Type 2 Diabetes Mellitus - quality prescribing strategy: improvement guide 2024 to 2027

4. Lifestyle interventions and when remission is a realistic aim for someone with type 2 diabetes mellitus (T2DM)

Lifestyle intervention

Lifestyle management is a fundamental aspect of diabetes care and includes:

• diabetes self-management education and support
• weight management intervention and support
• nutritional advice
• promoting physical activity
• smoking cessation counselling
• psychosocial care

Weight loss can delay the onset of T2DM^[32] and can lead to remission.^[33]

Clinicians should help individuals understand the impact excess body weight has on T2DM and medications prescribed. They should discuss prioritising diet and lifestyle interventions at diagnosis and each subsequent review. Individuals may require referral to structured education programmes, diet and lifestyle support and weight management services.

People whose diagnosis is doubtful, or individuals presenting with significant weight loss/osmotic symptoms, should be discussed with the local acute diabetes specialist team.

Achieving remission of T2DM

The criteria for remission of T2DM was agreed in 2021^[34] by an international group of diabetes experts to standardise and simplify the criteria across the UK, Europe and the USA.

A person with T2DM is in remission if:

• they have had an HbA1c level below 48mmol/mol (6.5%) for a least three months; and
• they have not taken any medications to manage their blood glucose levels during this time.

Why is it important to offer and support remission?

Supporting remission achievement is important to:

• improve a person’s health and wellbeing
• motivate the individual to continue to strive for freedom from diabetes and remain in remission
• reduce the burden of T2DM on their lives from:
  • medications, NHS appointments
  • complications of diabetes
  • cost of holiday and life insurance
• reduce prescribing and risk of long-term complications, reducing the disease and medication benefit for both the individual and wider NHS
• improved environmental sustainability - reduced medicines usage (with their associated production and supply) reduces the carbon footprint from medicines use.

Early data from the NHS England remission programme shows participants on average lose 7.2kg (over one stone) after one month, and 13.4kg (over two stone) after three months. New data also shows that people on the remission programme, who are eating and drinking the low-calorie alternatives, not only lose weight but maintain the weight loss. This is a significant step forward and comes after trials showed that around half of people who had similar weight loss were able to achieve remission of their T2DM after one year.^[35]

What is a remission intervention?

It is a two-year intensive weight-loss programme delivered by specialist dietitians – with psychology support for those who need it. The intervention involves three key stages outlined in Table 5.

Stage 1

12 weeks: Total diet replacement

• Low energy diet of shakes and soups
• Goal setting and obstacle management
• Support to deal with social situations
• Fortnightly appointments with a dietitian

Stage 2

12 weeks: Food reintroduction

• Gradual reduction of shakes and soups as meals are reintroduced
• Ongoing support to achieve weight goals
• Meal and exercise planning
• Fortnightly appointments with a dietitian

Stage 3

18 months: Weight-loss maintenance

• Future weight management planning
• Ongoing support to achieve weight goals
• Strategies to form positive habits and maintain lifestyle changes for the future
• Monthly appointments with a dietitian

This evidence based dietetic remission intervention is available across all Scottish health boards.

See case study 1.

Who can be offered remission?

Patients who have been diagnosed with T2DM in the past six years and meet all of the following criteria should be offered the remission intervention:

• 18-65 years old
• Body mass index BMI
  • 25 or above (ethnic minorities)
  • 27 or above (White Caucasian)
• Currently not prescribed insulin
• Recent HbA1c (within the last 12 months) were:
  • above 48mmol/mol if not taking any diabetes medication; or
  • above 43mmol/mol if taking diabetes medication

How to access the remission programme?

Contact the local Nutrition and Dietetic Department for information on how to refer into remission programmes.

What monitoring is required for remission?

Dietitians leading the intervention will advise on specific monitoring to meet individual’s needs. The following are routinely measured:

• HbA1c
• blood pressure
• body weight/weight loss

Note:

Some GLP-1RA are licensed for weight management. These preparations have Scottish Medicines Consortium (SMC) restrictions regarding treatment threshold (BMI and HbA1c levels, accounting for ethnicity), and are currently used in combination with structured weight management programmes. Whilst weight management is integral to the prevention and management of T2DM, recommendations for these agents in individuals without a diagnosis of T2DM are beyond the scope of this guidance.

List 1 Lifestyle support resources

• My Diabetes My Way is an interactive website to help support those with diabetes and their friends and families. This e-learning course aims to give you the information you need about what type 2 diabetes is, what it might mean for your health and what you can do to manage it. The topic list (to the right) will give you an idea of all the information covered in this course.
• NHS Inform provides health information that anyone living in or visiting Scotland can trust. NHS contains detailed information on diabetes.
• The Association of UK Dietitians has produced a Type 2 Diabetes food fact sheet.
• Diabetes UK provides a range of information on its website. Some of this information is available in different languages, large print, Braille, British Sign Language, easy read and audio.
• Diabetes UK has produced a guide on improving care for people with diabetes and a learning difficulty.
• Diabetes UK has produced an easy read guide on what to do when you have type 2 diabetes.