THE FUTURE OF DIABETES | Added: 12, August 2017



HEALTH CARE AND DIABETES

Why is health care so costly for treating diabetes?

There are many reasons that health care for diabetes is so costly. Many experts cite the spending policies of the health care system. In particular, little is spent to keep people healthy through preventive care. Great sums are spent when a person becomes sick or disabled-which is truly necessary-but not for chronic diseases such as diabetes. In addition, other costs are associated with diabetes because it is not a disease that “goes away” as readily as some other ailments; these costs include purchases of needles for insulin, medications, test strips, etc. The prices of these necessities continue to rise, and as the number of people with diabetes rises (as most agree it will), demand for such items will rise. Instead of helping, most health care insurance plans choose to ignore the extra costs of living with diabetes. These extra costs may be one of the reasons that people often choose to ignore the fact that they have the disease.

How can governments handle the number of people projected to have diabetes in the next decade?

The number of people projected to develop diabetes-both type 1 and type 2-will no doubt rise in the next decade, and some say beyond. Several organizations are addressing this problem. For example, the International Diabetes Federation launched the Global Diabetes Plan in 2011 after the world leaders met at the United Nations in New York to agree to actions concerning diabetes and other non-communicable diseases. Several countries, including Australia, have their own plans to help understand what needs to be accomplished in terms of helping people with diabetes or even trying to reduce the number of people who develop the disease. There are also programs using digital means to collect information and data from people with the disease as a step toward providing education and access to information to the public. (For more information about organizations helping the diabetes effort, see the chapter “Resources, Websites, and Apps.”)

MITIGATING DIABETES

What is the ultimate goal for those who research diabetes-and, especially, for people who have diabetes?

Of course, the main goal not only for diabetes research, but also for people who have diabetes, is to restore the body’s ability to manufacture its own insulin. For many people with diabetes, that also means eliminating the need for injections or diabetes medications.

What recent research involves helping people with diabetes produce their own insulin?

In 2016, researchers at the Diabetes Research Institute (DRI, under the University of Miami in Florida) announced they were one step closer to the goal of enabling people with type 1 diabetes to produce their own insulin instead of relying on injections. The first person to receive the new method of transplanting insulin-producing cells was a woman who developed type 1 diabetes in her teens. She was a prime candidate, as she has what is called severe hypoglycemia unawareness, or the inability to sense that her blood glucose levels are dropping to a dangerously low level (for more about severe hypoglycemia unawareness, see the chapter “Type 1 Diabetes”).

The researchers used what is called a “biodegradable scaffold” that was implanted on the surface of the omentum (the sheet of protective tissue that hangs down from the stomach and covers the abdominal organs). In a new technique, they implanted donor islet cells, those that produce insulin, into the scaffold. The old technique used islet cells infused into the liver, but because the liver is not an ideal site for transplantation-mainly because inflammation can develop-the researchers implanted the cells in the omentum. The results so far are promising: to date, the woman is no longer injecting insulin for her diabetes.

NEW TESTS FOR DIABETES

Why are so many people with diabetes undiagnosed?

According to recent research by the Centers for Disease Control and Prevention, nearly 28 percent of the people (or about eight million people) who have diabetes are undiagnosed. One of the major reasons is understandable to many people. The CDC found that because the screening test for diabetes involves drawing blood with a needle, many people avoid the procedure. In addition, a person is required to fast before the test-usually for more than 12 hours-something that makes the procedure even more uncomfortable for many people.

Are researchers working on a device that uses light to measure glucose levels?

One of the most sought-after devices for people with diabetes is one that would measure glucose levels without having to prick a finger to get blood. One such device that may be offered in the future uses light to measure glucose levels through the skin. The research is based on chemistry. The researchers shine light on different substances to determine which ones absorb light and how much is absorbed. In the case of glucose, researchers are trying to detect the sugar molecule’s signature absorption of infrared light, but so far, the measurements only track the glucose levels closely-but not in as detailed a way as needed.

What device was recently developed that uses sweat to detect glucose?

