Obesity Medicine 13 (2019) 59–64

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Obesity Medicine
journal homepage: www.elsevier.com/locate/obmed

Original research

The impact of multiple lifestyle interventions on remission of type 2 diabetes T

mellitus within a clinical setting
R. Davea,∗, R. Davisb, J.S. Daviesc
a
Chowpatty Medical Centre, 3 Baig Mansion, Babulnath Road, Mumbai 400 007, India
b
University of South Wales, Cardiff Medicentre, Heath Park, Cardiff CF14 4UJ, UK
c
University Hospital of Wales, Heath Park, Cardiff, UK

A R T I C LE I N FO A B S T R A C T

Keywords: Aims: To assess the impact of multiple lifestyle interventions (LSI) in type 2 diabetes mellitus. (T2DM)
Type 2 diabetes mellitus Methodology: T2DM subjects were enrolled in a one year LSI program consisting of diet, exercise, diabetes
Lifestyle interventions education and pharmacotherapy review with support from a diabetes educator (DE). Outcome measures were
Diet and exercise weight loss, medication and diabetes status.
Remission of diabetes
Results: n = 45 Indian subjects with T2DM. Weight loss at the end of one year: > 10% n = 12 (26.8%); 5–10%
Weight loss
n = 9 (20%); < 5% n = 20 (44.4%) (p < 0.05), weight gain (1–3 kg) n = 4 (8.8%). 41 participants gained
2.8 ± 0.9 kg in years 1–5. Remission of T2DM at one year n = 35 (77.8%) and at five years n = 21 (51.2%).
Treatment cost savings at one year = $189/patient/year and $145/patient/year during years 1–5; an average
saving of $765/patient over 5 years.
Conclusion: Intensive LSI over one year resulted in weight loss, improved glycaemic control and T2DM remission
in the majority of subjects. Medication costs were reduced. Over five subsequent years, diabetes remission
persisted in the majority despite modest weight regain.

1. Introduction oral hypoglycemic agents (OHA), 50% of individuals require insulin

therapy within 10 years of T2DM diagnosis (Turner et al., 1999). OHAs
Type 2 diabetes mellitus (T2DM) is a heterogeneous disorder ac- cannot abolish the progressive loss of β-cell (Fonseca, 2009) and drug
counting for 90–95% of cases of diabetes mellitus (DM) and is primarily therapy alone does not address the underlying lifestyle issues which
characterized by a decline in β-cell function resulting in progressive fuel the development of T2DM.
decline of insulin secretion and worsening of insulin resistance (IR) Lifestyle interventions (LSI) are defined as any intervention that
(American Diabetes Association, 2015). T2DM is considered to be an includes exercise, diet and at least one other component (e.g., coun-
incurable, chronic and progressive condition (Kaufman, 2005) with the selling, stress management, smoking cessation) (Sumamo et al., 2011).
rate of progression of disease governed by modifiable risk factors LSI is a routinely recommended approach for primary prevention of
(obesity, sedentary lifestyle, diet and smoking) and non-modifiable risk T2DM but is applied less often once T2DM is diagnosed (Ades et al.,
factors (Family history, ethnicity, age) (Wu et al., 2014). 2015). Studies suggest that only 34% of individuals with T2DM ever see
Obesity is a potent independent risk factor for the development and a registered dietitian (RD) and rarely achieve significant weight loss or
progression of T2DM determined by both the degree of obesity and its improved fitness (Ades, 2015). Lack of referral and financial re-
site (Eckel et al., 2011). It has been well established that modest sus- imbursement together with the patients’ poor perception of the impact
tained weight loss of 5–10% can reduce the risk of T2DM (Ahmed and of LSI have been identified as factors that lead to the under-utilization
Crandall, 2010) by decreasing IR, improving glucose tolerance and of LSI programs in the management of T2DM (Alameddine et al., 2013).
glycemic control (Delahanty, 2002). Despite the established relation- The Look AHEAD (Action for Health in Diabetes) study draws our
ship between obesity and T2DM (Abdullah et al., 2010) the current attention to a possible paradigm shift in the management of T2DM by
model of care often concentrates on pharmacological interventions that suggesting that T2DM can be reversed, its risk lowered and its com-
may contribute to weight gain with incremental dose increases and plications delayed by implementing inexpensive, easy to use LSI that
hence increased cost of care (Hamdy, 2008). Despite treatment with address obesity (Gregg et al., 2012). This alternative model of care

