How can you achieve remission?
Type 2 diabetes has long been seen as a chronic, progressive disease, but emerging evidence shows it can be reversed in many cases. “Reversal” – often termed diabetes remission – means blood sugar levels return to non-diabetic ranges without the need for glucose-lowering medications. A recent international consensus defines remission as achieving HbA₁c <6.5% (48 mmol/mol) for at least 3 months without diabetes drugs.
For Canadian family physicians and their patients, this is a paradigm shift: Type 2 diabetes need not be lifelong and inevitable. In fact, Diabetes Canada now states that remission is a worthwhile goal in certain individuals through intensive lifestyle change or bariatric surgery. This post blends patient-friendly explanations, supported with medical literature, to explore how lifestyle interventions can lead to type 2 diabetes remission.
The Science of Diabetes Remission: Beta Cells and Organ Fat
Understanding why lifestyle changes can reverse diabetes requires a peek “under the hood.” In type 2 diabetes, two key problems are at work: insulin resistance (especially in liver and muscle) and impaired insulin secretion from pancreatic β-cells. Researchers have found these problems are largely driven by excess fat in the liver and pancreas. According to the Twin Cycle Hypothesis, chronic overeating leads to fat buildup in the liver, which then spills over to the pancreas, creating a vicious cycle that dampens insulin production.
Encouragingly, this process can be reversed. Dr. Roy Taylor’s landmark studies at Newcastle University showed that losing substantial weight, of around 15kgs, can dramatically de-fat these organs and restore normal metabolism. In one trial, patients on a very-low-calorie diet achieved normal blood sugars and normal β-cell function, some within weeks. Liver fat fell rapidly (a >30% drop within 7 days), restoring the liver’s responsiveness to insulin and normalizing fasting glucose. Over the next few weeks, fat in the pancreas also decreased, coinciding with dormant β-cells “waking up” and regaining their insulin-secreting ability.
In short, losing the fat inside the liver and pancreas appears to unlock the body’s natural ability to control blood sugar. Not everyone will achieve remission – individual β-cell capacity matters – but for many, type 2 diabetes is indeed “a reversible condition of intra-organ fat excess”. Notably, shorter diabetes duration is linked to higher remission rates, since β-cells haven’t been dysfunctional for as long. This science underpins all the lifestyle strategies discussed below: the goal is to reduce insulin resistance and relieve stress on β-cells, largely by reducing excess fat weight – especially from the midsection and organs.
Nutritional Strategies for Diabetes Remission
Diet is the cornerstone of diabetes remission. There is no one-size-fits-all “magic” diet, but evidence-based dietary approaches have shown particular promise:
Very Low-Calorie Diets (VLCD): Intensive weight-loss programs using meal replacements (~800 kcal/day) have yielded striking results. The landmark DiRECT trial in the UK put patients on a 825–853 kcal/day liquid diet for 3–5 months. At 12 months, 46% of participants achieved remission (HbA₁c <6.5% off meds), compared to 4% of those on usual care . Two years later, 36% remained in remission – over one-third – versus just 3% of controls . Crucially, those who lost ≥10 kg and kept it off had the highest success: among patients maintaining at least 10 kg weight loss, 64% were in remission . This underscores that degree of weight loss correlates with diabetes reversal. While such low-calorie regimens are challenging, they demonstrate that dramatic weight loss can remove the root cause (excess liver/pancreas fat) and allow blood sugars to normalize. In practice, these diets should be medically supervised, but elements (like meal replacements or structured plans) can be used to kick-start weight loss safely in primary care.
Whole-Food Plant-Based Diets: Diets centered on vegetables, fruits, whole grains, legumes, and nuts, with minimal animal products or processed foods, have shown impressive improvements in diabetes. High-fiber plant foods help with satiety and weight loss, improve insulin sensitivity, and can lower lipids and blood pressure – all beneficial for diabetes management. A recent 24-week randomized trial in the Marshall Islands compared a whole-food, plant-based diet plus exercise to standard care. The plant-based group dropped HbA₁c by an extra 1.3% at 12 weeks (and 0.7% extra by 24 weeks) compared to controls. Perhaps most striking, 23% of participants on the plant-based intervention achieved diabetes remission (in those who started with HbA₁c <9%). They were able to reduce or stop medications in the process. This aligns with other studies noting that plant-focused diets often allow patients to reduce medications and sometimes get off insulin entirely. For many patients, a whole-food plant-based diet is sustainable long-term, emphasizing real, unrefined foods rather than strict calorie counting. It’s an approach supported by Diabetes Canada and the American Diabetes Association (ADA) as a healthy eating pattern for diabetes, and now we see it can drive remission in some cases.