Although the study is in its infancy, researchers are trying to develop a device that can detect glucose levels using sweat. In 2016, a team from the Hong Kong Polytechnic University and Zhejiang University in China developed such a device to help early diagnosis of diabetes. The technology is part of two fields, one called optofluidics, which melds the fields of photonics (using light to detect certain chemicals), and the other called microfluidics (controlling small amounts of fluid along microchannels). The researchers hope that this device will eventually be used to detect glucose levels in a person’s body from droplets of sweat, but more tests on the “lab-on-a-chip” need to be made. In particular, the device uses a fiber-optic biosensor and a microfluidic chip, creating a way of monitoring glucose levels that promises to be not only cheap but also portable.

What are some other ways glucose levels may be measured in the future?

Many research institutions are working hard to find a way for people with diabetes to measure glucose levels without having to prick fingers, thighs, or arms. For example, in 2015, the University of California at San Diego reported it had developed a temporary tattoo that used electrodes and sensors to measure blood glucose levels. Google (yes, the search-engine company) is also seeking better glucose monitoring through the use of contact lenses for people with diabetes. The computer company Apple is working on a smartwatch that can monitor and display health-sensor data including blood glucose levels (such a watch is available but so far without the blood glucose readings). And in 2014, a saliva test kit called the iQuickIt Saliva Analyzer went through clinical trials to measure blood glucose with a simple saliva test. It works by putting a one-time-use strip (called a Draw Wick) into the person’s mouth for a few seconds, obtaining a small sample of saliva. Although none of these devices or methods is currently available to the general public, it shows that there are institutions-and people-who are sensitive to the plight of people pricking their fingers day after day to monitor their blood glucose levels.

Are there any devices that screen for prediabetes and type 2 diabetes without using needles?

Yes, in 2016, a device produced in Canada was developed that tests for prediabetes and type 2 diabetes without needles, blood, or fasting (currently, it is used only in Canada and the European Union and only as an investigational device in the United States). The Scout DS™ device uses technology that employs light to detect and measure specific biomarkers associated with prediabetes and type 2 diabetes. The patient lays his or her arm in the device’s armrest, and in around 80 seconds, a number is displayed on the attached screen. If the score is high, then the patient is advised to see a health care professional for a follow-up evaluation. It is hoped that such a device can be used in other places, such as pharmacies, offices, etc., to allow quick screenings-to catch people who are at risk for diabetes or allow an easy check for people who have diabetes.

FUTURE MEDICINES TO TREAT DIABETES

Will there ever be a generic insulin?

As of this writing, there is no generic insulin on the market. In 2012, the Food and Drug Administration outlined many tough standards for the approval of biosimilars (generic versions of medications that are made by microorganisms), including insulin. As of this writing, there is no generic insulin being submitted or tested by the FDA, but that may change soon. The patents for several types of insulin will soon expire, meaning there may be more of an interest in developing generic insulin. But it will take a long time for testing and approval.

What study is being conducted to determine whether metformin can help delay or prevent type 1 diabetes in at-risk children?

Although in its infancy, at this writing, a six-year study is being conducted in Scotland to determine whether the oral medication called metformin-the most commonly prescribed diabetes medicine in the world, taken by people with type 2 diabetes-can help prevent, or at least delay the onset of, type 1 diabetes in at-risk children. One of the reasons for the interest is that Scotland has the third-highest rate of type 1 diabetes in the world, and for reasons yet unknown, the numbers continue to rise.

For people with type 2 diabetes, metformin decreases the amount of glucose in the liver. It also improves the body’s insulin sensitivity not only in the liver but also in muscles and fat cells. This process also helps protect beta cells in the pancreas from stress. Type 1 diabetes is an autoimmune condition in which the pancreas’s insulin-producing beta cells are destroyed. The researchers believe that stress signals sent out by the beta cells is what starts the immune-system attack in type 1 diabetes, not a problem with the immune system itself. They hypothesize that relieving the stresses on the beta cells in at-risk children will stop the process of developing type 1 diabetes. And that relief may come from taking metformin.