∗
Corresponding author.
E-mail addresses: rutumdave@gmail.com (R. Dave), rdavis@diploma-msc.com (R. Davis), Daviesjs@diploma-msc.com (J.S. Davies).

https://doi.org/10.1016/j.obmed.2019.01.005
Received 31 October 2017; Received in revised form 13 April 2018; Accepted 23 January 2019
2451-8476/ © 2019 Elsevier Ltd. All rights reserved.
R. Dave et al. Obesity Medicine 13 (2019) 59–64

focuses on body weight management, which is a root cause of T2DM. (Table 1). Other data collected included lipid levels, blood pressure
Weight loss results in improved glycaemic control by significantly im- (BP) and cost of medications.
proving hepatic insulin sensitivity, lowering intrahepatic lipids (Lim
et al., 2011; Stanford et al., 2012), thereby reducing the requirement
for medication and leading to decreased cost of care (Hamdy, 2008). 2.3. Clinic support
Similar benefits are seen following weight loss with pharmacotherapy
(Van Gaal and Dirink, 2016) and bariatric surgery (Yska et al., 2015) Participants received care and support from one designated case
yet, LSI is found to be of lower cost and is a safer than the other modes manager who was a qualified and experienced diabetes educator (DE).
of treatment (Yeh et al., 2016; Lawley, 2014; Lois and Kumar, 2008). In addition to co-ordinating with the physician for change in treatment,
As a reflection of the global epidemic of obesity and associated the diet and exercise recalls sent by the participant were reviewed and
T2DM there is greater emphasis placed on successful LSI programs. This commented upon to achieve improved compliance to the diet and ex-
study was designed to assess the impact of multiple LSI on diabetes care ercise plan. Participants could contact the DE as required. Email or
in an Indian population with T2DM within a typical outpatient clinic telephone reminders were provided in cases of missed weekly contacts
setting and assess the savings that might accrue through reductions in and to plan quarterly appointments with laboratory investigations.
medication costs. Laboratory investigations were individualized to patient requirement
based on presence of other co-morbidities. In addition, to motivating
2. Methodology the participants, educational resources and health tips were emailed on
a weekly basis. Participants were encouraged to involve any carers in
A cohort of obese and overweight subjects over the age of 18 with a implementing the plan. If required the carers were also educated to
diagnosis of T2DM were identified from the clinic register of a private assist the patient, to better manage and implement the LSI strategies.
endocrinology practice in Mumbai, India. Following interview, 45 Support from carers predominantly included meal planning with op-
subjects with T2DM were enrolled onto an LSI program. tions and tailoring to the patient's likes and dislikes. Each counselling
session at the clinic was planned on a one to one basis and though
2.1. At baseline and to one year recommended on a quarterly basis, could be planned as required.

Subjects underwent an intensification of LSI each week delivered by

2.4. Data collection
a dedicated RD.

• Dietary counselling: Participants were counselled using the ADA

A number of varied data points were collected at baseline and
follow up visits at one year post intervention, 5 years post intervention
guidelines for management of T2DM (American Diabetes
and through email contact (Table 2).
Association, 2011) using a stepwise approach of counselling and
personalized, individualized and tailored meal plans.
• Exercise counselling: Participants were encouraged to increase daily 2.5. Data analyses
activity levels and implement a bespoke exercise schedule with
minimum target duration of 45 min, 6 days a week. Analyses were performed using SPSS software for Windows (version
• Education and monitoring: Participants were trained to self-monitor 16.0, 2007, SPSS Inc, Chicago, IL). Data are presented as frequency
fasting blood sugar (FBS) and post prandial blood sugar ([PPBS] (percentage) or Mean ± SD. Independent Sample T test was used to
post breakfast, lunch and dinner) twice weekly (weekday and compare difference in parameters between males and females. Paired
weekend) and email/SMS results including details of food recall, sample T test was used to analyze the difference in parameters between
exercise and weight using a template on a weekly basis to the onset, year one and year five. Cross tabulations were computed and
educator. Education included hypoglycemia management and an analyzed using chi-square test to study associations. p value less than
awareness of adverse drug reaction (ADR) for the medications pre- 0.05 was considered to be statistically significant.
scribed.

