tag:theconversation.com,2011:/us/topics/type-1-diabetes-6236/articlesType 1 diabetes – The Conversation2023-07-19T12:24:41Ztag:theconversation.com,2011:article/2088322023-07-19T12:24:41Z2023-07-19T12:24:41ZGlobal diabetes cases on pace to soar to 1.3 billion people in the next 3 decades, new study finds<figure><img src="https://images.theconversation.com/files/537560/original/file-20230714-21-ha7ae5.jpg?ixlib=rb-1.1.0&rect=0%2C51%2C6845%2C4300&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Aging and obesity are likely to be the two primary drivers of the expected rise in diabetes. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/glycemia-test-royalty-free-image/1336828471?phrase=diabetes&adppopup=true">fotograzia/Moment via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>The number of people living with diabetes worldwide is on pace to more than double in the next three decades, for a total of 1.3 billion people by 2050. That is one of the key findings from our <a href="https://doi.org/10.1016/S0140-6736(23)01301-6">study on the global burden of diabetes</a> recently published in The Lancet.</p>
<p>We analyzed and synthesized all available epidemiological data on diabetes burden – defined as health decline due to diabetes captured through the number of cases, disease severity and deaths. Our study included more than 27,000 data sources to produce estimates of diabetes prevalence, disability and deaths for 204 countries and territories from 1990 through 2021. Using a modeling tool that takes into account sociodemographic factors and obesity, we projected diabetes prevalence out to 2050. </p>
<p>We also estimated the <a href="https://doi.org/10.1186/1478-7954-1-1">proportion of diabetes disability and death</a> attributable to specific risk factors related to obesity, diet, physical activity, environment or occupation, tobacco use and alcohol use.</p>
<p>This analysis is part of the larger <a href="https://www.healthdata.org/gbd">Global Burden of Diseases, Injuries, and Risk Factors Study</a>, which has quantified health decline due to hundreds of diseases, injuries and risk factors since 1990. Thousands of health experts and researchers around the world both contribute to and use estimates from this study, which is continually updated.</p>
<p>Our team projected that every country is expected to experience an increase in diabetes cases by 2050. In the regions that are expected to be hardest hit – including North Africa and the Middle East and Pacific island nations – there are countries where as many as 1 in 5 people could be living with diabetes in 2050 if current trends continue. Among older adults in these regions, diabetes prevalence is expected to be even higher.</p>
<p>While both <a href="https://www.cdc.gov/diabetes/basics/diabetes.html">type 1 and type 2 diabetes</a> are characterized by high levels of blood sugar, also known as glucose, <a href="https://www.cdc.gov/diabetes/basics/type2.html">type 2</a> is a largely preventable disease that occurs due to gradual insulin resistance and is commonly diagnosed among adults. <a href="https://www.cdc.gov/diabetes/basics/type1.html">Type 1</a>, on the other hand, is an autoimmune disease where the body cannot produce insulin and typically develops during childhood or adolescence.</p>
<p>The vast majority of new diabetes cases in the next three decades are projected to be type 2. We expect the two primary drivers will be aging populations and increases in obesity. In 2021, obesity was the most important risk factor for type 2 diabetes, accounting for more than half of disability and death from the disease.</p>
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<h2>Why it matters</h2>
<p>People living with diabetes are at significantly higher risk of developing and dying from other major diseases, including <a href="https://doi.org/10.1016/S0140-6736(20)30752-2">ischemic heart disease and stroke,</a> and from complications such as <a href="https://www.thinkglobalhealth.org/article/putting-vision-loss-and-aging-focus">vision loss</a> and foot ulcers. This compounds the stress of diabetes on health care systems, requiring more comprehensive screening and management. However, a study found that <a href="https://doi.org/10.1016/s2666-7568(21)00089-1">fewer than 1 in 10 people</a> with diabetes in low- and middle-income countries have access to comprehensive diabetes treatment.</p>
<p>Based on <a href="https://doi.org/10.1186/s40842-016-0039-3">an abundance of research</a>, the two primary drivers of the expected rise in diabetes cases will be aging and obesity. As people age, their bodies’ <a href="https://doi.org/10.1161/CIRCRESAHA.118.312806">ability to regulate blood sugar levels changes</a>.</p>
<p>In addition, studies indicate that <a href="https://doi.org/10.1016/j.amepre.2011.10.026">obesity rates will continue to rise</a>. No program has yet shown <a href="https://doi.org/10.1038/s41574-019-0176-8">sustainable and population-level reductions in obesity</a>. </p>
<p>To reverse this trend in obesity rates, an approach that targets both the behavioral and structural factors related to <a href="https://doi.org/10.1002/oby.20922">maintaining a healthy diet</a> and <a href="https://doi.org/10.1016/j.jada.2005.02.045">getting enough physical activity</a> will be needed.</p>
<h2>What other research is being done</h2>
<p>Our study reports on diabetes trends and risk factors over time by age, sex and geography. However, there are other factors that offer clues to why diabetes disproportionately afflicts certain populations.</p>
<p>Research shows that there are many complex social and economic dynamics at play when it comes to trying to live a healthy lifestyle. <a href="https://doi.org/10.1016/j.diabres.2012.12.005">Low income</a>, <a href="https://doi.org/10.1136/bmjopen-2014-005710">low education level</a> and <a href="https://doi.org/10.1016/S2213-8587(23)00119-5">living in urban areas</a> are all associated with a higher risk of developing type 2 diabetes. Studies also show that <a href="https://diabetesatlas.org/atlas/indigenous-2022/">type 2 diabetes disproportionately affects Indigenous populations</a> across the world, largely owing to colonization and resulting disruptions to traditional ways of life.</p>
<p>The rapid increase in the number of people living with diabetes that we project in our study doesn’t have to become a reality. Understanding how these trends are tied in with how people live is the first step toward changing the course of this disease over the coming decades.</p><img src="https://counter.theconversation.com/content/208832/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Diabetes rates worldwide have been rising steadily since the early 1990s when these data were first estimated. This trend is only going up.Lauryn Stafford, Fellow in Health Metrics Sciences, University of WashingtonLiane Ong, Lead Research Scientist at the Institute for Health Metrics and Evaluation, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1966342023-01-08T13:26:53Z2023-01-08T13:26:53ZType 2 diabetes in young people puts their eyes at risk<figure><img src="https://images.theconversation.com/files/501160/original/file-20221214-15950-g5r5q3.jpg?ixlib=rb-1.1.0&rect=5%2C7%2C989%2C654&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When it comes to eye care, regular visits to the optometrist or ophthalmologist can detect the early signs of diabetic damage.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Sixteen-year-old Karl is seen for the first time in my optometry practice. He was referred to me for a fluctuating vision problem. During his examination, I saw signs suggesting he may have diabetes, which could have explained the fluctuating vision. This suspicion became a reality when his family doctor confirmed the diagnosis. Karl’s world was turned upside down.</p>
<p>As an optometrist, I invite you to dive into a reality that should concern us all.</p>
<h2>What is diabetes?</h2>
<p>Diabetes is an insidious disease. Its symptoms <a href="https://www.mayoclinic.org/diseases-conditions/type-2-diabetes-in-children/symptoms-causes/syc-20355318">(thirst, need to urinate often, fatigue, weight loss, darker skin areas on the neck and underarms)</a> often go unnoticed, at least in the early stages of the disease.</p>
<p>Diabetes affects the lives of <a href="https://data.worldbank.org/indicator/SH.STA.DIAB.ZS?locations=XU">one in 14 people in Canada (7 per cent) and one in 10 in North America (10 per cent)</a>.</p>
<p>Two types of diabetes can be diagnosed:</p>
<ul>
<li><p><a href="https://www.diabete.qc.ca/en/understand-diabetes/all-about-diabetes/types-of-diabetes/type-1-diabetes/">Type 1</a>, which is insulin-dependent and develops when the body cannot produce the insulin needed to metabolize the sugars we ingest and which feed our tissues</p></li>
<li><p><a href="https://www.canada.ca/en/public-health/services/diseases/type-2-diabetes.html">Type 2</a>, which develops when insulin is produced, but in insufficient quantities. Sometimes the insulin that is produced is ineffective in doing its job.</p></li>
</ul>
<p>Type 1 diabetes is usually associated with the development of the disease in childhood and adolescence. Type 2, the most common, usually develops later in life, <a href="https://www.diabete.qc.ca/en/understand-diabetes/all-about-diabetes/types-of-diabetes/">often after age 50</a>.</p>
<h2>A counter-intuitive diagnosis, but not a rare one</h2>
<p>From this definition, it would have been logical to conclude that Karl was affected by Type 1 diabetes, the course and treatment of which are well controlled by physicians. However, in his case, and after the required testing, his doctor identified Type 2 diabetes. This diagnosis is counter-intuitive and poses significant challenges. The speed of onset, the initial severity of the disease and the mechanisms of resistance, or of reduced insulin secretion, may be different in patients who develop the disease at a younger age <a href="https://pubmed.ncbi.nlm.nih.gov/15735201/">than in adults</a>.</p>
<p>In addition, treatment options, involving trial and error, become more complex due to the much longer duration of this type of disease when it starts at a young age. Both major and minor changes <a href="https://pubmed.ncbi.nlm.nih.gov/12090830/">that affect the blood vessels in the Type 2 diabetic patient</a> can have serious consequences that are difficult to predict since the course of treatment can continue for 40 to 60 years.</p>
<p>However, Karl’s situation is not exceptional. <a href="https://www.thelancet.com/pdfs/journals/landia/PIIS2213-8587(17)30186-9.pdf">More and more young people and adolescents</a>, especially those who are <a href="https://pubmed.ncbi.nlm.nih.gov/12241736/">overweight, obese, and sedentary</a>, are affected by Type 2. Almost 75 per cent of them have <a href="https://www.cdc.gov/diabetes/basics/type2.html">parents or siblings with diabetes</a>.</p>
<p>While at first sight, this confirms genetics as a risk factor for developing the disease, in this specific case, it was more a consequence of <a href="https://www.cdc.gov/diabetes/basics/type2.html">poor lifestyle habits, especially dietary habits, and lack of physical activity</a>, which are often shared by the whole family.</p>
<h2>Impact on vision</h2>
<p>The fact that Karl developed Type 2 diabetes earlier, rather than later in life also puts him at a higher risk of developing eye complications. An <a href="https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2786928">article</a> about this topic recently caught my attention. This study looked at the records of 1,362 people with diabetes living in Minnesota, so, in North America and then extrapolate to Canada. The data was compiled between 1970 and 2019, which also allows us to measure the evolution of the situation over the last decades.</p>
<p>The results are astonishing: young people with Type 2 diabetes (compared to Type 1 diabetics of the same age) are 88 times more likely to develop retinopathy (abnormal blood vessels and/or hemorrhages in the retina). In addition, the risk of this retinopathy becoming “proliferative,” and therefore threatening to vision, is increased 230 times. There is also a 49-fold increase in the risk of fluid accumulation in the retina (macular edema) and a 243-fold increase in the risk of developing a mature cataract at a young age. The latter requires surgery which is riskier in young people than in the case of age-related senile cataracts.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="photograph of a fundus" src="https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500479/original/file-20221212-113662-60amw4.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"></a>
<figcaption>
<span class="caption">Vascular and metabolic complications of diabetes visible on the fundus (hemorrhages, exudates).</span>
<span class="attribution"><span class="source">(Langis Michaud)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<p>What should we remember from this? That the major problems, which often require surgical interventions to save vision, occur much more rapidly in young Type 2 diabetics than in those affected by Type 1. These patients must therefore be followed more closely. Indeed, almost one in two Type 2 patients will develop some form of retinopathy within one to eight years of diagnosis. In comparison, one in three Type 1 diabetics will develop retinopathy between six and 10 years following diagnosis.</p>
<h2>Significant repercussions</h2>
<p>Already having increased significantly in the last 10 years, the prevalence (number of cases) of Type 2 diabetes in young people is predicted to <a href="https://pubmed.ncbi.nlm.nih.gov/23173134/">quadruple by 2050</a>. This prediction is most alarming for health professionals, but also for policymakers and managers of public health agencies. The lifetime cost of direct medical care for a single diabetic patient aged 25-44 years was <a href="https://pubmed.ncbi.nlm.nih.gov/23953350/">US$125,000 in 2013</a>. These costs have since increased and many more dollars need to be added to cover the period between 15 and 25 years, which is not taken into account. Indeed, if 20 per cent of the youth population develops diabetes by 2050, millions (perhaps billions?) of health-care dollars will have to be spent on their care by our governments.</p>
<p>The long-term quality of life of people with diabetes is also reduced. <a href="https://pubmed.ncbi.nlm.nih.gov/30345893/">Another study</a>, this time of young people with Type 1 diabetes, shows that their disease has a negative impact on their life. They have to devote a lot of time to their care (missing activities with their friends). And the burden of their disease on their relatives weighs heavily on their shoulders. The fear of hypoglycemia (lack of sugar that can lead to coma) or of developing serious complications of the disease also affects them. Achieving autonomy is more difficult for these adolescents, and their quality of life is proportional to the freedom they can or cannot exercise.</p>
<h2>Eat well, exercise and visit your optometrist</h2>
<p>Type 1 diabetes is difficult to prevent, mainly because we don’t know all the reasons why it occurs and to proactively screen for it. The situation is different for Type 2 diabetes, which is strongly associated with unhealthy lifestyle in young people. Eating a healthy diet, exercising regularly, and combating sedentary lifestyles, including limiting screen leisure time (to less than two hours per day), are good ways to avoid or delay the onset of diabetes in young people. Screen time is also associated with <a href="https://pubmed.ncbi.nlm.nih.gov/28288985/">insulin resistance</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/31270831/">obesity</a> in young people. In other words, healthy lifestyles must be encouraged and especially shared within the family unit.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="young children ride bikes" src="https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500780/original/file-20221213-16037-bsk51g.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">Healthy habits are good ways to avoid or delay the onset of diabetes in young people.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>As far as eyes are concerned, regular visits to the optometrist or ophthalmologist can detect early signs of diabetic complications <a href="https://guidelines.diabetes.ca/cpg/chapter30">(signs are seen in up to 30 per cent of patients shortly after diagnosis)</a>. These health professionals can also detect other oculo-visual problems arising from the disease, such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518369/">loss of ability to focus up close (accommodation), partial paralysis of certain muscles of the eye resulting in double vision, delayed healing of surface corneal changes, dry eye or glaucoma</a>. Testing should be done <a href="https://guidelines.diabetes.ca/cpg/chapter30">at the time of medical diagnosis of diabetes</a>, or in anyone with a high-risk profile (heredity, obesity, sedentary lifestyle).</p>
<p>Since healthy lifestyle habits are an integral part of the treatment of the disease, it is not too late for Karl to enjoy a happier future. But it is important not to neglect regular follow-ups by his medical doctor and frequent visits to his family optometrist.</p><img src="https://counter.theconversation.com/content/196634/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Langis Michaud 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>The risk of developing eye complications is high in young people with Type 2 diabetes, which is increasingly affecting children and adolescents, especially those who are more sedentary.Langis Michaud, Professeur Titulaire. École d'optométrie. Expertise en santé oculaire et usage des lentilles cornéennes spécialisées, Université de MontréalLicensed 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>
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<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>
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<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>
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</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>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1546695269823414273"}"></div></p>
<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/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>
<hr>
<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>
<hr>
<p>
<em>
<strong>
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>
<hr>
<p>
<em>
<strong>
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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</em>
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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/1843132022-06-15T20:01:56Z2022-06-15T20:01:56ZTime in hospital sets back tens of thousands of children’s learning each year, but targeted support can help them catch up<figure><img src="https://images.theconversation.com/files/468635/original/file-20220614-18-r7p1do.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4718%2C3147&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><a href="https://www.nap.edu.au/">NAPLAN</a> scores can tell us about a child’s learning, but can they also help us to support learners who have had a serious injury or a long-term chronic illness like asthma or epilepsy? </p>
<p>Children who spend time in hospital for these reasons miss out on time in class and are at risk of performing below the <a href="https://www.nap.edu.au/results-and-reports/how-to-interpret/standards">national minimum standard</a> (NMS) in numeracy and literacy as measured by NAPLAN. A serious injury or chronic illness can have a cumulative effect, resulting in lower educational performance, non-completion of high school, and potentially limiting their social, educational and later employment opportunities. </p>
<p>Knowing these risks in advance means parents and educators can plan to support children before the shock of poor school or NAPLAN results. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/every-teacher-needs-to-be-a-literacy-teacher-but-thats-not-happening-in-most-australian-schools-184557">Every teacher needs to be a literacy teacher – but that's not happening in most Australian schools</a>
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</em>
</p>
<hr>
<p>Serious injury, asthma, mental health, epilepsy and diabetes impact more than a million children each year. More than 100,000 end up in hospital. </p>
<p>We compared their NAPLAN results with kids of the same age and gender who lived in the same area but who had not been hospitalised for those conditions. We found spending time in hospital for these conditions did set back learning, with the exception of type 1 diabetes. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1450099372927164422"}"></div></p>
<h2>What did the study find?</h2>
<p><strong>Injury</strong></p>
<p>About <a href="https://doi.org/10.1186/s12887-021-02891-x">70,000 people</a> under the age of 16 are hospitalised with an injury each year in Australia. This can disrupt their ability to attend school or concentrate and learn. </p>
<p>Recovery from injury can be unpredictable. Some young people may fully recover. Others experience ongoing difficulties at school.</p>
<p><a href="https://doi.org/10.1186/s12887-021-02891-x">Compared to matched peers</a>, students who had been hospitalised with an injury had a 12% higher risk of not achieving the NMS in numeracy on NAPLAN and a 9% higher risk of not achieving the NMS in reading.</p>
<p><strong>Asthma</strong></p>
<p>Around <a href="https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/asthma-prevalence-children">460,000 young people</a> have asthma in Australia. If asthma is not adequately controlled, it can have a wide-ranging impact on their lives, including on their performance at school.</p>
<p>Our <a href="https://doi.org/10.1111/cea.14022">analysis</a> of 28,114 young people hospitalised with asthma showed a difference between the sexes. Young males’ risk of not achieving the NMS was 13% higher for numeracy and 15% higher for reading compared to matched peers. In contrast, females hospitalised with asthma showed no difference.</p>
<p><strong>Mental illness</strong></p>
<p>Around 14% of young people experience a mental illness in Australia that can affect their health, relationships and school life. In our <a href="https://doi.org/10.1177/00048674211061684">study</a> of 7,069 young people hospitalised with a mental illness, young males had almost twice the risk of not achieving the NMS on NAPLAN for both numeracy and reading compared to their peers. Young females had a 1.5 times higher risk of not achieving the NMS for numeracy and those with diagnosed <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/conduct-disorder">conduct disorder</a> had twice the risk of not achieving the NMS for reading.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-transition-into-adolescence-can-be-brutal-for-kids-mental-health-but-parents-can-help-reduce-the-risk-180487">The transition into adolescence can be brutal for kids' mental health – but parents can help reduce the risk</a>
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</p>
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<p><strong>Epilepsy</strong></p>
<p>Across the country, about <a href="https://epilepsyfoundation.org.au/about-us/media-room/#:%7E:text=1%20in%20200%20Australian%20children%20live%20with%20epilepsy.">one in 200 children</a> are living with epilepsy. Epilepsy can affect attention, concentration and memory, all which can be a barrier to performing well at school. </p>
<p>Our <a href="https://doi.org/10.1016/j.seizure.2022.05.014">study</a> of 2,383 young people hospitalised with epilepsy found young males and females had a three times higher risk of not achieving the NMS on NAPLAN for both numeracy and reading compared to peers.</p>
<p><strong>Type 1 diabetes</strong></p>
<p>Type 1 diabetes was the exception and showed no adverse impact on school performance. In Australia, an estimated 6,500 young people have type 1 diabetes. Our <a href="https://doi.org/10.1111/pedi.13317">analysis</a> of 833 young people hospitalised with type 1 diabetes did not find any difference in achieving the NMS in numeracy or reading on NAPLAN compared to matched peers.</p>
<p>This finding is likely explained by improved glucose control and type 1 diabetes management. It is also possible that school assessments, such as NAPLAN, do not capture everyday difficulties that students with diabetes experience.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-parents-can-do-to-make-a-childs-chronic-illness-easier-41359">What parents can do to make a child's chronic illness easier</a>
</strong>
</em>
</p>
<hr>
<h2>How can we support these students’ learning?</h2>
