tag:theconversation.com,2011:/es/topics/insulin-3278/articlesInsulin – The Conversation2024-03-04T13:26:22Ztag:theconversation.com,2011:article/2239092024-03-04T13:26:22Z2024-03-04T13:26:22ZSouth Africa has more than 4 million people living with diabetes – many aren’t getting proper treatment<p>Diabetes is a chronic condition that affects how the body turns food into energy. </p>
<p>In South Africa there has been a notable <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8199430/">rise in the prevalence of type 2 diabetes</a> in recent years, due to changing diets. People are consuming more processed foods, sugary drinks and high-calorie meals. </p>
<p>Other factors are the lack of physical activity and high levels of obesity. </p>
<p><a href="https://theconversation.com/over-12-of-south-african-adults-have-diabetes-education-is-critical-to-achieve-good-outcomes-194502">Type 2 diabetes</a> is the most common form, making up 90% of cases. With this type, the body produces insulin but can’t use it effectively. It typically affects overweight adults with a family history of the condition.</p>
<p>Approximately one in nine South African adults have diabetes, totalling around <a href="https://diabetesatlas.org/data/en/country/185/za.html">4.2 million individuals</a>. </p>
<p>Diabetes is also the leading cause of death <a href="https://www.statssa.gov.za/publications/P03093/P030932017.pdf">among women</a> in the country. </p>
<p>As public health specialists and clinicians focusing on diabetes, we <a href="https://www.tandfonline.com/doi/full/10.1080/16089677.2024.2311497">researched</a> the standard of primary care that people living with type 2 diabetes receive in South Africa. </p>
<p>We found that the management of diabetes falls short of optimal standards, putting individuals at risk of the many side effects associated with diabetes.</p>
<h2>What we found and why it matters</h2>
<p>We examined 479 medical records of individuals diagnosed with type 2 diabetes across 23 primary healthcare facilities in the Tshwane district of Gauteng province. </p>
<p>The majority of patients were women. Patients had been living with diabetes for an average of 5.5 years. The average age was 58 years.</p>
<p>When it comes to managing diabetes, there are targets for blood glucose, blood pressure and cholesterol. We used guidelines set out by the <a href="https://www.semdsa.org.za/for-members/guidelines">Society for Endocrinology, Metabolism and Diabetes South Africa</a> for this study. </p>
<p>Our audit found a significant number of patients with type 2 diabetes were not receiving adequate treatment. </p>
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Read more:
<a href="https://theconversation.com/over-12-of-south-african-adults-have-diabetes-education-is-critical-to-achieve-good-outcomes-194502">Over 12% of South African adults have diabetes - education is critical to achieve good outcomes</a>
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<p>Only 23% of patients met the glucose target. This meant more than 70% of the patients were at risk of serious health complications.</p>
<p>Patients attended clinic visits regularly, yet they experienced prolonged periods of <a href="https://www.nhsinform.scot/illnesses-and-conditions/blood-and-lymph/hyperglycaemia-high-blood-sugar/">hyperglycaemia</a> (high blood sugar levels).</p>
<p>We also found that healthcare providers often displayed <a href="https://diabetes.medicinematters.com/quality-of-life/type-2-diabetes/tackling-clinical-inertia-the-role-of-patient-engagement/15918202">clinical inertia</a>. In other words, they failed to set targets or to initiate or adjust treatment to achieve these goals. They delayed starting or changing a patient’s treatment plan, even when it was clear the current plan wasn’t working well.</p>
<p>Factors contributing to clinical inertia included a uniform treatment approach not suited to all patients, limited treatment options and an inadequately equipped healthcare system. </p>
<p>Given the absence of comprehensive surveillance systems like <a href="https://link.springer.com/article/10.1007/s00592-020-01576-8">diabetes registries</a>, studies serve as the primary source of information regarding the implementation and quality of diabetes care in South Africa. </p>
<p>Our results aligned with various studies conducted across South Africa, including one about <a href="https://doi.org/10.1016/j.pcd.2014.05.002">a decade ago within the same district</a>.</p>
<p>A more recent study of 116,726 patients in <a href="https://doi.org/10.1016/j.pcd.2022.05.011">Cape Town</a> found three-quarters of participants had poor glycaemic control as blood sugar levels were not being managed well.</p>
<p>These consistent findings highlight the extra effort needed to overcome clinical inertia to improve diabetes care in South Africa.</p>
<h2>High cost of poor treatment</h2>
<p>For poorly managed patients, diabetes can lead to <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">severe health complications</a>, such as nerve damage, kidney issues, heart disease, stroke, vision impairment and mental health disorders.</p>
<p>For society as a whole, suboptimal diabetes care places a strain on the healthcare system and contributes to higher healthcare costs. </p>
<p>Another consequence is <a href="https://link.springer.com/article/10.1007/s11892-019-1124-7">loss of productivity</a> due to absenteeism from work and even disability, which has an <a href="http://www.samj.org.za/index.php/samj/article/view/13330/9830">economic impact on the country</a>.</p>
<h2>Ways forward</h2>
<p>Monitoring the quality of diabetes care and evaluating the effectiveness of therapies and treatment in clinical practice is a challenge in South Africa. </p>
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<a href="https://theconversation.com/diabetes-is-a-ticking-time-bomb-in-sub-saharan-africa-149766">Diabetes is a ticking time bomb in sub-Saharan Africa</a>
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<p>New strategies could include: </p>
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<li><p>adopting individualised patient-centred management with access to a wider choice of glucose-lowering drugs </p></li>
<li><p>addressing clinical inertia and the failure to intensify therapy when indicated </p></li>
<li><p>building a health system that caters for the needs of South Africans with diabetes.</p></li>
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<p>Inadequate treatment for the country’s many people living with diabetes has devastating consequences, not just for individuals and their families, but for the country’s health system at large.</p><img src="https://counter.theconversation.com/content/223909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rheeder received research funding from Eli Lilly Global health partnerships (2019-2023)</span></em></p><p class="fine-print"><em><span>Patrick Ngassa Piotie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Healthcare workers in South Africa aren’t always well equipped to treat diabetes. This has devastating consequences for patients.Patrick Ngassa Piotie, Project Manager, University of Pretoria Diabetes Research Centre, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2240062024-02-20T17:25:39Z2024-02-20T17:25:39ZOne million people in England may have undiagnosed type 2 diabetes – what you need to know<p>Around 5 million people in England (about one in nine adults) are on the cusp of developing type 2 diabetes, according to new data from the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/riskfactorsforprediabetesandundiagnosedtype2diabetesinengland/2013to2019">Office for National Statistics (ONS)</a>. </p>
<p>Experts also warn that 1 million people unknowingly already have the condition, most likely older adults. Type 2 diabetes can lead to long-term damage to your body, so an early diagnosis is crucial. Here’s what you need to know.</p>
<h2>How did the ONS arrive at this figure?</h2>
<p>This estimate of people living with diabetes came from the Health Survey for England. This randomly selects people in a way that gets a representative sample of people of different ages, genders, ethnicities and backgrounds. </p>
<p>To estimate the prevalence of diabetes, <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/riskfactorsforprediabetesandundiagnosedtype2diabetesinengland/2013to2019">26,751 adults</a> were tested out of the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2021">population of England</a>, which is around <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/populationestimatesforenglandandwales/mid2022">57 million</a>.</p>
<h2>What is type 2 diabetes?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/books/NBK581938/">Type 2 diabetes</a> is a long-term condition that affects how the body can deal with glucose (blood sugar). </p>
<p>As a result of genetics and possibly living with a higher body weight, the body becomes less sensitive to the hormone insulin, which normally helps move glucose from the blood into the muscles so it can be stored and used. This leads to insulin resistance, which can persist for decades. </p>
<p>In people who develop type 2 diabetes, their body’s ability to make enough insulin to match the resistance and control glucose starts to fail. So there is a combination of insulin resistance and reduced insulin production that results in high blood glucose and the diagnosis of type 2 diabetes.</p>
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<figcaption><span class="caption">How insulin resistance works.</span></figcaption>
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<h2>What does diabetes do to your body if left untreated?</h2>
<p>If diabetes is not well managed, it can result in short-term symptoms including increased thirst, a frequent need to pass urine, and even weight loss and blurred vision. </p>
<p>If glucose levels stay high for the longer term, it can affect how nerves work and it can affect blood flow to important organs. This can result in complications including blindness, kidney disease, heart disease, loss of sensation, and foot ulcers.</p>
<h2>What are the signs that I might have diabetes?</h2>
<p>For many people with type 2 diabetes, there may be no symptoms. Or, if there are symptoms, they can be vague like tiredness or needing to go to the toilet at night. </p>
<p>It is important to look at risk factors that include weight gain (particularly around the middle), having family members with diabetes, being of Asian or African heritage, being male, over 50, and having high blood pressure. Depending on how many of these <a href="https://arc-em.nihr.ac.uk/sites/default/files/field/attachment/Leicester%20Risk%20Score%20%E2%80%93%20English_0.pdf">risk factors</a> you have, your doctor might suggest regular tests to see if you have diabetes or are at risk of developing it. </p>
<h2>How will my doctor test for diabetes?</h2>
<p>Typically this is by a blood test, most often one called HbA1c. It measures your average blood glucose (sugar) levels for the last two-to-three months.</p>
<p>If you have a level over <a href="https://www.diabetes.org.uk/for-professionals/improving-care/clinical-recommendations-for-professionals/diagnosis-ongoing-management-monitoring/new_diagnostic_criteria_for_diabetes">48 mmol/mol</a>, it could mean that you have diabetes.</p>
<p>It is also possible to test for diabetes by measuring the glucose level in your blood. If it is above 7mmol/l (fasting) or 11.1 mmol/l (two hours after eating) and you have symptoms of thirst, weight loss and vision changes, your doctor can diagnose diabetes.</p>
<h2>Can I buy a test for diabetes that I use at home?</h2>
<p>To diagnose diabetes, you need to have a laboratory-grade test. Although you can use glucose machines to test your glucose level, they are not accurate enough to diagnose diabetes.</p>
<p>It is also best to avoid using continuous glucose monitors (as are <a href="https://www.wired.co.uk/article/zoe-nutrition-apps">fashionable</a> right now), as the spikes that these can show after eating might be <a href="https://wchh.onlinelibrary.wiley.com/doi/full/10.1002/pdi.2475">normal and not a sign of diabetes</a>.</p>
<h2>How is diabetes treated?</h2>
<p>Type 2 diabetes is treated with diet and exercise, which in some cases can even bring it into <a href="https://onlinelibrary.wiley.com/doi/10.1111/jhn.12938">remission</a> and normalise blood glucose. </p>
<p>Often it also needs to be treated with drugs, which can vary according to your weight and your blood glucose levels. </p>
<p>Typically people start on <a href="https://www.nhs.uk/medicines/metformin/">metformin</a>, but additional treatments might be needed, which can include injected treatments such as GLP-1 agonists and insulin. </p>
<h2>How will my life change if I have diabetes?</h2>
<p>Living well with diabetes often follows the same principle of trying to be healthier. It involves eating a healthy and varied diet – and going easy on refined carbohydrates and sugary foods and drinks. It also involves being as active as you can to help your muscles use glucose and remove it from the blood. If appropriate, trying to reduce your body weight can help your body’s insulin work better.</p>
<p>Alongside lifestyle changes, having regular health checks (including eye checks) and taking your medication as advised will help to reduce the risk of your diabetes leading to complications.</p>
<h2>How can I avoid getting diabetes in the first place?</h2>
<p>The best way to reduce the risk of developing diabetes is to have a healthy diet, be active, and manage your weight. A study in the US showed this approach, which helped people at risk of developing type 2 diabetes lose 7% of their body weight, reduced their risk of <a href="https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp">diabetes by 58%</a>.</p><img src="https://counter.theconversation.com/content/224006/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Duane Mellor is the research officer for the Diabetes Specialist Interest Group of the British Dietetic Association.</span></em></p>Find out the signs and symptoms of type 2 diabetes.Duane Mellor, Lead for Evidence-Based Medicine and Nutrition, Aston Medical School, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2167872023-11-14T13:25:49Z2023-11-14T13:25:49ZInsulin injections could one day be replaced with rock music − new research in mice<figure><img src="https://images.theconversation.com/files/558688/original/file-20231109-21-ic46x7.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2120%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Turns out pop songs and movie soundtracks are key to a new system to deliver insulin.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cheering-audience-at-music-concert-royalty-free-image/1384296998">Sammyvision/Moment via Getty Images</a></span></figcaption></figure><p>More than <a href="https://www.cdc.gov/diabetes/basics/diabetes.html">37 million people</a> in the U.S. have diabetes. According to the American Diabetes Association, <a href="https://www2.diabetes.org/newsroom/press-releases/2022/american-diabetes-association-announces-support-for-insulin-act-at-senate-press-conference">8.4 million Americans</a> needed to take insulin in 2022 to lower their blood sugar. Insulin, however, is <a href="https://doi.org/10.1111/jphp.12852">tricky to deliver</a> into the body orally because it is a protein easily <a href="https://theconversation.com/many-drugs-cant-withstand-stomach-acid-a-new-delivery-method-could-lead-to-more-convenient-medications-183421">destroyed in the stomach</a>.</p>
<p>While researchers are developing <a href="https://www.acs.org/pressroom/presspacs/2023/january/another-step-toward-an-insulin-tablet.html">pills that resist digestion</a> in the stomach and <a href="https://samueli.ucla.edu/smart-insulin-patch/">skin patches</a> that monitor blood sugar and automatically release insulin, the most reliable way currently to take insulin is through frequent injections.</p>
<p>I am a professor of <a href="https://medicine.iu.edu/faculty/13502/sullivan-william">pharmacology and toxicology</a> at Indiana University School of Medicine, where my colleagues and I study drug delivery systems. Researching innovative new ways to get medications into the body can improve how well patients respond to and comply with treatments. An easier way to take insulin would be music to the ears of many people with diabetes, especially those who aren’t fans of needles.</p>
<p>In a recent study in <a href="https://doi.org/10.1016/S2213-8587(23)00153-5">The Lancet Diabetes & Endocrinology</a>, researchers engineered cells to release insulin in response to specific sound waves: the music of the band Queen. Though it still has a long way to go, this new system may one day replace the insulin injection with a dose of rock ’n’ roll.</p>
<h2>What is diabetes?</h2>
<p><a href="https://www.mayoclinic.org/diseases-conditions/diabetes/symptoms-causes/syc-20371444">Diabetes is a chronic disease</a> that arises when the body fails to make enough insulin or respond to insulin. <a href="https://my.clevelandclinic.org/health/articles/22601-insulin">Insulin is a hormone</a> the pancreas makes in response to the rise in sugar concentration in the blood when the body digests food. This crucial hormone gets those sugars out of the blood and into muscles and tissues where it is used or stored for energy.</p>
<p>Without insulin, <a href="https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631">blood sugar levels remain high</a> and cause symptoms that include frequent urination, thirst, blurry vision and fatigue. Left untreated, this hyperglycemia can be life-threatening, causing organ damage and a diabetic coma. According to the U.S. Centers for Disease Control and Prevention, diabetes is the <a href="https://www.cdc.gov/diabetes/basics/diabetes.html">No. 1 cause</a> of kidney failure, lower-limb amputations and adult blindness, making it the eighth most common cause of death in the U.S.</p>
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<figcaption><span class="caption">Diabetes results when the body either doesn’t produce enough insulin or is no longer responsive to it.</span></figcaption>
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<p>Treating diabetes is straightforward: When the body is lacking insulin, give it more insulin. Scientists have <a href="https://www.vox.com/2019/4/3/18293950/why-is-insulin-so-expensive">mastered how to make the hormone</a>, but direct injection is the only effective way to get it into the body. Diabetic patients usually have to carry insulin vials and needles wherever they go. Considering that <a href="https://theconversation.com/over-half-of-adults-unvaccinated-for-covid-19-fear-needles-heres-whats-proven-to-help-161636">many people fear needles</a>, this may not be an ideal way to manage the disease.</p>
<p>This challenge has sparked researchers to look into new ways to deliver insulin more easily.</p>
<h2>What is cellular engineering?</h2>
<p>Cells are the basic unit of life. Your body is composed of <a href="https://pubmed.ncbi.nlm.nih.gov/35832316/">hundreds of different types of cells</a> that carry out specialized functions. In some diabetic patients, the pancreatic beta cells that make insulin have malfunctioned or died. What if there were a way to replace these defective cells with new ones that could produce insulin on demand?</p>
<p>That’s where cellular engineering comes in. <a href="https://doi.org/10.1126/science.adf8627">Cellular engineering</a> involves genetically modifying a cell to perform a specific function, like producing insulin. <a href="https://medlineplus.gov/genetics/gene/ins/">Installing the gene that makes insulin</a> into cells is not difficult, but controlling when the cell makes it has been a challenge. Insulin should be made only in response to high blood sugar levels following a meal, not at any other time.</p>
<p>Scientists have been exploring the idea of using <a href="https://www.britannica.com/science/ion-channel">ion channels</a> – proteins embedded in a cell’s membrane that regulate the flow of ions such as calcium or chloride – like a remote-controlled device to activate cellular activity. Cells with specific types of ion channel in their membranes can be <a href="https://doi.org/10.1126/science.abb9122">activated in response to certain stimuli</a>, such as light, electricity, magnetic fields or mechanical stimulation. Such ion channels exist naturally as sensory devices to help cells and organisms respond to light, magnetism, touch or sound. For example, <a href="https://doi.org/10.1016/j.neuron.2018.07.033">hair cells in the inner ear</a> have mechanosensitive ion channels that respond to sound waves. </p>
<h2>Combining cellular engineering with Queen</h2>
<p>Bioengineering professor <a href="https://scholar.google.com/citations?user=Re5ypoQAAAAJ&hl=en">Martin Fussenegger</a> of ETH Zurich, a university in Basel, Switzerland, led a recent study that used a mechanosensitive ion channel as a remote control to signal cells to <a href="https://doi.org/10.1016/S2213-8587(23)00153-5">make insulin in response to specific sound waves</a>.</p>
<p>These “MUSIC-controlled, insulin-releasing cells” – MUSIC is short for music-inducible cellular control – were cultured in the lab next to loudspeakers. His team tested a variety of musical genres of different intensities and speeds.</p>
<p>Among the songs they played were pop songs like Michael Jackson’s “Billie Jean,” Queen’s “We Will Rock You” and the Eagles’ “Hotel California”; classical pieces such as Beethoven’s “Für Elise” and Mozart’s “Alla Turca”; and movie themes such as Soundgarden’s “Live To Rise,” which was featured in “The Avengers,” a Marvel film. They found that pop music heavy in low bass and movie soundtracks were better able to trigger insulin release compared with classical music, and cells were able to release insulin within minutes of exposure to the song.</p>
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<span class="caption">Many people with diabetes have to take frequent insulin injections to control their blood sugar levels.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/taking-an-insulin-shot-at-home-royalty-free-image/1426368585">Caíque de Abreu/E+ via Getty Images</a></span>
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<p>In particular, they found that the Queen song “<a href="https://www.youtube.com/watch?v=-tJYN-eG1zk">We Will Rock You</a>” most faithfully mimicked the rate of insulin release in normal pancreatic beta cells.</p>
<p>The team then implanted the MUSIC-controlled, insulin-releasing cells into diabetic mice. Listening to the Queen song for 15 minutes once a day returned the amount of insulin in their blood to normal levels. Blood sugar levels returned to normal as well. In contrast, mice that were not exposed to the song remained hyperglycemic.</p>
<h2>Could music make insulin in people?</h2>
<p>Despite these promising results, much more research is needed before this musical approach to producing insulin can be considered for human use.</p>
<p>One concern is the possibility of making too much insulin, which can also cause <a href="https://www.mayoclinic.org/diseases-conditions/hypoglycemia/symptoms-causes/syc-20373685">health problems</a>. Fussenegger’s study found that talking and background noise such as the racket made by airplanes, lawn mowers or firetrucks did not trigger the insulin production system in mice. The music also needed to be played close to the abdomen where the MUSIC-controlled, insulin-releasing cells were implanted.</p>
<p>In an email, Fussenegger explained that extensive clinical trials must be performed to ensure efficacy and safety of the technique and to determine how long the cellular implants can last. As with introducing any foreign material into the body, <a href="https://medlineplus.gov/ency/article/000815.htm">tissue rejection</a> is also a concern.</p>
<p>Cellular engineering may one day provide a much-needed alternative to frequent injections of insulin for the millions of people with diabetes around the world. In the future, different cell types could be engineered to release other drugs in the body more conveniently.</p><img src="https://counter.theconversation.com/content/216787/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill Sullivan receives funding from the National Institutes of Health.</span></em></p>Researchers successfully treated diabetes in mice by engineering cells to make insulin in response to the music of Queen.Bill Sullivan, Professor of Pharmacology & Toxicology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2169692023-11-03T16:38:11Z2023-11-03T16:38:11ZIs salt really a new culprit in type 2 diabetes?<figure><img src="https://images.theconversation.com/files/557450/original/file-20231103-27-mwn4i0.jpg?ixlib=rb-1.1.0&rect=0%2C11%2C7348%2C4891&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-wooden-table-salt-shaker-close-402073258">HandmadePictures/Shutterstock</a></span></figcaption></figure><p>When people think of foods related to type 2 diabetes, they often think of sugar (even though the <a href="https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/food-groups/sugar-and-diabetes#:%7E:text=Though%20we%20know%20sugar%20doesn,contain%20a%20lot%20of%20calories.">evidence for that is still not clear</a>). Now, a <a href="https://www.mayoclinicproceedings.org/action/showPdf?pii=S0025-6196%2823%2900118-0">new study from the US</a> points the finger at salt.</p>
<p>The study, conducted by researchers at Tulane University in New Orleans, used data on about 400,000 adults, taken from the <a href="https://www.ukbiobank.ac.uk/learn-more-about-uk-biobank">UK Biobank study</a>. The researchers followed the participants for nearly twelve years. In that time, around 13,000 developed type 2 diabetes.</p>
<p>In a press release, the principal investigator on the study <a href="https://www.eurekalert.org/news-releases/1006466">said</a> that “taking the saltshaker off the table can help prevent type 2 diabetes”. But is it really as simple as that?</p>
<p>For a start, this type of study, called an observational study, cannot prove <a href="https://academic.oup.com/book/25215/chapter-abstract/189683227?redirectedFrom=fulltext#">that one thing causes another</a>, only that one thing is related to another. (There could be other factors at play.) So it is not appropriate to say removing the saltshaker “can help prevent”. </p>
<p>My colleague Dan Green and I have previously <a href="https://onlinelibrary.wiley.com/doi/10.1111/jhn.13155">criticised</a> university press releases such as this as they can lead to misleading <a href="https://www.thetimes.co.uk/article/salt-type-2-diabetes-study-d79j6dx5f">news stories</a>. The Tulane study can only suggest an association between salt use and the risk of developing type 2 diabetes – nothing more. </p>
<p>This is before considering the quality of the data itself. </p>
<p>The data used to assess salt use, was based on the simple question: “Do you add salt to your food?” (It specifically excluded salt added in cooking.) </p>
<p>The question the participants in the study answered only had the options: “never/rarely”, “sometimes”, “usually” or “always”. This means it is not possible to estimate from the answers how much salt might be associated with an increased risk of developing type 2 diabetes. </p>
<h2>Processed food is the biggest source</h2>
<p>Normal salt intake in countries like the UK is about 8g or two teaspoons a day. But about three-quarters of this comes <a href="https://www.actiononsalt.org.uk/uk-20salt-20reduction-20programme/145617.html/#:%7E:text=The%20average%20person%20in%20the,8.1g%20salt%20a%20day.">from processed foods</a>. Most of the rest is added during cooking with very little added at the table. </p>
<p>The NHS advises that people should limit their daily salt intake to around 6g. Although people in the UK have reduced their salt intake over the last couple of decades, there is <a href="https://www.theguardian.com/politics/2023/sep/19/end-of-salt-reduction-drive-led-to-24000-premature-deaths-in-england-study">still a way to go</a>. </p>
<p>Given that salt reduction is a public health goal, it is important to be able to quantify intake to see if there is potential for what is known as a “dose-response” effect. The data reported was unable to suggest if consuming 2g of salt a day added at the table increases the risk of developing type 2 diabetes more than consuming, say, 1g a day.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/tm2JQVBMSU0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dose response explained.</span></figcaption>
</figure>
<p>The researchers used other tests of salt intake, including an estimate of how much salt participants lost in their urine over 24 hours. This is the most accurate way to measure <a href="https://pubmed.ncbi.nlm.nih.gov/26895296/#:%7E:text=24%2Dh%20urinary%20sodium%20excretion%20is%20the%20gold%20standard%20for,high%20participant%20burden%20and%20cost.">sodium or salt intake</a>. </p>
<p>This approach also suggested that higher sodium in the urine was linked to a higher risk of developing type 2 diabetes. However, what participants ate was not considered at all in this analysis. So it is not clear if salt can be directly implicated in increasing a person’s risk of developing type 2 diabetes.</p>
<p>There is some evidence that increasing salt intake, as measured by sodium in urine may be linked to increased levels of the stress <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/cen.12225?casa_token=IIO5k9JsOPcAAAAA%3AXlr4v0c64_9U9ULuHtg78d4qCQGCcdxF_GU8oYyXzfLgQivRcLtJdeL6tCe7BGJBR1LCr6vpBjPvQw">hormone cortisol</a>. This has been linked to increased blood pressure and the reduced effectiveness of the hormone insulin. </p>
<p>Insulin normally controls blood glucose levels and is a key part of how type 2 diabetes develops. However, evidence for this mechanism has only been shown <a href="https://link.springer.com/article/10.1007/s00125-014-3373-y">in rats</a>. </p>
<h2>Reducing salt is still a good idea</h2>
<p>What we can be more sure about is that people with type 2 diabetes, who often also have high blood pressure tend to see their blood pressure improve when they <a href="https://link.springer.com/article/10.1007/s13340-017-0305-3">consume less salt</a>. </p>
<p>So the take-home message is: using less salt as part of a healthy diet, which is known to reduce the risk of type 2 diabetes, is a good idea. </p>
<p>This study did not show how much we need to reduce our salt intake by, it only suggested a weak association between adding salt to food and risk of developing type 2 diabetes. So it is better to focus on what is known to <a href="https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp">reduce the risk of developing type 2 diabetes</a>, which is to maintain a healthy weight, be physically active and eat a <a href="https://www.sciencedirect.com/science/article/pii/S0168822710002019?casa_token=TPc8Ei1OTiEAAAAA:4IP9uceBr0B_p-MxZGgR2F_uQE0cxO8hME_sLKtkOnN2e1NCfLtwYX8pv7FLic3TrBzzCiI4">healthy diet</a>.</p><img src="https://counter.theconversation.com/content/216969/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Duane Mellor is a member of the British Dietetic Association</span></em></p>A new study suggests that adding salt to your food at the table is linked to an increased risk of type 2 diabetes. But caution is needed.Duane Mellor, Lead for Evidence-Based Medicine and Nutrition, Aston Medical School, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2059192023-08-14T20:00:06Z2023-08-14T20:00:06Z1 in 6 women are diagnosed with gestational diabetes. But this diagnosis may not benefit them or their babies<figure><img src="https://images.theconversation.com/files/539721/original/file-20230727-18363-k1nhbm.jpg?ixlib=rb-1.1.0&rect=115%2C49%2C5390%2C3615&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-pregnant-woman-worried-about-her-2210916539">Shutterstock</a></span></figcaption></figure><p>When Sophie was pregnant with her first baby, she had an <a href="https://www.ncbi.nlm.nih.gov/books/NBK279331/#:%7E:text=Oral%20glucose%20tolerance%20tests%20(OGTT,enough%20by%20the%20body's%20cells.)">oral glucose tolerance</a> blood test. A few days later, the hospital phoned telling her she had gestational diabetes.</p>
