The Future of Diabetes Part One

Will we ever find a cure for diabetes? Are there technologies that will help people manage diabetes more easily?

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Episode Transcript

Speaker 1 (00:00):
Brought to you by Toyota Let's go Places. Welcome to
Forward Thinking. He there and welcomed up Forward Thinking, the
podcast that looks at the future and says, I like
to play the drums. I think I'm getting good, but
I can handle criticism. I'm Jonathan Strickling, I'm Lauren Volga,

(00:23):
and I'm Joe McCormick in. Today is going to be
the first part of a two part series we're doing
about the future of diabetes and diabetes treatment. And Lauren,
this is a topic you have been hankering to do
for a while. I've I've been suggesting it for kind
of ever because I keep I keep running into all
of these new research articles about amazing things that have

(00:46):
been done in the in the treatment and diagnosis of diabetes,
and and it's a really big issue. I mean, this
isn't a thing that, like, you know, seven people are
are dealing with. This is this is a little bit
larger than that. Not not at things that only seven
people are dealing with are not worth looking into me
for those seven people, it could be it could be huge,
But no, that is exactly the point that why we

(01:08):
wanted to tackle this. Diabetes is something that affects millions
of people, It's going to affect millions more in the future. Obviously,
It's one of those topics that we should look at
and say, what's the forward thinking approach to dealing with
managing uh, diagnosing, perhaps in some distant future, curing diabetes. Yeah,

(01:29):
I would say with diabetes, it's not exactly like all
other diseases, not not just because it affects so many,
but because it is one where I would say, at
least from from where i'm you know, I'm no expert,
but just in what I read the end does sort
of seem to be in sight with diabetes more so
than with many other chronic diseases. At the very least,

(01:49):
the facility with which we can manage diabetes today has
has increased exponentially over the last several decades. And there's
just a lot of research progress. Yes, their entire organizations
that have been UH in in existence for since like
the nineteen forties, that have been dedicated to researching and

(02:12):
treating and diagnosing diabetes. So ah, yeah, and before we
got into this research, I didn't realize how long ago
people knew about this. Wow. Yeah, we've got a timeline
to go through. Yeah, I went a little crazy, y'all
when I was researching the history of diabetes and our
understanding of it, and uh, we should all know better

(02:32):
than to put a history section in there. I kept
thinking I should skip some stuff, but I kept finding
things that were so fascinating. But first, let's let's talk
about some numbers about why this is such a big deal. Yeah. Yeah,
because he said millions of people. So I mean, so,
so what's what's what's millions of people? We've got like
like trillions of people on the planet. Not quite trillions yet,

(02:53):
but sometimes it feels that way when you're on a
crowded Marta train. But according to Center for Disease Control
report in UH two thousand fourteen, there are twenty nine
point one million people in the United States who have diabetes,
and eight point one million of those people are undiagnosed.

(03:13):
So there's only like three hundred and something million people
in the United States. That's like significant percentage, nine point
three percent of the population in two thousand fourteen, so
not almost ten percent of the population having diabetes, and
out of that group, twenty seven point eight percent of
them don't have it as a diagnosed condition. They may

(03:34):
be aware that something is wrong, especially if they're suffering
some of the more severe symptoms of diabetes, but they
haven't been formally diagnosed with the disease. Um percentage wise,
the group that has the highest incidents rate of diabetes
is the sixty five and older group. That's twenty five
point nine percent of the population, more than a quarter

(03:55):
of all people over the age of sixty five the
United States have diabetes. As with many diseases, this is
a disease where risk factor tends to increase with age. Yes, yes,
and then uh, the actual largest as far as sheer
numbers go, Like the largest number of people that would
be in the forty five to sixty four year old

(04:16):
age range with the thirteen point four million diabetics, but
that only accounts for sixteen point two percent of people
in that age range, So percentage wise it's fewer, but
in sheer numbers it's the largest population. So uh, one
of those fun things that you start to think about
when you start, you know, grouping people into percentages. Uh.

(04:37):
More men than women are diabetic in the United States.
They're fifteen and a half million men with diabetes versus
thirteen point four million women, and that same CDC report
estimated that the total cost of diabetes in the United
States in two thousand twelve was two hundred forty five
billion with a B dollars two d forty five almost

(04:59):
two hundred fifty billion dollars. Uh. So that includes both
direct and indirect costs. So if you look at just
the direct costs of diabetes, this being the diagnosis and
treatment and management of the disease, that's seventy six billion.
So still I mean enormous number uh, indirect costs in
case you're wondering, well, what what the heck is that entail?

(05:22):
According to the CDC, they were lumping in things like disability,
loss of productivity due to the fact that people are
missing work uh, and premature death as contributors to indirect costs. Globally,
it's been estimated that about twelve percent of all health
expenditure is going to diabetes treatment. So yeah, this is

(05:43):
where the word trillion can be the start can start
to get thrown around, because when you're looking on a
global scale, uh, it is it is an enormous issue,
both financially and obviously as a quality of life and
and just health and survivability issues around the world, which
is why we're really tackling it. It doesn't look like

(06:04):
things are getting particularly better right now. The diabetes UH
prognosis is that it's going to be on the increase
over the next few years. Yeah, despite the optimistic news
that we're going to have it lit like like like
kind of the warning signs are out there. Researchers are
sort of going like, hey guys. Yeah, According to one

(06:25):
paper I was reading, by twenty thirty, there's an expectation
that there will be five hundred fifty two million people
with diabetes worldwide. And and it's difficult to make global
estimates about this kind of thing because some researchers think
that many more cases go undiagnosed and underestimated. Even in
those undiagnosed cases in other parts of the world, the