Lower Carbohydrate Diets: Carbohydrate restriction (reducing sugars and starches) offers another effective path to remission, mainly by lowering blood sugar levels and often reducing caloric intake spontaneously. Diets ranging from moderate low-carb (<130 g carbs/day) to ketogenic (<30 g carbs/day) have been tested. A 2021 systematic review (23 trials) found that patients on low-carb diets were more likely to reach remission at 6 months than those on higher-carb diets. In fact, about 32 more people per 100 achieved remission with a low-carb approach compared to control diets (number needed to treat = 4). These patients saw greater drops in HbA₁c and could often reduce diabetes medications. However, by 12 months some of the advantages diminished if the diet wasn’t maintained – highlighting that adherence is key with any diet. Still, real-world clinics (like Virta Health in the U.S.) have reported high remission rates using sustained very-low-carb (ketogenic) diets combined with intensive coaching, demonstrating the potential. Low-carb diets work by reducing post-meal glucose spikes and insulin demand, and they often promote quick weight loss (through diuresis and appetite suppression). Canadian and American guidelines now recognize low-carb eating as a valid option for type 2 diabetes management – provided the approach is nutritionally sound and monitored. For patients who enjoy protein and healthy fats, “cutting the carbs” – e.g. avoiding bread, pasta, sugar, and emphasizing vegetables, beans, and proteins – can be a powerful tool to improve control and aim for remission.
It’s worth noting that all these nutritional strategies share common threads: they create an overall calorie deficit (intentionally or as a byproduct of healthier food choices) and they improve diet quality. Whether through portion-controlled meal replacements, exclusively plant foods, or carb reduction, patients achieve weight loss and lower visceral fat. The best diet is ultimately one the patient can sustain. As Diabetes Canada puts it, healthy behavior changes leading to weight loss can indeed reverse type 2 diabetes in some – making nutrition therapy “the first tool” in pursuit of remission.
Physical Activity and Exercise: Improving Insulin Sensitivity
Regular physical activity is the next major pillar of diabetes remission. Exercise has insulin-sensitizing effects that are complementary to diet and weight loss. When muscles contract during exercise, they absorb glucose from the bloodstream for fuel, even without insulin. In fact, exercise opens an alternate gateway for glucose to enter muscle cells, bypassing insulin resistance. Muscles also store more glycogen and burn more fat after training, which helps lower blood glucose and improve metabolic health. Simply put, “getting active is probably the best way to combat insulin resistance”, according to the ADA.
For patients with type 2 diabetes, a combination of aerobic exercise (like brisk walking, cycling, swimming) and resistance training (weightlifting or bodyweight exercises) is ideal. Aerobic exercise increases insulin sensitivity in muscles and the liver, while resistance training builds muscle mass – providing more “sinks” to dispose of glucose. Studies show that supervised resistance training programs significantly improve HbA₁c and insulin sensitivity; however, without ongoing support, gains can be lost as adherence wanes. The Diabetes Prevention Program and other trials also confirm that higher activity levels lead to greater weight loss and diabetes risk reduction. For those already with diabetes, exercise can directly lower blood sugar and reduce the need for medication.
Guidelines: Diabetes Canada and the ADA recommend at least 150 minutes of moderate aerobic exercise per week, plus 2–3 sessions of resistance training targeting major muscle groups. Even everyday activities – taking the stairs, doing housework, walking the dog – help improve insulin sensitivity if done regularly. Importantly, patients should avoid long sedentary periods; moving every 30–60 minutes (even just standing or light walking) helps keep blood sugar levels stable. By improving muscle insulin sensitivity and promoting fat loss, exercise is a critical component of any remission effort. Many remission studies (DiRECT, Look AHEAD, etc.) included exercise alongside diet, and in clinical practice, combining diet + exercise produces the best outcomes. Physicians can encourage patients to start small (e.g. 10-minute walks after meals) and gradually build up – every bit of movement counts. Over time, consistent exercise not only aids in achieving remission but also confers cardiovascular benefits and improves mood and sleep, reinforcing a virtuous cycle of health.
