Literature Collection

Type 2 diabetes mellitus (T2DM) is a global health priority, with an estimated 629 million people projected to be affected by the year 2045. T2DM significantly increases the risk of atherosclerotic cardiovascular disease and other complications. Hyperglycaemia imprints early molecular and cellular changes, often termed "metabolic memory", predisposing individuals to long-term microvascular and macrovascular complications, even after glycaemic normalisation. T2DM remission is increasingly recognised as an achievable target, offering substantial benefits such as reduced morbidity, improved quality of life, and preservation of beta-cell function. Among therapeutic options, metabolic surgery (MS) demonstrates the most significant impact, particularly for long-term outcomes. MS induces profound hormonal changes, including increased glucagon-like peptide 1 (GLP-1) levels and improved bile acid metabolism, alongside reductions in ectopic fat in the liver and pancreas, which improve insulin sensitivity and secretion. However, intensive lifestyle and pharmacological interventions, such as GLP-1 receptor agonists and glucose-dependent insulinotropic polypeptide/glucagon-like peptide 1 dual agonists like tirzepatide, also show promise, particularly when implemented early in the disease course. Predictors of sustained remission include younger age, shorter diabetes duration, lower baseline HbA1c, absence of insulin use, fewer medications and greater total weight loss percentage. Emerging tools such as the DiaRem score, machine learning models, and biomarkers like FGF-21 enhance patient stratification and predict remission likelihood. This narrative review explores the mechanisms and therapeutic options for T2DM remission, evaluates their impact on long-term outcomes and highlights the importance of early, multidisciplinary, and personalised interventions to optimize remission and improve metabolic health.

SUMMARY: Type 2 diabetes (T2D) is a chronic metabolic disorder that affects millions of people worldwide, particularly the elderly population. Remission of T2D in elderly patients through lifestyle modifications has been well documented, especially in newly diagnosed patients with good glycemic control and without obesity. It is also common in patients with obesity undergoing bariatric surgery. In this report, we present the case of a 66-year-old male patient with a 30-year history of T2D and mild obesity who achieved remission of T2D through customized integrated intensive lifestyle modifications, including a vegan diet, exercise and psychological support. The patient showed an improvement in HbA1c (7.7 to 5.3%) and insulin resistance (HOMA-IR; 6.2 to 1.8) and a shift in BMI (25.3 to 23.7 kg/m2) through weight loss (73 to 67 kg). The patient remains in remission 33 months after the completion of the intervention. This case suggests the possibility of long-term remission with lifestyle changes in patients with advanced age, a longer duration of diabetes and mild obesity. LEARNING POINTS: Long-term sustained remission is possible in a geriatric patient with long-standing type 2 diabetes (T2D) of more than 30 years. Customized integrated intensive lifestyle intervention can lead to a significant improvement in glycemic control and insulin resistance in elderly patients with T2D. Integrated lifestyle interventions, including a vegan diet, exercise and psychological support, have the potential to stop the usage of oral hypoglycemic agents and insulin in an elderly patient with a prolonged history of T2D and mild obesity.