(06:46):
number of cases right now could be of what we
currently think there are a k A about five hundred
and twenty million cases worldwide, which would mean that you
would guess that number for would be even higher because
that was based upon sort of what we are pretty

(07:06):
sure or what we know so far. Right right in
the US alone, rates and expenses of diabetes are expected
to very nearly double during that time period. Yeah, that's
something else we'll be chatting about quite a bit. In fact,
let's go ahead and kind of transition into that. There's
been a lot of news over the past several years
about increases in the price of insulin, and we're going

(07:28):
to talk more about diabetes and what insulin you know,
what factor insulin plays in diabetes management. But the important
thing to remember here is insulin dosages are are something
that that people with type one or type two diabetes, uh,
that's usually part of their diabetes management. People with type one,
you need it. People of type two, you might not

(07:50):
need it, but you should certainly have access to it. Yes, yes,
So there are a lot of different types of insulin, uh,
not just in how it interacts the body, but how
it's produced. And that makes this conversation a little more complicated.
It it's not like we have a single that that
says insulin and you just draw off as much as
you need and you're good to go. There's actually lots

(08:12):
of different types. There's long acting, there's short acting, there's
instant acting. There's all different types of ways to derive insulin.
So it gets pretty complicated. But The thing you need
to remember is that the pharmaceutical game is a for
profit deal. So as that it means, you know, the
companies are trying to make a profit selling insulin no

(08:34):
matter what the type. Maybe there's not as much competition
as it sounds based upon the fact there's so many
different types of insulin. There are actually a few major
companies that are They provide the vast majority of insulin,
and at least in the United States um and there
are a lot of other factors that are playing a
role here, including drug wholesalers, pharmacies, insurance companies, all of

(08:58):
these things of act the price of insulin, and part
of the price also depends upon something that is completely
independent of diabetes and the demand for insulin, and that
is that the overall drug sales have been on on
a decrease like they would they've been decreasing over time.
So that sounds like that's pretty good except for pharmaceutical

(09:20):
companies that want to make a profit. One way you
can offset your losses in one area is to increase
the prices of another drug that's still in demand in
another area. And while that's not the only cause, or
even necessarily the primary cause for insulin prices on the increase.
It is a factor. It is a contributing factor. Um.
In fact, pharmaceutical companies said as much in a two

(09:43):
thousand eleven Reuters Health summit. They admitted to the fact
that part of the reason the insulin prices were on
the increases because other drugs were not selling as much.
So you cover your losses in one area by increasing
the price on another. It's frustrating, but that's kind of
how capitalism tends to work. So um. Anyway, the drug

(10:06):
companies are are really seeing a benefit to the strategy,
as you would imagine. I mean, you've got a growing market,
more people being diagnosed with diabetes who need access to
these medications. You can increase the price of those medications,
so more people buying stuff for more money means yea
for companies that make the stuff right. So um, And

(10:29):
I don't want to demonize anybody in this. It's not
I certainly have very strong opinions. Might not want to No, no,
I I I absolutely understand their their strategy behind this.
But when you when you hear stories about parents of
children with type one diabetes who are paying as much

(10:49):
as their mortgage every month to to get an insulin supply.
It's like, oh, that's not that's not chill. Yeah. There.
I do have a lot of strong opinions, but they
also range on the political scale, which is why I'm
trying trying to be as objective as possible. Absolutely that
that was that was an emotional aside from me, and

(11:09):
I completely agree with it for the record. But another
issue that we have here is that the United States
doesn't regulate the price of prescription drugs. So this this
really plays into that. Right, we don't have a regulatory
body that says you can't do that. We're we're seeing
stuff play out right now in the United States that
is sort of related to this issue. You know, we

(11:30):
had the Congress calling up the CEO of the company
that makes EpiPens to really talk about the increase in
EpiPen costs over the last you know, five or six years,
and so we're starting to see that kind of take
a turn here in the US. But as of right now,
there is no official body that says, hey, you can't

(11:52):
charge that much because people real people are dying or
suffering or or there they're taking extreme measures to stretch
their supply as much as possible in order to be
able to afford to live, and so there's there's a
lot of that going on right now. Also, you might

(12:12):
remember we did an episode about biologics, and insulin falls
into that category, meaning that there they aren't as easy
to replicate in the lab as small molecule drugs that
you would you would create a generic for. Right It's
it's a relatively uncomplicated biologic, but it's still much more
complicated than for example, UH aspirin. Yeah, so you know,

(12:33):
and patents can expire on the process for creating uh
biologically um derived drugs, But that doesn't necessarily mean that
someone's going to come along and create a cheaper, faster,
uh more efficient method of manufacturing it and thus lower
the cost and pass the savings onto you. That's not

(12:54):
necessarily going to be the case. In fact, there's only
so much cost you can cut from the manufacture RNG
side on the on biologics, So, uh, that doesn't necessarily
mean someone couldn't come in and sell the stuff for less.
But why would you when you can be making all
of this lovely money. But she can make a beautiful hat. Yeah, yeah,

(13:15):
you can. You can sit there and uh and and
light your your your giant stogie with your hundred dollar bills. Um,
I'm sure they're using it for for drug development and
paying many of their hard workers as well, not just
for money, hats but but but exactly, I mean getting
into numbers, it's hard. Another thing that it's difficult to
estimate is is the actual cost of a drug here

(13:37):
in the United States because the process of obtaining obsurance, insurance,
and then obtaining drugs either through that or through another program. Um.
It it means that we don't have like a solid
price sheet for a lot of stuff. But you looked
into one of the estimates, Yeah, this is okay, So
this is This again illustrates how complicated things are here

(13:59):
in the US and then other parts of the world
to UH. You could have two people in line to
buy the exact same drug, and one person is going
to pay one price and another person is going to
pay a dramatically different price, and it could all depend
upon the way that they are paying for that drug,
whether it's out of pocket through insurance, through programs like medicaid. UH.
These all have an impact, and it's all because of

(14:20):
the different relationships that are going on. Behind the scenes
to set prices, and it gets kind of crazy because
like we're used to the idea of you go to
a store and if if Lauren wants to buy like, uh,
some some chocolate milk, and I want to buy some
chocolate milk, We're not charge different prices for that chocolate milk.

