In the Diabetes Prevention Program (3,234 adults), an intensive lifestyle program that aimed for 7% weight loss and 150 minutes of weekly activity cut new type 2 diabetes by 58% compared with placebo over a mean of 2.8 years [1]. Remission of established type 2 diabetes was reported in some participants after large weight loss, such as 46% at 12 months in DiRECT, but only 13% of the 85 people who continued in the 5-year extension, so it is a possible result in a study, not something anyone should expect [9][11].
Key takeaways
- The Diabetes Prevention Program randomized 3,234 adults with elevated glucose; lifestyle change lowered new type 2 diabetes by 58% and metformin by 31% versus placebo over a mean of 2.8 years [1].
- At 15 years of follow-up, 55% of the lifestyle group, 56% of the metformin group and 62% of the placebo group had developed diabetes, so the benefit looks like delay, not permanent prevention [2].
- In Look AHEAD, 11.5% of the intensive lifestyle group had partial or complete remission in year 1 versus 2.0% of controls, falling to 7.3% by year 4; the authors called absolute rates modest [8].
- In DiRECT, 46% of the intervention group was in remission at 12 months versus 4% of controls, 36% versus 3% at 24 months, and 13% of 85 extension participants at 5 years [9][10][11].
- In adults with type 2 diabetes and overweight or obesity, mean weight change was -9.6% with semaglutide 2.4 mg versus -3.4% with placebo at 68 weeks, and -12.8% to -14.7% with tirzepatide versus -3.2% with placebo at 72 weeks [13][14].
What is prediabetes and how common is it?
Prediabetes is identified from blood sugar tests. CDC's eligibility page for its lifestyle change program lists these prediabetes-range results: an A1C of 5.7% to 6.4%, a fasting plasma glucose of 100 to 125 mg/dL, or a 2-hour glucose of 140 to 199 mg/dL after a 75 g glucose load [4].
CDC's National Diabetes Statistics Report lists an estimated 115.2 million U.S. adults aged 18 and older with prediabetes [7].
This article covers two different questions. The first is whether weight loss and activity can prevent or delay type 2 diabetes in people with prediabetes. The second is whether weight loss can lead to remission in people who already have type 2 diabetes. The trials below answer them separately, and the answers should not be mixed together. People with a diabetes diagnosis are not eligible for CDC's prevention program, which is a reminder that these are different situations [4].
What did the Diabetes Prevention Program find?
The Diabetes Prevention Program (DPP) found that an intensive lifestyle program lowered new cases of type 2 diabetes by 58% compared with placebo. The trial randomized 3,234 nondiabetic adults with elevated glucose levels to placebo, metformin or a lifestyle program. Participants had a mean age of 51 and a mean BMI of 34.0, 68% were women and 45% belonged to minority groups [1].
The lifestyle goals were a weight loss of at least 7% of starting weight and at least 150 minutes of moderate physical activity a week, such as brisk walking. Mean follow-up was 2.8 years. Metformin lowered new cases by 31% compared with placebo, and the lifestyle program was significantly more effective than metformin [1]. NIDDK reports that the trial ran from 1996 to 2001 at 27 clinical centers [2].
The 58% compares everyone assigned to the lifestyle program with everyone assigned to placebo. It is a group result, and it does not predict what will happen to one person who loses 7% [1]. CDC's description of the result refers to participants who lost 5 to 7 percent of their body weight [5]. To prevent one case over three years, about 6.9 people needed the lifestyle program and 13.9 needed metformin [1].
Source: [1] Diabetes Prevention Program Research Group, N Engl J Med 2002 [1]
Did the benefit last? The DPP Outcomes Study followed participants afterward. NIDDK reports that at 10 years the lifestyle group's onset of diabetes was delayed by 34%, about 4 years, and the metformin group's by 18%, about 2 years. At 15 years the delays were 27% and 18%. By then about 55% of the lifestyle group and 56% of the metformin group had developed diabetes, compared with 62% of the placebo group [2]. More than half of every group had developed diabetes, which is why the results are best described as delay.
Can weight loss put type 2 diabetes into remission?
In some studies, a share of people with type 2 diabetes reached glucose levels in the normal or near-normal range after weight loss, but this is a lab-defined outcome and absolute rates varied widely. An international expert group convened by the American Diabetes Association (ADA) recommended the term remission in a 2021 consensus report. Its usual criterion is an HbA1c below 6.5% (48 mmol/mol), measured at least 3 months after stopping glucose-lowering medication [12].
