--- topic: "Type 2 Diabetes" title: "Type 2 Diabetes: Diet, Exercise, and Remission" order: 1 description: "What weight loss, exercise, low-carb eating, fasting and supplements can do for type 2 diabetes, how often remission occurs, and how long it lasts." question: "Can type 2 diabetes be reversed or put into remission naturally?" answer: "It probably can, mainly early on: intensive weight loss put nearly half or more of trial participants in remission at one year, but many relapse." actions: - "Ask your care team about a supervised weight-loss plan, especially if diabetes is recent: in DiRECT, remission rose with weight lost, reaching 86% in those who lost 15+ kg [1]." - "Build up to 150+ weekly minutes of aerobic or resistance exercise: pooled trials found HbA1c (average blood sugar) fell 0.67 points, and 0.89 beyond 150 minutes [8]." - "Choose an eating pattern you can keep, such as Mediterranean-style eating: in newly diagnosed adults, 44% needed medicine after 4 years versus 70% on a low-fat diet [7]." cautions: - "Never stop or cut diabetes or blood pressure medicines alone: in DiRECT, clinicians withdrew them within a supervised programme [1], and a fasting trial reduced low-sugar-risk medicines first [9]." - "On insulin or sulfonylureas? Low-calorie, low-carb or fasting plans can swing blood sugar: 35% of users had low or high glucose events in a fasting trial's first two weeks [9]." - "Taking an SGLT2 inhibitor (names ending in -gliflozin)? Low-carbohydrate diets, fasting, dehydration and heavy drinking can trigger ketoacidosis even when glucose looks normal, so ask your doctor first [12]." confidence: 4 confidenceNote: "Randomised trials show remission after intensive weight loss, and a meta-analysis supports low-carbohydrate diets at six months, but remission often fades and no trial shows fewer heart attacks." evidenceSummary: rctCount: 5 observationalCount: 1 metaAnalysisCount: 3 totalParticipants: "8,500+" replicated: true newestStudyYear: 2024 references: - id: "1" pmid: "29221645" title: "Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial" authors: "Lean ME, Leslie WS, Barnes AC, et al." year: 2018 journal: "Lancet" - id: "2" pmid: "38423026" title: "5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: an extension study" authors: "Lean ME, Leslie WS, Barnes AC, et al." year: 2024 journal: "Lancet Diabetes Endocrinol" - id: "3" pmid: "23288372" title: "Association of an intensive lifestyle intervention with remission of type 2 diabetes" authors: "Gregg EW, Chen H, Wagenknecht LE, et al." year: 2012 journal: "JAMA" - id: "4" pmid: "34462270" title: "Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes" authors: "Riddle MC, Cefalu WT, Evans PH, et al." year: 2021 journal: "Diabetes Care" - id: "5" pmid: "32445735" title: "Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial" authors: "Taheri S, Zaghloul H, Chagoury O, et al." year: 2020 journal: "Lancet Diabetes Endocrinol" - id: "6" pmid: "33441384" title: "Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data" authors: "Goldenberg JZ, Day A, Brinkworth GD, et al." year: 2021 journal: "BMJ" - id: "7" pmid: "19721018" title: "Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial" authors: "Esposito K, Maiorino MI, Ciotola M, et al." year: 2009 journal: "Ann Intern Med" - id: "8" pmid: "21540423" title: "Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis" authors: "Umpierre D, Ribeiro PA, Kramer CK, et al." year: 2011 journal: "JAMA" - id: "9" pmid: "30646030" title: "Effect of Intermittent Compared With Continuous Energy Restricted Diet on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Noninferiority Trial" authors: "Carter S, Clifton PM, Keogh JB" year: 2018 journal: "JAMA Netw Open" - id: "10" pmid: "24019277" title: "Cinnamon use in type 2 diabetes: an updated systematic review and meta-analysis" authors: "Allen RW, Schwartzman E, Baker WL, et al." year: 2013 journal: "Ann Fam Med" - id: "11" pmid: "23796131" title: "Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes" authors: "Wing RR, Bolin P, Brancati FL, et al. (Look AHEAD Research Group)" year: 2013 journal: "N Engl J Med" - id: "12" pmid: "28003053" title: "SGLT2 Inhibitor-associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis" authors: "Goldenberg RM, Berard LD, Cheng AYY, et al." year: 2016 journal: "Clin Ther" --- It can, especially in the first years after diagnosis. In the DiRECT trial, a supervised programme of low-calorie formula diet and gradual food reintroduction put 46% of people into remission after one year, against 4% with usual care [1]. Remission tracked weight lost, but it often fades: 13% of those followed with continued support were still in remission at five years [2]. Gentler lifestyle programmes work less often [3]. Medicines still matter; never stop them without your care team. ## How it works **What remission means.** An expert group convened by the American Diabetes Association defined remission as an HbA1c (a blood test of average sugar over about three months) below 6.5% (48 mmol/mol), measured at least 3 months after stopping glucose-lowering medicine. It is not a cure, and they advise continuing to observe people in remission [4]. **Weight is the main lever.** In DiRECT (306 adults diagnosed within the past 6 years, not on insulin), remission rose with weight lost: none of the 76 people who gained weight, 7% of those who lost up to 5 kg, 34% at 5 to 10 kg, 57% at 10 to 15 kg and 86% at 15 kg or more. The programme withdrew diabetes and blood pressure medicines, used a formula diet of 825 to 853 kcal a day for 3 to 5 months, then reintroduced food and offered long-term support [1]. A trial in Qatar in adults aged 18 to 50 with diabetes for 3 years or less found remission in 61% versus 12% with usual care at 12 months [5]. **Keeping it off is harder.