Early findings from the NHS T2D Pathway to Remission Programme

Eddy Edson

Eddy Edson

Well-Known Member
Relationship to Diabetes
Type 2

Summary​

Background​

Randomised controlled trials have shown that total diet replacement (TDR) can lead to remission of type 2 diabetes. In 2019, the English National Health Service (NHS) committed to establishing a TDR-based interventional programme delivered at scale within real-world environments; development followed of the NHS Type 2 Diabetes Path to Remission (T2DR) programme, a 12-month behavioural intervention to support weight loss involving an initial 3-month period of TDR. We assessed remission of type 2 diabetes for programme participants.

Methods​

In this national prospective service evaluation of programme implementation, people in England aged 18–65 years and diagnosed with type 2 diabetes in the last 6 years were referred to the programme between programme launch on Sept 1, 2020, and Dec 31, 2022. Programme data were linked to the National Diabetes Audit to ascertain HbA1c measurements and glucose-lowering medication prescriptions. The primary outcome was remission of type 2 diabetes at 1 year, defined as two HbA1c measurements of less than 48 mmol/mol recorded at least 3 months apart with no glucose-lowering medications prescribed from 3 months before the first HbA1c measurement, and the second HbA1c measurement recorded 11–15 months after the programme start date. Outcomes were assessed in two ways: for all participants who started TDR on the 12-month programme before January, 2022, for whom there were no missing data; and for all participants who started TDR on the 12-month programme before January, 2022, and had completed the programme (ie, had a valid weight recorded at month 12) by Dec 31, 2022, for whom there were no missing data.

Findings​

Between Sept 1, 2020, and Dec 31, 2022, 7540 people were referred to the programme; of those, 1740 started TDR before January, 2022, and therefore had a full 12-month opportunity to undertake the programme by the time of data extraction at the end of December, 2022. Of those who started TDR before January, 2022, 960 (55%) completed the programme (defined as having a weight recorded at 12 months). The mean weight loss for the 1710 participants who started the programme before January, 2022 and had no missing data was 8·3% (95% CI 7·9–8·6) or 9·4 kg (8·9–9·8), and the mean weight loss for the 945 participants who completed the programme and had no missing data was 9·3% (8·8–9·8) or 10·3 kg (9·7–10·9). For the subgroup of 710 (42%) of 1710 participants who started the programme before January, 2022, and also had two HbA1c measurements recorded, 190 (27%) had remission, with mean weight loss of 13·4% (12·3–14·5) or 14·8 kg (13·4–16·3). Of the 945 participants who completed the programme, 450 (48%) had two HbA1c measurements recorded; of these, 145 (32%) had remission, with mean weight loss of 14·4% (13·2–15·5) or 15·9 kg (14·3–17·4).

Interpretation​

Findings from the NHS T2DR programme show that remission of type 2 diabetes is possible outside of research settings, through at-scale service delivery. However, the rate of remission achieved is lower and the ascertainment of data is more limited with implementation in the real world than in randomised controlled trial settings.

A wealth of interesting detail and discussion in the body of the paper. Obviously, these are just 12 month results & you would expect five year follow up to show the same maybe ~5% remission & weight loss maintenance as you see from all lifestyle interventions (including low carb & whaetever else), in the absence of bariatric or pharma additions.
 
Eddy Edson said:

Summary​

Background​

Randomised controlled trials have shown that total diet replacement (TDR) can lead to remission of type 2 diabetes. In 2019, the English National Health Service (NHS) committed to establishing a TDR-based interventional programme delivered at scale within real-world environments; development followed of the NHS Type 2 Diabetes Path to Remission (T2DR) programme, a 12-month behavioural intervention to support weight loss involving an initial 3-month period of TDR. We assessed remission of type 2 diabetes for programme participants.

Methods​

In this national prospective service evaluation of programme implementation, people in England aged 18–65 years and diagnosed with type 2 diabetes in the last 6 years were referred to the programme between programme launch on Sept 1, 2020, and Dec 31, 2022. Programme data were linked to the National Diabetes Audit to ascertain HbA1c measurements and glucose-lowering medication prescriptions. The primary outcome was remission of type 2 diabetes at 1 year, defined as two HbA1c measurements of less than 48 mmol/mol recorded at least 3 months apart with no glucose-lowering medications prescribed from 3 months before the first HbA1c measurement, and the second HbA1c measurement recorded 11–15 months after the programme start date. Outcomes were assessed in two ways: for all participants who started TDR on the 12-month programme before January, 2022, for whom there were no missing data; and for all participants who started TDR on the 12-month programme before January, 2022, and had completed the programme (ie, had a valid weight recorded at month 12) by Dec 31, 2022, for whom there were no missing data.