<p>Despite having only a slightly raised glucose (blood sugar) level, Sophie describes being diagnosed as affecting her pregnancy tremendously. She tested her blood glucose levels four times a day, kept food diaries and had extra appointments with doctors and dietitians. </p>
<p>She was advised to have an induction because of the risk of having a large baby. At 39 weeks her son was born, weighing a very average 3.5kg. But he was separated from Sophie for four hours so his glucose levels could be monitored. </p>
<p>Sophie is not alone. About <a href="https://www.aihw.gov.au/reports/diabetes/diabetes/contents/how-many-australians-have-diabetes/gestational-diabetes">one in six</a> pregnant women in Australia are now diagnosed with gestational diabetes. </p>
<p>That was not always so. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827530/">New criteria</a> were developed in 2010 which dropped an initial screening test and lowered the diagnostic set-points. Gestational diabetes diagnoses have since <a href="https://www.aihw.gov.au/reports/diabetes/diabetes/contents/how-many-australians-have-diabetes/gestational-diabetes">more than doubled</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Gestational diabetes rates more than doubled after the threshold changed.</span>
<span class="attribution"><span class="source">AIHW</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>But <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2204091">recent</a> <a href="https://pubmed.ncbi.nlm.nih.gov/33704936/">studies</a> cast doubt on the ways we diagnose and manage gestational diabetes, especially for women like Sophie with only mildly elevated glucose. Here’s what’s wrong with gestational diabetes screening.</p>
<h2>The glucose test is unreliable</h2>
<p>The test used to diagnose gestational diabetes – the oral glucose tolerance test – has poor reproducibility. This means subsequent tests may give a different result.</p>
<p>In a <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2214956">recent Australian trial</a> of earlier testing in pregnancy, one-third of the women initially classified as having gestational diabetes (but neither told nor treated) did not have gestational diabetes when retested later in pregnancy. That is a problem. </p>
<p>Usually when a test has poor reproducibility – for example, blood pressure or cholesterol – we repeat the test to confirm before making a diagnosis. </p>
<p>Much of the increase in the incidence of gestational diabetes after the introduction of new diagnostic criteria was due to the switch from using two tests to only using a single test for diagnosis.</p>
<figure class="align-center ">
<img alt="Pregnant woman cooks dinner with her child" src="https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women with only mildly elevated glucose levels are being diagnosed with gestational diabetes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/black-pregnant-woman-cooking-her-daughter-2019300152">Shutterstock</a></span>
</figcaption>
</figure>
<h2>The thresholds are too low</h2>
<p>Despite little evidence of benefit for either women or babies, the current Australian criteria diagnose women with only mildly abnormal results as having “gestational diabetes”. </p>
<p>Recent studies have shown this doesn’t benefit women and may cause harms. A <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2204091">New Zealand trial</a> of more than 4,000 women randomly assigned women to be assessed based on the current Australian thresholds or to higher threshold levels (similar to the pre-2010 criteria). </p>
<p>The trial found no additional benefit from using the current low threshold levels, with overall no difference in the proportion of infants born large for gestational age. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sixteen-pound-baby-born-in-brazil-heres-what-increases-the-risk-of-giving-birth-to-a-giant-baby-198423">Sixteen-pound baby born in Brazil: here's what increases the risk of giving birth to a giant baby</a>
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<hr>
<p>However, the trial found several harms, including more neonatal hypoglycaemia (low blood sugar in newborns), induction of labour, use of diabetic medications including insulin injections, and use of health services. </p>
<p>The study authors also looked at the subgroup of women who were diagnosed with glucose levels between the higher and lower thresholds. In this subgroup, there was some reduction in large babies, and in shoulder problems at delivery. </p>
<p>But there was also an increase in small babies. This is of concern because being small for gestational age can also have consequences for babies, including long-term health consequences.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=438&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=438&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=438&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">NEJM</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Testing too early</h2>
<p>Some centres have begun testing women at higher risk of gestational diabetes earlier in the pregnancy (between 12 and 20 weeks).</p>
<p>However, a <a href="https://pubmed.ncbi.nlm.nih.gov/37144983/">recent trial</a> showed no clear benefit compared with testing at the usual 24–28 weeks: possibly fewer large babies, but again matched by more small babies.</p>
<p>There was a reduction in transient “respiratory distress” – needing extra oxygen for a few hours – but not in serious clinical events. </p>
<h2>Impact on women with gestational diabetes</h2>
<p>For women diagnosed using the higher glucose thresholds, dietary advice, glucose monitoring and, where necessary, insulin therapy has been shown to reduce complications during delivery and the post-natal period. </p>
<p>However, current models of care can also cause harm. Women with gestational diabetes are often denied their preferred model of care – for example, midwifery continuity of carer. In rural areas, they may have to transfer to a larger hospital, requiring longer travel to antenatal visits and moving to a larger centre for their birth – away from their families and support networks for several weeks. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">Are you at risk of being diagnosed with gestational diabetes? It depends on where you live</a>
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<hr>
<p>Women say the diagnosis often dominates their antenatal care and their whole <a href="https://pubmed.ncbi.nlm.nih.gov/32028931/">experience of pregnancy</a>, reducing time for other issues or concerns. </p>
<p>Women from culturally and linguistically diverse communities <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-021-03981-5">find it difficult</a> to reconcile the advice given about diet and exercise with their own cultural practices and beliefs about pregnancy.</p>
<p>Some women with gestational diabetes <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-2745-1">become</a> extremely anxious about their eating and undertake extensive calorie restrictions or disordered eating habits.</p>
<figure class="align-center ">
<img alt="Woman stands in garden looking at her pregnant belly" src="https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some pregnant women become extremely anxious after being diagnosed with gestational diabetes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/gYnEka3-tCI">Unsplash/Jordan Bauer</a></span>
</figcaption>
</figure>
<h2>Time to reassess the advice</h2>
<p>Recent evidence from both randomised controlled trials and from qualitative studies with women diagnosed with gestational diabetes suggest we need to reassess how we currently diagnose and manage gestational diabetes, particularly for women with only slightly elevated levels.</p>
<p>It is time for a review to consider all the problems described above. This review should include the views of all those impacted by these decisions: women in childbearing years, and the GPs, dietitians, diabetes educators, midwives and obstetricians who care for them.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/had-gestational-diabetes-here-are-5-things-to-help-lower-your-future-risk-of-type-2-diabetes-114298">Had gestational diabetes? Here are 5 things to help lower your future risk of type 2 diabetes</a>
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</em>
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<p><em>This article was co-authored by maternity services consumer advocate Leah Hardiman.</em></p><img src="https://counter.theconversation.com/content/205919/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC Investigator grant.</span></em></p><p class="fine-print"><em><span>Jenny Doust receives funding from NHMRC and MRFF. </span></em></p>About one in six pregnant women in Australia are now diagnosed with gestational diabetes. Rates have more than doubled since the thresholds for diagnosis were changed.Paul Glasziou, Professor of Medicine, Bond UniversityJenny Doust, Clinical Professorial Research Fellow, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2068482023-07-20T12:29:04Z2023-07-20T12:29:04ZBlame capitalism? Why hundreds of decades-old yet vital drugs are nearly impossible to find<figure><img src="https://images.theconversation.com/files/537557/original/file-20230714-29-wo8n77.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C6000%2C3970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is presently no end in sight to the drug supply shortage. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-pharmacist-checking-the-shelves-with-a-royalty-free-image/1344251576?phrase=generic+drugs&adppopup=true">FG Trade/E+ via Getty Images</a></span></figcaption></figure><p><a href="https://www.npr.org/sections/health-shots/2019/12/31/792617538/a-decade-marked-by-outrage-over-drug-prices">Past public ire</a> over high drug prices has recently taken a back seat to a more insidious problem – <a href="https://pharmanewsintel.com/features/drug-shortages-a-growing-concern-for-the-healthcare-industry-worldwide">no drugs</a> <a href="https://www.nytimes.com/2023/05/17/health/drug-shortages-cancer.html">at any price</a>.</p>
<p>Patients and their providers increasingly face <a href="https://www.nytimes.com/2023/06/26/health/cancer-drugs-shortage.html">limited or nonexistent supplies of drugs</a>, many of which treat essential conditions such as cancer, heart disease and bacterial infections. The American Society of Health System Pharmacists now <a href="https://www.ashp.org/products-and-services/database-licensing-and-integration/ashp-drug-shortages">lists over 300 active shortages</a>, primarily of decades-old generic drugs no longer protected by patents.</p>
<p>While this is not a new problem, the number of drugs in short supply has increased in recent years, and the average shortage is lasting longer, with more than 15 critical drug products <a href="https://www.hsgac.senate.gov/wp-content/uploads/2023-03-20-HSGAC-Majority-Draft-Drug-Shortages-Report.pdf">in short supply for over a decade</a>. Current shortages <a href="https://www.ashp.org/drug-shortages/current-shortages/drug-shortages-list?">include widely known drugs</a> such as the antibiotic amoxicillin; the heart medicine digoxin; the anesthetic lidocaine; and the medicine albuterol, which is critical for treating asthma and other diseases affecting the lungs and airways.</p>
<p>What’s going on?</p>
<p>I’m a <a href="https://scholar.google.com/citations?user=3jf-nyIAAAAJ&hl=en&oi=ao">health economist</a> who has studied the pharmaceutical industry for the past 15 years. I believe the drug shortage problem illustrates a major shortcoming of capitalism. While costly brand-name drugs often yield high profits to manufacturers, there’s relatively little money to be made in supplying the market with low-cost generics, no matter how vital they may be to patients’ health. </p>
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<figcaption><span class="caption">The shortage includes chemotherapy drugs, antibiotics, medications to treat ADHD and other critical drugs. Some patients are able to get their drugs, while others are not, and in some cases patients are getting ‘rationed care.’</span></figcaption>
</figure>
<h2>A generic problem</h2>
<p>The problem boils down to the nature of the pharmaceutical industry and how differently the markets for brand and generic drugs operate. Perhaps the clearest indication of this is the fact that <a href="https://www.rand.org/pubs/research_reports/RR2956.html">prices of brand drugs in the U.S. are among the highest</a> in the developed world, while generic drug prices are among the lowest. </p>
<p>When a drugmaker develops a new pill, cream or solution, the government grants the company an exclusive patent for up to 20 years, although most patents are filed before clinical testing, and thus the effective patent life is closer to eight to 12 years. Nonetheless, patents allow the drugmakers to cover the cost of research and development and earn a profit without the threat of competition from a rival making an identical product.</p>
<p>But once the patent expires, the drug becomes generic and any company is allowed to manufacture it. Since generic manufacturers are essentially producing the same product, profits are determined by their ability to manufacture the drug at the lowest marginal cost. This often results in low profit margins and can lead to cost-cutting measures that can compromise quality and threaten supply. </p>
<h2>Outsourced production creates more supply risks</h2>
<p>One of the consequences of generics’ meager margins is that drug companies outsource production to lower-cost countries.</p>
<p>As of mid-2019, 72% of the manufacturing facilities making active ingredients for drugs sold in the U.S. <a href="https://www.fda.gov/news-events/congressional-testimony/safeguarding-pharmaceutical-supply-chains-global-economy-10302019">were located overseas</a>, with India and China alone making up nearly half of that. </p>
<p>While overseas manufacturers often <a href="https://openknowledge.worldbank.org/server/api/core/bitstreams/3842481d-7bc7-532b-8cd2-ab30f57c6519/content">enjoy significant cost advantages</a> over U.S. facilities, such as easy access to raw materials and lower labor costs, outsourcing production at such a scale raises a slew of issues that can hurt the supply. <a href="https://www.nytimes.com/2011/08/13/science/13drug.html?pagewanted=al">Foreign factories are more difficult</a> for the <a href="https://theconversation.com/the-fdas-lax-oversight-of-research-in-developing-countries-can-do-harm-to-vulnerable-participants-170515">Food and Drug Administration to inspect</a>, tend to have more production problems and are far more likely than domestic factories to be shut down once a problem is discovered. </p>
<p><a href="https://www.fda.gov/news-events/congressional-testimony/safeguarding-pharmaceutical-supply-chains-global-economy-10302019">In testimony to a House subcommittee</a>, Janet Woodcock, the FDA’s principal deputy commissioner, acknowledged that the agency has little information on which Chinese facilities are producing raw ingredients, how much they are producing, or where the ingredients they are producing are being distributed worldwide. </p>
<p>The COVID-19 pandemic underscored the country’s reliance on foreign suppliers – and the risks this poses to U.S. consumers.</p>
<p>India is the world’s largest producer of generic drugs but imports 70% of its raw materials from China. About <a href="https://www.cidrap.umn.edu/sites/default/files/downloads/cidrap-covid19-viewpoint-part6.pdf">one-third of factories</a> in China shut down during the pandemic. To ensure domestic supplies, the Indian government restricted the export of medications, <a href="https://www.nytimes.com/2020/03/03/business/coronavirus-india-drugs.html">disrupting the global supply chain</a>. This led to shortages of drugs to treat COVID-19, such as for respiratory failure and sedation, as well as for a wide range of other conditions, <a href="https://www.uspharmacist.com/article/drug-shortages-amid-the-covid19-pandemic">like drugs to treat chemotherapy</a>, heart disease and bacterial infections. </p>
<h2>Low profits hurt quality</h2>
<p>Manufacturing drugs to consistently high quality standards requires constant testing and evaluation. </p>
<p>A company that sells a new, expensive, branded drug has a strong profit motive to keep quality and production high. That’s often not the case for generic drug manufacturers, and <a href="https://www.statnews.com/2020/06/02/bring-manufacturing-generic-drugs-back-to-u-s/">this can result in shortages</a>. </p>
<p>In 2008, an adulterated version of the blood-thinning drug Heparin <a href="https://www.pharmaceutical-technology.com/features/generic-drug-safety-us-regulators-struggle-global-market">was recalled worldwide</a> after being linked to 350 adverse events and 150 deaths in the U.S. alone.</p>
<p>In 2013, the Department of Justice <a href="https://oig.hhs.gov/fraud/enforcement/generic-drug-manufacturer-ranbaxy-pleads-guilty-and-agrees-to-pay-500-million-to-resolve-false-claims-allegations-cgmp-violations-and-false-statements-to-the-fda/#">fined the U.S. subsidiary of Ranbaxy Laboratories</a>, India’s largest generic drug manufacturer, US$500 million after it pleaded guilty to civil and criminal charges related to drug safety and falsifying safety data. In response, the FDA banned products made at four of the company’s manufacturing facilities in India from entering the U.S., <a href="https://www.nytimes.com/2013/05/14/business/global/ranbaxy-in-500-million-settlement-of-generic-drug-case.html">including generic versions of gabapentin</a>, which treats epilepsy and nerve pain, and the antibiotic ciprofloxacin.</p>
<p>And while there may be multiple companies selling the same generic drug in the U.S., there may be only a single manufacturer supplying the basic ingredients. Thus, any hiccup in production or shutdown due to quality issues can affect the entire market.</p>
<p>A recent analysis found that approximately 40% of generic drugs sold in the U.S. <a href="https://ssrn.com/abstract=3011139">have just one manufacturer</a>, and the share of markets supplied by just one or two manufacturers has increased over time. </p>
<figure class="align-center ">
<img alt="A man in a suit points in front of a lectern that says $30 insulin, with fridges of insulin in the background." src="https://images.theconversation.com/files/537321/original/file-20230713-19-4vturh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537321/original/file-20230713-19-4vturh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537321/original/file-20230713-19-4vturh.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537321/original/file-20230713-19-4vturh.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537321/original/file-20230713-19-4vturh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537321/original/file-20230713-19-4vturh.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537321/original/file-20230713-19-4vturh.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">California Gov. Gavin Newsom partnered with Civica Rx to manufacture insulin for the state.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/CaliforniaGovernor/fb9c46b454aa451b87d3120061aa4fd2/photo?Query=insulin%20california&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=27&currentItemNo=6">AP Photo/Damian Dovarganes</a></span>
</figcaption>
</figure>
<h2>Repatriating the drug supply</h2>
<p>It is hard to quantify the impact of drug shortages on population health. However, a recent survey of U.S. hospitals, pharmacists and other health care providers found that drug shortages <a href="https://www.usp.org/sites/default/files/usp/document/supply-chain/pediatric-oncology-drugs-and-supply-chain.pdf">led to increased medication errors</a>, delayed administration of lifesaving therapies, inferior outcomes and patient deaths. </p>
<p>What can be done?</p>
<p>One option is to simply find ways to produce more generic drugs in the U.S.</p>
<p>California <a href="https://nashp.org/california-enacts-law-to-produce-generic-prescription-drugs/#">passed a law</a> in 2020 to do just that by allowing the state to contract with domestic manufactures to produce its own generic prescription drugs. In March 2023, California <a href="https://californiahealthline.org/news/article/california-generic-insulin-contract-civica-rx-newsom/">selected a Utah company</a> to begin producing low-cost insulin for California patients.</p>
<p>Whether this approach is feasible on a broader scale is uncertain, but, in my view, it’s a good first attempt to repatriate America’s drug supply.</p><img src="https://counter.theconversation.com/content/206848/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Geoffrey Joyce does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The shortages, which have been going on for years, have typically affected only low-cost generics rather than profitable brand-name drugs.Geoffrey Joyce, Director of Health Policy, USC Schaeffer Center, and Associate Professor, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2009882023-03-03T19:39:29Z2023-03-03T19:39:29ZEli Lilly is cutting insulin prices and capping copays at $35 – 5 questions answered<figure><img src="https://images.theconversation.com/files/513277/original/file-20230302-29-2ho2wi.jpg?ixlib=rb-1.1.0&rect=0%2C603%2C6498%2C3822&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetes management is becoming more affordable in the U.S. after years of price hikes.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/in-this-photo-illustration-a-man-looks-at-his-supplies-for-news-photo/1235021851">Matt Harbicht/Getty Images for Tandem Diabetes Care</a></span></figcaption></figure><p><em>Pharmaceutical giant Eli Lilly is <a href="https://www.nbcnews.com/health/health-news/eli-lilly-caps-cost-insulin-35-month-rcna72713">slashing the list prices for some of its most popular insulin products</a> by 70% and <a href="https://apnews.com/article/insulin-diabetes-humalog-humulin-prescription-drugs-eli-lilly-lantus-419db92bfe554894bdc9c7463f2f3183">capping insulin copays at US$35</a> for uninsured patients and those with private health insurance. These changes follow efforts by the <a href="https://aspe.hhs.gov/sites/default/files/documents/bd5568fa0e8a59c2225b2e0b93d5ae5b/aspe-insulin-affordibility-datapoint.pdf">federal government</a>, the <a href="https://www.vox.com/policy-and-politics/23574178/insulin-cost-california-biden-medicare-coverage">California state government</a>, <a href="https://theconversation.com/nonprofit-drugmaker-civica-rx-is-taking-aim-at-the-high-insulin-prices-harming-people-with-diabetes-182204">nonprofits</a> and <a href="https://www.mobihealthnews.com/news/mark-cuban-cost-plus-drug-company-partners-diabetes-management-platform">some companies</a> to make insulin more affordable for the <a href="https://news.yale.edu/2022/07/05/insulin-extreme-financial-burden-over-14-americans-who-use-it">more than 7 million</a> Americans with diabetes who require it.</em></p>
<p><em>The Conversation asked <a href="https://scholar.google.com/citations?user=E3XmWfEAAAAJ&hl=en&oi=sra">Dana Goldman</a> and <a href="https://healthpolicy.usc.edu/director/karen-van-nuys-ph-d/">Karen Van Nuys</a>, two scholars who have <a href="https://doi.org/10.2337/dci18-0019">researched insulin pricing</a>, to explain why Eli Lilly is dramatically cutting the cost of some of its insulin products and to sum up how it may improve access to this essential medical treatment.</em></p>
<h2>1. Why is Lilly reducing prices now?</h2>
<p>High insulin prices have not earned any U.S. manufacturer many friends, with list prices <a href="https://www.goodrx.com/healthcare-access/research/how-much-does-insulin-cost-compare-brands">increasing 54% from 2014 to 2019</a>.</p>
<p>Most troublingly, <a href="https://lowninstitute.org/1-3-million-americans-forced-to-ration-insulin-new-study-estimates/">an estimated 1.3 million</a> uninsured people with diabetes and patients <a href="https://www.acpjournals.org/doi/10.7326/M22-2477">with inadequate insurance have resorted to rationing</a> their insulin. Skipping doses because of high insulin prices has sometimes had <a href="https://khn.org/news/insulins-high-cost-leads-to-deadly-rationing/">tragic and even deadly consequences</a>.</p>
<p>But growing competition has shaken up the insulin market in recent years.</p>
<p>For example, Walmart introduced its own <a href="https://corporate.walmart.com/newsroom/2021/06/29/walmart-revolutionizes-insulin-access-affordability-for-patients-with-diabetes-with-the-launch-of-the-first-and-only-private-brand-analog-insulin">private-brand insulin</a> in 2021. Mylan, a large generic drugmaker, developed a version of long-acting insulin called Semglee, priced 65% lower than its branded competitor. But few consumers use those products.</p>
<p>Efforts to produce cheaper insulin by the nonprofit drugmaker <a href="https://civicarx.org/civica-to-manufacture-and-distribute-affordable-insulin/">CivicaRx</a> and the <a href="https://www.theverge.com/2022/7/8/23200404/california-insulin-drug-prices-governor-newsom">state of California</a> are several years out and won’t provide immediate relief.</p>
<p>Then there’s the <a href="https://aspe.hhs.gov/sites/default/files/documents/bd5568fa0e8a59c2225b2e0b93d5ae5b/aspe-insulin-affordibility-datapoint.pdf">Inflation Reduction Act</a>, a big spending package Congress approved in 2022. It capped insulin out-of-pocket costs at $35 for <a href="https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare">Americans with Medicare</a>, a government health insurance program that covers people over 65. </p>
<p>And, in fact, Lilly itself has been trying to disrupt insulin prices. In 2019, the drugmaker introduced <a href="https://investor.lilly.com/news-releases/news-release-details/lilly-introduce-lower-priced-insulin">insulin lispro</a>, a lower-cost version of its blockbuster insulin, Humalog.</p>
<p><iframe id="UW6jg" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/UW6jg/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>2. What does this mean for Americans who need insulin?</h2>
<p>Part of the problem with the existing system is that some patients, especially if they’re uninsured or have high deductibles, end up paying the list price – which can mean spending <a href="https://www.nytimes.com/2023/03/01/business/insulin-price-cap-eli-lilly.html">$1,000 or more a month</a> on insulin. This can be a crushing financial burden.</p>
<p>Lilly’s new $35 out-of-pocket cap means that privately insured patients and those without insurance requiring insulin will spend no more than that monthly for copays. Its 70% reduction in the list price of two popular name brand insulins, Humalog and Humulin, will bring some financial relief. And the company has also reduced its generic lispro’s list price to $25 a vial, <a href="https://www.goodrx.com/conditions/diabetes-type-2/guide-to-saving-on-insulin#authorized-generic-insulins">down from $126</a>.</p>
<p>The evidence is clear that these <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8342747/">price reductions will improve patient adherence</a> – which means fewer missed doses of this lifesaving medication.</p>
<h2>3. How might Lilly’s actions affect the whole industry?</h2>
<p>Lilly has put pressure on its biggest competitors, Novo Nordisk and Sanofi, to follow suit.</p>
<p>These lower prices could also make Lilly’s insulins affordable to cash-paying patients. As a result, these insulins could be added to the list of drugs provided by pharmacies that are disrupting the U.S. prescription drug industry, like <a href="https://costplusdrugs.com/">Mark Cuban’s Cost Plus Drug Co.</a> and <a href="https://blueberrypharmacy.com/">Blueberry Pharmacy</a>. These companies provide low-cost drugs with transparent markups or through membership programs, typically without insurance.</p>
<h2>4. Why did insulin get so expensive in the US?</h2>
<p>That lispro, Lilly’s own, cheaper authorized generic insulin, hasn’t completely displaced the equivalent name brand Humalog in the market by now may seem surprising. But it is the result of the complex U.S. prescription drug distribution system.</p>
<p>Insulin prices are the <a href="https://news.usc.edu/194289/insulin-costs/">result of a complex set of negotiations</a> between manufacturers and pharmacy benefit managers, which act on behalf of insurers. The three largest – CVS Caremark, Express Scripts and Optum Rx – <a href="https://www.xcenda.com/-/media/assets/xcenda/english/content-assets/white-papers-issue-briefs-studies-pdf/xcenda_pbm_exclusion_may_2022.pdf">handle about 80% of all prescriptions</a>.</p>
<p>These middlemen negotiate directly with Lilly and other insulin manufacturers, focusing on two key sums: the list price and the rebate. Manufacturers are paid the list price but then must pay a rebate to the pharmacy benefit managers.</p>
<p>How do pharmacy benefit managers get manufacturers to pay rebates? They maintain formularies – lists of drugs that patients in a health plan can access. If an insulin manufacturer wants to supply diabetes patients, it needs to remain on those formularies. And doing so requires the manufacturer to pay bigger rebates. Otherwise, pharmacy benefit managers can exclude the manufacturer.</p>
<p>In 2016, OptumRx, which negotiates insulin prices for about 28 million people, excluded only four types of insulin from its formulary. By 2022, OptumRx <a href="https://www.xcenda.com/-/media/assets/xcenda/english/content-assets/white-papers-issue-briefs-studies-pdf/xcenda_pbm_exclusion_may_2022.pdf">was excluding 13 insulins</a>.</p>
<p>Keeping insulin on formularies, in short, has required high rebates, and list prices have increased along with them. Ironically, as insulin list prices have been rising, manufacturers have been making less money off of insulin sales, while <a href="https://doi.org/10.1001/jamahealthforum.2021.3409">middlemen have been making more</a>. The key to true price competition is to ensure access to all versions of insulin and to convince patients and providers that people with diabetes can substitute lower-cost versions without compromising their health.</p>
<h2>5. What might happen next?</h2>
<p>The Federal Trade Commission, a government agency that <a href="https://www.ftc.gov/news-events/news/press-releases/2022/06/ftc-launches-inquiry-prescription-drug-middlemen-industry">probes anti-competitive practices</a>, and Congress are now <a href="https://www.grassley.senate.gov/news/news-releases/grassley-urges-ftc-to-complete-its-investigation-into-pharmacy-benefit-managers-to-shine-light-on-drug-pricing-practices">investigating pharmacy benefit managers’ rebate</a> and formulary practices, among other things. These investigations, along with Lilly’s moves, may lead other insulin manufacturers to lower their list prices. </p>
<p>And once its competitors decide whether they will follow Lilly’s example, pharmacy benefit managers will be under a lot of scrutiny to see whether they give preferred formulary placement to the lowest-cost insulin products, or to those that pay the highest rebates.</p><img src="https://counter.theconversation.com/content/200988/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Goldman's research is supported by the Schaeffer Center at the University of Southern California, which is in turn supported by gifts and grants from public and private sources. More detail is available in the Schaeffer Center annual report here: <a href="https://healthpolicy.usc.edu/report/2021-schaeffer-center-annual-report/">https://healthpolicy.usc.edu/report/2021-schaeffer-center-annual-report/</a></span></em></p><p class="fine-print"><em><span>Karen Van Nuys is an employee of the Schaeffer Center at the University of Southern California. The Schaeffer Center is supported by gifts and grants from public and private sources; more detail is available in the Schaeffer Center annual report here:
