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Understand and Prevent Diabetes

(43) Diabetes




Kidney damage

  It’s bad enough having diabetes. If I’m at risk also of kidney damage, what should I look for?

There are several ways in which diabetes may affect the kidneys, and they will show up in the routine urine and blood tests that you have at your diabetes clinic. A lot of glucose in the urine puts you at risk of infection that can spread from the bladder up to the kidneys (‘cystitis’ and ‘pyelo-nephritis’). Occasionally long-standing kidney infections may cause very few symptoms and are only revealed by routine tests. People with long-standing and poorly controlled diabetes are at risk of damage to the small blood vessels supplying the kidney just as the retina of the eye may be affected. This does not produce any symptoms but will be picked up on a routine urine test carried out at the diabetes clinic. Most clinics now use a special test for detecting ‘microalbuminuria’, which as the name implies is a microscopic amount of albumin (protein) in the urine. This is a useful test as it can pick up the earliest signs of kidney damage.

With more severe kidney disease, large amounts of albumin may be lost in the urine. This may make the urine froth and lead to a build-up of fluid in the body, which in turn leads to swelling around the ankles (oedema). Kidney failure may eventually develop in people who have had long-standing kidney problems.

This is usually picked up by blood tests and urine tests years before the symptoms develop.

I have developed kidney failure. Will be possible to have dialysis or even a transplant although I have diabetes?

Yes. The majority of people who are unfortunate enough to end up with kidney failure are suitable for both forms of treatment.

Dialysis (or chronic renal replacement therapy) is of two major types. The older type is haemodialysis where the blood is washed in a special machine twice a week; the more recent is a type of dialysis known as CAPD (chronic ambulatory peritoneal dialysis) where the fluid is washed in and out of the abdomen on a daily basis. People with diabetes seem to be very good at learning this method, which in some ways is simpler and cheaper than haemodialysis.

Transplantation is the aim of most dialysis programmes, but the supply of suitable kidneys is a limiting factor. The source of kidneys is from either people dying accidentally or live related donors who have agreed to give one of their two normal kidneys to a relative with kidney failure. A normal person can manage perfectly well with one kidney without any shortening of life provided that the kidney does not get damaged. The donor will, of course, have to have an operation and will be slightly more vulnerable as a result because they will have only one kidney to rely on instead of two.

I was found to have protein (albumin) in my urine when I last attended the diabetes clinic – what does this mean?

If it was only a trace of protein, it may mean nothing, but you should get your urine checked again to make sure it remains clear. If it is a consistent finding, it suggests either that you could have an infection in the bladder or kidney (cystitis or pyelonephritis) or that you have developed a degree of diabetic kidney damage (nephropathy). There are many other causes of protein (albumin) in the urine and it may not be related to your diabetes. If the protein in your urine is a consistent finding, it will need to be investigated, and you should ask to be kept informed of the results of the tests.

At my last clinic visit, I was told that I had microalbuminuria. What is this?

The very earliest stage of diabetic kidney disease leads to a leak of very small amounts of protein (albumin) into the urine. If it is a consistent finding, it suggests that your kidneys have been damaged by diabetes. If this is the case, then attention to control of your blood glucose and treatment of any tendency towards raised blood pressure is of great importance, as this can stabilise or even reverse the condition.

 Nerve damage

There are various conditions that can affect the nervous system of someone with diabetes: diabetic neuritis, diabetic neuropathy, autoimmune neuropathy and diabetic amyotrophy.

I have been on insulin for 3 years. Eighteen months ago I started to get pains in both legs and could barely walk. Despite treatment, I am still suffering. Can you tell me what can be done to ease this pain?

There are many causes of leg pains, and only one is due specifically to diabetes. This is a particularly vicious form of neuritis – in other words, a form of nerve damage, which causes singularly unpleasant pain, chiefly in the feet or thighs, or sometimes both. The pain sensation is either one of pins and needles, or of constant burning, and is often worse at night causing lack of sleep. Contact from clothes or bedclothes is often acutely uncomfortable.

