Type 2 Diabetes Remission
When I first started writing about Diabetes, I described type 2 diabetes as being a chronic, progressive condition requiring lifelong treatment. But now we can safely say that this doesn’t have to be the case for everyone diagnosed with prediabetes or type 2 diabetes.
Type 2 diabetes/ prediabetes remission can sometimes be achieved through a combination of intentional, sustained lifestyle changes and/or medical interventions. How successful remission is in the long run, however, is often dependent on the extent to which the Type 2 diabetes disease process has progressed before intervention is started.
In other words, to successfully put type 2 diabetes into remission you need to take action as soon as possible after diagnosis.
Introduction
Remission of type 2 diabetes is generally defined as having an HbA1c level< 48 mmol/mol for 3-6 months without the need for blood glucose lowering medications.
This paradigm shift offers hope for reducing long-term complications and the associated burden on health systems. International studies have shown that lifestyle modification, bariatric surgery, and newer pharmacological agents can all contribute to remission, although the durability of remission and its generalisability to different populations remain areas of active investigation. In Aotearoa New Zealand, where type 2 diabetes disproportionately affects Māori and Pacific peoples, so the challenge is not only how wide-scale remission can be achieved, but also how it can be achieved equitably.
Remission vs Reversal
There have been various different terms used to talk about “normalisation” of blood glucose levels in type 2 diabetes. Each have different connotations if you think about them.
- Resolution means the diabetes is completely gone and won’t come back.
- Cure suggests the body is fully back to normal and no more treatment or check-ups are needed.
- Reversal means blood sugar levels have dropped below the diabetes range, but support is still needed to stop them from rising again.
- Remission means blood sugar levels are back to normal or below the diabetes level, but the person still needs ongoing support and regular check-ups.
Because people in remission still need care and monitoring, remission is the preferred term to describe word for people whose blood sugar levels are below the diabetes level but who still need to watch for any return of diabetes or other health problems.
Perspectives on Type 2 Diabetes Remission
Globally, type 2 diabetes affects more than 500 million people, with prevalence projected to rise substantially in coming decades. Lifestyle interventions have demonstrated strong potential for inducing remission. The landmark DiRECT trial in the UK used a low-calorie, meal replacement–based programme and showed that nearly half of participants achieved remission after one year, with sustained remission in a subset after two years. Weight loss of 10–15 kg was strongly associated with success.
Bariatric surgery appears to lead to the highest remission rates, with studies showing 50–80% remission in the first two years following surgery, though some individuals relapse over time. Surgery alters gut hormones, improves insulin sensitivity, and reduces beta-cell stress, offering mechanisms beyond weight loss alone.
Increasingly, international diabetes care guidelines recognise remission as an achievable target and encourage clinicians to discuss it with patients. Don’t be afraid to ask your healthcare team! We need to keep up with the rest of the world!
Efforts to achieve remission in New Zealand face unique challenges. Socioeconomic deprivation, food insecurity, and high costs of healthy foods all contribute to barriers to lifestyle modification. Access to bariatric surgery is highly restricted, with limited publicly funded capacity and long waiting lists. Newer pharmacological agents are not widely funded by Pharmac, limiting their accessibility to those who can afford out-of-pocket costs. These structural barriers compound inequities and mean that remission strategies must be culturally tailored, community-led, and supported by policy changes to achieve meaningful impact for Māori and Pacific communities.
Achieving Diabetes Remission
Lifestyle-Based approaches
Dietary interventions remain central to achieving remission. Very low-calorie diets, typically providing 800–1200 kcal per day through meal replacements or structured plans, have been most studied and shown to induce remission in up to half of participants. Carbohydrate restriction and intermittent fasting are alternative strategies with growing evidence bases. In New Zealand, culturally adapted interventions are being trialled, recognising the importance of food practices and the need for supportive family- and community-based approaches.
Physical activity enhances insulin sensitivity and supports weight loss maintenance, though on its own is less effective for inducing remission. Combining increased activity with dietary strategies remains the cornerstone of lifestyle management.
Weight loss is the key driver of remission. Data suggest that losing ≥10–15 kg is strongly associated with sustained remission, although this threshold may vary by ethnicity and baseline metabolic profile.
Bariatric surgery is the most effective intervention, with high remission rates in the short to medium term. However, in New Zealand, publicly funded access is limited, and eligibility criteria prioritise those with severe obesity and comorbidities. Pacific peoples are underrepresented in surgical uptake despite higher disease burden, highlighting inequities that require urgent attention.
Pharmacological approaches
Newer pharmacological agents (funded in NZ only relatively recently) can offer additional support towards remission:
- Glucagon-like peptide-1 receptor agonists GLP-1 RAs (such as liraglutide and semaglutide) promote satiety, reduce energy intake, and support substantial weight loss. In clinical trials, remission rates approach those seen with intensive lifestyle programmes. However, in New Zealand, these medications are not currently funded, limiting availability to those able to afford private prescriptions.