<a href="https://healthpolicy.usc.edu/report/2021-schaeffer-center-annual-report/">https://healthpolicy.usc.edu/report/2021-schaeffer-center-annual-report/</a></span></em></p>The drugmaker’s move responded to the growing competition that has shaken up the insulin market in recent years.Dana Goldman, Dean of the Sol Price School of Public Policy; Professor of Pharmacy, Public Policy, and Economics, University of Southern CaliforniaKaren Van Nuys, Executive Director of the Value of Life Sciences Innovation program; Fellow at the USC Schaeffer Center, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1999702023-02-24T06:59:00Z2023-02-24T06:59:00ZMore Indonesian children are living with diabetes – so what can we do to prevent it?<figure><img src="https://images.theconversation.com/files/512154/original/file-20230224-534-b4cons.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Regular exercise and heathy diets, including low consumption of processed foods, are important to prevent diabetes.</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/children-in-the-kitchen-holding-slices-of-capsicum-3984735/">Pexels/Gustavo Fring</a></span></figcaption></figure><p>Indonesian children under 18 were 70 times more likely to be living with diabetes in January 2023 than they were in 2010, <a href="https://www.kompas.id/baca/english/2023/02/15/preventing-child-diabetes">the Indonesian Pediatric Society</a> revealed this month. </p>
<p>The Indonesian Pediatric Society said that <a href="https://www.bbc.com/indonesia/articles/clj6rene4y7o">the childhood diabetes prevalence has increased</a> from 0.028 per 100.00 children in 2010 to 2 per 100.000 children in January 2023. The authors have tried to searched for the original report, but it is not publicly available.</p>
<p>In addition to the Indonesian Pediatric Society data, two other peer-reviewed publications indicate that both <a href="https://www.researchgate.net/publication/348228590_Type_1_diabetes_mellitus_in_children_Experience_in_Indonesia">type 1</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6177658/">type 2 diabetes</a> are increasing among Indonesian children. </p>
<p>Both types of diabetes are chronic conditions, meaning they are long lasting and can’t be cured. People with diabetes must consistently control their blood sugar to achieve optimal life. </p>
<p>Excess weight is a major risk factor for developing diabetes. It is why <a href="https://www.healthychildren.org/English/health-issues/conditions/chronic/Pages/Type-2-Diabetes-A-Manageable-Epidemic.aspx">controlling diets</a> is vital for preventing overweight, obesity and diabetes. </p>
<p><a href="http://labdata.litbang.kemkes.go.id/images/download/laporan/RKD/2018/Laporan_Nasional_RKD2018_FINAL.pdf">The 2018 National Health Research report</a> showed that a tenth of Indonesian children between the age of 5 and 12 years old were obese. </p>
<p>As a researcher in infant and young child feeding, and an accredited practising dietitian, we find that encouraging healthy family diets for children from the time they are babies is one way to keep children’s blood sugar levels in check. </p>
<h2>Preventing diabetes in children with breastmilk from birth</h2>
<p>There are two main types of diabetes: type 1 and type 2 diabetes.</p>
<p>The most typical diabetes diagnosed in children is <a href="https://www.healthychildren.org/English/health-issues/conditions/chronic/Pages/Diabetes.aspx">type 1 diabetes</a>. It happens when the body cannot produce enough of a hormone (insulin) to regulate turning food into energy. </p>
<p>The cause of type 1 diabetes is unclear, though it is often considered genetic. However, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481976/">many studies</a> have shown <a href="https://www.diabetesincontrol.com/breastfeeding-helps-to-prevent-type-1-diabetes/">breastfeeding reduces the risk of type 1 diabetes</a>.</p>
<p>Type 2 diabetes can be diagnosed in children and is preventable. The risk factors of <a href="https://www.healthdirect.gov.au/diabetes">type 2 diabetes</a> are also genetic. </p>
<p>A study <a href="https://academic.oup.com/nutritionreviews/article/70/9/509/1835283">has shown</a> the benefit of breastfeeding in preventing <a href="https://academic.oup.com/ajcn/article/109/Supplement_1/817S/5456706">the risk of type 1 diabetes for babies</a>, as well as avoiding the risk of <a href="https://link.springer.com/article/10.1007/s11892-019-1121-x">type 2 diabetes across the lifespan</a>. </p>
<p>The first 1000 days of life significantly impact <a href="https://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_report_021416-1.pdf">child development</a>, including predicting their future diet. </p>
<p>WHO and UNICEF <a href="https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding">recommend</a> parents initiate breastfeeding immediately after birth for at least 30 minutes, with exclusive breastfeeding from birth until six months old, complementary feeding from 6 months old and to continue breastfeeding until two years old or beyond. </p>
<p>After two years old, a child does not need milk, though breastmilk may still be given because it can help <a href="https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Breastfeeding-Benefits-Your-Babys-Immune-System.aspx">increase a child’s immunity</a>.</p>
<h2>Avoiding high sugar Growing-Up Milk</h2>
<p>Many parents feel that the child’s nutrition is complete with Growing-Up Milk (GUM), sometimes called Toddler Milk. GUM is marketed for children aged between 12 and 36 months old.</p>
<p>However, an <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.13186">Indonesian study</a> has shown that GUM tends to be high in sugar. The average sugar content in GUM in the Indonesian market is 7.3 grams per 100 ml (equal to the sugar in lemonade). The study echoes similar research that <a href="https://journals.co.za/doi/abs/10.7196/SAMJ.2019.v109i5.13314">identified high sugar content</a> in baby foods in South Africa. </p>
<p>Many GUMs distributed in Indonesia claim health benefits for children. However, the sugar content in them make them inappropriate for a child’s diet. </p>
<p>Instead of GUM, parents should give children from 6 months of age fresh and locally sourced foods. They should be prepared accordingly to the family’s diet. </p>
<p>A wide variety of fruits, vegetables and whole grains should also be given to children. Fruits, vegetables and whole grains are rich in nutrients and are shown to <a href="https://www.who.int/news-room/fact-sheets/detail/healthy-diet">be effective in preventing diabetes</a>. </p>
<h2>What can the government do?</h2>
<p>The government should focus on promoting breastfeeding and providing <a href="https://www.hse.ie/file-library/sroi-on-phn-led-breastfeeding-groups-main-report.pdf">support</a> because breastfeeding is effective <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5334-8">in reducing diabetes risk</a>, improves <a href="https://pubmed.ncbi.nlm.nih.gov/33413439/">child immunity</a> and brings [<a href="https://pubmed.ncbi.nlm.nih.gov/34602882/">economic benefits</a>].</p>
<p>The government should also control the distribution and <a href="https://www.who.int/publications/i/item/9241541601">marketing of breastmilk substitutes</a> and <a href="https://www.who.int/publications/i/item/WHO-NMH-NHD-19.27">GUM</a>, which can be misleading.</p>
<p>So far, the Indonesian government has introduced <a href="http://hukor.kemkes.go.id/uploads/produk_hukum/PMK%20No.%2049%20ttg%20Standar%20Mutu%20Gizi,%20Pelabelan,%20Periklanan%20Susu%20Formula.pdf">labelling and marketing standards</a> for Growing-Up Milk, but it could do more by stopping the cross-promotion of infant formula and Growing-Up Milk.</p>
<p>The government should also consider a sugar tax. </p>
<p>The sugar tax aims to reduce sugar consumption by reducing the affordability of buying sugar-based products. </p>
<p><a href="https://link.springer.com/article/10.1007/s40258-021-00685-x">A systematic review</a> has shown the effectiveness of this policy. </p>
<p>However, we suggest combining this policy with other interventions, such as increasing health literacy and opportunities for physical activity, particularly among children.</p><img src="https://counter.theconversation.com/content/199970/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Para penulis tidak bekerja, menjadi konsultan, memiliki saham atau menerima dana dari perusahaan atau organisasi mana pun yang akan mengambil untung dari artikel ini, dan telah mengungkapkan bahwa ia tidak memiliki afiliasi di luar afiliasi akademis yang telah disebut di atas.</span></em></p>For parents, encouraging healthy family diets for children from the time they are babies is one way to keep children’s blood sugar levels in check. The Indonesian government can do more to help too.Andini Pramono, PhD Candidate, Department of Health Economics, Wellbeing and Society, National Centre for Epidemiology and Population Health, Australian National UniversityKatelyn Barnes, Postdoctoral Research Fellow, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1960162022-12-13T22:56:16Z2022-12-13T22:56:16ZWhy does the Alzheimer’s brain become insulin-resistant?<figure><img src="https://images.theconversation.com/files/499100/original/file-20221205-26-1etuem.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C988%2C555&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Type 2 diabetes, characterised in its advanced stages by insulin resistance, is an important risk factor for Alzheimer's disease.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>As the population ages, the number of people with <a href="https://braininstitute.ca/research-data-sharing/neurodegenerative-disorders">neurodegenerative diseases</a>, such as <a href="https://alzheimer.ca/en/about-dementia/what-alzheimers-disease">Alzheimer’s disease</a>, increases. Approximately <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/dementia-highlights-canadian-chronic-disease-surveillance.html">75,000 Canadians</a> are diagnosed with Alzheimer’s disease each year and experience a decline in their cognitive abilities. The ordeal usually lasts for several years while their family members watch helplessly.</p>
<p>Neurodegenerative diseases are characterized by <a href="https://www.sciencedirect.com/science/article/abs/pii/S0924977X13001107">proteinopathies</a> — abnormal accumulations of proteins in the brain that impair the functioning of <a href="https://cancer.ca/en/cancer-information/resources/glossary/n/neuron">neurons</a>. The most widely studied therapeutic approach to developing drugs for Alzheimer’s is to try to reduce the aggregation of <a href="https://canjhealthtechnol.ca/index.php/cjht/article/view/eh0103/683">amyloid-beta peptide</a> and <a href="https://nouvelles.umontreal.ca/en/article/2022/10/20/unlocking-the-mysteries-of-tauopathies-a-protein-that-gives-hope/">tau protein</a> in neurons.</p>
<p>However, in order to reach their targets, the drugs must first cross the <a href="https://www.theglobeandmail.com/canada/article-toronto-researchers-look-at-new-approach-for-treating-alzheimers/">blood-brain barrier</a> (BBB) from the blood to the brain. This is because <a href="https://www.biorxiv.org/content/10.1101/2020.12.10.419598v1.full">endothelial cells</a>, cells that line the tiniest blood vessels in the brain, regulate the exchange between blood and the brain. They maintain a balance that allows access to essential molecules such as glucose, but restrict the passage of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3494002/">most pharmaceuticals</a>, including the new and <a href="https://www.ft.com/content/32478dbf-7270-4eb6-a576-663a47a3603e">much-hyped</a> drug <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2212948">lecanemab</a>.</p>
<p>When these brain endothelial cells become diseased, the balance is upset. The brain struggles to get the substances it needs back into the circulation and rejects those that might harm it.</p>
<p>The brain and the other organs of the body are thus in constant communication, while in health or in disease.</p>
<p>As experts in neurodegenerative diseases and the BBB, we have conducted a study on insulin receptor dysfunction in Alzheimer’s disease.</p>
<h2>Insulin and the brain</h2>
<p><a href="https://www.healthlinkbc.ca/health-topics/types-insulin">Insulin</a> is an essential hormone for life. It is best known for its effect on the regulation of <a href="https://www.diabetescarecommunity.ca/living-well-with-diabetes-articles/blood-sugar-levels-in-canada/?gclid=Cj0KCQiAyracBhDoARIsACGFcS4fee8N8dfBJj9HKxpUiGlNO6RANNF9BiZN52dsd6oxqgLCW7Od_WsaArF9EALw_wcB">blood sugar</a> and remains an essential part of the pharmaceutical treatment of <a href="https://www.healthlinkbc.ca/health-topics/types-insulin">diabetes</a>. In recent decades, researchers have noted vascular and metabolic abnormalities <a href="https://pubmed.ncbi.nlm.nih.gov/30022099/">in a high proportion of patients with dementia</a>.</p>
<p>Indeed, Type 2 diabetes, characterized in the later stages by <a href="http://www.diabetesclinic.ca/en/diab/1basics/insulin_resistance.htm">insulin resistance</a>, is a major risk factor for Alzheimer’s disease. There is some evidence to suggest that the <a href="https://pubmed.ncbi.nlm.nih.gov/29377010/">Alzheimer’s brain is less responsive to insulin</a>. Conversely, studies have shown that insulin can <a href="https://pubmed.ncbi.nlm.nih.gov/32730766/">improve memory</a>, prompting the development of clinical trials on the effect of insulin on Alzheimer’s disease.</p>
<p>Yet we still don’t know what cell types and mechanisms are involved in the action — and loss of action — of insulin in the brain. The vast majority of insulin is produced by the <a href="https://pancreaticcancercanada.ca/the-pancreas/">pancreas</a> and secreted into the bloodstream. Therefore, to affect the brain, insulin must first interact with the BBB and its endothelial cells, which are in contact with the blood and can take up insulin through <a href="https://pubmed.ncbi.nlm.nih.gov/36280236/">receptors</a>.</p>
<h2>Alzheimer’s and the insulin receptor</h2>
<p>In order to measure the amount of these insulin receptors in the brain, <a href="https://doi.org/10.1093/brain/awac309">we performed analyses directly in human tissues</a>. These samples came from a <a href="https://www.rushu.rush.edu/research/departmental-research/religious-orders-study">cohort</a> of over a thousand people who agreed to donate their brains after death. We have access to them through a partnership with researchers at Rush University in Chicago.</p>
<p>We found that the <a href="https://healthenews.mcgill.ca/new-insights-into-how-insulin-interacts-with-its-receptor/">insulin-binding receptor</a> is predominantly located in the microvessels, so, within the BBB itself. Moreover, the abundance of this receptor is decreased in Alzheimer’s patients. This decrease could lead to the loss of insulin response in the Alzheimer brain.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="schematic" src="https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=781&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=781&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=781&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=982&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=982&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499093/original/file-20221205-15238-9izujo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=982&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The brain insulin receptor is located mainly at the BBB, and its ability to respond to blood insulin is diminished in Alzheimer’s disease.</span>
<span class="attribution"><span class="source">(Manon Leclerc)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Insulin receptor dysfunction</h2>
<p>In order to better control the experimental variables and measure the response of the insulin receptor, we then tested our hypotheses in mice. The <em>in situ</em> cerebral perfusion technique consists of injecting insulin directly into the carotid artery (an artery located in the neck) so that it reaches the brain in its entirety. We have shown that circulating insulin mainly activates receptors located on the cerebral microvessels.</p>
<p>Although it was generally accepted that insulin crosses the BBB to reach cells such as neurons deeper in the brain tissue, our results show that the proportion of insulin that crosses the BBB is low.</p>
<p>These two observations thus confirm that the majority of insulin must interact with cells in the BBB before it can exert an action on the brain.</p>
<p>We then applied the same method to <a href="https://www.criver.com/products-services/research-models-services/genetically-engineered-model-services/transgenic-mouse-rat-model-creation/transgenic-mice?region=3601">transgenic mice</a>, which were genetically modified to model Alzheimer’s disease. We found that the response to insulin at the BBB was dysfunctional, with no activation of the insulin receptor in these diseased mice.</p>
<p>Thus, in both humans and rodents, the brain insulin receptor is located primarily at the BBB, and its ability to respond to blood insulin is impaired in Alzheimer’s disease.</p>
<h2>A significant breakthrough</h2>
<p>In sum, our results suggest that alterations in the number, structure and function of insulin receptors at the level of BBB endothelial cells may contribute to the cerebral insulin resistance observed in Alzheimer’s disease.</p>
<p>Alzheimer’s research efforts are currently focused on drugs that, in order to reach their therapeutic target, the neurons, must first cross the BBB, which severely restricts their passage. By targeting the metabolic dysfunction of the brain instead, we propose a research alternative that has two major advantages.</p>
<p>The first is that we can use treatments that do not have to cross the BBB barrier, since it is the endothelial cells themselves that become the therapeutic target. The second involves <a href="https://www.nature.com/articles/nrd.2018.168">“drug repurposing,”</a> which consists of taking advantage of the phenomenal therapeutic arsenal already approved to fight diabetes and obesity, but using this in the context of Alzheimer’s.</p>
<p>It should be remembered that the few drugs available to us provide only a modest improvement in symptoms. Combating insulin resistance in the brain would make it possible to break the vicious circle between neuropathology (disease that affects the brain) and diabetes, and in theory slow down the progression of the disease.</p>
<h2>The work is not finished</h2>
<p>On the basic research side, we will continue to study the mechanisms downstream from the microvessels to understand the action of insulin on the deep layers of the brain.</p>
<p>We hope that clinical research will follow suit with human studies to repurpose drugs that target certain metabolic diseases, such as diabetes, towards fighting Alzheimer’s.</p>
<p>In the meantime, while waiting for pharmaceutical solutions, each of us would do well to adopt the preventive cocktail that we all know well: a healthy diet combined with frequent physical and mental exercise.</p><img src="https://counter.theconversation.com/content/196016/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frederic Calon has received funding from: Canadian Institutes of Health Research (CIHR), Natural Sciences and Engineering Research Council of Canada (NSERC), Fonds de la recherche du Québec en santé (FRQS), Alzheimer Society of Canada.</span></em></p><p class="fine-print"><em><span>Manon Leclerc has received scholarships from the Fondation du CHU de Québec and the Fonds de Recherche du Québec - Santé (FRQS).</span></em></p><p class="fine-print"><em><span>Vincent Emond ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>Impaired insulin receptors in the blood vessels between the blood and the brain may contribute to the insulin resistance observed in Alzheimer’s disease.Frederic Calon, Professeur, Université LavalManon Leclerc, PhD student, Université LavalVincent Emond, Professionnel de recherche, Université LavalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1942462022-11-15T17:51:40Z2022-11-15T17:51:40Z100 years after insulin was first used, why isn’t NZ funding the latest life-changing diabetes technology?<figure><img src="https://images.theconversation.com/files/495009/original/file-20221114-14-k6su5n.jpeg?ixlib=rb-1.1.0&rect=8%2C8%2C2901%2C1889&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Abby Lee Harder with her daughter Presley, showing the blood-glucose sensor that helps manage her diabetes.</span> <span class="attribution"><span class="source">Diabetes NZ</span></span></figcaption></figure><p>This year marks a century since an extraordinary <a href="https://www.nature.com/articles/s41591-021-01418-2">medical breakthrough</a> – the use of insulin to treat diabetes mellitus. Some physicians at the time described the effect of administering this hormone as like witnessing “resurrection experiences”. Children near death were given a chance at life.</p>
<p>As we mark the centenary, we also need to focus on the pressing need in Aotearoa New Zealand to make the latest treatments and technologies available to all – and not just those who can afford them. </p>
<p>It is a remarkable story of medical and scientific progress.</p>
<p>The term “diabetes” was used from the first century BC to describe a condition characterised by polydipsia (thirst) and polyuria (passing large quantities of dilute urine); “mellitus” was added in the 1600s to indicate that sweetness in the urine differentiated this condition from other causes of these symptoms.</p>
<p>But it took another 300 years for a link between diabetes and the pancreas to be discovered. The term “insulin” was coined in 1909 by the Belgian scientist Jean de Meyer who speculated that a secretion from the pancreas could regulate the amount of glucose (sugar) in the blood. </p>
<p>Insulin was finally isolated from the pancreas in 1921 and was shown to keep dogs without a pancreas alive for several months. Rapid progress followed. In January 1922, 14-year-old Leonard Thompson, hospitalised and near death in Toronto, became the first person to receive insulin and survive diabetes. </p>
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<h2>Insulin arrives in New Zealand</h2>
<p>By the end of 1922, insulin was being commercially produced and distributed worldwide. It is generally accepted that the first use of this miraculous substance in New Zealand was in 1923 when Dr (later Sir) Charles Burns injected Isobel Styche with insulin in Dunedin Hospital. </p>
<p>There’s <a href="https://pubmed.ncbi.nlm.nih.gov/7019787/">some debate</a> about this, however, with another patient possibly receiving treatment as early as 1922. </p>
<p>A young New Zealand doctor named Thomas Johnson, at that time working in London, heard about the discovery of insulin and realised it might save the life of Jake Cato, a young man he had been looking after in Napier. </p>
<p>In collaboration with Cato’s father, who happened to be the head of the New Zealand Shipping Company based in Napier, Johnson arranged for one of the company’s ships to bring the precious substance to New Zealand. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/495008/original/file-20221114-20-rguw13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495008/original/file-20221114-20-rguw13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495008/original/file-20221114-20-rguw13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495008/original/file-20221114-20-rguw13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495008/original/file-20221114-20-rguw13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495008/original/file-20221114-20-rguw13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495008/original/file-20221114-20-rguw13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Finger-prick blood-glucose measurement remains the reality of most New Zealand diabetics.</span>
<span class="attribution"><span class="source">Getty Images</span></span>
</figcaption>
</figure>
<h2>Breakthroughs in glucose monitoring</h2>
<p>At the same time as insulin therapy was being developed, glucose-monitoring technology was also progressing. Crude assessment of glucose in the urine, used in New Zealand until the early 1980s, was superseded by the development of finger-prick blood-glucose measurements. </p>
<p>Performed up to ten or more times daily on hand-held meters, finger-prick measurements remain the reality for most of the 25,000 children and adults who live with <a href="https://www.diabetes.org.nz/type1diabetes">type 1 diabetes</a> in New Zealand. </p>
<p>This particular form of diabetes results in an absolute deficiency of insulin. It’s caused by the body’s immune system attacking and destroying the insulin-producing cells in the pancreas.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-discovery-of-insulin-a-story-of-monstrous-egos-and-toxic-rivalries-172820">The discovery of insulin: a story of monstrous egos and toxic rivalries</a>
</strong>
</em>
</p>
<hr>
<p>Over the past ten years, the pain and burden of finger-prick glucose monitoring have encouraged the development of continuous glucose monitors (<a href="https://starship.org.nz/health-professionals/glucose-monitoring-systems/">CGMs</a>). These small patches, worn on the skin, measure glucose levels continuously and are replaced every seven to 14 days. </p>
<p>CGM devices can now “talk” to insulin pumps, devices worn on the body that provide continuous subcutaneous insulin instead of the many injections required daily. These technologies act like a partially automated artificial pancreas, reducing the large number of complex decisions people with diabetes have to make daily to remain healthy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/495011/original/file-20221114-12-o513sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495011/original/file-20221114-12-o513sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495011/original/file-20221114-12-o513sh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495011/original/file-20221114-12-o513sh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495011/original/file-20221114-12-o513sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495011/original/file-20221114-12-o513sh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495011/original/file-20221114-12-o513sh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Insulin pumps deliver continuous, measured doses, meaning multiple daily jabs aren’t required.</span>
<span class="attribution"><span class="source">Getty Images</span></span>
</figcaption>
</figure>
<h2>Treatment and equity</h2>
<p>While insulin pumps are funded in New Zealand for some, the government drug-buying agency Pharmac does not fund CGMs. That’s despite CGMs being funded in the UK, Canada, Australia (since 2017) and much of Europe, and being the recommended method of glucose monitoring in all major diabetes guidelines worldwide. </p>
<p>However, CGMs are widely used in New Zealand by those who can afford them. They help prevent the unpleasant effects of low blood glucose and can give advance warning of less common but serious risks of collapse and seizures, and occasionally death. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-zealand-needs-urgent-action-to-tackle-the-frightening-rise-and-cost-of-type-2-diabetes-157581">New Zealand needs urgent action to tackle the frightening rise and cost of type 2 diabetes</a>
</strong>
</em>
</p>
<hr>
<p>CGMs also help mitigate long-term complications and early death from too much glucose. </p>
<p>The lack of government funding has led to widespread inequity. Māori, Pacific peoples and those on lower incomes are less able to access life-enhancing CGM devices. Recent New Zealand research has highlighted that glucose outcomes for Māori, if they are wearing a CGM, appear equal to those for non-Māori. </p>
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<h2>Better health for all</h2>
<p>Jake Cato’s life-saving insulin therapy was made possible by the wealth and connections of his parents. We would like to think that in 2022, a century on from the first person in the world receiving insulin, this should not still be a factor.</p>
<p>Access to life-saving and disability-preventing therapies for the one-in-500 New Zealand children (and thousands of adults) living with type 1 diabetes must not be restricted to those with money and connections.</p>
<p>That’s why the wider availability of diabetes management technologies – taken for granted in other comparable countries – is the big issue this <a href="https://www.diabetes.org.nz/diabetes-action-month">Diabetes Action Month</a>, and will be highlighted at the forthcoming <a href="https://www.otago.ac.nz/diabetes/news/otago0231654.html">Transforming lives: 100 years of insulin</a> event in Wellington. </p>
<p>While there is much to celebrate during this centenary year, the good health promised by these medical breakthroughs is still not available to all in Aotearoa New Zealand. We can and should do better.</p><img src="https://counter.theconversation.com/content/194246/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben Wheeler has received research funding from Medtronic, Dexcom, and iSENs, manufacturers of continuous glucose monitoring devices and other advanced diabetes technologies.</span></em></p><p class="fine-print"><em><span>Cherie Stayner and Jim Mann do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>On the centenary of insulin’s first use, doctors, researchers and people with diabetes are asking why New Zealand lags other countries in funding the latest devices to monitor blood sugar.Ben Wheeler, Associate Professor of Paediatric Endocrinology, University of OtagoCherie Stayner, Research Manager, Edgar Diabetes and Obesity Research Centre; Science Communicator, Healthier Lives–He Oranga Hauora National Science Challenge, University of OtagoJim Mann, Professor of Medicine and Director, Healthier Lives–He Oranga Hauora National Science Challenge and Co-Director, Edgar Diabetes and Obesity Research Centre, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1936132022-11-14T18:23:13Z2022-11-14T18:23:13ZWhy South Asians are at increased risk for diabetes: A complex interplay of genetics, diet and history<figure><img src="https://images.theconversation.com/files/493649/original/file-20221105-25-6t92cl.jpg?ixlib=rb-1.1.0&rect=2%2C2%2C1524%2C1020&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Person having their blood glucose level measured with a glucometer.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/why-south-asians-are-at-increased-risk-for-diabetes--a-complex-interplay-of-genetics--diet-and-history" width="100%" height="400"></iframe>
<p>In 2021, there were <a href="https://www.diabetesatlas.org">537 million adults living with diabetes</a>, of which approximately 90 per cent had Type 2 diabetes. When someone has Type 2 diabetes, specialized cells within the pancreas known as “beta cells” produce insufficient amounts of insulin.</p>
<p><a href="https://doi.org/10.1038%2Fs41591-021-01418-2">Insulin is a hormone</a> that travels through the bloodstream and tells other cells to take excess sugar out of the blood and use this sugar as energy, making sure the body keeps doing everything it needs to. </p>
<p>Individuals with Type 2 diabetes are “insulin resistant,” meaning cells do not adequately recognize insulin. These individuals require more insulin than normal to regulate blood sugar levels. When beta cells fail to compensate for the increased insulin demand, blood sugar levels rise, adversely affecting organ function.</p>
<p>Globally, the South Asian community is composed of over two billion individuals. In Canada, <a href="https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2022_Backgrounder_Canada_English_1.pdf">14.4 per cent of South Asians have Type 2 diabetes</a>, the highest prevalence of any other ethnic group in the country.</p>
<p>As a member of the South Asian community, it is incredibly common for me (Lahari Basu) to learn that someone I know has been diagnosed with Type 2 diabetes. When I joined <a href="http://www.bruinlab.com/">Dr. Jenny Bruin’s lab</a> at Carleton University to study diabetes for my PhD, I was intrigued by this question: Why are South Asians disproportionately impacted by Type 2 diabetes?</p>
<p>That answer lies in a web of genetic, behavioural and cultural factors.</p>
<h2>Genetic variants</h2>