Fortunately, this form of neuritis is rather uncommon and always disappears, although it may take many months before doing so. Very good control of your diabetes is important as it will help to alleviate the symptoms and speed their recovery.

Relief is otherwise obtained by good painkillers, as recommended by your doctor, and sometimes assisted by sleeping tablets. Always remember that eventually recovery occurs, as otherwise, you will find that it is easy to get despondent. Also remember that the diagnosis must be made by a doctor who will consider all the various causes of leg pains before coming to a diagnosis of diabetic neuritis.

I have had diabetes for many years but my general health is good and I am very stable. During the last year, however, I have developed an extreme soreness on the soles of my feet whenever pressure has been applied, e.g. when digging with a spade, standing on ladders, walking on hard ground or stones, even when applying the accelerator in the car.

If I thump an object with the palm of my hand, I suffer the same soreness. The pain is extreme and sometimes lasts for a day or so. Could you tell me if you have heard of this condition in other people and what is the reason for it?

These symptoms may be due to diabetic neuropathy, a condition of damage to the nerves, which occasionally occurs in long-standing diabetes. It affects the feet more often than other parts of the body and often produces painful tingling or burning sensations in the feet, although numbness is perhaps more common. Strict control of your diabetes is important for the prevention and treatment of this complication – it can be made worse by moderate or high alcohol consumption.

I have diabetes controlled on diet alone. I suffer from neuritis in my face. My GP says there is no apparent reason for this but I wondered if it had anything to do with my diabetes.

Not necessarily, as there are a number of types of neuritis that can affect the face, which have absolutely nothing to do with diabetes? Examples include both shingles (herpes zoster) and Bell’s palsy, although, of course, both these conditions can affect people with diabetes.

There are forms of diabetic neuritis that do affect the face: one from occasionally affects the muscles of the eye leading to double vision, while another form can cause numbness and tingling. There is also a very rare complication known as ‘gustatory sweating’ where sweating breaks out across the head and scalp at the start of a meal.

I have recently been told that the tingling sensation in my fingers is due to carpal tunnel syndrome and not neuropathy as was first thought. Can you please explain the difference?

 In carpal tunnel syndrome (which commonly occurs in people who do not have diabetes), the nerves supplying the skin over the fingers, the palm of the hand and some of the muscles in the hand get compressed at the wrist. Occasionally injections of hydrocortisone or related steroids into the wrist will relieve it, or it may require a small operation at the wrist to relieve the tension on the nerve. This usually brings about a dramatic relief of any pain associated with it and a recovery of sensation and muscle strength with time.

Diabetic neuropathy more commonly affects the feet than the hands and is usually a painless loss of sensation starting with the tips of the toes or fingers and moving up the legs or arms. It is only occasionally painful and may be difficult to treat. It is due to some form of generalised damage to the nerves, not to compression of any one nerve.

I have had diabetes for 27 years and have developed a complaint called bowel neuropathy. Please, can you explain what this is and what the treatment is?

Bowel neuropathy is one of the features of ‘autonomic neuropathy’, which may occur in some people with long-standing diabetes where there is a loss of function of the nerves supplying various organs in the body. In your case, the nerves that regulate the activity of your bowels have been affected. The symptoms include indigestion, occasionally vomiting, and episodes of alternating constipation and diarrhoea. Occasionally the episodes of diarrhoea are preceded by rumblings and gurglings in the stomach and sometimes this responds to a short course of antibiotics.

Otherwise eating a high-fibre diet is encouraged to prevent constipation. Irritable bowel syndrome can cause symptoms, not unlike this – it has nothing to do with diabetes, although it may occur in people with diabetes. If there is ever passage of blood or mucus within your stools, you should seek medical advice without delay.

