Diabetes Remission

Information

Definition:

The international criteria for remission of type 2 diabetes agreed in 2021 states:

“A person is in remission of T2DM if they have an HbA1c <48mmol/L for at least 3 months AND they have not taken any medications to control their blood glucose levels during this time”.

Coding:

Code as ‘diabetes in remission ‘ C10p.
Retain original T2DM code C109-2 as people in remission of diabetes should continue to be monitored at the same rate – this includes foot and retinopathy screening recall systems. Useful 9 processes of care infographic to follow.
Do not use the code ‘diabetes resolved’. It is reserved only for cases of misdiagnosis or diabetes due to a secondary factor that has since been removed, such as acute steroid use. These patients no longer require annual review for diabetes.

Referral to Type 2 Remission through Counterweight Plus:

This is a 2 year intensive weight loss programme, offering a structured evidence-based approach delivered by a Registered Dietitian specialising in this programme.

It incorporates three phases; total diet replacement (800kcal/day) for approximately 12 weeks, a stepped food reintroduction phase and then a weight loss maintenance phase.

Delivery will be virtual via groups or 1:1 input.

This service is part of the Scottish Government’s “A Healthier future: Type 2 Diabetes prevention, early detection and intervention framework.” The intervention and the protocol used in NHS Lothian is the same one as the DiRECT study.

M.A/D.R.M & L.E 07-08-24

Patients who wish to try to achieve remission of diabetes can be referred to the two-year intensive weight loss programme ‘Counterweight Plus’ programme Type 2 Diabetes Remission through Counterweight Plus – Adult Weight Management and Type 2 Diabetes Prevention Service (nhslothian.scot)

Who can refer:

General Practitioners

Secondary care

Self referral

Who to refer:

Patients can be referred if they meet the following criteria:

Adults aged 18-65 years
T2DM diagnosis in past 0-6 years
HbA1c ≥48mmol/mol at last check within 12 months, if on diet alone or
HbA1c ≥43mmol/mol if on treatment with oral hypoglycaemic agents
Ethnic Minorities: Body Mass Index (BMI) of 25 or above
White Caucasian: Body Mass Index (BMI) of 27 or above

Additional Considerations:

We do not recommend this programme for people who have a history of an eating disorder due to a risk of re-triggering disordered eating, however we will consider these individually on a case by case basis
Disordered eating and Eating disorders are often missed and undiagnosed in this patient cohort. If this is picked up at assessment, patients may need further support or may be advised against this intervention
Please provide the Counterweight Plus Information Leaflet to patients prior to referral Counterweight Plus Information Leaflet.pdf .

Who not to refer:

Unfortunately we cannot accept patients that:

Are currently prescribed insulin to treat their Type 2 Diabetes
Have an eGFR <30 mls/min/1.732 ie CKD >stage 3
Have Severe or unstable Heart Failure defined as equivalent to the New York Heart Association (NYHA) classifications, grade 3. (https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure)
Have suffered from a Myocardial infarction within previous 6 months
Are pregnant, breastfeeding or actively trying to conceive
Have a current or suspected eating disorder and/or active purging
Are actively misusing or dependent on alcohol or other substances

How to refer:

Please refer patients via Sci-gateway – AHP Dietician > weight management > T2DM Remission

Please provide the Counterweight Plus Information Leaflet to patients prior to referral to ensure patients interest in the programme Counterweight Plus Information Leaflet.pdf
Please ensure first line dietary and lifestyle advice has been provided to the patient prior to referral.
Those who do not think this programme would be realistic for them can be referred to our routine weight management service Weight Management Service Adult – RefHelp (nhslothian.scot)
For patients who are eligible for DESMOND, please refer to this service at the same time. DESMOND – RefHelp (nhslothian.scot)

Counterweight Plus information leaflet: https://services.nhslothian.scot/awmt2d/wp-content/uploads/sites/24/2022/02/GMwC_Leaflet.pdf

Diabetes UK information prescriptions: https://www.diabetes.org.uk/professionals/resources/resources-to-improve-your-clinical-practice/information-prescriptions-qa

Diabetes UK Diabetes and Driving https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/driving

Diabetes and `Driving GOCVUK https://www.gov.uk/diabetes-driving

Lothian Wellbeing Lifestyle Change Resources: https://services.nhslothian.scot/wellbeinglothian/manage-your-weight/

Diabetes UK Type 2 Diabetes: https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2