Remission of type 2 diabetes in Scotland

BACKGROUND: Remission is broadly defined as normal glycaemic parameters in the absence of glucose-lowering therapy among people with a diagnosis of type 2 diabetes. Until recently, the main route to remission was through surgical treatment of obesity. In 2018, the Diabetes Remission Clinical Trial (DiRECT) suggested that remission of type 2 diabetes was possible through a very low-calorie diet intervention in a primary care setting. This intervention is now available across the United Kingdom. Questions remain regarding how to define remission of type 2 diabetes in clinical practice, how many people achieve remission of type 2 diabetes in routine care and how primary care professionals (PCPs) understand and support people to initiate and sustain remission. METHODS: This thesis uses three different research methods. For the first of these, I conducted a systematic search to describe the heterogeneity of remission definitions in published literature. In the second, I used quantitative methods to conduct a cross-sectional analysis of the population-based register of people with diabetes in Scotland to estimate the prevalence of remission of type 2 diabetes. For the final section of the thesis, I used qualitative methods to explore how primary care professionals have understood and defined remission of type 2 diabetes, and how this influenced their approach to care of people in remission or who wish to try to achieve remission. FINDINGS: There were 96 unique definitions of remission of type 2 diabetes in 178 papers from 2009 to 2020. Approximately 5% of people with a diagnosis of type 2 diabetes and a previous HbA1c of >48 mmol/mol (6.5%) in Scotland in 2019 were in remission of type 2 diabetes (defined as all HbA1c values <48mmol/mol (6.5%) in the absence of glucose-lowering therapy for a continuous duration of ≥365 days). Factors associated with remission were: older age, HbA1c <48 mmol/mol (6.5%) at diagnosis, no previous history of glucose-lowering therapy, weight loss between diagnosis of diabetes and 2019 and previous bariatric surgery. Semi-structured interviews with Scottish PCPs suggested an ambivalence about the value of identifying remission as it did not change clinical management. This also meant that there was frequently no compelling reason to code people as being in remission in electronic health records. People in remission were not typically offered additional support to sustain remission, many PCPs felt they required less support than people with type 2 diabetes. Remission through unintentional weight loss was not thought to be compatible with the prevailing perception of remission as an effortful endeavour. Whilst most practice nurses reported mentioning remission at the annual review of people with a diagnosis of type 2 diabetes, many PCPs pointed out that more effective discussions required skill and sensitivity. PCPs wanted training on motivational interviewing and more resources to provide patient-centred care with more rapid access to specialist services. However, some PCPs also stated that complementary public health policies were needed to address the obesogenic environment. CONCLUSIONS: Consistent, unambiguous guidance is needed on defining and coding remission of type 2 diabetes in primary care. This requires consensus on the purpose and value of remission. Pathways are needed to identify and support people who achieve remission through intentional weight loss with different approaches needed for people who meet criteria for remission through unintentional weight loss. Exploring the needs and perspectives of people in remission is likely to offer additional insights. Further research is needed to establish the proportions of people that achieve sustained remission of type 2 diabetes following intentional weight loss, to the factors associated with sustained remission and whether people in remission have better long-term outcomes than people whose type 2 diabetes is well-controlled with glucose lowering therapy

Defining remission of type 2 diabetes in research studies: A systematic scoping review

BackgroundRemission has been identified as a top priority by people with type 2 diabetes. Remission is commonly used as an outcome in research studies; however, a widely accepted definition of remission of type 2 diabetes is lacking. A report on defining remission was published (but not formally endorsed) in Diabetes Care, an American Diabetes Association (ADA) journal. This Diabetes Care report remains widely used. It was the first to suggest 3 components necessary to define the presence of remission: (1) absence of glucose-lowering therapy (GLT); (2) normoglycaemia; and (3) for duration ≥1 year. Our aim is to systematically review how remission of type 2 diabetes has been defined by observational and interventional studies since publication of the 2009 report.Methods and findingsFour databases (MEDLINE, EMBASE, Cochrane Library, and CINAHL) were searched for studies published from 1 September 2009 to 18 July 2020 involving at least 100 participants with type 2 diabetes in their remission analysis, which examined an outcome of type 2 diabetes remission in adults ≥18 years and which had been published in English since 2009. Remission definitions were extracted and categorised by glucose-lowering therapy, glycaemic thresholds, and duration. A total of 8,966 titles/abstracts were screened, and 178 studies (165 observational and 13 interventional) from 33 countries were included. These contributed 266 definitions, of which 96 were unique. The 2009 report was referenced in 121 (45%) definitions. In total, 247 (93%) definitions required the absence of GLT, and 232 (87%) definitions specified numeric glycaemic thresholds. The most frequently used threshold was HbA1cConclusionsWe found that there is substantial heterogeneity in the definition of type 2 diabetes remission in research studies published since 2009, at least partly reflecting ambiguity in the 2009 report. This complicates interpretation of previous research on remission of type 2 diabetes and the implications for people with type 2 diabetes. Any new consensus definition of remission should include unambiguous glycaemic thresholds and emphasise duration. Until an international consensus is reached, studies describing remission should clearly define all 3 components of remission.Systematic review registrationPROSPERO CRD42019144619