The calf muscle in one leg seems to be shrinking. There is no ache and no pain. Is this anything to do with diabetes?

I have been taking insulin for 30 years. You do not mention whether you have noticed any weakness in this leg. Occasionally diabetic neuropathy can affect the nerves, which supply the muscles, in such a way that the muscle becomes weak and shrink in size without any accompanying pain or discomfort. It sounds as if this may be your problem. I have had diabetes for many years and have developed pain in my legs. My thighs, in particular, are very weak and wasted. I have been told that I have ‘diabetic amyotrophy’ Will it get better?

Diabetic amyotrophy is a rare condition causing pain and weakness in the legs and is due to damage to certain nerves. It usually occurs when diabetes control is very poor, but occasionally affects people with an only slight elevation of the blood glucose. Strict control of diabetes leads to its improvement but it may take up to 2 years or so for it to settle. The nerves affected are those usually supplying the thigh muscles as in your case, which becomes wasted and get weaker.




(44) Diabetes

Diabetes UK

Diabetes Research and Wellness Foundation


Heart and blood vessel disease

 I have read that poor circulation in the feet is a problem for people with diabetes. Is there any way I can improve my circulation to avoid developing this?

Narrowing (‘hardening’) of the arteries is a normal part of growing older – and the arteries to the feet can be affected by this process, leading to poor circulation in the feet and legs. This occurs in people with diabetes as well as those without, but it is more common in those who have. The causes of arterial disease are not very well understood, but we know that smoking and poor diabetes control makes it worse. So if you have diabetes and smoke cigarettes, the risk of bad circulation increases greatly.

Stop smoking, control your blood glucose, and keep active – these are the only known recipes for helping the circulation.

I am in my seventies and am worried that I might develop heart problems. I am already being treated for high blood pressure. Is heart disease likely?

Heart disease is two to five times more common in people with diabetes and it goes hand in hand with high blood pressure, excess body weight and raised cholesterol. There is increasing realization that this grouping of risk factors is an important cause of premature death in diabetes. Knowing this, it is important that your blood pressure and cholesterol levels are controlled well.

My husband died recently from a heart attack. He had had diabetes for 12 years and was controlled on tablets, and at about the same time that he developed diabetes he started having angina attacks. I wondered whether these were related and whether poor control had anything to do with his fatal heart attack?

There is certainly a connection between heart disease and diabetes. It has been shown that control of high blood pressure, cholesterol, and blood glucose are effective in preventing heart disease.

I am in my early twenties, but haven’t had good diabetes control for a couple of years. Will this affect my arteries in later life?

It is unlikely to have much effect but any period of poor control is not going to do any good either. Our arteries get more rigid and more clogged up as we get older and this process can be aggravated by periods of poor diabetes control and smoking.

My left leg has been amputated because I developed diabetic gangrene. I now get a lot of pain in my right foot and calf. Could too much insulin be the cause of this pain?

No. It sounds very much as if the blood supply to your leg is insufficient and that the pain in your right foot and calf is a reflection of this poor blood supply, which was the reason why you developed gangrene in your left leg. You must be very worried, particularly about the survival of your right leg. There are a number of different ways of protecting your remaining leg and these include:

• stopping smoking (if you smoke)

• keeping diabetes, blood pressure and cholesterol under very good control, and

• maintaining close contact with a podiatrist who has a special interest in diabetes.

If you do notice any sign of increased pain or change in colour, you should seek medical advice immediately.

My husband had a heart attack last year. Nine months later he had part of his leg amputated. We have been told that he could have further problems but have been given no advice. Please give us some information on what we should do to try and avoid this.

It sounds as though your husband has generalized arterial disease (arteriosclerosis) affecting his blood vessels to the heart and to the leg. There are a number of things which you and he can do that may be of help in preventing further trouble. Firstly, if he smokes, he should stop straight away; secondly, he should keep his diabetes and blood pressure as well controlled as possible; thirdly, he should keep his remaining foot and leg warm and make sure that he has expert foot care, either by a chiropodist or by you, under the supervision of a chiropodist or district nurse. If you see any signs of damage to his foot or any discolouration then seek medical advice immediately.

