In honor of World Diabetes Day, we’re getting everyone up to speed on the history and science behind one of the world’s most common chronic conditions.
In 2021, the International Diabetes Federation estimated that over 10% of the world’s adult population has diabetes.
That’s 540 million people—and nearly half don’t even know they have it.
Those who do know their diabetes diagnosis are burdened with the task of managing the disease.
Depending on their personal circumstances, meals must be carefully considered and timed. They must always be aware of how they are feeling, lest their glucose levels drop and cause them to go into shock.
Often, they must test their blood sugar by repeatedly pricking a finger to collect drops of blood or checking a continuous glucose monitor that collects readings via tiny wires under the skin.
If they don’t stay on top of their blood sugar, the outcome could be dire—diabetes is the leading cause of non-traumatic amputations, adult-onset blindness, and kidney failure requiring transplant or dialysis.
For World Diabetes Day, which helps bring awareness to the disease every November 14, you’re all going to get a crash course in the disease.
The full and proper name for diabetes is diabetes mellitus, a combination of the Greek word for “siphon”, meaning “to pass through,” and the Latin word for “honeyed” or “sweet.”
When you put them together, you roughly get “something that is sweet and passed through,” and this refers to the fact that the urine of people with diabetes is extra sweet.
There is actually a very rare condition called diabetes insipidus, which is marked by increased urination, but the only relation the diseases have is the act of “passing through” (diabetes).
The sweetness is the result of excess sugar in the urine, which is also found in the blood. High blood sugar is of course the hallmark of the disease.
It’s time to talk about the different kinds of diabetes, and for that we have to take a little trip to one of the less-considered organs: the pancreas.
In your upper abdomen, behind your stomach and in front of your spine, is the pancreas, a palm-sized organ shaped like a tadpole or pear.
It has two main jobs: to produce enzymes that aid in the digestion of food in the small intestine and to produce hormones to help control blood sugar.
When you eat, the food is digested and sugars within the food enter your bloodstream.
If your islets of Langerhans detect that there is too much sugar in your bloodstream they will release the hormone insulin, which works to move excess sugar from your blood into your cells.
That sugar can then be used as energy in the cells or stored in fat, muscle, or in the liver.
If your islets of Langerhans sense there is too little glucose in your bloodstream, then the pancreas can release a hormone called glucagon that stimulates the liver to convert stored glucose into a usable form to raise your blood sugar levels.
Diabetes is what happens when your body has difficulties regulating these levels of blood sugar. And there are two types of diabetes, simply known as type 1 and type 2.
Type 1 diabetes is known as an autoimmune disease, because the body’s own immune cells infiltrate the islet of Langerhans and attack and destroy the cells that produce insulin.
Type 1 diabetes used to be referred to as “juvenile diabetes,” because it’s often diagnosed in children, though it can happen at any age.
The cause or trigger for type 1 diabetes isn’t fully known. There are some cases that are genetic, but there’s also mounting evidence that at least some cases could be triggered by viral infections.
It is commonly diagnosed in children as their immune systems are exposed to various viruses for the first time.
Type 2 diabetes is a little different, and about 90% of people with diabetes have type 2 diabetes.
In these cases, the body may begin to develop resistance to insulin, or does not produce enough insulin to reduce blood sugar levels.
Cells that would normally be triggered by the release of insulin to take up excess glucose no longer properly respond to the signal, so the blood sugar levels can remain elevated.
Type 2 diabetes used to be known as “adult onset diabetes” but cases are rising in younger age groups in the U.S. and around the world.
Some regions, such as Africa, are expected to see over a 100% increase in diabetes over the next 20 years.
The mechanisms by which our bodies become insulin resistant aren’t totally clear, but we do have a good idea of the things that contribute to an increased risk of developing type 2 diabetes.
For example, drinking a lot of beverages that are high in sugar increases risk, as does living a sedentary lifestyle, smoking, and having high blood pressure or poor cholesterol.
Much of the strategies to manage type 2 diabetes (and to an extent type 1) rely on diet and exercise.
Research has shown that proper diet and exercise can lower blood sugar and improve insulin resistance in people with type 2 diabetes.
When exercise and diet isn’t enough, there are medications that can be taken, such as metformin, that reduce blood sugar levels by preventing the liver from releasing glucose.
Diabetes inspired two of the most incredible advances in modern medicine: the discovery and synthesis of insulin and GLP-1 agonists.
Let’s start with insulin. World Diabetes Day is held on November 14 every year because that is the birthday of Sir Frederick Banting who, along with his assistant Charles Best, discovered and isolated the insulin found in the pancreas.