(14:41):
I mean it might be it might be like twenty
cents more expensive at like your favorite big box store,
us my favorite, but if we're going to the same store, yeah,
I mean, I mean, okay, let's be fair. Some stores
they have a picture of me and they say, charge
an extra dollar for chocolate milk. He is a chocolate
milk fiend and he doesn't pay attuch the price tags.
But in a fair world that doesn't happen. But in

(15:04):
the drug world, that's it's totally different. So there was
a research fellow, Dr Jing Lao, who was worked in
the division of pharmacoepa, demiology and pharmaco economics. Wow, I
didn't think I was going to get through either of
those at Brigham and Women's Hospital in Boston. It wrote
an article in two thousand and fifteen for JAMMA in

(15:26):
Internal Medicine. I always like to go Jamma for this,
you know, getting jam out. So he found that between
two thousand and fourteen, medicaid costs per unit of insulin
increased between six dollars and eighty six per unit to
fifteen dollars and thirty eight cents per unit, depending upon

(15:48):
the type of insulin. Now this was just through Medicaid,
but but the same is true across the board. And
he said, no matter how he cut or analyzed the data,
there was always a price increase. It didn't matter how
he was, like, you couldn't massage the data so that
there wasn't a price hike, right to clarify, Yeah, like
like like increasing by six dollars and eighty six cents

(16:08):
was the lowest of the price increases that occurred. And
and it went all the way up to that fifteen
per unit per unit, and and that was and again
it depended upon the type of insulin. Like we mentioned earlier,
there were tons of different types of insulin um and
some types of insulin, like long acting insulin, were affected
more than others, largely because fewer diabetic patients were using

(16:30):
long acting insulin and companies still had to produce it.
There's still a demand for it, but to offset that
manufacturing costs of producing something. When you know, if you're
a company and you're producing insulin and no one is
using this particular type, you could shut that production down,
switch that those resources to something else and make more money.

(16:51):
But if there's still a demand for it, but it's
not as big a demand as it used to be,
then the way you cover those losses again as you
hike the price UH. And this sends up being a
burden on people who are dependent upon that specific type
of insulin. UH. This is a huge problem for a
growing number of people, So it's it's even more more

(17:12):
concerned than if it were just a huge problem to
start with. It's a huge problem and the number of
people effects is increasing. So diabetes is an illness that
disproportionately affects people in lower socioeconomic classes, largely because they
may not have access to UH a good healthy diet,
and or they may not have the opportunity to do

(17:33):
any sort of exercise routines or anything. Things that have
been shown to, if not prevent diabetes, often either decrease
its effects or or put off when it would actually
set in for a person. So sure Sure also recent
studies have shown and we'll talk about this a little
bit later, that stuffit like a like stress and even
air quality can can be increasing risks can can increase

(17:58):
your risks of developing type two diabetes. And not only that,
but you have people in these same socioeconomic classes who
will go to extreme measures to skip or ration medications
to reduce that financial impact they have for purchasing medications.
That can also lead to patients attempting to manage diabetes
primarily through diet, like in other words, trying their best

(18:21):
to eat a healthy diet and not have to take
insulin because insulin is so expensive, which certainly helps um
and can in some cases lead to effective management of
the disease, but in many cases it cannot. Right there,
it cannot help in type one. I mean it will not,
it will not magically have you produce insulin if you

(18:42):
have type one diabetes. Will talk more about that in
a second. If you have type two diabetes and it's
not severe, it might be that through managing your diet
and exercising more, that's all you need and you don't
have to take any insulin shots or or have any
other method of having insulin doses. But for some people
that's just it's just not enough. It's physically not enough.

(19:03):
It's not that they are bad people. Is not that
they aren't working hard enough. It is not that they're
not eating healthy enough. They literally aren't producing enough insulin.
So I want to make that clear. I don't want
any sort of blaming going on here for people who
actually are suffering through this. I mean, if you can,
if you can get a direct facts to that, to
those people's like pancreas, pancreases, pancrea, um, then maybe you

(19:24):
can blame the pancreas. Yeah, but as far as we know,
the pancreas is not one of the more sentient organs
and therefore hasn't made any you know, actual decisions. It
never responds to my snapchats. Yeah, weird. I wrote a
song about it. Yeah, yeah, he wrote a song about
the pancreas. I don't remember that. I just remember that.