Blood pressure problems

Now I have been diagnosed with diabetes, will I be more prone to high blood pressure and strokes?

Yes, there seems to be a very strong link between Type 2 diabetes and high blood pressure. Unfortunately these both increase the risk of strokes. The good news is that strict control of both diabetes and blood pressure keeps down this risk. Since publication of the UKPDS findings, we realize that the blood pressure should be kept as low as 130 mmHg in diabetes.

I have been told that my blood pressure is raised as a result of diabetic kidney problems and, because of this, it is very important that I take tablets to lower it – why is this?

There is good evidence to show that lowering the blood pressure to normal in people such as yourself protects the kidneys from further damage and helps delay any further kidney problems. We also know that controlling blood pressure reduces the risk of heart disease and stroke. There have been some studies done in Germany and the UK showing that self-monitoring of blood pressure and the active participation of people in their own treatment can significantly reduce blood pressure. In the studies, people were provided with a blood pressure monitor, and were given information about high blood pressure, and non-drug remedies, such as reducing salt and increasing fruit and vegetable intake, and exercising, and were taught how to use an individual flow chart for medication. The British Hypertension Society provides advice on how to select a reliable monitor, and if you think that you may benefit from self-monitoring of blood pressure, you should discuss this with your health professional.

The mind

My 68-year-old mother has had diabetes for 44 years. In the past few years her mental state has deteriorated considerably and she is now difficult to manage. Is this common for someone who has been on insulin for so long?

Memory loss (most commonly Alzheimer’s disease) is mainly a problem of the elderly. People are also more likely to develop diabetes as they get older, so it is likely that both these problems may sometimes affect the same person. There is some disturbing evidence that memory loss may be more common in old people with diabetes than those without. However, the extra risk in diabetes is only small, and we do not know the relevant importance of other factors such as smoking and high blood pressure. So it is possible, but not certain, that your mother’s memory problem is related to diabetes.

I had a brain haemorrhage 18 months ago and I have had diabetes since childhood. Am I more likely to get complications from diabetes?

Brain haemorrhages and strokes are more common in people with diabetes than in those without, particularly if blood pressure levels are high. Your treatment is no different than from anyone else with your condition. Your doctor will be on the lookout for chest infections and pneumonia, particularly if you have any problems with swallowing.

I have been very depressed since my diagnosis. Are peo- ple with diabetes more prone to depression or suicide, or other psychiatric illnesses?

There is some evidence to suggest that people with diabetes are prone to depression, and the suicide rate is higher than in the general population. This is probably due to the demands of a long-term condition that has an impact on daily living rather than a result of the diabetes itself. Recent studies have found that the tendency to depression can be helped by letting people become more involved in the management of their diabetes. You have obviously taken a first step in recognizing that you have depression. Visit your doctor to discuss how you feel.

There is help out there! I have read that hypos can cause brain damage - is this true?

The strict answer is yes, but only very occasionally. Only a severe hypo causing a long period of unconsciousness can lead to brain damage and this is extremely unusual. There is no evidence to suggest that the repeated hypos, which may be common in people taking insulin, cause any permanent brain damage.




(45) Diabetes

 Diabetes Treatments of the Future


Research and the future

New developments and improvements in existing treatments can occur only through research; therefore research is vital to every person with diabetes. In the UK, Diabetes UK spends large sums each year (more than £4.9 million in 2000) on research into diabetes; similar large amounts of money are contributed by the Medical Research Council, the Wellcome Trust and other grant giving bodies. The more money that is raised for research into diabetes, the greater the benefits to the population with diabetes. At the time of writing, it costs about £40,000 to support a relatively junior research worker for just 1 year. The discovery of insulin was made by a doctor and a medical student (Banting and Best) doing research together for just one summer (1921). There have been many important but less dramatic discoveries since then, each in some way contributing to our understanding of diabetes and many improving the available treatment.