<p>In 2013, researchers confirmed that South Asians are particularly insulin resistant. Compared to Caucasians, <a href="https://doi.org/10.1016/j.metabol.2013.10.008">South Asians had higher insulin concentrations in their blood after ingesting sugar</a>. This means that South Asian individuals require more insulin to regulate their blood sugar levels, a characteristic of Type 2 diabetes.</p>
<p>There are numerous possible explanations for this, but genetic variants could be one culprit. Variation, or mutations, in genes can alter cell function. In the case of beta cells, genetic variants can lead to inappropriate levels of insulin secretion and insulin resistance.</p>
<figure class="align-center ">
<img alt="Cropped image of a young man in a plaid shirt holding an insulin pen" src="https://images.theconversation.com/files/494899/original/file-20221111-2672-d6vtg1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/494899/original/file-20221111-2672-d6vtg1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494899/original/file-20221111-2672-d6vtg1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494899/original/file-20221111-2672-d6vtg1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494899/original/file-20221111-2672-d6vtg1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494899/original/file-20221111-2672-d6vtg1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494899/original/file-20221111-2672-d6vtg1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Individuals with Type 2 diabetes are insulin resistant, meaning cells do not adequately recognize insulin. Some people with Type 2 diabetes inject insulin with an insulin pen.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>It turns out that South Asians have <a href="https://doi.org/10.1038/s42003-022-03248-5">acquired mutations in various genes required for proper beta cell function</a>. They also have a higher prevalence of mutations in a <a href="https://doi.org/10.1038%2Fng.921">gene called GRB14</a>, resulting in increased insulin resistance.</p>
<p>Although not all South Asians have these mutations, a significant proportion do. There are also likely other gene variants that have yet to be uncovered in this population. These gene variants begin to paint an interesting picture of how genetic predisposition increases their risk of developing diabetes.</p>
<h2>Physiological adaptations</h2>
<p>Genetic variants only explain a small part of the increased insulin resistance in South Asian individuals. This observed insulin resistance may also have historical context.</p>
<p>South Asians have faced multiple famines throughout history. The recurrence of depleted food sources and malnutrition led to the development of a <a href="https://doi.org/10.2337%2Fdc11-0442">starvation adaptation</a>. This adaptation allowed them to efficiently process food and store fat during times of abundance, providing an advantage during famine.</p>
<p>Now, with urbanization and migration, this trait can be detrimental to South Asians. The adaptation does not bode well in a world with increased access to high-fat foods. Combined with modern-day diets, this adaptation can result in <a href="https://doi.org/10.1007/s00125-022-05803-5">increased fat storage and abdominal obesity in South Asian individuals</a>, leading to greater risk of insulin resistance and diabetes.</p>
<h2>Cultural differences</h2>
<p>Food plays an important social role in South Asian culture. For as long as I can remember, big family dinners were integral to my lifestyle and cultural identity. For us, food is a way to communicate, to honour ancestors and to celebrate.</p>
<p>The staples of South Asian cuisine include white rice, flatbreads and potatoes, with most cooking being done in clarified butter. This diet is influenced from a time before refrigerators and food abundance, focusing on shelf-stable, self-preserving foods. Diets high in carbohydrates and fat have been <a href="https://doi.org/10.1017/s0007114508073649">linked to increased insulin resistance and decreased metabolism</a> (the process of converting food into energy).</p>
<h2>Culture-centred treatment</h2>
<figure class="align-right ">
<img alt="A woman in a green shirt listening to a man in a white coat with his back to the camera" src="https://images.theconversation.com/files/494900/original/file-20221111-11-bzc8rr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/494900/original/file-20221111-11-bzc8rr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494900/original/file-20221111-11-bzc8rr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494900/original/file-20221111-11-bzc8rr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494900/original/file-20221111-11-bzc8rr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494900/original/file-20221111-11-bzc8rr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494900/original/file-20221111-11-bzc8rr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Implementing treatment programs that focus on the culture of the patients can help approach diabetes management in a new light.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>There is clearly a complex relationship between South Asian ethnicity and diabetes risk. The interplay of culture and genetics presents a unique challenge for this community. For many, <a href="https://doi.org/10.1002/pdi.619">unfamiliarity with diabetes</a> may prevent them from getting the care they need.</p>
<p>Implementing <a href="https://doi.org/10.1186/s12992-019-0451-4">treatment programs that focus on the culture of the patients</a> can help approach diabetes management in a new light. Healthier versions of traditional foods, familiar languages and being cognizant of cultural barriers can help South Asians with diabetes understand the seriousness of the condition, their predisposition to it, and how to manage their symptoms.</p>
<h2>A call for South Asian-centric research</h2>
<p>As a South Asian woman studying diabetes, learning about this phenomenon opened my eyes to how little we know about ethnicity-specific diabetes risk. <a href="https://doi.org/10.1136%2Fbmjopen-2016-014889">South Asians are severely underrepresented in clinical research</a>. To truly understand the complex relationship between Type 2 diabetes and South Asians, it is vital to conduct clinical studies that specifically target this ethnic group.</p>
<p>A better scientific understanding of the link between South Asians and increased Type 2 diabetes and implementing culture-centred management programs can help alleviate the mystery and stigma behind this phenomenon.</p><img src="https://counter.theconversation.com/content/193613/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Bruin receives funding from the Canadian Institutes of Health Research (CIHR), Natural Sciences and Engineering Research Council of Canada (NSERC), and JDRF. </span></em></p><p class="fine-print"><em><span>Lahari Basu does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In Canada, 14.4 per cent of South Asians have Type 2 diabetes, the highest prevalence of any other ethnic group in the country. Why is this population so disproportionately affected by diabetes?Lahari Basu, PhD Candidate, Department of Biology and Institute of Biochemistry, Carleton UniversityJennifer Bruin, Associate professor, Department of Biology and Institute of Biochemistry, Carleton UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1945022022-11-14T10:44:38Z2022-11-14T10:44:38ZOver 12% of South African adults have diabetes - education is critical to achieve good outcomes<figure><img src="https://images.theconversation.com/files/494927/original/file-20221112-29604-1ypgsq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Type 2 diabetes mostly affects adults of a certain age.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>Over <a href="https://www.up.ac.za/tshwane-insulin-project-tip/news/post_2937261-world-diabetes-day-up-insulin-project-acknowledges-crucial-role-of-nurses-in-managing-the-disease">12%</a> of adults in South Africa have diabetes. Since 2019, researchers at the University of Pretoria have been working on the <a href="https://www.up.ac.za/diabetes-research-centre/article/3107624/tshwane-insulin-programme-tip">Tshwane Insulin Project</a>. The project consists of delivering training workshops on comprehensive diabetes and hypertension management in primary care. The researchers also provide technical assistance to healthcare professionals to improve diabetes care. The Conversation Africa spoke to project manager Dr Patrick Ngassa Piotie about what diabetes is and why it’s so difficult to manage.</em></p>
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<h2>What is diabetes?</h2>
<p>Diabetes mellitus, or <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">diabetes</a>, refers to a group of conditions that affect how the body uses blood glucose (sugar). Diabetes occurs when the pancreas is no longer <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes.html">able to make insulin</a>, or when the body cannot make good use of the insulin it produces. This leads to elevated glucose levels in the blood. Over time, high blood glucose levels cause damage to the body and the failure of various organs.</p>
<p>There are different types of diabetes. Type 2 is the most common. It accounts for 90% of all cases. With type 2, the body is still able to produce insulin but can’t use it correctly. Type 2 diabetes mostly affects adults of a certain age, who are overweight, don’t exercise, and have a family history of diabetes.</p>
<p>Type 1 diabetes can develop at any age, but it occurs most frequently in children and adolescents. With type 1 diabetes, the pancreas produces very little to no insulin. This means people who have type 1 diabetes need insulin daily to maintain blood glucose levels. </p>
<p>Lastly, there’s diabetes that occurs during pregnancy – gestational diabetes. It affects both mother and child, but usually disappears after pregnancy.</p>
<p>Pre-diabetes is a reversible condition. It happens when blood glucose levels are higher than normal, but <a href="https://www.mayoclinic.org/diseases-conditions/diabetes/symptoms-causes/syc-20371444">not high enough to be called diabetes</a>. It can lead to diabetes unless measures such as lifestyle modifications are taken to prevent it.</p>
<p>The symptoms of diabetes are linked to the high levels of sugar in the blood. They include feeling tired and weak, feeling more thirsty than usual, urinating often, or losing weight without trying. Other symptoms such as blurry vision, recurring infections or slow-healing sores are signs of an advanced stage of the disease.</p>
<h2>How is it managed?</h2>
<p>This depends on the type of diabetes. For example, people with type 1 diabetes need daily insulin injections. The management of type 2 diabetes consists of adopting a healthy lifestyle including increased physical activity and healthy diet. However, type 2 diabetes is a progressive disease. This means that, as the condition progresses, people with type 2 diabetes will need oral drugs and/or insulin to keep their blood glucose levels under control.</p>
<p>Managing diabetes is not just about keeping the blood glucose levels within normal ranges. Often, people with diabetes and healthcare professionals must control the blood pressure and cholesterol levels as well. In addition, a key aspect of managing diabetes is to prevent complications by protecting target organs such as the kidneys and the heart, or the feet.</p>
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Read more:
<a href="https://theconversation.com/technology-and-home-visits-can-help-south-africans-with-diabetes-cope-with-insulin-186000">Technology and home visits can help South Africans with diabetes cope with insulin</a>
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<p>At the <a href="http://www.diabetes.up.ac.za">University of Pretoria Diabetes Research Centre</a>, we have developed an acronym that summarises our approach to good diabetes care: the <a href="https://www.up.ac.za/media/shared/856/ZP_Resources/living-with-diabetes_starting-insulin.zp225902.pdf">four “Bs” and four “Cs”</a> or 4Bs 4Cs.</p>
<p>The 4Bs are critical elements to control diabetes:</p>
<ul>
<li><p>Blood pressure control</p></li>
<li><p>Blood glucose control</p></li>
<li><p>Blood cholesterol control</p></li>
<li><p>Breathe air, don’t smoke</p></li>
</ul>
<p>The 4Cs are important tests that people with diabetes should receive every year:</p>
<ul>
<li><p>Check eyes, with a diabetic eye screening – a specific test to check for eye problems caused by diabetes</p></li>
<li><p>Check mouth, by going to the dentist</p></li>
<li><p>Check kidneys, with a laboratory test</p></li>
<li><p>Check feet, with a simple easy-to-do foot exam.</p></li>
</ul>
<p>To manage diabetes, healthcare professionals need the full participation of people with diabetes and their families. That is why it’s important that people with diabetes and their families receive <a href="https://www.semdsa.org.za/">diabetes education</a>. People with diabetes must be <a href="https://worlddiabetesday.org/about/theme/">equipped</a> with the skills to navigate self-management decisions and activities. </p>
<h2>What are the main challenges in managing the condition?</h2>
<p>In South Africa, most people with diabetes rely on the public health system for care. This system is overburdened, overstretched and under-resourced. These systemic challenges have an impact on the delivery of diabetes care, despite the availability of diabetes medication – including insulin – free of charge at primary care clinics.</p>
<p>Healthcare professionals often don’t have time for diabetes education because of long queues and congested health facilities. As a result, people with diabetes <a href="https://pubmed.ncbi.nlm.nih.gov/28156143/">don’t receive the education they need</a>. This, in turn, means people don’t have a good understanding of their condition, which affects their ability to adopt appropriate self-management behaviours, and to adhere to their medication.</p>
<p>Research conducted in South Africa has consistently shown that healthcare workers <a href="https://pubmed.ncbi.nlm.nih.gov/32242428/">don’t comply with diabetes management guidelines</a>. They also fail to implement the recommended processes of care such as measurements of body mass index, waist circumference or weight.</p>
<p>Having paper-based medical records instead of electronic medical records is an additional barrier. The medical records are often lost or misplaced. In a context where healthcare professionals rotate often between departments, it becomes difficult to preserve patient history and to ensure continuity of care. A paper-based system makes it difficult to implement structured diabetes care.</p>
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Read more:
<a href="https://theconversation.com/our-research-shows-gaps-in-south-africas-diabetes-management-programme-160275">Our research shows gaps in South Africa's diabetes management programme</a>
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<p>South African <a href="https://pubmed.ncbi.nlm.nih.gov/35532128/">studies</a> have found that screening for diabetes-related complications is lacking. For example, healthcare professionals are <a href="https://www.diabetessa.org.za/challenges-facing-sa-in-the-fight-against-diabetic-retinopathy/">not able to screen patients for eye problems</a> caused by diabetes. Diabetic eye screening requires a specific camera that is not available in most clinics and community health centres. </p>
<h2>How can these be addressed?</h2>
<p><a href="https://guidelines.diabetes.ca/cpg">Diabetes care</a> should be structured, evidence-based and facilitated by a multidisciplinary team trained in diabetes management.</p>
<p>South Africa’s health system should be strengthened. Investments are needed to improve the delivery of diabetes care. There is a pressing need for the continuous training of healthcare professionals in diabetes management.</p>
<p>Because of the heavy workload on primary care nurses and doctors, allied healthcare workers, community health workers and health promoters should be trained to carry out non-clinical duties like diabetes education and support.</p>
<p>The recognition and integration of diabetes educators within the public healthcare system should be a priority. This will ensure that diabetes education becomes systematic and consistent. It should be repeated at regular intervals. Families of people living with diabetes should also be involved and receive diabetes education because their support is crucial.</p>
<p>Technology, digital health solutions and telehealth can improve the delivery of quality diabetes care. Clinical information systems such as electronic medical records and electronic patient registries can have a positive impact on evidence-based diabetes care. Those systems should be introduced as a matter of urgency.</p>
<h2>What are some of the key lessons from the Tshwane Insulin Project so far?</h2>
<p>The use of digital health, enhancing the role played by community health workers and following patients proactively are some of the <a href="https://pubmed.ncbi.nlm.nih.gov/34733467/">innovations that were introduced</a>.</p>
<p>Most healthcare professionals are eager to embrace change and new knowledge. And people with diabetes and their families were appreciative of the education they were receiving. They qualified it as life changing.</p>
<p>Improving diabetes care and outcomes in South Africa will require a strong will and unwavering support from the health authorities, the introduction of clinical information systems, the use of technology and digital solutions, advocacy and accountability.</p><img src="https://counter.theconversation.com/content/194502/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick Ngassa Piotie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Improving diabetes care in South Africa requires strong will and support from health authorities, introduction of clinical information systems, the use of technology and digital solutions.Patrick Ngassa Piotie, Project Manager, University of Pretoria Diabetes Research Centre, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1860002022-07-17T09:43:56Z2022-07-17T09:43:56ZTechnology and home visits can help South Africans with diabetes cope with insulin<figure><img src="https://images.theconversation.com/files/472534/original/file-20220705-20-yx5ycz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Insulin refusal is high among some patients.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Approximately <a href="https://health-e.org.za/2021/11/14/most-south-africans-do-not-know-they-have-diabetes/">4.5 million</a> South Africans have <a href="https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199#:%7E:text=Metformin%20(Fortamet%2C%20Glumetza%2C%20others,body%20uses%20insulin%20more%20effectively">type 2 diabetes</a> – a condition characterised by high levels of sugar in the blood. It can be treated with drugs and managed through healthy eating and exercise. But if it’s not managed well, it can be life-threatening. Diabetes is one of the <a href="https://www.statssa.gov.za/publications/P03093/P030932018.pdf#page=47">leading causes of death</a> in South Africa. </p>
<p>Blood sugar levels rise to dangerous levels when the pancreas does not produce enough insulin, a hormone that regulates the movement of sugar in the body. </p>
<p>As <a href="https://www.everydayhealth.com/hs/better-type-2-diabetes-control/how-diabetes-changes/">diabetes progresses</a>, insulin injections become the only treatment option. But the transition from oral medication to injectable insulin is often a bumpy one. Managing a patient on insulin requires patients to inject at least once a day and to measure their blood sugar levels at least twice a day. In addition, healthcare workers must have the knowledge, skills and time required to monitor patients and adjust the insulin dose when necessary.</p>
<p>To address this problem, we <a href="https://journals.sagepub.com/doi/full/10.1177/20420188211054688">developed an intervention called the Tshwane Insulin Project</a>. Our <a href="https://www.up.ac.za/news/post_2988422-ups-real-world-diabetes-research-is-reaching-out-to-the-community-one-family-at-a-time">intervention</a> combines various elements. One is a digital tool, <a href="https://www.vulamobile.com/">the Vula app</a>, which health professionals can use to communicate with each other. </p>
<p>Another aspect of the intervention involves community health workers in the care of people with diabetes. We also train healthcare professionals at primary care level to manage people living with diabetes, including those who need insulin.</p>
<p>Our intervention is a more efficient way of managing people with diabetes because healthcare providers share the tasks of patient education, insulin initiation and follow-up. The intervention also reduces the number of referrals from clinics to hospitals because of unavailability of doctors or lack of skills to manage patients on insulin.</p>
<h2>The intervention</h2>
<p>When a person’s blood sugar is not controlled with two drugs, they get the correct information about insulin and why it is necessary. If the patient agrees to go on insulin, the doctor prescribes it and the primary care nurse informs the patient.</p>
<p>The mobile app is very useful in primary healthcare settings because the doctor can send a prescription remotely using the app. Patients don’t have to wait for doctors to visit the facility. The nurse can check if the patient meets the criteria for insulin therapy and the doctor can confirm that, remotely, based on the information provided by the nurse.</p>
<p>Once the patient is initiated on insulin, the nurse contacts the community health worker team assigned to the clinic to inform them about the new patient.</p>
<p>Community healthcare workers are a very important part of this intervention.</p>
<p>Before the intervention, patients were sent home with a huge amount of information to digest by themselves. They would have to remember how, where and when to inject their insulin; how to draw the appropriate dose; how to measure their sugar levels; how to identify when their sugar levels are low (hypoglycaemia); and what to do at that moment.</p>
<p>Research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5601201/">shows</a> that this can be overwhelming for patients. Some are illiterate, with limited medical knowledge. With the involvement of community health workers in the intervention, patients are no longer alone. Patients are visited at home every week. The community health workers remind patients of key education messages, injection sites and techniques. </p>
<p>The community health workers are also important in the adjustment of insulin doses. Before the intervention, most patients would have their insulin doses adjusted during clinic visits – which happened once a month at best – because they could not do it themselves. Insulin is always started at a low dose for safety reasons and to help the patient adjust. Then the dose is progressively increased until the optimal dose is reached. That optimal dose varies from one patient to another. When the dose is adjusted only once a month it takes too long to reach the ultimate dose. Many patients never reach that dose and remain with high glucose levels despite injecting. </p>
<p>With our intervention, during the weekly home visit, the community health workers communicate the blood sugar levels to the doctor via the mobile app. The doctor assesses the sugar levels and indicates whether the insulin dose should be increased, decreased, or maintained. With weekly dose adjustments, the patient reaches the optimal insulin dose faster and the condition is controlled sooner. The ability to adjust a patient’s insulin dose as often as weekly thanks to the team doing a home visit is a game changer. </p>
<p>The insulin project intervention was tested with a limited number of patients at ten clinics in the Tshwane district in South Africa. The results of this trial <a href="https://www.tandfonline.com/doi/full/10.1080/16089677.2022.2074122">are promising</a>. There was no report of low blood sugar, which meant that the intervention was safe. Patients who completed the 14-week follow-up with home and clinic visits recorded a reduction of their <a href="https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/hba1c">glycated haemoglobin or HbA1c</a> by 2.2%, meaning that their blood sugar was better controlled after the intervention.</p>
<p>We are currently conducting a large-scale evaluation of the intervention. </p>
<h2>Remaining hurdles</h2>
<p>There is a lot of <a href="https://diabetesjournals.org/clinical/article/25/1/39/1493/Insulin-Myths-and-Facts">misinformation around insulin</a>. As a result, some people with type 2 diabetes perceive the progression from oral medication to insulin as a sign of failure. Even worse, some believe insulin means that death is near. </p>
<p>We’ve also found high rates of insulin refusal by patients – as high as <a href="https://repository.up.ac.za/handle/2263/79812">50%</a> in some areas. Many patients are not meeting their treatment targets. They remain on oral therapy with high blood sugar levels which leave them exposed to <a href="https://www.diabetes.org.uk/guide-to-diabetes/complications">serious complications</a>.</p>
<p>In addition, many healthcare professionals, especially those working at primary care clinics, are not equipped to manage patients who need insulin. Their lack of skills and knowledge may contribute to patients’ fears. And community health workers are in short supply. The number of community health workers is estimated at <a href="https://bhekisisa.org/opinion/2020-05-20-community-health-care-workers-in-south-africa-investment-case-covid19-coronavirus-tracing-programme/">55,000 for the whole country</a> which is not enough considering the population needs. The Medical Research Council estimated that South Africa needs <a href="https://www.samrc.ac.za/sites/default/files/files/2017-10-30/SavingLivesSavingCosts.pdf">41,000 more</a> to bring the total to 96,000. </p>
<p>Despite all of these challenges, we are confident that interventions like ours can improve the management of people living with diabetes. The support of health authorities and healthcare workers is crucial for a <a href="https://phcfm.org/index.php/phcfm/article/view/3467">successful implementation</a>.</p><img src="https://counter.theconversation.com/content/186000/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rheeder receives funding from Lilly Global Health Partnership</span></em></p><p class="fine-print"><em><span>Elizabeth M. Webb and Patrick Ngassa Piotie do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As diabetes progresses, insulin injections become the only treatment option. But the transition from oral medication to injectable insulin is often a bumpy one.Patrick Ngassa Piotie, Project Manager, University of Pretoria Diabetes Research Centre, University of PretoriaElizabeth M. Webb, Associate professor, University of PretoriaPaul Rheeder, Project Head, Tshwane Insulin Project, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1794542022-05-19T12:23:24Z2022-05-19T12:23:24ZIs intermittent fasting the diet for you? Here’s what the science says<figure><img src="https://images.theconversation.com/files/453968/original/file-20220323-23-zm8qqm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intermittent fasting could have an array of health benefits, but as of yet there are no long-term studies into its effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/intermitted-farsting-diet-concept-royalty-free-image/1361961784?adppopup=true">neirfy/iStock via Getty Images Plus</a></span></figcaption></figure><p>What if I told you all you need to do to lose weight is read a calendar and tell time? These are the basics for successfully following an intermittent fasting diet. </p>
<p>Can it be that simple, though? Does it work? And what is the scientific basis for fasting? As a registered dietitian and <a href="https://experts.okstate.edu/mckale.montgomery">expert in human nutrition and metabolism</a>, I am frequently asked such questions.</p>
<p>Simply stated, intermittent fasting is defined by alternating set periods of fasting with periods in which eating is permitted. One method is <a href="https://doi.org/10.1093/ajcn/86.1.7">alternate-day fasting</a>. On “fast days,” followers of this form of fasting are restricted to consuming no more than 500 calories per day; on “feast days,” which occur every other day, they can eat freely, with no restrictions on the types or quantities of foods eaten. </p>
<p>Other methods include the increasingly popular <a href="https://doi.org/10.1038/s41574-022-00638-x">5:2 method</a>. This form of fasting involves five days of feasting and two days of fasting per week. </p>
<p>Another variation relies on time-restricted eating. That means followers should fast for a specified number of hours – typically 16 to 20 per day – while freely consuming foods within a designated four- to eight-hour period.</p>
<p>But what about eating breakfast and <a href="https://doi.org/10.1056/NEJM198910053211403">then small meals throughout</a> the day to keep the body’s metabolism running? After all, that’s the <a href="https://doi.org/10.1093/ajcn/81.1.16">conventional wisdom</a> that many of us grew up with. </p>
<p>To answer these questions, it helps to understand the basics of human metabolism. </p>
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<figcaption><span class="caption">A TV host went on a two-month intermittent fast to lose weight. Did it work?</span></figcaption>
</figure>
<h2>Human metabolism 101</h2>
<p>The human body requires a continual supply of energy to sustain life, and the foods we eat provide us with this energy. But because eating is often followed by periods of time without eating, an intricate set of biological pathways is in place to meet the body’s energy demands between meals. </p>
<p>Most of the pathways function at some level all the time, but they fluctuate following a meal in a predictable pattern called the <a href="https://doi.org/10.1007/s13679-018-0308-9">fed-fast cycle</a>. The time frames of the cycle can vary, depending on the food types eaten, the size of the meal and the person’s activity level.</p>
<p>So what happens, metabolically speaking, after we eat? Consuming carbohydrates and fats leads to a rise in blood glucose and also <a href="https://doi.org/10.1001/jama.2013.280593">lipid levels</a>, which include cholesterol and triglycerides. </p>
<p>This triggers the release of insulin from the pancreas. The insulin helps tissues throughout the body take up the glucose and lipids, which supplies the tissues with energy. </p>
<p>Once energy needs are met, leftover glucose is stored in the liver and skeletal muscle in a condensed form called glycogen. When glycogen stores are full, excess glucose converts to fatty acids and is stored in fat tissue. </p>
<p><a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/absorptive-state">About three to 18 hours</a> after a meal – again, depending upon a person’s activity level and size the of the meal – the amount of circulating blood glucose and lipids returns to baseline levels. So tissues then must rely on fuel sources already in the body, which are the glycogen and fat. A hormone called glucagon, secreted by the pancreas, helps facilitate the breakdown of glycogen and fat to provide energy for the body between meals. </p>
<p>Glucagon also initiates a process known as <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/gluconeogenesis">gluconeogenesis</a>, which is the synthesis of glucose from nondietary sources. This helps maintain the right level of blood glucose levels.</p>
<p>When the body reaches a true fasting state – about 18 hours to two days without additional food intake – the body’s stores of glycogen are depleted, and tissues like the heart and skeletal muscle start to rely heavily on fats for energy. That means an increase in the breakdown of the stored fats. </p>
<p>“Aha!” you might say. “So intermittent fasting is the key to ultimate fat burning?” Well, it’s not that simple. Let’s go through what happens next.</p>