<p>It is essential that we identify students who are likely to need learning support because of an injury or chronic illness. Supports can include online learning options, flexible programming or mobilising peer support to enable sharing of class notes and homework activities. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1361455225442295808"}"></div></p>
<p>Monitoring students’ progress when they return to school will help to identify ongoing learning support needs.</p>
<p>There are also ways to manage symptoms and enhance performance at school. With asthma, for example, a comprehensive asthma management plan, using medication to manage symptoms, and <a href="https://www.schn.health.nsw.gov.au/find-a-service/health-medical-services/asthma-improvement">healthcare co-ordination</a> between GPs, hospitals and community services can all reduce the chance of ending up in hospital. For epilepsy, learning to identify seizure triggers, lifestyle and medication management are <a href="https://www.epilepsy.org.au/strong-foundations/overview/">key</a>.</p>
<p>Improving teachers’ understanding of symptom management for chronically ill or injured students is important too. For example, a New South Wales program, <a href="https://education.nsw.gov.au/early-childhood-education/whats-happening-in-the-early-childhood-education-sector/resource-library/asthma">Aiming for Asthma Improvement in Children</a>, encourages self-paced training for school staff on asthma management and first aid, along with resources for managing asthma in schools. For epilepsy, Strong Foundations provides <a href="https://www.epilepsy.org.au/strong-foundations/learning-and-participation/">advice</a> on the skills children with epilepsy need to manage in the classroom and playground.</p>
<p>Early identification and recognition that an injured or chronically ill student may need learning support at school and at home are critical to ensure they are not left behind academically.</p>
<hr>
<p><em>This article is part of The Conversation’s <a href="https://theconversation.com/topics/breaking-the-cycle-119149">Breaking the Cycle</a> series, which is supported by a philanthropic grant from the Paul Ramsay Foundation.</em></p><img src="https://counter.theconversation.com/content/184313/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Mitchell has received funding from the NHMRC, the MRFF, the ARC, and various state and federal government departments for past projects. This research was funded by a philanthropic donor to Macquarie University. This article is part of The Conversation's Breaking the Cycle series, which is about escaping cycles of disadvantage. The series is supported by a philanthropic grant from the Paul Ramsay Foundation.</span></em></p><p class="fine-print"><em><span>Anne McMaugh has received funding from the Australian Research Council for past projects. This research was funded by a philanthropic donor to Macquarie University</span></em></p>A study of thousands of students hospitalised with an injury or illness confirms they are likely to fall behind their classmates. But good management and targeted help with learning cut the risk.Rebecca Mitchell, Associate Professor Health and Societal Outcomes, Macquarie UniversityAnne McMaugh, Senior Lecturer in Educational Psychology, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1802112022-04-07T13:17:17Z2022-04-07T13:17:17ZPeople who’ve had COVID appear more likely to develop diabetes – here’s why that might be<figure><img src="https://images.theconversation.com/files/456893/original/file-20220407-19-39gm73.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3024%2C2017&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/young-african-nurse-taking-blood-senior-1909444498">DisobeyArt/Shutterstock</a></span></figcaption></figure><p>Many people who have had COVID-19 have gone on to develop diabetes. But diabetes is relatively common, and COVID is too, so that doesn’t necessarily mean one leads to the other. </p>
<p>The question is whether people who have had COVID are more likely to develop diabetes than those who haven’t. And if so, is it COVID that’s causing diabetes, or is there something else that links the two?</p>
<p>Recent studies suggest there is an association between having COVID and going on to be diagnosed with diabetes. <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7102e2.htm">US data</a>, based on records of more than 500,000 people aged under 18 who had COVID, found these young people were more likely to receive a new diabetes diagnosis following their infection, compared to those who didn’t have COVID and those who’d had other respiratory infections prior to the pandemic. The study didn’t specify which types of diabetes people developed.</p>
<p>Another <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00044-4/fulltext#%20">US study</a> in an older age group found the same patterns in their analysis of over four million patients. In this case, most of the diabetes cases were type 2.</p>
<p>A <a href="https://link.springer.com/article/10.1007/s00125-022-05670-0">German study</a> based on medical records of more than eight million patients again found people who had COVID were more likely to subsequently be diagnosed with type 2 diabetes.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-get-diabetes-from-eating-too-much-sugar-95833">Do you get diabetes from eating too much sugar?</a>
</strong>
</em>
</p>
<hr>
<h2>Remind me, what is diabetes?</h2>
<p>There are various different kinds of diabetes. What they all have in common is that they affect the body’s ability to produce or respond to the hormone insulin. Insulin controls the amount of sugar in our blood, so if we don’t produce enough of it, or it’s not working properly, our blood sugar goes up.</p>
<p>The most common type of diabetes by far is <a href="https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2">type 2 diabetes</a>. It often comes on in adulthood and is characterised by insulin resistance. In other words, people with type 2 diabetes are still producing insulin, but the insulin isn’t working properly. Treatments vary and include medication, changes to diet, and increased physical activity.</p>
<p>The next most common is <a href="https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-1">type 1</a>. Type 1 diabetes often, but not always, comes on in childhood or adolescence. I was diagnosed at the age of ten. In type 1 diabetes, the body stops producing insulin altogether. People with type 1 diabetes need to take injections or infusions of insulin for the rest of their lives.</p>
<h2>So how could COVID cause diabetes?</h2>
<p>There are many plausible theories about how COVID might cause diabetes, but none have been proven. One possibility is that <a href="https://theconversation.com/inflammation-the-key-factor-that-explains-vulnerability-to-severe-covid-144768">inflammation</a> caused by the virus could bring about insulin resistance, which is a feature of type 2 diabetes. </p>
<p>Another possibility relates to ACE2, a protein found on the surface of cells, which SARS-CoV-2 (the virus that causes COVID-19) attaches to. <a href="https://www.diabetes.org.uk/about_us/news/new-worse-cases-coronavirus">Some studies</a> have shown that the coronavirus can enter and infect insulin-producing cells via ACE2, which might cause the cells to die or change how they work. This could mean people are not able to produce enough insulin, leading to diabetes.</p>
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<img alt="A senior man measuring his blood sugar." src="https://images.theconversation.com/files/456816/original/file-20220407-19-arv88i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/456816/original/file-20220407-19-arv88i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/456816/original/file-20220407-19-arv88i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/456816/original/file-20220407-19-arv88i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/456816/original/file-20220407-19-arv88i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/456816/original/file-20220407-19-arv88i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/456816/original/file-20220407-19-arv88i.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">Diabetes affects the body’s ability to produce or respond to the hormone insulin.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mature-man-checking-blood-sugar-level-1768027778">pikselstock/Shutterstock</a></span>
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<p>In type 1 diabetes, the immune system attacks insulin-producing cells, but we don’t know why. One theory is that the immune system is triggered by something else – say, <a href="https://www.bmj.com/content/342/bmj.d35">a virus</a> – and then accidentally also attacks insulin-producing cells. It could be that COVID is causing some people’s immune systems to do just this.</p>
<h2>Not so fast</h2>
<p>Just because it appears people who have had COVID are more likely to develop diabetes, and there are plausible theories to explain this, it still doesn’t necessarily mean COVID causes diabetes.</p>
<p>It could be that COVID is causing temporary rises in blood sugar, that then resolve over time. A <a href="https://www.massgeneral.org/news/press-release/diabetes-in-patients-with-covid-may-simply-be-transitory">US study</a> of 594 people newly diagnosed with diabetes while hospitalised with COVID found that blood sugar levels often returned to normal after discharge from hospital, without treatment. </p>
<p>We also know that <a href="https://www.endocrinology.org/press/press-releases/dexamethasone-effectively-reduces-covid-19-deaths-but-potential-diabetic-like-complications-should-be-monitored/">dexamethasone</a> – a steroid used to treat people with severe COVID – causes temporary rises in blood sugar.</p>
<p><a href="https://www.massgeneral.org/news/press-release/diabetes-in-patients-with-covid-may-simply-be-transitory">Some scientists</a> have questioned whether COVID is causing a new type of diabetes altogether, or whether people are being mistakenly classified as having diabetes after COVID. </p>
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<p>Further, a lot of diabetes tends to go undetected, especially type 2. It could be that people who are diagnosed with diabetes after having COVID actually had diabetes before getting COVID, but that the diabetes wasn’t picked up until they were being treated for COVID.</p>
<p>Rising levels of diabetes could also reflect an impact of pandemic restrictions, or changed behaviour as a result of infection or fear of infection, including delayed medical care and changes in diet and physical activity levels.</p>
<h2>The four Ts</h2>
<p>Type 2 diabetes tends to develop slowly over time, and even type 1 diabetes can take months to years to show up. So it’s likely to be some time before anyone can say definitively if COVID is leading to an increase in diabetes. </p>
<p>Regardless, it’s really important that people be aware of the signs and symptoms of this condition. Diabetes UK tells us to look out for the <a href="https://www.diabetes.org.uk/get_involved/campaigning/4-ts-campaign">four Ts</a>: toilet (going to the toilet a lot or wetting the bed), being thirsty, tired, and thinner. These are typical symptoms of type 1 diabetes. For type 2, a lot of people don’t get symptoms, or don’t notice them. However, the four Ts still apply, with blurred vision and general itching or thrush also <a href="https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2">listed as symptoms</a>.</p>
<p>If you suspect you or a family member may have diabetes, don’t delay seeking medical attention. A quick finger prick test by a healthcare provider can determine immediately if your blood sugar is high, and whether further investigations might be needed.</p><img src="https://counter.theconversation.com/content/180211/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Hartmann-Boyce has received funding from the National Institute for Health Research, Cancer Research UK, the British Heart Foundation, and the World Health Organization. The views and opinions expressed here are her own and do not necessarily reflect those of the her funders, the National Health Service (NHS) or the Department of Health. </span></em></p>A number of recent studies indicate people who have had COVID are more likely to be diagnosed with diabetes.Jamie Hartmann-Boyce, Associate Professor and Director of Evidence-Based Healthcare DPhil Programme, University of OxfordLicensed 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/1497662020-11-12T15:14:24Z2020-11-12T15:14:24ZDiabetes is a ticking time bomb in sub-Saharan Africa<figure><img src="https://images.theconversation.com/files/368529/original/file-20201110-21-1bo5kk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Diabetes is a serious, chronic condition that affects the lives and well-being of individuals, families, and <a href="https://www.diabetesatlas.org/en/">societies globally</a>. It is characterised by excess levels of sugar in the blood. </p>
<p>There are three main types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.</p>
<p>Type 1 diabetes often begins from childhood. It occurs when the body attacks the pancreas with antibodies. The pancreas is damaged and is unable to produce the hormone, insulin, responsible for regulating the blood sugar level. As a consequence, people with type 1 diabetes rely on daily injections of insulin to survive. Type 1 diabetes constitutes about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146037/">5%–10%</a> of all cases of diabetes</p>
<p>Type 2 diabetes occurs mostly in adults from the ages of <a href="https://www.ncbi.nlm.nih.gov/books/NBK513253/">20 to 79</a>. It accounts for about <a href="https://www.idf.org/aboutdiabetes/type-2-diabetes.html#:%7E:text=Type%202%20diabetes%20is%20the,keep%20rising%2C%20releasing%20more%20insulin.">90%</a> of all diabetes cases. In type 2, the pancreas produces insulin, but it is either not enough or the body cells fail to use it – what’s known as insulin resistance. People who are obese have a high risk of developing type 2 diabetes.</p>
<p>Gestational diabetes refers to high blood sugar that appears only in pregnancy, and usually goes away after delivery. But women with gestational diabetes have high chances of developing type 2 diabetes later in their life.</p>
<p>In 2019 about <a href="https://www.diabetesatlas.org/en/">1 in 11 adults</a> in the world – 436 million people – had diabetes. Of these, 19 million lived in sub-Saharan Africa. Around 60% of them were not aware of their condition.</p>
<p>These numbers are expected to grow exponentially over the next 25 years. The number of people with diabetes in sub-Saharan Africa is expected to more than double to <a href="https://www.dovepress.com/mitigating-the-burden-of-diabetes-in-sub-saharan-africa-through-an-int-peer-reviewed-fulltext-article-DMSO">45 million by 2045</a>. This is because many people are at high future risk of diabetes, otherwise known as people with prediabetes. In 2019, about 45 million Africans aged 20 to 79 years had impaired glucose tolerance, which is a form of prediabetes.</p>
<p>The <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30925-9/fulltext">Global Burden of Disease Study</a> estimates that diabetes is the fifth leading cause of deaths due to noncommunicable diseases in the region. Others ahead of it are stroke, ischaemic heart disease, congenital birth defects, and chronic liver diseases.</p>
<p>The expected rapid rise in diabetes must not be overlooked as it could have devastating <a href="https://theconversation.com/lifestyle-diseases-could-scupper-africas-rising-life-expectancy-107220">health and economic consequences</a> for the region. Most national health systems are unprepared to deal with the growing burden as they struggle to cope with infectious diseases. The COVID-19 pandemic has added to these pressures.</p>
<p>Given that this is a lifestyle disease, governments need to act urgently to encourage changes in behaviour in a bid to manage it.</p>
<h2>Implications of high rates of diabetes</h2>
<p>Diabetes and other noncommunicable diseases result in people living many years in poor health in sub-Saharan Africa. The <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30977-6/fulltext">average life expectancy</a> in the region is currently estimated to be 64.5 years, with 11% of those years spent in poor health.</p>
<p>One-third of all health loss (measured using disability-adjusted life-years) in 2019 in sub-Saharan Africa was due to noncommunicable diseases such as diabetes. This figure rose from 18% in 1990. Disability-adjusted life-years is a measure of disease burden that captures both <a href="https://theconversation.com/people-in-africa-live-longer-but-their-health-is-poor-in-those-extra-years-108691">early death and ill health</a>. </p>
<p>According to the Global Burden of Disease Study, the proportion of all years of life lost to early death due to diabetes and other noncommunicable diseases increased by more than 68% in sub-Saharan Africa <a href="https://doi.org/10.1016/S0140-6736(20)30925-9">between 1990 and 2019</a>.</p>
<p>Diabetes can lead to death and <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">life-threatening complications</a>, such as severe damage to the heart, blood vessels, eyes, kidneys, and nerves. These complications can lead to heart attacks, strokes, blindness, kidney failure, and lower limb amputation. For example, adults with diabetes are three times more likely to suffer from heart attacks and strokes than adults without diabetes.</p>
<p>Diabetes can also increase the <a href="https://www.dovepress.com/mitigating-the-burden-of-diabetes-in-sub-saharan-africa-through-an-int-peer-reviewed-article-DMSO">risk of infectious diseases</a> such as pneumonia and tuberculosis. It has also been shown that people living with diabetes who are infected with SARS-CoV-2 are more likely to develop <a href="https://dx.doi.org/10.1111/cob.12414">severe COVID-19</a>, to require extended stay in the hospital, to have a greater need for ventilation, and to have higher chances of <a href="https://doi.org/10.1016/j.dsx.2020.04.044">dying from COVID-19</a>.</p>
<h2>Future risks</h2>
<p>Sub-Saharan Africa faces unique challenges in <a href="https://www.dovepress.com/diabetes-in-sub-saharan-africa-from-policy-to-practice-to-progress-tar-peer-reviewed-article-DMSO">combating diabetes</a>. These include the lack of funding for noncommunicable diseases, lack of studies and guidelines specific to the population, lack of medications, differences in urban and rural patients, and inequity between public and private sector health care. </p>
<p>Because of these challenges, diabetes has a more significant impact on health loss in sub-Saharan Africa than any other region in the world.</p>
<p>The <a href="https://www.diabetesatlas.org/en/">International Diabetes Federation</a> estimated the cost of diabetes in sub-Saharan Africa in 2019 to be US$ 9.5 billion, and this will increase to US$ 17.4 billion by 2045.</p>
<p>The rising prevalence of diabetes is linked to the increase in obesity and other lifestyle changes such as poor eating habits and lack of physical activity. </p>
<p>The risk factors for developing diabetes are <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">modifiable</a>, meaning they can be changed. People should be encouraged to eat healthily, be physically active, and avoid extreme weight gain. Such simple lifestyle changes are effective in preventing type 2 diabetes. </p>
<p>Studies over the past two decades have unequivocally shown that <a href="https://doi.org/10.1111/j.1464-5491.2007.02157.x">lifestyle modification</a> can prevent or delay the onset of type 2 diabetes in people who are at high future risk of the disease. Such studies have been conducted in <a href="https://www.diabetesatlas.org/en/">numerous countries</a>, including the United States of America, Finland, China, India, Japan, and Pakistan. </p>
<p>A coordinated multi-sectoral approach within and across countries is needed to stem the tide of diabetes in sub-Saharan Africa.</p><img src="https://counter.theconversation.com/content/149766/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andre Pascal Kengne received from the South African Medical Research Council (SAMRC); The European & Developing Countries Clinical Trials Partnership (EDCTP) and The Global Alliance for Chronic Diseases (GACD).</span></em></p><p class="fine-print"><em><span>Charles Shey Wiysonge receives funding from the South African Medical Research Council.</span></em></p><p class="fine-print"><em><span>Chinwe Juliana Iwu-Jaja 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 rapid rise in diabetes mustn’t be overlooked, as it could have devastating health and economic effects. Most national health systems are already struggling with infectious diseases.Chinwe Juliana Iwu-Jaja, Public Health researcher, Stellenbosch UniversityAndre Pascal Kengne, Director of the Non-Communicable Diseases Research Unit at the South African Medical Research Council, Professor in the Department of Medicine, University of Cape TownCharles Shey Wiysonge, Regional Adviser, Immunisation, WHO Regional Office for Africa, Stellenbosch UniversityLicensed 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>
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</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.tag:theconversation.com,2011:article/1390792020-06-01T10:09:34Z2020-06-01T10:09:34ZCoronavirus and diabetes: the different risks for people with type 1 and type 2<figure><img src="https://images.theconversation.com/files/338345/original/file-20200528-51509-syj4qo.jpg?ixlib=rb-1.1.0&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/young-africanamerican-woman-using-digital-glucometer-1341884993">New Africa/Shutterstock</a></span></figcaption></figure><p>In early 2020, it seemed like people with diabetes were disproportionately dying with COVID-19, but the data provided more questions than answers. What type of diabetes did people have? Were people dying because the condition itself put them at greater risk, or because those with it tend to be older and have other illnesses? And what should people with diabetes do to protect themselves? </p>
<p>Now, researchers are harnessing <a href="https://www.england.nhs.uk/publication/type-1-and-type-2-diabetes-and-covid-19-related-mortality-in-england/">data from NHS England</a> to address these questions – and some of their findings are unexpected.</p>
<p>It is still unclear whether people with diabetes are more likely to catch the virus. We won’t know if this is true until sustained, widespread testing is rolled out. But we do know that a disproportionate number of people with the condition have been hospitalised with COVID-19. In the UK, <a href="https://www.medrxiv.org/content/10.1101/2020.04.23.20076042v1">data spanning February to April</a> shows people with diabetes made up approximately 25% of hospitalised cases; that’s almost <a href="https://www.diabetes.co.uk/diabetes-prevalence.html">four times higher</a> than the estimated rate of diabetes in the general population.</p>
<p>Once in hospital with COVID-19, data also shows that people with diabetes have worse outcomes than people without. The increase in risk is striking but isn’t necessarily surprising – people with diabetes are prone to worse outcomes from infections generally, as <a href="https://www.nfid.org/2019/11/07/facts-about-diabetes-and-flu/">data from flu</a> shows.</p>
<p>When it comes to COVID-19, early studies suggest people with diabetes are approximately <a href="https://www.cebm.net/covid-19/diabetes-and-risks-from-covid-19/">twice as likely</a> to be categorised as having “severe disease” and are more likely to be <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e2.htm">admitted to intensive care units</a>. In England, <a href="https://www.diabetes.org.uk/about_us/news/coronavirus-statistics">one in four people</a> who die in hospital with COVID-19 have diabetes. </p>
<p>Previous studies, however, didn’t shed light on the details behind these headline statistics, and didn’t break down data by diabetes type. We now have this information, and it shows a significant – and surprising – difference.</p>
<h2>Higher risk if you have type 1 diabetes</h2>
