The first description of diabetes was recorded in Egyptian medical texts around 552 BC. But, as recently as a century ago, the most effective treatment available was a strict low carbohydrate diet, which wasn’t terribly effective. People with diabetes tended not to live long.
That changed 100 years ago, when Canadian surgeon, Frederick Banting, and his assistant, Charles Best gave purified insulin from cows to Leonard Thompson, a 14-year-old boy with type 1 diabetes. The pair’s work demonstrated that insulin could reduce blood glucose levels. The work earned them a Nobel Prize and more importantly, it saved Thompson's life, and millions since.
Since that discovery, advances in diabetes treatment have arrived in rapid succession, with synthetic insulin, glucose monitors, insulin pumps and other innovations. Even so, diabetes, and in particular type 2 diabetes, remains a large-scale epidemic: globally, more than 537 million people live with diabetes, according to the International Diabetes Federation.1 Diabetes is also strongly associated with cardiovascular disease, to the extent that among those with type 2 diabetes, it is the leading cause of death.2
At the moment, the field is at a juncture. Diabetes treatment options have never been better but diabetes rates have never been higher. With the next 100 years starting now, what lies ahead?
A growing crisis
In November, Scientific American’s Custom Media division hosted an expert panel to examine the disease burden of type 2 diabetes, along with complications, and treatments. The session included three leading experts in diabetes and was part of a series supported by Know Diabetes by Heart, a joint initiative between the American Heart Association and the American Diabetes Association.
Incidence of diabetes has far outpaced projections. In the U.S., one in 10 adults—34.2 million—have diabetes. “For those 65 and older, that number becomes nearly 30 percent,” said Boris Draznin, an endocrinologist and director of the adult diabetes program at University of Colorado School of Medicine, at the event. 3
Mikhail Kosiborod, a cardiologist at St. Luke’s Mid-America Heart Institute and professor of Medicine at the University of Missouri Kansas City, was also a panelist at the event. He explained that most scientists agree the sharp increase in type 2 diabetes is due, largely, to “skyrocketing rates of obesity.” In 1999, 30 percent of Americans were obese; that figure rose to 42 percent by 2018.4 With excessive weight gain, many people develop insulin resistance, which elevates glucose levels in the blood, and leads to diabetes.
“More people living with diabetes means more people developing ... complications,” said Katherine Tuttle, a nephrologist at Providence Health Care and professor of Medicine at the University of Washington, at the event. The most dangerous are chronic kidney disease and what she calls “a tsunami of cardiovascular conditions.”
The healthcare costs, too, are staggering. In 2017, the American Diabetes Association estimated the yearly cost of diagnosed cases at $327 billion, with one out of every seven health care dollars spent treating diabetes or its complications.5 Kosiborod said that on the current trajectory he is concerned that “we’re not going to have enough resources to provide proper care for everybody”.
Getting ahead of diabetes
All three experts discussed the urgent need to better educate the public about diabetes. A recent Harris poll revealed more than 60 percent of people surveyed were aware of associated heart and kidney disease risks.6
In general, Tuttle said, “People don’t take [diabetes] as seriously as they should. By the time that we see these patients, they often have very advanced disease.”
For decades, the American Diabetes Association and other organizations have recommended that doctors test patients yearly for albumin, a protein which, when found in urine, is an early marker of kidney damage and a possible predicator of heart problems. Depending on the setting, just 10 to 40 percent of patients are tested.7
While diagnosis and treatment are critical, prevention is perhaps even more so. “Lifestyle is the cornerstone on which everything is built,” Draznin said. That is often easier said than done. “If you live in a place where it’s unsafe to walk or can’t obtain or afford healthy foods, then the deck is already stacked against us,” Tuttle said. “I think that we need major societal and cultural shifts to support people. Public health needs to be a priority.”
Advances in treatment
For those who have diabetes, Kosiborod said the objective of health care professionals is to “make our patients live longer and feel better.”
The ability to reach those goals improved greatly with the introduction of new, better forms of insulin. An unexpected result of large clinical trials that began in 2008 had been the identification of medications that better prevent further complications, including heart attack, stroke, heart failure and kidney disease. Some of these drugs can do all of those things, including SGLT2 inhibitors (sodium-glucose cotransporter-2).
Such research has transformed diabetes management into “one of the most evidence-based [fields] in the entirety of medicine,” Kosiborod said. “We’re living in an age of renaissance...with many highly efficacious and well-tolerated treatments that can be life-changing for patients with diabetes.”
While there is more to be discovered about the precise mechanisms of the disease, treatment is moving towards a more holistic approach. “This is really a syndrome, a systemic condition that affects multiple organs,” he said.
Technology has also revolutionized treatment with continuous glucose monitoring devices. “They allow people to see exactly what happens after they eat...what happens with their glycemic control during exercise or during an afternoon nap,” Draznin said.
Yet for all this good news, the current pandemic has revealed cracks in the healthcare system for those with diabetes. COVID-19 is much more likely to severely impact patients with diabetes and associated conditions, such as heart and kidney conditions and obesity. That translates into a more severe illness with higher risk of complications, hospitalization and loss of life.
The pandemic has also highlighted the need for prevention and education in addition to acute care. Making sure that all receive needed care will require stronger public policy and support from insurance companies, Tuttle said. “When we have treatments like this, how can we not let people know – and not deliver these therapies?” she asked.
“It really is time that we have a call to action about this.”
For information and tools to manage type 2 diabetes and heart disease, visit KnowDiabetesByHeart.org.