Can J Diabetes 46 (2022) 762e774

Contents lists available at ScienceDirect

Canadian Journal of Diabetes

journal homepage:
www.canadianjournalofdiabetes.com

Special Article

Remission of Type 2 Diabetes: User’s Guide

Diabetes Canada Clinical Practice Guidelines Expert Working Group:
Susie Jin RPh, CDE, CRE; Harpreet S. Bajaj MD, MPH, ECNU, FACE;
Anne-Sophie Brazeau RD, PhD; Julia Champagne MSc, RD;
Barbara MacDonald RN, MS-DEDM, CDE; Dylan MacKay PhD;
Sonja M. Reichert MD, MSc, CCFP; Michael Vallis PhD, RPysch

On behalf of the Diabetes Canada Clinical Practice Guidelines Steering

Committee:
Harpreet S. Bajaj MD, MPH, ECNU, FACE; Jeremy Gilbert MD, FRCPC;
Robyn Houlden MD, FRCPC; James Kim MD; Barbara MacDonald RN, MS-DEDM, CDE;
Dylan Mackay PhD; Kerry Mansell BSP, PharmD; Doreen Rabi MD, MSc, FRCPC;
Peter Senior MBBS, PhD, FRCP; FRCP(E); Diana Sherifali RN, PhD, CDE

Introduction B One year after using a low-calorie (w800-850 kcal/day) diet,

almost half of people were in remission; and, at 2 years,
While the “Remission of Type 2 Diabetes” chapter within the approximately 1 out of every 3 people remained in remis-
Diabetes Canada Clinical Practice Guidelines provides a synthesis of sion (6).
the evidence regarding diabetes remission, this accompanying B Two years after a lifestyle intervention comprising struc-
user’s guide is intended to provide practical support to the health- tured exercise training that aimed for 240 to 420 min/week
care provider (HCP) to apply this evidence in clinical practice. over 5 days with an energy-restricted diet to promote w5%
Recent studies show that remission of type 2 diabetes may be to 7% weight loss, about 1 out of 4 people were in remission
possible in a subset of individuals using a variety of interventions, of type 2 diabetes (4).
including bariatric surgery (1,2), and low-calorie diets with (3,4) or
without (5-7) large increases in physical activity. Of note, remission However, because the possibility of remission exists for some
is not synonymous with cure. Rather, the term remission is chosen people, an ethical dilemma presents when caring for an adult with
to reflect the often temporary resolution of hyperglycemia and type 2 diabetes. What discussion would we have with the person
subsequent possible relapse with progression of type 2 diabetes. who asks us about diabetes remission? Or, perhaps even more
complex, with whom should we, as HCPs, start the conversation
Remission may not be a reality for many people with type 2 about diabetes remission? How do we continue to provide
diabetes. Of the studies that demonstrated remission: compassionate care, without discrimination, racism, oppression
and stigma, particularly pertaining to body size, when discussing a

Remission resulted pursuant to the person requiring a sus- management plan for type 2 diabetes, that may or may not include
tained commitment to engage in a substantial inter- diabetes remission? It was in response to these questions that the
ventiondi.e. either bariatric surgery (1,2) and/or a low-calorie resources within this User’s Guide were created.
diet (with either strict adherence to liquid-only formula intake Figure 1 illustrates remission in context of the overall manage-
for several months (5-7), and/or combined with structured ment approaches recommended for a person with type 2 diabetes,
regular physical activity (3,4)). with the background of decline in beta-cell function over time. This

In the controlled investigative context (which is often more schematic overlays the various stages of diabetes management,
successful than real-life experience): including prevention and diagnosis, and highlights the potentially
B The success rate for bariatric surgery varied from 30% to 63% optimal timeframe for the consideration of remission. Prevention of
(after 1 to 5 years) (2), with 35% to 50% of people who were type 2 diabetes is emphasized across the lifespan of an individual
initially in remission of type 2 diabetes eventually experi- (11), particularly for those at increased risk (see Table 1 in the 2018
encing relapse (8,9) on average at 8.3 years (data quoted post “Screening For Diabetes in Adults” chapter) (12). However, at the
Roux-en-Y gastric bypass surgery) (10). time of type 2 diabetes diagnosis (see Table 3 in the 2018
1499-2671/Crown Copyright Ó 2022. Published on behalf of Canadian Diabetes Association.
The Canadian Diabetes Association is the registered owner of the name Diabetes Canada.
https://doi.org/10.1016/j.jcjd.2022.10.005
 S. Jin et al. / Can J Diabetes 46 (2022) 762e774 763

Type 2 diabetes
diagnosis
Multifactorial management (ABCDES3) to
prevent/delay diabetes complications

Diabetes
function (%)
Beta-cell prevention

Diabetes
remission
potential?
Reduce
progression

Individualize approach (behaviour + pharmacotherapy) and targets

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Duration of type 2 diabetes

Figure 1. Potential goals and approaches for type 2 diabetes.

“Definition, Classification and Diagnosis of Diabetes, Prediabetes - ASKed and initiated by the HCP; with consideration of the
and Metabolic Syndrome” chapter) (13), there may already be ethical dilemma - “with whom should we be initiating
substantially reduced pancreatic beta-cell function. Beginning at remission conversations?”.
diagnosis, evidence-informed strategies are applied to reduce the
progression of diabetes complications (see the ABCDES3 tool in the
Shared Decision-Making Checklist for Remission of Type 2
Diabetes Canada Quick Reference Guide) (14), including the setting Diabetes, Figure 4
of individualized targets (see Table 2 in the “Remission of Type 2 B This resource is intended to serve as a checklist for the HCP

Diabetes chapter”) (15). With respect to remission, Figure 1 serves to support shared decision-making conversations while
to support conversations with people affected by type 2 diabetes to informing the person considering remission of type 2 diabetes.
explain the need for preserved pancreatic beta-cell function and
Low-Calorie Diet for Remission of Type 2 Diabetes, Figure 5
why remission is more likely for those people who have been B HCPs could use this resource to outline the level of commitment

diagnosed with type 2 diabetes for a shorter time (specifically, if required by a person over a prolonged time period (potentially
attempting remission with the low-calorie diet approach, study over their lifetime) to arrive at and maintain remission of type 2
participants had diabetes duration of less than 6 years [6]). diabetes. Using this resource to support early conversations
Remission is a journey, not a destination. It may take a person may help to manage expectations, enhance self-efficacy, mini-
several turns-in-the-road before they are able to arrive at and mize the potential for emotional distress or stigma, as well as
maintain remission, and some may never get to remission. As such, reduce the chances of negative outcomes if remission does not
it is important that the person be supported throughout (and result (e.g. feelings of failure, increased stigma).
beyond) the remission management approach by a collaborative B Designed to show possible options for liquid foods (followed

diabetes care team, which may include a primary care provider (e.g. by a slow re-integration of solid foods) for people interested
family doctor or nurse practitioner), dietitian, pharmacist, nurse, in pursuing a low-calorie diet approach to remission.
physical activity trainer and endocrinologist, in addition to B This resource is adapted from the low-calorie (w800-850

nurturing family and social supports. kcal/day) diet used in the Diabetes Remission Clinical Trial
(DiRECT) (6). This trial:
- Enrolled nonpregnant adults with type 2 diabetes with a

Resources body mass index (BMI) 27-45 kg/m2 with less than 6
years duration and less than 12% A1C, who were not on
The following resources were developed with the intention of insulin therapy, with an estimated glomerular filtration
supporting conversations about diabetes remission: rate of 30 ml/min/1.732 m2.
- Resulted in about half of study participants in remission

The Capability, Opportunity, Motivation, Behaviour (COM-B) at 1 year; with just over 1 in 3 participants in remission at
Model, Figure 2 the 2-year follow-up.
- Note that DiRECT is a United Kingdom (UK) study allowing a

Behaviour is the result of capability, opportunity and motivation. w800-850 kcal/day diet. This study’s intervention was
Health-care professionals could review the domains with a person adapted for Canadian use due to the Canadian Food
with type 2 diabetes to help determine the suitability for remission Inspection Agency setting a minimum daily caloric intake of
and/or to identify which domain(s) the person needs reinforcing to at least 900 calories in full meal replacement products (16).
support the person in their management plan for remission.

