Epidemiology of type 2 diabetes remission in Scotland in 2019: A cross-sectional population-based study

Abstract

Background: Clinical pathways are changing to incorporate support and appropriate follow-up for people to achieve remission of type 2 diabetes, but there is limited understanding of the prevalence of remission in current practice or patient characteristics associated with remission.

Methods and findings: We carried out a cross-sectional study estimating the prevalence of remission of type 2 diabetes in all adults in Scotland aged ≥30 years diagnosed with type 2 diabetes and alive on December 31, 2019. Remission of type 2 diabetes was assessed between January 1, 2019 and December 31, 2019. We defined remission as all HbA1c values <48 mmol/mol in the absence of glucose-lowering therapy (GLT) for a continuous duration of ≥365 days before the date of the last recorded HbA1c in 2019. Multivariable logistic regression in complete and multiply imputed datasets was used to examine characteristics associated with remission. Our cohort consisted of 162,316 individuals, all of whom had at least 1 HbA1c ≥48 mmol/mol (6.5%) at or after diagnosis of diabetes and at least 1 HbA1c recorded in 2019 (78.5% of the eligible population). Over half (56%) of our cohort was aged 65 years or over in 2019, and 64% had had type 2 diabetes for at least 6 years. Our cohort was predominantly of white ethnicity (74%), and ethnicity data were missing for 19% of the cohort. Median body mass index (BMI) at diagnosis was 32.3 kg/m2. A total of 7,710 people (4.8% [95% confidence interval [CI] 4.7 to 4.9]) were in remission of type 2 diabetes. Factors associated with remission were older age (odds ratio [OR] 1.48 [95% CI 1.34 to 1.62] P < 0.001) for people aged ≥75 years compared to 45 to 54 year group), HbA1c <48 mmol/mol at diagnosis (OR 1.31 [95% CI 1.24 to 1.39] P < 0.001) compared to 48 to 52 mmol/mol), no previous history of GLT (OR 14.6 [95% CI 13.7 to 15.5] P < 0.001), weight loss from diagnosis to 2019 (OR 4.45 [95% CI 3.89 to 5.10] P < 0.001) for ≥15 kg of weight loss compared to 0 to 4.9 kg weight gain), and previous bariatric surgery (OR 11.9 [95% CI 9.41 to 15.1] P < 0.001). Limitations of the study include the use of a limited subset of possible definitions of remission of type 2 diabetes, missing data, and inability to identify self-funded bariatric surgery.

Conclusions: In this study, we found that 4.8% of people with type 2 diabetes who had at least 1 HbA1c ≥48 mmol/mol (6.5%) after diagnosis of diabetes and had at least 1 HbA1c recorded in 2019 had evidence of type 2 diabetes remission. Guidelines are required for management and follow-up of this group and may differ depending on whether weight loss and remission of diabetes were intentional or unintentional. Our findings can be used to evaluate the impact of future initiatives on the prevalence of type 2 diabetes remission.

Fig 1. Flow diagram showing the number of individuals with type 2 diabetes diagnosed in Scotland between January 1, 2004 and December 31, 2018 who were alive on December 31, 2019 and were registered with a Scottish health board who were eligible for inclusion in descriptive analyses/multiple imputation analysis and complete case analysis.

Fig 2. Prevalence of remission of type 2 diabetes among people with type 2 diabetes in Scotland who had at least 1 HbA1c ≥48 mmol/mol (6.5%) after diagnosis of diabetes and had at least 1 HbA1c recorded in 2019 stratified by age group and change in weight from diagnosis to 2019.

Fig 3. ORs for remission of type 2 diabetes (95% CI) in Scotland 2019 derived from multivariable logistic regression model adjusted for all covariables listed on the plot with multiple imputation for missing data.

CI, confidence interval; GLT, glucose-lowering therapy; OR, odds ratio.

Fig 4. ORs for remission of type 2 diabetes (95% CI) in Scotland 2019 derived from multivariable logistic regression model adjusted for all covariables listed on the plot with multiple imputation for missing data.

People with previous history of dementia, end-stage renal disease, liver cirrhosis, cancer, or metastases in the last 5 years removed. N = 152,934. CI, confidence interval; GLT, glucose-lowering therapy; OR, odds ratio.