The goal provided to each patient was to lose 5–10% of current 3. Results
body weight. Supervision of glycemic control was monitored and ad-
justments to medication made as deemed appropriate by the physician. 3.1. Participants’ baseline characteristics
Follow up site visits were planned for each patient at quarterly intervals
( ± 15 days). Participants were supported in this program for a period The baseline characteristics of 45 participants (30 males, 15 fe-
of one year, after which they were returned to routine care where, as males) enrolled in the LSI program is provided in Table 3. Mean age was
per the clinic standard operating procedures, they were counselled to 45.1 ± 10.2 years and HbA1c 79 ± 4 mmol/mol (9.4 ± 2.5%), BMI
seek a consultation every 3 months and offered the weekly email con- 28.9 ± 4.8 kg/m2 and the Asian classification for BMI was employed
tact as an optional paid service. Reiteration of lifestyle modification since all the participants were Indians (World Health Organisation,
(LSM) is typically a component of every consultation in routine care. 2004). The majority of subjects (n = 26) had been diagnosed with
T2DM for less than 1 year, with 17 subjects having the disease for over
2.2. At year five 5 years and only 2 subjects diagnosed over 10 years prior to enrolment.
At baseline 43 subjects were treated with OHAs. Of these 31 subjects
Data were collected from records that were updated to October required two or less OHAs to treat their diabetes, 12 subjects required 3
2016. In order to collect data at year five for participants with poor or more OHAs and 3 subjects were being treated using a combination of
compliance to clinic visits, telephone contact was made. Subjects were OHA and insulin. Data for 41 participants (27 males, 14 females) were
encouraged to attend clinic for a follow up visit, in order to assess their collected at year five. Two participants were lost to follow up and all
current status of T2DM. Data were collected over the telephone in in- attempts to contact them via email and telephone were unsuccessful.
stances where the patient was unable/unwilling to visit the clinic. One participant died of cancer, while one was excluded as she under-
Criteria used to define responders to LSI were weight loss and re- went a pregnancy and delivered in early 2016. Table 4 provides a
ducing requirement of treatment based on weekly SMBG and quarterly baseline comparison of characteristics observed between responders
HbA1c. The ADA definition of remission was used (Buse et al., 2009) and non-responders to LSI.

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Table 1
Definitions of diabetes remission (Buse et al., 2009).
Remission Definition

Partial remission Sub-diabetic hyperglycaemia (HbA1c) not diagnostic of diabetes [ < 6.5%], fasting glucose 5.6–6.9 mmol/l) of at least one year's duration in the absence
of active pharmacologic therapy or ongoing procedures
Complete remission Return to “normal” measures of glucose metabolism (HbA1c in the normal range [ < 5.7%], fasting glucose < 5.6 mmol/L) of at least one year's duration
in the absence of active pharmacologic therapy or ongoing procedures.
Prolonged remission Complete remission that lasts for more than five years and might operationally be considered a cure.

