Characterised by high blood sugar levels, type 2 diabetes is associated with wide-ranging health complications, it's not an easy condition to live with, requiring long-term monitoring and maintenance, and has long been thought of as a lifelong disease that gets progressively worse…until now.

In the last 5 years, breakthrough scientific research has confirmed that this chronic disease can in fact be reversed. Even better, studies show that nearly half of people living with the condition could achieve reversal and the way to get there is devoid of medication or surgery.[1] As word spreads, there’s growing confusion over the terminology—type 2 diabetes reversal? Remission? A cure? As you start to learn more about this incredible discovery, it’s important to take a moment to familiarise yourself with the differences in this terminology, and what it means for your health in the long run.

Definitions of type 2 diabetes remission

As scientific evidence grows in favour of type 2 diabetes remission, it's important to note that there are different definitions of remission in some studies. For example, some people are classed as being in remission when their blood sugar levels are within a normal range while still being on medication such as metformin.[2] 

When we refer to remission, we follow the official updated definition released by Diabetes UK in 2021: ‘Type 2 diabetes remission is a sustained metabolic improvement where HbA1C levels return to below 6.5% (48mmol/mol) and which is sustained for at least 3 months in the absence of glucose-lowering medications.’[3] 

How is type 2 diabetes reversal measured?

If you’ve been diagnosed with type 2 diabetes, chances are you found out as a result of something called HbA1c (glycated haemoglobin for anyone interested). This measurement refers to the number of red blood cells that have glucose attached to them. It's used to diagnose type 2 diabetes because if you have the condition, the body isn’t able to use glucose properly and this excess then sticks to red blood cells.

Type 2 diabetes is officially in remission when HbA1c levels return to below 6.5% (48mmol/mol) and stay there for least 3 months without glucose-lowering medications

Diabetes UK

The amount of sugar in our blood naturally changes throughout the day as a result of our actions (it will always increase after eating for example), so taking a one-time measurement isn’t an accurate representation of overall blood sugar levels. Red blood cells live for 3-4 months, meaning that HbA1c results can capture the average blood sugar levels of the preceding few months.

To be diagnosed with type 2 diabetes, you’ll have consistently high blood sugar levels of more than 48mmol/mol. To manage type 2 diabetes is to find ways to keep blood sugar levels as close to the healthy range as possible, and if you’re working towards reversing type 2 diabetes, you’re aiming to lower your HbA1c levels. When HbA1c levels return to below 6.5% (48mmol/mol), type 2 diabetes is classed as being in remission.[3]

How to reverse type 2 diabetes

The research so far points towards weight loss as the key to reaching remission and the more weight you lose, the higher your chances are of reversing the disease process underlying type 2 diabetes.[1,4-6]

This connection to weight comes from the finding that people with type 2 diabetes tend to have excess fat inside the liver and pancreas, both of which are responsible for blood sugar control. This has nothing to do with the visible fat we associate with being overweight—10% of people living with type 2 diabetes are of a healthy weight, challenging the view that the condition is a result of obesity (there are in fact a lot of risk factors for type 2 diabetes).[7] Instead, these internal fat deposits interfere with the pancreas’ ability to produce insulin and the liver’s sensitivity to insulin. In other words, the cells in the pancreas that produce insulin stop working properly and the liver is unable to detect insulin anyway, and so continues to produce glucose. Taken together, this results in elevated blood sugar levels.

Scientists have found that with significant weight loss these internal fat deposits can go away and, remarkably, the pancreas starts producing insulin again and the liver stops producing glucose in response to the insulin. So, what do we mean by ‘significant’? Well, the evidence points to a weight loss of 15kg as being the aim for most people who want to reach type 2 diabetes remission but people who lose less than that have also reversed the condition.[1,4]

It sounds like a lot we know, but it's possible even just by making changes to your diet and lifestyle. Food plays a major role in our blood sugar levels and for people with type 2 diabetes, this effect is even greater. Everyone responds differently to food, which is why there isn't a single advertised ‘type 2 diabetes diet’. Instead, it’s about finding the right eating approach that suits your living circumstances—work, family, hobbies, budget, and your health goal, it all matters. Total diet replacement has been clinically proven to be the safest and most effective way to lose a substantial amount of weight, and a recent study hailed total diet replacement as the best way to reach type 2 diabetes remission.[1,2,8] 

In conjunction with eating habits, making changes to your physical exercise routine can also help you on your journey to remission. Exercise has been shown to help lower blood sugar levels and improve insulin sensitivity, two positives for people with type 2 diabetes. Regular movement is key here—instead of fixing yourself up for 5 rigorous workout sessions in the gym each week (which you’re welcome to do if you so wish!), try to move regularly throughout the day. A lunchtime walk, marching on the spot while the kettle boils, an hour of gardening, taking the stairs instead of the lift—it all adds up in helping you lose weight, maintain that weight loss, and keeping your blood sugar levels under control. 