(19:46):
There is one. That's all I wait, no, are you
thinking of part of like a surgeon? No? No, no,
that is that that song I could do from beginning
to end right now, because he finally made it through
med school somehow he made it through. But no, the
there is to a karaoke episode. Sometimes oh man, she
knows not what she asks for. So at any rate,

(20:09):
we need to remember that these effects aren't just devastating
for the people who can no longer afford or or
have are having difficulty affording insulin. It affects all of us, right,
because whether it's affecting us through insurance rates or other
types of economic factors, even if you have no emotional

(20:29):
connection with somebody who's going through this, there is an impact. Yeah,
that the loss of productivity in a workplace, the the
overall right, the rates of insurance, the the the rates
of hospital availability due to those resources being taken up
by by people who have unfortunately encountered side effects with
that kind of disease. Um. I mean, you know, what

(20:51):
I'm saying is is that you don't have to be
a crazy socialist in order to get to want to
help solve this problem. Now, this this problem is something
that everyone, regardless of your economic philosophy, should want solved
because no matter what, it does have an impact, right
you know. So uh and so yeah, so, what what
is diabetes? We've been talking about it for like for

(21:14):
like trillions of well, you know, like like I wanted to.
I wanted to do that thing where we go like like, hey,
there's this problem, you've maybe heard of it, and then
we describe what it is. It might have been better
to do it. This is great, all right, Yeah, diabetes,
Let's let's talk about diabetes. Yeah, so diabetes. Hey, and

(21:34):
I'm gonna take laughter wherever we can find it in
these episodes, because this is something that I feel very
strongly about. In the interest of full disclosure, one of
my parents is type two diabetic, so this I I
and I also obviously I am concerned. I'm I don't
know if you guys know this, Lauren, you do because
you bring it up all the time. I'm getting up
there in years, so I am concerned about this sort

(21:57):
of stuff. I think that if you go back through
the record, did Joe and I have equal mocking Yeah,
but you are also my co host on text for
two years, so I don't think I've ever mocked your age.
Usually you're the one who brings it up, That's true.
I I am probably the most guilty of the three
of us. So. Diabetes, also known as diabetes militis, is

(22:19):
a disease in which the body suffers due to blood
sugar levels that are too high. So glucose levels in
the blood are above healthy levels. And glucose, to be fair,
is important stuff. I mean, it is what our cells
use as a fuel source. But to get the glucose
where you need it, your body produces a hormone called insulin,

(22:39):
and diabetes is a disease really kind of a family
of diseases that impact insulin production leading to increased blood
sugar levels. So you mainly have type one and type
two diabetes. There are other ones as well, but those
are the two big broad categories, right, and so the
common distinction that is made is the type one diabetes

(23:00):
is the diabetes that is experienced from early onset diabetes,
and type two diabetes is adult onset diabetes. Yeah, that's
why it used to be known as In fact, that
was the official term for type two diabetes until relatively recently,
when when I guess you realize you didn't have to
be an adult. Yeah no. But but as as we've

(23:21):
said earlier in this episode, in type one, your body
does not produce insulin at all, um, and that is
because type one diabetes is actually an autoimmune disorder. The
bodies over zealous immune system is targeting and killing the
cells in the in the pancreas that make your insulin
for you. Yeah, those are called beta cells or some

(23:42):
sometimes in in there. You go, yeah, yeah, no, wonder
I couldn't just say that. That's very strange. I looked
it up. But the yeah, the beta cells in this
case are attacked by T cells immune system white blood
cells right right that in the fact, there's ongoing research
about why the T cells attack the beta cells and UH,

(24:03):
and discovering the cause of this is one way that
we might be able to help discover ways of curing
diabetes in the future. But there is some research on
that that we will get to either later in this
episode or probably in the next one, actually, I think
in the second episode. Yeah, And then we've got type
two diabetes, right where the body might produce insulin, but
it doesn't do it very well. It's not very effective

(24:26):
at it, so glucose tends to stay in the blood
stream and accumulate and get to dangerous levels. It's the
It is much much more common than type one diabetes. Yeah,
in the United States, about of diabetes cases are type
two and UH. And what happens in type two specifically,
is that for a number of reasons um that the
body becomes resistant to insulin. It no longer insulin no

(24:51):
longer prompts your body's cells to take gluc to take
glucose out of the blood stream um. So, so you're
glucose levels in the blood remain high, which prompts your
pancreas to keep making more and more insulin um. Eventually,
this leads to an overload situation where the pancreases beta
cells start dying off because they just haven't had a break.

(25:14):
And then there are other types of a big one
being gestational diabetes that occurs in about seven percent of
all pregnant women in the United States, has the same
symptoms as type two diabetes, and generally happens the first
time a woman is pregnant. It often will go away
after the woman gives birth, but it can increase the
risk of the woman later developing type two diabetes. So,

(25:34):
and like we said, there are other ones as well.
There's one that's actually linked to steroid usage in fact,
But but but the primary ones are are really type
two and then type one. Uh so, what's the big deal? What?
Why are we worried? About glucose in the bloodstream. Well,
in and of itself, it's not terrible, but it leads

(25:54):
to some deterioration of different things in the body. Yeah,
like your kidneys and your eyes are often to u
two types of tissue that are are first affected by this.
So you can suffer impairment, vision impairment, you can go blind, Actually,
you can suffer really bad kidney damage. You can also

(26:15):
cause nerve damage. It could contribute to heart disease or strokes,
as well as some other related issues. It can also
necessitate amputation in some cases. And the reason for that
is that you could suffer nerve damage in your extremities,
mostly your feet, most frequently your feet, and then not
notice when you when you develop things like sores or

(26:36):
other injuries on those on your feet, which can then
get worse and worse to the point where they necessitate
an amputation. Um. And so actually that's one of the
things that that doctors will tell you if they diagnose
you with diabetes is to frequently inspect your feet because
you may have uh sores or wounds or something along

