FREE booklet: The GLP-1 Story by Dr. Sayantan Banerjee. Get your copy →

Can Type 2 Diabetes Go Into Remission After 10 Years, or If You're on Insulin?

Remission gets harder with time, but it isn't always out of reach. Dr. Sayantan Banerjee explains beta-cell reserve, C-peptide tests and realistic goals for long-standing diabetes.

TYPE 2 DIABETES REMISSION

Dr. Sayantan Banerjee

10/31/20268 min read

Most of what you read about type 2 diabetes remission comes from studies of people diagnosed recently. The DiRECT trial, the one most often quoted, only included people diagnosed within the previous six years, and nobody on insulin. So if you have had diabetes for 10, 15 or 20 years, or you already inject insulin, it is natural to wonder whether any of this applies to you.

The honest answer is that remission becomes less likely the longer you have had diabetes, and it is less common in people on insulin. But it isn't impossible, and even when full remission doesn't happen, the same steps can bring large improvements. This article explains why time matters, how to get a realistic picture of your own chances, and what goals make sense.

Why time matters: the beta cells

Type 2 diabetes has two main parts. The first is insulin resistance, where the liver and muscles respond poorly to insulin, often because of excess fat in the liver. The second is beta-cell dysfunction, where the insulin-producing cells in the pancreas don't make enough insulin, or don't release it quickly enough after meals.

Insulin resistance responds well to weight loss, often within weeks. Beta-cell function is the harder part. Early in diabetes, many beta cells seem to be stunned rather than lost. They are under strain from high glucose and excess fat, and they can recover when that strain is removed. Over many years, though, some beta cells appear to stop working permanently or to change into other cell types.

The longer you have had diabetes, the more likely it is that a larger share of your beta cells can no longer recover. That is the main reason remission becomes less common with time. It also explains why people who need insulin, whose bodies are producing less of their own, have lower remission rates on average.

What the studies show

The Newcastle group behind DiRECT tested this question directly in a small study published in Diabetes Care in 2016. They put people with short-duration and long-duration type 2 diabetes on the same very low calorie diet for eight weeks. Both groups lost similar amounts of weight. Most of those with shorter-duration diabetes returned to normal fasting glucose. Among those who had had diabetes for more than eight years, about half did.

So time made a big difference, but it didn't make remission impossible. Half of the long-duration group responded well.

The 2023 Chinese trial of an intermittent calorie-restricted diet included people who had had diabetes for up to 11 years, some of whom used insulin. Remission rates in that trial were high, around 47% at six months, though it was a small study.

After bariatric surgery, duration of diabetes and insulin use are two of the strongest predictors of whether remission happens and how long it lasts. People on insulin with long-standing diabetes have lower remission rates after surgery, but many still see large falls in HbA1c and medication.

Getting a realistic picture: C-peptide

If you have had diabetes for a long time, a useful test to ask about is C-peptide.

When your pancreas makes insulin, it releases an equal amount of a small protein called C-peptide. Insulin injections don't contain C-peptide, so measuring it in your blood shows how much insulin your own body is still making, even if you inject insulin.

A reasonable level of C-peptide suggests you still have meaningful beta-cell function, and improvement through weight loss is more likely. A very low level suggests your body is making little insulin of its own, and remission is unlikely, although lowering insulin resistance can still reduce the amount of insulin you need.

C-peptide is often measured alongside glucose, because the two need to be interpreted together. Your doctor or diabetes specialist can explain your result.

Make sure the diagnosis is right

This is easy to overlook. Some people diagnosed with type 2 diabetes actually have a slow-onset form of autoimmune diabetes, often called latent autoimmune diabetes in adults, or LADA. It behaves like type 2 at first, but the immune system is gradually destroying the beta cells, as in type 1.

LADA is more likely if you were diagnosed as an adult but weren't overweight, if you needed insulin within a few years of diagnosis, if tablets stopped working quickly, or if you or close family have other autoimmune conditions such as thyroid disease. A blood test for antibodies, such as GAD antibodies, can help confirm it.

This matters because remission through weight loss isn't expected in autoimmune diabetes, and very low calorie diets can be risky if your body makes little insulin. If anything in that list sounds familiar, ask your doctor whether testing is appropriate.

Rarely, other forms of diabetes, such as monogenic diabetes or diabetes caused by pancreatic disease, are mistaken for type 2. These also need different treatment.

What to aim for if you've had diabetes for years

I find it helpful to think of the goal as a ladder, rather than a single target.

Lower HbA1c. Every 1% fall (about 11 mmol/mol) lowers the risk of eye, kidney and nerve complications.
Fewer or lower-dose medicines. Many people can reduce or stop some tablets as their weight and liver fat fall.
Less insulin. People on insulin often need much less as insulin resistance improves. Some can stop it, especially if their C-peptide is reasonable.
Good control without insulin. Moving from insulin to tablets or a GLP-1 medicine is a big step for quality of life.
Remission. HbA1c below 6.5% (48 mmol/mol) for at least three months off all glucose-lowering medicines.

Each rung is a real gain. Not reaching the top doesn't make the lower rungs less valuable.

If you take insulin: safety comes first

If you inject insulin, changing your diet substantially without a plan can cause dangerous hypoglycaemia. Insulin doses often need to fall quickly once you eat less, sometimes within the first days. Please work closely with your diabetes team.

