Fierce Dispute

A Fierce Debate at EASD 2023 About Diabetes Remission

Two professors yesterday at the EASD meeting engaged in a fierce and collegial debate about the feasibility of lasting remission in type 2 diabetes with very low calorie diets. Professor Kamlesh Khunti brought a polished presentation of objective data. He was unequivocal. Is lasting remission feasible in a real world setting? “It’s a definite no for me,” he said.

In sharp contrast, Professor Roy Taylor brought a great deal of passion but not terribly impressive data. The remission rate from his DiRECT study after five years was only 13% – before accounting for “quite a few” patients who dropped out. He explained:

“This [13% remission rate] isn’t an intention to treat analysis. The percentage remission would be approximately six or seven percent if we looked at the whole cohort.”

Still, he insisted it is “certainly feasible” to get lasting remission. Unfortunately, he has yet to publish this data with peer review.

Treatment Alternatives

Perhaps the starkest contrast between the presentations of Khunti and Taylor was the acknowledgement of alternatives for managing diabetes and obesity. Taylor made no mention of alternatives to his very low calorie diet (VLCD) strategy. Khunti compared the data for all of them – VLCD, metabolic surgery, lifestyle, and obesity medicines.

The medical benefits of surgery and pharmacotherapy are more impressive. In contrast to the results Taylor presented, data from the SOS study of metabolic surgery shows a 30% remission rate after 15 years.

An Undercurrent of Bias and Blame

One thing really troubles us about the large promises Taylor makes for the DiRECT program. It is an undercurrent of bias and blame. In dismissing surgery or medical options for managing obesity and diabetes, there is a strong suggestion that this is a behavioral problem more than a biological one. In fact, Taylor said that people understand diabetes remission is not permanent:

“People are advised that diabetes will not have gone away. The risk remains with them. And if they put on weight, the diabetes will return.”

The unspoken implication is that they will have no one to blame but themselves. This is the foundation for implicit weight bias. The belief that weight regulation is volutional, not biological, is prevalent but incorrect.

Click here for more on the DiRECT trial and here for more on bias in obesity and diabetes care.

Fierce Dispute, photograph by Renato Augusto Martins, licensed under CC BY-SA 4.0

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October 5, 2023

2 Responses to “A Fierce Debate at EASD 2023 About Diabetes Remission”

  1. October 05, 2023 at 7:42 am, Adva Weinerman said:

    I have been reading your information for a while now. I am trying to learn about weight loss and diabetes. However, you state that overweight is responsible for diabetes while there are many thin people who have diabetes and are given suitable medications. As an aside note I will say that I am seeking for the wholly grail that will enable me to lose weight which has been unsuccessful for me for many years now (I was thin until I turned 40). I am eating properly as best I can, do not eat processed food, hardly eat carbohydrates and nothing helps. I hope to hear that maybe there will be a better understanding of what causes some people to have overweight despite many efforts to lose.

    • October 06, 2023 at 3:50 am, Ted said:

      You make an important pont, Adva. Type 2 diabetes can occur in the absence of obesity, even though obesity often contributes to it. Conversely, type 2 diabetes can contribute to obesity. I share your hope for a better understanding of obesity.