Remission of metabolic diseases

About the author

Dr. Yvo Sijpkens is an internist at Haaglanden Medical Center in The Hague and medical advisor to Stichting Je Leefstijl Als Medicijn. He specializes in lifestyle medicine and its application in conditions such as diabetes and metabolic dysfunction.

Read more about Yvo Sijpkens →

In brief

• Remission means the disease “sleeps” - not cure, but an active state you help maintain
• For type 2 diabetes: HbA1c below 48 mmol/mol, at least 3 months, without or with significantly reduced medication
• For MASLD: decreased liver fat, normalized liver enzymes, no progression of fibrosis
• Remission occurs through lower insulin, less liver and abdominal fat, and cellular recovery
• TCR is a medical lifestyle treatment, not a temporary diet

What is remission?

For metabolic diseases, we prefer the word “remission” over “cure”.

For type 2 diabetes, we speak of remission when blood glucose values return to the non-diabetic range and stay there for a longer period, without or with significantly reduced medication.

For fatty liver (MASLD), we mean by remission that fat content in the liver has clearly decreased, liver inflammation has calmed and fibrosis is not progressing further.

Important

Remission means the disease “sleeps” so to speak. If lifestyle worsens, the disease can return. Remission is an active state that you help maintain.

What happens with metabolic dysfunction?

Metabolic dysfunction means the body has difficulty properly processing energy (sugars and fats). Usually we see:

• Insulin resistance: cells respond less well to insulin
• Too much fat in the liver and around the abdomen (visceral fat)
• Chronic, low-grade inflammation

Consequences include

• Rising glucose and insulin levels
• Higher chance of type 2 diabetes
• Fatty liver (MASLD)
• High blood pressure and lipid metabolism disorders
• Increased risk of cardiovascular disease

Remission means we reverse this pattern as much as possible.

How can remission occur?

Remission is the result of favorable changes at multiple levels in the body.

Lower insulin

By using fewer fast carbohydrates and limiting eating moments per day, insulin levels drop. Cells become sensitive to insulin again.

Less liver and abdominal fat

Weight loss, especially around the abdomen, reduces liver fat and visceral fat. This improves both glucose and fat metabolism.

Switching to fat burning

With therapeutic carbohydrate restriction (TCR) and sometimes with fasting, the body switches from sugar burning to fat burning. Ketones are then produced: an efficient fuel that can activate cellular repair processes.

Cellular recovery

Lower insulin, less liver fat and active recovery processes lead to:

• Better liver and pancreas function
• Less inflammation
• Better muscle function and maintenance or increase of muscle mass with the right combination of exercise and protein intake

Lifestyle as maintenance

When nutrition, exercise, sleep and stress structurally improve, metabolism can remain in remission long-term. Lifestyle is then a form of targeted treatment and maintenance.

Role of therapeutic carbohydrate restriction (TCR)

TCR is a medical lifestyle treatment, not a temporary diet.

Characteristics of TCR

• Fewer fast and refined carbohydrates (such as sugar, white bread, soft drinks, cookies, snacks)
• More complete proteins (for example fish, eggs, meat, dairy, legumes)
• More healthy fats (such as olive oil, nuts, seeds, fatty fish)
• Plenty of vegetables, preferably low in starch

Effects of TCR

• Lower post-meal glucose spikes
• Drop in insulin levels
• Decrease in liver fat and visceral fat
• Calmer appetite and fewer cravings

In some people, nutritional ketosis occurs (measurable ketones in blood or urine). This can be beneficial for liver fat, weight, glucose values and certain neurological complaints.

Medication

With medication use, medical guidance is always needed.

Remission of type 2 diabetes

Remission of type 2 diabetes is especially promising if:

• Diabetes hasn’t existed long (a few years)
• There is still sufficient own insulin production
• There is willingness to really change nutrition and lifestyle
• Medication is carefully tapered under guidance

Important building blocks

• Clear goals for HbA1c and fasting glucose
• A form of TCR, tailored to person and medication
• Sufficient protein intake and strength training to maintain muscle mass
• Weight loss focused on abdominal fat
• Attention to sleep, stress, smoking and alcohol

Adjusting medication

Medication such as insulin, sulfonylureas, GLP-1 agonists and SGLT2 inhibitors may only be adjusted in consultation with the healthcare provider.

