From telegraph.co.uk
Treating the condition is costing the NHS £1.5m an hour, but advances in technology, medication and diagnosis mean the future looks bright
In the 20 years I’ve been caring for patients living with diabetes, the situation has spiralled. I remember diagnosing a 19-year-old with a complication of type 2 (T2) diabetes at the beginning of my career – it was so unusual that my team and I wrote it up as a case report.
When I was a medical student in the mid-1990s, approximately 1.4 million people in the UK were diagnosed with T2 diabetes. Today, 12 million people – that’s one in five adults in the UK – live with diabetes or prediabetes and these conditions are increasingly seen in teenagers and even younger children. A T2 diagnosis at 30 can shorten life expectancy by up to 14 years, and treating the condition is costing the NHS £1.5m an hour.
It’s not a coincidence that these figures have risen at an alarming rate at a time when ultra-processed foods now make up 57 per cent of calories consumed by adults in the UK. T2 diabetes and prediabetes (a condition of high blood sugar not yet severe enough to be diagnosed as T2 diabetes) has a clear association with diet, being overweight and more sedentary. Type 1 (T1) diabetes – an autoimmune disease in which the body destroys the cells in the pancreas that produce insulin – accounts for less than 10 per cent of cases and is not linked to lifestyle factors.
The statistics around T2 diabetes look daunting, but we can turn things around. Look at what we achieved with smoking-related lung cancer when we brought in bold public health measures and robust smoking legislation. With advances we’re seeing in technology, medication, and the timing of T2 diagnosis, the future of diabetes care is looking bright. This is why.
We’re testing insulin levels earlier
At the moment, the first time most people even think about T2 diabetes is when their GP tells them they have raised blood sugar, following a blood test known as HbA1c. The NHS over-40 health check includes this test, which reveals your blood glucose levels for the previous two or three months. It’s a good screening, but it doesn’t give you a completely clean bill of health. Even when your HbA1c result is within the reference range, you can’t tell how hard your pancreas is having to work to produce the hormone insulin to keep your blood sugar level normal.
As you become resistant to insulin, the pancreas has to ramp up insulin production to keep clearing enough sugar from the blood. I sometimes explain it to my patients like this: you might look at a racehorse and say: “My, that horse is galloping very fast. What an incredible animal,” but the jockey is having to go hell for leather to keep it moving. That jockey is your pancreas, trying to produce enough insulin to keep everything on track.
I often test my patients’ insulin level on a blood test if I’m worried about their metabolic health. I do think we will start testing insulin levels more widely, but until then, everyone should be aware of five key markers of insulin resistance, collectively known as metabolic syndrome (see box below), so they can take stock of their health. These markers are a warning light flashing on the dashboard that you may have insulin resistance. We need to take action at that point, and stop waiting for T2 to set in.
Simple things like eating a reduced-carb diet, fasting, minimising ultra-processed food and making sure you move your body every day can help reverse insulin resistance.
The tech in this space is sophisticated
Tech is already revolutionising the diabetes landscape. Continuous glucose monitors (CGM) – wearable sensors with a tiny detector filament that sits just under the skin to measure the glucose in the fluid surrounding your cells (known as interstitial fluid) which can be used to infer blood sugar levels – have totally transformed blood sugar monitoring for people with T1 diabetes. They’ve replaced numerous daily finger-prick blood tests with real-time data, and alerts that allow people to decide whether they need to eat something, or inject insulin.
In the past, my patients would have to very diligently keep a diary of their finger-prick results, but now they can just hand me their phone and I have weeks and weeks of data in front of me, all broken down into graphs and metrics.
By linking these monitors to a wearable insulin infusion pump, scientists have created a first-generation version of an “artificial pancreas”. The pancreas is an organ that’s about as long as your hand and found behind your stomach. One of its roles is to produce the hormone insulin, and it’s incredibly clever – it will release a tiny amount of insulin even if we are just thinking about food, in anticipation of us eating.