<p>Compared to people without diabetes, people with <a href="https://www.diabetes.org.uk/diabetes-the-basics/what-is-type-1-diabetes">type 1</a> diabetes are approximately <a href="https://www.diabetes.org.uk/about_us/news/coronavirus-statistics">3.5 times as likely</a> to die in hospital with COVID-19, while people with <a href="https://www.diabetes.org.uk/diabetes-the-basics/what-is-type-2-diabetes">type 2</a> are approximately twice as likely. This came as a surprise to some, because, unlike type 1, type 2 diabetes is often accompanied by <a href="https://www.mayoclinic.org/diseases-conditions/metabolic-syndrome/symptoms-causes/syc-20351916">other diseases</a>, typically comes on in older age, and can be associated with raised body weight. <a href="https://www.medrxiv.org/content/10.1101/2020.04.23.20076042v1">All of these factors</a> are linked to worse outcomes from COVID-19. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/wZAjVQWbMlE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The causes, types and complications of diabetes in more detail.</span></figcaption>
</figure>
<p>There are a number of possible explanations as to why outcomes are worse in type 1 compared to type 2.</p>
<p>First, the length of time someone has had diabetes might impact their vulnerability to COVID-19. Unlike type 2, people are most often diagnosed with type 1 at a young age (I was diagnosed at ten). In people hospitalised with COVID-19, someone with type 1 has likely had diabetes for much longer than someone with type 2. The longer someone has diabetes, the more likely they are to have <a href="https://www.diabetes.org.uk/guide-to-diabetes/complications">complications</a>, which include damage to the heart and kidneys. </p>
<p>Second, in type 1, your immune system attacks the cells that make insulin and you eventually stop making insulin altogether. <a href="https://www.nhs.uk/conditions/type-1-diabetes/about-insulin/">Insulin</a> is the hormone that helps the body process sugar in the blood. Type 2 isn’t a disease of the immune system. In type 2, your body makes insulin but is resistant to it. The immune systems of people with type 1 may be different from people with type 2, which could impact how people respond to infection.</p>
<p>Finally, data shows that <a href="https://www.diabetes.co.uk/news/Controlling-blood-sugar-levels-could-improve-COVID-19-health-outcomes.html">higher blood sugar levels increase the risk of COVID-19</a>. We know that on average blood sugar levels are <a href="https://files.digital.nhs.uk/pdf/s/k/national_diabetes_audit_2016-17_report_1__care_processes_and_treatment_targets.pdf">higher in people with type 1 than with type 2 diabetes</a>, because of the different nature of the diseases. Blood sugar levels can be even harder to manage when fighting infections.</p>
<p>But these are all just theories. We need more research before we know for sure how the type of diabetes impacts COVID-19 outcomes.</p>
<h2>Age is the key risk factor</h2>
<p>To illustrate this, I’m going to use myself as an example and do some crude calculations. I’m 36 and have type 1 diabetes. Most people with COVID-19 aren’t hospitalised. However, if hospitalised with COVID-19, the average 36-year-old has a <a href="https://www.cebm.net/covid-19/global-covid-19-case-fatality-rates/">0.3%</a> chance of dying. Because I have type 1 diabetes, my chances of dying are 3.5 times higher. That means my current chances of dying with COVID-19 once hospitalised are around 1%. </p>
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<img alt="" src="https://images.theconversation.com/files/338341/original/file-20200528-51516-1i3qk0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/338341/original/file-20200528-51516-1i3qk0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338341/original/file-20200528-51516-1i3qk0i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338341/original/file-20200528-51516-1i3qk0i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338341/original/file-20200528-51516-1i3qk0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338341/original/file-20200528-51516-1i3qk0i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338341/original/file-20200528-51516-1i3qk0i.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">Both age and diabetes increase the risk of COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blood-glucose-monitoring-on-finger-senior-331947959">Robert Kneschke/Shutterstock</a></span>
</figcaption>
</figure>
<p>However, if the average 80-year-old is hospitalised with COVID-19, they have a <a href="https://www.cebm.net/covid-19/global-covid-19-case-fatality-rates/">15%</a> chance of dying. So, though diabetes does increase my risk, my age still remains the most important factor, by far, in determining my chances of dying with COVID-19. My risk at 80 would still be higher than someone of that age without diabetes, so both would need to be taken into account. </p>
<p>It is really important to note that these figures are not someone’s overall risk of dying from COVID-19, they are the risk of dying <em>if</em> they contract COVID-19 and <em>if</em> the infection is then severe enough to warrant hospitalisation.</p>
<h2>How to reduce the risk</h2>
<p>The advice to people with diabetes is to practice <a href="https://www.gov.uk/coronavirus">social distancing and handwashing</a> like the rest of the population, <a href="https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/staying-home">to maintain a healthy lifestyle</a>, and to try to keep <a href="https://www.diabetes.co.uk/news/Controlling-blood-sugar-levels-could-improve-COVID-19-health-outcomes.html">blood sugars in an ideal range where possible</a>. </p>
<p>But aiming for tighter blood sugar control can feel daunting. Now might be a <a href="https://www.cebm.net/covid-19/managing-diabetes-during-the-covid-19-pandemic/">particularly difficult time for people to manage diabetes</a>, with disruptions in care, routines, activity, mental wellbeing and diet known to create challenges. Certain groups will face more challenges than others; both COVID-19 and diabetes disproportionately affect people from <a href="https://www.cebm.net/covid-19/bame-covid-19-deaths-what-do-we-know-rapid-data-evidence-review/">non-white ethnic groups</a> and people from <a href="https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-covid-19-kills-the-most-deprived-at-double-the-rate-of-affluent-people-like-other-conditions">less advantaged backgrounds</a>.</p>
<p>Support is available from healthcare providers and from organisations like <a href="https://www.diabetes.org.uk/how_we_help/helpline">Diabetes UK</a>. Now more than ever, governments and healthcare systems need to ensure all people with diabetes get the support they need.</p><img src="https://counter.theconversation.com/content/139079/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Hartmann-Boyce 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>New data shows the threat posed by COVID-19 differs significantly between people with type 1 and type 2 diabetes.Jamie Hartmann-Boyce, Senior Research Fellow, Departmental Lecturer and Co-Director of Evidence-Based Healthcare DPhil programme, Centre for Evidence-Based Medicine, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1319572020-02-19T11:26:45Z2020-02-19T11:26:45ZDiscovery of gene associated with 20 autoimmune diseases leads to promising drug trials<figure><img src="https://images.theconversation.com/files/316134/original/file-20200219-11005-1fautxq.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C5160%2C3445&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Psoriasis is an autoimmune condition.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/problem-many-people-eczema-on-hand-580580401">Ternavskaia Olga Alibec/Shutterstock</a></span></figcaption></figure><p>No matter how many times a day we wash our hands, clean our house or wash our dishes, we’re still surrounded by bacteria and viruses which can cause <a href="https://www.reactgroup.org/toolbox/understand/bacteria/bacteria-and-disease/">illness and disease</a>. So we <a href="https://www.livescience.com/26579-immune-system.html">rely on our immune system</a> to fight off these potential threats constantly. In most people, the immune system operates as an effective –- even if not perfect – defensive mechanism. </p>
<p>But in some people the immune system may go awry, causing it to perceive parts of the body itself as a threat and <a href="https://www.immunology.org/sites/default/files/autoimmunity-briefing.pdf">attack the body’s own tissues and cells</a>. This is what happens in <a href="https://www.diabetes.org.uk/type-1-diabetes">type 1 diabetes</a>, where the immune system targets cells in the pancreas that make insulin. It also happens in <a href="https://www.arthritisaction.org.uk/living-with-arthritis/what-is-arthritis/rheumatoid-arthritis/">rheumatoid arthritis</a>, when the immune system attacks the lining of the joints. Both of these are examples of <a href="https://www.diabetes.co.uk/autoimmune-diseases.html">autoimmune diseases</a>. </p>
<p>There are more than 80 different autoimmune conditions that affect more than <a href="https://www.immunology.org/sites/default/files/connect-immune-research-are-you-autoimmune-report.pdf">4 million people in the UK alone</a>. While treatments that reduce autoimmune attacks have been developed, there is still <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061980/">no cure for these diseases</a>. Existing drugs might also not be effective in all patients, and can cause severe side effects. In order to develop better treatments, we need to have a better understanding of how these diseases develop.</p>
<p>Over the past decade, many studies investigating the genetics of autoimmunity have found a common feature: a particular gene, called <a href="https://ghr.nlm.nih.gov/gene/TYK2">TYK2</a>. This gene has been associated with <a href="https://www.nature.com/articles/s41588-019-0550-4">at least 20 autoimmune diseases</a>, including multiple sclerosis, type 1 diabetes, rheumatoid arthritis, lupus, and psoriasis. </p>
<p>Since the discovery of this gene, a drug that targets TYK2 has been developed and is <a href="https://news.bms.com/press-release/bristolmyers/bristol-myers-squibbs-novel-oral-selective-tyk2-inhibitor-delivered-signi">showing promise</a> for the treatment of psoriasis, a disease that causes <a href="https://www.psoriasis.org/about-psoriasis;">raised, red, scaly patches</a> on the skin. Based on the results, this clinical trial gives hope not only for treating psoriasis, but for the treatment of other autoimmune conditions as well. </p>
<h2>From gene to drug</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/26304966">TYK2 plays an integral role</a> in regulating <a href="https://immunology.sciencemag.org/content/3/30/eaau8714">how active the immune system is</a>. But key to the effect of TYK2 on autoimmunity is what scientists call “<a href="http://stm.sciencemag.org/cgi/pmidlookup?view=short&pmid=27807284">gene variants</a>”. Every person will have one of several possible variants of the TYK2 gene. These variants are essentially slightly different versions of the gene, which might make the immune system more or less active depending on what variant a person has.</p>
<p>Certain variants that increase activity in the immune system have been found to increase the likelihood that a person will develop an autoimmune disease, while other variants can actually <a href="http://stm.sciencemag.org/cgi/pmidlookup?view=short&pmid=27807284">protect</a> against <a href="https://www.nature.com/articles/s41588-019-0550-4">more than 20 different autoimmune diseases</a>. While genetics is only one of many factors which influence whether a person develops autoimmunity, this discovery may be a major help in improving treatments of many autoimmune diseases.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/316135/original/file-20200219-11017-1989rq6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/316135/original/file-20200219-11017-1989rq6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/316135/original/file-20200219-11017-1989rq6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/316135/original/file-20200219-11017-1989rq6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/316135/original/file-20200219-11017-1989rq6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/316135/original/file-20200219-11017-1989rq6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/316135/original/file-20200219-11017-1989rq6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This gene has been linked with more than 20 autoimmune diseases.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/dna-molecules-structure-genetic-code-3d-1353967346">Blue Andy/Shutterstock</a></span>
</figcaption>
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<p>Since a higher level of TYK2 activity results in autoimmunity, a <a href="https://stm.sciencemag.org/content/11/502/eaaw1736?rss=1">team of researchers tested</a> the use of a drug, called BMS-986165, which inhibits TYK2 function in treating autoimmune conditions. The drug works by reducing the gene’s activity in the immune system. Promising results were reported when testing the drug both in pre-clinical and clinical settings.</p>
<p>The team first studied the effects of the drug in human blood cells. After having observed the effect of the drug on the cells, they then moved on to animal models to test the effect it had on a whole organism. The drug was <a href="https://stm.sciencemag.org/content/11/502/eaaw1736?rss=1">shown to protect mice</a> from several different autoimmune diseases, including <a href="https://www.nhs.uk/conditions/lupus/">lupus</a>, which causes long-term inflammation to the skin, joints, and organs. Treatment with the drug reduced the number of attacking immune cells by 50% in some cases. </p>
<p>These promising results follow on from a <a href="https://news.bms.com/press-release/bristolmyers/bristol-myers-squibbs-novel-oral-selective-tyk2-inhibitor-delivered-signi">2018 study</a>, which successfully trialled the drug for the treatment of psoriasis. The study found 75% of patients showed a reduction in the size of skin lesions and severity by 75%. Of these patients, 25% had complete clearance of lesions. </p>
<p>These studies, in conjunction with the evidence of the role of TYK2 in another 20 autoimmune diseases, suggest a potential for the use of this drug in the treatment of the other conditions as well. Currently, BMS-986165 is under evaluation in clinical trials in patients with Crohn’s disease, lupus and further trials for psoriasis. </p>
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<img alt="" src="https://images.theconversation.com/files/315932/original/file-20200218-11040-p9wweg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/315932/original/file-20200218-11040-p9wweg.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/315932/original/file-20200218-11040-p9wweg.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/315932/original/file-20200218-11040-p9wweg.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/315932/original/file-20200218-11040-p9wweg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/315932/original/file-20200218-11040-p9wweg.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/315932/original/file-20200218-11040-p9wweg.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><em>This article is part of a series tied to Medicine made for you, a series by The Anthill podcast on the future of healthcare and how it could soon get a lot more personal. <a href="https://theconversation.com/uk/topics/medicine-made-for-you-82269">Read more here</a>.</em></p><img src="https://counter.theconversation.com/content/131957/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Calliope Athina Dendrou receives funding from the Wellcome Trust and Rosetrees Trust. </span></em></p><p class="fine-print"><em><span>Melissa Grant-Peters 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>A drug created to target this gene was found to be effective in treating autoimmune conditions like lupus and psoriasis.Melissa Grant-Peters, DPhil student, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1266872019-12-11T18:53:26Z2019-12-11T18:53:26ZDiabetes and pregnancy can be a tricky (but achievable) mix: 6 things to think about if you want a baby and 1 if you don’t<figure><img src="https://images.theconversation.com/files/303927/original/file-20191127-112512-1f0qfds.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C991%2C658&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A successful pregnancy if you have diabetes comes down to planning and making sure you have the right health-care team behind you.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-tests-gestational-diabetes-by-1565040010">from www.shutterstock.com</a></span></figcaption></figure><p>The number of people with diabetes is expected to increase from <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html">463 million in 2019 to 700 million by 2045 globally</a>. So more women with diabetes will be having babies in the future.</p>
<p>If you have diabetes, here’s how to have the best chance of a safe and successful pregnancy, and to give your baby the best start in life. </p>
<p>Alternatively, if you have diabetes and want to avoid pregnancy, here’s what to think about when it comes to contraception.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-diabetes-11842">Explainer: what is diabetes?</a>
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<h2>Why are women with diabetes and their babies at greater risk?</h2>
<p>Women with diabetes have an <a href="https://dmsjournal.biomedcentral.com/articles/10.1186/1758-5996-4-41">increased risk</a> of pregnancy complications, particularly if they’re among the <a href="https://care.diabetesjournals.org/content/27/suppl_1/s76.full-text.pdf">more than 60%</a> whose pregnancies are unplanned.</p>
<p>Harm can be to the mother, <a href="https://www.ajog.org/article/S0002-9378(00)70225-0/fulltext">such as preeclampsia</a>, where her blood pressure increases, her body swells and her liver and kidneys may be damaged. If left untreated, preeclampsia can lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4317712/pdf/nihms658214.pdf">seizures and loss of mother and baby</a>.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-pre-eclampsia-and-how-does-it-affect-mums-and-babies-97781">Explainer: what is pre-eclampsia, and how does it affect mums and babies?</a>
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<p>Pregnancy can also affect the mother’s diabetes directly, from changes in how her body uses insulin. </p>
<p>Early in pregnancy, women may become more sensitive to insulin and be more likely to have extremely low blood sugar levels (<a href="https://www.nature.com/articles/nrendo.2014.170">become</a> <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1464-5491.2012.03604.x">hypoglycaemic</a>), severe enough to lose consciousness.</p>
<p>Later in pregnancy, hormones released from the placenta make the body more resistant to insulin, which can make controlling her blood glucose <a href="https://insights.ovid.com/pubmed?pmid=17982337">much more difficult</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.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">Babies are at a greater risk of malformations due to sub-optimal levels of glucose they may be exposed to in the womb.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-medically-accurate-illustration-fetus-1482584390?src=0c4a42c3-cfd0-47b8-bc56-ccd8736197c3-1-28&studio=1">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Babies are also at <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-6-30">higher risk</a> <a href="https://link.springer.com/article/10.1007%2Fs00125-013-3108-5">of malformations</a>, such as congenital heart defects and central nervous system defects, because of the mother’s <a href="https://care.diabetesjournals.org/content/30/7/1920.long">sub-optimal blood glucose levels</a>. </p>
<p>If higher blood glucose levels continue or the mother has extreme blood glucose levels, <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-6-30">this may lead to</a> miscarriage, stillbirth or the baby dying shortly after birth.</p>
<p>So it’s no wonder the childbearing years can be daunting.</p>
<p>Here are some tips from the <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">Australasian Diabetes in Pregnancy Society</a> on contraception, pre-pregnancy care and antenatal care.</p>
<h2>1. Think about contraception early, even if you want a baby</h2>
<p>Are you planning to become pregnant? If “yes”, then contraception is important to make sure you’re ready for pregnancy, and when it happens, there’s the greatest chance of a healthy baby (see point 2). If “no” and you are sexually active, or soon will be, then you also need effective contraception.</p>
<p>So, start discussing contraception early in your childbearing years, ideally before you become sexually active. You can do this either through your diabetes team or your regular health-care provider.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.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">Long-acting reversible contraception, like this intrauterine device, is recommended for women with diabetes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-intrauterine-device-on-blue-background-731018869">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Long-acting reversible contraception (for instance, intrauterine devices or implants) are strongly recommended as these have the <a href="https://theconversation.com/few-australian-women-use-long-acting-contraceptives-despite-their-advantages-44896">lowest failure risk</a> and minimal, if any, impact on your diabetes.</p>
<p>Some oral contraceptives are less effective than long-acting reversible contraception and can lead you to gain weight (which <a href="https://www.tandfonline.com/doi/abs/10.1080/07315724.2003.10719316?journalCode=uacn20">can impact</a> how well your diabetes is managed). Weight gain may also increase your risk factors for heart disease, and <a href="https://www.health.gov.au/sites/default/files/pregnancy-care-guidelines_0.pdf">increases the risk</a> of pregnancy complications, such as having a large baby.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/few-australian-women-use-long-acting-contraceptives-despite-their-advantages-44896">Few Australian women use long-acting contraceptives, despite their advantages</a>
</strong>
</em>
</p>
<hr>
<h2>2. If you want a baby, find a pre-pregnancy diabetes management service</h2>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/30322376">pre-pregnancy diabetes management service</a> is a one-stop-shop that looks after your pre-pregnancy care including contraception (see point 1) to make sure the time for conception is right for you.</p>
<p>Using one of these services <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-792">has been shown to reduce the risk</a> of your baby being malformed by 75% or dying before or at birth by 66% compared to those that do not receive such pre-pregnancy care.</p>
<p>So ask your health-care provider if there is a service like this in your area, and if there is, ask for a referral well before trying to conceive.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-psychological-support-can-help-people-living-with-diabetes-10647">How psychological support can help people living with diabetes</a>
</strong>
</em>
</p>
<hr>
<p>At a pre-pregnancy diabetes service, you will get advice and support on all aspects of diabetes from a multidisciplinary team including: a diabetes specialist, a diabetes educator and dietitian, linked with obstetric or gynaecology services.</p>
<p>This includes the impact pregnancy can have on diabetes complications; the impact of diabetes on your baby and pregnancy outcomes; miscarriage and IVF; folic acid supplementation (see point 5); and medication safety (see point 6).</p>
<p>But these services are not available in all areas. Before our diabetes contraception and pre-pregnancy service <a href="https://www.ncbi.nlm.nih.gov/pubmed/30322376">opened in 2018</a>, few clinics in NSW specialised in diabetes pre-pregnancy care.</p>
<h2>3. Choose the right health-care provider for your pregnancy</h2>
<p>Once you know you’re pregnant, ask your GP to refer you to a diabetes specialist team of health-care professionals experienced in managing diabetes in pregnancy. This team will work with an obstetric team. </p>
<p>Such a <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">multi-disciplinary</a> approach means endocrinologists, obstetricians trained in high-risk pregnancy care, dietitians and diabetes educators, among others, will be looking after you.</p>
<p>Early referral is essential, preferably before eight weeks gestation. This is to allow your insulin to be carefully managed to avoid uncontrolled changes in glucose that, as mentioned earlier, can affect you and your baby.</p>
<p>Every woman should have access to diabetes specialist services through a hospital, but in rural and remote areas this may be some distance away. </p>
<p>Although there may be some telehealth options, it is important that ongoing management and particularly the birth are planned with that diabetes specialist team as soon as possible. Your GP will need to refer you.</p>