<h2>The starvation state</h2>
<p>Though many tissues adapt to using fats for energy, the brain and red blood cells need a continual supply of glucose. But when glucose is not available because of fasting, the body starts to break down its own proteins and <a href="https://doi.org/10.1152/ajpendo.1997.273.6.E1209">converts them to glucose instead</a>. However, because proteins are also critical for supporting essential bodily functions, this is not a sustainable process.</p>
<p>When the body enters the starvation state, the body goes into self-preservation mode, and a metabolic shift occurs in an effort to spare body protein. The body continues to synthesize glucose for those cells and tissue that absolutely need it, but the breakdown of stored fats increases as well to provide energy for tissues such as the skeletal muscle, heart, liver and kidneys. </p>
<p>This also <a href="https://www.ncbi.nlm.nih.gov/books/NBK493179/#">promotes ketogenesis</a>, or the formation of ketone bodies – molecules produced in the liver as an energy source when glucose is not available. In the starvation state, ketone bodies are important energy sources, because the body is not capable of solely utilizing fat for energy. This is why it is inaccurate when some proponents of intermittent fasting claim that fasting is a way of burning “just fat” - it’s not biologically possible.</p>
<p>What happens when you break the fast? The cycle starts over. Blood glucose and lipids return to basal levels, and energy levels in the body are seamlessly maintained by transitioning between the metabolic pathways described earlier. The neat thing is, we don’t even have to think about it. The body is well-equipped to adapt between periods of feasting and fasting. </p>
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<figcaption><span class="caption">Intermittent fasting – fact or fiction? What the science actually says.</span></figcaption>
</figure>
<h2>Possible downsides</h2>
<p>If an “all-or-nothing” dietary approach to weight loss sounds appealing to you, chances are it just might work. Indeed, intermittent fasting diets have produced <a href="https://doi.org/10.1001/jamainternmed.2017.0936">clinically significant</a> amounts of weight loss. Intermittent fasting may also <a href="https://doi.org/10.1038/s41574-022-00638-x">reduce disease risk</a> by lowering blood pressure and blood lipid levels.</p>
<p>On the flip side, numerous studies have shown that the weight reduction from intermittent fasting diets is <a href="https://doi.org/10.1001/jamainternmed.2017.0936">no greater than</a> the weight loss on a standard calorie-restricted diet.</p>
<p>In fact, the weight loss caused by intermittent fasting is due not to spending time in some sort of magic metabolic window, but rather to reduced overall calorie consumption. On feast days, dieters do not typically <a href="https://doi.org/10.1186/1475-2891-9-35">fully compensate</a> for lack of food on fasted days. This is what results in mild to moderate weight loss. Approximately 75% of the weight is fat mass; the rest is lean mass. That’s about the <a href="https://doi.org/10.1038/s41574-022-00638-x">same ratio as a standard low-calorie diet</a>.</p>
<p>Should you still want to go forward with intermittent fasting, keep a few things to keep in mind. First, there are no studies on the long-term safety and efficacy of following this type of diet. Second, studies show that intermittent fasters don’t get enough of <a href="https://doi.org/10.1016/j.clnu.2020.02.022">certain nutrients</a>. </p>
<p>Exercise is something else to consider. It helps preserve lean muscle mass and may also contribute to increased weight loss and long-term weight maintenance. This is important, because nearly a quarter of the weight lost on any diet is muscle tissue, and the efficacy of intermittent fasting for weight loss has been demonstrated <a href="https://doi.org/10.1038/s41574-022-00638-x">for only short durations</a>.</p>
<p>Also, once you stop following an intermittent-fasting diet, you will very likely gain the weight back. This is a critical consideration, because many people find the diet difficult to follow long-term. Imagine the challenge of planning six months’ worth of feasting and fasting around family dinners, holidays and parties. Then imagine doing it for a lifetime. </p>
<p>Ultimately, the best approach is to follow an eating plan that meets current dietary recommendations and fits into your lifestyle.</p><img src="https://counter.theconversation.com/content/179454/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>McKale Montgomery receives funding from the National Institutes of Health.</span></em></p>Proponents of intermittent fasting say the clock can help you win the battle of the bulge. But the science behind it is a little more complicated.McKale Montgomery, Assistant Professor of Nutritional Sciences, Oklahoma State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1822042022-05-09T12:05:35Z2022-05-09T12:05:35ZNonprofit drugmaker Civica Rx is taking aim at the high insulin prices harming people with diabetes<figure><img src="https://images.theconversation.com/files/461576/original/file-20220505-11-rf28d7.jpg?ixlib=rb-1.1.0&rect=552%2C0%2C2505%2C1949&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">High insulin prices are leaving some people who need the drug without access.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/advocates-with-t1internationals-new-york-new-jersey-and-news-photo/1166231700?adppopup=true">Erik McGregor/LightRocket via Getty Images</a></span></figcaption></figure><p>Doctors have been treating <a href="https://www.diabetes.org.uk/research/research-impact/insulin">diabetes with insulin</a> since <a href="https://www.cmaj.ca/content/167/12/1396">1922</a>. A century later, about <a href="https://www.cdc.gov/diabetes/data/statistics-report/index.html">1 in 5 of the 37 million Americans</a> living with diabetes take this medication – a hormone that helps cells absorb sugar from the blood.</p>
<p>This medication helps avert a host of medical problems including heart disease, kidney disease and stroke. Some <a href="https://familydoctor.org/insulin-therapy/">1.6 million Americans living with Type 1</a> diabetes, a condition in which people don’t produce any insulin, depend on it for their survival. So do millions more people with <a href="https://my.clevelandclinic.org/health/diseases/21501-type-2-diabetes">Type 2 diabetes</a> – a condition in which the body doesn’t make enough insulin.</p>
<p>But an estimated 1 in 4 of the Americans who need it have so much trouble affording this <a href="https://doi.org/10.1001/jamainternmed.2018.5008">lifesaving medication</a> that they skimp on doses because insulin prices have been skyrocketing for years. For example, the full cost – not counting insurance coverage – of about one month’s worth of a <a href="https://www.mayoclinic.org/drugs-supplements/insulin-glargine-recombinant-subcutaneous-route/description/drg-20067770">commonly used kind of insulin called glargine</a> has nearly tripled from US$99 in 2010 to <a href="https://www.businessinsider.com/insulin-price-increased-last-decade-chart-2019-9?r=US&IR=T">$284 in 2022</a>. </p>
<p>The exact amount Americans pay for insulin varies quite widely, <a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/sep/not-so-sweet-insulin-affordability-over-time">depending on their insurance coverage</a> and which version of the <a href="https://www.kff.org/medicaid/issue-brief/pricing-and-payment-for-medicaid-prescription-drugs/">medication they’re prescribed</a>.</p>
<p><a href="https://civicarx.org/civica-to-manufacture-and-distribute-affordable-insulin/">Civica Rx</a>, a nonprofit that <a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0189">manufactures generic drugs</a>, is trying to help solve this problem. It’s planning to produce <a href="https://www.healthline.com/diabetesmine/why-is-there-no-generic-insulin">generic insulin</a> for no more than $30 for a month’s worth of the drug at a factory being built in Petersburg, Virginia. Eventually the drugmaker intends to sell all three of the most popular kinds of insulin, starting in 2024 with glargine.</p>
<p>Based on my <a href="https://scholar.google.com/citations?user=rTIsA4UAAAAJ&hl=en&oi=ao">research regarding the pharmaceutical industry</a> and my work as a doctor who treats patients with diabetes, I believe this effort, announced in March 2022, may greatly increase access to insulin for hundreds of thousands of people who need but can’t currently afford it.</p>
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<h2>Generic insulin competition is limited</h2>
<p>Americans rely on robust <a href="https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/generic-competition-and-drug-prices">competition from low-cost generic drugs</a> to make pharmaceutical products more affordable. This system has historically been more successful with blockbuster drugs like atorvastatin – a cholesterol-controlling drug better known by the <a href="https://www.axios.com/lipitor-pfizer-drug-patent-sales-2019-6937cdfb-47f1-46bc-8cf0-39e6b88e235e.html">brand name Lipitor</a> – and azithromycin – an antibiotic sold under the <a href="https://www.vox.com/2016/2/16/11008134/generic-drugs-safe-effective-cheaper">brand name Zithromax</a>.</p>
<p>Unfortunately, this system has failed to restrain increases in insulin prices, which are <a href="https://pharmanewsintel.com/news/insulin-prices-8x-higher-in-the-us-compared-to-similar-nations">far higher in the United States than other countries</a>.</p>
<p>One reason this has been the case has to do with the fact that insulin is a <a href="https://www.fda.gov/about-fda/center-biologics-evaluation-and-research-cber/what-are-biologics-questions-and-answers">biologic drug</a>, meaning that it’s produced using DNA technology by living organisms. Biologic drugs are harder to manufacture and are regulated by the Food and Drug Administration in a different manner than more conventional drugs.</p>
<h2>Seeing reasons for optimism</h2>
<p>I’m excited about this initiative because it promises to increase access to all people who require insulin in the U.S., regardless of insurance status or where they buy medications.</p>
<p>One reason is that Civica Rx is a nonprofit that will be more able than private-sector drugmakers to put the interests of those who pay for insulin – patients and health insurers – ahead of investors’.</p>
<p>Another is its pricing strategy. Civica Rx plans to charge only about 20% of the list prices for brand-name insulin products. <a href="https://corporate.walmart.com/newsroom/2021/06/29/walmart-revolutionizes-insulin-access-affordability-for-patients-with-diabetes-with-the-launch-of-the-first-and-only-private-brand-analog-insulin">Walmart and some other big-box retailers</a> already sell insulin at a discount, but their prices are still higher than what the nonprofit plans to charge. </p>
<p>And findings from <a href="https://doi.org/10.1016/S2213-8587(15)00364-2">my own research suggest</a> that intellectual property protections will not likely be a substantial barrier to Civica’s efforts. </p>
<p>I’m also optimistic because of support from large insurers like <a href="https://civicarx.org/civica-to-manufacture-and-distribute-affordable-insulin/">Anthem and Blue Cross Blue Shield Association</a> for this effort. It’s reassuring that Civica Rx’s leadership includes many people with decades of experience in the <a href="https://civicarx.org/board-of-directors/">pharmaceutical industry and in health policy</a>.</p>
<p>But I see some reasons to be less optimistic. </p>
<p>First, there have been prior attempts to manufacture generic insulin in the U.S. <a href="https://www.biopharma-reporter.com/Article/2013/06/17/Insulin-CMO-Sued-by-US-City-Over-Failed-Manufacturing-Plant">None have succeeded</a>.</p>
<p>Another possibility is that brand-name insulin manufacturers may try to push doctors to prescribe <a href="https://www.news-medical.net/health/Drug-Patents-and-Generics.aspx">newer patent-protected versions</a> of insulin, which would be harder for Civica Rx to market as a generic – at least initially.</p>
<p>Success is far from guaranteed, given that the established players all have a strong financial interest in seeing Civica’s efforts fail.</p>
<h2>Lawmakers are taking action</h2>
<p>Several state legislatures have also tried to deal with this problem. Some have enacted laws <a href="https://www.nashp.org/drug-price-transparency-laws-position-states-to-impact-drug-prices/">mandating drug price transparency</a> and provided funds to guarantee <a href="https://www.minnpost.com/state-government/2020/04/a-great-day-minnesota-legislature-finally-passes-emergency-insulin-bill/">emergency access to insulin</a>.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two women and two men in suits next to an 'affordable insulin' sign in front of the U.S. Capitol building." src="https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461578/original/file-20220505-17-yssztk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Members of Congress – from left, Rep. Dan Kildee, D-Mich.; House Majority Whip James Clyburn, D-S.C.; Rep. Angie Craig, D-Minn.; and Rep. Lucy McBath, Ga. – express support for capping insulin prices at $35 a month or less in March 2022.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/InsulinCosts/37695cd7b2174975adfe0bc92170e895/photo?Query=insulin&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=364&currentItemNo=8">AP Photo/J. Scott Applewhite</a></span>
</figcaption>
</figure>
<p>But to date these assorted responses have <a href="https://www.goodrx.com/healthcare-access/research/how-much-does-insulin-cost-compare-brands">failed to lower prices for brand-name insulin products</a>, although I think it’s possible that prices would have risen faster without them.</p>
<p>Congress is also responding.</p>
<p>Four weeks after Civica Rx announced its plans to produce insulin at well below current prices, the U.S. House of Representatives <a href="https://www.npr.org/2022/03/31/1090085513/house-passes-bill-to-cap-insulin-prices">passed a bill that would limit insulin copays to $35</a> for insured patients. This measure was also in <a href="https://www.wusa9.com/article/news/verify/insulin-costs-about-10-to-make-but-retails-for-nearly-300-pharmaceutical-companies-eli-lilly-novo-nordisk-sanofi-pbms-insuli/65-73a3cafd-3340-45cd-8324-a5e3e1c78fa5">President Joe Biden’s</a> stalled <a href="https://www.youtube.com/watch?v=GJT_04kyv5I">Build Back Better</a> spending plan.</p>
<p>The House bill would leave out many patients – most <a href="https://khn.org/news/article/insulin-copay-cap-passes-house-hurdle-but-senate-looks-for-a-broader-bill/">notably the uninsured</a>. But this measure would also <a href="https://khn.org/news/article/insulin-copay-cap-passes-house-hurdle-but-senate-looks-for-a-broader-bill/">mark a positive step</a> should <a href="https://khn.org/news/article/insulin-copay-cap-passes-house-hurdle-but-senate-looks-for-a-broader-bill/">the Senate</a> <a href="https://rollcall.com/2022/04/06/with-senate-readying-vote-on-insulin-bill-advocates-seek-changes/">follow suit</a>.</p>
<p>People living with insulin-dependent diabetes have been waiting a long time for someone to do something to make it more affordable. It looks like that time may finally be arriving.</p><img src="https://counter.theconversation.com/content/182204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Through his University, Jing Luo receives funding from The Leona M. and Harry B. Helmsley Charitable Trust and has previously received funding from Arnold Ventures. Both of these organizations have made contributions to Civica.</span></em></p>About 1 in 4 Americans with diabetes who need insulin struggle to pay for this lifesaving drug.Jing Luo, Assistant Professor of Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1732102022-01-28T13:27:13Z2022-01-28T13:27:13ZNew insights from biology can help overcome siloed thinking in cancer clinical trials and treatment<figure><img src="https://images.theconversation.com/files/441611/original/file-20220119-25-164wpa0.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C537%2C420&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Metabolic conditions like obesity and diabetes can influence how cancer develops and responds to treatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/chemo-therapy-royalty-free-image/1134307405?adppopup=true">Eric Kitayama/iStock via Getty Images Plus</a></span></figcaption></figure><p>Rarely does an oncologist closely question a breast cancer patient about their blood glucose, body weight, lipid profile, or medications for diabetes and cardiovascular disease. Instead, these issues are usually the concern of the patient’s primary care provider. </p>
<p>Medical experts have <a href="https://doi.org/10.1152/physrev.00030.2014">recognized that obesity</a>, defined as a body mass index of 30 or greater, increases the <a href="https://doi.org/10.1016/j.canep.2016.01.003">risk of several cancers</a>. They include cancers of the breast, esophagus, kidney, gallbladder, liver, colon and several other organs. We have been aware of this relationship for <a href="https://doi.org/10.1038/sj.onc.1207751">about 20 years</a>. Despite this awareness, medicine is still missing a holistic view of people with cancer.</p>
<p>When testing new cancer drugs, clinical trials traditionally exclude patients with a history of heart disease, kidney disease, diabetes or similar chronic conditions related to obesity. The purpose is to make <a href="https://doi.org/10.1001/jamaoncol.2019.1187">study results easier to interpret</a>. But this practice leaves cancer researchers with a weak understanding of how patients could be monitored and treated for <a href="https://doi.org/10.1038/nrc1550">obesity-driven cancers</a>. One way it limits their knowledge is by leaving out significant numbers of patients. Among them are patients of color, who are already underrepresented in <a href="https://doi.org/10.3233/SHTI190369">scientific studies</a> generally and <a href="https://doi.org/10.1002/cncr.23157">cancer treatment treatment trials</a> in particular.</p>
<p>As a <a href="https://profiles.bu.edu/Gerald.Denis">molecular oncologist</a> at Boston Medical Center, I explore how metabolic conditions like <a href="https://scholar.google.com/citations?user=2f8xa-oAAAAJ&hl=en">obesity and diabetes</a> can influence whether someone develops cancer. I look closely at how these conditions can affect how the cancer grows, spreads or responds to treatment.</p>
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<img alt="Blue-gloved hand holding clear vial of blood." src="https://images.theconversation.com/files/441767/original/file-20220120-8584-1uztb33.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441767/original/file-20220120-8584-1uztb33.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441767/original/file-20220120-8584-1uztb33.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441767/original/file-20220120-8584-1uztb33.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441767/original/file-20220120-8584-1uztb33.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441767/original/file-20220120-8584-1uztb33.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441767/original/file-20220120-8584-1uztb33.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Less invasive cancer detection and treatment is one potential benefit of better communication between endocrinologists and cancer specialists.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/blood-sample-for-lipid-profile-testing-medical-royalty-free-image/1354714222?adppopup=true">Juan Ruiz Parmo/iStock via Getty Images Plus</a></span>
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<p>Our teams at Boston Medical Center’s Cancer Center have have identified how obesity and diabetes may provoke cancer to spread in potentially deadly ways. In particular, <a href="https://doi.org/10.1016/S0026-0495(78)80007-9">insulin-resistant fat cells</a> are likely to play a critical role in provoking breast cancer cells to move from the original tumor to distant organs like the lungs, liver, bones or brain. These distant metastases commonly define the end stage before someone with breast cancer dies.</p>
<p>Our results show that in the <a href="https://doi.org/10.1126/scisignal.abj2807">microscopic neighborhood inside or near a tumor</a>, cancer cells and noncancerous fat cells sit right next to each other, like neighbors on a park bench. Our research has shown that these two cell types engage in active “cross-talk.” This communication may inhibit or promote a tumor’s ability to grow and spread. How that happens is not well understood, partly because oncologists – whether studying cancer or treating it – generally don’t take nearby fat cells into consideration. </p>
<h2>Strategic diagnosis and treatment</h2>
<p>Acknowledging the relationship between fat cells and cancer cells offers opportunities to find and treat cancer less invasively. With molecules isolated from just a teaspoon or less of a patient’s blood, specialists can learn the risk that the cancer might be growing and spreading. These molecules, <a href="https://doi.org/10.1016/j.molonc.2012.01.010">called biomarkers</a>, can also show which patients are in the greatest danger of treatment failure. Taking occasional blood samples is less invasive than repeated biopsies, which involves getting samples of breast or other tissue. </p>
<p>When endocrinologists and oncologists consult with one another, they can consider obesity and metabolism alongside the current standard of care for patients with cancer. This combination would likely benefit populations, like <a href="https://doi.org/10.1200/JCO.2003.08.010">older adults</a>, in which both obesity and metabolic disease are more prevalent. </p>
<p>Furthermore, the cancer patient population may soon include more <a href="https://doi.org/10.1038/s41571-020-00445-1">young people</a>. A 2019 study found that people age 50 or younger have a <a href="https://doi.org/10.1016/S2468-2667(18)30267-6">disproportionately elevated risk</a> for certain obesity-driven cancers, including obesity-associated colorectal cancer. The relationship between fat cells and cancer cells could explain some of these trends.</p>
<h2>Closing gaps in care</h2>
<p>And already, more young African American adults are developing <a href="https://doi.org/10.1097/MEG.0000000000001205">aggressive colorectal cancers</a> than young adults of <a href="https://doi.org/10.3322/caac.21555">other races</a>. This fact came to the nation’s attention in 2020, when actor <a href="https://doi.org/10.2196/29387">Chadwick Boseman died</a> from an <a href="https://doi.org/10.1002/cncr.33919">aggressive colon cancer</a> at age 43. </p>
<p>Although Boseman was not overweight, his death brought attention to the community of African American adults who experience higher risks not only <a href="https://doi.org/10.1007/s10549-015-3353-z">for obesity</a> and <a href="https://doi.org/10.2105/ajph.92.4.543">diabetes</a> but also for several cancers including <a href="https://doi.org/10.1007/s11934-017-0724-5">prostate</a>, <a href="https://doi.org/10.1158/1055-9965.EPI-07-0336">breast</a> and <a href="https://doi.org/10.1053/j.gastro.2019.10.029">colorectal</a>. And despite their higher risks, Black patients are often not effectively counseled <a href="https://doi.org/10.1093/jnci/djab073">by physicians</a> regarding cancer risk and treatment.</p>
<p>[<em>Get fascinating science, health and technology news.</em> <a href="https://memberservices.theconversation.com/newsletters/?nl=science&source=inline-science-fascinating">Sign up for The Conversation’s weekly science newsletter</a>.]</p>
<p>At Boston Medical Center, 50% of our patients have diagnoses of obesity and 30% have Type 2 diabetes. We see similar numbers and patterns in our cancer patient population. One potential reason is that Boston Medical Center is a <a href="https://doi.org/10.1177/1077558708315440">safety-net hospital</a>, providing essential and excellent care to a very diverse range of patients regardless of insurance, immigration status or medical literacy. Such hospitals are often located in neighborhoods with high rates of <a href="https://doi.org/10.1001/archinternmed.2011.287">obesity and diabetes</a>.</p>
<p>Black and Latino adults with cancer tend to be overrepresented in <a href="https://doi.org/10.1007/BF02345673">safety-net hospital systems</a>. They receive cancer screenings <a href="https://doi.org/10.1016/j.athoracsur.2019.11.052">less often</a>. They also experience
<a href="https://doi.org/10.1080/03630242.2010.530928">longer wait times</a>, first for diagnosis and then for treatment. These factors contribute to <a href="https://doi.org/10.1016/j.canep.2017.05.003">worse survival rates</a> among Black and Latino cancer patients. Some of these worse outcomes may be a result of cancer and diabetes <a href="https://doi.org/10.1530/ERC-16-0222">interacting in these patients</a>.</p>
<p>Addressing disparities like these would be a natural benefit of bringing together previously disconnected clinical specialties. Research on the linkage among obesity, diabetes and cancer is revealing new pathways and molecules that tie these different diseases together. These new insights could improve outcomes for patients who are at greatest risk, and prompt more holistic assessments and treatments for all patients.</p><img src="https://counter.theconversation.com/content/173210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gerald Denis receives funding from the National Cancer Institute.</span></em></p>Fat cells and cancer cells talk to each other. Specialists in both systems can do the same.Gerald Denis, Professor of Medicine and Pharmacology, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1749152022-01-14T10:42:00Z2022-01-14T10:42:00ZThe discovery of insulin: meet the feuding scientists who all lay a claim – podcast<figure><img src="https://images.theconversation.com/files/440709/original/file-20220113-8662-11segqz.jpg?ixlib=rb-1.1.0&rect=35%2C251%2C5955%2C3116&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">200 units or 10cc of insulin from the 1930s manufactured by Eli Lilly and Company, Indianapolis - USA. </span> <span class="attribution"><a class="source" href="https://www.alamy.com/vintage-1930s-insulin-lilly-u-20-10cc-200-units-eli-lilly-and-company-indianapolis-usa-image451274244.html?pv=1&stamp=2&imageid=EEACFBC2-96CE-457A-ADB3-5215D962FDE4&p=769754&n=0&orientation=0&pn=1&searchtype=0&IsFromSearch=1&srch=foo%3dbar%26st%3d0%26pn%3d1%26ps%3d100%26sortby%3d2%26resultview%3dsortbyPopular%26npgs%3d0%26qt%3dbanting%2520insulin%26qt_raw%3dbanting%2520insulin%26lic%3d3%26mr%3d0%26pr%3d0%26ot%3d0%26creative%3d%26ag%3d0%26hc%3d0%26pc%3d%26blackwhite%3d%26cutout%3d%26tbar%3d1%26et%3d0x000000000000000000000%26vp%3d0%26loc%3d0%26imgt%3d0%26dtfr%3d%26dtto%3d%26size%3d0xFF%26archive%3d1%26groupid%3d%26pseudoid%3d367023%26a%3d%26cdid%3d%26cdsrt%3d%26name%3d%26qn%3d%26apalib%3d%26apalic%3d%26lightbox%3d%26gname%3d%26gtype%3d%26xstx%3d0%26simid%3d%26saveQry%3d%26editorial%3d%26nu%3d%26t%3d%26edoptin%3d%26customgeoip%3dGB%26cap%3d1%26cbstore%3d1%26vd%3d0%26lb%3d%26fi%3d2%26edrf%3d0%26ispremium%3d1%26flip%3d0%26pl%3d">Walter Cicchetti / Alamy Stock Photo </a></span></figcaption></figure><p>This episode of The Conversation’s <a href="https://theconversation.com/uk/topics/in-depth-out-loud-podcast-46082">In Depth Out Loud podcast</a> tells the story of the monstrous egos and toxic rivalries behind the discovery of insulin. </p>
<iframe src="https://embed.acast.com/5e29c8205aa745a456af58c8/61e0322cda22ee0012c8cd7a" frameborder="0" width="100%" height="190px"></iframe>
<p><iframe id="tc-infographic-563" class="tc-infographic" height="100" src="https://cdn.theconversation.com/infographics/563/073b078b1fc9085013377310bc6db3368fb84a13/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>You can read the text version of <a href="https://theconversation.com/the-discovery-of-insulin-a-story-of-monstrous-egos-and-toxic-rivalries-172820">this in-depth article here</a>. The audio version is read by Martin Buchanan in partnership with Noa, News Over Audio. Listen to more articles from The Conversation, for free, on the <a href="https://newsoveraudio.com/publishers/103?mpId=17937807d4095-03ef8e1781bb1c8-445466-1fa400-17937807d41112&embedPubName=The%20Conversation&embedPubId=103">Noa app</a>. </p>
<p>Kersten Hall, author and honorary fellow at the school of philosophy, religion and history of science at the University of Leeds, recounts a tale that at times resembles Game of Thrones in lab coats, with pipettes rather than poisoned daggers.</p>
<p><em>The music in In Depth Out Loud is Night Caves, by <a href="https://www.youtube.com/watch?v=dvwbOVMlp3o">Lee Rosevere</a>. In Depth Out Loud is produced by Gemma Ware.</em></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>This story came out of a project at The Conversation called Insights, which is supported by Research England. You can read <a href="https://theconversation.com/uk/topics/insights-series-71218">more stories in the series here</a>.</p><img src="https://counter.theconversation.com/content/174915/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kersten’s new book ‘Insulin – the Crooked Timber: A History from Thick Brown Muck to Wall Street Gold’ will be published by Oxford University Press on 13th January 2022 and is available to pre-order. <a href="http://www.kerstenhall.com">www.kerstenhall.com</a></span></em></p>The audio version of an in-depth article on the feuding scientists who battled for credit over the discovery of insulin.Kersten Hall, Author and Honorary Fellow, School of Philosophy, Religion and History of Science, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1728202022-01-11T15:24:54Z2022-01-11T15:24:54ZThe discovery of insulin: a story of monstrous egos and toxic rivalries<figure><img src="https://images.theconversation.com/files/439331/original/file-20220104-27-17r0qse.jpg?ixlib=rb-1.1.0&rect=84%2C10%2C878%2C483&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Frederick Banting and John Macleod. </span> <span class="attribution"><a class="source" href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AP10042">Fisher Insulin Collection, Rare Book Library, University of Toronto.</a></span></figcaption></figure><p>When Frederick Banting’s phone rang one morning in October 1923, it was the call that every scientist must dream of receiving. On the other end of the line, an excited friend asked Banting if he had seen the morning newspapers. When Banting said no, his friend broke the news himself. Banting had just been awarded the Nobel prize for his <a href="https://www.nobelprize.org/prizes/medicine/1923/summary/">discovery of insulin</a>.</p>
<p>Banting told his friend to “go to hell” and slammed the receiver down. Then he went out and bought the morning paper. Sure enough, there in the headlines he saw in black and white that his worst fears had come true: he had indeed been awarded the Nobel – but so too had his boss, John Macleod, professor of physiology at the University of Toronto.</p>
<p>This is a tale of monstrous egos, toxic career rivalries and injustices. But of course, there is another character in this drama: diabetes itself.</p>
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<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/the-discovery-of-insulin-a-story-of-monstrous-egos-and-toxic-rivalries-172820&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p><em>You can listen to more articles from The Conversation, narrated by Noa, <a href="https://theconversation.com/uk/topics/audio-narrated-99682">here</a>.</em></p>
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<p>According to a recent World Health Organization <a href="https://www.who.int/publications/i/item/9789240039100">report</a>, about 9 million people with type 1 diabetes are alive today thanks to insulin. I’m one of them, and it was my own shock diagnosis with this condition, just over ten years ago, that first led me to investigate the discovery of insulin – the drug that I would be injecting several times a day for the rest of my life.</p>
