SGLT2 inhibitors and dietary calorie restriction for type 2 diabetes remission

The view that the hyperglycaemia associated with type 2 diabetes is inexorably progressive was challenged by the publication of the DiRECT study in 2018.12 Through a mean weight loss of 10 kg achieved by a period of total diet replacement (often referred to as the “soups and shakes” diet), 46% of participants achieved remission of type 2 diabetes at 12 months. The longer term sustainability of the remission achieved is less clear, with 36% still in remission at two years in the DiRECT study but only 13% at five years with continued support.34 The English NHS Type 2 Diabetes Path to Remission Programme provides access to similar interventions in the real world for people within six years of diagnosis of type 2 diabetes and body mass index >27 (appropriately adjusted according to ethnicity), with 12 month remission rates of approximately 30%.5 Around 35 000 people have now been referred into the national programme.

The linked study by Liu and colleagues (doi:10.1136/bmj-2024-081820) investigated the combined effect of the sodium-glucose cotransporter-2 (SGLT-2) inhibitor dapagliflozin with calorie restriction on remission of type 2 diabetes over 12 months.6 They used a moderate calorie restriction (reduction by 500-750 kcal/day) for participants in both arms, which they argue is more practical and acceptable than the more restrictive total diet replacement approach adopted in DiRECT. Participants were randomised 1:1 to dapagliflozin or placebo. …