: (1) weight loss; (2) fasting plasma glucose or HbA1c below the WHO diagnostic threshold (<7 mmol/L or <48 mmol/mol, respectively) on two occasions separated by at least 6 months; (3) the attainment of these glycaemic parameters following the complete cessation of all glucose-lowering therapies.”
In clinical practice, I’ve defined remission of type 2 diabetes as blood sugar levels “at or below the cut-offs for diagnosis” (HbA1C & FBG) without the use of medication.
Choice of the Term “Remission”
The consensus report’s expert panel outlined that while several terms have been proposed to describe those who have become free of a previously diagnosed disease state, including ‘resolution’, ‘reversal’, ‘remission’, and ‘cure’, with respect to type 2 diabetes, ‘remission’ is the most appropriate term [1,2,3]. They chose the term remission as it is widely used in the field of oncology (cancer treatment), as defined as a decrease in or disappearance of signs and symptoms of cancer [6].
The expert panel believes that the term remission captures that (1) “diabetes may not always be active and progressive”, while also implying that (2) “notable improvement may not be permanent”, and (3) is consistent with the view that a person may need ongoing support and regular monitoring to prevent relapse [1,2,3].
Remission vs. Absence of Disease
The panel highlighted that the tendency to equate remission with “no evidence of disease” is not appropriate with respect to type 2 diabetes because diabetes is defined by hyperglycemia, which exists on a continuum [1,2,3], and noted that any criterion chosen to define remission is somewhat arbitrary. They also highlighted that remission is not equivalent to “no evidence of disease” because the underlying cause of type 2 diabetes is rarely resolved, including insufficient release of insulin from βeta-cells and insulin resistance.
Use of Glucose-Lowering Medication
The issue of whether remission could be diagnosed while a person was receiving ongoing medication support was also addressed. This is an important consideration, as some studies, such as those from Virta Health [7,8] define remission of type 2 diabetes as a HbA1C < 6.5% and fasting blood glucose ≤ 5.5 (100 mg/dl) while taking no other medication except metformin.
The panel concluded that a diagnosis of remission can only be made after all glucose-lowering agents have been withheld for an interval that is sufficient both to allow waning of the drug’s effects and to assess the effect of the absence of drugs on HbA1c values. This includes the use of metformin for weight maintenance, GLP-1 receptor agonists (such as Ozempic), and SGLT2 inhibitors (such as Jardiance). If these drugs cannot be discontinued for 3 months or longer, remission cannot be diagnosed even if normal blood sugar values are maintained.
Timeline for Determining Remission
Whether the changes made are dietary, lifestyle, or surgical, varying amounts of time are required to determine whether remission has been achieved.
Pharmacotherapy: At least 3 months after the medication has been completely stopped, before tests of HbA1C can reliably evaluate remission.
Surgical Intervention: At least 3 months after the surgical procedure and 3 months after medication has been stopped.
Lifestyle Changes: At least 6 months after beginning the intervention and 3 months after medication has been stopped.
Need for Ongoing Monitoring
Since improvements may not be permanent, a person will likely need ongoing support and regular monitoring. The panel cautions that a “legacy effect” of prior poor blood sugar control can continue in body tissues after remission of symptoms. Ongoing monitoring is required for HbA1C, as well as retinal screening for retinopathy, renal function tests for nephropathy, and foot evaluation for neuropathy.
Conclusions of the Expert Panel
The expert panel concluded that the term “remission” should be used to describe a sustained metabolic improvement in type 2 diabetes to nearly normal levels defined as a return of HbA1c to < 6.5% (<48 mmol/mol) that occurs spontaneously, or following an intervention and that persists for at least 3 months in the absence of usual glucose-lowering medication (pharmacotherapy).
NOTE: Be sure to read the following post about why it is time to stop calling type 2 diabetes ”a chronic, progressive disease”.
More Info
Learn about me and how I can support you in pursuing remission of type 2 diabetes. You can view my Comprehensive Dietary Package here.
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Joy
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Note: A consensus report is not an American Diabetes Association (ADA) position statement but represents the expert opinion of this international expert panel’s collective analysis, evaluation, and opinion.
References
- Riddle MC, Cefalu WT, Evans PH, et al. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes. J Clin Endocrinol Metab. 2021;106(11):3333-3341. doi:10.1210/clinem/dgab585 [https://academic.oup.com/jcem/article/106/11/3333/6358409]
- Riddle MC, Cefalu WT, Evans PH, et al. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes. Diabetes Care. 2021;44(10):2438-2444. doi:10.2337/dci21-0034 [https://diabetesjournals.org/care/article/44/10/2438/138556/Consensus-Report-Definition-and-Interpretation-of]
- Riddle MC, Cefalu WT, Evans PH, et al. Consensus report: definition and interpretation of remission in type 2 diabetes. Diabetologia. 2021;64(11):2359-2366. doi:10.1007/s00125-021-05542-z [https://link.springer.com/article/10.1007/s00125-021-05542-z]
- Buse JB, Caprio S, Cefalu WT, et al. How do we define cure of diabetes? Diabetes Care. 2009;32(11):2133-2135. doi:10.2337/dc09-9036 [https://diabetesjournals.org/care/article/32/11/2133/29004/How-Do-We-Define-Cure-of-Diabetes]
- Nagi D, Hambling C, Taylor R. Remission of type 2 diabetes: a position statement from the Association of British Clinical Diabetologists (ABCD) and the Primary Care Diabetes Society (PCDS). Br J Diabetes. 2019;19(1):73-76. doi:10.15277/bjd.2019.221 [https://bjd-abcd.com/index.php/bjd/article/view/221]
- Barnes E. Between remission and cure: patients, practitioners and the transformation of leukaemia in the late twentieth century. Chronic Illn. 2008;3(4):253-264. doi:10.1177/1742395307085333 [https://pubmed.ncbi.nlm.nih.gov/18083679/]
- McKenzie AL, Hallberg SJ, Creighton BC, et al. A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes. JMIR Diabetes. 2017;2(1):e5. doi:10.2196/diabetes.6981 [https://diabetes.jmir.org/2017/1/e5/]
- Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Ther. 2018;9(2):583-612. doi:10.1007/s13300-018-0373-9 [https://pubmed.ncbi.nlm.nih.gov/29417495/]
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Joy Erdile is the Registered Dietitian at BetterByDesign Nutrition Ltd., and has been supporting clients’ nutritional needs since 2008. Joy has a post graduate degree in Human Nutirion, more than 17 years of experience in private practice, and is a published in mental health nutrition. She is licensed in BC, Alberta, and Ontario, and her areas of expertise range from routine to clinically complex cases. Joy is passionate about helping people feel better and restore their health, and believes that there is no one-size-fits-all approach, but that Nutrition is BetterByDesign©.