Table 2 Table 3
Data points collected at different time points in the study. Baseline Characteristics of participants enrolled in the study.
Data Characteristics At Baseline Email/ Follow up At Year 1 Characteristic Total (%) Male Female
SMS visits and 5
contact Number 45 30 (66.7) 15 (33.3)
Height (cms) 167.7 ± 8.4 171.8 ± 6.3 159.5 ± 5.5
Demographic data X Weight (kg) 81.6 ± 18.1 86 ± 19.8 72.8 ± 9.4
Food Preference X BMI (kg/m2) 28.9 ± 4.8 29 ± 5.6 28.6 ± 3.0
Food Allergies X X 18.5–22.9 3 (6.7) 3 (10) 0 (0)
Smoking X X X 23–24.9 4 (8.9) 3 (10) 1 (6.7)
Alcohol consumption X X X X 25–29.9 21(46.7) 12 (40) 9 (60)
Medical history X > 30 17 (37.8) 12 (40) 5 (33.3)
Duration of diabetes (yrs) X WC (cms) 98.1 ± 15.6 101.4 ± 17 91.7 ± 10.2
Age of onset (yrs) X Age of onset (T2DM) 43.2 ± 10 43.8 ± 8.5 41.9 ± 12.8
Treatment:Diabetes X X X X (yrs)
Concomitant conditions X X X X ≤30 years 3 (6.7) – –
Other Treatment X X X X 31–50 years 32 (71.1) – –
Anthropometric Data ≥51 years 10 (22.2) – –
Height (cms) X Age at intervention 45.1 ± 10.2 45.4 ± 8.0 44.5 ± 13.9
Weight (kgs) X X X X (yrs)
BMI (kg/m2) X X X ≤30 years 3 (6.7) – –
Ideal Body Weight (IBW) X 31–50 years 29 (64.4) – –
(kgs) ≥51 years 13(28.9) – –
Laboratory Investigations Duration of T2DM (yrs) 1.9 ± 2.7 1.4 ± 2.3 2.7 ± 3.3
HbA1c (%) X X X < than 1 year 26 (57.8) – –
Lipids (mg/dl) X Optional Optional 1–3 years 5 (11.1) – –
Liver Enzymes X Optional Optional 3–5 years 6 (13.3) – –
(SGOT,SGPT) (IU/L) 5–10 years 6 (13.3) – –
Other tests (optional: as per X X X More than 10 years 2 (4.4) – –
patient requirement) HbA1c at intervention 79 ± 4 81 ± 3 75 ± 5
Self-Monitoring of Blood X mmol/mol (%) (9.4 ± 2.5) (9.6 ± 2.4) (9.0 ± 2.6)
Glucose (SMBG) Mild (6–7.99%) 15 (33.3) – –
Procedures Moderate (8–9.99%) 17 (37.8) – –
Electrocardiogram (ECG) X X X Severe (> 10) 13 (28.9) – –
Other test (optional: as per X X X Mode of treatment
patient requirement) LSI only 2(4.4) – –
Physical activity (Recalls) X X X OHA only 40(88.8) – –
Diet (Recalls) X X X OHA and insulin 3(6.8) – –
Hospitalisation (if any) X X X X Number of OHA
0 2(4.4) – –
1 9 (20) – –
2 22 (48.9) – –
3.2. Weight
3 12 (26.7) – –
Hypertension 17 (37.7) 14(46.7) 3(20)
Participants’ mean weight loss from baseline at end of year one was Dyslipidaemia 10 (22.2) 10 (33.3) 0(0)
7.6 kgs and at year five was 6.4 kgs Significant weight loss was observed
at year one (p < 0.05) with 26.8% (n = 12) achieving weight
loss ≥ 10%, 20% (n = 9) achieving 5–10% weight loss and 44.4% Table 4
(n = 20) achieving ≤5% weight loss. 4 subjects (8.8%) gained between Baseline Characteristics of responders vs. non responders.
1 and 3 kg at the end of year one. Weight regain was noted at year five Characteristic Responder Non responder
across all three categories but continued to be significantly lower when
compared to baseline. 9 subjects (21.5%) had weight higher than their Age (yrs) 44.9 ± 11 45.6 ± 8.4
Weight (kgs) 81.3 ± 18.3 82.5 ± 17.9
original baseline weight at year five. The difference in mean weight
BMI (kg/m2) 28.7 ± 5.0 29.3 ± 4.2
from baseline to year five across the three original weight loss cate- WC (cms) 97.3 ± 15.6 100.6 ± 16.0
gories was 0.8 kgs (≤5% weight loss), 2 kgs (5–10% weight loss) and Duration of diabetes (yrs) 1.06 ± 2.20 4.51 ± 2.70
12.2 kgs (≥10% weight loss). HbA1c mmol/mol (%) 81 ± 5 (9.6 ± 2.6) 69 ± 1 (8.48 ± 1.37)
OHAs 1.83 2.50

3.3. HbA1c
subjects. Despite higher rates of failure, well controlled glycemia is
Mean HbA1c ( ± SD) was 79 ± 4 mmol/mol (9.4 ± 2.5%) at observed at year five, which may be attributed to addition of phar-
baseline, 42 ± 1 mmol/mol (6.0 ± 0.5%) at year one and macotherapy in patients who failed remission.
48 ± 1 mmol/mol (6.5 ± 1.2%) at year five. Mean HbA1c reduced
significantly at year one and year five compared to baseline for all