(26:57):
those lines that you weren't aware of because you couldn't
it due to the nerve damage. But if you're able
to take care of your feet, then you can you
can avoid the necessity of an amputation further down the road. Um,
and all of this is part of why it's so
important that that people have access to insulin who need it,
because that helps that helps mitigate that kind of damage. Yes,

(27:17):
uh yeah, so this is life or death was really
what we're talking about, you know, it's and and to
really bring home how big a problem this is and
how long it's been around, we now have Jonathan's epic
timeline of diabetes, not my personal one as far as
I know, I'm if I do have diabetes, I am
I'm currently undiagnosed. Uh, but it really is an epic

(27:41):
timeline though, oh yeah, no, it's crazy. So the first
timeline I consulted really started in nineteen ten, and it
was going it was going into like the formal, academic,
real deep study of diabetes. But if you want to
look at how long have people been aware that something
along these lines was going on and sort of the

(28:02):
path of discovery to figuring out what was actually happening,
you gotta go way back to fifteen fifty two b C.
And this is by the way just the earliest known record,
so it could predate like like our our knowledge of
something related to diabetes could predate this. But heasy Ra,

(28:25):
a physician, noted the symptom of frequent urination for an
as yet unnamed disease at that time, which is later
by by experts been identified as diabetes um In b C,
there are Hindu writings that make reference to an emaciating
disease that has an odd symptoms, which is that ants

(28:45):
are attracted to the urine of people who have the disease.
I imagine that's because we discovered later that the kidneys
are trying to purge glucose from the body through the urine. Yes,
so there's elevated levels of glucose or sugar in the
urine and ants like like sugar. So uh five that
are BC were the first descriptions of sugar being present

(29:06):
in the urine of people with the disease. The disease
specifically obese people. Two BC. Apollonius of Memphis coins the
term diabetes, so we get the terms that's crazy, that's it.
We got diabetes two BC. So the word means to
go through or to siphon and it's referencing the symptom

(29:28):
of a patient draining more fluid than they could consume,
so that frequent urination. So that was the defining feature
of the disease for a very long time because that
was you know, obviously, early physicians had to have very
limited um means to base their observations, right, They couldn't
look into the human body without usually killing somebody, So

(29:50):
that kind of made it difficult to pursue any kind
of harder yes, challenging first century c e. The Greeks
described diabetes as a disease that results in quote a
melting down of the flesh and limbs into urine end quote.
I love ideas that people have. Yeah, if you skip

(30:11):
ahead about a hundred sixty three years to one sixty
four in the Common era, Galen of Pergamum, a Greek
physician diagnoses diabetes as a kidney disease. Uh, this would
not be the only time people were slightly off track,
you know, they you can understand mostly urine kidneys equal

(30:32):
urine just working backward. Just turned out that they were
not quite on the right track there. Then we get
into the dark ages. Physicians would diagnosed diabetes with water tasters,
which is exactly what you think it is. I'm guessing
making water, tasting the water that you make exactly. The
physicians would take a sip of the patient's urine and

(30:53):
if they tasted sugar, if the urine had any sweetness
to it, they would know that the patient had diabetes. Wow,
jors really went the extra mile in the dark ages. Uh.
That's also when they added the word militis to diabetes.
Militis is Latin for honey, so sweetness. So you've got
to siphon from diabetes and then you have honey with

(31:14):
the militis siphoning sweetness from your body. Yeah. Yeah, So
sixteenth century we get a poetic go ahead, Paracelsus, who
is a Swiss German philosopher, physician, and occultist. Uh so
he said that diabetes is a serious general disorder. Getting
away from that specific kidney diagnosis from earlier. Uh, now

(31:37):
we're gonna skip over to seventeen seventy six. Lot of
stuff was going on that year. Don't know if you
guys are familiar with it, but you know there's a
whole musical about it. So I will bore you here
just to say sit down, John um. An English physician
by the name of Matthew Dobson made notes about diabetes
and noticed that some people die in less than five weeks,
while others can live with a chronic condition, and the

(32:00):
pending upon the severity, could survive for several years, which
is really the earliest record of someone making note that
there seems to be two different pathways for this disease,
not to the point where any kind of formal description
was made of either type, but rather just a general observation.
Then we get to a Scottish military surgeon named John

(32:23):
Rollo experimented with patients by putting them on a high
fat and protein diet after noticing that the sugar content
in their urine would increase if they ate starchy foods.
The idea was get them off the starchy foods, put
them on high fat and protein diet foods, and the
following year he published a work saying that there was
elevated level of sugar in the blood as well as

(32:45):
the urins. This is the first time we actually see
someone say maybe there's more to this. One of these
other humors could possibly be involved. Yeah, it's not not
that people were still using the idea of humor. Were
they They were not. People are still using it today,
all right, some people misuse humor, and I call those
the satire sites that don't know. Never mind, that's totally

(33:07):
different to how sorry, I just got completely distracted. Uh
skipping ahead of eighteen forty eight. By the way, there's
tons of other stuff that I could have included. I
finally got some self control. It began to not include
every little interesting fact that was coming across. But in
eighteen forty eight, a French physician Clothe Barnard we we,

(33:29):
I'm so bad at French. I casey, where's Casey? My
French is terrible. My French is terrible. So but anyway,
Bernard learns that glycogen is formed by the liver and
the knee hypothesizes that the same type of sugars found
in the urine of diabetics um. In eighteen sixty nine,

(33:49):
a German medical student Paul longer Hans, which is going
to sound familiar to anyone who's heard of the islets
of longer Hans, identified two different types of cells in
the pancreas. Now one type of cell. He said, all right,
I understand this. This is the stuff that secretes the
pancreatic fluids that we've kind of observed in previous medical