Intermittent Fasting and Time-Restricted Eating
Intermittent fasting (IF) – eating patterns that cycle between periods of eating and fasting – has garnered attention as a strategy for weight loss and metabolic health. For type 2 diabetes, intermittent fasting can improve insulin sensitivity, promote fat burning, and even spur cellular clean-up processes that benefit the pancreas and liver. There are several approaches to IF, including Time-Restricted Eating (TRE) (e.g. 16 hours fasting, 8-hour eating window each day) and intermittent calorie restriction (e.g. the 5:2 diet with two very-low-calorie days per week). The rationale is that longer fasting periods allow insulin levels to fall for extended times, which switches the body into fat-burning mode and reduces lipids stored in liver and pancreas.
Early studies suggest IF can be safe and effective for people with type 2 diabetes, with medical guidance. A small Canadian case series famously reported that 24-hour fasts done 2–3 times per week led to dramatic reductions in insulin requirements and even remission in a few insulin-treated patients. More robust evidence comes from a 2022 randomized trial in China: 36 patients underwent a supervised intermittent fasting regimen (Chinese Medical Nutrition Therapy, with ~840 kcal every other day) for 3 months. Remarkably, 55% achieved diabetes remission (HbA₁c <6.5% off meds for at least 1 year) and around 90% of participants were able to reduce medication use. This challenges the notion that only newly diagnosed patients can reverse diabetes – in this study, even people with >6 years of diabetes had success. Another larger trial in New Zealand (MSFM trial) found that a 5:2 fasting diet achieved better 6-month glucose control than standard medication, highlighting the potential of IF to rival pharmacotherapy.
How does IF help? Aside from weight loss, fasting periods lower insulin and may “reset” insulin sensitivity in cells. There is evidence that early TRE (restricting eating to the first 6–8 hours of the day) can improve 24-hour blood sugar profiles and insulin response, even without weight loss, by aligning food intake with circadian rhythms. Patients often find that structured fasting simplifies their routine (fewer meals to plan) and can break unhealthy grazing or snacking habits. Of course, IF isn’t for everyone – those on insulin or sulfonylureas must carefully adjust doses to avoid hypoglycemia, and individuals with a history of eating disorders should avoid fasting. But for motivated patients, “feeding windows” or the occasional fast can be powerful tools. Practical tip: even an “overnight fast” of 14 hours (say, 7pm to 9am) can be a gentle start that might improve morning blood sugars. Ultimately, intermittent fasting is another way to induce the caloric restriction and fat loss that drive diabetes remission, with some patients finding it a more achievable framework than constant dieting.
Sleep, Stress, and Hormones: The Overlooked Factors
Lifestyle change isn’t only about diet and exercise – sleep quality and stress management play a significant role in glucose metabolism. Inadequate sleep and chronic stress can sabotage diabetes control by increasing insulin resistance and raising blood sugar levels. Research has shown that even one night of partial sleep deprivation can make the body more insulin resistant by the next day. In one study, sleeping only ~6 hours per night for 6 weeks led to a ~15% increase in insulin resistance. When cells don’t respond well to insulin, the pancreas has to produce more, and blood sugar tends to run higher. It’s no surprise, then, that chronic short sleepers are at higher risk for developing type 2 diabetes. On the flip side, restoring healthy sleep (7–9 hours of quality sleep per night) can improve insulin sensitivity and help with appetite regulation (via hormones like leptin and ghrelin), making weight loss easier. Practical advice: Patients should be counseled on sleep hygiene – regular sleep schedules, limiting screen time before bed, and treating sleep apnea if present – as part of their diabetes care.
Stress is another hidden culprit. The body’s stress hormone, cortisol, has a direct effect on blood sugar. High cortisol (from chronic stress or poor sleep) triggers the liver to dump extra glucose into the bloodstream and makes muscle and fat cells less sensitive to insulin. Essentially, cortisol puts the body in “fight or flight” mode, ensuring plenty of fuel (glucose) is available – which is counterproductive when we’re trying to lower blood sugar. A study from Ohio State tracked people with type 2 diabetes over six years and found those with chronically elevated or flatter cortisol rhythms (a sign of prolonged stress) had worsening glucose control and higher HbA₁c. Another study in 2020 showed a clear association between higher daily cortisol levels and higher blood sugar in people with diabetes. All this means that managing stress can improve diabetes. Techniques like mindfulness meditation, deep breathing exercises, yoga, or counseling can lower stress and cortisol levels. Even simple practices – a daily walk in nature, a relaxing hobby, or social support – can buffer stress. Many patients notice their blood glucose spikes during acute stress or illness; over the long term, reducing overall stress load can make blood sugars easier to control and aid in weight loss (since cortisol can also promote abdominal fat gain).