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3.4. Remission of T2DM weight from that of the end of year one, 11 subjects (26.8%) continued
to be in partial remission and 8 (19.5%) in complete remission de-
Twenty-four subjects (53.3%) reached the partial remission defini- monstrating the continued benefits of initial weight loss.
tion at year one while 8 (17.8%) subjects reached the complete re- The findings of this study are broadly in line with other similar
mission definition. At year five, 11 (26.8%) subjects achieved partial studies. Wing et al. (1987) noted the association between higher weight
remission while complete remission was sustained by 8 (19.5%) sub- loss and greater reductions in HbA1c (Wing et al., 1987). In the Look
jects. AHEAD (The Look AHEAD Research Group, 2014) study participants
Of the participants who reached the remission threshold, 26.7% randomized to intensive LSI achieved a weight loss of 8.5% with an
(n = 12) attained it in the first 12 weeks following the start of LSI, 11.5% absolute rate of remission from diabetes in the first year. The
48.9% (n = 22) achieved it at between 12 and 52 weeks with one prevalence ratio of any form of remission was observed to be highest
subject (2.2%) achieving remission beyond one year. 19 participants during the first year when maximum reduction in weight was observed.
sustained remission for 3–5 years (42.2%), while 11.1% (n = 5) sus- In this study, weight regain ensued at the end of the first year with
tained remission for 1–3 years. weight loss of only 4–4.7% being maintained for the remainder of the
The duration of T2DM was 23 months with 57.8% (n = 26) having study. The absolute rate of remission subsequently fell to 7.3% from
diabetes for less than 12 months. There was a significant inverse re- 11.5% at the end of 4 years (The Look AHEAD Research Group, 2014).
lationship at year one (p = 0.005) and year five (p = 0.039) between Steven et al. (2013) compared the rate of remission with magnitude of
the rate of remission and duration of diabetes. Greater chance of re- weight loss (Steven et al., 2013). Remission of diabetes was observed in
mission was observed in participants who had T2DM for < 12 months 80, 63 and 53% of those with > 20, 10–20 and < 10 kg weight loss
than those with a duration of T2DM of 5 or more years (p < 0.05). (Steven et al., 2013). Similar findings were noted in our study popu-
lation where the rate of remission was 42%, 15% and 24.5% in parti-
3.5. Pharmacological treatments cipants who experienced weight loss ≥10%, 5–10% and < 5% re-
spectively at year one. At year five weight regain was experienced in all
At the outset of the LSI program, 43 subjects were receiving oral categories and failure of remission (relapse) was also higher with re-
hypoglycemic agents (OHAs) with 12 taking three or more OHAs. mission dropping to 19.5% vs. 42%, 9.7% vs. 15% and 21.9% vs.
Subjects being treated with three or more OHAs were least likely to 24.4%. The lowest percent relapse was observed in the participants who
achieve remission from T2DM at the end of year one (6 out of 12) and lost the maximum weight at year one and regained the least weight at
were more likely to fail to sustain remission at the end of year five (9 year five thus implying the relationship between weight management
out of 12). Of the three subjects receiving insulin, all had stopped in- and remission of T2DM.
sulin by the end of year one and had continued without insulin at the Together with remission of T2DM, there was also a decline in the
end of year 5. requirement for pharmacological treatments. Of the two participants
At baseline hypertension (HTN) and dyslipidemia were documented who were able to discontinue treatment for dyslipidemia, one patient
as co morbidities for 17 and 10 subjects respectively. A reduction in the reported a weight loss of ≥10% with the other achieving a weight loss