Findings​

Between Sept 1, 2020, and Dec 31, 2022, 7540 people were referred to the programme; of those, 1740 started TDR before January, 2022, and therefore had a full 12-month opportunity to undertake the programme by the time of data extraction at the end of December, 2022. Of those who started TDR before January, 2022, 960 (55%) completed the programme (defined as having a weight recorded at 12 months). The mean weight loss for the 1710 participants who started the programme before January, 2022 and had no missing data was 8·3% (95% CI 7·9–8·6) or 9·4 kg (8·9–9·8), and the mean weight loss for the 945 participants who completed the programme and had no missing data was 9·3% (8·8–9·8) or 10·3 kg (9·7–10·9). For the subgroup of 710 (42%) of 1710 participants who started the programme before January, 2022, and also had two HbA1c measurements recorded, 190 (27%) had remission, with mean weight loss of 13·4% (12·3–14·5) or 14·8 kg (13·4–16·3). Of the 945 participants who completed the programme, 450 (48%) had two HbA1c measurements recorded; of these, 145 (32%) had remission, with mean weight loss of 14·4% (13·2–15·5) or 15·9 kg (14·3–17·4).

Interpretation​

Findings from the NHS T2DR programme show that remission of type 2 diabetes is possible outside of research settings, through at-scale service delivery. However, the rate of remission achieved is lower and the ascertainment of data is more limited with implementation in the real world than in randomised controlled trial settings.

A wealth of interesting detail and discussion in the body of the paper. Obviously, these are just 12 month results & you would expect five year follow up to show the same maybe ~5% remission & weight loss maintenance as you see from all lifestyle interventions (including low carb & whaetever else), in the absence of bariatric or pharma additions.
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Crikey yet another competing definition of this so called 'remission'. So of the 1710 T2s who set out bright eyed and bushy tailed on this project 45% dropped out in the first year - surely info that suggests this programme is not a viable option for a roll-out. 1710 set out on the course and at the end of the year 145 were in 'remission'. That's just 8% which means that 92% of participants were not in remission. That's just an awful result and simply does not justify the NHS rollout of it. They would do more good giving out test strips and training on how to use them to newbies. Of course we have no idea from this carefully cherry picked reporting how many of the T2s who were not in 'remission' according this definition did actually achieve HbA1cs under 48. The manipulation of the percentages in this field is familiar to us from Taylor et al . The figure of 32% success rate we are hearing on news outlets is cynical jiggerypokery intended to give the impression that 32% of the original cohort are in 'remission' when as we know it's only 8%. They have just consigned the half of participants who dropped out to Davey Jones's Locker - why include people who prove you wrong and show that your big idea is not doable !
It's unfortunate that the NHS jumped in on this crash diet in 2019 and rolled it out before waiting for the 5 year report on the DiRECT study ( another diabolical result).
Still it's a step forward of sorts, for decades the advice of Diabetes UK and the NHS was to begin with a programme of Diet and Exercise. Of course there actually was no programme of Diet and Exercise for new T2s and they had 'to fly by the seat of their pants'. So at least the NHS is moving the right direction even if the programme they have chosen is not viable and the aim, 'remission', is a fantasy. Change the title to 'Pathway to Good Control' and drop the obscurantist, 'anti- vaxxer' objection to medication and we might be getting somewhere.
 
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I gave out my 'just don't eat high carb foods' advice not long ago and got 'surely that's too simple' in return, but when the sink is overflowing it is best to simply turn off the tap - surely?
 
I must say, I feel proud to have taken part and be one of the statistics to have achieved (still in now) Remission!

I'm even happier that it is now being rolled out across the whole of the UK 😉
 
Burylancs said:
So of the 1710 T2s who set out bright eyed and bushy tailed on this project 45% dropped out in the first year - surely info that suggests this programme is not a viable option for a roll-out. 1710 set out on the course and at the end of the year 145 were in 'remission'. That's just 8% which means that 92% of participants were not in remission. That's just an awful result and simply does not justify the NHS rollout of it. They would do more good giving out test strips and training on how to use them to newbies. Of course we have no idea from this carefully cherry picked reporting how many of the T2s who were not in 'remission' according this definition did actually achieve HbA1cs under 48.
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What do you imagine the 'drop out' rate from good and responsible use of test strips would be? How many would stop testing and go back to eating whatever they like? Seems to me you're doing a bit if cherry picking here yourself, lumping those who gave up on months living on a 'soups and shakes' diet, which is difficult, no doubt, with those who could tolerate and persevere. You can't force people to do what's good for them, and 'good control' requires much motivation and commitment too and for a much longer period of time.

If you look at the results in the paper carefully there are some interesting curiosities. The early stages of the programme were largely delivered online due to the pandemic, but those who got 1 to 1 attention were more likely to achieve remission. Those who were recently diagnosed did much better. Those who lost the most weight did better. I did hope for better results than this to be honest, though for a soups and shakes diet with advice given over the internet it's not all bad news.

