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Type 2 Diabetes Remission Trajectories and Variation in Risk of Diabetes Complications: A Population-Based Cohort Study

Hajira Dambha-Miller, Hilda O. Hounkpatin, Beth Stuart, Andrew Farmer, Simon Griffin

Abstract

Biochemical remission of type 2 diabetes is achievable through dietary changes, physical activity and subsequent weight loss. We aim to identify distinct diabetes remission trajectories in a large population-based cohort over seven-years follow-up and to examine associations between remission trajectories and diabetes complications. Group-based trajectory modelling examined longitudinal patterns of HbA1c level (adjusting for remission status) over time.

Introduction

People with type 2 diabetes compared to those without are more likely to have CVD including peripheral arterial disease, ischaemic stroke, stable angina, heart failure, and non-fatal myocardial infarction. Intensive multifactorial management is effective at reducing these complications, and recent evidence demonstrates that biochemical remission of the disease is achievable through dietary changes, physical activity and subsequent weight loss [2,3]. Remission is defined as a level of glycaemia below the diagnostic threshold (HbA1c < 6.5% or 48 mmol/mol) in the absence of medication or bariatric surgery. We have previously demonstrated that ≥ 10% weight loss achieved early after diagnosis is strongly associated with remission ((RR 2.43 (95% CI 1.78 to 3.31, p<0.01)) [4]. 

Materials and Methods

The Electronic Care and Health Information Analytics (CHIA) database is a pseudo-anonymised live electronic database with routinely collected primary care data for approximately 1.5 million people from 150 primary care practices across Hampshire and the Isle of Wight (Southern England, UK) with linked clinical and biochemistry data from local hospitals. From 120,000 people coded with type 2 diabetes by this criteria on the 1st January 2013, we included 60,287 in our cohort who also had linked and continuous records for seven years until 1st April 2020 (or death) and for whom remission status could be assessed.

Results

In this population-based cohort of 60,287 people with type 2 diabetes, remission was common with 19% of people achieving remission at some point for at least 6 months. Achieving remission regardless of duration or pattern of HbA1c level and remission status over time was associated with a lower risk of microvascular complications, macrovascular complications, and CVD events. However, the risk of these complications and mortality varied according to remission trajectories over time.

Discussion

The findings extend our previous findings by highlighting that lower risk of CVD outcomes is achieved regardless of duration of remission, though patients with consistently low HbA1c levels have lowest risk of CVD outcomes. Consistent with the observational studies and in contrast to some of the trials of glucose-lowering drugs [18], we observed consistent trends in unadjusted and adjusted models between remission group and a lower incidence of both macrovascular and microvascular complications. Weight loss of ≥10% was an important predictor of remission trajectory, which is consistent with previous findings on the link between weight loss and remission [4,17].

Conclusion

Remission of type 2 diabetes at any point during the course of diabetes is common in routine clinical care but patterns of remission including maintenance, vary considerably. People who achieve remission, even for shorter periods of time, continue to benefit from this lower exposure to hyperglycaemia, which may, in turn, lower the risk of CVD outcomes including mortality.

Citation: Dambha-Miller H, Hounkpatin HO, Stuart B, Farmer A, Griffin S (2023) Type 2 diabetes remission trajectories and variation in risk of diabetes complications: A population-based cohort study. PLoS ONE 18(8): e0290791. https://doi.org/10.1371/journal.pone.0290791

Editor: Billy Morara Tsima, University of Botswana School of Medicine, BOTSWANA

Received: February 23, 2023; Accepted: August 16, 2023; Published: August 29, 2023

Copyright: © 2023 Dambha-Miller et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: "We do not have governance permissions to share individual-level data on which these analyses were conducted since they derive from clinical record data. However, direct data requests can be made to the database Electronic Care and Health Information Analytics (CHIA) governance team, who may be contacted by email: info.chie@nhs.net or phone: +44(0)3001231519."

Funding: HDM is an Associate Professor in Primary Care Research and received National Institute for Health Research School of Primary Care Research (NIHR SPCR) funding (SPCR2014-10043) for this project. The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the UK National Institute for Health Research (NIHR) or the Department of Health and Social Care. AF is a NIHR Senior Investigator and receives support from NIHR Oxford BioMedical Research Centre. The University of Cambridge has received salary support in respect of SJG from the NHS in the East of England through the Clinical Academic Reserve. The specific role of this author is articulated in the ‘author contributions’ section. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0290791#abstract0
 

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