Researchers started speculating about the existence of insulin as far back the 19th century.
Two German researchers in the late 1800s had found that if they removed the pancreas of a dog, it would develop symptoms of diabetes and die.
And then in 1910, the British physiologist Sir Edward Albert Sharpey-Shafer theorized that there was only one chemical missing from the pancreas in people who had diabetes.
He dubbed the theoretical chemical “insulin” from the Latin “insula,” which means “island.”
Prior to the isolation and purification of insulin people with diabetes did not survive.
They might be able to survive for a bit with a very strict diet, but there’s no replacement if your body is entirely unable to produce insulin.
Excess blood sugar decreases the elasticity of blood vessels, which can cause them to narrow, reducing blood flow.
This can have many downstream effects on the body, such as damage to the blood vessels in the eyes (which can cause vision loss and blindness), high blood pressure, and increased risk of heart attack or stroke.
Reduced blood flow to the feet and legs can cause swelling and pain, making wounds in those areas slower to heal, which increases risk of infection and the need for amputation.
Diabetes is associated with a two to four times higher risk of heart attack or stroke, and new data suggests it could be the leading cause of non-alcohol fibrotic liver disease, as well as a risk factor for both dementia and cognitive impairment.
It truly cannot be overstated how miraculous the invention of insulin as a treatment for diabetes was. In 1922, the first recipient of insulin was a 14-year-old boy who was on death's door.
After receiving the injection, his dangerously high blood sugar levels returned to nearly normal in just 24 hours.
In a noble act, Banting refused to put his name on the patent for insulin, feeling it would be unethical to profit from a discovery that was necessary to save so many lives.
Instead, the patent was sold to the University of Toronto for $1, so that anyone who needed it could get it…and it would have been really nice if things had actually stayed that way.
As with many necessary and lifesaving products, pharmaceutical companies saw dollar signs.
A 2019 study found that the gross annual cost of insulin for someone with type 1 diabetes doubled from about $3,000 in 2012 to nearly $6,000 in 2015.
Another nonprofit group found that the three major manufacturers of insulin were marking their product up as much as 5,000% over what it cost to manufacture.
The cost of insulin has become so high that many adults have reported rationing, or underusing insulin as a result of their difficulty paying for it.
In 2022, the Biden administration passed the Inflation Reduction Act, which included the Affordable Insulin Now Act, written by Georgia’s own Senator Warnock.
This bill capped the out-of-pocket price for insulin at $35 a month for Medicare beneficiaries. But that only helps people over 65 get better access to the medication.
In March of 2023, three of the largest manufacturers of insulin followed suit (after much public pressure) and agreed to either seriously reduce out-of-pocket costs or cap them at $35 a month as well for certain types of insulin.
$35 is no small sum for people in poverty living with diabetes, but it’s a step closer to improved access for what is largely one of the greatest miracle drugs to be discovered in the 20th century.
It appears that this miracle is happening once again with the development of GLP-1 agonists.
Glucagon-like peptide-1 (GLP-1) is a hormone naturally produced in our intestines that stimulates insulin release and suppresses glucagon production, which are two things needed to reduce your blood sugar.
If you’re like me, and you wonder why you would name something “glucagon-like” if it actually suppresses glucagon, it’s because both hormones come from the same source.
The GLP-1 that our body releases has a very short half-life—it lasts about 2 minutes.
GLP-1 agonists are a class of medications that mimic the actions of naturally occurring GLP-1. One example of this drug you might recognize is Ozempic.
These drugs can have a half-life that ranges from one day to about one week, depending on which you take.
The long-acting formula stimulates insulin production to help lower blood sugar over a longer period.
GLP-1 agonists also help control type 2 diabetes by aiding in weight loss.
The mechanisms by which the medications help people lose weight aren’t 100% clear, but we do know that they can slow what’s known as “gastric emptying.”
This is the process by which the contents of your stomach are emptied into your intestines to be absorbed into your bloodstream.
By slowing this process down, people feel full longer, which can reduce the amount of food they eat.
Because GLP-1 agonists, in conjunction with lifestyle changes, have been shown to help people lose more weight, more quickly than diet and exercise alone, they’ve become increasingly popular as a weight loss drug.
This has caused difficulties for manufacturers trying to produce enough medication to meet need, and up until very recently many of the name brand drugs have been put on the FDA’s list of drugs experiencing shortages.
But the demand might not be such a bad thing. With one in eight Americans reporting having used GLP-1 agonists, companies are highly motivated to improve the drugs by doing things like making them in pill form, which would be easier to produce and administer than the injections that are currently available.
