Dr. Kevin Most: Diabetes

Dr. Kevin Most

This past week we saw quite a bit of news on Diabetes. The cost of insulin, the impact of that cost, the impact of exercise with Seniors and diabetes, the epidemic numbers of type 2 diabetics and the latest update on a possible vaccine. Each of these remind us it is probably time for a quick primer on diabetes.

So what is diabetes? This is a disease that impacts how we use and regulate glucose in our body. Glucose being the power source for cells in our body to function properly, to protect us and to make sure our structure is correct. In order for our body to use glucose appropriately we need a hormone named insulin. Insulin is made in the pancreas. What it does is signals cells in the body to absorb glucose so it can be used for our energy source. It also allows us to store glucose in our liver and muscles for use when we have not eaten for a while, thus making sure we have glucose to keep our body running even when we are fasting.

Here are some quick diabetes facts-
1.) 30 Million people in the US have diagnosed Diabetes, 90-95% are Type 2 diabetics
2.) Over 8 million have not been diagnosed,
3.) If we add in the 85 million pre diabetics we are over 100 million people in the US ( close to 10% of the country)
4.) 1.4 million new cases of diabetes each year in the US
5.) Cost to the US health system is $327 Billion/yr.
6.) Per capita healthcare costs for a diabetic is 2-3 times higher when compared that to the average cost of non-diabetic

So what happens in diabetics? In the disease we term Type 1 diabetes, some call it juvenile diabetes, the pancreas does not make enough or any insulin. This occurs because the body for some reason turns on the immune system and it attacks and destroys the pancreas cells that produce insulin. It is somewhat similar to arthritis, where the body’s immune system attacks our joints. For some reason the body decides that these cells are foreign and attacks and destroys them. Because of this attack the body cannot make insulin and thus needs insulin to be delivered from an outside source. The body does not fight the insulin, it just fights the cells that make insulin. We know that in some cases this is a genetic issue that is handed down from generation to generation, however in others there is no genetic trail. In those patients the thought is there may have been a viral infection that has triggered this immune mishap.

Type 2 diabetes or Adult onset diabetes is completely different. In these individuals the pancreas is working just fine producing insulin, in fact in many cases it over produces insulin as it tries to control blood sugar levels. In these individuals the body becomes resistant to insulin and thus it is not able to function properly. The body initially will compensate to make additional insulin to push past the resistance, however this fails and the body is unable to properly regulate the level of glucose in our body. Because of this Type 2 diabetics do not need more insulin they need medication that helps the insulin they make more effective. The medications essentially lower the resistance of insulin.

Type 2 diabetes is by far the most common form of diabetes, many feel we are hitting or have already hit epidemic numbers of this disease. 95 % of the close to 30 million people with diabetes have Type 2. Obesity is a major independent risk factor for developing Type 2 diabetes. The importance of weight control or even modest weight loss can help control this disease and the adverse effects it has on our body. The bad thing about Type 2 diabetes is that a large portion of this group have yet to be diagnosed and are receiving no treatment. Although it was once called Adult onset diabetes, this has changed back to Type 2. One of the reasons is that we have seen a dramatic increase in the number of obese children who have Type 2 diabetes. This is very concerning as the lifelong adverse events from diabetes should not be started as a youth.

We also see a large increase in those over the age of 65 where we see rates as high as 30% of all seniors with this illness. A recent study has shown the importance of daily exercise in seniors. We know that daily exercise helps with bone strength , cardiac wellness and psychological wellbeing. One are we did not understand until just recently is the impact inactivity can have on seniors and their risk of Type 2 diabetes. Research that just came out, shows that inactivity in Seniors for 2 weeks has a very significant impact not only on muscle mass but more importantly on advancing Type 2 diabetes in individuals. Individuals who were thought to be pre diabetic ( 84 million people in the US carry this diagnosis. It occurs when your blood sugar is higher than normal but not at a level where you would be considered a diabetic) These pre diabetic individuals were monitored for both their glucose levels as well as the number of steps they took each day. Individuals with less than 1,000 steps a day are considered homebound. This study showed that even 2 weeks of minimal exercise caused individuals to become full blown diabetic, the more concerning factor was that these seniors when they reverted back to their normal exercise pattern did not shake the Type 2 diabetes that younger adults can do by exercising. In seniors it appears to have a longer term effect which is discouraging. This also highlights that we must have seniors maintain their activity as much as possible.