- Sodium-glucose co-transporter-2 (SGLT2) inhibitors can help with modest weight loss and improve blood glucose levels, in addition to reducing cardiovascular and renal complications. While their ability to induce remission is less dramatic, they are valuable in supporting long-term disease management.
- Combination therapy using lifestyle modification and pharmacological agents appears most effective, offering synergistic effects that improve both weight and glycaemic outcomes.
Access remains the critical barrier. Without equitable funding of these therapies, Māori and Pacific communities—those most affected by diabetes—are least likely to benefit.
Challenges in the New Zealand Context
Remission is not always permanent. It is common for type 2 diabetes to return, particularly if weight is regained, so ongoing monitoring is essential. Achieving lasting remission requires long-term behavioural, medical, social and whānau support.
Health inequities pose a major challenge. Māori and Pacific peoples face structural barriers including poverty, housing insecurity, and systemic racism within health care. Without addressing these wider determinants of health, remission will remain out of reach for many. Programmes that are kaupapa Māori or Pacific-led have demonstrated better engagement and outcomes, underscoring the importance of culturally safe care.
Policy also plays a role. Food pricing, advertising regulation, and subsidies for healthier options could support dietary interventions at a population level. Expanding eligibility for bariatric surgery and funding for newer pharmacological agents would also increase access to remission pathways.
Future Directions
Looking ahead, remission should become an explicit target within New Zealand’s diabetes guidelines. This might reframe the goals of treatment from long-term management alone to potential reversal. Scaling up evidence-based interventions such as very low-calorie diets and expanding access to bariatric surgery are critical. Equally, advocacy for Pharmac funding for wider access of (for example) continuous glucose monitoring systems is needed.
Most importantly, interventions must be tailored for Māori and Pacific peoples, recognising cultural values, family structures, and community leadership. Investment in indigenous-led research and programmes is essential to ensure remission is achievable equitably.
Summary
Type 2 diabetes remission is now a realistic and evidence-based goal. Lifestyle modification, bariatric surgery, and pharmacological therapies all play a role in inducing remission, although sustainability remains a challenge for many.
| Class | PHARMAC Funding | Key Benefits / Caveats |
|---|---|---|
| Biguanides Metformin | Funded; generally widely accessible. | Good efficacy for HbA1c lowering, low cost; usually weight-neutral or modest weight loss; GI side effects; needs monitoring in renal impairment. |
| Sulfonylureas Gliclazide Glipizide Glibenclamide | Funded. | Strong HbA1c lowering; risk of hypoglycaemia; may cause weight gain; less favourable in people with cardiovascular risk or older age. |
| Thiazolidinediones Pioglitazone | Funded (or available to prescribe) though sometimes with reservations. | Good insulin sensitivity effects; risk of weight gain, fluid retention; potential adverse effects (heart failure risk, bone fracture risk) must be considered. |
| Alpha-glucosidase inhibitors Acarbose | Funded or available though less commonly used. | Acts in gut to slow carbohydrate absorption; modest HbA1c lowering; GI side effects often limit tolerance. |
| DPP-4 Inhibitors ("gliptins") Vildagliptin Sitagliptin Saxagliptin Linagliptin | Vildagliptin is the only one fully funded; others are approved but not funded. t2dm.nzssd.org.nz+2bpac.org.nz+2 | Weight-neutral; low risk of hypoglycaemia; useful when metformin is contraindicated or not tolerated; modest HbA1c effect; cost matters when self-funded. |
| SGLT-2 Inhibitors (“flozins”) Empagliflozin Dapagliflozin | Empagliflozin is funded under special authority criteria; dapagliflozin is approved but not generally funded or subsidised for many patients. t2dm.nzssd.org.nz+2bpac.org.nz+2 | Benefits include glucose lowering, cardiovascular & renal protection, weight loss, low hypoglycaemia risk (if not used with insulin/sulfonylureas); risks include genitourinary infections, risk of DKA especially in certain settings; efficacy depends on renal function. |
| GLP-1 Receptor Agonists Dulaglutide (Trulicity) Liraglutide (Victoza) Semaglutide (Wygovy/Ozempic) | Funded for some patients with T2D under special authority, depending on eligibility (especially empagliflozin & dulaglutide, more recently also liraglutide when criteria met). Access has had supply restrictions. t2dm.nzssd.org.nz+3bpac.org.nz+3Pharmac+3 | Strong HbA1c lowering, good weight loss effects, cardiovascular risk reduction; cost higher; injectable; GI side effects common; supply constraints recently causing access restrictions. |
| Also see Insulins and Type 2 Diabetes | ||
Page updated September 2025