What drug more associated with the lungs is currently being tested on people with diabetes?

One drug associated with the lungs (in particular to treat emphysema) is currently being tested on people with type 1 diabetes, called by the general name alpha-1 antitrypsin (A1AT; several companies call the drug by specific names, but they are not mentioned here). In type 1 diabetes, the body’s autoimmune system attacks the beta cells that are responsible for secreting insulin from the pancreas. As the disease progresses and more and more of the beta cells no longer function, the person with type 1 diabetes usually becomes completely dependent on insulin. It is thought that the A1AT drug may help those with type 1 diabetes if the clinical trials prove successful. In particular, researchers believe the A1AT may stop pancreatic inflammation and allow the survival of active and operating beta cells.

A form of A1AT was first tested on animals with diabetes, with promising results. Another smaller-sample test on humans who had type 1 diabetes was run around 2012, with results showing that many of the participants were able to take significantly less insulin than when they started the trial. The alpha-1 antitrypsin drug is currently being control-tested on many pediatric and young-adult patients with type 1 diabetes in several cities across the United States and in other countries, with most of the projected results expected by 2017. But there is one caveat: At this writing, the drug may be successful only with people with newly diagnosed diabetes or periods during which there may still be some existing functioning beta cells in the pancreas.

What other conditions have been treated with the anti-inflammatory drug alpha-1 antitrypsin (A1AT)?

Type 1 diabetes is currently the center of study for the anti-inflammatory drug known as alpha-1 antitrypsin (A1AT), but it has also been used in the past for other health conditions. For example, it has been used to treat people with severe lung diseases, such as emphysema. It is also hoped that besides type 1 diabetes, A1AT can eventually be used to treat other autoimmune diseases, such as rheumatoid arthritis and certain types of asthma.

NEW WAYS OF TREATING DIABETES

What is islet-cell transplantation?

Within the islets of Langerhans are the important alpha and beta cells. The alpha cells produce glucagon, while the beta cells secrete insulin-both important in keeping blood glucose levels balanced in the body (for more about the islets, see the chapter “How Diabetes Affects the Endocrine System”). Islet-cell transplantation involves the pancreas, specifically the islets of Langerhans. In particular, the beta cells are found in small clusters (islets) of the pancreas and are responsible for producing insulin. Researchers hope not to transplant the entire pancreas but to target, extract, and replace only those cellular components that are needed to restore the pancreas’s normal function.

What is an “artificial pancreas”?

At this writing, an artificial pancreas is not a physical unit that replaces a person’s own pancreas but is a combination of two technologies-a unit that monitors a person’s glucose levels and a pump that delivers the correct amount of diabetic medication to the person to balance their glucose levels. This mimics what a person’s pancreas would do in terms of monitoring glucose levels and determining how much insulin or glucagon the body needs. For a person without diabetes, the body’s pancreas naturally finds a good balance between glucose, insulin, and glucagon. But for a person with diabetes (especially type 1), insulin is needed several times a day to keep blood glucose levels in check. The artificial pancreas helps people with type 1 diabetes whose beta cells make little, if any, insulin by monitoring blood glucose levels and compensating for imbalances with insulin and glucagon pumps.

An artificial pancreas would function much like a real one, producing insulin, glucagon, and amylin.

What artificial pancreas for type 1 diabetes recently received approval from the Food and Drug Administration?

In fall 2016, the FDA approved the world’s first “artificial pancreas,” called the Medtronic MiniMed 67G hybrid closed-loop system, for people with type 1 diabetes (age 14 older). This system automatically monitors blood glucose levels and then provides the person with the correct dosage of basal insulin with relatively little input from the user. It can be used in “auto mode,” meaning completely automatically, or users can calibrate the unit for a more hands-on approach.