It’s really important at this stage to highlight that while studies suggest that people who lose more than 15kg are more likely to enter remission, any weight loss is beneficial for your health and wellbeing. Weight loss of any amount can:

• Help regulate your blood sugar levels (and therefore reduce diabetes medications)
• Reduce your risk of cardiovascular disease
• Improve your mobility and reduce joint pain
• Improve your sleep
• Boost energy levels
• Improve your mood
• Raise your confidence
  

Lifestyle changes can quickly normalise blood sugar levels, so please do speak to your doctor before undertaking any new eating or exercise approach. They can discuss your options with you and will be able to make adjustments to your medication doses. 

Is type 2 diabetes reversal the same as a cure?

The notion of type 2 diabetes reversal is incredibly exciting but remember, it's incredibly new. The DiRECT trial only finished a few years ago so while we have results spanning 2-3 years after remission, the field is too new to draw any conclusions into long-term outcomes—we’re quite literally at the beginning of a major medical discovery.[1,4] Rest assured, research is ongoing and as our understanding of type 2 diabetes reversal, it’s important to understand that reversal doesn’t mean a cure. 

Type 2 diabetes remission isn’t a one-off event, it needs to be maintained

Type 2 diabetes remains a lifelong condition but the research shows that it is possible to reverse the disease process, putting it (and its symptoms) into remission. This means that you’ll be able to naturally regulate your blood sugar levels without the need for medication but you will not have cured yourself of type 2 diabetes. 

This leads to the issue of permanence. So far, studies have been unable to confirm the permanence of type 2 diabetes reversal. Taking the steps to remission into consideration, in which weight loss helps the body regain natural control of blood sugar levels, it's fair to say that weight regain can cause someone to exit remission. This happens because if the internal fat deposits around the liver and pancreas return, they will impede their ability to control blood sugar once again.

Habit change will help you stay in remission

All this points to the most important step of the type 2 diabetes reversal journey, and that’s the creation of healthy habits. It’s all very well (and motivating!) losing enough weight to reach remission but that’s only half the story—to stay in remission for as long as possible, you need to maintain that weight loss. It's this habit change (or lack of) that causes weight regain after so many weight loss attempts—old habits die hard and without investing proper time in building that foundation, it’s all too easy to fall back into old routines once the weight has dropped. It’s not just us saying this either! All of the successful studies into type 2 diabetes found that the participants who entered and stayed in remission were the ones who had taken part in behaviour change interventions alongside their dietary adjustments.[1,4,5,9]

So if you’re hoping to reach remission, remember to factor this into your plan. Rather than a quick win, consider investing a prolonged period of time to safely lose weight while exploring sustainable nutritional, physical, and mental habits. Type 2 diabetes remission isn’t a one-off event, it needs to be maintained.

Can everyone with type 2 diabetes go into remission?

It’s been seen that despite losing 10-15kg of weight, some people don't reach remission. Scientists are still working hard to understand why this is the case but there seems to be a general agreement that it is to do with the insulin-producing cells (called beta cells) in the pancreas. By the time someone is diagnosed with type 2 diabetes, these cells have reduced in number by 50%, and the longer you have the condition, the more they deteriorate.[10] Scientists originally thought that these cells had ceased to exist but the discovery of reversal, in which these cells recover and start producing insulin again, suggests otherwise. Researchers are now investigating this recovery process—if the cells are damaged beyond repair then significant weight loss may not be enough to successfully reverse type 2 diabetes. 

45.6% of people following a low-calorie, diet-based weight management programme were in remission after a year

Lean et al., Lancet

This is why the general message is that reversal is more likely the nearer you are to diagnosis because the longer you have untreated type 2 diabetes, the more the beta cells in the pancreas will deteriorate.[6] That being said, plenty of people who have lived with type 2 diabetes for more than a decade have successfully reached remission so it’s definitely worth a shot. And remember, all of the health benefits that come with losing weight and controlling blood sugar levels will still be felt even if you don’t reach remission!

Type 2 diabetes is a complex condition and there are a lot of factors at play when we talk about reversing it or going into remission. While it's early days in terms of our collective understanding of this process, there’s no denying that we’re at a turning point that will hopefully change the lives of millions of people around the world. So, if you hope to reach type 2 diabetes remission, take your time, ask questions, and know that you have the power to reverse the disease process and live a longer, healthier, happier life in remission.