By Dr Tumi Moshoeshoe-Mthombeni

For many years, type 2 diabetes was largely approached as an inevitably progressive condition: once diagnosed, the expectation was lifelong treatment, increasing medication and the possibility of complications. For someone who had watched a relative experience dialysis, amputation or premature death, the diagnosis could feel like a death sentence. Remission rarely featured in the conversation.

Today, we can offer a more hopeful, evidence-based message. Type 2 diabetes remission is possible for some people. This November, as we mark Diabetes Awareness Month, we should consider what this means for our clinical practice—and examine whether our own assumptions prevent patients from being offered that possibility.

The science has changed. Our conversations need to change with it.

From lifelong progression to the possibility of remission

The international consensus defines type 2 diabetes remission as an HbA1c below 6.5%, sustained for at least three months without glucose-lowering medication. Remission does not mean cure: hyperglycaemia can recur, and ongoing glycaemic monitoring and screening for complications remain necessary.[1]

Structured lifestyle programmes helped change our understanding of what is achievable. The Diabetes Prevention Programme (DPP) demonstrated that intensive lifestyle support, targeting 7% weight loss and at least 150 minutes of moderate physical activity weekly, reduced progression to type 2 diabetes by 58% over approximately three years. This was a prevention study, rather than a remission trial, but it established the value of specific goals and sustained behavioural support. Its approach remains reflected in the 2026 American Diabetes Association recommendations.[2]

The Diabetes Remission Clinical Trial (DiRECT) subsequently demonstrated remission through a structured weight-management intervention delivered in primary care. Among selected adults with relatively recently diagnosed type 2 diabetes, 36% of the intervention group were in remission at two years. At five years, 13% of the 85 participants assessed in the extension group remained in remission.[3] These findings offer both hope and perspective: remission is achievable, but maintaining it requires continuing support.

A meaningful target, rather than an arbitrary number

“Lose some weight” offers little direction. Equally, prescribing the same kilogram target to every patient overlooks their starting point.

For people with type 2 diabetes and excess adiposity, percentage-based weight-loss goals provide a more individualised framework. Losing 5–10% of initial body weight can improve metabolic health; losses of 10–15% or more offer a greater opportunity for remission.[4] For someone weighing 100 kg, these represent 5–10 kg and 10–15 kg respectively. They are treatment targets to discuss together, not guarantees or tests of commitment.

We must also avoid making remission the only acceptable outcome. Improved glycaemia, better function and reduced treatment burden matter. Continued medication use should never be presented as personal failure.

What does ACLM recommend?

The American College of Lifestyle Medicine’s 2025 clinical practice guideline places lifestyle interventions at the centre of type 2 diabetes care. It addresses all six pillars: a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, social connection and avoidance of risky substances.

Crucially, it recommends assessing current habits and readiness for change, agreeing priorities through shared decision-making, and using SMART goals. Intensive interventions require clinical supervision, including medication review to prevent hypoglycaemia as glucose levels improve.[5]

The practical implication is that lifestyle medicine needs more than a handout. Patients need an achievable plan, appropriate education and someone who will help them adjust that plan when life gets in the way.

Before judging motivation, examine the barriers

How often have we described someone as “non-compliant” without understanding what made the treatment plan difficult to follow?

An elevated HbA1c does not tell us whether someone cares about their health. A missed appointment does not reveal whether they could afford transport. Difficulty changing food choices does not tell us who buys or prepares meals, whether food runs short, or whether the advice made sense in the first place.

The 2024 international consensus on diabetes stigma identifies blame and negative judgements as important drivers of stigma, with consequences for wellbeing, self-care and access to healthcare.[6]

We can begin by noticing our language and questioning our assumptions. Instead of asking, “Why haven’t you followed the diet?”, we might ask, “Which part of the plan has been hardest to fit into your day?”

In South African practice, meeting people where they are means discussing affordable, culturally familiar foods, work schedules, caregiving responsibilities and safe opportunities for movement. It also means asking permission to discuss weight and listening to what the patient wants their health to make possible.

Turn the destination into a manageable next step

Remission may be a long-term aspiration. SMART goals—Specific, Measurable, Achievable, Relevant and Time-bound—help translate that aspiration into daily action.

A collaboratively chosen goal might be:

“For the next two weeks, I will walk for ten minutes after supper on four days each week and record it on my phone.”

Another might be:

“On weekdays for the next fortnight, I will replace my lunchtime sugary drink with water.”

Then explore the hurdles. Is the neighbourhood safe? Would indoor movement be more practical? What happens during a night shift? How confident does the person feel about the goal?

At follow-up, review what worked, acknowledge effort and revise what proved unrealistic. An unmet goal gives us information about the plan; it should not become a judgement about the person.

A different approach to chronic disease care

The opportunity before us extends beyond remission. It is an opportunity to protect self-esteem, build self-efficacy—the belief that “I can do this”—and strengthen the skills needed for everyday self-management.

Our role is to provide clear information, appropriate treatment and consistent encouragement while recognising the circumstances in which people live. We should offer remission as a possibility without turning it into another source of blame.

This Diabetes Awareness Month, let us ask ourselves: Have I given this person a reason for hope, a realistic next step and the support to take it?

References

Riddle MC, et al. Consensus report: Definition and interpretation of remission in type 2 diabetes. Diabetes Care. 2021;44:2438–2444. doi:10.2337/dci21-0034.

American Diabetes Association Professional Practice Committee. Prevention or delay of diabetes and associated comorbidities: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1).

Lean MEJ, et al. Five-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT): An extension study. Lancet Diabetes Endocrinol. 2024;12:233–246. doi:10.1016/S2213-8587(23)00385-6.

Davies MJ, et al. Management of hyperglycaemia in type 2 diabetes, 2022: An ADA/EASD consensus report. Diabetologia. 2022;65:1925–1966. doi:10.1007/s00125-022-05787-2.

Rosenfeld RM, et al. Lifestyle interventions for treatment and remission of type 2 diabetes and prediabetes in adults: An ACLM clinical practice guideline. Am J Lifestyle Med. 2025;19(2 Suppl):10S–131S. doi:10.1177/15598276251325488.

Speight J, et al. Bringing an end to diabetes stigma and discrimination: An international consensus statement on evidence and recommendations. Lancet Diabetes Endocrinol. 2024;12:61–82. doi:10.1016/S2213-8587(23)00347-9.