The melding of this type of technology is not new. These pieces of equipment have been around since the 1970s, but the larger devices were clumsy to use. Today’s technology has allowed scientists to develop much smaller devices. People can use smartphone technology to keep balanced glucose levels no matter what activity they pursue or what they eat. For example, one version of an artificial pancreas has been tested many times and includes a smartphone that has an “artificial pancreas” app. A person’s continuous glucose monitor takes measurements every few minutes and wirelessly sends the information to the smartphone that contains the artificial pancreas app, which uses the measurements to calculate how much insulin or glucagon to give the user. From there, the smartphone beams the information to two pumps the person is wearing to balance the glucose levels. In this case, the insulin pump delivers medication to lower the blood glucose level, or the other pump containing glucagon delivers medication to raise the level.

Will there ever be a true artificial pancreas?

The ultimate goal for people who have diabetes and researchers who study the disease is to develop what is often termed a “bionic pancreas,” one that could actually replace a person’s non-functioning pancreas. In fact, there are laboratories working on melding the continuous glucose-monitoring units with insulin and glucagon pumps to create such an artificial pancreas.

But there are several difficulties so far, especially the size of such a unit. In addition, there are problems with the speed of the insulin delivery and with the shelf life of glucagon. Even with the current so-called “artificial pancreas” (see above), there are often problems with the lag time between the sensor reading and fluctuation in blood glucose levels. For example, one test showed that by the time the blood glucose started to rise after a person ate, there wasn’t enough time for insulin measurements and subsequent delivery to prevent blood glucose levels from rising too fast. In addition, glucagon usually comes in powdered form and needs to be dissolved in water before injected or infused. The problem with a glucagon pump is that the glucagon has a short shelf life-usually just a day-before it becomes unstable. Studies are continuing, and with advancements in technology, many researchers believe such a unit is possible. Some say as of this writing that the problems will be solved within the next half decade.

THE FUTURE OF GENETICS AND DIABETES

Do researchers believe a person’s genetics is connected to developing type 1 diabetes?

Yes, some parts of a person’s genetic makeup can be connected to type 1 diabetes, but for most people, genetics is only a part of what contributes to the disease. Research on type 1 diabetes has shown that dominant genes associated with diabetes can either protect against or cause a person to be more susceptible to the disease.

Do researchers believe a person’s genetics is connected to developing type 2 diabetes?

Some parts of a person’s genetic makeup can be connected to type 2 diabetes, but like type 1 diabetes and genetics, it is not all that contributes to the condition. As with type 1 diabetes, research on type 2 diabetes has shown that dominant genes associated with diabetes can either protect against or cause a person to be more susceptible to the disease. But with type 2 diabetes, there appears to be a stronger connection between genetics and disease. In particular, scientists have discovered that a gene on chromosome 7 in the human body is linked to type 2 diabetes. It is thought that when the gene mutates, it creates a gene that releases a faulty enzyme, which is then unable to stimulate the pancreas to produce insulin. (For more about genetics, mutations, and type 2 diabetes, see the chapter “Prediabetes and Type 2 Diabetes.”)

Why is the study of genetics so difficult to interpret at this time, especially in terms of such diseases as diabetes?

One of the major reasons why the study of genetics is so difficult to understand in terms of certain diseases is that genetic mechanisms are so complex. For example, genetic diseases fall into three different types of categories: a single gene that is defective, mutations in multiple genes, and abnormalities in a person’s chromosomes. In addition, whereas one person may show symptoms of a disease at birth, others may not show symptoms until many years later-sometimes for three to seven decades. And with most people living longer, especially in the Western cultures, the incidence of mutations, abnormalities, and defective genes becomes even more problematic. Thus, some diseases such as diabetes, cancer, and heart disease are also on the increase. But to find out a definitive cause and effect is often a matter of speculation, especially when it comes to a person’s genetics.

In gene therapy, a vector is used to carry a modified gene into cells, which then are able to use the gene to produce the desired proteins they couldn’t produce before.

Can genes affect other genes?

Yes, researchers have found that two or more genes not only can alter the effects of other genes but can also mask other genes. Technically termed epistasis, this phenomenon may be why people develop such diseases as diabetes and Alzheimer’s. Researchers have also discovered that this gene interaction can be both negative and positive and vary from person to person. Currently, epistasis is one of the major reasons for the difficulty in interpreting the interrelationship between genetics and such diseases as diabetes.