Frequently Asked Questions (FAQs)

5As, Figure 3
Case Studies
B A counselling framework for shared decision-making

B This resource is intended to support conversations about FAQs

remission of type 2 diabetes that are either: Is remission possible?
- ASKed and initiated by the person affected by type 2 Recent studies show that remission of type 2 diabetes may be
diabetes, OR possible in a subset of individuals using a variety of interventions,
 764 S. Jin et al. / Can J Diabetes 46 (2022) 762e774

Capability, Opportunity, Movaon, Behaviour (COM-B) Model

How to use this resource: Behaviour is the result of Capability, Opportunity and Movaon. Health-care professionals
could review the domains with a person with type 2 diabetes to help determine the suitability for remission and/or to
idenfy which domain(s) the person needs reinforcing to support the person in their management plan for remission.

Memory, attention and decision processes

Cognitive and interpersonal skills
Behavioural regulation
Knowledge

Physical Social

Psychological BEHAVIOUR Physical

Automatic Reflective
Goals
Intentions
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Optimism
Beliefs about capabilities
Beliefs about consequences
Social/professional role and identity

Figure 2. Capability, Opportunity, Motivation, Behaviour (COM-B) Model

5As Adapted for Remission of Type 2 Diabetes

How to use this resource: A counselling framework for shared decision-making. This resource is intended to support conversations about remission of type 2 diabetes that are either:
• OR
• ASKed and initiated by the health-care provider (HCP); with consideration of the ethical dilemma of “with whom should we be initiating remission conversations?”

Ask permission to discuss:

• Remission is not a cure.
• a without
antihyperglycemic medications.
• Remission is most often a result of a minimum 15 kg weight loss, which would need to be
maintained.
• Weight is not under behavioural control and weight loss is biologically resisted; those who
are successful cannot be predicted beforehand.
• Remission requires a substantial commitment from the person to engage in a prolonged
intervention—i.e. either bariatric surgery and/or a low-calorie diet (with either strict

structured physical activity).

Timely follow-up to determine need

for evaluating plan and possible
relapse management Biomedical factors:
• Duration of diabetes diagnosis
• Comorbidities, especially CKD, HF, ASCVD and risk of ASCVD
• A1C
• BMI

Social factors:
• Cultural issues
• Financial Issues
• Social support

Psychological factors:
• Depression or other mental health disorders, including
eating disorders
4 Agree on plan • Expectations
• Readiness to change
• Reasons to adhere to intensive intervention (diet or surgery)
• Past experience of learned helplessness, psychological
reactance

Having established a Bond alliance, seek agreement between Using shared decision-making, advise on approach. The following 3 options have the best evidence for remission:
HCP and individual on:
• Goal alliance
○ Bariatric surgery Refer to a bariatric surgery program

}
with support of HCP); and
○ Low-calorie total dietary/meal replacement diet followed by structured food rein-
of the individual) troduction and increased physical activity for weight loss maintenance, Consider referral to engage a diabetes care
see “Low-Calorie Diet for Remission of Type 2 Diabetes” (Figure 5) team (care to include timely reduction/dis-
• Task alliance continuation of existing antihyperglycemic
○
print & web 4C=FPO

Structured exercise program (aiming for 240 to 420 min/week spread over 5 days medications)
○ self-management support by HCP per week) combined with a calorie-restricted diet

• Support the individual’s capability, opportunity and motivation to change, balanced by evidence of behaviour change.
•
equated with self-esteem.

Figure 3. 5As adapted for remission of type 2 diabetes

 S. Jin et al. / Can J Diabetes 46 (2022) 762e774 765

Shared Decision-Making Checklist for Remission of Type 2 Diabetes

How to use this resource: This resource is intended to serve as a checklist for the health-care provider (HCP) to support shared
decision-making conversations while informing the person considering remission of type 2 diabetes.

I understand that remission from type 2 diabetes:

resolution of hyperglycemia and subsequent possible relapse with progression of type 2 diabetes;
is an outcome from an approach to diabetes management that, based on current best evidence, requires
a substantial commitment to engage in a prolonged intervention—i.e. bariatric surgery and/or a low-

structured physical activity);

often requires a maintained minimum 15 kg weight loss to induce nondiabetes glucose levels;
is not based on other blood vessel health indicators, such as blood pressure and blood lipids, which may
still be indicated to be treated with prescription medications; and
means that I am willing to stop taking and will refrain from taking all medications indicated for type 2
diabetes in order to be considered in remission from type 2 diabetes.

I understand that the evidence shows that remission as an outcome of this approach to diabetes manage-
ment may be appropriate for people with type 2 diabetes (18 years and older):

remission, a duration of diabetes of less than 6 years);

who have excess body weight;
who are informed about and interested in this approach without pressure or coercion; and
who have access to a specialized clinical team with experience in this approach to type 2 diabetes
management.

I understand that there is NOT enough current evidence to:

understand the impact of this glucose-centric approach without clinical guidance for other aspects of
vascular health, comorbidities and overall health and wellness;
understand the short- and long-term risks of this approach to diabetes management—physically,
metabolically, mentally and holistically;

diabetes;
understand how remission of type 2 diabetes compares to staying on diabetes medications, particularly

populations;

occurs followed by relapse of type 2 diabetes; and

understand the level of expertise that HCPs require to support people with type 2 diabetes with respect to
movement into, during and out of remission.

I understand that:

be considered in the individualized approach to my type 2 diabetes management, and these options have
been discussed with me;
even if I don’t arrive at remission, through the pursuit of remission, with modest weight loss (i.e. approx-
imately 5% to 10% of initial body weight), I could have substantial improvement in my insulin sensitivity,
blood pressure and cholesterol, and improved management of glycemic targets;
print & web 4C=FPO

I have a right to care that is free of discrimination, racism and oppression;

my diabetes plan can and needs to be adjusted at any time based on my needs and preferences; and
my quality of life is determined by me, and I am at the centre of the health-care model.

Figure 4. Shared decision-making checklist for remission of type 2 diabetes

 766 S. Jin et al. / Can J Diabetes 46 (2022) 762e774

Low-Calorie Diet for Remission of Type 2 Diabetes*

How to use this resource: This resource is designed to support the person with type 2 diabetes who is interested in diabetes remission through the low-calorie diet approach. Of note, diabetes remission
is not suitable for all people. In DiRECT*, after 1 year, almost half of people were in remission, and at 2 years, approximately 1 out of every 3 people were in remission. This requires a substantial
commitment to engage in a prolonged health behaviour intervention. It is recommended that this form be used in collaboration with a registered dietitian and/or a diabetes care team.