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<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>This story is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> and is working with academics from different backgrounds who have been engaged in projects to tackle societal and scientific challenges.</em> </p>
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<h2>‘The pissing evil’</h2>
<p>Diabetes derives its name from the ancient Greek word for “to flow” – a reference to one of its most common symptoms and for which the 17th-century English doctor <a href="https://hsm.ox.ac.uk/thomas-willis">Thomas Willis</a> (1625-75) gave it the far more memorable name of “the pissing evil”. But frequent trips to the toilet were the least of a patient’s worries.</p>
<p>Before the discovery of insulin, a diagnosis of <a href="https://www.nhs.uk/conditions/type-1-diabetes/">type 1 diabetes</a> meant certain death. Unable to metabolise sugar from carbohydrates in their diet, patients became weak and emaciated until, due to the production of toxic compounds known as <a href="https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/ketones-and-diabetes">ketones</a>, they slipped into a coma and died. Even at the start of the 20th century, there was little that could be done for patients with this condition, other than to put them on a starvation diet that might at best delay the inevitable. </p>
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<img alt="Portrait photo of a man." src="https://images.theconversation.com/files/439357/original/file-20220104-23-f4e4y6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/439357/original/file-20220104-23-f4e4y6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=815&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439357/original/file-20220104-23-f4e4y6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=815&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439357/original/file-20220104-23-f4e4y6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=815&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439357/original/file-20220104-23-f4e4y6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1024&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439357/original/file-20220104-23-f4e4y6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1024&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439357/original/file-20220104-23-f4e4y6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1024&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Boston diabetes doctor Elliott P. Joslin.</span>
<span class="attribution"><a class="source" href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AP10132">Insulin Collection, University of Toronto.</a></span>
</figcaption>
</figure>
<p>Little wonder then that doctors were stunned at the discovery of a hormone that could return the elevated sugars in diabetic patients to healthy levels and even bring them out of a coma. And since it was made by small patches of islet-like tissues in the pancreas, this substance was given the name “insulin”, derived from the Latin for “island”. When the eminent American diabetes doctor <a href="https://www.joslin.org/about/history/our-founder#">Elliott Joslin</a> first used insulin to treat his patients in early 1922, he was so stunned by its power that he likened it to the “Vision of Ezekiel”, the Old Testament prophet who is said to have seen a valley of dry bones rise up, be clothed in flesh and restored to life.</p>
<p>Joslin’s colleague Walter Campbell was equally impressed, but much less poetic. He described the crude pancreatic extracts as “thick brown muck”. And although the thick brown muck was saving lives, it very quickly became apparent that it could also take them. If injected in the wrong dose, it would cause a patient’s blood sugar levels to crash, sending them into <a href="https://www.nhs.uk/conditions/low-blood-sugar-hypoglycaemia/">hypoglycaemic shock</a> and the possibility of a fatal coma.</p>
<p>For the newspapers, however, insulin was hailed as a miracle. And accolades quickly began to flood in for its discoverer. Banting received <a href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AL10032">a letter</a> from Canadian prime minister Mackenzie King granting him a lifetime pension from the government of Canada; he was invited to open the Canadian Exhibition (an honour reserved for “a distinguished Canadian or British citizen”) and was even summoned for an audience at Buckingham Palace with King George V. Then came the Nobel prize.</p>
<figure class="align-center ">
<img alt="Old newspaper front page" src="https://images.theconversation.com/files/439338/original/file-20220104-13-1eqxi1w.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/439338/original/file-20220104-13-1eqxi1w.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=333&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439338/original/file-20220104-13-1eqxi1w.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=333&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439338/original/file-20220104-13-1eqxi1w.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=333&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439338/original/file-20220104-13-1eqxi1w.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=418&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439338/original/file-20220104-13-1eqxi1w.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=418&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439338/original/file-20220104-13-1eqxi1w.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=418&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The front page of the Toronto Star from March 22, 1922 talks of Banting and Best’s accomplishments regarding insulin and a diabetes cure.</span>
<span class="attribution"><a class="source" href="https://images.thestar.com/content/dam/thestar/yourtoronto/once-upon-a-city-archives/2016/01/14/once-upon-a-city-discovering-insulin-was-banting-at-his-best/banting-front-page.jpg">Matteo Omied / Alamy Stock Photo / Toronto Star</a></span>
</figcaption>
</figure>
<h2>Why so angry?</h2>
<p>But why was Banting so furious? As far as he was concerned, having to share the award with Macleod was not just a travesty, but an insult. He thought that Macleod had no right whatsoever to have any claim on the discovery of insulin, as an entry from a journal written in 1940 makes abundantly clear:</p>
<blockquote>
<p>Macleod on the other hand was never to be trusted. He was the most selfish man I have ever known. He sought at every possible opportunity to advance himself. If you told Macleod anything in the morning it was in print or in a lecture in his name by evening … He was unscrupulous and would steal an idea or credit for work from any possible source. </p>
</blockquote>
<p>And yet, had it not been for Macleod, Banting might never have been awarded the prize in the first place and would probably have remained a struggling GP in provincial Ontario. </p>
<p>After his return to Canada from the <a href="https://en.wikipedia.org/wiki/Western_Front_(World_War_I)">western front</a> as a wounded war hero, Banting had found his career going rapidly downhill. Having trained as a doctor, he had hoped to establish a private medical practice. But such hopes seemed to be rapidly evaporating, and he found himself cooking his meals over a Bunsen burner, writing prescriptions for baby feed and unable even to afford a trip to the cinema. Hopes of an alternative career as a landscape painter were quickly shot down in flames when his creative efforts were met with scorn by a local dealer. In every direction he looked, Banting saw a hostile world. </p>
<p>This also proved to be the case in his first meeting with Macleod. Banting had approached him with what he believed to be a novel approach for isolating the much sought after anti-diabetic hormone made by the pancreas that might at last tame diabetes. But instead of being greeted with unfettered enthusiasm, Banting recalled that Macleod listened for a while and then began reading some letters on his desk. </p>
<p>It wasn’t that Macleod lacked enthusiasm. Rather, he was simply concerned that although Banting had the inspiration for the work, he lacked the specialist surgical skills to carry it out. But he nevertheless gave Banting the benefit of the doubt and arranged for him to begin work with <a href="https://www.thecanadianencyclopedia.ca/en/article/charles-best">Charles Best</a>, a final year honours student. Their partnership has since been described as “a historic collaboration” – although, as Banting later recalled, it did not get off to the best start. For when he found some serious discrepancies in some of Best’s initial data, he laid down the law in no uncertain terms:</p>
<p><em>>I was waiting for him, and on sight gave him a severe talking to. He thought that he was both God’s and Macleod’s appointed, but when [I] was finished with him he was not sure … We understood each other much better after this encounter.</em></p>
<figure class="align-center ">
<img alt="Two men pose with a dog." src="https://images.theconversation.com/files/438244/original/file-20211217-17-2b4xgc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/438244/original/file-20211217-17-2b4xgc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=835&fit=crop&dpr=1 600w, https://images.theconversation.com/files/438244/original/file-20211217-17-2b4xgc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=835&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/438244/original/file-20211217-17-2b4xgc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=835&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/438244/original/file-20211217-17-2b4xgc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1050&fit=crop&dpr=1 754w, https://images.theconversation.com/files/438244/original/file-20211217-17-2b4xgc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1050&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/438244/original/file-20211217-17-2b4xgc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1050&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Frederick Banting (right) and Charles Best (left) with a dog on the roof of the Medical Building at the University of Toronto in August 1921.</span>
<span class="attribution"><a class="source" href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AP10077">Thomas Fisher Rare Book Library, University of Toronto</a></span>
</figcaption>
</figure>
<p>With these teething troubles sorted, Banting and Best sweated away in the laboratory throughout the summer of 1921, making pancreatic extracts and testing their effects on the blood sugar levels of diabetic dogs. Banting may have been abrasive towards Best, but for his lab dogs, he had nothing but love and fondness:</p>
<blockquote>
<p>I shall never forget that dog as long as I shall live. I have seen patients die and I have never shed a tear. But when that dog died I wanted to be alone for the tears would fall despite anything I could do. </p>
</blockquote>
<p>With Macleod away in Europe for the summer, Banting wrote in great excitement to tell him about their latest results. But his response came as a disappointment. </p>
<p>Macleod gently pointed out that some of the experimental results were inconsistent and lacked appropriate controls. And when, on his return at the end of the summer, Macleod informed Banting that the University of Toronto could not agree to a list of his demands for more lab space and resources, Banting stormed out of the room raging: “I’ll show that little son of a bitch that he is not the University of Toronto,” and threatening to take his work elsewhere. </p>
<p>By the end of 1921, things had got worse. Macleod felt it was now time for Banting and Best to present their work in public at a formal scientific conference. But when Banting rose to address the American Physiological Society at the University of Yale that December, the prestige of the audience took its toll on his nerves. His presentation was a disaster. He later wrote:</p>
<blockquote>
<p>When I was called upon to present our work I became almost paralyzed. I could not remember nor could I think. I had never spoken to an audience of this kind before – I was overawed. I did not present it well.</p>
</blockquote>
<p>Desperate to snatch victory from the jaws of defeat, Macleod stepped in, took over and finished the presentation. For Banting, this was a brazen coup by Macleod to rob him of the credit for having discovered insulin – and to rub salt into the wound, it had been done in front of the most eminent doctors in the field. It confirmed Banting’s growing suspicions that insulin was slipping from his grasp – and he desperately needed to reassert his authority over the discovery.</p>
<p>An opportunity to do just that came in January 1922. By the time that 14-year-old Leonard Thompson’s father brought him into Toronto General Hospital, the boy was at death’s door from type 1 diabetes. When this work was first published, Banting described how the boy’s condition had left him “poorly nourished, pale, weight 65lbs, hair falling out, odour of acetone on his breath … appeared dull, talked rather slowly, quite willing to lie about all day”. One senior medical student gave a blunt and grim prognosis: “All of us knew that he was doomed.” </p>
<figure class="align-right ">
<img alt="Black and white portrait of a boy in a suit." src="https://images.theconversation.com/files/439342/original/file-20220104-25-1o3o5id.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/439342/original/file-20220104-25-1o3o5id.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=949&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439342/original/file-20220104-25-1o3o5id.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=949&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439342/original/file-20220104-25-1o3o5id.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=949&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439342/original/file-20220104-25-1o3o5id.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1193&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439342/original/file-20220104-25-1o3o5id.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1193&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439342/original/file-20220104-25-1o3o5id.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1193&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The first insulin patient, Leonard Thompson.</span>
<span class="attribution"><a class="source" href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AP10046">Insulin Collection, University of Toronto.</a></span>
</figcaption>
</figure>
<p>On the afternoon of January 11, 1922, Thompson was injected with 15cc of pancreatic extract that had been prepared by Best. Hopes were high, but the effect was disappointing. Despite causing a 25% drop in Leonard’s blood sugar levels, he continued to produce ketones – a sure sign that the extract had only limited anti-diabetic effect. But much more seriously, the extract had triggered a toxic reaction resulting in the eruption of abscesses at the injection site. Reporting on this work in the Canadian Medical Association Journal, Banting and Best drew the dismal conclusion that “no clinical benefit was evidenced” by the injection of their extract.</p>
<p>Two weeks later, on January 23, Thompson was injected once again. And this time, the result was starkly different. When they published their work, the Toronto team <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1524425/">recorded</a> that Thompson “became brighter, more active, looked better and said he felt stronger”. His blood sugar levels were markedly reduced. But perhaps the most important result of all was that this time there were no toxic side-effects. </p>
<h2>‘I would knock hell out of him’</h2>
<p>So what had changed in those two weeks? The answer was that this second batch of extract had not been prepared by Banting and Best but by their colleague <a href="https://www.thecanadianencyclopedia.ca/en/article/james-bertram-collip">James Collip</a>. He was a biochemist by training and with his expertise had been able to remove enough of the impurities from the raw pancreatic extract so that, when injected, it did not cause a toxic reaction.</p>
<figure class="align-right ">
<img alt="Black and white image of a man." src="https://images.theconversation.com/files/439344/original/file-20220104-21-4eldnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/439344/original/file-20220104-21-4eldnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=888&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439344/original/file-20220104-21-4eldnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=888&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439344/original/file-20220104-21-4eldnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=888&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439344/original/file-20220104-21-4eldnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1116&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439344/original/file-20220104-21-4eldnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1116&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439344/original/file-20220104-21-4eldnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1116&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Photograph of James Bertram Collip.</span>
<span class="attribution"><a class="source" href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AP10005">Insulin Collection, University of Toronto.</a></span>
</figcaption>
</figure>
<p>The secret of Collip’s success was alcohol. Banting and Best had themselves used alcohol to clean up their preparations of impurities, but it was Collip who really cracked the method of doing this to make an extract that could be used to successfully treat a patient with no adverse reactions. He had also discovered that although insulin might save lives, it could take them too. For when Collip injected some of his purified preparation into healthy animals, they became convulsive, comatose and eventually died. This was because Collip’s preparations were now so pure, that they were plunging the animals into hypoglycaemic shock. This is a danger which every type 1 patient is today taught to recognise and also – again thanks to Collip’s work – how to remedy it with some quick-acting sugar.</p>
<p>For Banting, however, Collip’s discoveries were not a cause for celebration but a new threat. When Collip was reluctant to divulge the secrets of his success, Banting’s temper boiled over:</p>
<blockquote>
<p>I grabbed him in one hand by the overcoat where it met in front and almost lifting him I sat him down hard on the chair. I do not remember all that was said but I remember telling him that it was a good job he was so much smaller – otherwise I would ‘knock hell out of him’. </p>
</blockquote>
<p>As he sank further into a festering stew of fear and suspicion, Banting began calming his nerves with alcohol stolen from the lab. “I do not think that there was one night during the month of March 1922 that I went to bed sober,” he said. </p>
<p>Two months later, when Macleod made the first <a href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AT10010">formal announcement</a> of the discovery of insulin to the scientific world at a meeting of the Association of American Physicians in Washington, Banting was not present. He claimed that he could not afford the train fare.</p>
<p>But Banting was not the only person left seething at the decision of the Nobel committee. There was yet another expert who could claim he discovered insulin – over 20 years before the Canadians.</p>
<h2>The tragedy of Georg Zuelzer</h2>
<p>In 1908, German doctor <a href="https://pubmed.ncbi.nlm.nih.gov/32750450/">Georg Zuelzer</a> had shown that pancreatic extracts could not only reduce the sugars and ketones in the urine of six diabetic patients but also bring at least one of those patients out of a diabetic coma. Calling his preparation “Acomatol”, Zuelzer had been so confident about its effectiveness in treating diabetes that he had even filed a patent on it.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/439346/original/file-20220104-23-11pp2vu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/439346/original/file-20220104-23-11pp2vu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=868&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439346/original/file-20220104-23-11pp2vu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=868&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439346/original/file-20220104-23-11pp2vu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=868&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439346/original/file-20220104-23-11pp2vu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1090&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439346/original/file-20220104-23-11pp2vu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1090&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439346/original/file-20220104-23-11pp2vu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1090&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Georg Zuelzer’s work was halted by the first world war.</span>
</figcaption>
</figure>
<p>Like Banting and Best, he too had also faced problems with side-effects. Impurities in the preparation had caused fever, shivering and vomiting in patients and Zuelzer knew that this would have to be overcome if Acomatol was ever to be used clinically. But he also knew how to do this because in his patent he had explained how alcohol could be used to remove these impurities. </p>
<p>By 1914, things were looking hopeful. Zuelzer now had the support of Swiss pharmaceutical <a href="https://www.roche.com/about/history.htm">Hoffman La Roche</a> and best of all, his preparations were causing no signs of fever, shivering or vomiting. But now Zuelzer observed some new – and serious – side-effects. Test animals became convulsive and sometimes slipped into a coma. And before Zuelzer even had the chance to work out what was going on, disaster struck.</p>
<p>With the outbreak of the first world war in the summer of 1914, Zuelzer’s research on insulin was brought to an abrupt halt from which it never recovered. Then, nearly a decade later came the news that the Nobel prize had gone to Banting and Macleod. This was a severe blow –- and it was quickly followed by another. </p>
<p>Only now did Zuelzer realise that the side-effects of convulsion and coma were not due to impurities, but rather the symptoms of hypoglycaemic shock arising from a preparation of insulin that was so pure it was causing a catastrophic crash in blood sugar levels. Little wonder that Zuelzer has been compared with a character in a Greek tragedy <a href="https://link.springer.com/chapter/10.1007/978-3-642-48364-6_32">by historians</a> Paula Drügemöller and Leo Norpoth. He had a potent preparation of insulin in his hands, only to have it snatched from his grasp by circumstances well beyond his control. </p>
<h2>‘That son-of-a-bitch Best’</h2>
<p>So why don’t we remember Zuelzer? According to the late historian <a href="https://books.google.co.uk/books/about/The_Discovery_of_Insulin.html?id=NEW8NwCXjGoC&redir_esc=y">Michael Bliss</a>, the answer has much to do with Charles Best who, just like Zuelzer, felt hurt by the award going to Banting and Macleod. When Banting first heard that he had been awarded the Nobel, he sent a telegram to Best who was in Boston at the time, saying: “Nobel trustees have conferred prize on Macleod and me. You are with me in my share always.”</p>
<p>True to his word, he publicly announced that he would share half of his C$20,000 prize money with Best. But if Banting was hoping that this might offer Best some consolation for not having shared in the prize, he was mistaken. Best’s resentment at having been overlooked began to irritate Banting. In 1941, shortly before boarding a flight on a secret war-time mission to the UK, Banting made clear that his former generosity towards Best was long since gone:</p>
<blockquote>
<p>This mission is risky. If I don’t come back and they give my [Professorial] Chair to that son-of-a-bitch Best, I’ll never rest in my grave. </p>
</blockquote>
<p>His words proved to be tragically prophetic. Shortly after take-off, Banting’s plane crashed, and he was killed. As Macleod had died in 1935, Best and Collip were now the only remaining members of the original research team from Toronto that had discovered insulin. And Best was determined that his name would be remembered.</p>
<p>But to stake his claim on the discovery of insulin, Best needed to make clear exactly when this had taken place. Had it been during the summer of 1921 when, working alone, he and Banting had isolated pancreatic extracts that could reduce the blood sugar levels in a diabetic dog? Or had it been in January 1922 when Leonard Thompson had first been successfully treated? If it was the latter, then Best had somehow to deal with the inconvenient fact that it had been Collip’s preparation – not his – that had actually been used to successfully treat Leonard Thompson.</p>
<p>As Best’s star began to rise in the North American medical establishment, he gave many addresses in which, if he mentioned Collip’s contribution at all, it was either diminished or used only to highlight the crucial role that Best had played in recovering the production of insulin after Collip had temporarily lost the secret of its purification.</p>
<p>Best insisted that the pivotal moment in the story of insulin had been when Leonard Thompson was injected for the first time on January 11, 1922 with an extract made by himself and Banting. That the real moment of therapeutic success had been two weeks later, when the boy had been treated with Collip’s preparation, was conveniently played down. At the same time, Best also claimed that the crucial innovation of using alcohol to remove toxic impurities had largely been his own. </p>
<p>He would subsequently go even further by insisting that insulin had been discovered during the summer of 1921 when he and Banting had been working alone, testing their extracts on diabetic dogs, well before Collip had arrived in Toronto. Collip’s response meanwhile was largely one of stoic silence. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/439349/original/file-20220104-13-1t0id0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/439349/original/file-20220104-13-1t0id0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=847&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439349/original/file-20220104-13-1t0id0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=847&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439349/original/file-20220104-13-1t0id0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=847&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439349/original/file-20220104-13-1t0id0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1065&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439349/original/file-20220104-13-1t0id0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1065&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439349/original/file-20220104-13-1t0id0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1065&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Disgraced Romanian scientist Nicolae Paulescu.</span>
<span class="attribution"><a class="source" href="https://insulin.library.utoronto.ca/islandora/object/insulin%3AP10081.">Insulin Collection, University of Toronto.</a></span>
</figcaption>
</figure>
<h2>Convincing the world</h2>
<p>Best appeared to have finally secured his place in medical history. At least so it seemed, until the late 1960s, when he received a letter that gave the wasps’ nest yet another poke. It revealed that during the summer of 1921, just as Banting and Best were embarking on their own research, a Romanian scientist called Nicolae Paulescu had already published similar experiments in a European scientific journal. But Paulescu’s scientific work has since been overshadowed by the ugly revelation of his anti-Semitic politics and the role that he played in inciting the Holocaust in Romania.</p>
<p>When Best was himself asked whether researchers such as Paulescu, Zuelzer and a handful of others such as the Rockefeller scientist Israel Kleiner, deserved any credit for the discovery of insulin, his reply spoke volumes: </p>
<blockquote>
<p>None of them convinced the world of what they had … This is the most important thing in any discovery. You’ve got to convince the scientific world. And we did. </p>
</blockquote>
<p>Michael Bliss, who has written extensively on the work of Banting and Best has written about how Best appears to have been “deeply insecure about and obsessed with his role in history”. He added: “The fumbling attempts to manipulate the historical record would have been pathetic and hardly worthy of comment had they not been so grossly unjust to Best’s former associates and, for a time, so influential.” </p>
<h2>Wall Street gold</h2>
<p>Whatever judgments we may pass on Best, there is no denying that he had grasped a crucial insight about an important way in which science was changing. Doing experiments in the lab was only half the story: scientists had also to persuade the wider world of the value of those experiments. And by the time of his death in 1978, this was a lesson that scientists were taking to heart. </p>
<p>That September, a team of scientists from the City of Hope Hospital in Southern California and the fledgeling biotechnology company Genentech in San Francisco gave a press conference to announce that they had done something amazing. Ever since the days of Banting and Best, type 1 patients had been having to treat themselves by injecting insulin recovered from the tissues of cows or pigs as a by-product of the meat industry. Now, thanks to the Genentech/City of Hope collaboration they could, for the first time, inject themselves with human insulin.</p>
<p>This achievement was a decisive victory in helping to win the hearts and minds of the media and public who were fearful of the new technology. Wall Street loved it, too. </p>
<p>When the bell was rung to open trading on the morning of October 14, 1980, dealers dived into a feeding frenzy for shares in the newly floated Genentech. It made its founders, venture capitalist Bob Swanson and scientist Herb Boyer both <a href="https://www.bloomberg.com/news/articles/2004-10-17/robert-swanson-and-herbert-boyer-giving-birth-to-biotech">multimillionaires</a>. </p>
<p>But diabetes remained an incurable chronic condition. Even as he was comparing its power with the Vision of Ezekiel, Elliott Joslin was also offering a stark warning: “Insulin is a remedy which is primarily for the wise and not for the foolish.” Joslin’s point was that Insulin could only be effective if its use went hand in hand with discipline, thought and responsible behaviour on the part of the patient. </p>
<p>This lesson applies elsewhere too – but may well be one we don’t always want to hear. Speaking at the <a href="https://www.theguardian.com/environment/2021/nov/09/changes-behaviour-tackle-climate-crisis-patrick-vallance-cop26">recent COP summit</a> in Glasgow, the UK government’s chief scientific adviser, Sir Patrick Vallance, pointed out that we can’t expect technology alone to solve all the problems we face. The truth is that, as much as we may wish for technological solutions to do all the heavy lifting, they can only be effective when they are accompanied by changes in our behaviour. </p>
<p>This is as true for managing diabetes with insulin as it is for dealing with challenges of a pandemic through vaccines, masks and social distancing, or climate change through carbon capture, electric cars and turning off the lights when we leave the room. And so, as we face challenges of the future, the story of insulin has important lessons for us all.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