In summary, adequate sleep and stress reduction are key “lifestyle medicines”. They set the hormonal stage for success in other areas: well-rested, less-stressed individuals have more energy to exercise, better impulse control around food, and more balanced cortisol and insulin levels. Family physicians should inquire about sleep and stress at diabetes visits and offer resources (like cognitive behavioral therapy for insomnia, or stress management programs) as part of a comprehensive remission plan.
Targeting Organ Fat: Why Where You Lose Weight Matters
Not all weight loss is equal when it comes to diabetes remission. Fat distribution – specifically losing visceral fat (around organs) – is critical. A person might lose 5–10% of body weight and still see little improvement if that weight loss is mostly from lean tissue or subcutaneous fat; conversely, a modest weight drop that specifically drains fat from the liver and pancreas can have an outsized benefit on blood sugar. Studies using MRI scans have shown that people who achieve remission tend to have significantly reduced intrahepatic (liver) fat and intrapancreatic fat. In the DiRECT trial, every participant who went into remission had their liver fat content fall to normal and pancreatic fat decrease, whereas those who didn’t remit retained more fat in these organs. Professor Taylor often summarizes: it may only take losing ~0.5 gram of fat from the pancreas to restore normal insulin secretion – a tiny amount in absolute terms, but that requires shedding several kilos of body weight overall. The concept of a “personal fat threshold” has been proposed: each individual has a threshold of fat storage their organs can tolerate; cross that, and type 2 diabetes manifests. For some, especially of normal weight, this threshold is low – meaning they get diabetes at a lower BMI because their organs overflow with fat sooner. For others, the threshold is higher. The encouraging insight here is that weight loss needed for remission is proportional to how much excess fat a person has in liver/pancreas, not necessarily how heavy they are overall.
For primary care, this means setting realistic weight-loss goals tied to diabetes status. Evidence suggests that losing ~10–15% of body weight is often enough to normalize blood glucose in early type 2 diabetes. For example, a 100 kg patient might need to lose around 10–15 kg to hit their remission threshold. Of course, some may need more and some less, but this range is a common target seen in studies. The quality of weight loss is key: visceral fat (tummy/organ fat) tends to be lost first with healthy diet and exercise, whereas crash diets without exercise might lose more muscle. That’s why combining resistance training (to preserve muscle) and a high-quality protein diet is useful when cutting calories. Interestingly, the pattern of weight loss can also matter – losing a lot quickly (as in VLCDs or bariatric surgery) may have a different hormonal impact than slow loss. Rapid loss often leads to a quick reduction in liver fat and dramatic improvement in fasting sugars. However, any approach that leads to sustained fat loss will help.
The bottom line: to reverse diabetes, focus on the waist more than the scale alone. Patients often rejoice in looser pants or a smaller waistline, and that’s a sign visceral fat is coming down. Even before overall BMI hits “normal,” reductions in waist circumference and liver enzymes (like ALT, which often correlates with liver fat) can indicate progress toward remission. Physicians can use these metrics to motivate patients – for instance, tracking waist circumference or fat percentage along with weight. By keeping the spotlight on organ fat, we reinforce that “where you lose fat” – from around the organs – is what drives the return to healthy blood sugars.
Practical Steps and Mindset for Sustainable Change
Achieving diabetes remission is a marathon, not a sprint. It requires not just short-term dieting but long-term lifestyle transformation. This is where behavioural strategies and mindset become crucial. Both physicians and patients should recognize that support and coaching can dramatically improve success. Research shows that education alone isn’t enough – patients benefit from ongoing self-management support, accountability, and help navigating obstacles. In fact, health coaching interventions focusing on goal-setting, problem-solving, and building self-efficacy have led to lasting improvements in diet and activity habits in diabetics.
