Diabetes - Finding the Cause

If diabetes could be prevented, then there would be no need for special machines or surgical procedures. Finding the cause would pave the way for prevention of diabetes and is thus extremely important.

The diabetes syndrome, in most of its forms, is basically genetic, or inherited. As noted before, however, it may have many other causes (e.g., it may result from surgery, certain medications, or other stressful diseases). Type 2 diabetes is an inherited disease, but the gene of inheritance, and even the chromosomes that carry it, have not been positively identified. Some genes and chromosomes have been identified but there are probably many genes involved in different forms of Type 2 diabetes. Work to identify them continues since knowing the cause is the first step to finding a prevention or a cure.

The gene, or genes, for Type 1 diabetes is closer to being identified. Type 1 diabetes, which is associated with the immune system (immunology), is a syndrome of diseases rather than one disease. Immunology is closely associated with inherited traits (genetics). People diagnosed with diabetes are often found to have family histories of the disease. Genetic markers are now being revealed, and it someday may be possible for people to take a blood test that will show whether they are predisposed to get one of the diseases of this syndrome. Perhaps some future research will lead to the ability to make changes in the genes by gene splicing or insertion of the new genes, based on such findings so that a person can avoid both developing the disease and passing it on.

Prevention of diabetes, especially Type 1 diabetes, is a highly desirable goal. A study, called the Diabetes Prevention Trial (DPT), is currently under way for this purpose. In DPT-1, first-degree relatives (parents, children, and siblings of persons with Type 1 diabetes) are screened by a blood test that measures antibodies to the pancreas. If these are positive, further testing is carried out to determine how much damage has been done to the beta cells of the pancreas. If these latter tests meet certain criteria, the person can be randomized to either insulin treatment or no treatment. In the treatment group, insulin is given by injection in low doses to see if full-blown diabetes can be prevented. In DPT-2, first-degree and second-degree relatives (aunts, uncles, cousins, and grandparents) are screened with the blood test and, if positive, are randomized to either an oral form of insulin or a placebo. The purpose of the insulin in both groups is not to treat diabetes but to somehow interfere with the immune system and prevent diabetes in those susceptible.

Research is progressing rapidly in determining the relationship of the immune system to Type 1 diabetes and developing chemicals to stimulate or suppress the immune system. Although this work is still in its early stages, we are very hopeful that a way to prevent Type 1 diabetes will be found in the not too distant future. We strongly hope that this is the last generation of children who will develop Type 1 diabetes.

There is also a nationwide study on the prevention of Type 2 diabetes. This is designed to see if Type 2 diabetes is preventable. Known as DPP, it is a study of people who are likely to develop Type 2 diabetes based on screening criteria such as a history of previous gestational diabetes; people who are obese have a strong family history of diabetes and are in certain high-risk ethnic groups; and similar other criteria. These individuals are divided into several groups such as those who participate in support groups with diet and exercise only, groups taking an oral hypoglycemic drug, and groups taking metformin as well as a control group to which nothing is done. The people will be followed for several years to see if the incidence of developing full-blown diabetes is different with different forms of prevention. It is hoped that one or more of the treatments will prevent people from developing Type 2 diabetes and the treatment can then be transposed to the general high-risk population. It should be a lot cheaper in both money and human suffering to prevent than to treat diabetes.

Update for Management of Type 1 and Type 2 Diabetes

The attitude toward the management of Type 1 diabetes, and to a lesser extent Type 2 diabetes, has been greatly changed by the Diabetes Control and Complications Trial (DCCT), which has shown conclusively that we need to obtain and maintain a high degree of control in order to prevent complications of diabetes. This has resulted in a great impetus to develop new methods of management. Various people are searching for new ways to provide this management using various kinds of protocols, algorithms, and mathematical formulas. It has been shown that the exchange system does not fit well into this kind of management, so new dietary regimens or methodologies are being searched for and researched in order to improve control. These include carbohydrate counting and the point system. Carbohydrate counting is in fact a modification of the point system.

However, the techniques for really good control in keeping with the DCCT focus and principles have been developed in the past. They are: (1) the care of the individual with diabetes by an especially trained team that is educated and experienced in the management of Type 1 diabetes; (2) education of the patient in all aspects of diabetes including principles of self-management so that the patient can become empowered to take responsibility for his or her own care; (3) the use of a flexible dietary program that will match the insulin administration and, finally; (4) a flexible multidose insulin regimen that then can be modified to fit the various lifestyles of individuals with diabetes. These are the principles that have and will guide the development of methodologies for managing Type 1 diabetes.

The DCCT study has proven beyond a doubt that blood sugar needs to be controlled in order to prevent the complications of the disease. But this study involved only people with Type 1 diabetes. What about Type 2 diabetes? Several studies have now been done to prove the same thing for Type 2 diabetes. The best of these studies is the UKPDS, the results of which were released only a few weeks before this was written. The study was discussed in an earlier chapter and will not be further discussed except to say again that the study is conclusive that control of blood sugar and blood pressure will prevent the complications of diabetes. This points up again the need for diabetes education, self-monitoring of blood sugar, and involvement of yourself in the day-to-day management of the disease, whether it is Type 1 or Type 2. This need for good control may lead to more persons going on insulin sooner than before, but this is a small price to pay for good health. New oral agents have been and are being developed to help keep people in good control without insulin, but the important words are good control, not the tools we use to get the good control. Don't be afraid to use whatever tool or tools work for you and assist your doctor and educator in finding the proper tools by supplying the needed data (i.e., your daily blood sugars). These drugs can be combined in a variety of ways to effect good control. One, two, or even three drugs at a time can be used with or without a variety of insulin schedules to accomplish your goal: a long, healthy, productive life free of the complications of diabetes mellitus.

There are a number of other drugs being developed to work in association with lowering your blood sugar to assist you in a better life. Some of these drugs are to regulate the emptying of the stomach, either to slow it down or to speed it up. There are also drugs being developed to slow, prevent, or reverse various complications. Unfortunately, many of these drugs tested so far are quite toxic, but the work goes on to develop better and less toxic drugs for these purposes. We hope that other technologies such as insulin that can be inhaled, taken orally, or be absorbed through the skin, implantable sensors, bloodless meters, et cetera will soon be available. Until they are, it is very important that you use the tool available to maintain as good control as possible in order to prevent complications and to benefit from these new developments when they become available.

All this has led to the need for more self-blood-glucose monitoring in people with Type 2 diabetes so that these various medications can be individualized to meet the specific needs of these people as their needs change. Without self-blood-glucose monitoring, and education, medication cannot be tailored to the needs of the individual, and the kind of control necessary to meet the standards of the DCCT and the UKPDS cannot be obtained. Therefore, it is our feeling that all diabetic patients should be well educated and should be doing self-blood-glucose monitoring.