In type 2 diabetes, a primary care–led weight management program increased weight loss and diabetes remission at 2 years

Primary care practices that want to adopt such an intervention for their patients will need a dietician or practice nurse to deliver an intensive weight loss program, noted an ACP Journal Club commentary.


A weight management program led to sustained diabetes remission in about a third of participating patients with type 2 diabetes of less than six years' duration and a body mass index of 27 to 45 kg/m2. The trial randomized patients to either usual care or a program including withdrawal of drugs for diabetes and hypertension, total diet replacement, stepped food reintroduction, and structured support for weight-loss maintenance.

The study was published on March 6 by The Lancet Diabetes & Endocrinology. The following commentary by Anupam Goel, MD, FACP, was published in the ACP Journal Club section of the Aug. 20 Annals of Internal Medicine.

The 2-year results of DiRECT support the hypothesis that intensive behavior modification for weight loss can lead to sustained remission in early-stage diabetes. The 2-year diabetes remission rate is similar to the 40% achieved with Roux-en-Y gastric bypass surgery.

Primary care practices that expect to adopt this intervention will need a dietician or practice nurse to deliver an intensive weight loss program with total diet replacement and can anticipate problems getting patients to join and remain in the program. In DiRECT, 1087 of 1510 potentially eligible patients either declined or did not respond. 306 of the remaining 423 patients met all inclusion criteria. Of the 157 patients enrolled in the weight management intervention, 32 (20%) withdrew from treatment by 12 months and 48 (31%) by 24 months.

The cost-effectiveness of the DiRECT intervention vs usual care was assessed at 1 year. The intervention may be more cost-effective than gastric bypass surgery or a lifetime of medications for diabetes, but such analyses have not yet been published. However, the DiRECT approach could be perceived as limiting patients' self-efficacy to integrate the necessary behavioral changes into their daily lives to sustain weight loss in the long-term. Additional research may be needed to help us empower our patients to view their relation to food as one linked to appetite instead of cycles of weight suppression, disinhibition, and weight gain and to better manage their own food-related behaviors to reduce risk for diabetes.