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Expert Interview

Has DiRECT And Type 2 Diabetes Remission Gone Mainstream?

I'm Roy Taylor, Professor of Medicine and Metabolism at Newcastle University.

Are you surprised your research has now gone mainstream?

I don't really see it like that. This is something I've been focusing on really since 2006 when the ideas came into focus. But even before that, I was following a line of unpicking just what happens in the body in type 2 diabetes.

I've been at it since 1985 or so. And I worked through the fat compartment and then we started [on] muscle and we were working on the liver in the late 1990s and suddenly [in] 2006 it became clear it was possible to change type 2 diabetes very fast, And that set the clock whirring.

I developed the twin cycle hypothesis and then we set about testing it, resulting in our study that we published in 2011. And that showed, yes, type 2 diabetes can be reversed with a low calorie diet. But more importantly, it showed us exactly what was going on.

The liver fat, astonishingly high in type 2 diabetes, falls to normal. The pancreas fat comes down gradually, gradually, and the pancreas recovers gradually, gradually. And that's amazing because we always thought that the pancreas had to go downhill inevitably in type 2 diabetes.

So rushing on from there, we showed that this was something that [is] dependent on the duration of diabetes: the longer [you] have had it, the less likely it is to completely reverse. And we also showed that it was durable for 6 months of complete weight neutrality after losing weight. All the changes remained rock solid.

So am I surprised that we've been able to translate it into the general population and see this? Not really. But there hasn't been any time for surprise because it's been fairly busy over the last couple of decades.

And type 2 diabetes remission based on DiRECT is now very much in NHS England's plans?

Yes, the speed of this comes as a surprise, because this is something NHS England has actually grasped and taken forward really, very rapidly. And so yes, that's very good. But at the heart of it, I'm a general physician. I've spent most of my life looking after acute medicine, all-comers coming through the doors and all sorts of illnesses and so my work is rooted in practicality. And so what I do has to be relevant. And so it's nice that the relevance has been recognised. But it's all about people. And trying to help people back towards a state of health and happiness. And so that practicality shines through. Hopefully that's reflected in its rapid uptake.

How do you react to the many patient stories of type 2 diabetes remission based on your work?

Well that's always heart-warming, because it's all about the individual and all about helping people back to this state of relative health and happiness. And that does seem to be happening in quite large numbers of people who are able to do it and so yes, that's very nice. But what else are doctors for? I'm very pleased to be involved with this, but it's what we do.

The DiRECT 2-year results presented today were good. Where do you go next?

There are two lines. We need to follow up this group. We follow them up for a total of 2 years in the proper randomised controlled trial. We have funding to follow up the intervention group participants for a total of 3 years. And we've applied for further funding because we need to see what happens to these people as time goes on.

Separately, we need to see what happens to people who have type 2 diabetes but have actually got a normal BMI, or near normal BMI. And so we're running a study called ReTUNE, also funded by Diabetes UK, really to try and determine [what happens with] type 2 diabetes in people of normal weight - is that behaviour really the same? And particularly, we want to chase a concept that I introduced part of this way along the journey: the personal fat threshold.

Some people can run along perfectly happy with a BMI of 35, metabolically normal. Put it up to 37, 38, they get diabetes; bring it down to 35 [again, and] they're fine.

If I put my BMI up to the dizzy heights of say, 22, I might be at risk of diabetes, because I'm not built to be at 22. So we've got to realise we're individuals. Now that's a crashingly simple thing to say. And it's woeful, that I have to point it out. But a lot of the guideline-based medicine, evidence-based medicine, is all about imagining that the population consists of uniform people who are all sitting on the average line, and it's not like that. So in the new research, ReTUNE, we're going in search of the personal fat threshold and I hope that will be illuminating.