Type 2 Diabetes Remission: What Is It and How Can It Be Done?

Key takeaways:

A type 2 diabetes diagnosis is not a guarantee of gradually worsening metabolic health. In fact, some people can halt progression and even put it in remission.
While type 2 diabetes can present and progress in many different ways, it is often associated with weight gain. For many people, the main path to remission involves weight loss.
For a long time, lifestyle changes and weight loss surgery were the only tools people had to help them reach remission. Now, medications are an effective option, but they raise questions about what defines success.

Type 2 diabetes is a progressive disease. Even with lifestyle changes and treatment, A1C levels can increase over time, requiring people to raise the intensity of their treatment and add more medications, such as insulin.

However, many people with type 2 diabetes can keep their blood sugar steady for long periods of time, and some have even been able to put it into remission.

Diabetes remission is usually defined by an A1C level of someone without diabetes (less than 6.5%) and staying there without the continued use of diabetes medications. Keep in mind that remission is not the same as a permanent cure – your A1C levels may go back up. But for as long as it lasts, remission can offer a break from the frequent pills, injections, blood sugar checks, and all the other things that come with diabetes management.

What exactly is diabetes remission?

Type 2 diabetes is a complex condition, and it plays out differently in different people. For many, disease progression is strongly associated with weight gain.

The majority of type 2 diabetes cases are driven by fat accumulation around organs like the liver and pancreas. Fat in the liver can cause cells to become resistant to insulin, and in the pancreas can impair insulin-producing beta cells.

Removing extra fat from these organs helps restore normal insulin production and reduce insulin resistance, giving people a chance to go into remission. Because people see reductions in the amount of fat in and around internal organs when they lose weight overall, general weight loss is recognized as the main pathway to diabetes remission.

In 2021, the American Diabetes Association (ADA) released a consensus report that defined diabetes remission as having an A1C below 6.5% (the cutoff for a type 2 diabetes diagnosis) and discontinuing all diabetes medications for at least three months. That means a person would need to stop taking treatments like metformin, insulin, sulfonylureas, SGLT-2 inhibitors like Jardiance and Farxiga, and GLP-1 drugs for at least three months.

Of course, it should be noted that some of these drugs have wide-ranging health benefits. In particular, there is a lot of evidence that SGLT-2 inhibitors and GLP-1 drugs can protect the heart and kidneys. Discontinuing these medications may mean fewer side effects, financial savings, and lower treatment burdens, but it may not be in your best interest to stop taking them if you have or are at risk for heart and kidney disease.

Although many experts contributed to and agreed on the ADA’s report, it should be noted that there continues to be some debate about the definition of remission. Therefore, remission, as defined by the ADA, should not necessarily be the goal for everyone with type 2 diabetes.

Still, even if you have no plans to stop your diabetes medications, reducing A1C and body weight in a way that supports your overall health will lower the risk of long-term complications. Taking these steps can also increase well-being and even lead to lower insurance costs.

How to reach type 2 diabetes remission

Some people can reach remission by making voluntary changes to their dietary and exercise habits, while others need help from medications and weight loss surgery. It usually takes a combination of strategies, but reaching and staying in remission is possible.

Diet

A notable study, the Diabetes Remission Clinical Trial (DiRECT), tested whether restricting calories would lead to diabetes remission. Study participants ate around 850 calories per day for three months, followed by 2-8 weeks on a food reintroduction program, and then a program for weight loss maintenance, which involved monthly check-ins and encouragement to increase daily physical activity.

After one year, 46% of the participants on the low-calorie diet had achieved remission. In comparison, only 4% of people who followed standard diabetes care guidelines went into remission. Diabetes remission was closely related to weight loss. Here are some of the key findings:

Lost 0-11 pounds, 7% achieved remission
Lost 11-22 pounds, 34% achieved remission
Lost 22-33 pounds, 57% achieved remission
Lost 33 pounds or more, 86% achieved remission

Remission was not permanent for everyone, but many participants who reached it were able to maintain it for years. After two years, 70% of those in remission at the first year maintained remission. After five years, 26% of those in remission at the second year maintained it.

