It may not be easy to reach the point where type 2 diabetes is so well controlled that it’s considered in remission, and it’s not likely in every case, but it’s possible for some people. New guidelines from a group of U.S. and international medical organizations, published in August 2021 in Diabetes Care, lay out the steps that are necessary to get there.
Many strategies patients use to manage type 2 diabetes — including lifestyle changes, medication, and weight-loss surgery — can help them get to remission, according to the guidelines, which were drafted by members from the Endocrine Society, the European Association for the Study of Diabetes, Diabetes UK, and the American Diabetes Association. Whatever intervention, or combination of approaches, people use, the guidelines note, there’s still one target they need to hit for doctors to consider the disease in remission: an A1C of below 6.5 at least three months after stopping medication under a doctor’s supervision. A1C is a three-month average of blood sugar levels. (The recommendation does not apply to people with type 1 diabetes, who must take insulin for life to manage blood sugar.)
“If they (people with type 2 diabetes) artificially lower blood glucose with drugs, you cannot see if the disease process has been halted,” says Michael Lean, MD, a diabetes researcher and nutrition professor at the University of Glasgow in Scotland, who also involved in the guidelines.
Anita Courcoulas, MD, MPH, chief of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center in Pennsylvania, who wasn’t involved in drafting the guidelines, adds that it takes about three months for this process to be verified when a patient is taken off medication.
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When Doctors May Consider Remission Potential for a Person With Type 2 Diabetes
The choice of whether to take a patient off medication to verify remission isn’t always straightforward for doctors. Ultimately, it depends on the patient, says Caroline Messer, MD, an endocrinologist at Fifth Avenue Endocrinology in New York City.
“I look at the trend for my patients,” says Dr. Messer, who wasn’t involved in the guidelines either. “If they’re on medication and their numbers go below 6.5 and are consistently dropping, and they’re also making a concerted effort with lifestyle changes, then I would stop medication for three months and then test again to see if A1C rises back up or not.”
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Why Remission From Diabetes Doesn’t Mean Abandoning Healthy Habits
If A1C does climb above 6.5 percent again, a person would need to go back on medication, Messer says. If it doesn’t, Messer likes to tell them that they now have diet- and exercise-controlled diabetes.
“If you gain weight, if you stop exercising, if you change your diet, diabetes can return,” Messer says. In other words, even if a person has entered what’s considered remission from diabetes, they can’t completely let go of diabetes-friendly diet and lifestyle habits.
The chances of remission can vary with the approach to managing diabetes, and remission isn’t always permanent.
For example, a review published in Nutrients in April 2019 found that weight loss surgery may lead to remission in 80 percent of patients at one year, but only 45 percent of them sustained remission after five years.
Similarly, a study published in July 2019 in The Lancet Diabetes & Endocrinology found that intensive weight management with low-calorie meal replacements could lead to remission in 46 percent of participants after one year, but remission rates slipped to 36 percent after two years.
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When Is Type 2 Diabetes Considered in Remission?
How soon doctors can consider diagnosing remission can vary based on the methods used to get blood sugar levels on target, the guidelines stress.
For example, a person who lowers their blood sugar to a healthy range after undergoing metabolic surgery — a weight loss procedure done in part to help individuals with overweight or obesity manage conditions like diabetes — must be at least three months post-surgery before they can be considered in remission.
People who don’t use surgery or medication to manage diabetes — and instead make lifestyle changes like overhauling their eating and exercise habits — must stick with these new routines for at least six months before they’re considered in remission.
“The longer time period of six months for the effect of lifestyle therapy is due to the fact that weight change is slower after lifestyle interventions compared to metabolic surgical interventions, so this time period allows for the full effect of the lifestyle intervention to be realized,” says Dr. Courcoulas.
Remission is more likely when people receive treatment to lower their blood sugar soon after diabetes gets diagnosed, says Matthew Riddle, MD, lead author of the guidelines and a professor of endocrinology, diabetes, and clinical nutrition at Oregon Health and Science University in Portland. Therefore, remission may be easier to reach with an earlier diagnosis.
People who try multiple approaches at once — like medication and lifestyle changes — may also have a better shot at remission, Dr. Riddle says.
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Screenings After Type 2 Diabetes Remission
Once individuals are in remission, in addition to following healthy habits, they still need to have their A1C levels tested at least once a year, the guidelines advise, and no more than every three months.
This is in part because people may not always maintain any weight loss that helped them achieve remission, the guidelines note. Testing is also necessary because researchers aren’t yet certain how long remission can last or what factors may contribute to a relapse.
Beyond checking blood sugar, people with diabetes need ongoing monitoring by a diabetes specialist.
In the period shortly after remission, individuals have an increased risk of diabetes complications due to the rapid drop in blood sugar that helped them achieve remission, the guidelines note. Down the line, there’s also a risk that complications could develop, especially when blood sugar rises to levels slightly above normal, to an A1C above 5.7 percent but less than 6.5 percent, which signals prediabetes.
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After Remission, Diabetes-Related Complications May Linger
It's not yet clear whether people in remission can avoid vascular complications when their blood sugar levels are in the prediabetes range, Courcoulas says. Vascular complications can include damage to the blood vessels in the eye that impacts vision, diabetic nerve damage that can lead to loss of sensation or impaired motor control in the limbs, and reduced kidney function.
People in remission may fare better over the long term when they keep up the habits that got them there, Courcoulas says.
“Exercise regularly, maintain a healthy lifestyle, and see your treating doctor for ongoing monitoring of both A1C levels and for possible relapse or complications of diabetes, even if you have experienced remission,” Courcoulas advises.
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