<h2>4. Keep healthy glucose levels before and during pregnancy</h2>
<p>Whichever health professional or team of health professionals looks after you, <a href="https://care.diabetesjournals.org/content/19/5/514">maintaining your blood glucose levels</a> within range as much as possible before and during pregnancy is vital.</p>
<p>It helps women with diabetes fall pregnant safely, reducing the chance of miscarriage. If you are using IVF, fewer miscarriages will mean fewer rounds of IVF.</p>
<p>Healthy glucose levels also provide a growing baby an environment where it will flourish, reducing the chances of pregnancy complications.</p>
<p>So, when monitoring your blood glucose <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">aim for</a>:</p>
<ul>
<li>fasting blood glucose level, 4-5.5 mmol/L</li>
<li>one hour after eating level, less than 8.0 mmol/L, and </li>
<li>two hours after eating, less than 7 mmol/L. </li>
</ul>
<p>Naturally, these may need to be higher if hypoglycaemia is a problem.</p>
<p>If you have type 1 diabetes and are planning pregnancy, are pregnant or have very recently had a baby, you now have access to a <a href="https://www.ndss.com.au/living-with-diabetes/managing-diabetes/continuous-glucose-monitoring/">free glucose sensor</a>, a wearable device that monitors your glucose continuously. With this device, you should aim to be within <a href="https://care.diabetesjournals.org/content/early/2019/06/07/dci19-0028">3.5-7.8mmol/L more than 70% of the day</a>.</p>
<p>At present there is not enough evidence to support using a continuous glucose monitoring during pregnancy if you have type 2 diabetes. But glucose monitoring remains very important before breakfast and after meals.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-is-it-safe-to-express-milk-before-giving-birth-78399">Health Check: is it safe to express milk before giving birth?</a>
</strong>
</em>
</p>
<hr>
<h2>5. Take a high-dose folate supplement</h2>
<p>Pregnant women with diabetes are recommended to take a <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">high dose of folate</a> (5 milligrams daily, as opposed to <a href="https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/red-book/preventive-activities-prior-to-pregnancy#ref-num-14">0.4-0.5 milligrams</a> in women without diabetes.</p>
<p>That’s because the risk of having a baby with a neural tube defect <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(01)07104-5/fulltext">is raised</a> in women with diabetes.</p>
<p>So if your health-care professional doesn’t raise this, mention it yourself and buy a folate supplement from your local pharmacy.</p>
<h2>6. Ask about your medications</h2>
<p>It’s important to talk to your health-care provider as soon as you know you are pregnant so they can advise whether it is safe to continue taking your existing diabetes medication.</p>
<p>Insulin does not cross the placenta and is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984914/pdf/13300_2018_Article_411.pdf">the preferred medication</a>, if required. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-metformin-the-diabetes-drug-developed-from-french-lilac-64430">Weekly Dose: metformin, the diabetes drug developed from French lilac</a>
</strong>
</em>
</p>
<hr>
<p>Metformin does not cause malformations but does cross the placenta. It’s used <a href="https://www.mja.com.au/system/files/issues/180_09_030504/sim10814_fm.pdf">where the benefits</a> from improved glucose control outweigh any possible theoretical long-term risks to the baby. </p>
<p>Other oral medications to lower blood glucose are generally not approved for use during pregnancy.</p>
<hr>
<p><em>If you have diabetes and want to know more about pregnancy or avoiding pregnancy, resources are available from the <a href="https://www.adips.org/">Australasian Diabetes in Pregnancy Society</a>, <a href="https://www.diabetesaustralia.com.au/pregnancy">Diabetes Australia</a> and our <a href="https://www.westernsydney.edu.au/domtru/projects/dcapp">Diabetes Contraception and Pre-pregnancy Program</a>. Information is also available from the government’s health-care advisory service <a href="https://www.pregnancybirthbaby.org.au/diabetes-during-pregnancy">Pregnancy, Birth and Baby</a> and <a href="https://www.ndss.com.au/about-diabetes/pregnancy/resources/">National Diabetes Services Scheme</a>.</em></p><img src="https://counter.theconversation.com/content/126687/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Freya MacMillan was involved in the development of the Diabetes Contraception and Pre-Pregnancy Program in South Western Sydney and is currently involved in the evaluation and improvement of this service. She receives funding from South Western Sydney Primary Health Network and South Western Sydney Local Health District for this work.</span></em></p><p class="fine-print"><em><span>David Simmons is affiliated with Western Sydney University (WSU), South Western Sydney Local Health District (SWSLHD) and Maridulu Budyari Gumal (Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)) and the WSU/SWSLHD Diabetes Obesity Metabolism Translational Research Unit that have work underway to reduce the risk of malformations and other pregnancy complications among women with diabetes</span></em></p><p class="fine-print"><em><span>Tinashe Dune receives funding from the Australian Research Council and has recieved fundng from the Department of Family and Community Services. Dr Dune is involved in the evaluation of the Diabetes Contraception and Pre-Pregnancy Program in South Western Sydney. She is Director of the Secretariat for African Women Australia, a not-for-profit incorporated association which aims to raise the profile and voices of African women in Australia.</span></em></p>Women with diabetes are at high risk of pregnancy complications. But there is a lot women can do to have a healthy pregnancy and a healthy baby.Freya MacMillan, Senior Lecturer in Interprofessional Health Science, Western Sydney UniversityDavid Simmons, Professor of Medicine Western Sydney University, Head of Department Endocrinology, Campbelltown Hospital, Western Sydney UniversityTinashe Dune, Senior Lecturer in Interprofessional Health Sciences, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1255282019-11-14T12:58:57Z2019-11-14T12:58:57ZWhy telling people with diabetes to use Walmart insulin can be dangerous advice<figure><img src="https://images.theconversation.com/files/298210/original/file-20191022-55685-l2xn2q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A vial of insulin. Prices for the drug, crucial for those with diabetes, have soared in recent years.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/girl-fills-syringe-insulin-injections-diabetes-797801446?src=XBWyvf26jiANYJib9nanUg-1-10">Oleksandr Nagaiets/Shutterstock.com</a></span></figcaption></figure><p>About <a href="https://www.nytimes.com/2019/04/03/health/drug-prices-insulin-express-scripts.html">7.4 million people</a> in the U.S. require manufactured insulin to stay alive. I’m one of them. I’ve lived with Type 1 diabetes for over 15 years and inject two kinds of insulin every day. These insulins are notoriously expensive, and <a href="https://www.forbes.com/sites/lelalondon/2018/11/14/this-is-the-shocking-cost-of-type-1-diabetes/#49d590030caf">even with health insurance</a>, people with diabetes regularly struggle to make ends meet.</p>
<p>The price of some insulins is now <a href="https://energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/documents/Testimony_Lipska_Insulin%20Prices.pdf">seven times more expensive</a> than it was two decades ago. Studies find that upwards of <a href="https://www.sciencedaily.com/releases/2018/12/181203131124.htm">one in four people</a> with diabetes ration their insulin to stretch prescriptions, putting themselves at <a href="https://www.cbsnews.com/news/insulin-prices-2019-diabetes-rationing-insulin-amid-rising-drug-prices-sanofi/">risk of dying</a>. As a result, advocacy groups ranging from the <a href="https://www.ama-assn.org/press-center/press-releases/ama-urges-federal-action-respond-insulin-price-hikes">American Medical Association</a> to <a href="https://www.t1international.com">T1International</a> are calling the situation a crisis. </p>
<p>In place of political or corporate action that would make insulin readily available, an unusual social media phenomenon is developing that puts the onus on people with diabetes to stay well. Those with diabetes are being confronted with “alternatives” to high-priced insulin. The most widespread of these appears to be so-called <a href="https://www.snopes.com/fact-check/insulin-walmart-vial/">Walmart insulin</a>, an older and much cheaper insulin. </p>
<p>These <a href="https://www.vox.com/science-and-health/2019/4/10/18302238/insulin-walmart-relion">older insulins</a> have been thrust into the spotlight because of a widely circulated meme on social media that suggests people could manage their disease better if they simply purchased these products. Such insulins cost US$25 a vial and can be obtained without a prescription. However, these insulins do not present a solution to the current health care crisis. Worse, they may put some people’s lives at risk.</p>
<p>I’m a communication scholar who specializes in the rhetoric of health and medicine. My research focuses on how public understandings of diabetes affect political and cultural responses to the disease. I recently published a <a href="https://www.amazon.com/Managing-Diabetes-Cultural-Politics-Biopolitics/dp/1479835285/ref=sr_1_9?keywords=managing+diabetes&qid=1571671555&sr=8-9">book-length study</a> about competing conceptions of diabetes “management” and how that term guides our thinking about the disease, which can be seen as easily controlled or at other times, fatal. In that work, I detail the ways management is often reduced to a set of individual choices and, in the process, covers over more difficult exchanges about access to care and insulin availability. </p>
<p>Conversations about <a href="https://www.washingtonpost.com/outlook/2019/02/19/drug-prices-are-killing-diabetics-walmart-insulin-isnt-solution/">Walmart insulin</a> follow a similar pattern by subtly encouraging people with diabetes to make fraught choices while deflecting focus on systemic changes that would improve their lives. </p>
<h2>The limits of ‘human’ insulin</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/298212/original/file-20191022-55685-jfknkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298212/original/file-20191022-55685-jfknkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298212/original/file-20191022-55685-jfknkt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298212/original/file-20191022-55685-jfknkt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298212/original/file-20191022-55685-jfknkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298212/original/file-20191022-55685-jfknkt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298212/original/file-20191022-55685-jfknkt.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">A man pricks his finger to draw blood so he can determine his blood sugar levels, an important part of managing diabetes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-taking-blood-sample-lancet-pen-716756734?src=NNZzETx3yFUG8iagFcmcBQ-1-9">Africa Studio</a></span>
</figcaption>
</figure>
<p>Walmart sells older versions of “human” insulin, which were once the best option for staying well. “Human” insulin is a synthetic substance that is engineered through <a href="https://www.britannica.com/science/recombinant-DNA-technology">recombinant DNA</a> technologies to mimic insulins produced by the body. These insulins were widely used from the early <a href="https://www.diabetes.co.uk/insulin/history-of-insulin.html">1980s until the mid-1990s</a>. They differ from newer “analog” insulins, which absorb more quickly and give people with diabetes greater control over their bodies.</p>
<p>People who resort to Walmart insulins, especially those who transition to it after years of using analogs, often struggle with the lack of flexibility and more precise timing required when using older forms of the substance. If insulin does not absorb quickly enough, it leaves <a href="https://www.doi.org/10.1001/jamainternmed.2018.3332">people imperiled</a>. </p>
<p>This is exactly what happened to 27-year-old <a href="https://www.washingtonpost.com/local/he-lost-his-insurance-and-turned-to-cheaper-form-of-insulin-it-was-a-fatal-decision/2019/08/02/106ee79a-b24d-11e9-8f6c-7828e68cb15f_story.html">Josh Wilkerson</a> this past summer. The Washington Post reports that after aging out of his parent’s insurance, Wilkerson transitioned to Walmart insulin to afford treatment. But the older insulin did not take. He suffered multiple strokes, went into a coma and eventually died. His blood sugar was reported to be 17 times higher than normal. </p>
<p>Although it is difficult to assess how many people have experienced complications from adopting these insulins, we do know that the <a href="https://care.diabetesjournals.org/content/41/6/1299">price of analogs continues to rise</a>, as do <a href="https://www.nih.gov/news-events/news-releases/rates-new-diagnosed-cases-type-1-type-2-diabetes-rise-among-children-teens">rates of diabetes</a>. As such, the number of people pursuing Walmart insulin as an alternative is likely to increase. </p>
<p>Of course, changes to a lifesaving medication like insulin should be made in consultation with a physician. But access to medical care holds the same challenges that prescriptions do. <a href="https://www.washingtonpost.com/outlook/2019/02/19/drug-prices-are-killing-diabetics-walmart-insulin-isnt-solution/">It requires money and time</a>. </p>
<p>And if people are transitioning to Walmart insulin, <a href="http://www.startribune.com/counterpoint-legislators-should-make-insulin-policy-not-give-medical-advice/562563552/">they likely don’t have either of those</a>. </p>
<h2>Medical memes and bad advice</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/298211/original/file-20191022-55712-1634olu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298211/original/file-20191022-55712-1634olu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298211/original/file-20191022-55712-1634olu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298211/original/file-20191022-55712-1634olu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298211/original/file-20191022-55712-1634olu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298211/original/file-20191022-55712-1634olu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298211/original/file-20191022-55712-1634olu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Each person with diabetes is different, and he or she should work with a health care professional to make sure he or she has the correct insulin dose and type.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-africanamerican-woman-using-digital-glucometer-1341884993?src=XBWyvf26jiANYJib9nanUg-2-13">Africa Studio/Shutterstock.com</a></span>
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</figure>
<p>With November being Diabetes Awareness Month, the occasion offers us an opportunity to be more aware of the medical advice we post to social media. Those who share information about these older insulins are inadvertently putting the onus on people with diabetes to stay well, even as such insulins are not effective for everyone. <a href="https://www.t1international.com/blog/2018/06/01/t1international-statement-ada-insulin-access-paper/">Diabetes advocates</a> have repeatedly warned about the limitations of Walmart insulin but such messages continue to circulate unabated. </p>
<p>These memes regularly appear on my own social media, but they are never accompanied by a critique of insulin prices, the health care industry or the alleged price-gouging <a href="https://www.npr.org/sections/health-shots/2018/11/28/671659349/we-re-fighting-for-our-lives-patients-protest-sky-high-insulin-prices">practices</a> of pharmaceutical companies. In my analysis, these posts suggest that insulin is accessible, and if a person with diabetes does not pursue a cheaper option, it’s their fault, not the fault of opportunistic insulin manufacturers. </p>
<p>I believe Walmart insulin magnifies a <a href="https://www.usnews.com/news/health-care-news/articles/2018-11-20/study-insulin-access-will-decrease-by-2030-as-diabetes-spreads">class-based system of health care access</a>, where people with insurance or money can access insulins that others cannot. Advocates like <a href="https://twitter.com/Kidfears99/status/1183434674217066498">Laura Marston</a> contend that the U.S. is the only developed country that pushes patients to utilize antiquated insulins rather than work to make analogs available. </p>
<p><a href="https://www.bbc.com/news/world-us-canada-47491964">Policy experts</a> who study insulin contend that the best way to help people with diabetes is to cap the amount that can be charged for analogs. Colorado has recently moved to do just that, though the law <a href="https://www.t1international.com/blog/2019/07/09/colorados-insulin-price-cap-foundation-build-upon/">does not appear to cover everyone</a>. Two of the three corporations that manufacture analog insulin claim they are moving toward generics, but those are <a href="https://www.ft.com/content/7e19cd4c-b94a-11e9-8a88-aa6628ac896c">yet to have any effect</a> on the market and are still four times more expensive than analogs sold in Canada. </p>
<p>When I was diagnosed, a nurse educator warned me to watch what advice I take from people. Everyone thinks they know something about diabetes because everyone knows someone who lives with, or died from, the disease. Conversations about Walmart insulin reproduce this logic by subtly suggesting that people who do not live with the condition have vital information about the disease that people with diabetes do not. People like me know what we need to live: insulin. And if we know there are better forms of the medicine that would keep more of us alive, why not advocate for those possibilities? </p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/125528/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey Bennett 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 provides an opportunity to look at the messaging around Walmart insulin, touted as a solution to soaring insulin prices. Cheaper insulins may not work as well for many people.Jeffrey Bennett, Associate Professor of Communication Studies, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1159782019-05-30T22:44:20Z2019-05-30T22:44:20ZGestational diabetes in the mother increases Type 1 and Type 2 diabetes risks for the whole family<figure><img src="https://images.theconversation.com/files/276152/original/file-20190523-187172-92y0cv.jpg?ixlib=rb-1.1.0&rect=0%2C120%2C6689%2C4094&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New research shows that diabetes is a family affair. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>You probably know someone with diabetes, as it is an increasingly common disease. In 2017, <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html">more than 425 million adults were living with diabetes, and more than 1,106,500 children were living with Type 1 diabetes</a>, globally. </p>
<p>There are <a href="https://www.diabetes.ca/diabetes-basics/what-is-diabetes">three common types of diabetes</a>. In Type 1, the body’s immune system attacks the cells that make insulin, the hormone that gets blood sugar (our body’s fuel) where it needs to go. In Type 2, the body makes insulin but the insulin cannot do its job. In both cases, blood sugar levels go up. </p>
<p>A third kind of diabetes, gestational diabetes, is temporary during pregnancy. However, our recent studies show that diabetes in one family member is related to diabetes in other family members. </p>
<p>Gestational diabetes in mothers is linked to future diabetes not only in the mothers themselves, but <a href="https://doi.org/10.1093/aje/kwx263">also in their partners</a> and <a href="https://doi.org/10.1503/cmaj.181001">children</a>.</p>
<h2>Couples share diabetes risk</h2>
<p>In most cases, Type 2 and gestational diabetes are related not only to genetics, but also to <a href="https://doi.org/10.1007/s10654-016-0176-0">lower physical activity</a> and <a href="https://doi.org/10.1093/aje/kwx095">less healthy ways of eating</a>. Improving eating and activity can <a href="https://doi.org/10.1007/s11892-003-0034-9">cut Type 2 diabetes risk by half</a>. A lot of studies have shown that many women with gestational diabetes go on to develop Type 2 diabetes in the <a href="https://doi.org/10.1016/S0140-6736(09)60731-5">decade after pregnancy</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.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">Couples often follow the same lifestyle patterns.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>We looked at data from about 70,000 couples who were parents in Quebec. We found that if the mother had gestational diabetes, the father was 20 per cent more likely to develop Type 2 diabetes in the <a href="https://academic.oup.com/aje/article/186/10/1115/3896096">10 years after pregnancy</a>. </p>
<p>If the mother had both gestational diabetes and gestational hypertension — temporary high blood pressure during pregnancy — the father was 80 per cent more likely to develop Type 2 diabetes in the future. </p>
<p>Couples share <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2091401">physical activity, eating</a> and <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa066082">weight patterns</a>. We think that is why they share diabetes risk. </p>
<p>It’s time to share action: to improve health behaviours together and try to prevent diabetes development in the future.</p>
<h2>What about the kids?</h2>
<p>We had information on the children of the couples we studied, from birth to 22 years old. More than <a href="https://www.childhealthbc.ca/sites/default/files/10%2010%2018%20Status%20Report%20on%20the%20BC%20Pediatric%20Diabetes%20Program%20(Final).pdf">90 per cent of diabetes</a> that starts before the age of 22 in most Canadian provinces is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933641/">Type 1, not Type 2</a>. </p>
<p>The exception is Manitoba where there are many <a href="https://www.aadnc-aandc.gc.ca/eng/1100100020400/1100100020404">Indigenous Canadians</a>, an established <a href="https://guidelines.diabetes.ca/docs/cpg/Ch38-Type-2-Diabetes-and-Indigenous-Peoples.pdf">link with diabetes</a> and a <a href="https://doi.org/10.1016/j.jcjd.2012.04.013">high occurrence of Type 2 in young people</a>. </p>
<p><a href="http://care.diabetesjournals.org/content/39/12/2240.long">Studies from Manitoba</a> show a link between <a href="https://jamanetwork.com/journals/jamapediatrics/article-abstract/2684232">gestational diabetes in mothers and Type 2 in kids</a>. One study in Sweden showed a link between having either Type 2 or gestational diabetes in the mother and the <a href="https://link.springer.com/article/10.1007/s00125-015-3580-1">development of Type 1 in the kids</a>.</p>
<p>We found that between birth and 22 years, the kids of mothers with gestational diabetes were <a href="https://doi.org/10.1503/cmaj.181001">twice as likely to develop Type 1 diabetes</a>. If you had 5,000 young people whom you watched for two years, our results indicate that two of them would develop Type 1 if their mom did not have gestational diabetes. Four or five would develop Type 1 if their mom did have gestational diabetes. So it is rare, but it is important. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A small percentage of children whose mother had gestational diabetes will go on to develop Type 1 or Type 2 diabetes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>A study also from Quebec shows that one quarter of young people who develop Type 1 <a href="https://doi.org/10.1503/cmaj.170676">come to the hospital in a medical crisis</a> the first time they are diagnosed. The early signs of Type 1 may be missed: being really thirsty, having to urinate more often, a bit of blurry vision, some fatigue you can’t explain. </p>
<p>Understanding the link with gestational diabetes might be another useful piece of the puzzle — to push young people, their families and their healthcare providers to consider the possibility of diabetes, just as they do when their parents are known to have Type 1 or Type 2. </p>
<h2>Gestational diabetes is a family affair</h2>
<p>We don’t yet know why there is a link between gestational diabetes in mothers and Type 1 in young people. The important thing to remember though is that gestational diabetes is a family affair. </p>