Studies define remission differently. DiRECT counted HbA1c below 6.5% off diabetes medication for at least 2 months [9]. Look AHEAD counted partial remission (prediabetes-range glucose) and complete remission (normal glucose), both without diabetes medication [8]. Percentages from different trials are therefore not directly comparable.
Look AHEAD analyzed 4,503 U.S. adults with type 2 diabetes and a BMI of 25 or higher, 2,241 in an intensive lifestyle group and 2,262 in a diabetes support and education group. It was an ancillary analysis of a 4-year randomized trial, and remission was not a prespecified outcome [8].
| Measure | Intensive lifestyle | Support and education |
|---|---|---|
| Any remission, year 1 | 11.5% | 2.0% |
| Any remission, year 4 | 7.3% | 2.0% |
| Sustained at least 2 years | 9.2% | 1.7% |
| Sustained at least 4 years | 3.5% | 0.5% |
Within the intensive lifestyle group, year-1 remission was 16.4% among people who lost more than 6.5% of body weight, 5.4% with a 1% to 6.5% loss, and 2.7% with weight gain or a loss under 1%. It was 21.2% when diabetes had lasted under 2 years and 4.1% at 7 or more years [8]. The authors described the absolute remission rates as modest and noted the intervention was more intensive than typical clinical programs [8].
What did the DiRECT trial show?
DiRECT reported that 46% of the intervention group was in remission at 12 months, versus 4% of the control group. It was an open-label, cluster-randomized trial in 49 general practices in Scotland and the Tyneside region of England, with 149 participants per group in the main analysis, funded by Diabetes UK [9].
The program was intensive. Participants stopped antidiabetic and antihypertensive drugs, followed a total diet replacement of 825 to 853 kcal a day for 3 to 5 months, then went through a stepped food reintroduction and received support for long-term weight maintenance [9]. Eligible adults were aged 20 to 65, had type 2 diabetes for under 6 years, and were not using insulin [11].
At 12 months, mean weight fell 10.0 kg versus 1.0 kg, and 24% of the intervention group lost 15 kg or more versus none of the controls. Remission was 86% among those who lost 15 kg or more, and none of the 76 participants who gained weight reached remission. Serious adverse events occurred in 4% of the intervention group and 1% of controls [9].
| Time point | Intervention | Comparison | Notes |
|---|---|---|---|
| 12 months [9] | 46% | 4% (controls) | Randomized; 149 per group |
| 24 months [10] | 36% (53 people) | 3% (5 people) | 40% of the intervention group still used diabetes medication versus 84% of controls |
| 5 years [11] | 13% (11 of 85) | 5% of 93 original controls | Extension was not randomized; participants chose to continue |
At 5 years, extension participants had lost a mean of 6.1 kg and original controls 4.6 kg. Among people in remission at year 2, 26% were still in remission at year 5 [11]. The 5-year numbers are small and the comparison was not randomized, so they should be read cautiously [11].
How much weight did medications produce in people with type 2 diabetes?
In two large placebo-controlled trials, adults with overweight or obesity and type 2 diabetes lost more weight on semaglutide or tirzepatide than on placebo. Both trials gave participants lifestyle support alongside treatment or placebo, and both placebo groups lost some weight too.
STEP 2 was a phase 3, double-blind trial at 149 outpatient clinics in 12 countries. It randomized 1,210 adults, and the trial added a lifestyle intervention for everyone. After 68 weeks, mean weight change was -9.6% with semaglutide 2.4 mg and -3.4% with placebo (difference -6.2 percentage points, 95% CI -7.3 to -5.2). A loss of at least 5% was reached by 68.8% (267 of 388) on semaglutide and 28.5% (107 of 376) on placebo [13].
The Zepbound prescribing information (revised 01/2026) reports a 72-week study of 938 adults with a BMI of 27 or higher and type 2 diabetes. Mean weight change was -3.2% with placebo (315 people), -12.8% in the lower-dose tirzepatide group (312) and -14.7% in the higher-dose group (311). A loss of at least 5% was reached by 32.5%, 79.2% and 82.8%, respectively [14]. The label lists this as Study 2; the trial was published as SURMOUNT-2.