Useful steps:

Ask your team for a written plan for reducing insulin as you change your diet.
Check your glucose more often, especially before meals, before bed, and before driving.
Ask about a continuous glucose monitor, which can make it much safer to reduce insulin. Eligibility rules vary in the NHS and between US insurers.
Always carry fast-acting glucose.
Tell your team about any hypos, even mild ones.

Many people on insulin find that as they lose weight their doses fall steadily. Some can switch to non-insulin treatments, including GLP-1 medicines, which also help with weight.

Approaches that suit long-standing diabetes

The same principles apply as for anyone seeking remission. Sustained weight loss and lower liver fat are the core. But a few approaches deserve particular mention.

Supervised total diet replacement. The NHS Path to Remission programme generally requires a diagnosis within the last six years and excludes insulin users, but some specialist services and private programmes offer supervised low-calorie diets to people with longer-duration diabetes. In the US, medically supervised programmes may accept people on insulin.

GLP-1 and dual GLP-1/GIP medicines. Semaglutide and tirzepatide lower glucose and help with weight loss, and may allow insulin doses to be cut or stopped. While you take them, a normal HbA1c counts as good control rather than remission.

Bariatric surgery. For people with a high BMI, surgery offers the largest and longest-lasting improvements, even in long-standing diabetes. NICE and US guidelines both include it as an option for people with type 2 diabetes and obesity.

Lower-carbohydrate eating. Many people with long-standing diabetes find that reducing carbohydrates lowers glucose quickly and reduces medication needs. This must be done with your team if you take insulin or sulfonylureas.

Exercise, especially strength training. Building muscle gives glucose more places to go and helps whatever beta-cell function you have go further.

Stories you may hear

You may come across accounts online of people who reached remission after 20 or 30 years of diabetes. Some of these are real. They tend to involve large, sustained weight loss, and often people who still had reasonable beta-cell function. They are encouraging, but they aren't typical. Use them as motivation, not as a measure of whether you have succeeded.

When remission isn't the right goal

For some people, especially older adults, people with frailty, or those with other serious illnesses, aggressive weight loss isn't appropriate. In these cases, the focus may be on avoiding hypos, keeping glucose in a safe range, and maintaining strength and independence. Your doctor can help you decide what goals make sense for your situation.

A 12-week starting plan for long-standing diabetes

This is a general outline. Agree every step with your diabetes team, especially if you take insulin or a sulfonylurea.

Weeks 1 to 2: get the facts. Ask for your latest HbA1c, kidney function, liver tests and, if appropriate, a C-peptide test and antibody test. Write down every medicine and dose. Agree a plan for reducing medicines if your glucose falls.

Weeks 3 to 4: change the easiest things first. Cut out sugary drinks and juice. Build each meal around vegetables and protein. Start a 10-minute walk after your largest meal. Check your glucose more often, as agreed with your team.

Weeks 5 to 8: step up. Choose your main weight-loss approach, whether a structured low-calorie diet, lower-carb eating or a supervised fasting pattern. Add two short strength sessions a week. Expect your team to reduce some medicines during this time if your readings fall.

Weeks 9 to 12: review. Weigh yourself weekly and measure your waist. Book an HbA1c test at around 12 weeks. Review your progress with your doctor and decide on the next phase.

By the end of 12 weeks, many people with long-standing diabetes have lower glucose readings, fewer or lower-dose medicines, and a clearer idea of what is possible for them. That is a strong position from which to plan the next step, whether it is aiming for remission or holding on to the improvement you have made.

How my book can help

The Type II Diabetes Remission Strategy explains insulin resistance, liver fat and beta-cell fatigue in plain language, so you can understand your own situation better. Its 16-week programme is designed to be followed alongside your medical care, and its tracker journal helps you record readings and changes to discuss with your doctor, whether your goal is remission or simply fewer medicines. See the book page.

Frequently asked questions

Can type 2 diabetes be reversed after 10 years? Remission is less likely after many years, but some people still achieve it, mainly with substantial weight loss. Large improvements in HbA1c and medication are common.

Can you reverse diabetes if you're on insulin? Remission is less common, but many people on insulin can reduce or stop it as weight and liver fat fall. Always do this with your diabetes team.

What is a C-peptide test? A blood test that shows how much insulin your own pancreas is making.

Should I get tested for LADA? Ask your doctor if you were diagnosed without being overweight, needed insulin early, or have other autoimmune conditions.

Is it worth trying if remission is unlikely? Yes. Lower HbA1c and fewer medicines reduce complications and improve quality of life.

Can GLP-1 medicines help with long-standing diabetes? Often yes. They lower glucose and weight, and may reduce insulin needs.

Does age affect my chances? Remission is somewhat less common in older people, partly because they have often had diabetes for longer. Health gains from weight loss and activity still apply at any age, but goals should take frailty and other conditions into account.

What HbA1c should I aim for if remission isn't realistic? Your doctor will set a personal target. For many adults it is around 7% (53 mmol/mol), with higher targets for some older or frail people to avoid hypos.

Will losing weight help my insulin injections work better? Usually yes. As insulin resistance falls, the same dose has a stronger effect, which is why doses often need reducing.