Phase 1: Phase 2: Phase 3:

Total Dietary Replacement Food Reintroduction Weight Maintenance + Relapse Management

Total Dietary Replacement (~3–5 months) Food Reintroduction (~1–2 months) Weight Maintenance
• Low calorie diet (800–900 kcal/day) • Low calorie diet (800–900 kcal/day) • Energy and protein needs calculated by registered dietitian (RD) or diabetes care team
• 3–4 meal replacement products per day • 2–3 meal replacement products (DCT) and tailored to the client to maintain the weight loss
(shakes† and soups†)—no additional food per day (shakes† and soups†) • Transition to nutrient-balanced foods
• ≥2 L calorie-free fluids/day + 1 complete real-food meal† • Regular physical activity encouraged
Examples of calorie-free fluids: o 100 mL milk • Weekly weighing
o water, plain/sparkling o 90 g high-protein food (meat, • HCP‡ to follow up monthly + ongoing support and nutrition education from RD or DCT
o black tea/black coffee fish, poultry, eggs, tofu) • Social and peer support encouraged
o 0-calorie drinks o 2 portions non-starchy
• Soluble fibre supplement (optional) vegetables Aim: maintain weight loss
Examples of soluble fibre supplements: o 1 portion of fruit
o psyllium • ≥2 L calorie-free fluids/day
o wheat dextrin • Fibre supplement (optional) Relapse Management Plan†
• No exercise is recommended in this • HCP‡ to follow up every 2 weeks
• If weight regain ≥2 kg, reintroduction of meal replacement products (soups and shakes) to
phase • Provide nutrition education +
get back on track. Quantity and duration of meal replacement products to be determined
• Health-care provider (HCP)‡ to follow up printed materials (worksheets,
between client and HCP.
after 1 week, then every 2 weeks info on portion sizes)
• During consultation for relapse management, the HCP should explore the reasons for
o If BMI falls below 23 kg/m2, the food
weight regain and provide support to prevent recurrence.
reintroduction phase should be started Aim: client readiness to prepare
healthy, balanced meals on
Aim: reach a 10–15 kg weight loss Aim: weight loss to return to maintenance weight
their own

* Adapted from the DiRECT trial, which enrolled nonpregnant adults with type 2 diabetes with † See page 2.
BMI 27–45 kg/m2 with less than 6 years’ duration and less than 12% A1C, who were not on ‡ At each HCP appointment, weight, blood pressure and blood glucose should be monitored.
insulin therapy, with an estimated glomerular filtration rate of ≥30 mL/min/1.732 m2.

Low-Calorie Diet for Remission of Type 2 Diabetes (continued)

Phase 1: Phase 2: Phase 2:
Total Dietary Replacement Partial Dietary Replacement Food Reintroduction

Suitable meal replacement shakes available in Canada Example Day 1: 2 shakes + 1 soup + 1 complete meal

Brands Nutritional information, per serving Breakfast Vanilla shake

Optifast 900 225 kcal, 22.5 g pro, 18.8 g CHO, 7 g fat + V&M Lunch High-protein soup

Boost High Protein 240 kcal, 15 g pro, 34 g CHO, 5 g fat + V&M Supper 90 g chicken breast with 1 cup of roasted vegetables
(asparagus, mushrooms, peppers, onions)
Boost Diabetic 190 kcal, 16 g pro, 17 g CHO, 7 g fat + V&M 100 mL glass of milk
Small apple
Ensure High Protein 225 kcal, 12 g pro, 31 g CHO, 6 g fat + V&M
Evening Chocolate shake
Glucerna 225 kcal, 11.3 g pro, 26.7 g CHO, 8.2 g fat + V&M

Orgain Organic Protein Shake 250 kcal, 16 g pro, 32 g CHO, 7 g fat + V&M
Example Day 2: 2 shakes + 1 soup + 1 complete meal (divided)

Suitable high-protein, low-fat soups available in Canada Breakfast Vanilla shake mixed with 100 mL milk

Brands Nutritional information, per sachet/serving Lunch High-protein soup

ProtiDiet 70-90 kcal, 15 g pro, 3–5 g CHO, 0 g fat Supper 90 g salmon filet with 1.5 cups of arugula salad
(arugula, tomato, onions, cucumbers) with a citrus
BariWise 100 kcal, 15 g pro, 8 g CHO, 1.5 g fat vinaigrette
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Broth or bone broth 60–90 kcal, 12–22 g pro, 0 g CHO, 0–3 g fat Evening Strawberry shake + half banana

CHO, carbohydrates; pro, protein; V&M, vitamins and minerals.