Remission of fatty liver (MASLD)

Typical characteristics of MASLD

• Overweight or abdominal fat
• Insulin resistance or type 2 diabetes
• Elevated liver enzymes (ALAT, ASAT, GGT)
• Sometimes elevated triglycerides and ferritin

Remission of MASLD means

• Clear decrease in liver fat on imaging (ultrasound, FibroScan or MRI)
• Normalization or clear decrease in liver enzymes
• Stabilization or improvement of fibrosis score

Lifestyle interventions for MASLD

• 5 to 10 percent weight loss often gives noticeable liver benefit
• TCR or another energy-restricting strategy, fitting the patient
• Limiting or stopping alcohol
• Sufficient protein and exercise for muscle mass maintenance
• Strongly reducing fast sugars (soft drinks, fruit juices, candy, pastries)

Remission criteria in practice

Type 2 diabetes

Complete remission:

• HbA1c in normal range (below 42 mmol/mol)
• Without blood glucose-lowering medication

Partial remission:

• HbA1c between 42 and 48 mmol/mol
• Clearly lower than at diagnosis
• With significantly reduced medication or only metformin

Criterion	Complete remission	Partial remission
HbA1c	< 42 mmol/mol	42-48 mmol/mol
Medication	None	Significantly reduced or only metformin
Duration	At least 3 months stable	At least 3 months stable

These criteria must be stable for 3 to 6 months and periodically reassessed.

Fatty liver (MASLD)

Practical remission criteria for MASLD:

• Clear decrease or disappearance of liver steatosis on imaging
• Normalization or clear, stable decrease in ALAT and ASAT
• No further progression of fibrosis, but stable or improved FibroScan or NAFLD fibrosis score

Along with:

• Improvement in weight and waist circumference
• Improvement in blood pressure, lipids and glucose
• Stable lifestyle change (nutrition, exercise, alcohol, sleep)

For whom is remission less achievable?

Remission is less likely with:

• Long-standing diabetes with clear insulin deficiency
• Liver cirrhosis
• Severe comorbidity (such as severe heart failure or advanced kidney insufficiency)
• Untreated severe psychiatric problems or addiction

Still useful

Even then, lifestyle improvement is useful: fewer complications may occur, quality of life often improves and medication need may decrease.

Safety and medical guidance

Extra caution is needed with:

• Use of insulin or sulfonylureas (risk of hypoglycemia)
• Use of blood pressure medication (risk of hypotension with rapid weight loss)
• Kidney function disorders
• Polypharmacy (use of multiple medications simultaneously)

Therefore:

• Develop the remission plan together with internist, GP or lifestyle team
• Never adjust medication independently
• Regularly check glucose, HbA1c, liver enzymes, lipids and kidney function

What can you do today?

1. Keep a simple food diary (what, when, how much)
2. Stop soft drinks, fruit juice, candy and chips
3. Choose a protein source and vegetables with every meal
4. Walk at least 30 minutes daily
5. Limit eating moments to 2 or 3 per day
6. Discuss with your doctor whether a remission-focused lifestyle plan suits you

Key message

Remission of type 2 diabetes and fatty liver is achievable in some people, especially if:

• The diagnosis is still relatively recent
• Nutrition, exercise, sleep and stress are seriously addressed
• Medication is carefully coordinated and if possible tapered

Lifestyle is not an extra measure here, but a form of intensive, targeted treatment of your metabolism. Remission is not guaranteed, but is a meaningful and realistic goal to pursue together with your care team.

Veelgestelde vragen

What is remission of type 2 diabetes?

In remission, blood glucose values return to the non-diabetic range (HbA1c below 48 mmol/mol) and stay there for at least 3 months, without or with significantly reduced medication. The disease 'sleeps' so to speak, but can return with worsening lifestyle.

Is diabetes remission the same as cure?

No, we prefer to speak of remission rather than cure. Remission is an active state that you help maintain with lifestyle. If lifestyle worsens, the disease can return. It is not a definitive cure.

For whom is diabetes remission achievable?

Remission is especially promising if diabetes hasn't existed long (a few years), there is still sufficient own insulin production, and there is willingness to really change nutrition and lifestyle. With long-standing diabetes with insulin deficiency, remission is less likely.

What is remission of fatty liver (MASLD)?

In remission of MASLD, fat content in the liver has clearly decreased on imaging, liver enzymes have normalized or clearly decreased, and fibrosis is not progressing further. This is achieved with 5-10% weight loss, TCR and limiting alcohol.

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