I would wonder what might result from offering this programme to those diagnosed prediabetic, what might be achieved if weight were addressed at an earlier stage in disease progression. I would wonder what might result from more ambitious weight loss targets - if bigger weight loss was associated with better remission odds perhaps that means the programme might not be quite long enough. Maybe a fasting blood glucose test and a blood triglyceride test might be an indicator of whether a person might benefit from being offered 'round 2'.

You are certainly right about medication and good control in the long run. I do remember what it was like when I was first diagnosed, reading patient information leaflets for several medications that basically said 'May Cause Death'. The idea of remission, of getting off these medications, was a powerful factor in motivating me to take diabetes and weight loss very seriously. I'm now at a point where I don't want to be off the meds if staying on them means I have better prospects for long-term health. Perhaps a new, enticing, motivating word is needed for those who have not achieved a HbA1c under 42 mmol/mol following big weight loss. Something that puts scary words on a patient information leaflet into context, balancing that worry (which is very low risk in reality) with the prospect of better chances at saving eyesight and feet. No harm in my view in dangling the 'R' word though as a carrot that gets people to lose a lot of weight, which is a good thing in every respect I'm sure you'd agree.
 
Burylancs said:
Crikey yet another competing definition of this so called 'remission'. So of the 1710 T2s who set out bright eyed and bushy tailed on this project 45% dropped out in the first year - surely info that suggests this programme is not a viable option for a roll-out. 1710 set out on the course and at the end of the year 145 were in 'remission'. That's just 8% which means that 92% of participants were not in remission. That's just an awful result and simply does not justify the NHS rollout of it. They would do more good giving out test strips and training on how to use them to newbies. Of course we have no idea from this carefully cherry picked reporting how many of the T2s who were not in 'remission' according this definition did actually achieve HbA1cs under 48. The manipulation of the percentages in this field is familiar to us from Taylor et al . The figure of 32% success rate we are hearing on news outlets is cynical jiggerypokery intended to give the impression that 32% of the original cohort are in 'remission' when as we know it's only 8%. They have just consigned the half of participants who dropped out to Davey Jones's Locker - why include people who prove you wrong and show that your big idea is not doable !
It's unfortunate that the NHS jumped in on this crash diet in 2019 and rolled it out before waiting for the 5 year report on the DiRECT study ( another diabolical result).
Still it's a step forward of sorts, for decades the advice of Diabetes UK and the NHS was to begin with a programme of Diet and Exercise. Of course there actually was no programme of Diet and Exercise for new T2s and they had 'to fly by the seat of their pants'. So at least the NHS is moving the right direction even if the programme they have chosen is not viable and the aim, 'remission', is a fantasy. Change the title to 'Pathway to Good Control' and drop the obscurantist, 'anti- vaxxer' objection to medication and we might be getting somewhere.
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All of this seems to be in line with what I'd expect. What would you have expected?
 
The success rate is low. But I'm not surprised because of what is actually made available in terms of shakes and soups in the Oviva NHS programme. You are given 4 flavours, and need to take 4 shakes/soups a day. Imagine eating the same thing, even your favourite meal, every single day for 3 months. It's not just boring, it's crazy, for lack of better words...

On top of that, you cannot choose WHICH 4 flavours, you get whatever they give you. If you don't like them, tough. I feel the attitude is, "you're lucky you get this for free, so shut up". It doesn't matter that the supplier has a much wider range of flavours than just the 4, and that you might actually like those instead. From the supplier's perspective, they much prefer you paying for their programme, rather than do it over the NHS.

I'm still going to give it a go (starting on the 18th). I won't be sticking with their 4 flavours only, though. I know for a fact I'd be off it in two weeks... Luckily I can afford it!
 
Meglorien said:
The success rate is low. But I'm not surprised because of what is actually made available in terms of shakes and soups in the Oviva NHS programme. You are given 4 flavours, and need to take 4 shakes/soups a day. Imagine eating the same thing, even your favourite meal, every single day for 3 months. It's not just boring, it's crazy, for lack of better words...

On top of that, you cannot choose WHICH 4 flavours, you get whatever they give you. If you don't like them, tough. I feel the attitude is, "you're lucky you get this for free, so shut up". It doesn't matter that the supplier has a much wider range of flavours than just the 4, and that you might actually like those instead. From the supplier's perspective, they much prefer you paying for their programme, rather than do it over the NHS.

I'm still going to give it a go (starting on the 18th). I won't be sticking with their 4 flavours only, though. I know for a fact I'd be off it in two weeks... Luckily I can afford it!
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Hi,

Pleased to see you giving it a go - see what happens, one step at a time...

I initially didn't think much of the flavour choice either, but I did enjoy looking forward to the coffee one in the morning!

For me it was the 'reset' I needed...easy to choose (as not much choice) and repeat - food re-introduction then opened up a whole new world of finding all sorts of 'different' food for me to explore (it was always there, I chose not to eat it previously as chose KFC etc..)

Enjoy the journey 😉
 
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