Source: [13][14] s: STEP 2 (Lancet 2021) [13]; Zepbound prescribing information, 01/2026 [14]. Two separate trials, not a head-to-head comparison.
These are two different trials with different populations, lengths and designs, so they should not be ranked against each other. Both report average weight change, and individual results varied. This article draws no conclusion about diabetes remission from these weight results.
The Zepbound label also notes that combining it with insulin or an insulin secretagogue such as a sulfonylurea raises hypoglycemia risk. In the type 2 diabetes trial, hypoglycemia occurred in 10.3% of patients taking a sulfonylurea and 2.1% of those not taking one [14]. Any change to diabetes medicines belongs with the clinician managing them.
What do the ADA and CDC offer for prevention and care?
The ADA released its Standards of Care in Diabetes 2026 on December 8, 2025, as a supplement to the January 2026 issue of Diabetes Care. Its news release says the document covers diagnosis and management of diabetes and prediabetes, along with ways to prevent or delay diabetes [15].
The release highlights eating patterns with evidence for preventing type 2 diabetes, including Mediterranean-style and low-carbohydrate approaches. It also lists new guidance on tailoring obesity medications for people who have diabetes, more emphasis on monitoring nutritional intake during obesity treatment, and expanded discussion of physical activity. The Obesity Society endorsed Section 8, which covers obesity [15]. This article relies on the release and does not quote individual numbered recommendations from the full sections.
CDC's National Diabetes Prevention Program is a partnership of public and private organizations. Its core is a yearlong, group-based lifestyle change program led by a trained Lifestyle Coach, offered in person or online [3][5]. CDC recognizes organizations that meet its standards, which include an approved curriculum, a trained coach and data submitted every 6 months [5].
To join, a person must be 18 or older, not pregnant, have no prior type 1 or type 2 diabetes diagnosis, and have a BMI of 25 or higher (23 or higher for Asian Americans). They also need a prediabetes-range test in the past year, a history of gestational diabetes, or a Prediabetes Risk Test score of 5 or higher [4].
The Medicare Diabetes Prevention Program has its own rules. It requires Medicare Part B, a BMI of 25 or higher (23 or higher if Asian), a blood test in the past year in the prediabetes range, and no history of type 1 or type 2 diabetes. It lasts 2 years and is free with Part B [6].
What are the limits of this evidence?
- The DPP followed participants for a mean of 2.8 years in a selected group with a mean BMI of 34.0 [1]. Long-term follow-up figures come from NIDDK's summary of the DPP Outcomes Study [2].
- Look AHEAD remission was an exploratory analysis. The authors noted no oral glucose tolerance test, and that the intervention was more intensive than typical programs [8].
- DiRECT was open-label, enrolled adults aged 20 to 65 with diabetes under 6 years and no insulin use, and most intervention participants were not in remission at 2 years [9][10][11].
- Remission definitions differ across ADA, DiRECT and Look AHEAD, so rates cannot be compared directly [8][9][12].
- The medication trials report average weight outcomes over 68 to 72 weeks. They do not tell any one person how much they will lose [13][14].
- The ADA Standards of Care are summarized here only through the ADA's news release, not the full section text [15].
What this means in practice
- Ask what your A1C and fasting glucose are. The evidence for prevention (DPP) and for remission (Look AHEAD, DiRECT) applies to different groups [1][4][8].
- For prediabetes, the strongest randomized evidence is for a structured lifestyle program. CDC-recognized programs are yearlong group programs led by a trained coach [1][3][5].
- If you have Medicare Part B, ask whether the Medicare Diabetes Prevention Program applies. It is free with Part B for those who meet the criteria [6].
- Larger weight loss was linked with higher year-1 remission in Look AHEAD, but even then most people did not reach remission. Treat remission as a possible result, not a plan [8].
- Do not stop diabetes or blood pressure medicines on your own. In DiRECT they were stopped inside a structured program run through primary care practices [9].
- If you take insulin or a sulfonylurea, tell your clinician before any weight loss medicine, because the Zepbound label notes higher hypoglycemia risk with those drugs [14].
- Bring your last lab results and medication list to your appointment, so the discussion is based on your numbers and not on trial averages.
When to talk to a clinician
Talk to a licensed clinician if you have been told your blood sugar is in the prediabetes range, if you have type 2 diabetes, or if you take medicines for blood sugar or blood pressure. Whether any treatment is appropriate is something a clinician decides after an evaluation. This article describes research and is not medical advice.
