The NHS Type 2 Diabetes Path to Remission Programme, formerly known as the NHS Low Calorie Diet Programme, is designed for people with type 2 diabetes within 6 years of diagnosis. It aims to support highly clinically significant weight loss and the potential attainment of diabetes remission (meaning glycaemic levels below the threshold for diabetes, maintained without glucose-lowering medication). It is commissioned centrally by NHS England and is currently available in 21  Integrated Care Boards (ICBs), with a further nine ICBs due to go live in September 2023 and full nationwide coverage expected by 1st April 2024.

      The programme features an initial 12-week period of low-calorie, total diet replacement (TDR). During this time, participants replace all food with a micronutrient-complete, specially formulated diet, usually in the form of shakes, soups or bars, comprising a total daily energy intake of 800–900 kcal. Then follows a 6-week period of food reintroduction, with the remainder of the 12-month programme focusing on support with weight maintenance through lifestyle and behaviour change. If 2 kg or more of weight is regained after the initial TDR phase, the participant is offered a further 4 weeks of TDR.

      This approach is largely based on two underpinning randomised controlled trials, the Diabetes Remission Clinical Trial (DiRECT) and Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET). The former was the landmark trial of using TDR to drive weight loss (typically 10–15 kg) and attain remission of type 2 diabetes, which was achieved in almost half of the intervention group (Lean et al, 2018), while the latter showed that similar weight loss outcomes could be attained using commercial providers to deliver the intervention rather than NHS healthcare professionals (Astbury et al, 2018)

Eligibility criteria

Aligned to these trials, there are a number of eligibility criteria for the Path to Remission programme. These include:

● Duration of diagnosis of type 2 diabetes of less than 6 years.

● Age 18–65 years.

● BMI of 27 kg/m2 or greater in people from white ethnic groups (adjusted to 25 kg/m2 or greater in people from Black, Asian and other ethnic groups).

● Not being treated with insulin.

● Most recent HbA1c result (within the last 12  months) of 43–87 mmol/mol if taking glucose-lowering drugs, or 48–87 mmol/mol if not taking glucose-lowering drugs.

● There are a number of other criteria for safety; a full list is detailed on the referral form.

Delivery of the programme

      Under the most recent programme iteration, which went live in the first wave of ICBs in June 2023 and is being rolled out nationwide this financial year, people referred are given a choice of one-to-one delivery, either in person or digitally, with built-in facilitation of peer support. The entire programme, including all TDR, is free of charge to participants.

      Referrals come from General Practice, with the programme being delivered by commercial providers. For safety, discussion of medication adjustments to take place on starting the programme is an important part of the referral process, as some glucose-lowering medications (e.g. sulfonylureas and SGLT2 inhibitors) and blood pressure-lowering medications may pose safety risks alongside TDR.

      The providers are responsible for arranging monitoring of weight, fingerprick blood glucose levels and blood pressure (if indicated) in participants. Measurements are processed by the provider, with defined thresholds for escalation to General Practice if necessary. For non-urgent clinical matters or queries related to the programme, each provider is required to have a Medical Director for advice and support, limiting the burden on General Practice.

Outcomes to date

      Early outcomes from the programme were announced at the Diabetes UK Conference in April 2023. From September 2020, when the programme pilots first launched, to December 2022, there were 7554 eligible referrals to the programme. Contrary to some preconceptions about TDR acceptability, uptake from referral to starting the programme was strong, at 68%, and of those programme starters, 90% remained on the programme for the full duration of TDR and 55% stayed on until its end at 12 months.

      The mean weight loss for participants at programme end was 10.9 kg, or 9.8% of baseline body weight. Analyses of remission rates, using data extracted through the National Diabetes Audit, are eagerly awaited and will follow; however, the weight loss reported for those completing the programme is comparable to the intervention groups in the trials on which the programme is based. This is encouraging for the potential of the programme, delivered at scale and across the nation, to support remission of type 2 diabetes.

References

1. Astbury NM, Aveyard P, Nickless A et al (2018) Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET): Pragmatic randomised controlled trial. BMJ 362: k3760

2. Lean ME, Leslie WS, Barnes AC et al (2018) Primary care-led weight management for remission of type 2 diabetes (DiRECT): An openlabel, cluster-randomised trial. Lancet 391: 541–51

This article is excerpted from the Diabetes & Primary Care Vol 25 No 4 2023 by Wound World.