<p>Future Type 2 diabetes can be prevented in many family members within the home environment — by eating more home-cooked healthy meals and lots of fruits and vegetables, by reducing fried foods and eating out and with a whole family emphasis on being active. </p>
<p>Type 1 diabetes, though rare, might also be diagnosed earlier in kids and teens, with an awareness of the link to mom’s gestational diabetes.</p>
<p>Finally, we need greater effort at the public health and policy levels to build awareness of diabetes risk and to support community-based diabetes prevention programs.</p><img src="https://counter.theconversation.com/content/115978/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaberi Dasgupta 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>Many couples share exercise, eating and weight patterns. Families of women with gestational diabetes and gestational hypertension more likely to develop Type 2 diabetes in the future.Kaberi Dasgupta, Professor of Medicine, McGill University; Physician-Scientist and Director of the Centre for Outcomes Research and Evaluation at the McGill University Health Centre, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1172492019-05-28T01:40:13Z2019-05-28T01:40:13ZFlash glucose monitoring: the little patches that can make managing diabetes a whole lot easier<p>Diabetes is the <a href="https://www.diabetesaustralia.com.au/diabetes-in-australia">fastest growing chronic condition</a> in Australia. At least 1.2 million Australians live with diabetes, and about 10% of them have type 1 diabetes.</p>
<p>Diabetes sees the <a href="https://www.diabetesaustralia.com.au/type-2-diabetes">body become resistant</a> to the effects of insulin, or lose its ability to produce insulin from the pancreas. Insulin keeps the body’s blood glucose levels, or “blood sugar”, within a healthy range. Everyone with type 1 diabetes, and some people with type 2 diabetes, will need to self-administer regular insulin injections.</p>
<p>People with diabetes, particularly type 1, must continually monitor their blood glucose levels to manage their condition. Over the years, a number of different innovations have allowed people to do this. </p>
<p>The most traditional method is finger prick testing, which requires a person to prick their finger to draw a drop of blood. They test the blood on a strip that’s inserted into a blood glucose testing device, and must do this several times a day. This technique can be painful and disruptive.</p>
<p>But now we have a new and exciting tool that can help ease this burden for people living with type 1 diabetes. It’s called the flash glucose monitoring system.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/between-health-and-faith-managing-type-2-diabetes-during-ramadan-115469">Between health and faith: managing type 2 diabetes during Ramadan</a>
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</em>
</p>
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<h2>What is it?</h2>
<p>Flash glucose monitoring was first introduced in Europe in 2014, and has been <a href="https://www.freestylelibre.com.au/ndss">available in Australia since 2016</a>.</p>
<p>This glucose monitoring system involves a small, water-resistant sensor applied to the back of the upper arm. The technology automatically measures and continuously stores tissue glucose levels 24 hours a day. The patch only needs to be changed once every two weeks.</p>
<p>The devices are suitable for adults and children over the age of four who have diabetes that requires insulin. This includes the 120,000 people living with type 1 diabetes and a sizeable portion of people living with type 2 diabetes. </p>
<p>To gain a reading, a reader or compatible smartphone is simply scanned over the sensor for one second. The reader or the smartphone then displays the current glucose reading, a glucose trend arrow (indicating whether a person’s blood sugar has gone up or down) and a chart showing glucose levels over the previous eight hours.</p>
<h2>What are the benefits?</h2>
<p>Flash glucose monitoring gives people living with diabetes a chance to see the full picture of their glucose levels that is not possible with traditional blood glucose test strips.</p>
<p>Patients also have the option to share their readings with their health-care providers, giving them deeper insights to make more informed treatment decisions.</p>
<p>One of the most beneficial things is that it is discreet and allows people living with diabetes to keep an active lifestyle while maintaining their blood glucose levels within safe ranges.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-5-diabetes-57874">How Australians Die: cause #5 – diabetes</a>
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</em>
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<p><a href="https://www.prnewswire.com/news-releases/new-real-world-evidence-analysis-of-nearly-half-a-million-freestyle-libre-system-users-shows-higher-rates-of-scanning-improves-glucose-control-300799635.html">Global data</a> suggests users of flash glucose monitoring check their glucose levels on average 12 times per day, which is considerably more than the number of finger prick tests most people are doing. </p>
<p>More scans give people a stronger awareness of their blood glucose highs, lows and trends, resulting in better overall blood glucose control and a lower risk of recording a severely low blood glucose level.</p>
<h2>This technology needs to be more accessible</h2>
<p>Outgoing <a href="https://www.huffingtonpost.co.uk/entry/theresa-mays-arm-at-blenheim-palace-diabetic-patches_uk_5b485908e4b0bc69a785e1b2">British PM Theresa May</a> has been seen wearing a flash glucose monitoring device. Closer to home, <a href="https://beyondtype1.org/paddy-mccartin-interview/">AFL footballer Paddy McCartin</a> has brought awareness to diabetes by wearing his on the football field.</p>
<p>But attaining subsidised flash glucose monitoring devices remains a challenge for everyday Australians. People have to pay for it out of pocket, which adds up to <a href="https://www.freestylelibre.com.au/glucose-monitoring-system/sensor">approximately A$2,400 a year</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276524/original/file-20190527-40055-ptd20y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276524/original/file-20190527-40055-ptd20y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276524/original/file-20190527-40055-ptd20y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276524/original/file-20190527-40055-ptd20y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276524/original/file-20190527-40055-ptd20y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276524/original/file-20190527-40055-ptd20y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276524/original/file-20190527-40055-ptd20y.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">People with diabetes have traditionally needed to prick their fingers to measure their blood glucose levels. This is now changing.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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</figure>
<p>And this cost is only a fraction of the financial burden a person with diabetes has to face. Other expenses can include maintaining their insulin pump, and appointments with endocrinologists, diabetes educators, optometrists, podiatrists, psychologists and general practitioners.</p>
<p>Right now, flash glucose monitoring is not on the National Diabetes Services Scheme <a href="https://www.ndss.com.au/product-and-supply">product list</a>, which means it’s not subsidised by the government. While traditional forms of blood glucose monitoring are subsidised, people who would benefit from flash glucose monitoring are largely not able to access it.</p>
<p>Flash glucose monitoring was <a href="https://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-hunt160.htm?OpenDocument&yr=2018&mth=11">supposed to be subsidised</a> from March 1 2019 for select groups, such as people under 21, expectant mothers and breastfeeding women. But nothing has come of it. According to the <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/health-pbs-healthpro-cgm.htm">Department of Health</a>, this is due to ongoing price negotiations.</p>
<p>Funding flash glucose monitoring devices has been seen as a priority in other parts of the world. It’s currently subsidised in <a href="https://www.freestylelibre.com.au/ndss">more than 30 countries</a>, including Spain, Ireland and Greece.</p>
<p>Diabetes Australia <a href="https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/1de588a0-4570-489e-867d-ae3e6e6890e4.pdf">supports the subsidy</a> of this technology to make it more accessible for people with diabetes.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-diabetes-11842">Explainer: what is diabetes?</a>
</strong>
</em>
</p>
<hr>
<h2>The bigger picture</h2>
<p>If patients don’t properly manage their diabetes, they risk heart disease, kidney failure, loss of vision and amputations. All of these complications require extensive health investments, but are avoidable with the right resources.</p>
<p>So subsidising a technology that’s going to help more people better manage their diabetes is worthwhile not just for the people that will see positive impacts in their day-to-day lives. This is an important investment on a broader scale.</p><img src="https://counter.theconversation.com/content/117249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria Craig 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>A small patch allows people with diabetes to measure their blood glucose levels easily. But this technology isn’t currently subsidised, so many everyday Australians who could benefit are missing out.Maria Craig, Professor University of Sydney and University of NSW Paediatric Endocrinologist, Children's Hospital at Westmead, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1030782018-09-26T15:47:46Z2018-09-26T15:47:46ZMapping the 100 trillion cells that make up your body<figure><img src="https://images.theconversation.com/files/236476/original/file-20180914-177941-1ptbf18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">University of Florida scientists will be analyzing every cell in the pancreas, among other organs, to understand the roots of Type 1 diabetes.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/human-body-organs-anatomy-pancreas-3d-1007278972?src=Ah7D5mSmYq7n40vTfLHLxg-1-0">Magic mine/Shutterstock.com</a></span></figcaption></figure><p>There are about 100 trillion cells that make up the human body. A new megascience endeavor will catalog and image each of the 200 or more types of cells from the 80 known organs and identify the genes that are active in these cells. </p>
<p>This new effort follows on the heels of the Human Genome Project that engulfed biology during the 1990s and early 2000s. Now scientists have conceived a new and exciting challenge: to create a cellular map of the entire human body, a project called the <a href="https://commonfund.nih.gov/HuBMAP">Human BioMolecular Atlas Program</a>, or HuBMAP. The University of Florida is one of five participating tissue mapping centers. Here at the UF Center we are charged with mapping the thymus, lymph node, and spleen – all key components of the immune system. </p>
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<span class="caption">The lymphatic system, which includes the thymus (yellow), spleen (brown) and lymph nodes connected by the lymphatic vessels (green), will be the subject of investigation for University of Florida’s HuBMAP investigators.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/illustration-female-body-lymphatic-system-307275149?src=DCjvNsEJeA8WZFTBVmmHAw-1-32">S K Chavan/Shutterstock.com</a></span>
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<p>I have been studying Type 1 diabetes, or juvenile diabetes, for nearly 35 years and along with my other colleagues at the <a href="https://diabetes.ufl.edu">UF Diabetes Institute</a> have been trying to find a way to prevent and cure the disease. This has been a challenge as until recently, because we didn’t know what caused Type 1 diabetes. </p>
<p>Our goal as a tissue mapping center is to identify the unique types of cells, which proteins they produce and which genes are turned on, and build a virtual three-dimensional model of each organ. This map will inform the research of many diseases, including Type 1 diabetes.</p>
<h2>Why is understanding the causes of Type 1 diabetes important?</h2>
<p>We know that Type 1 diabetes is a so-called “autoimmune disorder.” In Type 1 diabetes, immune cells known as “T lymphocytes” are thought to destroy the pancreatic beta cells that are responsible for producing insulin, which regulates the level of sugar in our blood. </p>
<p>Just over a decade ago, frustrated by the inability to prevent and cure the disease, I started an initiative to collect human pancreases from organ donors with Type 1 diabetes as well as those without the disease. The latter group was collected to provide an understanding of a “normal” healthy pancreas. To date, we have collected the pancreas from more than 500 individuals. We have distributed these tissues to some 230 projects in 21 countries around the world. The results of this effort have led to new discoveries that have rewritten our understanding about how this disease develops. </p>
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<span class="caption">Diabetes mellitus Type 1. Type 1 diabetes occurs when the immune system erroneously destroys the insulin-producing beta cells in the pancreas, which leads to high glucose levels in the blood, called hyperglycemia. Though Type 1 diabetes represents only 10 percent of all diabetes worldwide, it is most often diagnosed in children and adolescents; hence, patients face a lifelong need for insulin. At onset, patients generally experience high blood sugar, unexplained weight loss, and excessive thirst and hunger. Even with appropriate treatment, most patients eventually develop complications affecting the kidneys, feet, eyes and cardiovascular health.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/diabetes-mellitus-type-1-health-problems-335420627?src=FYRUEW1wt76O1GCRlQuFCQ-1-17">Designua/Shuterstock.com</a></span>
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<p>Patients diagnosed with Type 1 diabetes, some <a href="http://www.diabetes.org/diabetes-basics/statistics/">25,000</a> per year in the U.S. alone, face a lifelong dependence on daily insulin injections in order to survive and have a high risk of developing <a href="http://www.diabetes.org/living-with-diabetes/complications/">long-term medical complications</a> including blindness, kidney disease, numb feet, limb amputations and cardiovascular disease. Today, it is estimated that nearly <a href="http://www.diabetes.org/diabetes-basics/statistics/">1.25 million people</a> in the U.S. live with this disorder. </p>
<p>As upsetting as these complications are for individuals with the disease, perhaps even more daunting are the many daily lifestyle factors that must be controlled or accounted for to keep the disease in check: monitoring carbohydrates, estimating exercise, evaluating blood sugar levels, and administering insulin to avoid both high and low blood glucose levels. These represent just a few of the daily disease associated challenges.</p>
<p>For these reasons, the goal of our collective research efforts at the UF Diabetes Institute has always been to understand what causes this disease. Knowing that would enable us to predict who is at risk, identify ways to prevent the progression of the disease, and develop a curative therapy.</p>
<h2>Why study these organs?</h2>
<p>Type 1 diabetes is but one of more than 80 known autoimmune diseases that, for reasons unknown, the immune system turns against itself. Beyond autoimmunity, immune responses are also a key constituent to health in terms of fighting cancer and infectious disease. From our experience studying the pancreas and Type 1 diabetes, we see great strides in understanding the role for immunity in each of these settings through mapping. It will allow for a deep dive of how the immune system works. </p>
<p>In a healthy individual, T cells only become active when responding to infection or cancer cells. But in those predisposed to autoimmune disease, certain T cells can become erroneously activated by “self” proteins, leading them to destroy healthy tissue. </p>
<p>In other circumstances – like cancer or infectious disease – the immune system fails to provide a robust enough response to be effective. Or cells of the immune system proliferate uncontrollably, leading to blood and lymphatic cancers like lymphomas and leukemias. This is why the thymus, spleen and lymph node are tissues of interest for those studying the healthy human immune system. Researchers need to understand the healthy baseline for all these organs so that we can recognize when things begin to malfunction and change, leading to autoimmune disease, cancer and infectious disease. Expressed another way, we first need to understand what constitutes the normal lymphatic system throughout the human lifespan.</p>
<h2>Why is defining normal important?</h2>
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<figcaption><span class="caption">Harry Nick of the University of Florida describes HuBMAP.</span></figcaption>
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<p>You might wonder where exactly we get these normal cells. As we have done over the past 11 years, we will obtain transplant-grade human tissues from deceased organ donors through <a href="https://www.organdonor.gov/awareness/organizations/local-opo.html">Organ Procurement Organizations</a>, after a family member or legal executor provides informed consent. Given at a time of grieving, these precious anatomical gifts, which in the case of spleen, thymus and lymph node, are not usable for lifesaving transplantation procedures, provide an inimitable resource for scientific investigation and discovery. </p>
<p>Only tissues considered “normal” – unaffected by known or observable pathologies – will be included in these initial studies. We will be collecting tissues from donors ranging from infants to adults up to 70 years old. We hope this will provide insights into how age alters the types and health of all the cells in each organ. </p>
<p>At the UF Diabetes Institute a multidisciplinary team including cellular and molecular biologists, hematopathologists who study clinical lymphatic samples, biomedical engineers, immunologists and many others will collaborate for the HuBMAP program. Indeed, the UF tissue mapping center will collaborate extensively with a global network of experts in cutting-edge microscopy and data collection. </p>
<p>We are establishing an imaging pipeline to detect dozens of protein and RNA molecules that characterize nerve, blood vessel, the supportive tissue known as stroma, and immune cells from slices of tissue, using eight different forms of microscopy. </p>
<p>Within HuBMAP’s first two years, we plan to map the spleen, thymus and lymph node from 11 organ donors. </p>
<p>We expect that the resulting data will reveal new cell types, molecular and cellular structures, cell-cell interactions and their functional implications in human anatomy and physiology. Hence, the high-resolution, three-dimensional Human BioMolecular Atlas Program is expected to facilitate discovery.</p>
<p>As I hit my late 50s in life, the number of colleagues, friends and family members that are impacted by disease increases annually. I also recently became a grandfather. I would like to think what we propose to do will have a dramatic impact on human health for both current and future generations. That would be a legacy gift.</p><img src="https://counter.theconversation.com/content/103078/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Atkinson receives funding from the National Institutes of Health, JDRF, American Diabetes Association, and The Leona M. and Harry B. Helmsley Charitable Trust. He is the President of Insulin for Life-USA, a not-for-profit organization seeking to provide type 1 diabetes management supplies to those in need. </span></em></p>First, scientists wanted to decode all three billions units of the human genome. Now, a new effort will identify all the cell types in the human body to discover the roots of diseases, like diabetes.Mark Atkinson, Professor of Medicine , University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1004162018-07-24T16:10:04Z2018-07-24T16:10:04ZDiabetes: the good news and the bad news – and what next for the future<figure><img src="https://images.theconversation.com/files/229035/original/file-20180724-194134-e5ci51.jpg?ixlib=rb-1.1.0&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/little-happy-cute-boy-eating-donut-632097332">Shutterstock</a></span></figcaption></figure><p><a href="https://www.theguardian.com/society/2011/oct/10/diabetes-the-epidemic">Alarming stories</a> about the <a href="https://www.diabetes.org.uk/diabetes-the-basics">diabetes</a> epidemic that threatens millions of lives – and the NHS itself – have become commonplace, and with good reason. Around 4.6m people in the UK are living with diabetes while a further 12.3m are at increased risk of developing it. The NHS spends an estimated £14 billion a year on treating diabetes and its <a href="https://www.diabetes.org.uk/be-in-the-know-healthcare-essentials?gclid=EAIaIQobChMIo_Pgwc613AIVArTtCh3wEAweEAAYASAAEgLSmPD_BwE">complications</a>.</p>
<p>But there is some positive news amid the gloom. I chaired the 2018 <a href="http://wcpd10.com/">World Congress on Prevention of Diabetes and its Complications</a>, where experts from around the world came together to discuss progress in both science and prevention programmes.</p>
<h2>Type 1: preventable?</h2>
<p>Sometimes known as juvenile diabetes due to the age patients are normally diagnosed, type 1 is an <a href="https://www.healthline.com/health/autoimmune-disorders">autoimmune disease</a> that attacks insulin-producing cells, leaving patients facing a lifetime of injections and deteriorating health. Improved care has focused on the ways that insulin is delivered and on minimising the impact of health complications on daily life. Scientists are now more convinced than ever that this type of diabetes can be <a href="https://jdrf.org.uk/our-research/about-our-research/prevent/?gclid=EAIaIQobChMIlYD-wdi13AIVluFRCh15sAxdEAAYAiAAEgLtFfD_BwE">prevented</a>. Although type 1 diabetes is only 5% of all diabetes, it still accounts for tens of thousands of patients who face health challenges every day and require a lifetime of medical support. The impact of prevention of type 1 diabetes would be significant.</p>
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<p>The two breakthroughs that underlie this new optimism relate to early detection and prevention therapy. The genetic risk of type 1 diabetes is becoming clearer, and we now have the ability to measure a range of blood factors that appear during the early stages of the disease. Which means we are developing tools to identify those most likely to develop diabetes.</p>
<p>From there, we now have real hope that <a href="https://www.newscientist.com/article/2143414-type-1-diabetes-may-be-halted-by-experimental-immunotherapy/">immunotherapy</a> can stop the insulin-producing cells being destroyed. This covers a range of treatments – including vaccination – designed to change the way a person’s immune system works. The important thing is to find a therapy that specifically shuts off the part of the immune system that attacks the insulin-producing cells, leaving the rest of the defence system intact. Fears that immunotherapy would be too toxic and non-specific for children are being <a href="https://www.diabetes.org.uk/research/research-round-up/immunotherapy-shown-to-be-safe-in-people-with-type-1">challenged by evidence</a> in clinical trials. These have shown that the therapy can be safe, and encouragingly, have shown signs of slowing down the progress of the disease.</p>
<h2>Type 2: devastating</h2>
<p>This is the most common form of the disease, directly related to obesity and other lifestyle factors. Type 2 diabetes is devastating; within five to ten years patients could lose their kidneys, eyes, or legs. They may suffer cardiovascular and <a href="https://www.diabetes.org.uk/resources-s3/2017-11/diabetes-key-stats-guidelines-april2014.pdf">other deadly diseases</a> linked to diabetes.</p>
<p>Since roughly <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf">four out of every five</a> people with diabetes are overweight, the most effective single way to prevent the disease is to avoid weight gain. For 20 years, Finland, US and Australia have conducted diabetes prevention programmes to encourage lifestyle changes, and they are seeing <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539613/">positive results</a> in the health of their nations.</p>