Figure 5. Low-calorie diet for remission of type 2 diabetes

 S. Jin et al. / Can J Diabetes 46 (2022) 762e774 767

including bariatric surgery (1,2), and low-calorie diets with (3,4) or likely to be highly variable between individuals. The long-term
without increased physical activity (5-7) (see FAQ, “Who may be a benefits of remission are currently unknown.
good candidate for remission of type 2 diabetes?”). Because the
studies demonstrate that remission of type 2 diabetes is achieved What are the potential harms of setting a management plan of
through interventions that require a substantial, prolonged remission?
commitment, relapse is possible. As such, careful assessment must be By definition, to be in remission of type 2 diabetes, a person
given to people living with eating and/or mental health disorders, and should not be taking any antihyperglycemic pharmacotherapy that
concurrent medical conditions should be addressed when consid- is indicated in the management of type 2 diabetes. Theoretically,
ering discussions regarding remission of type 2 diabetes. Remission is there is the potential for harm if a person in a high-risk pop-
a journey, not a destination. It may take a person several tries before ulationdi.e. an individual with established atherosclerotic cardio-
they are able to arrive at and maintain remission, and some may never vascular disease (ASCVD), chronic kidney disease (CKD), heart
get to remission. For these reasons, it is important that the person be failure (HF) and/or over 60 years old with 2 or more cardiovascular
supported throughout (and beyond) the remission management (CV) risk factorsd chose to refuse cardiorenal protective medica-
approach by a collaborative diabetes care team. tions. Because people at high risk would benefit from organ-pro-
tective medications, they should continue these antihyperglycemic
Is remission equal to a cure/reversal? medications, even in normoglycemia, see recommendation #1 of
Remission is not a cure. Rather, it is temporary resolution of the Diabetes Canada “Remission of Type 2 Diabetes” chapter (15).
hyperglycemia that is frequently temporary; with subsequent Remission of type 2 diabetes generally requires a substantial
possible relapse and progression of type 2 diabetes. Remission can be commitment for the individual to engage in a prolonged health
consideredas as an approach to the management of type 2 diabetes behaviour intervention. As such, there is potential negative impact
and/or can be incorporated in a management plan for type 2 diabetes, on the person if they are not able to realize and/or sustain the
which would include deprescribing any existing antihyperglycemic management plan of remission. This risk of relapsedi.e. return of
therapies and incorporating therapies that can induce remission. glucose levels above diabetes thresholds, with or without weight
Remission, in itself, is not a SMART (Specific, Measurable, Achievable, regaindpresents potentially profound psychosocial harms,
Realistic and Timely) goal, and HCPs are reminded to support people including stigma, reduced self-efficacy and depression.
with inclination and circumstances for remission with the develop- In an attempt to minimize potential harms to a person who has the
ment of SMART goals for remission-inducing interventions through intention for remission of type 2 diabetes, HCPs are encouraged to be
shared decision-making. For example, in preparation for starting cognizant of language. Please refer to the “Language Matters - A
phase 1 of the “Low-Calorie Diet for Remission of Type 2 Diabetes” Diabetes Consensus Statement” (17) and consider using the
(Figure 5), a SMART goal might be: Before my follow-up appointment communication and shared decision-making tools provided in this
with my diabetes care team, I will purchase and taste test 3 of the 6 User’s Guide. HCPs supporting people seeking remission of type 2
suitable meal replacement shakes available in Canada. diabetes are encouraged to develop processes for recall and follow-up
appointments to ensure timely review and assessment of care plans.
What are the potential benefits of remission?
As no randomized controlled trials have evaluated the associa- Who may be a good candidate for remission of type 2 diabetes?
tion of type 2 diabetes remission on hard outcomes, such as car- Remission is more likely for individuals with early type 2 diabetes
diovascular events, kidney failure or mortality, the estimated (e.g. current studies using the low-calorie diet approach enrolled
benefits of type 2 diabetes remission are related more to having people with duration of type 2 diabetes less than 6 years); with
target A1C levels in the normal range with or without sustained overweight or obesity; with inclination and circumstances to engage
weight loss with no available evidence on improving health out- in weight loss; and who are not using insulin therapy. Careful
comes at present. Consistent within the guidelines, and as assessment must be given to people living with eating and/or mental
demonstrated in Diabetes Canada Remission Chapter, Figure 1, A1C health disorders, and concurrent medical conditions should be
targets expanded to include the option of type 2 diabetes remission, addressed when considering remission of type 2 diabetes. Remission,
studies show that adults with type 2 diabetes who target an A1C involving the absence of all antihyperglycemic medications, would
6.5 will benefit from a reduced risk of chronic kidney disease and not be recommended for individuals living with diabetes with con-
retinopathy. This benefit is expected regardless of the person’s current ASCVD, HF and/or CKD or for people over 60 years old with 2 or
management plan, i.e., whether through remission or through more CV risk factors because specific antihyperglycemic agent(s) are
pharmacologically-managed type 2 diabetes. Similarly, through indicated for renal or cardiovascular protection in these scenarios,
remission, if initial body weight was reduced by 5 to 10%, studies even in normoglycemia. See recommendation #1 of the Diabetes
show beneficial effects on health such as improved insulin sensi- Canada “Remission of Type 2 Diabetes” chapter (15) and recommen-
tivity, hypertension and dyslipidemia management.(26-28) For dations #9 and #10 of the Diabetes Canada “Pharmacologic Glycemic
more information, please see the FAQs, “What is the difference Management of Type 2 Diabetes in Adults: 2020 Update” (18).
between being in remission of type 2 diabetes and being pharma-
cologically-managed with the safe achievement of near-normo- What are the options for the management plan of remission of
glycemia?” and “What is success? If a person has the intention for type 2 diabetes?
remission of type 2 diabetes and is unable to stop their anti- There are currently 3 therapeutic approaches which have demon-
hyperglycemic medications and/or have or maintain A1C targets in strated remission of type 2 diabetes: bariatric surgery (1,2), a low-
the remission range, is this failure?” calorie (w800-850 kcal/day) total dietary/meal replacement diet
Specific to the absence of antihyperglycemic medications, the (6,7) and a structured exercise program combined with a calorie-
potential clinical benefits of remission may include reduced cost of restricted diet (4,19). Figure 5 is an example of a low-calorie diet
medication and no concern about medication side effects/interac- approach to remission of type 2 diabetes, whereas an example of a
tions. Further, from a psychosocial perspective, it is postulated that structured exercise program combined with a calorie-restricted
remission may offer people with type 2 diabetes hope, choice and diet can be found in the paper by Reid-Larsen et al (20). Of note,
encourage self-efficacy. HCPs should manage people’s expectations as, within these studies,
Because remission may be a temporary state of uncertain (and typically for health behavioural interventions, only half, or less, of
wide-ranging) duration, the potential benefits of remission are participants had an outcome of remission; whereas the remission
768 S. Jin et al. / Can J Diabetes 46 (2022) 762e774

rates post bariatric surgery appear to be generally more favourable (remission of) type 2 diabetes to minimize all modifiable risk factors,
in the published literature. thereby reducing and/or delaying diabetes complications.
The best predictors of remission are a shorter duration of type 2 Perhaps, the “Potential Goals and Approaches for Type 2 Diabetes”
diabetes and sustained weight loss of 15 kg of initial body weight. (Figure 1), best demonstrates what is known and not known about the
Thus, other health behavioural interventions that result in significant differences in these 2 management approaches. Beyond diagnosis of
and prolonged weight loss could theoretically induce remission of type 2 diabetes, we know that we can prevent and delay complications
type 2 diabetes. However, no recommendations are formulated in by applying a multi-factorial management approachdi.e. the
the Diabetes Canada “Remission of Type 2 Diabetes” chapter based ABCDES3 tool (14). However, it is unknown which intervention, if any,
on Mediterranean or low-/very-low-carbohydrate diets, as these will slow the rate of pancreatic beta-cell declinedi.e. Do anti-
studies did not meet the predefined level of evidence. hyperglycemic therapies preserve the pancreatic beta-cell more than
remission or vice versa? This concept is depicted in Figure 1 with a
What is the difference between low-energy, low-calorie and constant downward slope of beta-cell decline.
low-carbohydrate diets?
The 2 behavioural intervention trials, DiRECT (6) and the Diabetes Once a person has their type 2 diabetes in remission and has
Intervention Accentuating Diet and Enhancing Metabolism-I stopped all of their antihyperglycemic medications, should we
(DIADEM-I) trial (7)dwhich have the strongest evidence for remis- also discontinue the antihypertensives and cholesterol-
sion, to datedused low-energy diets involving meal replacement lowering medications?
products in their study protocol. As energy is measured in calories, The approach to management with antihypertensive and
DiRECT and DIADEM-I are, by definition, low-calorie diets. cholesterol-lowering medications remains consistent throughout
We ingest energy from macronutrients: carbohydrates, protein the management of a person with type 2 diabetes (with or without
and fat. Although the better-quality research focused on meal remission).
replacement shakes used in clinical trials, there are growing First, if BP and cholesterol values are above target, then antihy-
accounts of people adopting low-carbohydrate meal plans (with or pertensives (21) and cholesterol-lowering medications (22) remain
without a reduction in caloric content) as an approach to type 2 indicated and should be continued and/or advanced to achieve the
diabetes remission. Although, no recommendations regarding low- recommended targets. Note that angiotensin-converting enzyme
or very-low carbohydrate diets are formulated in the Diabetes (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy is
Canada “Remission of Type 2 Diabetes” chapter (due to the studies recommended as initial management of hypertension for people
not meeting the predefined level of evidence), the Diabetes Canada with cardiovascular disease or CKD, including albuminuria, or with
low-carbohydrate position statement did recognize that low- cardiovascular risk factors in addition to diabetes.
carbohydrate food patterns support weight loss, improve achieve- Second, if BP and cholesterol values are at target, then antihy-
ment of glycemic targets and/or reduce the need for anti- pertensives and statin therapy should be continued, if indicated for
hyperglycemic therapies (20). cardiovascular and renal protection (see the Diabetes Canada 2020
Quick Reference Guide: Which cardiovascular non-
If the DiRECT trial protocol used a low-calorie diet of w800-850 antihyperglycemic medications are indicated for my patient?)
kcal/day, why doesn’t the Diabetes Canada “Remission of Type 2 (23). Despite a person’s remission status, both ACE inhibitors (or
Diabetes: User’s Guide” use the same protocol? ARB) and statins are indicated for cardiorenal protection for:
DiRECT is a UK study with a protocol of a w800-850 kcal/day diet
secondary preventiondi.e. in people with a history of estab-
in phase 1 (6). This study’s intervention was adapted for Canadian lished ASCVD
use in the User’s Guide due to the Canadian Food Inspection Agency
primary prevention in the following populations:
setting a minimum daily caloric intake of at least 900 calories for full B concurrent microvascular disease (retinopathy, CKD and

meal replacements (16). Figure 5 outlines this adapted approach. neuropathy)