In diabetes, a person either lacks insulin (T1) or the body has become resistant or insensitive to insulin’s message (T2). In the later stages of T2, a person may have both insulin deficiency and insulin resistance.
An “artificial pancreas” for T1 diabetes combines a CGM which can now transmit its readings directly to an insulin infusion pump which then releases a precisely calculated dose to control an individual’s blood sugar. Some people with T1 diabetes are already using this technology, which still requires human input such as the amount of carbohydrate a person has eaten, whereas the next-generation versions are being developed to take this need for frequent human input out of the loop.
For years, diabetes treatment has been very “glucocentric” – with an intense focus on bringing the blood sugar down. This is certainly very important, both in terms of your everyday health, and also preventing long-term complications such as kidney, nerve or sight damage. Now though, there are some brilliant drugs coming through.
It’s easy to forget GLP-1s were originally developed for the treatment of T2, mimicking glucagon-like peptide-1 (or GLP-1), a hormone that’s naturally released by the gut after eating and which tells the pancreas to release insulin and help blood glucose levels return to normal. But these drugs are now also showing clear benefits outside of glucose control, for example in reducing the risk for having a heart attack or stroke.
I predict that GLP-1s are going to become even more efficient, the side effects will lessen, most injectable versions will be replaced by tablets and as drugs fall out of patent and prices drop, they will become more accessible.
There’s also a triple-hormone injection, Retatrutide (or triple-G), which is currently being trialled with results suggesting it can lower blood sugar levels in people with T2 diabetes. It contains pharma versions of not just GLP-1 and glucose-dependent insulinotropic polypeptide (GIP), which are both in Mounjaro, but also the hormone glucagon, which plays a role in revving up metabolism.
Meanwhile, there are SGLT2 inhibitors which are bringing huge benefits to people with T2 diabetes. They work to lower blood sugar by making the kidneys urinate excess sugar. They are not a silver bullet, as sugary urine can cause some people to experience recurrent UTIs or genital thrush, but they hold huge promise.
We’re also seeing advances in treating the side effects of living with diabetes. Certain diabetes medications and particularly insulin can cause a “hypo” (short for hypoglycaemia, when the level of glucose in your blood drops below normal limits after taking too much insulin or missing a meal) and they are incredibly frightening.
Historically, they’ve been treated with sweet food or gels to get the blood glucose up very quickly. But that doesn’t help with the “hypo hangover” – where, even after the blood glucose readings are back to normal, brain fog persists as it takes the brain a while to efficiently use glucose as a fuel. Hypo treatment drink Klario, a new product, contains glucose to raise blood sugar as well as an alternative ketone-based fuel source that the brain can use.
We can drive diabetes down and it’s vital we do
The T2 landscape has become unrecognisable in the 30 years since I was a medical student, and if we fast forward another three decades from here, there’s no reason to believe it won’t have transformed once more – but for the better.
Back in the late 1950s, when as many as 70 per cent of men smoked, it might have been inconceivable to imagine a world where people weren’t allowed to smoke in offices, hospitals, pubs, on trains and planes. But it has happened, and with it cases of lung cancer in men have fallen by almost 40 per cent since the early 1990s.
I believe we could find a world where supermarkets label UPFs with health warnings and they become highly taxed, just as cigarettes are now. I think incorporating movement into our days will start to be taken very seriously by schools and employers, and metabolic testing will be standard for anyone with any of the five signs of insulin resistance, from an increased waist size to high blood pressure.
It’s bold, but it’s vital, because we can’t be in a situation where we allow insulin resistance to become the norm. The message I reinforce with my patients who have prediabetes and T2 – particularly early on in the illness – is that this is a reversible condition. You really can stop it yourself through your lifestyle. And once insulin resistance melts away, and your body’s cells start hearing insulin again, good health will be yours.
As told to Amy Packer
Dr Saira Hameed is a consultant endocrinologist at Imperial College Healthcare NHS Trust and a senior tutor and honorary clinical senior lecturer at Imperial College London. She holds a PhD in neuroendocrinology. Her new book, Signals, The Inside Story of our Hormones (£20; Faber) is out now