So why are we talking about this today? Well last week two stories hit the news, one positive and one negative. As today is Monday, let’s get the bad news out of the way and finish with potentially good news. Last week national news picked up on the story of two deaths of diabetics, who died because they were unable to afford their insulin. Now we talk about the long term effects of diabetes on our eyes, heart, kidney and brain, but we rarely talk about the life threatening immediate concerns that a very elevated blood sugar can cause. Elevated blood sugars can cause the body to go into a coma and in some cases actually cause death. Insulin in these cases is the only thing that can save their lives. The cost of insulin has risen dramatically in recent years. The hormone itself is approaching 100 years since its discovery by a Canadian physician who identified it and then found out when given to dogs it lowered their blood sugar, now we had known about diabetes for 300 years but it has only been in the past 100 years that we have been able to treat it. In 1922 the first human was injected with insulin and it saved the life of a 14 yo boy, the next year the physicians, Dr Banting and Best won the Nobel Peace prize in medicine for this discovery.

Insulin as you may know is given by shots. The typical diabetic may give themselves 60,000 shots of insulin over their lifetime. You may ask why hasn’t anyone made this into a pill and there are 2 main reasons, one is the digestive enzymes in the stomach will break up the insulin and make it worthless and the second reason is the insulin that is not broken down is not absorbed.

For years up until the 80’s a lot of the insulin actually can from animal sources like pigs or cows. It was harvested , purified and used. Since the 80’s we have seen more synthetic or man-made insulin that mimics human insulin. Insulin manufacturing is complex as we have insulin that works quickly and others that work slowly. This combination allows for the insulin to closely mimic what is happening in the body. When we eat a big meal the body secretes insulin to control the large amount of glucose it is exposed to. As we digest food the amount of insulin needed decreases so the long acting insulin is then put to work instead of giving more shots. There is also some insulin that can be given thru the nose as an inhalation but it is costly and thus not studied well.

So why has the cost of insulin skyrocketed to a point that people cannot afford it? Insulin that in the past was priced at less than $35 a vial is now approaching $300. The answer is not totally clear, one reason speculated is that there are only 3 manufacturers for insulin and thus the competition for price is not there. Also the price that is being quoted is for the newer more exact insulin and the lower price less stable insulin is still available at a lower price. However it does not work as well or as accurate as the newer designed insulin.

The other interesting fact is that the oral medications that are used for Type 2 diabetes have actually fallen.

One of the biggest problems and actually plays into the media coverage of this is that the only individuals who pay list price are those without insurance. Many with insurance will pay a co pay which is usually a fraction of the list price. The stories that hit the news this week highlighting this issue shared stories of individuals who lost their jobs and insurance and were forced to pay list pricing for their medication. You have to realize that Type 1 diabetics also need equipment to check their own blood sugar a few times a day as the insulin dose is based on the glucose level. These individuals were then hit with the cost of the monitoring as well as the cost of the insulin. They could not afford it and they died from high blood sugars, the story was there to highlight that with the number of diabetics in the country and this cost rising we may see more of these stories.

So what is the good news? Well this one is a bit interesting, we have all heard of the disease Tuberculosis. This illness in many countries has been kept in check with a vaccine known as BCG vaccine and it has been used since 1908. It is used across the world to keep this disease in check. Over 100 million doses are given to children each year. The vaccine is given in 2 shots four weeks apart. Researchers noted that individuals who had received the vaccine had lower blood sugars after taking the vaccine. Researchers at Mass general in Boston are now doing a study to see if this vaccine could actually be used to treat Type 1 diabetes. Researchers think the vaccine works in 2 ways, the weakened virus consumes glucose and the body’s immune system is controlled better to not trigger the immune system from turning against itself. The vaccine is also showing some promise in patients with MS as well.

This vaccine study had been going on for 8 years with some mixed results initially but with much better results after 4 years and promising results 8 years out. Because of these results with a small population the study is now being expanded to a large number of individuals with Type 1 diabetes. Now we don’t want people to think this is a cure and we have eliminated diabetes, but we do need to be somewhat excited that this may lead to more research on the immune system that stops us from attacking our own cells. One cannot minimize the impact that this would have, think about not only the cost of medication but more importantly the cost of treating the adverse events that diabetes causes, heart attacks, vascular disease, kidney failure, amputations, cancer…. This list goes on. So the financial as well as quality of life cannot be minimized.

Researchers at Mass general are now also doing a study on Type 2 diabetes and the impact of the BCG vaccine, this study is currently being done in mice but with good results would be expanded to humans for trials as well. These trails can move along more quickly as the vaccine being used has been used for decades and thus it is known that it is safe.

That being said, we do need to realize that the best treatment for Type 2 diabetics is exercise and weight loss, even a small drop in the weight can make a dramatic difference in the level of glucose in their body