Although check-ins for the DiRECT study officially ended after two years, the researchers asked the participants if they would be interested in continuing with less frequent check-ins for another three. The participants who agreed were in remission at more than twice the rate as those without any assistance over that three-year period. There was a continued decline in the number of participants maintaining remission in the intervention group. The study showed how important support networks are for achieving and maintaining weight loss, but not everyone has access to the level of support that comes with being a participant in a clinical trial. That’s why it’s important to find a dietary strategy that is easy for you to implement and maintain.

One model for weight loss suggests that specifically focusing on reducing carbohydrate consumption may decrease fat storage, reduce hunger, and increase energy expenditure. It’s important to note that protein and fat both contribute to your overall calorie consumption, and simply replacing calories from carbs with calories from protein and fat is not likely to lead to substantial weight loss.

It’s possible to lower your A1C with a low-carb diet in the absence of weight loss. However, without accompanying weight loss, a low-carb diet probably won’t lead to remission or address the beta cell dysfunction at the root of type 2 diabetes.

If you are considering a low-carb diet, there are different targets you can aim for. Some people follow a ketogenic diet, typically eating fewer than 60 grams of carbs per day. This forces the body to burn fat instead of carbs for energy. Others follow less restrictive low-carb diets that still allow for up to 130 grams of carbs per day – i.e., a “Low Carb, High Fat” or “Low Carb, Healthy Fat” (LCHF) approach.

Ultimately, the calorie and carb counts that make sense for you will depend on your body and your needs, which may change over time. For example, two people who are trying to reach remission may see success by, among other changes, cutting their carbs to 50 grams per day. But after getting there, one of them may be able to raise their intake up to 100 grams of carbs per day and sustain remission, while the other has to stay at 50 grams per day.

The most important thing is to approach any changes you make to your diet safely and sustainably. Make sure to consult with your healthcare provider. Very rapid weight loss may result in too low blood pressure, for example, and calorie or carbohydrate restriction while on insulin or sulfonylureas can result in low blood sugar.

Once you reach your weight loss target, you may need to readjust your diet for maintenance and make sure that you’re enjoying what you’re eating enough to stick with it long-term.

Exercise

Exercise burns calories, but aside from high-performing athletes, few people can put enough time and intensity into exercise to lose weight without also changing how much they are eating. However, exercise has benefits even in the absence of weight loss.

People with prediabetes can also achieve remission (generally defined as sustaining an A1C level below 5.4%). Like type 2 diabetes remission, prediabetes remission is driven by reductions in the amount of fat on internal organs. Research has found that some people with prediabetes were able to achieve remission in the absence of weight loss because changing their diet and exercising more caused their bodies to redistribute fat stores away from their internal organs.

For people who are trying to achieve type 2 diabetes remission, weight management should still be the primary goal, but exercise can help give your body a chance to go into remission even if it is not a primary driver of weight loss.

In addition, intense exercise decreases your overall insulin resistance and causes your body to release hormones that help regulate appetite. Thus, regular physical activity plays an essential role in maintaining weight and remission as well.

Medications

GLP-1 medications like Ozempic (semaglutide) and Mounjaro (tirzepatide) provide a host of benefits, including weight management. They make you feel full faster and can help quiet “food noise.” Taking GLP-1s and similar medications allows you to worry less about the amount of food you are eating and devote more of your mental energy to the type of food you’re eating and the amount of exercise you’re getting.

To “officially” reach remission, by definition, you would have to stop taking a GLP-1, but even after achieving your weight loss goals, the benefits of staying on them may outweigh stopping.

It’s possible that you could just use a GLP-1 to kickstart your weight loss journey and then stop without losing progress, but research suggests that many people who discontinue GLP-1 drugs regain at least some of the weight they have lost. Furthermore, the heart and kidney health benefits of these medications only seem to last as long as you continue to take them.

At the end of the day, reaching and maintaining your A1C and weight goals – as well as preventing any diabetes-related complications – is more important for your long-term health than proving you’re in remission. You should consult with your healthcare providers and support network before deciding to pause or discontinue a GLP-1 medication.