(34:10):
exploratory surgeries things like that would be another one of
the bile let's just call it bile. But the second
type of cells, which would be what we end up
calling the islets of longer hans, also known as the
beta cells that we've mentioned earlier, they produced something else
that was kind of a mystery to him. He wasn't
sure what it was that would turn out to be

(34:31):
the hormone insulin um and so, but this was the
beginning of that realm of exploration. In the eighteen seventies,
you had a French pharmacist named a Pollinaire Bouchard that
who made note that diabetic patients have less sugar in
their urine. During a time of food rationing in Paris

(34:53):
when the Franco Prussian War was taking place, so people
were having less access to food. He noticed that his
diabetic patient ended up having less sugar in their urine,
and it began to give them the idea that perhaps
there could be individualized diets for people who have this
disease and that that could improve their condition. Um thanks

(35:15):
Franco Prussian War yeah. Sometimes sometimes some interesting developments come
out during times of conflict, and they aren't necessarily directly
related to the conflict. It's just out of necessity we
learned things like that, So kind of fortuitous in a
weird way. Fortuitous for diabetic patients, not so much for
people who were fighting in the Franco Prussian War. In

(35:37):
eighteen eighty nine, researchers at the University of Strasbourg and
France remove the pancreas of a dog to see how
it would affect the dog's digestion, and they observed that
the dog developed diabetes. So they said, okay, so the
pancreas seems to play some role in this disease that
we've been studying for for centuries now but had very
little actual understanding about it. By nineteen away we get

(36:01):
German physicist George Ludwig Zuelzer who experiments by injecting a
quote pancreatic substance in the quote into diabetic patients. It
seems to work a little bit. It actually does decrease
the level of glucose in their blood. Yes, severe side effects.
It is not a purified method of insulin dosage um.

(36:23):
It ends up being uh, it's not an effective treatment
because the side effects are so severe. In the nineteen hundreds,
you have a couple of different things happening. Dr Elliott Joscelyn,
By the way, this is where my notes originally started.
Dr Elliott Jocelyn wrote the first edition of the Treatment
of Diabetes militis in nineteen sixteen. In nineteen Sir Edward

(36:46):
Albert Sharpie Schaffer, which is possibly the best name I
have ever read, can't his name is my name too,
published a study on the pancreas. Sir Edward discovered that
the pancreas produces a substance that non diabetics would produce,
and that would be insulin. So this builds on that
that islets of Longer Hans research that was done decades before.

(37:11):
Uh So, the name actually comes from insula, which means island,
and it's called that because the islets of Longer Hans
were the source of the hormone. So they just continue
to use the island's motif. Um. So we've got siphoning,
we've got honey, and we've got islands all all wrapped

(37:32):
up here in this disease. Your islands aren't working. You
will siphon honey yes in doctors Frederick Banting and Charles
Best would experiment with dogs that had had their pancreases removed.
They inject dog insulin into the experiment animals and they
see that the glucose levels go down. UH. They would

(37:52):
actually eventually get awarded the Nobel Prize for that. In fact,
technically Banting was awarded it and shared it with Best.
James call Up developed a means of purifying insulence so
that it could be used on humans, and then by
three just two years later, you get the first commercial
production of insulin from Eli Lilly and Company, which is
still a major producer of insulind. Over the next several years,

(38:18):
companies would develop different approaches to producing insulin, including slow
acting insulins, fast acting insulin's. You know, all these sorts
of different approaches depending upon UH what you were specifically
trying to manage UM. One of the things that that
people who have severe diabetes wrestle with is the fact
that going to bed is terrifying because you want to

(38:40):
make sure that you take the right insulin dosage to
manage your glucose levels without going hypoglycemic, meaning your glucose
levels fall too low. Because that can lead to a
very dangerous episode, and if you're asleep, there's no you
don't have any warning signs before it happens. So the
different types of insulin are absolutely necessary to to deal

(39:00):
with UH diabetes at different stages. By ninety six, you
get Sir Harold Himsworth who publishes a paper distinguishing the
two types of diabetes according to insulin sensitivity. But it
wouldn't be until nineteen fifty nine that these two types
are formally defined in medical literature as type one and
type two UH. The American Diabetes Association would form in

(39:22):
nineteen forty in response to increase rates of diabetes and
heart disease in the United States. By nineteen forty four,
you get the insulin syringe. It's a standardized syringe used
for insulin dosages and it actually UH It revolutionizes diabetes
management at that point, so the insulin was obviously the
first major development, but this syringe made it far easier

(39:43):
to administer the insulin and UH dramatically improve the quality
of life of millions of people who were suffering from diabetes.
Nineteen sixty four you get the first strips to test
blood glucose levels up to that point, you were testing
urine not blood, which was less accurate. Also, the earliest

(40:04):
tests were incredibly elaborate, like you had to boil stuff,
and yeah, you know it was it was a very
long process in order you just to get that initial
read out of how much glucose was in your system. Right,
And this is frequently the kind of thing that you
need to be on top of in a kind of
immediate sense for best best response. Yeah, yeah, if you're
because if you're looking at it and you're like, well, here,

(40:27):
these are what my glucose levels were an hour ago,
it may not be the case at that point, and
you know, or maybe that you've already suffered some terrible
episode because of it. Uh. The first blood glucose meter
would be developed in nineteen seventy, which was meant for
clinical use, not home use. It was like a five
dollar device in nineteen seventy and was meant, you know,

