Substantial Weight Loss in Type 2 Diabetes May Control Hypertension

Sarah Edmonds

June 01, 2021

Substantial weight loss in people with type 2 diabetes aimed at managing the condition may also help control hypertension, according to new research from a wider clinical trial into the possibility of using diet to achieve remission of diabetes.

The study is based on data from the DIabetes REmission Clinical Trial (DiRECT), an ongoing investigation into whether an intensive weight loss and maintenance programme can halt progression of a condition expected to affect half a billion people worldwide by 2030.

Mike Lean, professor of human nutrition at the University of Glasgow School of Medicine and one of DiRECT’s principal researchers, said the blood pressure findings add to a growing body of evidence suggesting weight control should be a central pillar of diabetes treatment.

"Just over half of all people with type 2 diabetes also have high blood pressure. And that's an expensive disease to treat in its own right," he told Medscape News UK in an interview. "It produces strokes and bad outcomes. And it gets better with weight loss—it gets dramatically better."

Heart Benefits

The hypertension study, published in the May 31 edition of Diabetologia, the journal of the European Association for the Study of Diabetes, focused on 143 people with type 2 diabetes in the DiRECT weight management programme.

In the first 3 months of the diet programme, participants are restricted to a complete formula diet of low-calorie soups and shakes. They then receive support and diet advice targeted at helping them maintain the weight loss.

Of this group, 78 (55%) were taking drugs to control hypertension. At the start of the weight loss programme, 83% of this group stopped all blood pressure medication, while 5% stopped taking some.

The study found that mean blood pressure declined as participants lost weight and stayed at lower levels even after the period of total diet replacement ended.

For those who had not been diagnosed with hypertension, blood pressure fell sharply from the very start of the programme. In those who stopped taking antihypertension drugs at the outset of the weight loss programme, blood pressure did not begin to fall markedly until after the ninth week, and the decline was slower in patients who gave up two or more drugs.

Longevity

Prof Lean said the diabetes research community has long been aware of the beneficial effect of weight loss on type 2 diabetes—specifically, the loss of the last 15 kilograms gained, which he said appears to accumulate to toxic effect in the organs.

"We wrote a paper about the long-term survival of people who had type 2 diabetes who lost 15 kilos in weight in about 1990, where we show that they live just as long as people who never had diabetes," he said.

According to previously released data from DiRECT, 80% of patients who lost—and kept off—15kg achieved a complete remission of their diabetes for at least 2 years, without medication.

The hypertension study is the result of the team’s desire to delve into the impact of weight loss on other conditions linked to type 2 diabetes, including kidney disease, fatty liver, high cholesterol, and high blood pressure.

"So my thinking said, look, if the diabetes gets better, and really the whole disease process that we can see recovers with really quite big weight loss—15 kilos—what about the other things?" he said.

Metabolic Syndrome

The hypertension findings and yet-to-be-released research from DiRECT on the effect of weight loss on fatty liver both support the view that diet can help address a range of associated conditions, he told Medscape News UK.

"We now know that the whole disease process that is categorised as this rather vague metabolic syndrome is all tied up with fat being put into vital organs where it shouldn't be. And it's reversible. As long as you don’t leave it too long, it can be reversed."

Prof Lean said the 10-year survival rate for type 2 diabetes—50%—was lower than those for either breast cancer (75.9%, according to Cancer Research UK) or non-Hodgkin’s lymphoma (55%).

"So I think we need to treat type 2 diabetes much more seriously," he said.

"If we had chemotherapy (for diabetes), we would administer a very expensive chemotherapy to everybody. They would take it, their hair would fall out. They would have diarrhoea and vomiting for months, but they would get a remission of their diabetes.

"But we don't have chemotherapy, we have diet instead, which does the same job. We have to treat weight loss for type 2 diabetes as seriously as chemotherapy for a cancer."

Previous studies have shown that weight loss can reduce the need for antihypertensive drugs, but this is the first that involved the withdrawal of medication at the start of a trial. The DiRECT team opted to discontinue or reduce blood pressure treatment for safety reasons, since rapid weight loss can cause low blood pressure.

Some 28% of participants had to resume blood pressure treatments during the liquid diet period of the trial. However, another 28% made such lasting progress that they had still not resumed blood pressure treatments after 2 years.

"The overall effect on BP observed from weight loss in DiRECT was substantial, incorporating both the observed mean fall in BP and the reduced numbers of drugs being prescribed to fewer people, probably of a similar order to that achieved by many of the commonly prescribed antihypertensive," the authors wrote.

'Important Results'

Commenting, Dr Elizabeth Robertson, director of research at Diabetes UK, called the results "important".

She added: "We’re delighted to see more evidence of the life-changing impact of the DiRECT programme on people’s health. This makes us even more determined to make sure as many people as possible have access to type 2 diabetes remission services."

DiRECT is funded by Diabetes UK as a Strategic Research Initiative (award number 13/0004691), with support in kind (formula diet sachets) provided by Cambridge Weight Plan.

Leslie, W.S., Ali, E., Harris, L. et al. Antihypertensive medication needs and blood pressure control with weight loss in the Diabetes Remission Clinical Trial (DiRECT). Diabetologia (2021). https://doi.org/10.1007/s00125-021-05471-x

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