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TEN. What Woes the Future Hold for People with Diabetes?

What is the likelihood of a cure for type 2 diabetes? What form will it take and when will it be available?

When and how will we be able to prevent type 1 diabetes?

How can we stop the dramatic increase in diabetes presently occurring throughout the world?

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What is the likelihood of a cure for type 1 diabetes? What form will it take and when will it be available?

A true cure is likely to be some years off. Although pancreas transplants and islet transplants can lead to independence from insulin treatment and have resulted in dramatic improvement in quality of life for some, they remain a limited proposition for most, in view of the need for risky and expensive antirejection drugs and the late failure that tends to occur. In addition, donor tissues are in short supply. Manipulation of stem cells (early forms of cells that have the potential to develop into an array of different cell types) into pancreatic islet cells that produce insulin has a great deal of potential, but there are a number of operational issues that need to be addressed before this will become an accepted clinical therapy.

Even in a person with established type 1 diabetes, the use of an efficient closed-loop pump system would revolutionize management of the diabetes. Closed-loop means that detecting the blood glucose level and responding to it by injecting the right amount of insulin are both handled by the pump automatically, without the need for decision-making input from the patient. While this is actually more of a management tool than a cure, it would so effectively relieve the patient of the burden of their diabetes that it is for practical purposes almost as good. A number of companies are, as you might expect, actively working on this approach.

Since type 1 diabetes is an immunologic disorder, effective cure may result from manipulation of the immune system, especially if performed early in the course of the disease. An immunologic disorder in this case means one in which a person's own immune system attacks his or her tissues in error. Type 1 diabetes results from an attack of the immune system on the insulin-producing cells of the pancreas, ultimately destroying most of them. Therapies aimed at slowing, halting, or reversing this attack are currently in clinical trials. They are limited by the fact that the diabetes needs to be in an early stage for the treatment to be effective, that manipulating the immune system can cause a number of undesirable side effects, and that it tends to be a lengthy and complicated form of treatment, requiring admission to the hospital.

The latter approach in some form or another is likely to offer the best chance of cure for type 1 diabetes, as it addresses the root cause. Although the fact that clinical trials are ongoing is certainly encouraging, this option remains some way off.

While type 1 diabetes is a lifelong disorder that requires continuous attention and work by those affected, it is important to keep in mind that any cure must be safer and more effective than currently available treatments, which are continually improving and already allow the majority of people with type 1 diabetes to lead healthy and productive lives with few limitations.

What is the likelihood of a cure for type 2 diabetes? What form will it take and when will it be available?

The likelihood of a cure for type 2 diabetes arising from a single drug or therapy is quite small. Many factors are involved in the development of the disorder and it can almost be considered to arise from the body being under a generalized form of environmental and genetic stress — the stress being, in this case, the environmental stress of being overweight, lacking exercise, and other less well-recognized and understood factors. Most type 2 diabetes are predicated to some degree or another on being overweight (although this varies considerably from ethnic group to ethnic group) and therefore a medication or intervention that reverses or prevents obesity and overweight would be expected to have the additional benefit of preventing or curing type 2 diabetes. Indeed this has been conclusively shown to be true for bariatric surgery, which is a type of surgical operation that leads to weight reduction by either restricting the intake of food into the intestine, or leading to it being poorly absorbed from the intestine. Certain types of bariatric surgical procedures may lead to up to 90% reversal (we do not yet use the word cure here) of established type 2 diabetes and effective prevention of progression from prediabetes to frank diabetes. Surgical intervention of this kind is at present reserved for those at highest risk and is not feasible for everyone. There are some risks due to complications of the procedures themselves. Fortunately these are quite uncommon. There are also some subsequent side effects, such as a risk of inadequate balanced nutrition or vitamin deficiency with the bypass type of procedure as well as low blood sugar and diarrhea. However, this means of achieving effective weight loss can prevent or cure type 2 diabetes and a medication that leads to safe, durable, and effective weight reduction could achieve the same result. Possibly environmental adjustment on a social level to promote healthier lifestyles may achieve similar benefits for society as a whole, but this is notoriously difficult!

 
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