Supported self-management for people with type 2 diabetes:a meta-review of quantitative systematic reviews

OBJECTIVES: Self-management support aims to give people with chronic disease confidence to actively manage their disease, in partnership with their healthcare provider. A meta-review can inform policy-makers and healthcare managers about the effectiveness of self-management support strategies for people with type 2 diabetes, and which interventions work best and for whom. DESIGN: A meta-review of systematic reviews of randomised controlled trials (RCTs) was performed adapting Cochrane methodology. SETTING AND PARTICIPANTS: Eight databases were searched for systematic reviews of RCTs from January 1993 to October 2016, with a pre-publication update in April 2017. Forward citation was performed on included reviews in Institute for Scientific Information (ISI) Proceedings. We extracted data and assessed quality with the Revised-Assessment of Multiple Systematic Reviews (R-AMSTAR). PRIMARY AND SECONDARY OUTCOME MEASURES: Glycaemic control as measured by glycated haemoglobin (HbA1c) was the primary outcome. Body mass Index, lipid profiles, blood pressure and quality of life scoring were secondary outcomes. Meta-analyses reporting HbA1c were summarised in meta-forest plots; other outcomes were synthesised narratively. RESULTS: 41 systematic reviews incorporating data from 459 unique RCTs in diverse socio-economic and ethnic communities across 33 countries were included. R-AMSTAR quality score ranged from 20 to 42 (maximum 44). Apart from one outlier, the majority of reviews found an HbA1c improvement between 0.2% and 0.6% (2.2-6.5 mmol/mol) at 6 months post-intervention, but attenuated at 12 and 24 months. Impact on secondary outcomes was inconsistent and generally non-significant. Diverse self-management support strategies were employed; no single approach appeared optimally effective (or ineffective). Effective programmes tended to be multi-component and provide adequate contact time (>10 hours). Technology-facilitated self-management support showed a similar impact as traditional approaches (HbA1c MD -0.21% to -0.6%). CONCLUSIONS: Self-management interventions using a range of approaches improve short-term glycaemic control in people with type 2 diabetes including culturally diverse populations. These findings can inform researchers, policy-makers and healthcare professionals re-evaluating the provision of self-management support in routine care. Further research should consider implementation and sustainability.MC is supported by the Scottish School of Primary Care (academic fellowship in general practice)

Epidemiology of type 2 diabetes remission in Scotland in 2019: a cross-sectional population-based study

Background: Clinical pathways are changing to incorporate support and appropriate follow-up for people to achieve remission of type 2 diabetes, but there is limited understanding of the prevalence of remission in current practice or patient characteristics associated with remission. Methods and findings: We carried out a cross-sectional study estimating the prevalence of remission of type 2 diabetes in all adults in Scotland aged ≥30 years diagnosed with type 2 diabetes and alive on December 31, 2019. Remission of type 2 diabetes was assessed between January 1, 2019 and December 31, 2019. We defined remission as all HbA1c values &lt;48 mmol/mol in the absence of glucose-lowering therapy (GLT) for a continuous duration of ≥365 days before the date of the last recorded HbA1c in 2019. Multivariable logistic regression in complete and multiply imputed datasets was used to examine characteristics associated with remission. Our cohort consisted of 162,316 individuals, all of whom had at least 1 HbA1c ≥48 mmol/mol (6.5%) at or after diagnosis of diabetes and at least 1 HbA1c recorded in 2019 (78.5% of the eligible population). Over half (56%) of our cohort was aged 65 years or over in 2019, and 64% had had type 2 diabetes for at least 6 years. Our cohort was predominantly of white ethnicity (74%), and ethnicity data were missing for 19% of the cohort. Median body mass index (BMI) at diagnosis was 32.3 kg/m2. A total of 7,710 people (4.8% [95% confidence interval [CI] 4.7 to 4.9]) were in remission of type 2 diabetes. Factors associated with remission were older age (odds ratio [OR] 1.48 [95% CI 1.34 to 1.62] P &lt; 0.001) for people aged ≥75 years compared to 45 to 54 year group), HbA1c &lt;48 mmol/mol at diagnosis (OR 1.31 [95% CI 1.24 to 1.39] P &lt; 0.001) compared to 48 to 52 mmol/mol), no previous history of GLT (OR 14.6 [95% CI 13.7 to 15.5] P &lt; 0.001), weight loss from diagnosis to 2019 (OR 4.45 [95% CI 3.89 to 5.10] P &lt; 0.001) for ≥15 kg of weight loss compared to 0 to 4.9 kg weight gain), and previous bariatric surgery (OR 11.9 [95% CI 9.41 to 15.1] P &lt; 0.001). Limitations of the study include the use of a limited subset of possible definitions of remission of type 2 diabetes, missing data, and inability to identify self-funded bariatric surgery. Conclusions: In this study, we found that 4.8% of people with type 2 diabetes who had at least 1 HbA1c ≥48 mmol/mol (6.5%) after diagnosis of diabetes and had at least 1 HbA1c recorded in 2019 had evidence of type 2 diabetes remission. Guidelines are required for management and follow-up of this group and may differ depending on whether weight loss and remission of diabetes were intentional or unintentional. Our findings can be used to evaluate the impact of future initiatives on the prevalence of type 2 diabetes remission