The DiRECT Obsession with Behavior Change for Diabetes

Obsessive ThemeLetting go is hard. But there is a bright line between persistence and stubbornness. Persistence is absolutely necessary to advance a cause. But persistence gives way to stubbornness when facts line up to define serious limitations and people press on with a futile effort. Such is the case with the DiRECT obsession for “curing” type 2 diabetes through very low calorie liquid diets (VLCDs). The NHS is rolling out a “soups and shakes” program across all of England for this purpose.

Early Enthusiasm

When early results from the DiRECT trial emerged, the headlines were effusive. “Radical diet can reverse type 2 diabetes,” said the Guardian. “Low-calorie diet caused remission in 90% of trial patients who lost 15kg or more.”

After two years, only 36% of the patients in the DiRECT trial who went through this diet program still had their diabetes in remission – despite ongoing structured support.

Remission Uncommon at Five Years

More recently, five-year data from DiRECT filled out the picture. It showed that only 13% of patients who received extended support remained in remission for type 2 diabetes. That compares to five percent of the original control group who received neither the VLCD nor the ongoing support for weight management. It is sharply lower than the 46% remission rate seen five years after a gastric sleeve procedure.

Still, the champions for the DiRECT trial put a happy face on their results, concluding:

“The extended DiRECT intervention was associated with greater aggregated and absolute weight loss, and suggested improved health status over 5 years.”

Stepping Back

On one hand, the underlying idea is sound. Aggressive treatment for obesity can indeed put type 2 diabetes into remission. The DiRECT study was a success for showing that.

But it is really hard to see the wisdom of a big investment to roll out intensive VLCD interventions across all of England while severely restricting access to a more effective intervention – metabolic surgery. Recent data on metabolic surgery out to 12 years shows it is clearly superior for long-term remissions and glycemic control.

The Underlying Bias

And yet, policymakers can’t let go of the underlying bias that blames patients for not losing weight and keeping it off by simply changing their behavior. This bias harms people and leads NHS to direct resources toward interventions that will have little long-term benefit. Meanwhile patients who seek more effective options hit a brick wall.

This is a tragic mistake.

Click here for the five-year data from the DiRECT trial and here for data on access to effective obesity care in the NHS.

Obsessive Theme, painting by O. Louis Guglielmi / WikiArt

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July 7, 2024

One Response to “The DiRECT Obsession with Behavior Change for Diabetes”

  1. July 07, 2024 at 9:57 am, Richard Atkinson said:

    When will bureaucrats/politicians/government health officials and unfortunately many of our colleagues learn the meaning of chronic disease? Your comment about the underlying bias that promotes simply changing a treatment for chronic disease is right on. If the blame for a disease can be put on the patient, the politicians and others won’t have to pay for it. Obesity, diabetes, and other diseases are chronic and we have thousands of studies showing treating chronic diseases with behavioral treatments don’t work long term.