<p>Many countries with very high levels of type 2 have followed suit. This involves “<a href="https://theconversation.com/nudge-can-make-us-healthier-even-if-its-a-bit-1984-25339">encouraging</a>” people to agree to alter habits of a lifetime, and then provide years of support to maintain physical activity and improve their diet.</p>
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<img alt="" src="https://images.theconversation.com/files/229037/original/file-20180724-194152-8lto2a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229037/original/file-20180724-194152-8lto2a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229037/original/file-20180724-194152-8lto2a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229037/original/file-20180724-194152-8lto2a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229037/original/file-20180724-194152-8lto2a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229037/original/file-20180724-194152-8lto2a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229037/original/file-20180724-194152-8lto2a.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">People with diabetes need support to change the habits of a lifetime.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fast-food-228099592">Shutterstock</a></span>
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<p>However, this alone may only reach around half of all type 2 diabetes, so these countries are increasingly targeting the <a href="https://www.bbc.co.uk/news/blogs-magazine-monitor-27601593">obesogenic environment</a> that makes it easy to put on weight and hard to lose it. This starts with talking to the <a href="https://theconversation.com/time-for-business-to-deal-with-its-costly-sugar-problem-34767">food industry</a>, but also has to include legislation to reduce the impact of the most damaging aspects of our diet. A <a href="https://theconversation.com/when-it-comes-to-sugary-drinks-people-prefer-a-nudge-than-a-tax-58617">sugar tax</a> has already been introduced in many countries and we’ll learn very soon how effective it is in reducing diabetes and its health problems.</p>
<p>The Scottish government was met with <a href="https://www.thescottishsun.co.uk/news/2651941/scot-minimum-alcohol-pricing-cider/">tabloid fury</a> and <a href="https://www.economist.com/britain/2018/03/01/scotlands-minimum-price-for-alcohol-may-have-unexpected-effects">corporate lobbying</a> over its <a href="http://www.gov.scot/Topics/Health/Services/Alcohol/minimum-pricing">Minimum Unit Pricing</a> for alcohol and <a href="https://www.thetimes.co.uk/article/michael-glackin-snps-war-on-all-you-can-eat-buffets-will-do-families-a-fat-lot-of-good-j385x6w80">recent plans</a> relating to 2-for-1 pizzas and “all you can eat” buffets. These measures are never popular but they are <a href="https://theconversation.com/britains-drinking-habits-revealed-new-figures-95667">increasingly necessary</a>. Taxes and subsidies can help reset the balance between the cost of healthy and unhealthy food. Making high-fat and high-sugar foods more expensive could help to increase demand for healthy alternatives and consequently reduce price. </p>
<h2>Preventing complications</h2>
<p>People don’t drop dead because they develop diabetes. They can live for decades with the condition, but quality of life is another matter. Type 2 diabetes prevention programmes should also include people who already have the disease.</p>
<p>Lifestyle changes can slow progression and reduce serious health issues, and, in some cases, even reverse the disease. For many, strictly following a low-calorie diet immediately after a diagnosis can put type 2 <a href="https://www.diabetes.org.uk/research/research-round-up/research-spotlight/research-spotlight-low-calorie-liquid-diet">in remission</a>. But its success depends on individual commitment, so there needs to be support to help each person achieve this difficult goal, and then maintain the lifestyle to prevent the disease returning.</p>
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<img alt="" src="https://images.theconversation.com/files/229039/original/file-20180724-194131-18b1a5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229039/original/file-20180724-194131-18b1a5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229039/original/file-20180724-194131-18b1a5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229039/original/file-20180724-194131-18b1a5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229039/original/file-20180724-194131-18b1a5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229039/original/file-20180724-194131-18b1a5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229039/original/file-20180724-194131-18b1a5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&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">A low-calorie diet with lots of fresh fruit and vegetables can help put type 2 diabetes into remission.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/green-purple-fresh-juices-smoothies-fruit-519988807">Shutterstock</a></span>
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<p>The possibility of developing immunotherapy to prevent type 1, and proving that type 2 can be sent into remission, are the two most exciting developments in diabetes research for many years. </p>
<p>If it was possible to prevent at least half of type 2 cases – which we believe can be done by changing lifestyle and environmental factors – then the amount spent treating diabetes and its complications could be halved. That’s billions freed up for the NHS. Most importantly, it would improve patients’ quality of life and life expectancy.</p>
<p>The link between cheap, sugary and fatty food and obesity and type 2 diabetes is indisputable. The healthy/unhealthy food cost ratio has to change because the evidence is that education – while valuable – is not enough by itself. The <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002283">evidence</a> from many countries shows that in most chronic, lifestyle-related diseases, legislation is faster and often more effective.</p>
<p>The apocalyptic scenarios often painted are not inevitable, but they are likely if we carry on as we are. People need to accept some hard truths about their lifestyle, and bold political leadership is needed to make unpopular decisions for the benefit of the nation’s health.</p><img src="https://counter.theconversation.com/content/100416/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Calum Sutherland receives funding from the Medical Research Council and Diabetes UK to support research into the causes of all forms of diabetes and its health complications.</span></em></p>The diabetes epidemic can be fought through new therapies, prevention programmes and effective junk food legislation.Calum Sutherland, Reader School of Medicine, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/958332018-05-24T09:09:36Z2018-05-24T09:09:36ZDo you get diabetes from eating too much sugar?<figure><img src="https://images.theconversation.com/files/217298/original/file-20180502-153881-1ju4b7r.jpg?ixlib=rb-1.1.0&rect=0%2C34%2C1000%2C634&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/583235083?src=1Pw-3Dlta8VWxTGf4z-aEw-1-46&size=medium_jpg">Maria Uspenskaya/Shutterstock.com</a></span></figcaption></figure><p>There is widespread belief that sugar is the sole cause of diabetes. After all, the disease is characterised by <a href="https://academic.oup.com/jcem/article-abstract/44/5/859/2677214">high levels of sugar in the blood</a>. </p>
<p>Diabetes was first identified through the sweet smell of urine, and it later became apparent that sweet, <a href="http://annals.org/aim/article-abstract/694725/correlation-between-plasma-urine-glucose-diabetes">sugary urine</a> signified a high level of blood sugar. Over time, diabetes treatment has swung from eating primarily sugar (to replace what is lost), to <a href="http://www.hormones.gr/pdf/Hormones_2014-2_296.pdf">avoiding sweetness</a> (to limit high sugar levels). </p>
<p>Today, the debate on amounts and thresholds of sugar and their role in diabetes seems as fierce as ever.</p>
<p>Type 1 diabetes is an autoimmune disease, where genetics and environmental factors interact. Some research suggests that sugar intake may <a href="https://link.springer.com/article/10.1007/s00125-015-3657-x">play a role</a> in the development of type 1 diabetes, but the research isn’t conclusive.</p>
<p>For type 2 diabetes, a diet high in sugar could, in principle, influence or accelerate the progression of the disease depending on the pattern of consumption. But to suggest that dietary sugar might cause or contribute to type 2 diabetes needs strong scientific evidence that demonstrates that either sugar increases body weight and body fatness (necessary for type 2 diabetes), or that sugar has some kind of unique effect that leads to 2 diabetes, irrespective of weight or body fatness.</p>
<h2>What we mean when we talk about sugar</h2>
<p>What most people understand to be sugar is sucrose: a mix of glucose and fructose. A common misunderstanding is that blood glucose is derived solely from dietary sugar. Almost all of the sugar in the body, including the blood, is in the form of glucose – one of many sugars <a href="http://www.foodinsight.org/Background_on_Carbohydrates_Sugars">belonging to the family of carbohydrates</a>. </p>
<p>Sugars typically form a small part of the diet, not all of them are <a href="https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/glycaemic-index-of-foods-containing-sugars-comparison-of-foods-with-naturallyoccurring-v-added-sugars/B849AC7B0F6C7D6EAF8D3DA086A405D7">equally effective</a> at increasing blood glucose levels, and other carbohydrates, as well as <a href="http://care.diabetesjournals.org/content/early/2016/06/22/dc16-0709">fats and protein</a>, influence glucose levels, too. </p>
<p>Animal studies show that high sugar diets lead to rapid weight gain and impair the body’s ability to effectively regulate blood glucose. But these effects are <a href="https://academic.oup.com/edrv/article/30/1/96/2355050">mainly due to the fructose</a> component of sucrose and not glucose. </p>
<p>In people, diets high in sugar have also been shown to <a href="https://jamanetwork.com/journals/jama/fullarticle/199317?version=meter%20at%20null&module=meter-Links&pgtype=Blogs&contentId=&mediaId=%25%ADID%25%25&referrer=&priority=true&action=click&contentCollection=meter-links-clickPer">increase weight</a> as well as <a href="https://academic.oup.com/ajcn/article/89/6/1760/4596803">risk factors for cardiovascular disease</a>. But these effects only seem to occur when calories are <a href="http://hyper.ahajournals.org/content/early/2012/02/13/HYPERTENSIONAHA.111.182311.short">not being controlled</a>; simply exchanging extra sugar with calories from another source <a href="https://www.ncbi.nlm.nih.gov/pubmed/2527132">won’t prevent these negative effects</a>. Also, <a href="https://academic.oup.com/ajcn/article/92/4/905/4597588">observational studies</a> have failed to show a harmful association between dietary sugar and type 2 diabetes.</p>
<p>Type 2 diabetes has arisen through rising body weights. Fatter people eat more of many things – not only sugar – and extra calories from any nutrient will lead to weight gain. Most sugary processed foods, such cakes and chocolate, contain <a href="http://pediatrics.aappublications.org/content/120/3/576.short">large amounts of fat</a> which contribute heavily to the calorie content.</p>
<h2>Nothing special about sugar</h2>
<p>Recently, the debate has turned to sugar-sweetened drinks, such as fizzy drinks. Sugars in drinks are less satiating than sugars in solid foods, and this may <a href="https://www.nature.com/articles/0801229">drive our appetite to eat more</a>. <a href="https://www.bmj.com/content/351/bmj.h3576.full">Sugary drinks</a> have been linked to type 2 diabetes, independent of body fatness. But so have <a href="https://link.springer.com/article/10.1007/s00125-015-3694-5">artificially sweetened low calorie drinks</a>. Fruit juices, though, have not been linked to type 2 diabetes despite having similar sugar contents to fizzy drinks.</p>
<p>There is nothing special about sugar that sets it apart from other foods, and sugar does not cause type 2 diabetes on its own. Generally, people eating lots of sugar tend to have <a href="https://academic.oup.com/ajcn/article/77/5/1156/4689814">poorer diets and unhealthier lifestyles</a>. These, as well as other factors including <a href="http://gh.bmj.com/content/2/4/e000473">urban growth patterns</a>, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878692/">built environment</a>, the <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1399-5448.2007.00333.x">food environment</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Psychosocial+stress+at+work+doubles+the+risk+of+type+2+diabetes+in+middle-aged+women%3A+evidence+from+the+Whitehall+II+study">stressful jobs</a>, <a href="http://care.diabetesjournals.org/content/33/2/414.short">poor sleep</a> and <a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2011.0410">food pricing</a> probably contribute more to the rising incidence of type 2 diabetes than dietary sugar.</p>
<hr>
<p><em>More on evidence-based articles about diabetes:</em></p>
<ul>
<li><p><em><a href="https://theconversation.com/avoiding-type-2-diabetes-there-is-more-than-one-diet-to-choose-from-94780?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=IsItTrue">Avoiding type 2 diabetes – there is more than one diet to choose from</a></em></p></li>
<li><p><em><a href="https://theconversation.com/newly-identified-third-type-of-diabetes-is-being-wrongly-diagnosed-as-type-2-83536?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=IsItTrue">Newly identified third type of diabetes is being wrongly diagnosed as type 2</a></em></p></li>
<li><p><em><a href="https://theconversation.com/artificial-sweeteners-linked-to-diabetes-and-obesity-95314?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=IsItTrue">Artificial sweeteners linked to diabetes and obesity</a></em></p></li>
</ul><img src="https://counter.theconversation.com/content/95833/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Campbell receives funding from industry, charity, and research councils which support research in nutrition and diabetes. There are no conflicts of interest.</span></em></p>Nutrition expert – sugar does not cause type 2 diabetes on its own.Matthew Campbell, Nutritional Science, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/661492016-10-21T09:08:40Z2016-10-21T09:08:40ZWater-retaining hydrogels – the unsung heroes of medicine<figure><img src="https://images.theconversation.com/files/142022/original/image-20161017-12431-13qfnoq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hydrogel beads.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-377290516/stock-photo-color-balls-hydrogel-beads.html?src=KSZUGGc9lGh983qfGtd6rA-1-0">Baranov E/Shutterstock.com</a></span></figcaption></figure><p>Hydrogels, materials that can absorb and retain large quantities of water, could revolutionise medicine. Our bodies contain up to 60% water, but <a href="http://www.nature.com/nmat/journal/v15/n2/full/nmat4463.html">hydrogels can hold up to 90%</a>. It is this similarity to human tissue that has led researchers to examine if these materials could be used to improve the treatment of a range of medical conditions including heart disease and cancer.</p>
<p>These days hydrogels can be found in many everyday products, from disposable nappies and soft contact lenses to plant-water crystals. But the history of hydrogels for medical applications started in the 1960s. Scientists developed artificial materials with the ambitious goal of using them in permanent contact applications – ones that are implanted in the body permanently. </p>
<h2>Drug delivery</h2>
<p>One of the most exciting clinical applications being tested is in drug delivery. People with type 1 diabetes need to constantly inject themselves with insulin in order to control their blood sugar levels. But hydrogels could dispense with that need. </p>
<p>Researchers are working on hydrogels that contain insulin which can be injected under the skin. This creates a <a href="http://www.sciencedirect.com/science/article/pii/S0142961208001002">deposit of insulin within the body</a>. Because these materials contains a large amount of water, the insulin can move from the interior of the hydrogel to the exterior producing a slow release of the hormone. When all the insulin is released, the hydrogel is naturally disposed of by the body. In this way, multiple insulin injections can be replaced with a single hydrogel injection. </p>
<p>Others have sought to get rid of the need for insulin injections by trying to develop a tablet containing insulin which can be <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0059524">taken orally</a>. One of the main challenges is that insulin tends to be destroyed in the stomach before it can reach the intestines to be absorbed into the body. Scientists are using hydrogels to try to <a href="http://www.sciencedirect.com/science/article/pii/S0168365912007596">solve this problem</a>. By creating hydrogels which can protect the insulin from the stomach acids and adhere temporarily to the walls of the intestine, the insulin can be safely absorbed into the body, removing the need for an injection.</p>
<p>The treatment of cancer can also be improved through the use of hydrogels. Chemotherapy generally involves patients attending a hospital for treatment with the medicine administered either via injection or a drip. Researchers are attempting to reduce the cost of chemotherapy and improve patients’ quality of life by exploring the use of hydrogels as a <a href="http://www.sciencedirect.com/science/article/pii/S0168365908000242">means of delivering this treatment</a> too. Similar to diabetes, researchers are investigating whether these medicines can be delivered orally. This would reduce the need for patients to attend hospital for treatment and lessen the cost of providing chemotherapy. However, as anti-cancer drugs cannot be easily dissolved in water, researchers need to find a way to improve the ability of the body to absorb these drugs when they are <a href="http://www.sciencedirect.com/science/article/pii/S0142961214004979">taken orally</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/142542/original/image-20161020-8865-kdxrlc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/142542/original/image-20161020-8865-kdxrlc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142542/original/image-20161020-8865-kdxrlc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142542/original/image-20161020-8865-kdxrlc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142542/original/image-20161020-8865-kdxrlc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142542/original/image-20161020-8865-kdxrlc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142542/original/image-20161020-8865-kdxrlc.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">Hydrogels could improve cancer patients’ quality of life.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-222626152/stock-photo-cancer-woman-lying-in-bed-supported-by-mum.html?src=4wry83NwDMIt-UiYjvcopw-1-37">ESB Professional/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Tissue repair</h2>
<p>The uses of hydrogels are not limited to drug delivery. Recently, a group of researchers from the University of Pennsylvania demonstrated how hydrogels can be used to help <a href="https://www.acs.org/content/acs/en/pressroom/newsreleases/2016/august/after-the-heart-attack-injectable-gels-could-prevent-future-heart-failure-video.html">prevent damage to the heart</a>. People are at a greater risk of experiencing heart damage after a heart attack as the organ becomes enlarged and its walls tend to narrow and become scarred. Injecting hydrogels into the heart’s walls after an attack provide mechanical support and stabilises the damaged area.</p>
<p>Hydrogels can also be used to improve tissue healing and tissue regeneration by delivering stem cells or proteins – inside a wound or broken bone – to <a href="https://www.ncbi.nlm.nih.gov/pubmed/20882499">stimulate tissue regrowth</a>.</p>
<p>At Queen’s University Belfast, we are also working on several different medical applications of hydrogels including <a href="https://theconversation.com/explainer-what-are-microneedles-and-why-do-we-need-them-54623">hydrogel microneedle patches</a>, for the delivery of medicines through the skin, and a hydrogel capable of <a href="http://www.irishtimes.com/news/science/queen-s-university-scientists-take-fight-to-hospital-superbugs-1.1901272">destroying hospital superbugs</a> by preventing bacteria to form colonies. There seems to be no end to the versatility of this wonderful substance.</p><img src="https://counter.theconversation.com/content/66149/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eneko Larraneta 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>Humble hydrogels could one day replace hypodermic needles and repair damaged hearts.Eneko Larraneta, Lecturer in Pharmaceutical Sciences, Queen's University BelfastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/612832016-08-15T20:07:32Z2016-08-15T20:07:32ZType 2 diabetes increasingly affects the young and slim; here’s what we should do about it<p>It is well recognised that increasing <a href="http://www.who.int/diabetes/publications/en/">rates of type 2 diabetes</a> are mainly driven by obesity and lifestyle factors. But that’s not the whole story. Genetics and epigenetics – changes in gene expression – also play an important role.</p>
<p>We are starting to see an increase in type 2 diabetes in leaner people at a much younger age than usually associated with the disease. This means in addition to focusing on good diet and exercise, we need better awareness of groups most at risk of type 2 diabetes. </p>
<p>These include many ethnic groups, women with a history of gestational diabetes and people with a family history of diabetes. In my clinical practice, I have seen teenagers and even children as young as seven, as well as <a href="http://jama.jamanetwork.com/article.aspx?articleid=207653">younger patients of Asian, African and Middle Eastern origin</a> with type 2 diabetes.</p>
<p>Among Indigenous people in Central Australia, rates of diabetes are some of <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129553626">the worst in the world</a>, at around three times that of non-Indigenous people. Studies in some remote communities suggest a prevalence of type 2 diabetes of up to 30%, compared to a rate of around 5% in the non-Indigenous population.</p>
<p>All this indicates lifestyle decisions alone can’t be responsible. We need to stop the blame and shame for a condition that has an association with lifestyle, but for many is a consequence of the toxic mix of genetics and modern life.</p>
<h2>More than just lifestyle changes</h2>
<p>Type 2 diabetes accounts for more than 90% of all diabetes cases and affects mainly middle-aged and older people who are overweight or obese. </p>
<p>Type 2 diabetes is thought to occur from a combination of factors: when the pancreas can’t produce enough insulin; and when the insulin is unable to do its job, to regulate blood sugar.</p>
<p>Why these two factors happen is not completely understood. The physiology may vary between different populations but broadly relates to excessive storage of fat, reduced muscle activity with poor uptake of glucose and genetic predisposition.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/131724/original/image-20160725-31183-jd0tpi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/131724/original/image-20160725-31183-jd0tpi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/131724/original/image-20160725-31183-jd0tpi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/131724/original/image-20160725-31183-jd0tpi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/131724/original/image-20160725-31183-jd0tpi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/131724/original/image-20160725-31183-jd0tpi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/131724/original/image-20160725-31183-jd0tpi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&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 has the potential to alter gene expression in the developing foetus.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>In contrast, type 1 diabetes is unrelated to lifestyle factors, has onset in children or young adults and relates to a complete destruction of the insulin-producing (beta) cells in the pancreas. </p>
<p>The cause is not known but may relate to genetic predisposition and an environmental trigger, such as a virus or toxin. </p>
<p>Both types of diabetes may cause a range of serious complications, including loss of limbs, if not aggressively treated. </p>