At Healthy Weight Loss 4 U, every program begins with a clinician evaluation, and that evaluation is the place to raise prediabetes or diabetes, share your labs and discuss your medicines. No outcome is promised, and your plan depends on your health history.
Frequently asked questions
Can lifestyle changes prevent prediabetes from becoming type 2 diabetes?
How much weight did the Diabetes Prevention Program ask people to lose?
Is diabetes remission the same as a cure?
What did the DiRECT diet involve?
How much weight did semaglutide and tirzepatide trials show in type 2 diabetes?
Does Medicare cover a diabetes prevention program?
Who can join the CDC National Diabetes Prevention Program?
Do weight loss medicines raise the risk of low blood sugar?
Sources
- Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin (Diabetes Prevention Program Research Group); copy hosted by the Maryland Department of Health. New England Journal of Medicine, 2002. health.maryland.gov/phpa/ccdpc/diabetes/documents/nejm%20reduction%20in%20diabetes%20incidence.pdf
- Diabetes Prevention Program (DPP). NIDDK, National Institutes of Health, 2026. www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp
- Preventing Type 2 Diabetes with the Lifestyle Change Program. Centers for Disease Control and Prevention, 2026. www.cdc.gov/diabetes-prevention/lifestyle-change-program/index.html
- Are You Eligible to Join the National DPP Lifestyle Change Program?. Centers for Disease Control and Prevention, 2026. www.cdc.gov/diabetes-prevention/eligible-lifestyle-change-program/index.html
- What Is the National DPP?. Centers for Disease Control and Prevention, 2026. www.cdc.gov/diabetes-prevention/programs/what-is-the-national-dpp.html
- Preventing Type 2 Diabetes with Medicare (Medicare Diabetes Prevention Program). Centers for Disease Control and Prevention, 2026. www.cdc.gov/diabetes-prevention/lifestyle-change-program/ndpp-medicare-program.html
- National Diabetes Statistics Report. Centers for Disease Control and Prevention, 2026. www.cdc.gov/diabetes/php/data-research/index.html
- Association of an Intensive Lifestyle Intervention With Remission of Type 2 Diabetes (Look AHEAD; Gregg et al.). JAMA (author manuscript via CDC Stacks), 2012. stacks.cdc.gov/view/cdc/38316/cdc_38316_DS1.pdf
- Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet, 2018. www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33102-1/fulltext
- Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes & Endocrinology (University of Glasgow repository record), 2019. eprints.gla.ac.uk/180894
- 5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: an extension study. Lancet Diabetes & Endocrinology (University of Glasgow repository record), 2024. eprints.gla.ac.uk/315287
- Consensus report: definition and interpretation of remission in type 2 diabetes. American Diabetes Association, Diabetes Care (Newcastle University repository record), 2021. eprints.ncl.ac.uk/279068
- Semaglutide 2.4 mg once a week in adults with overweight or obesity, and type 2 diabetes (STEP 2): a randomised, double-blind, double-dummy, placebo-controlled, phase 3 trial. The Lancet (University of Leicester repository record), 2021. figshare.le.ac.uk/articles/journal_contribution/Semaglutide_2_4_mg_once_a_week_in_adults_with_overweight_or_obesity_and_type_2_diabetes_STEP_2_a_randomised_doubleblind_double-dummy_placebo-controlled_phase_3_trial/14510538/1
- ZEPBOUND (tirzepatide) prescribing information (revised 01/2026). U.S. Food and Drug Administration, 2026. www.accessdata.fda.gov/drugsatfda_docs/label/2026/217806s002lbl.pdf
- American Diabetes Association Releases Standards of Care in Diabetes 2026. American Diabetes Association, 2025. diabetes.org/newsroom/press-releases/american-diabetes-association-releases-standards-care-diabetes-2026
Keep reading
Health Benefits of 5 to 15 Percent Weight Loss
Read →Semaglutide vs Tirzepatide: What the Trials Show
Read →Keeping Weight Off: What Long-Term Studies Show
Read →Ozempic, Wegovy, Mounjaro, Zepbound: What Each Is FDA-Approved For
Read →Questions about your own situation? A clinician can review your history and goals. Related: Personalized Weight Loss Counseling.