Searching for causes and cures

Do you think that diabetes will ever be cured?

This question cannot be answered yet. We must always try to take an optimistic view, however, and, if diabetes cannot yet be cured, it is not for want of research. Not only does Diabetes UK have meetings to discuss research and progress, but there is also an annual European Association for the Study of Diabetes meeting and an International Diabetes Federation congress which meets every third year. In addition there are also a great many national organizations that meet regularly. More has been discovered during the last 30 years about the cause of diabetes than ever before, and during the same period there have been important advances in treatment. This is therefore a very exciting period in diabetes research and we can continue to look forward to improvements in our understanding of the disease even if, for the moment, a cure is a little too much to hope for.

I have a friend who has been treated with insulin for 12 years. He recently came off insulin altogether after having had an operation on his adrenal gland. He now tells me that his diabetes has been cured. I thought there was no cure for diabetes.

It sounds as if your friend was one of the very few people in whom the diabetes was secondary to some other condition. In his case the other condition was an adrenal tumour. When this was eventually diagnosed and appropriately treated by an operation, it resulted in a cure for his diabetes. This result has been recorded in two forms of adrenal tumour. One is called a ‘phaeochromocytoma’, where the tumour produces adrenaline and noradrenaline, both of which inhibit insulin secretion by the pancreas. The other adrenal tumour is one producing excess of adrenal steroids and cortisone, which again produces a form of diabetes reversible on removal of the tumour.

There are a number of other rare conditions often associated with disturbances of other hormone-producing glands in the body. In these cases cure of diabetes is possible after appropriate therapy of the hormonal disturbance. Unfortunately, less than 1% of all people with diabetes, who have such a hormonal imbalance, are suitable for surgery. Specialists are always on the lookout for these causes since the benefits from an operation are so tremendous.

Will it ever be possible to prevent diabetes with a vaccine?

There is some evidence to suggest that certain virus infections can cause diabetes but we are not clear how often this happens: it is probably very infrequently. If a virus were isolated, which was found to cause diabetes, it would then be possible to produce a vaccine that could be given to children like the polio vaccine, to prevent them from developing diabetes later in life. At present this possibility seems rather remote.


I gather that it is possible to identify people by looking at special blood tests within a family who are at high risk of developing diabetes. This sounds like an exciting development, as presumably children who have inherited an increased risk of diabetes will be those most in need of vaccination should a vaccine become available.

Yes, you are quite right. Studies of the so-called HLA tissue antigens in families in whom there appears to be a lot of diabetes, indicate that certain patterns of inherited antigens carry with ‘phaeochromocytoma’, where the tumour produces adrenaline and noradrenaline, both of which inhibit insulin secretion by the pancreas. The other adrenal tumour is one producing excess of adrenal steroids and cortisone, which again produces a form of diabetes reversible on removal of the tumour.

There are a number of other rare conditions often associated with disturbances of other hormone-producing glands in the body. In these cases cure of diabetes is possible after appropriate therapy of the hormonal disturbance. Unfortunately, less than 1% of all people with diabetes, who have such a hormonal imbalance, are suitable for surgery. Specialists are always on the lookout for these causes since the benefits from an operation are so tremendous.

With these tissue markers (discovered by using blood tests) it should be possible to identify the children who are likely to benefit most from a vaccine or an effective form of preventive treatment should one become available in the future. It will be in these susceptible individuals that the first clinical trials will need to be done.

Is it true those studying families who have several members with diabetes can help find a cure for the condition?

Family studies are very important for helping to understand the inheritance of diabetes. In some families there is a clear association between a certain genetic background and the development of diabetes. Some members who have not yet developed diabetes may have the ‘markers’ described in the answer to the previous question, indicating that they are at increased risk of developing the condition.