B 55 years old with CV risk factors (TC >5.2 mmol/L, HDL-C

What is the difference between being in remission of type 2 <0.9 mmol/L, hypertension, albuminuria, smoking)
diabetes and being pharmacologically-managed with the safe
achievement of near-normoglycemia? With respect to ACE inhibitor or ARB therapy for cardiovascular
In both scenarios, the person would have achieved glycemic and renal protection in the primary prevention of a person 55 years
targets. However, in the case of the person with pharmacologically- and older with BP values at target, the HCP may have to use clinical
managed type 2 diabetes, as opposed to remission, the person judgment, taking into consideration individualized risk-benefit
would remain on antihyperglycemic pharmacotherapy. analysis, personal preferences and medication tolerability.
Using the ABCDES3 tool (14) as a guide, the HCP can support a Additionally, statin therapy is indicated for cardiorenal protec-
person in a multi-factorial management plan to prevent or delay tion for:
diabetes complications. If, in both scenariosdthe person in remission
primary prevention in the following populations:
and the person pharmacologically-managed with the safe achieve- B people 40 years of age or older

ment of near-normoglycemiadthe A1C was 6.5%, then studies show, B people 30 years of age or older living with diabetes for more

as demonstrated in Table 2 of the “Remission of Type 2 Diabetes” than 15 years

chapter (15), that individuals would have successfully taken action to B if indicated pursuant to the Canadian Cardiovascular Society

reduce their risk of complications, particularly CKD and retinopathy. Lipid Guidelines
Similarly, if Blood pressure (BP) and Cholesterol targets are met, then
individuals in both scenarios have modified these risk factors and What is success? If a person has the intention for remission of
reduced their risk of complications of diabetes. Finally, if individuals in type 2 diabetes and is unable to stop their antihyperglycemic
both scenarios remain on indicated Drugs for cardiovascular protec- medications and/or have or maintain A1C targets in the remis-
tion (particularly, the person trying for remission does not discontinue sion range, is this failure?
medications indicated for cardiorenal protection), then, again, the With the intent of providing compassionate care, without
evidence demonstrates that individuals have supported themselves in discrimination, racism, oppression and stigma, particularly pertain-
applying multi-factorial management to prevent/delay complications. ing to body size, HCPs are generally cautioned to avoid any connota-
The ABCDES3 tool (14) can be used to support the person living with tion to success and, by extension, failure, when discussing remission
 S. Jin et al. / Can J Diabetes 46 (2022) 762e774 769

of type 2 diabetes. Being cognizant of the impact of language on a BuACR normal

person’s health outcomes, HCPs are encouraged to apply the Diabetes BLDL 1.8 mmol/L
Canada “Language Matters - A Diabetes Consensus Statement” in
Physical examination:
2
practice (17). When engaging a person in shared decision-making B BMI: 30 kg/m

conversations about remission of type 2 diabetes, HCPs can use the B BP: 120/80 mmHg

resources provided in this User’s Guide, such as the COM-B model, to

identify and develop a person’s domains to increase self-efficacy. The Scenario:
“5As” and the “Shared Decision-Making Checklist” were also devel- Mary arrives at her routine diabetes visit. To date, there has been
oped to support safe conversations about remission. no previous discussion of remission.
Providing potential harms of remission are mitigated (see FAQ
“What are the potential harms of setting a management plan of Question #1.
remission?”), the journey of remission may have many health bene- What are the considerations when initiating a discussion about
fits, even if remission is not actually realized. When a person is able to remission of type 2 diabetes with Mary?
lower their A1C without increasing the risk of hypoglycemia,
achieving an A1C closer to target thresholds, this may reduce the risk
You recall the key messages of the Diabetes Canada “Remission
of diabetes complications (24,25). Similarly, through the approach of of Type 2 Diabetes” chapter (15) which indicate Mary may be a
remission, if the person were to experience modest weight lossdi.e. 5 successful candidate for remission of type 2 diabetes, given that
to 10% of initial body weightdthat person may benefit from a sub- she:
B is a nonpregnant adult
stantial improvement in insulin sensitivity, hypertension and dysli-
B has had type 2 diabetes for a shorter duration
pidemia management, and achievement of glycemic targets (26-28).
B has excess body weight

B does not have ASCVD, HF or CKD

Should HCPs use these new definitions to fill out insurance
B is younger than 60 years old and therefore, independent of
forms: life, travel, etc.?
Remission of type 2 diabetes is not a cure, nor is it a “diagnosis”. the presence of CV risk factors, cardiorenal protective
HCPs need to exercise caution when completing insurance forms medications would not be indicated
and when considering the term “type 2 diabetes in remission”; Question #2.
particularly as this may be a temporary state with a high-relapse Now that you have decided to proceed with the discussion, how
rate. However, anecdotal experience has observed some individ- would you initiate the conversation?
uals who have maintained remission for several decades. It is vital
for HCPs to advocate for people affected by diabetes and to use the
Using the 5A tool (Figure 3), you begin by “ASKing” permission
term “remission” where professional judgment determines it is to discuss the topic. Mary agrees to proceed, as she is interested
appropriate. It is also important for individuals with type 2 dia- to understand whether she may be able to reduce or even
betes in remission to stay connected with their diabetes care team eliminate her antihyperglycemic medication.
for ongoing support and monitoring for timely evaluation and
Mary has several questions about remission and you decide to
implementation of a relapse management plan. use the “Shared Decision-Making Checklist for Remission of
Type 2 Diabetes” (Figure 4) to support the conversation. Mary
Case Studies
understands the probable rates of remission and relapse when
you review them with her and confirms that she does not have
The following 3 cases provide examples of people you may
a history of disordered eating.
encounter in your practice who show either a high, intermediate or

You then proceed to use the COM-B model (Figure 2) during the
low potential for remission. Each case illustrates how to use the
next step of the 5A tool “Assess”. Mary identifies she would be
tools provided in this guide, and gives examples of how to discuss
highly motivated to follow the recommendations to accom-
remission with people with type 2 diabetes, as well as suggested
plish her goal because once she “sets her mind to it, she can do
management paths.
anything”. And while she identifies work “stress” as a potential
CASE #1 barrier during further reflection, she feels confident that she
Mary is a 50-year-old female. Her case suggests a HIGH potential will be able to manage and even reduce this, if needed, by
for remission of type 2 diabetes. making some changes at work. Negative screening for anxiety
or depression on further evaluation.
Notes:

Diagnosed with type 2 diabetes 3 years ago Question #3.