<h2>Genetics and epigenetics</h2>
<p>So why are the young and slim getting type 2 diabetes? One theory is epigenetics. </p>
<p>Epigenetics describes the biological process in which environmental factors may affect the expression of genes (where the gene codes for a particular biological function) rather than the alteration of genes themselves. </p>
<p>This process can occur as early as in the womb – before the child is born – with consequences that affect genetic expression for much of their lives. </p>
<p>Conditions such as obesity and gestational diabetes, where women with no pre-existing diabetes develop it during pregnancy, have the potential to alter gene expression in a developing foetus. </p>
<p>This may lead to a predisposition for a range of chronic illnesses, including diabetes. Some ethnic groups are at much greater risk of gestational diabetes; Indigenous women have <a href="http://onlinelibrary.wiley.com/doi/10.1002/dmrr.2570/abstract">rates nearly double that</a> of non-Indigenous women.</p>
<p>The exact mechanisms that create such predispositions aren’t known and are the <a href="https://global.oup.com/academic/product/the-developing-genome-9780199922345?cc=us&lang=en&">subject of intense ongoing research</a>. </p>
<h2>Aggressive treatment</h2>
<p>Many studies have <a href="http://care.diabetesjournals.org/content/25/suppl_1/s28">shown early aggressive treatment</a> before any sign of diabetes damage can better prevent complications, such as heart disease, kidney failure or blindness. </p>
<p>Aggressive treatment means we should aim for blood sugar levels to be as close to normal – between 4 and 5.5 mmol per litre and non-fasting glucose of 4 to 7.8 mmol per litre – as possible. This often requires medication in addition to intensive lifestyle changes.</p>
<p>Not only is it more expensive to treat complications once they are symptomatic but the outcomes of doing so are poorer. Comparing <a href="http://www.sciencedirect.com/science/article/pii/S0140673698070196">some of the key diabetes studies</a> over the past 20 years, we found a strategy targeting near-normal blood glucose levels resulted in fewer kidney, eye and heart complications compared with those that had a more relaxed target. </p>
<p>The main factor limiting perfect control of blood glucose is hypoglycaemia. Characterised by low blood glucose levels, it can cause discomfort, confusion or even coma in extreme cases. </p>
<p>For this reason, we need newer medications which can better control blood sugar without the risk of hypoglycemia. Until we get these, the risk makes it acceptable to have less-than-perfect control in some instances.</p>
<p>Modern drug treatment has improved overall, however, and we have access to a range of therapeutics that can be used effectively from early in the disease. Lifestyle measures are an important part of treatment but their benefit may diminish as type 2 diabetes progresses or gets worse over time. </p>
<h2>Removing the stigma</h2>
<p>Governments must recognise the importance of access to effective new therapies for diabetes as well as adequately fund clinical services to properly manage this complex chronic illness – especially in highly endemic areas such as remote Indigenous communities. </p>
<p>Premature death rates for people with type 2 diabetes are <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1504347#t=article">around three times greater</a> than in the general population, largely due to heart disease and stroke. Adjusted years of life lost are greater for those with type 2 diabetes than for those with breast, lung or bowel cancer.</p>
<p>There is a significant stigma and shame attached to the diagnosis of type 2 diabetes, particularly in younger patients. This adds an unfortunate barrier to successful treatment. Until this is improved, we will continue to under-treat our patients and misinform our health providers.</p><img src="https://counter.theconversation.com/content/61283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neale Cohen receives funding from at Novo Nordisk, Medtronic, Lilly, Boerhinger Ingelheim, Abbott, Astra Zeneca, Novartis, Merck and Servier for advisory Board roles, clinical research activities and speaking engagements. </span></em></p>We are seeing increasing numbers of young, slim children with type 2 diabetes. This means obesity and lifestyle factors may not be the whole story behind the disease’s rising rates.Neale Cohen, General Manager Diabetes Services, BakerIDI Heart and Diabetes Institute, Baker Heart and Diabetes InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/496992015-10-26T16:38:22Z2015-10-26T16:38:22ZSometimes less is better – so why don’t doctors ‘deintensify’ medical treatment?<p>Doctors know a lot about when to start medications to treat disease. But sometimes our focus on starting medicines means we can confuse providing more care with providing better care. And better care sometimes means fewer medicines, not more.</p>
<p>For instance, patients with high blood pressure who have lost weight or are exercising more may find that they may no longer need blood pressure pills. Patients with heartburn who take proton-pump inhibitors (such as Nexium) may do just as well with a lower dose or occasional therapy. Patients who take medications for osteoporosis may be candidates for “drug holidays.” </p>
<p>And as we age, our bodies process medications differently and we become susceptible to different side effects. What may have been the right treatment for a patient when she was 50 can turn out to be <a href="http://www.aafp.org/afp/2013/0301/p331.html">dangerous at 80</a>. </p>
<p>That may mean many patients can have their treatment deintensified – changing or stopping medicines when they are no longer needed. But it turns out, doctors often don’t do this, even though it means patients risk fewer side effects and can avoid extra health costs. So why, and when, should a person’s drugs be deintensified?</p>
<h2>Who benefits from having treatment deintensified?</h2>
<p>Diabetes makes a great case study for deintensification, because patients often need treatment over the course of a lifetime. For decades, doctors have focused on treating diabetes intensively to lower their patients’ risks of developing kidney disease and other complications. But we now know that intensive treatment for diabetes, like nearly all medical treatments, can have also cause serious harm, such as low blood sugar levels, which can lead to falls and memory problems, and even death. </p>
<p>Many patients with diabetes may benefit from deintensification. Older patients, in particular, are more likely to experience drug side effects, and patients taking more than one medicine run a risk of harmful drug interactions. Older patients also have less to gain from intensive treatment of their diabetes because they have fewer years to develop the long-term effects of diabetes on their bodies. And as a person’s health status changes, they may need fewer – not more – medicines to manage their diabetes.</p>
<p>That doesn’t mean intensive treatment is bad – it just means that not every patient needs it, and some patients may need it for only a certain amount of time. For example, intensive treatment to lower blood sugar in younger people <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa052187">lowers their risk</a> of developing kidney and eye disease, and other harmful long-term effects of diabetes. </p>
<p>So drug choices need to be individualized based on what a person stands to gain from intensive treatment, balanced against <a href="http://diabetes.teithe.gr/UsersFiles/entypa/STANDARDS%20OF%20MEDICAL%20CARE%20IN%20DIABETES%202015.pdf">their risk</a> of treatment side effects. Deintensifying treatment means finding the sweet spot between too much and too little medicine. </p>
<p>Even though many clinical practice guidelines already recognize that goals for diabetes control and other chronic conditions should be based on a patient’s individual risk and benefits of treatment, this message hasn’t gotten through to all doctors and patients. And none of these guidelines specify who should have treatment deintensification and when that should happen. </p>
<h2>Older diabetes patients are often overtreated</h2>
<p>Several studies have found that older patients with diabetes are often overtreated – meaning that they are taking <a href="http://dx.doi.org/10.1001/jamainternmed.2014.7345">more medications</a>, or medications at too high doses, than they need to achieve a <a href="http://dx.doi.org/10.1001/jamainternmed.2013.12963">safe level of sugar control</a>. </p>
<p>Recently, <a href="http://archinte.jamanetwork.com/article.aspx?articleid=2466632">we reported</a> that doctors deintensified medications for only a quarter of nearly 25,000 older patients with diabetes who were treated to potentially dangerously low levels of sugar control. Deintensification rates barely budged even if the patient has had low blood sugar multiple times or had severely limited life expectancy. </p>
<p>In patients with low blood sugar who did not have their treatment deintensified, 40% did not even have their diabetes control values rechecked within six months. This means that the majority of overtreated patients continued to take medications that they did not need or at doses that were too high. </p>
<h2>Why don’t clinicians deintensify treatment?</h2>
<p>Doctors usually focus on intensifying therapy to control blood sugar, which means that deintensifying treatment can take a completely new mindset. </p>
<p>In another study, <a href="http://dx.doi.org/10.1001/jamainternmed.2015.5950">we asked</a> primary care providers what they thought would be appropriate treatment for a hypothetical patient in his late 70’s who has had diabetes for 20 years and also has kidney disease. The patient takes two pills every day to manage his diabetes, but could be fine just taking one of them. We found that 39% of almost 600 respondents felt that this patient would continue to benefit from stringent diabetes control – despite current expert recommendations to the contrary. </p>
<p>When we looked at reasons why, 42% of providers worried that not treating him intensively could harm the scores on their clinical report cards, which track the quality of care the doctors’ provide to their patients. Nearly one-quarter worried about legal liability resulting from decreasing medications. </p>
<p>Just as troubling, 30% wouldn’t deintensify the diabetes medications because they worried they wouldn’t have enough time to discuss these changes with the patient.</p>
<h2>Finding the treatment sweet spot</h2>
<p>This isn’t just an issue for people with diabetes – it’s an issue for anyone living with a chronic condition.</p>
<p>So how do we encourage appropriate deintensification in order to get to the sweet spot for treatment? There are many changes that could help. </p>
<p>First, health care systems should institute programs that systematically engage providers and patients to consider stopping medications that are no longer necessary. </p>
<p>For example, the VA has instituted a national “<a href="http://www.qualityandsafety.va.gov/ChoosingWiselyHealthSafetyInitiative/HypoglycemiaSite/Hypoglycemia.asp">Hypoglycemia Safety Initiative</a>” to encourage appropriate deintensification of diabetes medications in order to decrease the harm of intensive treatment among those at risk for hypoglycemia (low blood sugar).</p>
<p>Second, patients should ask their providers if their medications are still necessary. Some could possibly be stopped or the dose decreased. Providers should regularly reexamine their patients’ medication lists and discuss the options. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/99679/original/image-20151026-18450-1u8n54o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/99679/original/image-20151026-18450-1u8n54o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=513&fit=crop&dpr=1 600w, https://images.theconversation.com/files/99679/original/image-20151026-18450-1u8n54o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=513&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/99679/original/image-20151026-18450-1u8n54o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=513&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/99679/original/image-20151026-18450-1u8n54o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=645&fit=crop&dpr=1 754w, https://images.theconversation.com/files/99679/original/image-20151026-18450-1u8n54o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=645&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/99679/original/image-20151026-18450-1u8n54o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=645&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">As a person’s health changes, so should the medicine they take.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-135105938/stock-photo-empty-medical-prescription-with-a-pen-isolated-on-white-background.html?src=7lb47l3wbpmcFCcJoknKkA-1-5">Prescription pad via www.shutterstock.com.</a></span>
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<p>Third, while existing clinical practice guidelines already say that treatment should be based on risk and benefits for an individual patient, these guidelines should go a step further and include explicit recommendations for deintensification to help providers and patients decide when stopping a medication might be wise. </p>
<p>Fourth, the way we assess whether doctors are providing high-quality care should look not just at whether high-intensity treatment is provided for a patient, but also if doctors are deintensifying treatment when possible and beneficial.</p>
<p>Finally, we must get out the message that more is not always better. Campaigns such as <a href="http://www.choosingwisely.org">Choosing Wisely</a>®, in conjunction with <a href="http://consumerhealthchoices.org/campaigns/choosing-wisely/">Consumer Reports</a>, educate the public about care that might not be needed, but only 21% of US doctors surveyed <a href="http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf">were aware</a> of the campaign.</p>
<p>Changing the “more is better” mindset among both patients and providers will not be easy, but it will be essential if we want to ensure that patients get the treatments they need but not those that are unnecessary and potentially harmful.</p><img src="https://counter.theconversation.com/content/49699/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eve A. Kerr receives funding from the Veterans Health Administration, the National Institutes of Health and the Robert Wood Johnson Foundation. She is affiliated with the American College of Physicians. </span></em></p><p class="fine-print"><em><span>Jeremy Sussman receives funding from the Veterans Health Administration. </span></em></p><p class="fine-print"><em><span>Tanner Caverly receives funding from the Veterans Health Administration. </span></em></p>As people with chronic conditions age or as their health changes, they sometimes need less medication. So when, should a person’s drugs be scaled down?Eve A Kerr, Professor of Internal Medicine, University of MichiganJeremy Sussman, Assistant Professor of Internal Medicine, University of MichiganTanner Caverly, Clinical Lecturer, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/428332015-06-23T05:18:15Z2015-06-23T05:18:15ZHelping people with type 1 diabetes exercise safely – new findings<figure><img src="https://images.theconversation.com/files/85953/original/image-20150622-17729-ktt14v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">To exercise or to avoid the risks?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-287085200/stock-photo-road-sign-to-exercise-and-diabetes.html?src=csl_recent_image-2">arka 38</a></span></figcaption></figure><p><a href="https://www.diabetes.org.uk/About_us/What-we-say/Statistics/Diabetes-prevalence-2013/">There are</a> more than 3m people in the UK living with diabetes, amounting to 6% of the population. Of those, 10% or about 300,000 have type 1 diabetes, which usually develops during childhood and adolescence – as opposed to type 2, which tends to affect older adults and is more commonly associated with lifestyle and obesity. </p>
<p>Type 1 diabetes is an autoimmune disease that destroys the insulin–producing cells in the pancreas, preventing the body from producing the insulin that it needs to maintain the right level of blood glucose. People with type 1 diabetes are always treated with insulin injections or an insulin pump, without which they would die. The most common treatment is the <a href="http://www.diabetes.co.uk/insulin/basal-bolus.html">basal-bolus regimen</a>, which involves injecting a 24-hour-acting insulin once or twice daily to provide background insulin, along with fast-acting insulin injections before meals or snacks. </p>
<p>If the insulin dose is not right for the patient, they can have
hypoglycaemia (low blood-glucose) or hyperglycaemia (high blood-glucose). For people living with type 1 diabetes, the risk of hypoglycaemia is a day-to-day phenomenon. Symptoms include light headedness, tremors, confusion, unsteadiness, drowsiness and sometimes unconsciousness. It happens quickly, <a href="http://www.ncbi.nlm.nih.gov/pubmed/18088077">making it</a> one of the most feared complications from diabetes. </p>
<p>Hypoglycaemia is an acute emergency which needs immediate treatment with glucose – unlike hyperglycaemia, which can produce symptoms like excessive tiredness and large amounts of urine but only becomes an emergency if it continues for a few days. Both complaints are <a href="http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0470698098.html">usually caused by</a> taking too much insulin, increased exercise or not eating enough carbohydrates, so it is essential to strike the right balance between them. </p>
<h2>The risks of exercise</h2>
<p>Although we know that a patient’s level of exercise is a key variable in deciding how much insulin they need, there been very little research into how to maintain glycaemic control while exercising. This partly explains why people often avoid exercise <a href="http://www.ncbi.nlm.nih.gov/pubmed/18689694">for fear of</a> a hypoglycaemic attack. If they are already hypoglycaemic at the start of an exercise session, they can’t begin until they have consumed carbohydrates and waited until their blood glucose has risen to an acceptable level. Even then, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20536956">they may experience</a> a further episode while exercising, which can impinge on their performance and potentially force them to stop. There is also a risk of post-exercise hypoglycaemia, especially for afternoon and evening activity. </p>
<p>Patients <a href="http://www.ncbi.nlm.nih.gov/pubmed/18689694">commonly worry</a> about a hypo happening <a href="http://www.diabetes.co.uk/nocturnal-hypoglycemia.html">during the night</a>, which can be particularly unpleasant. The patient will often only be woken up once the symptoms have reached a more acute point than it would take for them to notice had they been awake, meaning that they tend to feel worse as a result. Sometimes the patient might sleep through the symptoms altogether, which can eventually lead to a serious condition called <a href="http://www.diabetes.co.uk/hypo-unawareness.html">hypo unawareness</a>, where they will have a severe episode with possible unconsciousness without noticing any symptoms. Yet there has been no evidence until now to confirm the link between exercise and these night-time hypo attacks. </p>
<h2>Our study</h2>
<p>My co-researchers and I decided to conduct a study to help people with type 1 diabetes to be more confident about taking exercise. We <a href="http://researchrepository.napier.ac.uk/7676/">created</a> a set of insulin/carbohydrate instructions for nine patients (five male, four female) taking moderate-intensity exercise before their evening meal. The instructions were based on our best information about how to manage blood glucose, carbohydrates and exercise. </p>
<p>We measured how effectively these instructions maintained acceptable glucose levels in each participant during and after two exercise sessions one week apart. For each exercise session, we tested each participant’s blood glucose at ten regular intervals. All participants used a basal-bolus analogue insulin regimen and exercised regularly, and each <a href="http://researchrepository.napier.ac.uk/7678/">participant reduced</a> the dose of fast-acting insulin that they were required to take before their evening meal by 30% – the sort of substantial cut that patients would not normally consider without medical advice. Even then, we found that they became hypoglycaemic on a number of occasions at night, and were unaware of this in about half of them. </p>
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<a href="https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/85944/original/image-20150622-17712-1j9tx96.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">Does it have to be this way?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=143498368752224860000&search_tracking_id=aNNEY3Rw9Io2Rb2Dp2qChQ&searchterm=treadmill&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=275521157">Syda Productions</a></span>
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<p>We found that the nine participants were in the acceptable glucose range just over half of the time, and hyperglycaemic almost 40% of the time. They were hypoglycaemic in the remaining 5% of tests, mostly between eight and 12 hours after exercising – at night, in other words. These responses were fairly evenly distributed across the people who participated. We concluded that the main risk from moderate-intensity exercise in the evening was delayed hypoglycaema during the night. </p>
<p>From our results, we were able to put together a set of instructions for people with type 1 diabetes taking exercise (<a href="https://theconversation.com/profiles/jacqui-charlton-173542">contact me</a> through my profile for the full set). To get a better understanding of how their body responds, patients should monitor their blood glucose before and after exercise, after their evening meal and before bedtime, and then before breakfast the following morning. They may need to reduce evening meal insulin dose by 30%-50%, and also have a carbohydrate snack at bedtime. It could also help to occasionally set an alarm and check their blood glucose between eight and 12 hours after their evening meal. </p>
<p>Our work to date has just been a pilot study. More research needs to be done with a larger group of participants with type 1 diabetes to see if it produces the same results. It would also be worth testing type 2 diabetics on the basal-bolus regime, since in principle they should enjoy similar benefits. With those caveats in mind, our hope is that by trying these strategies and keeping a close eye on how the body responds, people with type 1 diabetes should at last be able to exercise safely.</p><img src="https://counter.theconversation.com/content/42833/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacqui Charlton 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>Many diabetics avoid exercise because it upsets their insulin levels, and there is little medical advice on how to keep them safe. Here is an attempt to redress the balance.Jacqui Charlton, Lecturer in Diabetes Care, Edinburgh Napier UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/430332015-06-11T11:07:13Z2015-06-11T11:07:13ZDo kids born by C-section have a higher risk of chronic disease? A new study looks at the evidence<figure><img src="https://images.theconversation.com/files/84605/original/image-20150610-6787-xc885g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">With c-sections becoming so common, it's time that we started to investigate what that means for child health. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-50320798/stock-photo-baby-being-born-via-caesarean-section-coming-out.html?src=kGVNkZx7HRGkqOZmBxTWFg-1-5">Baby via www.shutterstock.com. </a></span></figcaption></figure><p>In many parts of the world, rates of cesarean delivery are too high, and growing. In the UK, for instance, about one-quarter of babies are born by cesarean. In the US, the rate is one-third, and in Brazil, it is one-half. The World Health Organization recommends that no more than <a href="http://www.who.int/bulletin/volumes/85/10/06-039289/en/">15% of deliveries</a> be by cesarean. </p>
<p>The reasons behind these variations and growing numbers are complex, and beyond my scope here. Whatever the reason, more and more babies are entering the world surgically. We need to understand the potential consequences. </p>
<h2>The high C-section rate is an emerging global health issue</h2>
