When and how will we be able to prevent type 1 diabetes?

There are a number of approaches that might reasonably lead to the prevention of type 1 diabetes in the foreseeable future. Although hereditary factors are involved in a persons risk of getting type 1 diabetes, it is clear that there is an important trigger in the environment. For example, if one of a pair of identical twins has type 1 diabetes, the chance of the other twin getting the disease is smaller than 50%. Definite identification of a major risk factor (such as an infectious agent, nutrient, or other chemical) could lead to effective protection against exposure or immunization against it. Whatever the trigger may be, the process that ultimately leads to type 1 diabetes is caused by the body's immune system, which activates a destructive attack on the insulin- producing cells of the pancreas. There are a number of ways in which this destructive process can be slowed or suppressed. Earlier efforts were either ineffective or led to a general suppression of the body's immune system, increasing the risk of infections. However, clinical trials of drugs that specifically target the self-destructive process in the pancreas are presently underway. These treatments require prolonged administration into the blood vessels over several days and often have unpleasant side effects. Also, to be truly preventive, they must be given when early evidence of future diabetes is discovered, but before the actual onset of diabetes, by which time intense and often irreversible destruction of the insulin-producing cells has already occurred. It is probable that it will be several years before any of these drugs is readily available. There is a great deal of investigation currently ongoing into the development of stem cells for use as replacements for lost insulin-producing cells. Stem cells are a small proportion of cells in tissues and organs that have not yet developed into final form. As such, when treated in a certain way, they can be persuaded to commit themselves to developing into one specific desired type of cell. There are a lot of questions remaining to be answered regarding the safety, effectiveness, and durability of stem cell treatments and there remains the issue that the immune system problem that destroyed the original insulin-producing cells might also destroy their replacements. However, clinical trials are underway in other diseases which, if successful, could accelerate interest in the use of stem cells for type 1 diabetes.

When and how will we be able to prevent type 2 diabetes?

The prevention of type 2 diabetes in global terms depends upon the prevention of overweight and obesity and the performance of healthy amounts of exercise. These two factors are responsible for the overwhelming majority of cases of type 2 diabetes in the world today, especially those in younger people. However, it is not clear that this can be achieved by individual education. Most adults who are overweight are aware that they overeat and take insufficient exercise, yet few are able to address these issues successfully in a long-term way. This is not because they are lazy or weak-minded, but because humans, and other species, have been conditioned throughout their evolution to defend themselves against starvation and backbreaking labor, both of which are injurious to survival. It is not surprising therefore that strong drives exist within us to take in as much food energy as we can to protect us against impending famine, and to seek a life of ease to protect us from injury and environmental exposure. It is only within the past century or two that sufficient food to lead to overweight has been available year-round for all but a fortunate few. Not surprisingly, therefore, human conditioning has not yet been able to adjust to this very recent change.

It is likely that significant reductions in weight and increases in exercise will come from social changes that build these into our environment and lifestyles. Some of these are already beginning to occur. Many states and school districts are increasing the amount of exercise in the core school curriculum and removing ready access to snacks and sweetened beverages on campus. Urban planners are considering new ways to make walking to school, work, and local shops appealing and limiting the access of automobiles to the inner city. Restaurant chains are attempting, with some success, to offer alternatives to calorie-dense high fat food items. It is important than such alternatives are appealing in taste and satisfying to hunger, or they will not be chosen.

Of course, modern medicine has a role to play in the prevention of type 2 diabetes, by developing safe and effective medications to suppress appetite or prevent weight gain. Also, drugs that can be taken by people at high risk to prevent early abnormalities in blood sugar from developing into full-blown diabetes will be valuable. However, since type 2 diabetes is largely a disease of the industrialized urban world, the healthiest and most generally effective way to prevent it will be to make the environment of the future less conducive to those habits that lead to its occurrence.

While individual counseling and education are worthwhile and effective in some cases, a broader approach will be necessary to impact favorably upon weight and exercise in population terms.

How can we stop the dramatic increase in diabetes presently occurring throughout the world?

Although both type 1 and type 2 diabetes are increasing in frequency throughout the world, it is type 2 diabetes that has shown the explosive rise in occurrence in the past couple of decades. Since this rise is most clearly associated with weight gain and lack of exercise brought on by our current lifestyle, this trend will probably only be stopped, or reversed, by addressing these two factors, as discussed in Question 99. While individual counseling and education are worthwhile and effective in some cases, a broader approach will be necessary to impact favorably upon weight and exercise in population terms. Interventions such as increasing the amount of exercise in the core school curriculum, provision of healthy school meals, and improved policies on the access of snack food vendors to school premises are among measures that are already taking hold and will hopefully have a favorable impact on our youth. The engineering of the workplace and social areas to encourage physical activity, such as removing automobile access to the inner city providing convenient and pleasant walkways and bicycle paths through frequently traveled areas of town, and probably financial disincentives from excessive automobile use should help to mobilize us. Countries with emerging economies are particularly affected by the switch to urban industrialized living, in terms of rising numbers of people with diabetes, yet they have perhaps the best opportunity to effect change. They are in the planning and growth stages and can make social and environmental decisions to improve the future before diabetes becomes an overwhelming problem.

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