Diabetes remission

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 ‘ C10P1”
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.

This service is part of the Scottish Government’s “A Healthier future: Type 2 Diabetes prevention, early detection and intervention framework.”

Primary care in Borders does not support Counterweight Plus. If individual GPs wish to refer then the service is available via the Weight Management Service.

If individual GPs wish to refer then the service may be available via the Weight Management Service, possibly via outsourced digital platform.

Who to refer, who not to refer, how to refer

Patients who wish to try to achieve remission of diabetes can be referred to the two-year intensive weight loss programme ‘Counterweight Plus’ programme. Please note that this is not currently supported by Primary Care in NHS Borders.

Who can refer:

General Practitioners

Secondary care (only with explicit agreement from patient’s GP that they are happy to support)

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 (see “Resources” below)

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 to the Borders General Hospital > Weight Management Team

Please specify on referral for consideration of Diabetes Remission programme

Primary care management

Please provide the Counterweight Plus Information Leaflet to patients prior to referral to ensure patients interest in the programme (see “Resources” below)
In order to start the Total Dietary Replacement phase, the patient will need to be medically signed off by their GP to stop all hypoglycaemic medication and anti-hypertensive medication (with a few exceptions). The risk of hypotension and low blood glucose levels increases on a low calorie diet. Counterweight have developed a medical mangagement protocol which helps to advise GPs re: omitting and re-introducing these medications as appropriate. These protocols will be shared with the patient's GP as part of the summary letter following the initial assessment
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
For patients who are eligible for Control-IT, please refer to this service at the same time CONTROL IT REFERRAL.doc

Resources and links

Counterweight Plus information leaflet Counterweight Plus A5 Roll Fold Leaflet 1220 DIGITAL.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
Diabetes UK Type 2 Diabetes: https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2

Borders Weight Management Team: nhsborders.scot.nhs.uk/patients-and-visitors/our-services/general-services/borders-adult-weight-management-team/

Local service details

Borders Weight Management Team,

Room 2DK30b

Borders General Hospital

MELROSE

TD6 9BS

Telephone Number: 01896 827236 or
Email: BordersWeight.ManagementTeam@borders.scot.nhs.uk