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<p class="fine-print"><em><span>Kersten’s new book ‘Insulin – the Crooked Timber: A History from Thick Brown Muck to Wall Street Gold’ will be published by Oxford University Press on 13th January 2022 and is available to pre-order. <a href="http://www.kerstenhall.com">www.kerstenhall.com</a></span></em></p>Meet the feuding scientists who battled for credit over the discovery of insulin.Kersten Hall, Author and Honorary Fellow, School of Philosophy, Religion and History of Science, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1727472021-12-22T13:13:33Z2021-12-22T13:13:33ZDuring a COVID-19 surge, ‘crisis standards of care’ involve excruciating choices and impossible ethical decisions for hospital staff<figure><img src="https://images.theconversation.com/files/438078/original/file-20211216-17-16i6mbg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Amid the latest surge of COVID-19 cases, health care workers yet again are having to make difficult triage decisions in caring for patients. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/healthcare-coworkers-working-in-icu-during-covid-19-royalty-free-image/1265188155?adppopup=true">Morsa Images/E+ via Getty Images</a></span></figcaption></figure><p><em>The Conversation is running a series of dispatches from clinicians and researchers operating on the front lines of the coronavirus pandemic. You can <a href="https://theconversation.com/us/topics/covid-19-front-lines-84846">find all of the stories here</a>.</em></p>
<p>As the <a href="https://www.cdc.gov/coronavirus/2019-ncov/variants/omicron-variant.html">omicron variant</a> brings a <a href="https://www.npr.org/sections/coronavirus-live-updates/2021/12/20/1066083896/omicron-is-now-the-dominant-covid-strain-in-the-u-s-making-up-73-of-cases">new wave of uncertainty and fear</a>, I can’t help reflecting back to March 2020, when people in health care across the U.S. watched in horror as COVID-19 <a href="https://www.vox.com/2020/3/27/21197400/new-york-covid-19-hospitals-coronavirus">swamped New York City</a>. </p>
<p>Hospitals were <a href="https://www.adn.com/nation-world/2020/03/31/hospitals-overflow-with-bodies-in-new-york-the-us-epicenter-of-the-virus/">overflowing</a> with sick and dying patients, while ventilators and personal protective equipment were in short supply. Patients sat for hours or days in ambulances and hallways, waiting for a hospital bed to open up. <a href="https://www.nytimes.com/2020/03/25/nyregion/nyc-coronavirus-hospitals.html">Some never made it</a> to the intensive care unit bed they needed. </p>
<p>I’m an infectious disease specialist and bioethicist at the University of Colorado’s Anschutz Medical Campus. I worked with a team nonstop from March into June 2020, helping <a href="https://www.cuanschutz.edu/docs/librariesprovider139/covid-19-resources/uchealth_csc-triage-decision-criteria-and-process_v4_10_20-final.pdf?sfvrsn=a3afd5b9_0">my hospital</a> and <a href="https://cdphe.colorado.gov/colorado-crisis-standards-care">state</a> get ready for the massive influx of COVID-19 cases we expected might inundate our health care system.</p>
<p>When health systems are moving toward crisis conditions, the first steps we take are to do all we can to conserve and reallocate scarce resources. Hoping to keep delivering quality care – despite shortages of space, staff and stuff – we do things like canceling elective surgeries, moving surgical staff to inpatient units to provide care and holding patients in the emergency department when the hospital is full. These are called “contingency” measures. Though they can be inconvenient for patients, we hope patients won’t be harmed by them. </p>
<p>But when a crisis escalates to the point that we simply can’t provide necessary services to everyone who needs them, we are forced to perform crisis triage. At that point, the care provided to some patients is admittedly less than high quality – sometimes much less.</p>
<p>The care provided under such extreme levels of resource shortages is called “<a href="https://www.ama-assn.org/delivering-care/ethics/crisis-standards-care-guidance-ama-code-medical-ethics">crisis standards of care</a>.” Crisis standards can impact the use of any type of resource that is in extremely short supply, from staff (like nurses or respiratory therapists) to stuff (like ventilators or N95 masks) to space (like ICU beds). </p>
<p>And because the care we can provide during crisis standards is much lower than normal quality for some patients, the process is supposed to be fully transparent and <a href="https://cdphe.colorado.gov/colorado-crisis-standards-care">formally allowed by the state</a>. </p>
<h2>What triage looks like in practice</h2>
<p>In the spring of 2020, our plans assumed the worst – that we <a href="https://www.nytimes.com/2020/03/21/us/coronavirus-medical-rationing.html">wouldn’t have enough ventilators</a> for all the people who would surely die without one. So we focused on how to make ethical determinations about who should get the last ventilator, as though any decision like that could be ethical. </p>
<p>But one key fact about triage is that it’s not something you decide to do or not. If you don’t do it, then you are deciding to behave as if things are normal, and when you run out of ventilators, the next person to come along doesn’t get one. That’s still a form of triage. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two doctors leaning over a patient while intubating, or placing the patient on a ventilator." src="https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/438371/original/file-20211220-13-e5kd8b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In the early months of the pandemic, the U.S. faced a shortage of ventilators. In some regions, hospitals were forced to make difficult decisions about which patients received them.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/healthcare-workers-intubating-a-covid-patient-royalty-free-image/1255594215?adppopup=true">Tempura/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>Now imagine that all the ventilators are taken and the next person who needs one is a young woman with a complication delivering her baby. </p>
<p>That’s what we had to talk about in early 2020. My colleagues and I didn’t sleep much. </p>
<p>To avoid that scenario, our hospital <a href="https://doi.org/10.7326/M20-1738">and many others</a> proposed using a scoring system that counts up how many of a patient’s organs are failing and how badly. That’s because people with multiple organs failing <a href="https://doi.org/10.1001/jama.286.14.1754">aren’t as likely to survive</a>, which means they shouldn’t be given the last ventilator if someone with better odds also needs it. </p>
<p>Fortunately, before we had to use this triage system that spring, we got a reprieve. Mask-wearing, social distancing and <a href="https://coloradosun.com/2020/03/16/colorado-governor-restaurants-bars-closed/">business closures went into effect</a>, and they worked. We bent the curve. In April 2020, Colorado had some days with <a href="https://covid19.colorado.gov/data">almost 1,000 COVID-19 cases per day</a>. But by early June, our daily case rates were in the low 100s. COVID-19 cases would surge back in August as those measures were relaxed, of course. And <a href="https://www.thedenverchannel.com/news/coronavirus/coronavirus-in-colorado-covid-19-updates-for-dec-14-dec-20-2020">Colorado’s surge in December 2020</a> was especially severe, but we subdued these subsequent waves with the same basic public health measures. </p>
<figure class="align-center ">
<img alt="A chart depicting the number of COVID-19 patients hospitalized from Feb. 2020 to Dec. 2021." src="https://images.theconversation.com/files/438727/original/file-20211221-49721-nhkoat.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/438727/original/file-20211221-49721-nhkoat.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/438727/original/file-20211221-49721-nhkoat.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/438727/original/file-20211221-49721-nhkoat.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/438727/original/file-20211221-49721-nhkoat.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/438727/original/file-20211221-49721-nhkoat.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/438727/original/file-20211221-49721-nhkoat.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Number of COVID-19 patients hospitalized from Feb. 24, 2020 to Dec. 20, 2021.</span>
<span class="attribution"><a class="source" href="https://ourworldindata.org/covid-hospitalizations">Our World in Data.org</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>And then what at the time felt like a miracle happened: A safe and effective <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7008e3.htm">vaccine became available</a>. First it was just for people at highest risk, but then it became available <a href="https://www.webmd.com/vaccines/covid-19-vaccine/news/20210420/all-us-adults-eligible-covid-vaccines">for all adults</a> by later in the spring of 2021. We were just over one year into the pandemic, and people felt like the end was in sight. So <a href="https://www.nature.com/articles/d41586-021-01394-0">masks went by the wayside</a>.</p>
<p>Too soon, it turned out.</p>
<h2>A haunting reminder of 2020</h2>
<p>Now, in December 2021 here in Colorado, hospitals are filled to the brim again. Some have even been over 100% capacity recently, and <a href="https://covid19.colorado.gov/data">a third of the hospitals</a> expect ICU bed shortages during the last weeks of 2021. The best estimate is that by the end of the month we’ll be overflowing and <a href="https://www.cpr.org/2021/11/17/colorado-covid-hospitalizations-icu-beds/">ICU beds will run out statewide</a>. </p>
<p>But today, some members of the public have little patience for wearing masks or avoiding big crowds. People who’ve been vaccinated don’t think it’s fair they should be forced to cancel holiday plans, when <a href="https://www.uchealth.org/today/covid-19-coronavirus-recent-updates/">over 80% of the people hospitalized for COVID-19 are the unvaccinated</a>. And those who aren’t vaccinated … well, many seem to believe they just aren’t at risk, which <a href="https://www.washingtonpost.com/nation/2021/12/16/covid-omicron-variant-live-updates/">couldn’t be further from the truth</a>. </p>
<p>So, hospitals around our state are yet again facing triage-like decisions on a daily basis.</p>
<p>In a few important ways, the situation has changed. Today, our hospitals have plenty of ventilators, but <a href="https://www.nytimes.com/2020/11/22/health/Covid-ventilators-stockpile.html">not enough staff to run them</a>. Stress and burnout are <a href="https://doi.org/10.1016/j.eclinm.2021.100879">taking their toll</a>. </p>
<p>So, those of us in the health care system are hitting our breaking point again. And when hospitals are full, we are forced into making triage decisions.</p>
<h2>Ethical dilemmas and painful conversations</h2>
<p>Our health system in Colorado is now assuming that by the end of December, we could be 10% over capacity across all our hospitals, in both intensive care units and regular floors. In early 2020, we were looking for the patients who would die with or without a ventilator in order to preserve the ventilator; today, our planning team is looking for people who might survive outside of the ICU. And because those patients will need a bed on the main floors, we are also forced to find people on hospital floor beds who could be sent home early, even though that might not be as safe as we’d like.</p>
<p>For instance, take a patient who has diabetic ketoacidosis, or DKA – extremely high blood sugar with fluid and electrolyte disturbances. DKA is dangerous and typically requires admission to an ICU for a continuous infusion of insulin. But patients with DKA only rarely end up requiring mechanical ventilation. So, under crisis triage circumstances, we might move them to hospital floor beds to free up some ICU beds for very sick COVID-19 patients. </p>
<p>But where are we going to get regular hospital rooms for these patients with DKA, since those are full too? Here’s what we might do: People with serious infections due to IV drug use are regularly kept in the hospital while they receive long courses of IV antibiotics. This is because if they were to use an IV catheter to inject drugs at home, it could be very dangerous, even deadly. But under triage conditions, we might let them go home if they promise not to use their IV line to inject drugs. </p>
<p>Obviously, that’s not completely safe. It’s clearly not the usual standard of care – but it is a crisis standard of care.</p>
<p>Worse than all of this is anticipating the conversations with patients and their families. These are what I dread the most, and in the last few weeks of 2021, we’ve had to start practicing them again. How should we break the news to patients that the care they are getting isn’t what we’d like because we are overwhelmed? Here’s what we might have to say:</p>
<p>“… there are just too many sick people coming to our hospital all at once, and we don’t have enough of what is needed to take care of all the patients the way we would like to … </p>
<p>… at this point, it is reasonable to do a trial of treatment on the ventilator for 48 hours, to see how your dad’s lungs respond, but then we’ll need to reevaluate …</p>
<p>… I’m sorry, your dad is sicker than others in the hospital, and the treatments haven’t been working in the way we had hoped.” </p>
<p>Back when vaccines came on the horizon a year ago, we hoped we’d never need to have these conversations. It’s hard to accept that they are needed again now.</p><img src="https://counter.theconversation.com/content/172747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Wynia receives funding from the National Academies of Sciences, Engineering and Medicine; the U.S. Health and Human Services Assistant Secretary for Planning and Response; and the National Center for Advancing Translational Sciences.
He serves as an unpaid advisor to the National Academies of Sciences, Engineering and Medicine, the Hastings Center, and the Defense Advanced Research Projects Agency. He is on the Fellows Council for The Hastings Center and the Advisory Council for Physicians for Human Rights.</span></em></p>A physician-bioethicist reflects on how health professionals are yet again facing painful reminders of the early months of the pandemic.Matthew Wynia, Director of the Center for Bioethics and Humanities, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1730962021-12-06T09:33:18Z2021-12-06T09:33:18ZA new report shows worrying growth of the diabetes pandemic<figure><img src="https://images.theconversation.com/files/435559/original/file-20211203-23-1e4nzh5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people with diabetes are undiagnosed. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Diabetes is rising at an alarming rate. One in 10 adults worldwide – 537 million people – now live with the disease. This is higher than the <a href="https://www.idf.org/e-library/epidemiology-research/diabetes-atlas/159-idf-diabetes-atlas-ninth-edition-2019.html">463 million</a> adults who lived with the condition in 2019. It presents a significant global challenge to the health and well-being of individuals, families and societies. Diabetes now ranks among the <a href="https://diabetesatlas.org/">top 10</a> causes of global mortality, responsible for an estimated 6.7 million deaths in 2021. </p>
<p>Africa account for 6% of these deaths. One in 22 (24 million) adults in Africa are living with diabetes. </p>
<p>The continent’s highest prevalence rate (11.3%) is in South Africa, where one in nine adults have diabetes: 4.2 million people. Yet almost half are undiagnosed. This year South Africa is predicted to register 96,000 deaths due to diabetes and an estimated US$7.2 billion rise in diabetes-related health expenditure. This is a huge hit to the country’s economy and equates to $1,700 per person.</p>
<p>These new figures are revealed in the <a href="https://diabetesatlas.org/">10th edition of the International Diabetes Federation Diabetes Atlas</a>, which gathers information on the burden of diabetes from countries across the world. It is compiled by the federation’s Atlas Committee, which I am a part of. </p>
<h2>Sharp increase</h2>
<p>The Atlas projects that 783 million adults will be living with diabetes by 2045. That’s an estimated 46% increase, compared to expected population growth of 20% over the same period. </p>
<p>With such a sharp increase expected in global prevalence, it’s clear that diabetes is spiralling out of control. It can no longer be ignored.</p>
<p>This year marks <a href="https://www.nature.com/articles/s41591-021-01418-2">100 years</a> since the discovery of insulin. Insulin is a hormone that lowers the level of blood glucose. There has never been a more appropriate time to reflect on the impact of diabetes and highlight the urgent need to improve access to care for the millions affected.</p>
<p>The urgency is even greater because COVID-19 has placed an additional burden on people living with diabetes, making them more susceptible to the worst complications. We are yet to see the impact of lockdowns, use of masks and the potential risk of COVID-induced diabetes on population health. There is a widely held concern that the pandemic may have caused a further rise in the prevalence of diabetes and its complications that will manifest over the coming years.</p>
<p>When diabetes remains undetected or is not adequately addressed, people with diabetes are at higher risk of serious and life-threatening complications, such as heart attack, stroke, kidney failure, blindness and lower-limb amputation. These complications result in a significantly reduced quality of life and higher healthcare costs.</p>
<h2>Access to diabetes care</h2>
<p>Diabetes does not discriminate: it is a disease that can affect anyone regardless of socioeconomic status or national boundaries. Globally, 88% of adults living with undiagnosed diabetes are in low- and middle-income countries. But even in high-income countries, almost a third of (29%) people with diabetes have not been diagnosed. </p>
<p>Low rates of clinical diagnosis are often a result of insufficient access to healthcare and lower capacity in existing health systems.</p>
<p>And even 100 years after the discovery of insulin, one in two people with diabetes who need insulin are unable to access or afford it. Left untreated with insulin, type 1 diabetes is fatal. </p>
<p>Other fundamental components of diabetes care, such as oral medicines, self-monitoring equipment and supplies, education and psychological support and access to healthy food and a place to exercise, are also unavailable to many people living with or at risk of diabetes across the world.</p>
<h2>Action to turn the tide</h2>
<p>Fortunately, much can be done to reduce the impact of diabetes. Evidence <a href="https://www.hsph.harvard.edu/nutritionsource/disease-prevention/diabetes-prevention/preventing-diabetes-full-story/">suggests</a> that type 2 diabetes can often be prevented. And early diagnosis and access to appropriate care for all types of diabetes can avoid or delay complications in people living with the condition.</p>
<p>It is vital to secure affordable access to the fundamental components of diabetes care for all who need them, ensure prompt diagnosis and timely treatment, and improve efforts to prevent type 2 diabetes.</p>
<p>I believe there are some rays of hope. The centenary of insulin has attracted greater attention to the diabetes cause. Earlier <a href="https://theconversation.com/diabetes-targets-would-cost-more-but-the-impact-would-be-worth-it-heres-how-167155">this year</a>, the World Health Organisation launched the <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">Global Diabetes Compact</a> and United Nations member states adopted a resolution that calls for urgent coordinated global action to tackle diabetes.</p>
<p>These are important steps towards addressing the continued and rapid rise of diabetes prevalence, particularly in countries that do not have a national diabetes plan or coverage for essential health services. But more action is needed. We cannot wait any longer for diabetes medicine, technologies, support and care to be made available to all that require them.</p><img src="https://counter.theconversation.com/content/173096/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ayesha Motala does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With such a sharp increase in global prevalence, it’s clear that diabetes is spiralling out of control. It can no longer be ignored.Ayesha Motala, Professor and Head Department of Diabetes and Endocrinology, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1719452021-12-05T23:26:42Z2021-12-05T23:26:42ZCOVID saw us sitting longer – and diabetes rose globally by 16% in 2 years. Time to get moving<p>New figures show global diabetes prevalence has <a href="https://diabetesatlas.org/">increased</a> by 16% in the past two years, with 537 million adults (aged 20-79) now estimated to be living with the chronic condition. </p>
<p>Over this same time period, COVID has stopped us doing some of the things that help prevent and manage diabetes. One particularly concerning example is an increase to sedentary behaviour (sitting down for long periods of time), which was already at dangerous levels pre-COVID. Some <a href="https://pubmed.ncbi.nlm.nih.gov/32481594/">estimates</a> indicate the pandemic added an average three hours to our sitting time each day.</p>
<p>Now lockdowns have eased in many places, it is vital we get moving again – and in the right way – to change this picture.</p>
<p>Reducing sitting time is a good starting place to help people with diabetes, pre-diabetes and other chronic conditions to reach healthier levels of physical activity.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/fewer-diabetes-patients-are-picking-up-their-insulin-prescriptions-another-way-the-pandemic-has-delayed-health-care-for-many-171364">Fewer diabetes patients are picking up their insulin prescriptions – another way the pandemic has delayed health care for many</a>
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<h2>A growing global problem</h2>
<p>Data from the <a href="https://diabetesatlas.org/">International Diabetes Federation’s 10th Diabetes Atlas</a>, officially launched today, shows about 10% of the world’s population aged 20–79 now live with diabetes, and diabetes prevalence is predicted to steadily increase to around 784 million adults by 2045.</p>
<p>Most of these people live with type 2 <a href="https://baker.edu.au/-/media/documents/fact-sheets/baker-institute-factsheet-understanding-diabetes.pdf">diabetes</a>, a chronic condition that affects the way the body processes blood sugar (glucose). In type 2 diabetes, repeated fluctuations in blood glucose levels eventually mean the body doesn’t respond properly with insulin – the hormone produced that allows glucose to go from the blood to the cells. </p>
<p>This can progress to common diabetes complications such as blindness, nerve damage, heart disease and kidney disease. <a href="https://baker.edu.au/impact/advocacy/dark-shadow-diabetes">Recent reports</a> point to an even wider range of diabetes impacts like increased risk of liver disease, dementia, depression, and some cancers.</p>
<p>Our research highlights regular movement as a key way to help manage diabetes and help prevent complications. Getting moving effectively improves <a href="https://care.diabetesjournals.org/content/39/6/964.long">glucose control</a>, <a href="https://journals.lww.com/jhypertension/Abstract/2016/12000/Interrupting_prolonged_sitting_with_brief_bouts_of.12.aspx">blood pressure</a>, <a href="https://journals.physiology.org/doi/abs/10.1152/ajpheart.00422.2020">vascular health</a> and <a href="https://bjsm.bmj.com/content/54/13/776">memory</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="man walking in park" src="https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435466/original/file-20211202-27-1962i2f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Spending less time sitting down is an achievable first step to a healthier lifestyle.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/man-walks-exercising-park-600w-558161632.jpg">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/a-disease-that-breeds-disease-why-is-type-2-diabetes-linked-to-increased-risk-of-cancer-and-dementia-139298">A disease that breeds disease: why is type 2 diabetes linked to increased risk of cancer and dementia?</a>
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<h2>Moving out of lockdown</h2>
<p>As we transition to COVID-normal, we must leave lockdown levels of physical inactivity and sedentary behaviour behind.</p>
<p>Reducing sitting time is a good “<a href="https://www.nature.com/articles/s41569-021-00547-y">first step</a>” because it appears more achievable for many and less daunting than a new exercise regime, especially for people who have been highly inactive or who live with a chronic health condition.</p>
<p>Simple lifestyle strategies to reduce sitting time and replace it with either standing or, even better, light physical activity improve metabolism, and for people with type 2 diabetes can prevent and help “sponge up” rising blood glucose levels if insulin isn’t being produced properly.</p>
<p>Breaking up sitting every hour with just two or three minutes of walking can <a href="https://care.diabetesjournals.org/content/39/6/964.long">make a difference to glucose control</a> compared with prolonged and uninterrupted sitting. <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0055542">And some evidence shows</a> greater time spent doing light activities daily like household chores, playing with pets, or light garden work, can provide greater blood sugar control over 24 hours than structured workouts. </p>
<p>We are <a href="https://baker.edu.au/optimise">currently testing</a> how these small changes influence diabetes in a clinical trial. Our goal is to help desk workers with diabetes reduce and break up their sitting time.</p>
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<a href="https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman stands at desk" src="https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435465/original/file-20211202-25-1qbpc3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Desks that convert from sitting to standing position can help.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/F9tEfwqN3Ho">Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<h2>Lorys’ story</h2>
<p>One of our trial participants, Lorys, 64, was gutted when he was diagnosed with type 2 diabetes 11 years ago.</p>
<p>Like many people, he was leading a sedentary lifestyle. A demanding job involving long hours at the computer meant he was sitting for most of the day, stressed and anxious about his health. Diabetes medication wasn’t improving his blood glucose levels as much as he would have liked. Then the pandemic arrived and working from home exacerbated the problem because he was doing less everyday activity, such as walking to and around the office.</p>
<p>As part of the trial, Lorys has started using a sit-stand workstation and an activity tracker to encourage regular short walks throughout the day. He’s focussed on gradual lifestyle changes, small steps that feel achievable and have already added up to make a big difference.</p>
<p>Since the start of this year, Lorys’ <a href="https://www.healthdirect.gov.au/hba1c-test">HbA1c</a> level – a key diabetes health marker – has almost halved. He’s lost weight and says his mental outlook is more positive. He says he no longer thinks of diabetes as a “death sentence”.</p>
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Read more:
<a href="https://theconversation.com/got-pre-diabetes-heres-five-things-to-eat-or-avoid-to-prevent-type-2-diabetes-80838">Got pre-diabetes? Here's five things to eat or avoid to prevent type 2 diabetes</a>
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<h2>5 ways to quit the sit</h2>
<p>Whether we have type 2 diabetes, pre-diabetes, or just want to get back to a healthier lifestyle post-lockdowns, most of us can benefit from some simple changes:</p>
<p><strong>1.</strong> try using a height-adjustable (sit-to-stand) desk. Start standing for a few minutes each day and gradually scale up to standing or walking for 30 minutes of every hour</p>
<p><strong>2.</strong> use phone meetings or phone calls as a prompt to stand</p>
<p><strong>3.</strong> try walking work meetings or catching up with friends for a walk</p>
<p><strong>4.</strong> after finishing a work task or an episode of your favourite TV show, take a short walk around the block</p>
<p><strong>5.</strong> set a calendar reminder or use a wearable device to prompt you to stand up and move regularly throughout the day.</p>
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<figcaption><span class="caption">The body is made for motion.</span></figcaption>
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<p>It’s been a tough couple of years, especially for people living which chronic health conditions. But it’s not too late to make changes to prevent and manage diabetes and its complications.</p><img src="https://counter.theconversation.com/content/171945/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christian Brakenridge receives funding from a Research Training Program scholarship through Australian Catholic University and is supported by the Baker Heart and Diabetes Institute.</span></em></p><p class="fine-print"><em><span>David Dunstan receives funding from National Health and Medical Research Council and Diabetes Australia. </span></em></p>Just over 10% of the world’s adults now live with diabetes and the COVID pandemic saw many people sitting down for longer periods – but small daily changes can improve health.Christian Brakenridge, PhD Candidate, Baker Heart and Diabetes InstituteDavid Dunstan, Professor and Laboratory Head of Physical Activity, Baker Heart and Diabetes InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1713642021-11-12T20:23:46Z2021-11-12T20:23:46ZFewer diabetes patients are picking up their insulin prescriptions – another way the pandemic has delayed health care for many<figure><img src="https://images.theconversation.com/files/431752/original/file-20211112-27-k9a554.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pandemic has made it harder for diabetes patients to receive the ongoing care they need.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/midsection-of-businessman-injecting-insulin-in-royalty-free-image/916358584">Maskot/Maskot via Getty Images</a></span></figcaption></figure><p>Insulin is as essential as water for many people with diabetes. Of the <a href="https://doi.org/10.2337/dci18-0019">more than 30 million</a> Americans with diabetes, approximately 7.4 million rely on insulin to manage their condition. But it is one of the <a href="https://doi.org/10.1016/j.mayocp.2019.11.013">most costly drugs</a> on the market, and the COVID-19 pandemic has intensified the already rampant problem of <a href="https://publichealth.jhu.edu/2021/the-impacts-of-covid-19-on-diabetes-and-insulin">insulin hoarding or rationing</a>.</p>
<p>Not only is diabetes associated with an <a href="https://doi.org/10.1056/NEJMc2018688">increased risk</a> of severe COVID-19 infection, but COVID-19 is also associated with both an increase in <a href="https://doi.org/10.1111/dom.14269">new diabetes diagnoses</a> and a <a href="https://dx.doi.org/10.5501%2Fwjv.v10.i5.275">worsening of preexisting diabetes complications</a>. By September 2021, death rates for people with diabetes were <a href="https://doi.org/10.2337/dci21-0001">50% higher</a> than before the pandemic, a net increase of more than twice the overall death rate of the general population.</p>
<p>I am a <a href="https://scholar.google.com/citations?user=nqtrb3oAAAAJ&hl=en">pharmacist</a> who studies ways to improve clinical, economic and quality-of-life outcomes in vulnerable populations. My <a href="https://doi.org/10.1001/jamanetworkopen.2021.32607">recent study</a> on how insulin prescription rates have changed because of the pandemic underscores the challenges that people with diabetes face in accessing care.</p>
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<h2>Insulin is vital for people with diabetes</h2>
