Understanding the mechanisms of reversal of type 2 diabetes
Open accessAbstract
Clinical and pathophysiological studies have shown type 2 diabetes to be a condition mainly caused by excess, yet reversible, fat accumulation in the liver and pancreas. Within the liver, excess fat worsens hepatic responsiveness to insulin, leading to increased glucose production. Within the pancreas, the β cell seems to enter a survival mode and fails to function because of the fat-induced metabolic stress. Removal of excess fat from these organs via substantial weight loss can normalise hepatic insulin responsiveness and, in the early years post-diagnosis, is associated with β-cell recovery of acute insulin secretion in many individuals, possibly by redifferentiation. Collectively, these changes can normalise blood glucose levels. Importantly, the primary care-based Diabetes Remission Clinical Trial (DiRECT) showed that 46% of people with type 2 diabetes could achieve remission at 12 months, and 36% at 24 months, mediated by weight loss. This major change in our understanding of the underlying mechanisms of disease permits a reassessment of advice for people with type 2 diabetes.
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Additional evidence confirms that obesity is a contributing factor for type 2 diabetes, hypertension, and thrombotic episodes, as well as conditions linked to inflammation such as heart failure with preserved ejection fraction.
“Additional evi dence confirms that obesity is a contributing factor for type 2 diabetes, hypertension, and thrombotic ep isodes, as well as conditions linked to inflammation such as heart failure with preserved ejection frac tion. 2-7”
From Comprehensive Long-Term Changes in Cardiovascular Risk Biomarkers With Tirzepatide (2026) · cites this paper as [4]
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Sattar, N., Welsh, P., Leslie, W. S., Thom, G., McCombie, L., Brosnahan, N., Richardson, J., Gill, J. M. R., Crawford, L., & Lean, M. E. J. (2023) · The Lancet Regional Health - Southeast Asia · doi:10.1016/j.lansea.2022.100111 · Cited by 58 · see citing works
Self-citationFirst-phase insulin secretion: can its evaluation direct therapeutic approaches?
Di Giuseppe, G., Ciccarelli, G., Soldovieri, L., Capece, U., Cefalo, C. M. A., Moffa, S., Nista, E. C., Brunetti, M., Cinti, F., Gasbarrini, A., et al. (2023) · Trends in Endocrinology & Metabolism · doi:10.1016/j.tem.2023.02.001 · Cited by 46 · see citing works
Insulin resistance and metabolic flexibility as drivers of liver and cardiac disease in T2DM
Colosimo, S., Mitra, S. K., Chaudhury, T., & Marchesini, G. (2023) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2023.111016 · Cited by 38 · see citing works
Sattar, N., McGuire, D. K., & Gill, J. M. R. (2022) · Circulation · doi:10.1161/circulationaha.122.060411 · Cited by 19 · see citing works
Self-citationLandgraf, R., Aberle, J., Birkenfeld, A. L., Gallwitz, B., Kellerer, M., Klein, H., Müller-Wieland, D., Nauck, M. A., Wiesner, T., & Siegel, E. (2022) · Experimental and Clinical Endocrinology & Diabetes · doi:10.1055/a-1624-3449 · Cited by 12 · see citing works
Ahmed, A., Amin, H., Drenos, F., Sattar, N., & Yaghootkar, H. (2023) · Diabetes Care · doi:10.2337/dc23-0855 · Cited by 10 · see citing works
Self-citationZhyzhneuskaya, S. V., Al‐Mrabeh, A. H., Peters, C., Barnes, A. C., Hollingsworth, K. G., Welsh, P., Sattar, N., Lean, M. E. J., & Taylor, R. (2025) · Diabetic Medicine · doi:10.1111/dme.15462 · Cited by 6 · see citing works
Self-citationComprehensive Long-Term Changes in Cardiovascular Risk Biomarkers With Tirzepatide
Sattar, N., Linetzky, B., Ruotolo, G., Verma, S., Sourij, H., Wang, H., Vanderman, K., Wilson, J. M., Griffin, R. M., Stefanski, A., et al. (2026) · JACC · doi:10.1016/j.jacc.2026.04.044 · Cited by 5 · see citing works
Self-citation
- Authors
- Taylor, R., Al-Mrabeh, A., & Sattar, N.
- Affiliations
- Newcastle University (GB)
- University of Glasgow (GB)
- Corresponding author
- Taylor, Roy
- Venue
- The Lancet Diabetes & Endocrinology
- Publisher
- Elsevier BV
- Published
- 2019-09
- Volume
- 7
- Issue
- 9
- Pages
- 726-736
- ISSN
- 2213-8587 (ISSN-L)
- OpenAlex
- W2946710786
- Cited by
- 299
- References
- 87
- Citations by year
- 2026: 35 · 2025: 47 · 2024: 42 · 2023: 46 · 2022: 41 · 2021: 53 · 2020: 26 · 2019: 8 · 2017: 1
- FWCI
- 4.91
- Type
- journal article
- Language
- en
- Open access
- green
- doi.org
- Licence
- Locations
- The Lancet Diabetes & Endocrinology (publishedVersion)
- PubMed (publishedVersion)
- Newcastle University ePrints (Newcastle Univesity) (cc-by-nc-nd)
- Funders
- Newcastle University
- National Institute for Health and Care Research
- European Foundation for the Study of Diabetes
- Novo Nordisk UK Research Foundation
- Novo Nordisk
- Amgen
- NIHR Newcastle Biomedical Research Centre
- Sanofi
- Diabetes UK
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Surgery › Pancreatic function and diabetes
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- type 2 diabetes remission, weight loss, hepatic insulin resistance, hepatic lipid accumulation, pancreatic fat accumulation, beta-cell dysfunction, beta-cell recovery, glucose production, DIRECT trial, primary care
- MeSH terms
- Blood Glucose, Diabetes Mellitus, Type 2, Humans, Insulin Resistance, Liver, Pancreas, Weight Loss, Insulin-Secreting Cells
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