Is it possible to prevent diabetes in these high-risk people?

Diabetes has a genetic link and close relatives of people with the condition have an increased chance of developing it, i.e. they are ‘high risk’. There is a trial taking place in the USA and Canada called the Diabetes Prevention Trial-Type 1, which is looking at people who are at high risk for Type 1 diabetes, and seeing if intervention can prevent or delay Type 1 diabetes. The participants have a test to see if their blood contains islet cell antibodies (ICA), the antibodies that destroy the insulin-producing cells, and, if they do, they are possible recruits for the trial. Over a 5-year period, these individuals either inject low doses of insulin twice a day, or take insulin orally in the form of a capsule (or are part of a control group where no insulin is given). The insulin capsules are made up of insulin crystals, which are thought to be effective against the islet cell antibodies, but are not effective for controlling the condition after onset. Animal research and studies in humans have suggested that diabetes can be delayed in those at high risk when they are given small doses of insulin. The results of the trial should be interesting.

I have heard that there is a new programme called DAFNE. What does it involve? Could I take part?

DAFNE stands for Dose Adjustment For Normal Eating. It is an educational programme, first developed in Germany, aimed at people with Type 1 diabetes, which teaches them how to adjust their insulin injections to fit their life and food patterns, rather than the other way around. The intensive course takes place over a 5-day period, and is run by specialist diabetes nurses and dietitians, and about eight people with diabetes take part. They have to take several insulin injections a day, as well as monitoring blood glucose levels at least four times a day. It teaches them how to count carbohydrate units and to adjust their insulin to their individual lifestyle, whilst keeping their blood glucose levels controlled. Results suggest that, for the right sort of person, DAFNE is a liberating experience and that the freedom to eat what you want improves the enjoyment of life. As DAFNE develops, more centres will be involved. A similar lifestyle programme for Type 2 diabetes, DESMOND, is under development. For further information speak to a member of your diabetes team, or contact the Careline.


(46) Diabetes

 Pancreas transplantion

Pancreas transplant



 I should like to volunteer to have a pancreas transplant. Is there someone I must apply to? How successful have these operations been?

Pancreatic transplantation is still in the experimental stages and it will be difficult to find anyone who will accept you as a volunteer. Technically, pancreatic transplants are even more difficult than liver, kidney or heart transplants. The pancreas is very delicate and, as the seat of many digestive juices, has a tendency to digest itself if damaged even slightly. The duct or passageway through which these juices pass is narrow, and has to be joined up to the intestines in a very intricate way so that the enzymes do not leak. Even if everything goes well technically, the body will still react against transplant so several immunosuppressant drugs have to be given. Some of these (particularly steroids), given in high doses to suppress rejection of the transplant tend to cause diabetes or make existing diabetes worse! The future looks much more promising with the transplant of the islet cells of the pancreas.

Are there any hospitals carrying out transplants of the islets of Langerhans? Would I be able to donate my cells to my insulin-treated daughter?

Yes, there are seven centres around the UK that have signed up to the Diabetes UK Islet Transplantation Consortium. This consortium is hoping to replicate and refine the technique developed by the English surgeon, James Shapiro, and his team in Edmonton, Canada. The Edmonton team took islet cells from donor pancreases and injected them into the liver of people with Type 1 diabetes. Once in the liver the cells developed a blood supply and began producing insulin. The entire transplantation process is now known as the ‘Edmonton Protocol’.

However, it is not possible to take islets from living donors so you would be unable to donate your cells to your daughter. This technique is still in the experimental stage but the results look promising. In Edmonton, 13 out of 15 islet cell transplants have been 100% successful, but until the people have lived with the transplants for a number of years it is difficult to know whether this can be seen as a cure.