The reason for the interest in genes and how they are involved in diseases, especially of the aging population, is obvious. If certain combinations, mutations, or degradations of certain genes can be identified in association with a disease such as diabetes, then there may be a way to mitigate or even slow down the progression of the disease, especially for at-risk people.

Why are chromosomes important in the future study of genetics and diabetes?

Diabetes is a complex disease influenced by what is called epistasis and environmental factors. For example, some research has indicated that the interactions between loci (the plural form of the word; it is the location or position of a gene’s DNA sequence on a chromosome) of chromosomes 2 and 15, along with loci on chromosomes 1 and 10, are found in most people with type 2 diabetes. Thus, research is currently being conducted on both type 1 and type 2 diabetes, loci, and chromosomes. Seven new loci were recently discovered, all linked to type 2 diabetes in the Japanese population. Researchers also discovered that four of the loci seemed to coincide with the risk of the disease in several other populations. More research needs to be conducted to determine all the connections and responsible genes for type 1 and type 2 diabetes, along with other epistasis-influenced diseases. And once these relationships are understood, it is hoped that the result will be better diagnosis and treatment of these diseases.

Are there any organizations that are collecting data to determine the future of genetics and diabetes?

Yes, several organizations are collecting data for a database concerning genetics and diabetes. For example, the American Diabetes Association has a national database that contains information and genetic material from many families that have members with type 2 diabetes. This data is meant to help researchers conduct genetic links and locate the genes involved in type 2 diabetes. (For more about such organizations, see the chapter “Resources, Websites, and Apps.”)

A FUTURE WITHOUT DIABETES?

Will type 1 diabetes ever go away?

Although many organizations are working to eradicate type 1 and type 2 diabetes, it will be much more difficult to get rid of type 1 diabetes than type 2. This is because type 1 diabetes is an autoimmune disease in which a person’s body essentially attacks itself so the person makes no insulin. But there may be hope. In 2014, scientists from Harvard University engineered a way to make large quantities of insulin-producing cells. They did this by using embryonic stem cells that were prompted to turn into insulin-producing cells. By 2015, researchers at the Massachusetts Institute of Technology had planted into mice similar engineered cells that switched off the disease for six months (which is thought to translate to several years in humans). If this research comes to fruition (it is still being studied, with the first human tests in 2016), then it would mean people with type 1 diabetes would just need a transfusion of engineered cells every few years to keep their blood glucose levels stable.

Is it true that once a person has type 2 diabetes, he or she will always have the disease?

This is an important question and one that researchers and those who have type 2 diabetes truly want answered. In the recent past, the fate of people with type 2 diabetes was usually sealed. In other words, they would have the disease for the rest of their lives and suffer the consequences of and complications from having diabetes. Most of the research shows that type 2 diabetes may be reversible but usually only a short time after the diagnosis. More recent studies show it may also be reversible in people who have had the disease for many years. But as always, more research is needed.

What recent study tried to find a way to reverse type 2 diabetes?

A study reported in early 2016 was based on a small clinical trial in England. The trial studied the effects of a strict liquid diet on 30 people-ages 25 to 80-and who ranged from being overweight to extremely obese. Each participant had lived with type 2 dia betes for up to 23 years. They were to complete an eight-week, low-calorie milkshake diet (taking no diabetes medication and eating only 600 to 700 calories a day, all from three diet milkshakes at mealtimes and half a pound of non-starchy, liquified vegetables). After the trial, participants would return to normal eating. Overall, around half of the participants went into remission immediately after the trial and were still diabetes-free after six months. The researchers don’t know why this worked, but there are a few speculations. One is that when a person goes on a low-calorie diet, the body may use up the fat from the liver, causing the fat levels to drop in the pancreas, too. This may cause the insulin-producing cells in the body to become active again, normalizing blood glucose levels. But the study was not for everyone. For instance, no one knows how long the effects will last or whether the regimen will work for the typical person with type 2 diabetes. And most of all, the biggest challenge at the end was returning to normal eating, especially after consuming a liquid diet.

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