Weight loss surgery

Weight loss surgery is another option for people with type 2 diabetes, particularly those who have a higher body mass index (BMI). The effects of these procedures do not depend on ongoing medication use, so they provide a clear path to an official declaration of remission.

Studies have found that bariatric surgery results in diabetes remission in 78% of individuals who undergo the procedure. Other research has found that 72% of people who received surgery were in remission two years following surgery, and 30% were in remission 15 years following surgery. Weight loss drives this to a large extent, but remission after surgery typically occurs so quickly that researchers think changes in hormone levels and metabolism also play a role.

Even though weight loss surgery could be a one-and-done path to remission, it does have some unique drawbacks. Depending on insurance for those in the US, this method may have a high financial cost. It also carries risks, including surgical complications, malnutrition, leaks in the gastrointestinal system, bowel obstruction, dumping syndrome (when food moves through your stomach too quickly), ulcers, and severe hypoglycemia. Other than the adjustable gastric band, bariatric surgery cannot be undone.

Again, the most important thing is to figure out what will help you reach your A1C and weight goals in a way that supports your overall health.

Can anyone put type 2 diabetes into remission?

The longer you’ve had type 2 diabetes, the more difficult it is to reach remission. Over time, the beta cells in the pancreas lose their ability to produce insulin. After a certain point, it may be impossible to restore normal insulin production. However, achieving remission is possible and is an excellent goal to strive for and discuss with your healthcare provider, if it is feasible and makes sense for you.

If you do achieve remission, it’s important to continue checking your blood sugar somewhat regularly to make sure you have not relapsed, which could happen for reasons outside of your control. The ADA recommends yearly A1C checks for people in remission, but it’s a good idea to keep fingerstick tests or a continuous glucose monitor (CGM) on hand if you want to check more frequently.

The ADA also recommends that anyone who has put their diabetes into remission continue to be screened for diabetes complications related to heart, kidney, nerve, and eye health. It may make sense to reduce the frequency of your screenings if you remain in remission for an extended period of time, but you should discuss this with your healthcare providers.

Habits to build on your way to remission

Marcia Kadanoff was diagnosed with type 2 diabetes in June 2017. With the help of diaTribe and Adam Brown's book, “Bright Spots & Landmines,” she discovered that type 2 diabetes can be put into remission with lifestyle changes. In 2019, Kadanoff spoke with diaTribe and shared some of the habits that helped her reach remission:

Check blood sugar frequently with a glucose meter or, ideally, a CGM to see how your blood sugar responds to different foods and eating styles. In the past, Kadanoff has used Abbott’s FreeStyle Libre CGM products and the LibreLink app.
Establish a low-carb, healthy fat (LCHF) way of eating. Incorporating fats like avocado, nuts, olive oil, cheese, and Greek yogurt reduced Kadanoff’s cravings for unhealthy foods. Also, make sure to have low-carb, go-to snacks on hand (Kadanoff likes macadamia nuts).
Take a walk and drink a glass of water when blood sugar levels are high (greater than 140 or 180 mg/dL, depending on your target range).
Aim for 10,000 steps per day, and try not to let more than two days in a row of inactivity go by. Walking is one of the most underrated exercise strategies.
Sleep is another factor that impacts diabetes, including insulin resistance, weight loss, and food choices. Aim for seven or more hours of sleep, including going to sleep at a regular hour and waking up at the same time each day.
Finding additional motivation for achieving remission besides weight loss, such as having more energy throughout the day, or not wanting to rely on medications.

The bottom line

If you are diagnosed with type 2 diabetes, your health trajectory is not set in stone. You can use lifestyle changes and medication to keep the disease in check. You may even be able to put it in remission and eliminate the need for medications altogether.

The main pathway to remission is through weight loss, and because the most effective weight loss medications are also diabetes medications, the line between treating diabetes and going into remission has blurred. However, remission remains an excellent goal to work towards, and the habits that you need to build to get there can also help you live a happy and healthy life with diabetes.

Learn more about type 2 diabetes here:

Share