Transplant of the islets of Langerhans still involves the use of drugs to prevent rejection of the new cells (immunosuppressive therapy), and as result only people who have extreme problems in controlling their blood glucose levels are being considered for transplantation. People who receive islet cell transplantations spend the rest of their lives taking immunosuppressive drugs, and the long-term effects of taking these drugs are not yet known and may be damaging.

Research into ‘microencapsulation’ of these islets is making some progress, and may one day offer a solution that will avoid lifelong immunosuppressive therapy. By enclosing the islets in a porous membrane and transplanting them into an animal with diabetes, it is possible to show that the insulin can get out of the ‘bag of islets’ and normalize the blood glucose at the same time as nutrients from the bloodstream can get in to sustain the islets – while this is going on the membrane keeps at bay the cells responsible for tissue rejection. Unfortunately, after a while, the membrane tends to get clogged with scar tissue and the islet graft stops working.

A few years ago there was excitement in the media about an article in the medical journal, The Lancet, reporting a successful transplant of encapsulated islets. The man who received the transplant was still being treated with immunosuppressant drugs as he had received a kidney transplant as well. This result was encouraging, but much more research still has to be done before this could be considered as a form of treatment for diabetes. Until there has been a major breakthrough in the transplantation of tissues from one individual to another, the hazards of long-term immunosuppressive therapy for someone receiving either a pancreas transplant or an islet cell transplant are greater than those of having diabetes treated with insulin. There are no tangible benefits yet for this form of therapy as a primary form of treatment for diabetes. The problems are not insuperable but much more research needs to be done before transplantation becomes a routine treatment for diabetes. Insulin pumps and artificial pancreas

I recently read about a device called a ‘glucose sensor’, which can control the insulin administered to animals with diabetes. Will this ever be used on humans and if so what can we expect from it?

The research into the development of a small electronic device that could be implanted under the skin and that could continuously monitor the level of glucose in the blood has been going on in the USA, the UK and several other countries for many years. The technical problems of such a device are, however, considerable, and it seems unlikely to be of use in people with diabetes for at least some time. Not only are there technical problems in achieving an accurate reflection of blood glucose level by such a subcutaneous implanted glucose sensor, but the further problem of ‘hooking it up’ to a supply of insulin to be released according to the demand is formidable. Clinical trials are being carried out in the USA and France using an intravenous glucose sensor in conjunction with an implantable pump. The early results are encouraging, but it will be several years before it is widely available.

I understand that there are ways of testing blood glucose without pricking the skin. Can you tell me more about them?

There are regular reports in the press about ‘non-invasive’ blood glucose monitoring devices being developed. Some devices being developed are not totally non-invasive. One involves a needle being inserted under the skin for up to 3 days at a time so that blood glucose readings can be taken every few minutes. At the moment the readings given can be accessed only by a healthcare professional, but it is hoped that eventually people would be able to read these results for themselves. This method of monitoring could be useful if the device were attached to an insulin pump adjusting the amount of insulin administered in response to the blood glucose level. Although this is not yet possible, it is likely to be developed in the very near future.

The other non-invasive blood glucose monitoring device is the GlucoWatch, developed by a Californian company called Cygnus Inc. This device is worn like a wristwatch and measures blood glucose from interstitial fluid. Interstitial fluid is the fluid that fills blisters when skin is damaged, and it can be extracted from the top layers of skin without the use of a lancet. It works by a process called reverse iontophoresis. This means that a very low electric current is applied to draw interstitial fluid through the skin. The glucose in the fluid is then collected in a gel that is part of the AutoSensor, which gives a glucose measurement. The AutoSensors must be replaced every 12 hours, and the device then needs a 3-hour warm-up period. The device must be calibrated against a finger-prick blood test each time a new AutoSensor is used. The readings are taken up to three times an hour. It has a memory that can store up to 4000 results. It is recommended that people do not alter medication based on a GlucoWatch result without checking this against a finger prick test. It is now available in the UK from Cygnus (UK) Ltd, but it is expensive.