(40:49):
that was just at the doctor's office. You weren't going
to buy one and take it to your home. But
nineteen seventy also saw the development of a very useful
piece of technology, the insulin pump, which as of evolved
quite a bit since its first invention, but an insulin
pump helps remove the need to do regular insulin shots. Essentially,

(41:09):
it's a device is a pump that can pump insulin
into you and you can typically set the pump so
that it puts injects a specific amount of insulin into
your system and UH it was a huge help for
people trying to manage diabetes. It's standard issue for anyone
who has type one diabetes UH and is more frequently

(41:31):
being used by people who have type two diabetes. It's
not as common, but more type two are seeking out
the possibility of using a pump um. So this is
the way it works is that you typically have a
little spring loaded device that has the tube through which
insulin will be delivered into your body, and it's got

(41:54):
a little needle at the end of it to puncture
you and and insert a catheter under your skin. So
you would typically find someplace around your abdomen. You would
place the spring loaded device onto that site after you've
already prepped it obviously activate it. It would then essentially
inject and then place the catheter into into the place

(42:17):
in your abdomen. You would remove the device. You would
then remove the needle and then you're left with a
catheter that leads into your body and the pump can
pump inslin directly into your system that way, um, and
it's designed at a point now where people can self
administer this. Actually watched a video of a young boy,

(42:37):
I mean maybe like twelve or thirteen years old doing this.
Hard to watch for somebody like me, who one I
feel a lot of empathy toward the kid, who, by
the way, was like, this is so much better than
having to give myself five or six in slun shots
to day. But also just the idea of like you've

(42:59):
got to do this and every and you can't just
set it and forget it. You've got to replace it. Like,
you can't leave it in place indefinitely. After after like
maybe up to three days, you would have to move.
You have to remove it and prepare a new site
and inject again. So it's a constant thing. It's one
of the things where you know, you're aware that this

(43:19):
is going to be part of your routine from that
point moving forward. It's one of the other things about
this disease that I think is easy to forget if
you have never had to deal with it. It's that
you know, the treatment for it and and even just
the monitoring of it can be painful. And it's something

(43:39):
that that diabetics deal with. I mean, it's much better
to deal with that than the symptoms of diabetes. Sure,
but you know, like just a prick is kind of
an argument that you could you could conjure up in
your head, but I don't know. Just to prick several
times a day every day for the rest of your
entire life is certainly certainly a thing. It's it could
be discourage. It can discourage people into even checking to

(44:02):
see if they should be diagnosed, because we have this
weird thing as humans we're not knowing is almost like
not having it. And if we don't admit it, then
we don't have to go through that that pain and
that frustration and that inconvenience. But the truth of the
matter is it's much better than the alternative. It's just
hard to imagine that when you aren't dealing with it yet.

(44:25):
Right moving on through the timeline, were almost done, uh
in the nineteen eighties. This is when researchers start to
develop the technique to synthesize insulin using bacteria, which really
simplified the manufacturing process allowed you to create much greater
yields of insulin um and it's still a complicated process,
but less so than it used to be. It also

(44:47):
means that there's less likelihood of having like a shortage
because you can more easily manufacture it. However, as we
mentioned at the top of this episode, it does not
necessarily mean it brings the price down, or at least
that doesn't. It's not a big enough factor for that
to be, you know, to to actually decrease the price.

(45:07):
So what was it like living with diabetes in the past.
Probably not very good. A lot of medical care in
the past. Yeah, Well, to be fair, if you had
type one diabetes, there wasn't really any living with it
at all. Anyway. You would typically have a life expectancy
of about five weeks because your body wasn't producing insulin.

(45:29):
No one knew about insulin, there was no it was.
It was pretty much a death sentence. If you had
type two diabetes, you might live a long life if
it's not a severe case and you're not over indulging
and you know, just just through happenstance um, but it
would also be a life riddled with complications. But for centuries,

(45:50):
no one knew how to treat diabetes, so your quality
of life would be poor to nonexistent, depending upon the
type you had. By the average life expectancy for a
ten year old child diagnosed with diabetes was one year,
so to eleven and that's it. If you were thirty
and you then developed diabetes, doctors will give you four

(46:13):
more years, And if you were fifty, the expected expectancy
was eight more years. So actually the older you were,
the longer you would survive after being diagnosed with diabetes.
But still, I mean you, you didn't have any reliable
treatments that could give you a better quality of life.
Doctor Rolo, who I mentioned earlier, wasn't the only physician

(46:36):
to attempt to treat diabetes with changes in diet, and
not all those attempts were successful. According to the Defeat
Diabetes Foundation, there was a French physician in the eighteen
fifties who treated diabetics by feeding them lots of sugar.
Well that makes a stupid kind of sense. If you
see the body is losing lots of sugar through urine,
then maybe you need to replace it. I don't know.

(46:59):
It didn't work, uh, and it was not a treatment
that was UM pursued for very long but and it's
not the only time people were wildly incorrect with how
they should treat diabetes, but it was one of those
notable ones. And I should also mention that while this
did appear on their website, I did some preliminary research
to try and find like some corroboration, couldn't find anything.

(47:22):
But that doesn't mean it it's not true. It just
means that while I like I was giving myself very
limited time for each of these items because I didn't wanna,
I didn't wanna spend too much time on this one
thing and then say like it's absolutely not true or
it really is true, and I didn't contribute anything else.