Past medical history: What advice would you provide as a management plan?
B hypertension

B dyslipidemia
You review with Mary that there is limited evidence on

Pertinent negatives: remission with bariatric surgery in those with a preoperative
B no ASCVD, CHF or CKD BMI <35 kg/m2. As such, you proceed to explore “The Low-
B no retinopathy Calorie Diet for Remission of Type 2 Diabetes” (Figure 5),
B no foot-related complications and advise Mary to actually not yet increase her exercise or

Current medications: activity levels dramatically from current levels at this time.
B metformin 500 mg PO BID You refer her to a dietitian to initiate phase 1. While Mary
B perindopril 4 mg PO daily agrees to see the dietitian for follow-up initially after week 1
B rosuvastatin 5 mg PO qhs and then every 2 weeks after, you plan to see Mary again in 3

Works as a receptionist, typically with long hours and high months for follow-up and provide her with a requisition to
stress repeat her A1C prior to follow-up.

Activity level is currently sedentary
You consider deprescribing antihyperglycemic agent(s) as per

Investigations: the recommendation #2 from the Remission of type 2 diabetes
B A1C 8% (up from 7% 6 months ago) chapter (Citation 15), but because Mary is taking metformin
770 S. Jin et al. / Can J Diabetes 46 (2022) 762e774

monotherapy, which has a low risk for hypoglycemia and Question.

weight gain, you suggest to continue this medication dose Is Mary’s type 2 diabetes in remission?
unchanged.

As per the Diabetes Canada definition of remission (15), Mary's
Scenario: 3 months later
diabetes will be considered as being in remission to normal
Mary has completed phase 1 of the “Low-Calorie Diet for
glucose levels if an additional A1C at 6 months after stopping
Remission of Type 2 Diabetes” (Figure 5).
all antihyperglycemic medications is <6%. You discuss the
results and how she is feeling overall and psychologically. You
Question #1.
also ask whether she feels it will be possible to maintain and
What do you do next?
sustain her management plan for her type 2 diabetes.

You decide you need more information, and further assess the
Scenario: 6 months later
current situation. You begin by reviewing Mary’s experience
Mary returns for a follow-up appointment 6 months after
during phase 1 and learn that, while there were periods of
stopping metformin.
difficulty, Mary remained highly motivated as she saw her
capillary blood glucose (CBG) improve, and other physical
Notes:
changes occur. She acknowledged how helpful her dietitian

Physical examination:
was in helping guide her during this phase.
B Maintained weight loss of 18% of initial starting weight

Investigation:
Notes:
B A1C 5.6%

Physical examination:
B Weight loss 10% of initial starting weight
Question #1.
B BP: 100/60 mmHg, with occasional episodes of orthostatic
Mary asks whether she has cured her diabetes?
hypotension

Investigation:

You remind her that her diabetes is in remission, and that
B A1C 6.5%
remission is not a cure. She is currently in phase 3 of the “Low-
Calorie Diet for Remission of Type 2 Diabetes” (Figure 5) and will
Question #2.
need to be vigilant about her calorie and protein intake and
In a shared-care decision discussion, Mary decides she would like
exercise levels. If weight rises, she may need to consider starting
to continue to pursue remission and asks what to do next.
a relapse management phase. See Figure 5 for an example of a
relapse management plan. Mary agrees. She understands her

Discontinue metformin
current diabetes status, and wants to stay in close contact with

You suggest she initiate phase 2 of the “Low-Calorie Diet for
her diabetes care team (e.g. dietitian and kinesiologist) at
Remission of Type 2 Diabetes” (Figure 5) and continue working
monthly intervals for now. She is okay to continue her rosu-
with her dietitian.
vastatin for vascular protection as the current evidence is

At this point, she could also gradually increase her activity from
unclear on the long-term vascular effects of remission. She has
currently sedentary to 150 minutes of aerobic exercise and
found that her activity, especially brisk walking outside, has
resistance training 2 times/week (29). Mary identifies that she
helped tremendously with her stress management and plans to
would also like to find a coach to help her with this as she has
continue walking even during the winter months.
previously tried to be active but finds it very difficult to sustain
this behaviour on her own. Together, you identify an appro- Question #2.
priately trained exercise professional, such as a registered What is your follow-up plan now?
kinesiologist or CSE-qualified clinical exercise physiologist, to
help her learn how to initiate, and safely progress, her exercise
You provide Mary with an A1C requisition for 3 and 6 months
regime during this phase. and plan to see her again in 6 months. If her A1C remains <6%,

As Mary is less than 55 years of age without a specific indica- you will continue to repeat her A1C every 6 months thereafter.
tion for cardiovascular or renal benefit from the ACE inhibitor/
ARB, Mary’s perindopril is discontinued (30). CASE #2

Mary is over 40 years old and may benefit from a statin, even Farah is a 55-year-old female. In this case, it is advised to proceed
with cholesterol levels at target, for cardiorenal protection. with CAUTION when considering remission of type 2 diabetes.
Mary’s statin is continued (30).
Notes:

Mary agrees to continue to see the dietitian for follow-up every

Diagnosed with type 2 diabetes 20 years ago
2 weeks; and to follow up with you in 3 months. You give Mary

Past medical history:
a requisition to repeat her A1C prior to the next 3-month
B hypertension
appointment.
B dyslipidemia

B osteoarthritis
Scenario: 3 months later

Pertinent negatives:
Mary has completed phase 2 and has moved into the mainte-
B no ASCVD, CHF or CKD
nance phase of the “Low-Calorie Diet for Remission of Type 2
B no foot-related complications
Diabetes” (Figure 5) 1 month ago.

Current medications:
Notes: B metformin 1,000 mg PO BID

Physical examination: B perindopril/indapamide 4/1.25 mg PO daily

B Weight down 18% of initial starting weight B rosuvastatin 10 mg PO qhs

B BP: 110/60 mm Hg, with resolution of orthostatic hypotension B naproxen 250 mg PO BID PRN

Investigation: B insulin glargine U-100 40 units SC once daily

B A1C 5.5% B insulin glulisine 18 units SC ac breakfast, lunch and supper

 S. Jin et al. / Can J Diabetes 46 (2022) 762e774 771

Works part-time as a librarian and enjoys volunteering weekly Bmetformin 1,000 mg PO BID
at a local hospital Bperindopril/indapamide 4/1.25 mg PO daily

Activity level: B rosuvastatin 10 mg PO qhs

B moderately intense walking for 30 minutes, 3 times/week B naproxen 250 mg PO BID PRN

B resistance band full-body strength training 1 to 2 times/ B insulin glargine U-100 36 units SC once daily

week B insulin glulisine 14 units SC ac breakfast, lunch and supper

Investigations: B semaglutide 1.0 mg SC weekly

B A1C 7.2% (stable for one year)
Total body weight reduction of 5%
B uACR normal.
BP: 126/76 mmHg
B LDL 2.0 mmol/L

Physical Examination: Question #1.