** At two years, 36% of the DiRECT group were in remission; at five years, 11 of 85 people (13%) who received continued support were [2]. A standard behavioural programme with counselling, calorie reduction and activity (4,503 US adults) produced partial or complete remission in 11.5% in year 1 and 7.3% by year 4, versus 2.0% with usual education [3]. **Food patterns.** Low-carbohydrate diets (under 130 g of carbohydrate a day) raised remission at 6 months (57% versus 31%, with remission defined by HbA1c alone), but the benefit was smaller if remission required being off medicines and was unclear by 12 months [6]. A Mediterranean-style diet delayed the need for medicine in newly diagnosed people [7]. See our [Mediterranean diet article](/mediterranean-diet/cardiovascular-and-longevity). **Exercise and fasting.** Structured exercise lowers HbA1c on its own [8]. Two non-consecutive days a week of 500 to 600 kcal gave similar HbA1c results to daily calorie restriction over a year [9]. See our [insulin resistance guide](/insulin-resistance/understanding-and-reversing). **Supplements are minor.** In 10 trials, cinnamon lowered fasting glucose by about 25 mg/dL on average but did not significantly change HbA1c [10]; see our [cinnamon article](/cinnamon/blood-sugar-benefits). **What remission does not prove.** A large trial of intensive weight-loss lifestyle changes did not reduce the rate of cardiovascular events [11]. Keep your regular checks. ## The evidence in detail ### DiRECT and DIADEM-I DiRECT randomised 49 UK primary care practices (306 adults aged 20 to 65, diabetes under 6 years, BMI 27 to 45, no insulin). At 12 months, remission (HbA1c under 6.5% at least 2 months off all diabetes drugs) occurred in 68 of 149 people (46%) versus 6 of 149 (4%) (odds ratio 19.7, 95% CI 7.8 to 49.8). Mean weight fell 10.0 kg versus 1.0 kg. Nine serious adverse events occurred in the intervention group and two in controls; two (biliary colic and abdominal pain) were possibly related [1]. At 24 months, 36% of the intervention group were in remission [2]. The five-year extension followed 85 people who continued support: they lost 6.1 kg on average and 13% were in remission; among all original intervention participants, 27% of visits were in remission versus 4% for controls, and 26% of those in remission at year 2 were still in remission at year 5 [2]. DIADEM-I (158 randomised, 147 analysed) used a similar formula-diet approach with physical activity support: weight fell 11.98 kg versus 3.98 kg, and remission occurred in 61% versus 12% (OR 12.03, 5.17 to 28.03) [5]. Both were open-label, in early diabetes, and used intensive supervised programmes. ### Look AHEAD The Look AHEAD lifestyle programme (2,241 intensive versus 2,262 education) achieved weight loss of 7.9% more than controls at year 1 and 3.9% more at year 4. Any remission was 11.5% in year 1 and 7.3% at year 4, versus 2.0%; sustained remission for 4 years was 3.5% versus 0.5%. The authors called absolute rates modest [3]. In the main trial (5,145 adults, stopped early for futility at a median 9.6 years), the primary cardiovascular outcome occurred at 1.83 versus 1.92 events per 100 person-years (HR 0.95, 95% CI 0.83 to 1.09) [11]. ### Diet and exercise trials A meta-analysis of 23 trials (1,357 people) found low-carbohydrate diets gave 57% (76 of 133) remission at 6 months versus 31% (41 of 131) (risk difference 0.32, 95% CI 0.17 to 0.47; eight studies, 264 people), with smaller non-significant effects when remission meant off medicine, and a marked drop in studies including insulin users. At 12 months data were sparse, and benefits for weight, triglycerides and insulin sensitivity diminished. Certainty was moderate to low [6]. In 215 newly diagnosed overweight adults, 44% on a Mediterranean-style diet versus 70% on a low-fat diet needed drugs by year 4 (HR 0.63, 0.51 to 0.86); investigators starting drugs were not blinded and intake was self-reported [7]. A meta-analysis of 47 trials (8,538 patients) found structured exercise lowered HbA1c by 0.67 points (95% CI 0.49 to 0.84), aerobic by 0.73, resistance by 0.57 and combined by 0.51; more than 150 minutes a week lowered it by 0.89 versus 0.36 for 150 minutes or less; advice alone changed nothing unless paired with diet advice [8]. ### Fasting and supplements In 137 adults with type 2 diabetes, two days a week of 500 to 600 kcal and daily restriction of 1,200 to 1,500 kcal produced equivalent HbA1c changes at 12 months (-0.3% versus -0.5%; 90% CI of difference -0.2 to 0.5); 97 completed the trial, and weight loss was not shown to be equivalent. Glucose events affected 35% of those taking sulfonylureas or insulin in the first two weeks [9]. Cinnamon at 120 mg to 6 g a day for 4 to 18 weeks (10 trials, 543 patients) lowered fasting glucose by 24.6 mg/dL (95% CI 8.7 to 40.5) but not HbA1c (-0.16%, -0.39 to 0.02), with high heterogeneity [10]. ### Where the evidence disagrees Remission rates depend on the definition and programme: 46% to 61% with formula diets, about 7% to 12% with standard behavioural programmes, and 57% at six months for low-carbohydrate diets defined by HbA1c alone [1][3][5][6]. Durability is the weak point, with most gains lost by five years without continued support [2]. Remission has not been shown to prevent heart attacks in a randomised trial [11], and the DiRECT-type programmes are not "natural" in the sense of unsupervised: they were medically managed [1][5]. SGLT2-inhibitor ketoacidosis can occur with low-carbohydrate diets or fasting [12]. **Bottom line (confidence 4 of 5).** Early type 2 diabetes can go into remission with large, sustained weight loss, and exercise and food-pattern changes help glucose control. It is a supervised, effortful process that often needs ongoing support, and medicines remain central for many people.