(47:43):
UM survival rates among infants born to mothers with diabetes
were really low. Initially, the fatality rate was greater than
fifty percent. Dr Priscilla White, who founded the Jocelyn Pregnancy
Clinic in nineteen dedicated much of her career to fighting
just aational diabetes, and by nineteen seventy four, Dr White

(48:03):
had reached a nine percent survival rate among babies born
to her patients, so an incredible turnaround of that that
rate so uh, I felt that was absolutely needed to
mention that Dr White played a great part in this.
Go twentieth century and go go go that, and go
that nice woman's research here. Yeah. Absolutely. By the nineteen twenties,

(48:25):
commercial production of insulin had really transformed diabetes management. In fact,
it became possible to manage diabetes beyond just trying to
change your diet. That was further boosted in the nineteen
fouries with the development of that syringe I talked about,
and by two thousand four, life expectancy for people with
diabetes was much longer, but still fifteen years lower than

(48:46):
that for the general population. So transitioning now into some
of the modern technology about how we diagnose and manage
diabetes today, Well, first of all, we've got a ton
of different gluecoast meters out there that are much more accurate.
They typically require you to to prick your finger and

(49:06):
put blood on a strip of paper and then analyze
that that blood using some sort of meter device, But
they tend to be very very accurate, which give people
a good idea of what type of insulin, how much
insulin they need to administer in order to manage their diabetes.
We have a lot better understanding of the effects of
different foods. So sometimes diabetics want to eat something that

(49:31):
is going to you know, raise their glucose levels, and
so they'll they'll sometimes at the rent fest and you're like, well,
there's going to be a deep fried Snickers bar. Yeah,
and so you might you might take that into account
and you adjust your your insulin dose dosage for that
day so that you can experience that. Like, it doesn't
necessarily mean forgoing all types of foods that you might

(49:53):
really like and then just eating things that are of
that aren't starching, like avoiding carbohydrates and highly uh. There's
also some improvements to technology so that insulin pump I
mentioned earlier. There are now wireless pumps that are in
various stages of development and deployment. And these wireless pumps,
first of all, when you're wireless pump, you might think like, well,

(50:15):
is this an internal thing? How is it wireless? It's
wireless in the sense that you can have a wireless
connection between the pump and a glucose meter, so that
you still have a pump that you have to wear
on your body somehow. Usually there's some sort of yep,
but still got a tube from the pump to going
underneath your skin. Uh. It clips on typically to a

(50:37):
piece of clothing or something along those lines, but it
can connect wirelessly to a glucose meter. So what you
would do is you would go to test your your
glucose your blood glucose level, and you'd prick your finger
and do all that, and then the meter would make
the measurement and then send that data to the wireless pump,
which would then administer the proper amount of insulin in

(50:58):
order to manage your eucost levels or even stop uh
administering insulin to make sure you don't go hypoglycemic. Right.
So what that means is is that if you're if you're, say,
out to dinner and and you know that you need
to you've either just finished something or you're about to eat,
you know that you need to adjust your insulin levels,
you don't need to uh take your pump off at

(51:21):
the dinner table and manually punch in the button and
do a whole thing and then like stick it back
in your body, or you know, go to go to
a restroom and do that kind of thing. You can
you can do it more more discreetly right right, Yeah,
so you don't. Yeah, it really means you don't have
to fuss with the pump at all, and that that
like that is again another quality of life issue beyond

(51:42):
the the pain of dealing with diabetes just to manage
it properly, there's also it's not so much a social stigma.
But you know, you don't want to have to this
embarrassing you have to take out a medical device and
you're sitting around dinner with You don't want to make
anyone feel self conscious. You don't want to draw attention
to it. You know, you just want to be able

(52:02):
to enjoy your time without that added frustration. Um. So yeah,
that those definitely have a a big advantage over the
traditional insulin pumps um and they're still in different stages
of development. We'll talk more about that in our next episode.
One of the things I saw I thought was really
interesting is that another implementation of this approach is using

(52:27):
smartphones and smart watches as your your way of of
getting an indication about your glucose levels. So there's this
one company that's offering a product that would pair with
Apple's iPhone and their their watch as well, and the
way it works is that you have an app, you
download it to your watch and your phone, and you
use a little sensor that this company provides and it

(52:50):
has a thin wire they say, it's about the thickness
of a hair, and you stick that under the skin, uh,
and secure the sensor to your body. It monitors your
glucose levels, sends that information to a secondary device which
then takes the data, sends it to the cloud where
it gets analyzed so that you get the actual proper

(53:13):
blood glucose level. That data is sent to your iPhone,
which they could be sent to your watch. There's a
lot of different stops along this this route, like a
lot of points here, but the point being that you
can look at your watch and get a very quick
accurate reading of what your blood gluecose levels are and
then respond if necessary. UM. So kind of interesting to see,

(53:35):
Like I wouldn't have necessarily thought of like the smartphone
or smart watches being a device that you could convert
into like a medical device in this way, but it
absolutely is something that could do that and allow you
to keep a really close look on that and that
could be very that could be life saving and right circumstances,
UM and and this is kind of wrapping up our

(53:57):
our initial episode about diabetes, and we've we've covered yeah,
all that all that good juicy history stuff. Where we
are now, um, you know, in the a lot of
a lot of really interesting things are coming in in
the future. We're going to talk about them next time. Yes,
so we'll we'll focus on a lot of research and
a lot of thought that has gone into ways to

(54:18):
manage and treat and possibly cure diabetes. And how far
off are these things? Um, how realistic are they? We're
going to take a look at some of those questions
in our next episode. If you guys have suggestions for
future episodes Beforeward Thinking, write to us. Let us know
our email addresses f W Thinking at how Stuff Works

(54:39):
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(55:00):
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