<p><a href="https://www.cdc.gov/diabetes/basics/diabetes.html">Diabetes</a> affects how the body converts food into energy. Usually when someone eats, the body breaks down the food into sugar that enters the bloodstream. The pancreas releases insulin that helps the sugar enter cells so it can be used as energy. </p>
<p>People with diabetes, however, are <a href="https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes">unable to absorb the sugar</a> because their bodies either don’t produce insulin or are unable to use insulin well. To keep their glucose levels under control, people with diabetes may need daily insulin injections. </p>
<p>Without these daily injections, increased blood sugar levels can lead to severe health problems. The most common complication, <a href="https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html">diabetic ketoacidosis</a>, is responsible for more than <a href="https://doi.org/10.2337/dc17-1379">500,000 days of patient hospitalizations</a> each year.</p>
<h2>Managing diabetes during a pandemic</h2>
<p>Although insulin is a vital component of diabetes management, the pandemic has led many patients to forgo the prescriptions they need. </p>
<p>My <a href="https://doi.org/10.1001/jamanetworkopen.2021.32607">recent study</a> looked at the insulin prescription claims of 285,343 people in the U.S. between January 2019 and October 2020. In the first week of 2019, there was an average of 17,037 new and existing insulin prescriptions picked up by patients per week. This number increased by 11 claims each week leading up to the pandemic.</p>
<p>By the first week of the pandemic in March 2020, however, insulin prescriptions decreased significantly by an average of around 396 prescriptions. Prescriptions continued to decrease an average of around 55 per week as the pandemic progressed through to October 2020. This decline <a href="https://doi.org/10.1001/jama.2020.9184">may result from</a> a combination of health insurance loss owing to unemployment, restricted access to clinicians and pharmacies and rationing or stockpiling of medications by both pharmacists and patients.</p>
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<figcaption><span class="caption">Insulin prices have tripled in the past 15 years.</span></figcaption>
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<p>And the effects of the pandemic on diabetes go beyond just insulin prescriptions. Diabetes management involves visits with a <a href="https://www.everydayhealth.com/type-2-diabetes/treatment/creating-your-care-team/">variety of health care providers</a> and routine testing. But diabetes patients in the U.S. had a significant drop in <a href="https://doi.org/10.1001/jamainternmed.2021.3047">usage of health care services</a> in 2020 compared with 2019, because of clinic closures and reduced capacities, health insurance loss and transportation difficulties. Patients are left in a bind, risking potentially life-threatening complications from missing needed diabetes care as well as <a href="https://dx.doi.org/10.1210%2Fclinem%2Fdgaa360">risking exposure to COVID-19</a> if they need emergency care for those complications.</p>
<h2>Ongoing effects of care delays</h2>
<p>As COVID-19 overwhelmed health care systems, people with chronic conditions like diabetes have experienced significant disruptions in routine and emergency medical care. By the end of June 2020, an <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a4.htm">estimated 41%</a> of U.S. adults had delayed or avoided medical care. </p>
<p>[<em>Over 115,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-newsletter-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>Even now, with hospitals crowded with unvaccinated COVID-19 patients, <a href="https://www.npr.org/sections/health-shots/2021/10/14/1043414558/with-hospitals-crowded-from-covid-1-in-5-american-families-delays-health-care">nearly 1 in 5</a> American households had to delay care for serious illnesses in the past few months. These care delays have the potential to worsen chronic conditions and contribute to <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm">excess deaths</a> directly and indirectly caused by COVID-19.</p>
<p>The full effect that the COVID-19 pandemic continues to have on diabetes management and care, however, has yet to be fully understood. More research on how the pandemic has affected people with diabetes is needed to ensure that these patients receive the care that they need.</p><img src="https://counter.theconversation.com/content/171364/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ismaeel Yunusa does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>World Diabetes Day on Nov. 14 marks an increase in diabetes deaths and new diagnoses as the COVID-19 pandemic continues to hinder care for chronic conditions.Ismaeel Yunusa, Assistant Professor of Clinical Pharmacy and Outcomes Sciences, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1716262021-11-12T10:12:13Z2021-11-12T10:12:13ZNigerians with diabetes will have poor outcomes unless the healthcare system changes<figure><img src="https://images.theconversation.com/files/431651/original/file-20211112-13-53qc83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rick Gershon/Getty Images</span> </figcaption></figure><p>Diabetes mellitus, an ancient disease, has now become a global burden. The United Nations in 2006 <a href="https://undocs.org/pdf?symbol=en/A/RES/61/225">recognised</a> diabetes as a disease that poses severe risks to families and development goals. <a href="https://idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html">In 2019</a>, about 463 million adults were living with diabetes and this is projected to rise to 700 million by 2045. The highest proportion of this increase will be in low- and middle-income countries, including Nigeria.</p>
<p>Scientific progress in medicine has changed the story of diabetes from an incurable disease to a <a href="https://www.medicalnewstoday.com/articles/317074#Is-diabetes-curable?">treatable condition</a>. Though the disease itself may not be reversible, its devastating complications can be prevented when effectively treated. People with diabetes can now live much longer. </p>
<p>But because of a lack of resources, many Nigerians living with diabetes are unable to benefit from the fruits of scientific discoveries. They are at risk of premature death or lifelong incapacitation. </p>
<p>Nonetheless, for those that are willing to make lifestyle changes, and can afford and adhere to treatment, they may escape these consequences.</p>
<h2>About diabetes</h2>
<p>Diabetes is a complex disorder, with <a href="https://care.diabetesjournals.org/content/41/Supplement_1/S13">different types and subtypes</a>. But all are characterised by high blood sugar arising from insulin deficiency. Insulin is a <a href="https://www.medicalnewstoday.com/articles/323760#what-is-insulin">hormone</a> secreted from the pancreas and normally helps to regulate the level of sugar in the body. With type 2 diabetes, cells or tissues resist the action of insulin. Often, diabetes is accompanied by long-term complications, especially when it has not been well managed. </p>
<p>The most common type of diabetes is type 2. This type <a href="https://care.diabetesjournals.org/content/41/Supplement_1/S13">accounts</a> for between 80% and 90% of all cases. <a href="https://care.diabetesjournals.org/content/41/Supplement_1/S13">Others</a> are type 1, secondary diabetes and gestational diabetes. Type 2 diabetes typically occurs from middle age while type 1 tends to occur in children and adolescents. Secondary diabetes is due to specific causes such as drugs, or diseases of the liver or pancreas. This can be reversed once the cause is effectively addressed. <a href="https://care.diabetesjournals.org/content/41/Supplement_1/S13">Gestational diabetes</a> occurs for the first time in pregnant women.</p>
<p>Both types 1 and 2 diabetes have genetic predisposition but usually <a href="https://pubmed.ncbi.nlm.nih.gov/25456640/">require</a> environmental <a href="https://diabetes.diabetesjournals.org/content/66/2/241">triggers</a> like diet and sedentary lifestyle. No population group is spared the risk of diabetes. It affects men and women equally, apart from the gestational type.</p>
<p><a href="https://diabetes.diabetesjournals.org/content/66/2/241">Diabetes</a> is a progressive disease and incurable by current scientific evidence. It is, however, highly amenable to treatment with diligent observance of lifestyle measures. These include dietary modification, exercise and the use of combinations of medicines when necessary. Diabetes, especially type 2, is preventable with healthy lifestyle and early screening to determine risk.</p>
<h2>Access denied: the Nigerian situation</h2>
<p>In Nigeria, the prevalence of diabetes has steadily increased from <a href="https://pubmed.ncbi.nlm.nih.gov/14032897/">1%</a> in the 1960s, to 2.2% in the early 1990s, to about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984944/">6% currently</a>. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984944/">rates</a> are relatively higher in cities compared to rural areas, and higher among Nigerians in the south and south-eastern parts of the country. </p>
<p>The prime culprits for this increase are the western lifestyle and modern technological comforts. More Nigerians are developing diabetes because of frequent consumption of western diets, like what’s on offer at fast-food outlets. These meals are loaded with saturated fat and carbohydrates, which promote excess weight gain, a <a href="https://pubmed.ncbi.nlm.nih.gov/2044434/">strong risk factor</a> for diabetes.</p>
<p><a href="https://www.njmonline.org/article.asp?issn=1115-2613;year=2018;volume=27;issue=1;spage=69;epage=77;aulast=Balogun;type=0">Our research</a> shows that variation in obesity across the country mirrors the prevalence of diabetes. Increasing urbanisation – and the sedentary life that comes with it – is contributing to an explosion of diabetes. We have <a href="https://pubmed.ncbi.nlm.nih.gov/23075694/">shown</a> that when people move from rural to urban settings, more of them develop diabetes.</p>
<p>Increasingly, Nigerians living with diabetes are becoming victims of complications of the disease. Many die or become debilitated for the rest of their lives. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566593/">Mortality</a> is unacceptably high when they develop <a href="https://pubmed.ncbi.nlm.nih.gov/18072385/">hyperglycaemic emergencies</a>, infections – often from diabetes <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1742-481X.2009.00627.x">foot ulcers</a> – and kidney disease. </p>
<p>The biggest reason is lack of access to correct information and basic diabetes care. There are few opportunities for Nigerians to know whether they already harbour diabetes or are at risk of developing it. Screening, information and basic care should be available through primary healthcare facilities, but these are not functioning properly in most parts of Nigeria. They are not well staffed and resourced.</p>
<p>Without quality diabetes education, it is difficult to achieve treatment goals. People become victims of unfounded myths about diabetes when they are not given the facts. </p>
<p>Awareness is generally low, not only in the rural areas but also in cities. People can have type 2 diabetes for months and years without <a href="https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193">classical symptoms</a>. They may only get screened and diagnosed when they are required to do medical screening as a precondition for employment. </p>
<p>When people with diabetes are not detected early and put on treatment, complications set in. More importantly, screening can be an opportunity for people at risk to start taking preventive measures. </p>
<h2>Recommendations</h2>
<p>Opportunities for awareness and screening should be created, even extended to schools. <a href="https://www.ajol.info/index.php/rejhs/article/view/143385">Knowledge</a> is key in preventing and detecting a disease. </p>
<p>Balanced diet and increased physical activities are cornerstones of diabetes prevention and control. Perhaps because of urbanisation, space for recreation is shrinking in Nigerian communities. Access to recreation centres should be integrated into urban planning. </p>
<p>Nowadays, there are many pharmacological options to treat diabetes. Granted that the newer formulations are expensive. But the older, cheaper medications should be readily available. It is tragic that 100 years after its discovery, <a href="https://care.diabetesjournals.org/content/41/6/1125.long">access to insulin</a> is grossly inadequate in Nigeria. The government apparently is unwilling to even subsidise the drug as many other African countries have done. Affordability of health services is a <a href="https://nairametrics.com/2021/06/17/nigerias-healthcare-cost-gallop-past-15-highest-on-record/">big issue in Nigeria</a>, where most people pay for them from lean pockets. The government must improve the health insurance coverage of Nigerians. </p>
<p>The present healthcare structure and system in Nigeria restrict access to health facilities and will not support high quality care of diabetes patients. There is an urgent need to find workable models and restructure the health system.</p><img src="https://counter.theconversation.com/content/171626/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Balogun does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The present healthcare structure in Nigeria contributes to the suffering of people living with diabetes in the country.William Balogun, Senior Lecturer and Consultant Endocrinologist, University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1627432021-07-21T12:16:19Z2021-07-21T12:16:19ZInsulin was discovered 100 years ago – but it took a lot more than one scientific breakthrough to get a diabetes treatment to patients<figure><img src="https://images.theconversation.com/files/412304/original/file-20210720-15-sb91vs.jpg?ixlib=rb-1.1.0&rect=0%2C91%2C2902%2C2241&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A single brilliant insight is only part of the story of how diabetes became a manageable disease.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/diabetic-girl-injecting-her-arm-with-insulin-news-photo/3324678">Douglas Grundy/Three Lions via Getty Images</a></span></figcaption></figure><p>Diabetes was a fatal disease before insulin was discovered on July 27, 1921. A century ago, people diagnosed with this <a href="https://www.niddk.nih.gov/-/media/Files/Strategic-Plans/Diabetes-in-America-2nd-Edition/chapter10.pdf">metabolic disorder usually survived only a few years</a>. Physicians had no way to treat their diabetic patients’ dangerously high blood sugar levels, which were due to a lack of the hormone insulin. Today, though, nearly <a href="https://www.diabetes.org/resources/statistics/statistics-about-diabetes">1.6 million</a> Americans are living normal lives with Type 1 diabetes thanks to the discovery of insulin.</p>
<p>This medical breakthrough is usually attributed to one person, Frederick Banting, who was searching for a cure for diabetes. But getting a reliable diabetes treatment depended on the research of two other scientists, Oskar Minkowski and Søren Sørensen, who had done earlier research on seemingly unrelated topics. </p>
<p><a href="https://scholar.google.com/citations?user=Itgu0QwAAAAJ&hl=en&oi=ao">I’m a biomedical engineer</a>, and I teach a course on the history of the treatment of diabetes. With my students, I emphasize the importance of unrelated basic research in the development of medical treatments. The story of insulin illustrates the point that medical innovations build on a foundation of basic science and then require skilled engineers to get a treatment out of the lab and to the people who need it.</p>
<h2>Basic research pointed to the pancreas</h2>
<p><a href="https://doi.org/10.4239/wjd.v7.i1.1">Diabetes had been known since antiquity</a>. The first symptoms were often a prodigious thirst and urination. Within weeks the patient would be losing weight. Within months, the patient would enter a coma, then die. For centuries, no one had any clue about what caused diabetes.</p>
<p>People had, though, been aware of the pancreas for centuries. The <a href="https://doi.org/10.1016/0002-9610(83)90286-6">Greek anatomist Herophilos</a> first described it around 300 B.C. Based on its anatomical location, people suspected it was involved in the digestive system. But no one knew whether the pancreas was an essential organ, like the stomach, or extraneous, like the appendix.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Portrait of a bearded man with glasses" src="https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=855&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=855&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=855&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1075&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1075&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412040/original/file-20210720-25-1i67eeo.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1075&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Oskar Minkowski discovered the pancreatic origin of diabetes almost by accident.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Minkowski.JPG">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>In 1889, <a href="https://doi.org/10.1007/BF00271257">Oskar Minkowski</a>, a pathologist at the University of Strassburg, in what was then Germany, was one of the most talented surgeons of his time. As part of a study, he performed a surgical feat that was thought to be impossible: keeping an animal alive after totally removing its pancreas.</p>
<p>The dog he operated on survived the surgery, but to Minkowski’s surprise, it began exhibiting all the symptoms of diabetes. Minkowski had discovered that removing the pancreas caused diabetes. Today, this is known as an animal model of the disease. Once an animal model of a disease is established, researchers can experiment with different cures in the animal in hopes they’ll find something that will then work in people.</p>
<p>Can you grind up a pancreas and feed it to a diabetic animal to cure or alleviate the symptoms of diabetes? No, that didn’t work. The problem, understood in today’s terms, is that the pancreas has two functions: producing enzymes for the digestive system and producing insulin. Mixed together, the digestive enzymes destroyed the insulin.</p>
<h2>Isolating the insulin</h2>
<p>In 1920, Fred Banting, a small-town doctor in London, Ontario, had an idea. He thought that he could surgically tie off the ducts between the pancreas and the digestive system in an animal. Wait for a few weeks, while the part of the pancreas that produces those digestive enzymes decays, then remove the pancreas completely. This decayed pancreas, he thought, would contain the insulin, but not the destructive enzymes.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="two men in early 20th C clothes standing with a dog between them" src="https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=816&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=816&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=816&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1025&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1025&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412303/original/file-20210720-27-tr5jkz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1025&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Charles Best (left) and Frederick Banting with one of the first dogs to be kept alive with insulin.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/discoverers-of-insulin-charles-best-and-frederick-banting-news-photo/2667496">Hulton Archive via Getty Images</a></span>
</figcaption>
</figure>
<p>On July 27, 1921, he concluded this experiment <a href="https://insulin.library.utoronto.ca/">in the laboratory of J.J.R. Macleod</a> at the University of Toronto. Banting, working with a Toronto student named Charles Best, prepared an extract from the atrophied pancreas of a dog. Then he injected the extract into another dog that had induced diabetes, due to the removal of its pancreas. The animal’s diabetes symptoms began to disappear.</p>
<p>Although Banting’s experiment was successful, his method of insulin purification was impractical. J.J.R. Macleod assigned the biochemist James Collip the task of coming up with a practical method of purifying insulin from a pancreas.</p>
<p>Collip developed a method based on alcohol purification. The concept was simple: He’d mash up a fresh pig pancreas, readily available from butcher shops, and mix it into a solution of alcohol and water. Collip slowly increased the percentage of alcohol in the solution. He found that the insulin would stay dissolved in the solution until he reached a critical concentration of alcohol, then it would suddenly fall out of solution, no longer dissolved in the liquid. By collecting that solid precipitate at the bottom of a flask, he had a purified form of insulin.</p>
<p>Collip’s extraction of insulin allowed Banting and others at the University of Toronto Hospital to <a href="https://insulin100.utoronto.ca/">begin treating patients</a>. The first injections took place in January 1922. Within weeks, the results were miraculous. These injections of insulin helped dozens of patients who were close to dying regain normal activities. Word spread. Demand for insulin increased.</p>
<h2>Insight from a brewery</h2>
<p>But disaster struck when Collip failed to purify larger batches of insulin. He was puzzled why, following the exact same recipe as he’d used before, his preparations lacked insulin. J.J.R. Macleod now turned to Eli Lilly and Company, a commercial firm in Indiana that made medicinal capsules, for help.</p>
<p>At Eli Lilly, <a href="https://doi.org/10.1093/clinchem/48.12.2270">the purification problem fell to George Walden</a>, a 27-year-old chemist. Walden thought of a measure that Danish chemist <a href="https://doi.org/10.1038/143629a0">Søren Sørensen</a> had introduced a dozen years before. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="beer with analysis tools at a brewery" src="https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412305/original/file-20210720-19-ejtxrh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The equipment has changed, but breweries still monitor the pH of their beers.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/still-life-analyze-still-life-beer-brewery-analysis-ph-news-photo/883613366">Stanzel\ullstein bild via Getty Images</a></span>
</figcaption>
</figure>
<p>Sørensen was the director in the early 1900s of the Carlsberg Laboratory, set up by the beer company to advance the science of brewing. He introduced the concept of pH as a way to quantify the acidity of a solution. A higher pH during the brewing stage leads to a more bitter-tasting beer.</p>
<p>When Walden measured the pH of the pancreas solution, he discovered that the acidity was far more important to the solubility of insulin than the alcohol concentration. He set up a purification procedure like Collip’s but based on pH rather than alcohol concentration. Collip’s failure to scale up purification of insulin was probably because he neglected to control the pH of the solution carefully.</p>
<p>This insight allowed for mass production of insulin.</p>
<h2>Vanquishing a human disease</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="ampules of commercial insulin from the 1920s" src="https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=652&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=652&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=652&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=820&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=820&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412306/original/file-20210720-23-181jgrc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=820&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Insulin samples from the 1920s.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/still-life-analyze-still-life-beer-brewery-analysis-ph-news-photo/883613366">Science & Society Picture Library via Getty Images</a></span>
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</figure>
<p>By May 1924, diabetes was no longer a fatal disease. Physician Joseph Collins, writing in The New York Times, described it this way: “One by one the implacable enemies of man, the diseases which seek his destruction, are overcome by Science. <a href="https://www.nytimes.com/1923/05/06/archives/diabetes-dreaded-disease-yields-to-new-gland-cure-previous-claims.html">Diabetes, one of the most dreaded, is the latest to succumb</a>.”</p>
<p>Today, the implacable enemies of man include cancer, Alzheimer’s disease and schizophrenia. The cures for each will likely be built from advances made by basic research.</p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>]</p><img src="https://counter.theconversation.com/content/162743/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James P. Brody has in the past received funding from the National Science Foundation, the National Institutes of Health and the US Department of Defense.</span></em></p>A biomedical engineer explains the basic research that led to the discovery of insulin and its transformation into a lifesaving treatment for millions of people with diabetes.James P. Brody, Professor of Biomedical Engineering, University of California, IrvineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1462262020-10-13T15:21:51Z2020-10-13T15:21:51ZCould an ‘invisible’ cell transplant treat diabetes?<figure><img src="https://images.theconversation.com/files/362992/original/file-20201012-19-1obyhav.jpg?ixlib=rb-1.1.0&rect=0%2C108%2C5184%2C3337&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/diabetic-patient-makes-insulin-injection-pen-1444798157">goffkein.pro/Shutterstock</a></span></figcaption></figure><p>Type 1 diabetes used to be a <a href="https://spectrum.diabetesjournals.org/content/27/2/82">death sentence</a>. After a diagnosis, patients were put on a starvation diet. The lucky ones would have a year or two to live. But, thanks to the discovery of insulin in the early 1920s, this is no longer the case. </p>
<p>We need insulin to regulate our blood sugar. After a meal, insulin helps our cells to use the sugar in our food. We use this sugar as fuel for energy – without insulin, sugar has nowhere to go. It stays in the bloodstream, and over time, damages blood vessels. </p>
<p>People with type 1 diabetes inject themselves with insulin to control their blood sugar level. However, while the treatment is a lifesaver, it can’t prevent people from developing diabetic complications. These conditions can be life limiting, so what if there was a treatment that was better than insulin injections?</p>
<p>Well, there might be, and it involves transplanting cells. </p>
<p>Over <a href="https://www.sciencedaily.com/releases/2017/06/170614114238.htm">450 million people have diabetes</a>, but less than 10% of these people have the kind known as type 1. In type 1 diabetes, the insulin-producing cells of the pancreas stop working. Scientists don’t know exactly how this happens, but the immune system seems to attack these cells by accident.</p>
<p>I work with researchers and surgeons at the universities of Strathclyde and Edinburgh who are replacing these faulty cells for a small group of people with severe type 1 diabetes. In a healthy person, around 1% of the pancreas cells produce insulin. Scientists are able to extract these insulin-producing cells from a donor pancreas and surgeons transplant them into a diabetic patient.</p>
<h2>Major obstacles</h2>
<p>A successful transplant would mean people with type 1 diabetes can start making their own insulin again. It sounds simple, but it doesn’t always work. Major obstacles are stopping this treatment from being more widely available. </p>
<p>As with transplanted organs, cells also face rejection. Cell transplant recipients have to take a cocktail of antirejection drugs. While these drugs make the immune system less likely to detect the transplanted cells, they also have serious side-effects.</p>
<p>Even successful cell transplants eventually fail. When the donor insulin-producing cells stop working, the patient’s diabetes comes back. Researchers still don’t know exactly why the transplant stops working. We think that despite the antirejection drugs, the patient’s immune system eventually detects that the cells are from a different body and attacks them. </p>
<p>It might even happen because of the drug treatment. Antirejection drugs can have a toxic effect on insulin-producing cells. Because of these risks, cell transplants are only available to a small group of patients who can’t control their blood sugar, even with insulin injections, and get hospitalised regularly. </p>
<p>Researchers are trying to get rid of the need for antirejection drugs. The cells can’t be rejected if they can’t be detected by the immune system. We think it could be possible to sneak the donor cells into patients’ bodies if they’re coated in a special material.</p>
<h2>Invisible cells</h2>
<p>Bioinvisible materials can be implanted in the body without being rejected by the immune system. We use a bioinvisible chemical called alginate, which is extracted from seaweed. In theory, cells encased in a bioinvisible material would evade detection by the immune cells that travel around our bodies, looking for invaders. </p>
<figure class="align-center ">
<img alt="Brown seaweed." src="https://images.theconversation.com/files/363002/original/file-20201012-19-2db02f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363002/original/file-20201012-19-2db02f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363002/original/file-20201012-19-2db02f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363002/original/file-20201012-19-2db02f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363002/original/file-20201012-19-2db02f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363002/original/file-20201012-19-2db02f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363002/original/file-20201012-19-2db02f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Alignate is found in the cell walls of brown seaweeds.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/seaweed-heap-kimmeridge-bay-dorset-uk-151117691">Robert Ford/Shutterstock</a></span>
</figcaption>
</figure>
<p>Cloaking the cells in bioinvisible alginate could stop the transplants from failing. In our lab, we have a machine that lets us trap clusters of insulin-producing cells in tiny alginate bubbles. The bubbles are around 200 micrometres wide – about the width of a human hair – and can hide over a thousand cells inside.</p>
<p>As well as being bioinvisible, alginate is porous. The pores are big enough to let insulin out and let oxygen and sugar in (the nutrients cells need to survive). But, more importantly, the pores are too small for immune cells to pass into the alginate bubbles and detect or damage the donor cells inside.</p>
<p>Transplanting cells cloaked in bioinvisible alginate has had promising results in <a href="https://search.proquest.com/docview/1801834396?fromopenview=truelink">animal trials and in small-scale human trials</a>. However, making the bubbles is difficult to scale up. Hopefully, in the future, it could lead to cell transplants without antirejection drugs. Many more people with diabetes, especially young people, could then get a cell transplant. This would stop them from developing the health complications that come from having years of high blood sugar. Maybe one day young people could get a bioinvisible cell transplant to treat their diabetes as soon as they’re diagnosed.</p><img src="https://counter.theconversation.com/content/146226/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katrina Wesencraft receives funding from the EPSRC and MRC. </span></em></p>How a seaweed extract could help treat type 1 diabetes.Katrina Wesencraft, PhD Candidate, University of Strathclyde Licensed as Creative Commons – attribution, no derivatives.