use of anti-hypertensive (n = 3, 7.3%) and lipid lowering agents of ≤5%. The three participants who were able to discontinue treatment
(n = 2, 4.8%) was noted at year five. for HTN had lost ≥10% weight.
Dyslipidemia and HTN along with T2DM are known to be strong
3.6. Compliance with clinic visits predictors and significant contributors to CVD morbidity and mortality
(Martín-Timón et al., 2014; Tacer and Rozman, 2011). The possibility
Attendance at quarterly visits to the clinic was calculated from year of remission of all these three chronic conditions holds great promise
one to year five. 22 participants (49%) attended once or less during the for preventive cardiac care and may have significant economic impact
year. 8 participants attended 2 appointments, 1 patient 3 of 4 yearly on the resources allocated for prevention and treatment of CVD (World
appointments and 12 subjects kept all 4 appointments. However poor Economic Forum, 2014).
compliance to visits did not influence the rate of remission (p > 0.05). The failure of remission at both year one and year five was highest
in participants with a longer duration of diabetes (5–10 years). The
3.7. Cost of treatment maximal number of subjects achieving remission of T2DM was observed
in those who had a diagnosis of diabetes for < 1 year. The remission
The cost of pharmacological agents for T2DM, HTN and dyslipi- rate at year one in participants with shorter duration of diabetes was
demia was calculated in this study. The average daily cost of treatment 55.5% (n = 25) and 39% (n = 16) at year five. Feldstein et al. studied
per day for all subjects at baseline was $32/day which was reduced to the effects of weight loss in participants who were newly diagnosed
$9/day at the end of year one. At year five the average daily cost of with T2DM and concluded that weight loss after recent diagnosis pre-
treatment was $16.5/day. Although higher than at the end of year one, dicted improved glycemic and blood pressure control even in the face of
spending at year five was lower than at baseline (p < 0.05). At the end weight regain (Feldstein et al., 2008), thus highlighting that the ther-
of year one and year five, reductions in drug therapies translated into apeutic advantages achieved through weight loss are more successful
savings of $188/year/patient and $144/year/patient respectively early after the diagnosis is made.
versus baseline costs. The average 5 yearly savings in treatment costs Current concepts of T2DM management suggest that the progressive
were $765/patient. nature of T2DM leads to a steadily increasing requirement of OHAs over
time (American Diabetes Association, 2013). The UKPDS demonstrated
4. Discussion the sequential requirement for additional OHAs to maintain glycemic
control (Yu et al., 2007). Three years post diagnosis, 50% participants
This study demonstrates that remission of T2DM can be achieved required more than one pharmacological agent and by nine years more
and maintained for as long as five years by employing and im- than 75% participants required multiple agents to achieve glycemic
plementing an LSI program in a real-world diabetes clinic. 35 (78%) control (Yu et al., 2007). Maximum failure of remission was noted in
subjects achieved diabetes remission one year after intervention with participants who were being treated with more than three OHAs at the
21 subjects (51%) still in remission at year five. A mean weight loss of time of intervention, despite weight loss. This emphasizes the im-
7.6 kg (7%) was associated with reaching partial remission threshold portance of early LSI following diagnosis and the need to capitalize on
for 24 subjects (53.3%) and complete remission threshold in eight the short window available to physicians to opt for LSI as the first line
subjects (18%) at year one. At year five, despite a gradual increase in of treatment. Therefore, maximizing LSI programs particularly in