<p>Cesarean can be a medical necessity, or even an emergency. Decision-making can be fraught, with doctors and soon-to-be parents discussing risks and benefits during labor. Let’s put that aside.</p>
<p>Instead, let’s talk about the kind of information that clinicians and parents want to weigh in cooler moments, when cesarean is neither a medical necessity nor an emergency. </p>
<p>There has been much media attention of late to cesarean delivery on maternal request. It appears that this is rare in the US. One source estimates that <a href="http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-Maternal-Request">2.5%</a> of births are cesareans requested by mothers. But it appears much more common in other parts of the world. For example, in southeast China, <a href="http://dx.doi.org/10.1097/AOG.0b013e31816e349e">20% of births</a> were recorded as cesareans on maternal request in 2006. In some middle-income countries, skyrocketing elective cesareans have become a pressing public health matter. </p>
<p>In the US, there’s another setting that is more relevant. Many women who have had previous cesareans are able to go on to have vaginal births, from a medical perspective. But fewer than <a href="http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_01.pdf">10% of births</a> to women who have had prior cesareans are vaginal deliveries. Repeat cesareans are a health concern worldwide, as more women receive a cesarean with their first birth. </p>
<p>The bottom line is that both of these settings – maternal request in low-risk pregnancy, and prior cesarean – offer a clear opportunity for a cool, deliberative weighing of risks.</p>
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<img alt="" src="https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.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">What do we know about the long-term effects of C-sections?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-151050818/stock-photo-new-born-infant-asleep-in-the-blanket-in-delivery-room.html?src=lOXbZs-mhEm3MeXtdXp4kA-1-53">Baby via www.shutterstock.com.</a></span>
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<h2>Weighing risks and benefits for the child</h2>
<p>In the short term – the hours and days surrounding birth – different modes of delivery bring different risks. For instance, parents might want to know that babies born by cesarean are more likely to need a brief stay in the newborn intensive care unit, while children born by vaginal delivery are more likely to have serious bruises under the scalp, requiring a short course of light therapy.</p>
<p>But when it comes to potential long-term health risks from C-section delivery, there is less information available. To date, discussions about delivery risks have tended to focus on long-term health problems with vaginal delivery. These include the very small risk of brain damage, injury to the the nerves of the arm (from shoulder dystocia), and other conditions.</p>
<p>This is changing, with growing evidence that delivery by cesarean may come with an increased chance of obesity, asthma and diabetes during childhood. In a piece that appears this week in the British Medical Journal, I <a href="http://dx.doi.org/10.1136/bmj.h2410">discuss and evaluate</a> this evidence, along with my colleague Jianmeng Liu of Peking University.</p>
<h2>Evidence of long-term child health risks</h2>
<p>The gold standard for evidence in medical science is the study where two treatments are compared in groups of volunteer patients whose treatment is determined by a coin flip. This is called a randomized study. Reviewing the published literature, we found six randomized studies comparing cesarean and vaginal delivery. All were conducted in scenarios where the optimal delivery choice was unclear (for example, delivery of twins and babies coming feet first, or “breech”). </p>
<p>These randomized studies mostly focused on the benefits and risks for mothers’ health. Only one of the studies followed children beyond the newborn period. The <a href="http://www.sciencedirect.com/science/article/pii/S0002937804006568">Term Breech Trial</a> found that children in the cesarean group were in worse general health than those in the vaginal delivery group at two years of age. While the researchers didn’t go into great detail about the kinds of health problems that the children had, this finding was striking. Unfortunately, the children were not followed up later in life.</p>
<p>We also reviewed the summary evidence from over 50 nonrandomized studies that compared the health of groups of children delivered by the two methods. Those generally find a correlation between cesarean delivery and increased likelihood of childhood <a href="http://www.nature.com/ijo/journal/v37/n7/abs/ijo2012195a.html">obesity</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2007.02780.x/abstract">asthma</a> and <a href="http://link.springer.com/article/10.1007/s00125-008-0941-z#page-1">diabetes</a>. </p>
<p>Using the summary data and extrapolating the findings to the US population, my coauthor and I estimated a childhood obesity rate of 15.8% for children delivered vaginally versus a 19.4% rate for children delivered by cesarean, a childhood asthma rate among children delivered vaginally of 7.9% versus a 9.5% rate for children delivered by cesarean, and a childhood type 1 diabetes rate of 1.79 cases per 1,000 children versus a rate of 2.13 per 1,000 for children delivered by cesarean. Again, these are just estimates, helping to translate the statistics into accessible numbers.</p>
<p>But importantly, correlation isn’t causation: women who have cesareans may be less healthy, and so their children might also be less healthy, regardless of how they are delivered. As it turns out, some correlational studies suffer from this limitation more than others. I believe that we can still get useful information about risks by focusing on the strongest of these correlational, nonrandomized studies. </p>
<p>As always, better data and further research are needed. I’ll have more to say about that later.</p>
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<img alt="" src="https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.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">We need more research to better understand potential long-term consequences.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-144900949/stock-photo-group-of-multiethnic-babies-isolated-on-white-background.html?src=pp-same_model-144900946-iCa_O-Xncev06iw0hlGHRw-1&ws=1">Babies via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Why might cesarean be linked to long term health risks?</h2>
<p>Stepping back, why might delivery matter? <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110651/">One theory</a> says that it has to do with intestinal bacteria, which are important in food uptake and fighting infections. During vaginal birth, babies swallow maternal vaginal bacteria, and those bacteria are early colonizers of the babies’ intestines. Cesarean-born babies miss this exposure. It is possible that the resulting early differences in resident gut bacteria result in differences in health, later on.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/23414680?dopt=Abstract">Another theory</a> focuses on the healthy, positive stress of labor and delivery, and the ways that stress “programs” a baby’s genes. According to this theory, the key programmers are levels of hormones such as oxytocin, cortisol and adrenalin. These give rise to so-called epigenetic changes that in turn determine the risk of disease later in life. </p>
<h2>What do the experts say?</h2>
<p>In medicine, expert advice is often delivered in the form of written clinical guidelines that summarize the evidence for clinicians and make recommendations for treatment. Recently, two influential groups – one in the <a href="http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-Maternal-Request">US</a>, and the other in the <a href="http://www.nice.org.uk/guidance/cg132/evidence/cg132-caesarean-section-full-guideline-3">UK</a> – issued guidelines for Cesarean Delivery on Maternal Request (CDMR). These guidance documents were pieces of advice to inform decisions in this very specific nonemergency situation.</p>
<p>After reviewing evidence, both groups concluded that vaginal delivery should be recommended for healthy women with low-risk pregnancies. In that group, requests for cesarean should be honored, after a women receives counseling about resources that are available, including pain control. Women requesting cesarean should also understand the risks and benefits of their choice. Strikingly, neither of the two documents mentioned the relatively new evidence on long-term risks to child health, such as obesity, asthma and diabetes. </p>
<h2>Time to talk it over</h2>
<p>It’s time for that evidence to enter the wider conversation. A good way to start would be to review and critically assess the evidence in updated guidelines. This would educate doctors and midwives, allowing them to present fuller information to their patients.</p>
<p>Make no mistake: the evidence linking cesarean to worse child health outcomes is far from airtight. We look forward to getting better evidence in future clinical trials, or cleaner correlational studies.</p>
<p>Again: cesarean is sometimes medically indicated, and is sometimes even an emergency. But in the US, and in many nations around the world, the high cesarean rate isn’t just a question of medical need. Patients, midwives and doctors are making choices, and those choices should be as informed as possible. </p>
<p>The evidence isn’t perfect. But then, it rarely is.</p><img src="https://counter.theconversation.com/content/43033/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jan Blustein received funding from NYU CTSA grant UL1TR000038 from the National Center for the Advancement of Translational Science (NCATS), NIH.</span></em></p>As more and more babies are delivered by cesarean section, we need to start investigating what that means for their long-term health.Jan Blustein, Professor of Health Policy and Population Health, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/412852015-05-07T10:14:30Z2015-05-07T10:14:30ZAn artificial pancreas has just made giving birth safer for diabetic women<figure><img src="https://images.theconversation.com/files/80814/original/image-20150507-1239-y8gizj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetic women are at greater risk of still births, miscarriages and delivery problems.</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Last week, a British diabetic women became the <a href="http://www.bbc.co.uk/news/uk-england-norfolk-32531067">world’s first</a> to complete a natural vaginal birth using an artificial pancreas. This news is a big step forward for all mothers with diabetes. </p>
<p>Pregnancy is riskier for women with diabetes of all types. Maternal mortality, birth defect rates, miscarriages and still births are greater than in the <a href="http://www.ncbi.nlm.nih.gov/pubmed/25897357">healthy population</a>, as is the tendency for delivery difficulties for babies with a higher birth weight.</p>
<p>Diabetes covers a <a href="http://www.diabetes.org.uk/Guide-to-diabetes/What-is-diabetes/">range of conditions</a> where certain cells cannot absorb enough glucose from the blood. In type 1 diabetes, this occurs because of problems with a patient’s pancreatic production of insulin, the chemical that enables the absorption. In type 2, it is because muscle cells cannot receive the insulin signal.</p>
<p>Diabetes means a patient’s blood glucose levels can easily become too high. This in turn leads to faults in the way the body uses hormones to send signals to different organs. This problem is what causes the higher risk of complications in pregnant diabetic women.</p>
<p>Even though we understand the need to monitor diabetic mothers throughout, after – and even before – their pregnancies, these relatively poor outcomes of pregnancy and labour persist. Women’s insulin levels are often carefully adjusted to cope with the changes in weight, mobility and nutritional needs that come with pregnancy, but this reflects only a small part of the challenge.</p>
<h2>Dangers of pregnancy</h2>
<p>The advent of <a href="http://www.diabetes.co.uk/cgm/continuous-glucose-monitoring.html">continuous glucose monitoring systems</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/21864757">has revealed</a> just how often pregnant diabetic women’s blood glucose levels fluctuate dangerously. This is the case even with careful management using insulin pumps, which create a more even administration than injections. Plus the personal discomfort, sleep interruption and false alarms that can come from using continuous glucose monitors <a href="http://care.diabetesjournals.org/content/36/7/1818.extract">make it harder</a> to ensure patients use them to manage the condition correctly.</p>
<p>The actual birth is even more of <a href="http://www.sciencedirect.com/science/article/pii/S1521690X11000856">a challenge</a> because of the greater chance for disaster. Withstanding and maintaining effective contractions in order to give birth requires large amounts of energy. That creates greater pressure for adequate blood glucose and insulin levels.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/80815/original/image-20150507-1234-1lyaqnm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/80815/original/image-20150507-1234-1lyaqnm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80815/original/image-20150507-1234-1lyaqnm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80815/original/image-20150507-1234-1lyaqnm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80815/original/image-20150507-1234-1lyaqnm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80815/original/image-20150507-1234-1lyaqnm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80815/original/image-20150507-1234-1lyaqnm.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">Artificial pancreas technology builds on and improves continuous glucose monitoring systems.</span>
<span class="attribution"><span class="source">University of Cambridge</span></span>
</figcaption>
</figure>
<p>Glucose levels are typically maintained during the birth through an intravenous glucose infusion and a manually adjustable dose of insulin. The insulin makes sure that the mother’s cells can absorb enough glucose, which in turn prevents the baby’s blood sugar levels from dropping to potentially fatal levels (neonatal hypoglycaemia).</p>
<p>After delivery, the insulin requirement drops sharply and clinical staff must be careful not to give the mother too much and reduce her blood sugar to a dangerous level (maternal hypoglycaemia). This risk <a href="http://www.sciencedirect.com/science/journal/15216934/25/1">develops soon after</a> contractions have ended, especially if the mother quickly begins breastfeeding and if medication given to her for labour prevents her from recognising the symptoms of hypoglycaemia.</p>
<p>With all these complications, it is small wonder that diabetic women are often advised to opt for caesarean sections, although these carry their own <a href="http://www.sciencedirect.com/science/journal/15216934/25/1">post-operative risks</a> as nutrition and mobility are again impaired.</p>
<h2>Automating care</h2>
<p>The advent of the artificial pancreas <a href="http://www.ncbi.nlm.nih.gov/pubmed/24757225">has the potential</a> to change this. <a href="http://www.dmu.ac.uk/research/research-faculties-and-institutes/health-and-life-sciences/pharmaceutical-technologies/artificial-pancreas/artificial-pancreas.aspx">The technology</a> uses a sensor embedded beneath the skin to determine blood glucose levels and trends and passes that information to the clinical staff. An external electronic device then uses an algorithm to decide how much insulin is needed and administers it using a pump.</p>
<p>Because the glucose readings come from tissue fluid, they only approximate blood sugar levels and can be inaccurate if the levels are changing quickly. Many of the artificial pancreas algorithms <a href="http://www.ncbi.nlm.nih.gov/pubmed/22575409">used recently</a> in research could cope with making automatic adjustments to the insulin pump output but would not yet be trusted to do so in all circumstances.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/NuzV3h2MyN4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Joan Taylor describes her work on artificial pancreas technology.</span></figcaption>
</figure>
<p>In critical care, including labour, some manual input for the artificial pancreas will still be important for safety. But eventually the technology will become fully automatic and should greatly reduce the present tragedies in maternity diabetes.</p>
<p>A fully internalised bionic pancreas is much further away – but whether biological, electronic, chemical or even mechanical, this will eventually solve the diabetes problem. Meanwhile the reported case of the first natural birth with the artificial pancreas in Norwich represents a triumph.</p><img src="https://counter.theconversation.com/content/41285/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Taylor receives funding from the Edith Murphy Foundation (current), a NIHR NEAT grant (2008-2011) and an East Midlands University Lachesis grant (2004-2008). These were all to produce an implantable artificial pancreas.</span></em></p>A British woman has become the first diabetic to give birth naturally using an artificial pancreas.Joan Taylor, Professor of Pharmaceutics, De Montfort UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/409812015-04-30T15:56:23Z2015-04-30T15:56:23ZWhy is diabetes killing so many teenagers?<figure><img src="https://images.theconversation.com/files/79962/original/image-20150430-30709-16uht5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Death rates from type 1 diabetes in UK males aged 15 to 24 have almost doubled since 2000.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/visionnewspaper/521827199/in/photolist-N7v3F-N7pTK-N7ko2-N7dws-6sBE6z-55nV4M-4u9SNL-6sFSKo-6sFTk3-6sBxax-jKFvjp-JVzrc-jKGX2A-4oLJ3p-rvMeJ4-rcsYCD-rcsZV8-rvFcq4-recZXb-h7Pwf7-h7MmsK-vNYqH-8Uu562-55DH1J-4XCM1B-9CCipc-55DFMo-55DNUN-55DHMd-55DN8L-55zL62-55zXrM-55DGhs-6sBCYD-6sFR3A-6sBCcc-6sFMLC-6sByQ4-hLuPbP-49EZ8C-JQiu-4aX8RT-fF2fGt-5Rcz4H-5ZSUJ-VWTx-6TdLT-6TdKB-6TdHu-pZAebp">York Vision/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Young British men have a problem with diabetes. <a href="http://www.diabetes.co.uk/news/2015/apr/type-1-diabetes-mortality-rate-higher-in-uk-than-most-of-europe-95680226.html">Recent studies</a> have highlighted that death rates from type 1 diabetes in boys and men aged 15 to 24 years have almost doubled since 2000 in the UK. This is higher than reported death rates among young men with diabetes in other European countries. Why has type 1 diabetes become such a problem for our young people?</p>
<p><a href="http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf">Overall</a>, about 10% of people with diabetes have type 1 diabetes. The condition is caused when the immune system makes a mistake. The cells in the pancreas that make insulin are crucial for controlling blood glucose levels, but in a patient with type 1 diabetes the immune system treats these cells as a threat and targets them for destruction.</p>
<p>When about 70% of these “beta cells” have been destroyed there is no longer enough insulin to control blood sugars, which means the patient will need daily insulin injections. The condition is more common in children and young people with an average age at onset of 12 years.</p>
<p>Young people dying as a result of type 1 diabetes is <a href="http://www.ncbi.nlm.nih.gov/pubmed/17901942">rare</a> but is possible if the condition is not diagnosed quickly. The disease is associated with increased risk of health complications, with particularly detrimental effects on the kidneys and eyes if the condition is not well managed. And poor management of insulin treatment can lead to blood glucose levels getting too high or too low, which can also cause death.</p>
<p>Type 1 diabetes is a growing problem in most developed countries, with particular increases among young people. From our <a href="http://www.ncbi.nlm.nih.gov/pubmed/9314756">research</a>, as well as other <a href="http://www.ncbi.nlm.nih.gov/pubmed/19481249">studies</a>, we know that the incidence of type 1 diabetes is increasing at a rate of 3% per year in most European populations. The rate is even higher in children diagnosed under the age of 5 years.</p>
<p>The cause for this increase in the number of people diagnosed with type 1 diabetes is unclear. Certain genes occur more often in people with the disease but these genes are not becoming more frequent. Instead, it appears that some factors in our environment are increasing the risk of type 1 diabetes.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/79965/original/image-20150430-30716-okzgip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/79965/original/image-20150430-30716-okzgip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79965/original/image-20150430-30716-okzgip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79965/original/image-20150430-30716-okzgip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79965/original/image-20150430-30716-okzgip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79965/original/image-20150430-30716-okzgip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79965/original/image-20150430-30716-okzgip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&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">Several factors mean young men can poorly manage their diabetes, potentially resulting in death.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/momboleum/3583757034/in/photolist-6sFG7o-GquyN-N7v3F-N7pTK-N7ko2-N7dws-6sBE6z-55nV4M-4u9SNL-3EW2MH-6sFSKo-6sFTk3-6sBCYD-6sFR3A-6sBCcc-6sFMLC-6sBxax-6sByQ4-hLuPbP-49EZ8C-JQiu-JVzrc-jKGX2A-4oLJ3p-rvMeJ4-rcsYCD-rcsZV8-rvFcq4-recZXb-4aX8RT-fF2fGt-5Rcz4H-5ZSUJ-VWTx-6TdLT-6TdKB-6TdHu-h7Pwf7-pZAebp-h7MmsK-h7Ng4h-f4zkdG-47GZvL-vNYqH-7BYGG-8Uu562-bbntCM-55DH1J-9CCipc-4iSAQX">Momboluem/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>A lot of research is ongoing trying to determine what these factors are and how they contribute to the increasing numbers of people with the condition. In particular, a <a href="https://teddy.epi.usf.edu/">study</a> called The Environmental Determinants of Diabetes in the Young (TEDDY) is examining early-life events including diet changes and viral infections. </p>
<p>But the increasing rates of type 1 diabetes cannot explain the rising death rate among young British men, because we know incidence of the disease is growing at similar rates in other European populations – but the diabetes-related deaths aren’t rising at the same rate.</p>
<p>Poor management of diabetes can result from a combination of factors including changes during <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793733/">puberty</a>, the lack of <a href="http://www.ncbi.nlm.nih.gov/pubmed/23659590">engagement</a> by teenage boys with the healthcare system, and other social factors during a time in their lives when they may start living away from home. During this same period, young men in the UK also transition from childhood to adult NHS services and this could <a href="http://www.ncbi.nlm.nih.gov/pubmed/25764182">result</a> in loss of follow-up for some patients. </p>
<p>National <a href="http://www.rcpch.ac.uk/improving-child-health/quality-improvement-and-clinical-audit/national-paediatric-diabetes-audit-n-0#National%20Paediatric%20Diabetes%20Audit%20Report%202013-2014">data</a> showing increased rates of diabetes-related complications in teenagers supports the view that there is an urgent need to focus on this age group. We need to ensure that all young people with diabetes attend all clinic appointments and that there is a support mechanism in place for those who have difficulties coping with their condition.</p>
<p>Perhaps research studies could be designed to establish whether social networks could be used to help young people who manage their diabetes well to help those who have problems.</p>
<p>Ultimately, if successful, this could save lives and save the NHS money by helping to prevent conditions such as diabetic kidney disease.</p><img src="https://counter.theconversation.com/content/40981/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathleen Gillespie receives funding from Diabetes UK and the Juvenile Diabetes Research Foundation.</span></em></p>Death rates for young men with type 1 diabetes in the UK have shot past similar figures for Western Europe. Greater focus on adolescents could save lives.Kathleen Gillespie, Reader in Molecular Medicine, University of BristolLicensed as Creative Commons – attribution, no derivatives.