2
B BMI: 42 kg/m What medication adjustments would you consider as next
B BP: 120/80 mmHg steps?

Discontinue perindopril/indapamide and naproxen

Scenario:

Start perindopril 8 mg once daily (32). Note that Farah does not
Farah arrives at her routine diabetes visit. She is frustrated and
need further BP-lowering effects (BP 126/76) and, therefore,
tired of injecting insulin 4 times daily. She is asking today if she can
the diuretic, indapamide, can be discontinued. However, due to
stop all of her insulin injections.
Farah’s treated dyslipidemia and hypertension, Farah would
benefit from continuing an ACE inhibitor at a dose that has
Question. demonstrated vascular protectiondi.e. perindopril 8mg PO
What are the considerations when initiating a discussion about daily (33).
remission of type 2 diabetes with Farah?
Reduce insulin glulisine to 10 units with meals, with instruc-
tion to further decrease if hypoglycemia occurs.

You recall “Potential Goals and Approaches for Type 2 Diabetes”
(Figure 1) and appreciate that remission is more likely in people Question #2.
with a shorter duration of diabetes when there is preserved beta- How would you counsel Farah in regards to her exercise? She
cell function. You ask if you may share this figure with her, and also asks if there are any “apps” you could recommend that may
express your concerns that she may be beyond the optimal win- help her put her type 2 diabetes in remission.
dow of time for diabetes remission; however, you also acknowl-
edge her desire to reduce the frequency of her insulin injections.
She is currently engaging in 90 minutes of moderately intense

You engage Farah in shared decision-making. You discuss the aerobic exercise/week plus 1 to 2 sessions of resistance
options that have evidence to demonstrate remission of type 2 training. You advise her that she could increase her aerobic
diabetes, including a behavioural interventional approach of duration to 150 minutes or more as per the Diabetes Canada
diet and exercise, as well as bariatric/metabolic surgery. You clinical practice exercise guidelines (29).
also assess her capability, opportunity, motivation and behav-
You remind her that she may need to further reduce her insulin
iour using the COM-B model (Figure 2). Farah has tried several due to exercise to prevent hypoglycemia.
different eating patterns over the years and does not wish to
While technology has been developed to facilitate positive
engage in a low- or very-low carbohydrate diet, nor does she behaviours related to food and physical activity, glucose moni-
feel that the “Low-Calorie Diet for Remission of Type 2 Dia- toring and medication taking (34), no digital health solution has
betes” (Figure 5) is the best approach for her at this time. as yet been proven to support people in type 2 diabetes remission.

She is interested in learning more about bariatric or metabolic
Together, you agree on a follow-up appointment following her
surgery as she feels this could also help to improve her osteo- surgery in 4 months.
arthritis, as well as her diabetes.

After reviewing the “Shared Decision-Making Checklist for Scenario:
Remission of Type 2 Diabetes” (Figure 4) with her, you refer Farah returns 1 month following successful bariatric surgery.
Farah for bariatric surgery. Her bariatric team has discontinued all prandial insulin and her

As there is a wait list for this procedure, you also discuss the option GLP1-RA.
of starting a GLP1-RA to help support weight loss and right away
reduce all insulin doses by 20% to help avoid hypoglycemia (31). Notes:

You ask her to repeat her A1C in 3 months, and return to the
Current medications:
clinic at that time for follow-up. B she remains on metformin

B she has reduced her insulin glargine U-100 to 25 units once

Scenario: daily
Farah returns 3 months later. She has increased her GLP1-RA as
Physical examination:
directed and is tolerating it well, but is worried as she is experi- B fasting morning blood glucose range 4-6 mmol/L

encing occasional post-meal mild to moderate hypoglycemia with B BP 116/70 mmHg

adrenergic symptoms, which she treats appropriately. She has met
Investigations:
with the bariatric team, and has decided to proceed with surgery B A1C 6.2%.

which has been scheduled 3 months from today. Farah also
You discuss the benefits of achieving pharmacologically-
expresses an interest in increasing her activity levels as her oste- managed diabetes with an A1C target of 6.5 % with a reduc-
oarthritis has improved substantially. tion of insulin injections. Farah is thrilled that she has managed
to reduce the complexity and frequency of insulin injections.
Notes: She wishes to continue to pursue the remission of type 2 dia-

A1C 6.5%, LDL 1.8 mmol/L betes approach, while understanding that she may not be able

Current medications: to stop all her antihyperglycemic agents. She will continue to
772 S. Jin et al. / Can J Diabetes 46 (2022) 762e774

down titrate her basal insulin dose to maintain blood glucose
Given he has initiated the conversation, you decide to utilize
levels in her target range, and avoid hypoglycemia, particularly the “Shared Decision-Making Checklist” (Figure 4) to guide the
if body weight decreases. conversation. You discuss that, while remission as per the

Together, you agree to continue to monitor her A1C, BP and Diabetes Canada ”Remission of Type 2 Diabetes” chapter (15) is
lipids routinely. not recommended due to his MI and HF histories, given the
proven benefit of sodium-glucose co-transporter 2 (SGLT2)
Question. inhibitors for reducing risk of major adverse cardiac events
Farah asks about her BP and cholesterol medication. She is not (MACE) and hospitalization of HF (18), there may be the pos-
experiencing any symptoms of low BP, but is wondering if she sibility of pharmacologically-managed type 2 diabetes with an
needs the perindopril now that her BP is normal. A1C target of 6.5 or 7% without needing to add further anti-
hyperglycemic agents. You ask if this management approach is

Farah is 55 years old with pharmacologically-managed type 2 of interest. Surinder answers “yes”.
diabetes with an A1C target 6.5 %, 1-month post bariatric
You proceed to use the 5A tool (Figure 3). Surinder explains his
surgery. You explain to Farah that people who are 55 years or main desire is not to increase and, if feasible, to reduce the cost
older with at least 1 cardiovascular risk factor could benefit of medication given he does not have drug coverage, but also to
from an ACE inhibitor (or ARB) for protection of their heart and be a healthy father for his young family. His partner is very
kidneys, even when their BP is normal (25). Through shared supportive of his health wishes. He identifies areas of concern,
decision-making, it is agreed that Farah will continue to be on namely he is not sure if he is able to exercise more than he
the perindopril as she is tolerating the ACE inhibitor with currently does and, while he is currently healthy from a psy-
adequate BP. BP will continue to be monitored. If, in follow-up, chological perspective, he has struggled with depression in the
Farah experiences symptoms of orthostatic hypotension, the past. You note that his A1C has risen in the last 6 months.
ACE inhibitor may be reduced or even discontinued based on
Question #2.
an individualized benefit:risk assessment.
How do you proceed in advising Surinder on next steps?

With respect to the statin, Farah is older than 40 years and the
statin is indicated for cardiorenal benefit at this time (30).

All medications remain unchanged.

Discussing the intervention options, together you decide that he
CASE #3
would like to proceed with a modified version of the “Low-Calorie
Surinder is a 42-year-old male. His case suggests that remission
Diet for Remission of Type 2 Diabetes” (Figure 5). This will entail
with elimination of antihyperglycemic agents is NOT RECOM-
bypassing phase 1 and rather proceeding to phase 2 as Surinder
MENDED, but pharmacologically-managed type 2 diabetes with an
would like to continue to enjoy one meal at home with his family
A1C target of 6.5%dwithout needing to add further anti-
in the evenings. You review weight loss targets, as well as chal-
hyperglycemic agentsdmay be considered given his co-morbidities.
lenges that may arise during this phase. Surinder has public
Notes: health insurance with limited access to a full diabetes care team,

Diagnosed with type 2 diabetes 10 years ago and you identify this as a potential challenge. You decide to see

Past medical history: him back sooner in 1 month to see how he is doing with the plan.
B recent myocardial infarction (MI) with established Scenario:
ASCVD, chronic heart failure (CHF), hypertension and Surinder returns after 1 month. He has lost some weight and,
dyslipidemia while he has been able to mostly follow the “Low-Calorie Diet for

Pertinent negatives:
Remission of Type 2 Diabetes” (Figure 5) phase 2 plan, he has had
B no CKD or retinopathy
occasional set-backs, especially on the weekends. He still wants to
B no foot-related complications
continue, but worries he may not realize his desired outcome.