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patients with a recent diagnosis of T2DM might be expected to max- 2013).

imize the opportunities of inducing remission from T2DM, reduce as- This study reveals the implementation of an LSI program into rou-
sociated co-morbidities and maximally reduce healthcare costs (Turner tine diabetic practice results in significant weight loss and remission of
et al., 1999). diabetes in the majority with benefits persisting beyond the one year of
In our study, participants who failed to achieve remission had active intervention. The program also is associated with the reduced
higher treatment expenses at baseline itself when compared to parti- drug costs that may be expected to make such programs cost effective.
cipants who achieved remission. Higher baseline expenses in partici- For a developing country like India, application of LSI, may be expected
pants who failed remission can be attributed to the requirement for to translate into improved population health, improved economic
multiple agents in order to achieve glycemic control owing to a longer productivity and lowered economic burden of disease (Yesudian et al.,
duration of T2DM and associated co-morbidities. Prevalence of dysli- 2014).
pidemia in the group that failed remission was higher (30%) compared
to the group that achieved remission (20%). Prevalence of hypertension 4.2. Limitations
was similar in both groups (40% vs. 37%). In the group that achieved
remission the average daily spending on antihypertensive treatments The major limitation of this study is the small and highly selected
and dyslipidemia remained similar from baseline to year one and year sample size. The subjects were selected after interview from a larger
five, however in the group whose diabetes persisted, the cost nearly clinic patient pool and confirmed their willingness to participate in LSI.
doubled at the end of five years. Therefore, this introduces a selection bias which may limit the applic-
A majority of participants were able to sustain remission for 3–5 ability of this approach in a wider clinical setting. That said however,
years while decreasing the average HbA1c by 3.4% and achieving the results of this study are valid in that remission of T2DM can be
weight loss of 7.7% and 5.1% at year one and year five respectively. achieved with lifestyle support.
Hamdy (2008) states that a ∼1% drop of HbA1c leads to cost savings of In this study, impact of weight loss has been studied only in re-
$776/patient/year (Hamdy, 2008) while Yu et al. estimated that 1% ference to hypertension and dyslipidemia in addition to T2DM.
weight loss in participants with T2DM lead to a total healthcare saving Inclusion of parameters that would have enabled us to study the impact
of $213/patient/year, and the diabetes-related healthcare cost saving of of weight management on cardiovascular disease, sleep apnea and non
$131.31/patient/year (Yu et al., 2007). Considering the cost savings alcoholic-fatty liver disease (NAFLD) would have been useful but were
from both reduced requirement of treatment (3–5 years) improved not collected.
HbA1c and weight loss, LSI does emerge as potential cost-effective A record of email/SMS data was maintained between baseline and
treatment strategy, although the cost of health care professional time in year one only if change in pharmacotherapy was advised. Assessing the
providing additional support for patients would also need to be factored relationship between remission and frequency of monitoring during the
into calculations. intensive period of treatment would have been worthwhile. These data
One of the features of this LSI program was close monitoring in the would have been valuable for new SMBG users (< 1 year) as increased
first year by a dedicated DE. A number of studies have proven that frequency of monitoring in new users has been associated with sig-
availability of an extended care model during the weight maintenance nificant decrease in HbA1c irrespective of line of treatment advised (LSI
phase would continue to help people lose weight and avert weight re- or pharmacotherapy) as opposed to older users where the benefits of
gain (Dalle Grave et al., 2005). However, no significant relationship SMBG are observed only in participants managed with pharma-
was observed between continued clinic/email contact and maintenance cotherapy (Karter et al., 2006).
of weight loss and therefore remission, suggesting that significant im- We are unable to comment on cost effectiveness of the intervention,
provements in weight management can be undertaken and maintained as we did not collect data on costs of physician and diabetes educator
by individuals in their usual environment with minimal or no profes- costs, email/SMS service, home blood glucose monitoring, laboratory
sional support (Steven et al., 2013). investigations, hospitalizations (if any), travel, paid exercise sessions (if
any), and loss of working days for physician visits and investigations
4.1. Implications (Rayappa et al., 1999).

Like other studies (Hamdy, 2008; Ades, 2015; Gregg et al., 2012; 5. Conclusion
Lim et al., 2011; Karter et al., 2014; Mottalib et al., 2015; Steven et al.,
2016; Bynoe et al., 2015; Barnard and Lattimore, 1982) this study re- This study demonstrates that diabetes remission can be achieved
veals that T2DM can be successfully managed by using simple lifestyle and maintained for as long as five years after employing a one year LSI
measures which are safe, efficacious and cost effective. The success of program in a primary outpatient clinic setting (Lean et al., 2018). The
this treatment option lies in motivating and encouraging participants to study suggests that maximal benefits of such a program are gained with
engage, actively in self-care activities that promote lifestyle changes the LSI intervention commencing as early as possible after a diagnosis
rather than depending on medical therapy. Despite the tailored and of T2DM is made and that LSI results in substantial cost savings in drug
individualized care made available to every patient, this model of care treatments.
was planned and executed within the regular framework of care, sug-
gesting that this clinic based model of care, can be translated success- Declaration of interest
fully to the routine clinical practice.
South Asians are genetically more prone to developing T2DM, at a The paper is based on work submitted in partial fulfilment of the
lower BMI (Misra and Shrivastava, 2013) and a younger age (United MSc Diabetes at the University of South Wales.
Kingdom Prospective Diabetes Study Group, 1994), and therefore more
likely to develop complications (Kaveeshwar and Cornwall, 2014). In Conflicts of interest
India, due to lack of social insurance policies, 85–95% of all healthcare
costs are borne by the individual with people from the lower income All authors declare that they have no conflict of interest.
groups bearing the greatest burden (Singh, 2013). The high cost of
treatment and poor affordability to care may lead to higher incidence of Funding
non-compliance especially in the poorer sections of the society (World
Health Organisation, 2016) exposing them to increased risk of diabetes- This research did not receive any specific grant from funding
related complications and added burden of disease (Kumpatla et al., agencies in the public, commercial, or not-for-profit sectors.

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