This qualitative research sought to identify factors influencing patient choice of, and patient-related internal and external enablers and barriers to engagement with, type 2 diabetes (T2D) remission strategies offered by the Remission in diabetes (REMI.D) project. Patients had a choice of three diets: Total Diet Replacement (TDR)-Formula Food Products, TDR-Food, and Healthy lifestyle approach; and three activity pathways: Everyday life, General Practitioner referral, and Social hub. Semi-structured interviews were recorded and transcribed. Thematic analysis used the Framework Method and NVivo 12 to assist with generation and organisation of codes, inductive and deductive (Theoretical Domains Framework). The REMI.D project was a place-based approach (place in this case being defined as two local authorities with significant rates of deprivation) situated in the North East of England. Twenty patients out of a possible 65 patients took part. Areas of interest included: patient choice, patient intention, patient adherence, patient non-adherence, and patient stigma. Addition of a more moderate dietary strategy (not dissimilar to the diet in the Healthier You NHS Diabetes Prevention Programme) to the existing NHS England T2D Path to Remission programme may enable more patients to achieve remission or delayed progression with deprescribing of diabetes medications. Embedding a tailored physical activity path within or as a bolt-on to the NHS programme requires consideration. Limited resources should be targeted towards patients who identify with more barriers or fewer opportunities for health behaviour modification. Further research on use of virtual programmes in deprived areas is warranted.

The UK Diabetes Remission Clinical Trial (DiRECT) demonstrated that a weight loss strategy consisting of: (1) 12 weeks total diet replacement; (2) 4 to 6 weeks food reintroduction; and (3) a longer period of weight loss maintenance, is effective in reducing body weight, improving glycaemic control, and facilitating type 2 diabetes remission(1). The DiRECT protocol is now funded for type 2 diabetes management in the UK(2). Type 2 diabetes is a growing problem in Aotearoa New Zealand(3), but the acceptability and feasibility of the DiRECT intervention in our diverse sociocultural context remains unclear. We conducted a randomised controlled trial of DiRECT within a Māori primary healthcare provider in O¯tepoti Dunedin. Forty participants with diabetes and obesity who wanted to lose weight were randomised to receive the DiRECT intervention or usual care. Both groups received the same level of individualised support from an in-house dietitian. We conducted individual, semi-structured interviews with 26 participants after 3 months. Questions explored perspectives and experiences, barriers and facilitators, and future expectations regarding dietary habits and weight loss. Interview transcripts were analysed using inductive thematic analysis(4). Participants struggled with weight management prior to the study. Advice from doctors, friends and whānau, and the internet was prolific, yet often impractical or unclear. The DiRECT intervention was mentally and physically challenging, but rapid weight loss and an improved sense of health and wellbeing enhanced motivation. Participants identified strategies which supported adaptation and adherence. Food reintroduction beyond 3 months was an exciting milestone, but the risk of reverting to previous habits was daunting. Participants feared weight regain and felt ongoing guidance was required for a successful transition to a real-food diet. Conversely, usual care participants described a gradual and ongoing process of health-focused dietary modification. While this approach did support behaviour change, a perceived slow rate of weight loss was often frustrating. Across both interventions, self-motivation and whānau support contributed to perceived success, whereas busy lifestyles, social and cultural norms, and financial concerns presented additional challenges. The role of individualised and non-judgemental dietetic support was a central theme across both groups. In addition to nutrition education and practical guidance, the in-house dietitian offered encouragement and promoted self-acceptance among participants. At 3 months, positive shifts in perspectives surrounding food, health, and sense of self were identified, which participants largely attributed to the level of nutrition support received: a new experience for many. The DiRECT protocol appears an acceptable weight loss approach among New Zealanders with diabetes and obesity, but tailored dietetic and behavioural support must be prioritised in its implementation. Future research should examine the broader health benefits associated with providing greater dietetic support and the cost-effectiveness of employing nutrition-trained health professionals within the primary care workforce.

There are two proven dietary approaches to shift type 2 diabetes (T2D) into remission: low-energy diets (LEDs) and low-carbohydrate diets (LCDs). These approaches differ in their rationale and application yet both involve carbohydrate restriction, either as an explicit goal or as a consequence of reducing overall energy intake. The aims of this systematic review were to identify, characterise and compare existing clinical trials that utilised ‘low-carbohydrate’ interventions with differing energy intakes. Electronic databases CENTRAL, CINAHL, Embase, MEDLINE and Scopus were searched to identify controlled clinical trials in adults with T2D involving low-carbohydrate intake (defined as <130 g carbohydrate/d) and reporting weight and glycaemic outcomes. The initial database search yielded 809 results, of which fifteen studies met the inclusion criteria. Nine out of fifteen studies utilised LCDs with moderate or unrestricted energy intake. Six trials utilised LEDs (<1200 kcal/d), with all except one incorporating meal replacements as part of a commercial weight loss programme. Interventions using both restricted and unrestricted (ad libitum) energy intakes produced clinically significant weight loss and reduction in glycated haemoglobin (HbA1c) at study endpoints. Trials that restricted energy intake were not superior to those that allowed ad libitum low-carbohydrate feeding at 12 and 24 months. An association was observed across studies between average weight loss and reduction in HbA1c at 6, 12 and 24 months, indicating that sustained weight loss is key to T2D remission. Further research is needed to specifically ascertain the weight-independent effects of carbohydrate restriction on glycaemic control in T2D.