Current medications:
B metformin 1,000 mg PO BID Question.
B empagliflozin 25 mg PO daily How do you proceed?
B ASA 81 mg PO daily

B perindopril 4 mg PO daily
Using the COM-B model (Figure 2), a shared-care decision
B atorvastatin 80 mg PO daily making model to guide the discussion, you help Surinder self-

Works as a self-employed carpenter. No drug coverage. assess to identify the domains that need building to adopt his

Activity level is moderate, mostly consisting of walking and desired health behaviour. As Surinder experiences his set-
lifting heavy objects during work hours. backs generally on the weekends, you develop Surinder’s

Investigations: motivation through reinforcement (recognizing what is work-
B A1C 8% (elevated from 7% 6 months ago) ing well for him); you support opportunity through discussing
B uACR normal social influences (planning for weekend social situations); and
B LDL 1.8 mmol/L you grow capability by exploring attention and decision pro-
B Triglycerides normal cesses (discussing options to mitigate his challenges).

Physical Examination:
Surinder feels supported in his management plan and agrees to
2 continue to implement phase 2 for another 2 months. You
B BMI: 30 km/m

B BP: 130/80 mmHg provide him with an A1C requisition for completion prior to his
next follow-up.
Scenario:
Surinder arrives at his routine diabetes visit. To date, there has Scenario:
been no discussion of remission, but he has read about this in a Surinder has now completed 3 months of phase 2 of the “Low-
news article and would like to discuss the topic with you today. Calorie Diet for Remission of Type 2 Diabetes” (Figure 5).
Question #1. Notes:
How do you answer Surinder’s question?
Physical examination:
 S. Jin et al. / Can J Diabetes 46 (2022) 762e774 773

B weight loss of 5% total body weight Question #2.

B BP: 116/74 mmHg What’s next for Surinder?

Investigations:
B A1C 7%
You determine Surinder is extremely happy with his progress.
While his overall medication-related expenses have not
Question. reduced, he is feeling much better both physically and psy-
Surinder is very curious to know - Is his type 2 diabetes in chologically and is now able to work full-time hours with
remission? improved energy. This has benefited his entire family. He feels
optimistic and hopeful that he will be able to prevent further

You remind him as per your initial shared decision-making complications from type 2 diabetes.
discussion that remission is not recommended due to his co-
While Surinder’s path to pharmacologically-managed diabetes
morbidities, but rather pharmacologically-managed diabetes with an A1C target of 6.5% cannot be considered remission,
with an A1C target of 6.5 or 7% (14) without needing to add Surinder has improved his metabolic cardiovascular risk factors.
further antihyperglycemic agents is an appropriate manage-
You provide him with a renewal of his current medications, as
ment approach. well as a lab requisition to repeat his A1C at 3 months and all

Surinder agrees to transition to the maintenance phase of other routine blood work in a timely manner.
the “Low-Calorie Diet for Remission of Type 2 Diabetes”
(Figure 5). Surinder identifies that he is feeling better and
has more energy and, as such, has started riding his bicycle Author Disclosures
on the weekend for 30 minutes each day at a moderate
intensity with his eldest son. They are enjoying this time S.J. reports consulting and/or speaking honoraria from Abbott,
together immensely. AstraZeneca, Dexcom, Eisai, GlaxoSmithKline, Novo Nordisk, Pfizer
and Roche, as well as funded clinical research with Novo Nordisk;
Scenario: H.S.B. reports research funding or trial fees paid to his institutions
Surinder returns 3 months later (6 months after initiating the by Amgen, AstraZeneca, Boehringer Ingelheim, Canadian Institutes
diabetes remission conversation). of Health Research (CIHR), Ceapro, Eli Lilly, Gilead, Janssen, Kowa
Pharmaceuticals Co. Ltd, Madrigal Pharmaceuticals, Merck, Novo
Nordisk, Pfizer, Public Health Agency of Canada, Sanofi, and Tricida,
Notes:
outside the submitted work, as well as speaking honoraria from

Physical examination: American Diabetes Association, Canadian Hypertension Education
B total weight loss is 8%
Program (CHEP+), Canadian Society of Endocrinology & Metabolism
B BP normal
(CSEM), Endocrine Society, International Diabetes Federation, LMC

Investigations: Physicians Inc., Medscape, Optum, Center for Advanced Clinical
B A1C is now 6.4%
Solutions, and Windsor Heart Institute; A.B. reports speaker fees
B LDL 1.2 mmol
from Dexcom Canada and holds research funds from CIHR, JDRF,
B triglycerides normal
Société Francophone du Diabète, Diabète Québec, Fonds de

Current medications: recherches du Québec en Santé; D.M. reports research funding to
B empagliflozin 25 mg PO daily
his institution by CIHR, the Kidney Foundation of Canada, Mitacs
B metformin 1,000 mg BID
Inc, NorWest Co-op Community Health, PepsiCo Inc, The Weston
B ASA 81 mg PO daily
Family Foundation, and the Winnipeg Foundation, outside the
B perindopril 4 mg PO daily
submitted work; M.V. reports ad boards and consultations with
B atorvastatin 80 mg PO daily
Abbvie, Abbott, Bausch Health, Lifescan, Lyceum, Novo Nordisk,
Roche and Sanofi, speaking fees for Abbott, Abbvie, Bausch Health,
Question #1. Lifescan, Lilly, Merck, Novo Nordisk, Pfizer, Roche and Sanofi, and
Surinder asks about his BP and cholesterol medication. He is not investigator-driven research funding from Novo Nordisk, Bausch
experiencing any symptoms of low BP, but is wondering if he needs Health and Abbott; S.M.R. reports consulting fees from Abbott,
the perindopril now that his BP is normal. Novo Nordisk, Bayer, Eli Lilly, Janssen and the Canadian Collabo-
rative Network and speaker fees from Abbott, Novo Nordisk, Eli

Due to Surinder’s comorbidities with a history of ASCVD and Lilly, Janssen, Sanofi, AstraZeneca and McMaster University; B.M.
CHF, the ACE inhibitor is indicated for cardiorenal protection has no conflicts to disclose..
(32). Of note, consideration should be given to increasing
Surinder’s perindopril to 8 mg PO daily, the dose that
Acknowledgements
demonstrated vascular protection (33).

Also to note, Surinder is 42 years old (less than 55 years
The authors are particularly grateful for the organizational,
old). If Surinder did not have established ASCVD, CHF or CV
communication and editorial skills of Tracy Barnes who has
risk factors (TG >5.2 mmol/L, HDL-C <0.9 mmol/L, smoking,
contributed extensively to the quality of this manuscript. Thank you
hypertension), or microvascular disease, an ACE inhibitor/
also to Jill Toffoli for her help editing and preparing the manuscript,
ARB therapy would be indicated strictly for BP management,
in particular, her design work on the tables and figures.
and could, therefore, have been considered for
discontinuation.

Surinder is 42 years old (40 years old) and has a history of References
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