Here are some practical approaches to foster sustainable change:
Set SMART Goals: Instead of vague goals like “eat better” or “exercise more,” patients do well with S.M.A.R.T. goals – for example, “Walk 30 minutes during lunch break on Monday, Wednesday, Friday” or “Replace sugary drinks with water or tea all week.” Achieving small goals builds confidence (self-efficacy), which fuels motivation for bigger changes.
Self-Monitoring: Keeping food logs, activity trackers, or daily blood sugar records can raise awareness and reinforce positive behaviors. Many patients find that seeing progress – such as watching their morning glucose drop from the 9–10 mmol/L range to 6–7 mmol/L over weeks – is highly motivating. Likewise, monitoring weight or waist weekly (not obsessively) can keep them on track. Modern tools like continuous glucose monitors or diet apps can provide immediate feedback that links lifestyle choices to glucose trends, reinforcing learning.
Build a Support Network: Social support makes change easier. This can include diabetes education classes, dietitian visits, walking groups, or even family involvement. When family physicians refer patients to resources like Diabetes Canada’s programs or the National Diabetes Prevention Program (for those with prediabetes or early diabetes), patients gain coaching and peer support that keep them engaged. Some patients benefit from structured programs (Weight Watchers, Jenny Craig, etc.), while others may prefer a buddy system – e.g. spouses or friends teaming up to cook healthy meals or exercise together.
Address Barriers and Relapse Prevention: Lifestyle change inevitably encounters roadblocks – illness, busy work schedules, loss of motivation, etc. A key part of coaching is helping patients strategize solutions. For instance, if time is an issue, can they do shorter but higher-intensity workouts? If healthy cooking feels overwhelming, can we simplify with meal prepping on weekends or using prepared salad kits, etc.? It’s also important to normalize occasional setbacks. Patients should know that regaining some weight or having a high A1c one season is not a failure, just a signal to reboot support. Many people cycle in and out of remission; the goal is to catch weight regain or rising sugars early and intensify lifestyle efforts or medications as needed. This “two steps forward, one step back” pattern is common – what matters is the overall trajectory toward healthier habits.
Mindset and Motivation: Cultivating a growth mindset – the belief that one can improve one’s health with effort over time – is powerful. Encourage patients to view lifestyle changes not as punishment or temporary fixes, but as medicine and self-care. Celebrating non-scale victories (like better energy, improved lab numbers, or being able to play with grandkids longer) helps shift focus from pure weight to overall well-being. Some individuals find techniques like motivational interviewing (often used by healthcare providers) or even mental health counseling useful to address emotional eating, depression, or other factors intertwined with their diabetes management.
Finally, physicians should emphasize that partial progress is still hugely beneficial. Not everyone will achieve full remission – and that’s okay. Even losing 5–7% of body weight or dropping A1c by 1–2% can dramatically reduce complication risks. The pursuit of remission is not “all or nothing.” Framing it as “Best possible control, with the fewest medications” may resonate with patients. This way, whether they reach complete remission or still need one metformin, they’ve made tremendous strides. The fact that type 2 diabetes can be reversed at all is a message of empowerment and hope for patients.
In summary, type 2 diabetes remission is an attainable goal for many patients through comprehensive lifestyle intervention. Weight loss – particularly loss of visceral and organ fat – is the main driver of restored blood sugar control, enabling β-cells to recover and insulin sensitivity to improve. Achieving this involves a holistic approach: evidence-backed nutrition strategies (be it calorie restriction, plant-based diets, or carb reduction), regular physical activity (to boost insulin action), metabolic “boosters” like intermittent fasting, and attention to sleep and stress. Equally important is the human aspect – practical support, education, and coaching to make these changes sustainable in the real world. Major studies like DiRECT and Look AHEAD, and guidelines from bodies such as Diabetes Canada and the ADA, now endorse intensive lifestyle therapy as a means not just to manage diabetes, but to potentially send it into remission. For Canadian family physicians, this represents a shift toward more proactive, hopeful messaging: with the right changes, patients can potentially be free of diabetes medications and complications for years. For patients, it is the ultimate motivation – knowing that through their own efforts, they can take control of their health in a way that was once thought impossible. By blending the latest science with compassionate coaching, we can support patients on the journey to reversing type 2 diabetes, one step at a time, and improve not just their glycemic numbers but their overall quality of life.