Diabetes UK Careline can provide an information sheet on the product.

I hear that there are pumps available that can be implanted like pacemakers – is this true? What are the likely developments with insulin pumps within the next 5 years?

Yes, it is true that insulin pumps have been implanted into people as part of research studies and there has been some encouraging progress in this field. Although still experimental and with a long time to go before being a regular form of treatment, some pumps have been developed that are small enough to be implanted into the muscles forming the wall of the abdomen and have been left there for several years. The implantable pump is licensed for sale in Europe but is currently not available in the UK, and it has not been approved by the FDA in the USA. It is made by MiniMed and is very expensive. This pump does not have a sensor to detect glucose; it simply infuses insulin at a slow rate that can be regulated from the outside using a small radio transmitter. This can be used to command the pump to infuse more insulin just before a meal, or to reduce the rate of infusion if the blood glucose readings are too low. The pump has a reservoir of insulin that can be refilled with a syringe and needle, through the skin, without too much trouble, but changing the batteries requires an operation! Although it looks promising, the major disadvantages are cost and complexity. This is still very much a research procedure and cannot yet be recommended for routine treatment.

I have heard about the artificial pancreas or ‘Biostator’. Apparently this machine is capable of maintaining blood glucose at normal levels, irrespective of what is eaten. Is this true? If so, why isn’t it widely available?

There are several versions of what you describe, namely an artificial pancreas, which measure the glucose concentration in the bloodstream continuously and infuse insulin in sufficient quantities to keep the blood glucose normal. Unfortunately these machines are technically very complex, bulky and extremely expensive. Their major value is for research purposes since they are quite unsuitable at present as devices for long-term control. There is a great deal of research going on in several bioengineering groups to try and make them the same size as a cardiac pacemaker, but it is still likely to be several years before the first machines become available for research studies, and it will be a long time after that before suitably reliable machines are available for daily treatment. Even when the technical problems have been resolved and it has been miniaturized to an acceptable size for implantation, the costs are likely to be a limiting factor.


(47) Diabetes


Diabetes type 2 - five food swaps to lower your blood sugar

 A Review of the Current Diabetes Treatment Landscape

Lower Blood Sugar Prevents Diabetes


New insulin and oral insulin

What advances can we expect in the development of new insulin in the coming years?

Over the last 20 years, we have gone through a stage of producing purer and purer insulins with patterns of absorption varying from the very quick-acting to the very long-acting formulations. In recent times biosynthetic human insulins have replaced the animal insulins for most people. We go into more detail about human insulins before, but basically, they are manufactured by interfering with the genetic codes of bacteria and yeasts and inserting material that ‘instructs’ the organisms to produce insulin. By inserting the genetic material coding for human insulin, scientists can get the organisms to produce human insulin. They can equally well get them to make any insulin with a known structure; indeed, they can even get them to make ‘new’ insulins with ‘invented’ structures – we are now in the era of ‘designer’ insulins! There is virtually unlimited capability to modify the natural insulin and see if we can improve on this: by analogy to other areas, we expect to be able to develop a whole new range of insulins with new properties that should be able to make therapy better.

We are already beginning to see the benefits from this remarkable advance in scientific manufacturing. Trials have shown that one of these insulins is absorbed much more quickly than any of the existing fast-acting insulins, is very good for covering meals and can be given immediately before the meal rather than 15–30 minutes beforehand. Two such insulins have now been released for general use, Humalog from Lilly and Novorapid from NovoNordisk. We are also looking for variations in the structure of the insulin, which will ‘target’ the insulin more directly to the liver, the major organ responsible for glucose production in the body. Normally insulin is produced by the pancreas and goes directly to the liver but, unfortunately, in insulin-treated people, the injected insulin reaches the liver only after it has been through all the other tissues in the body. It should be possible to modify the structure in such a way that it can be targeted at the liver and in that way, perhaps, it may turn out to be a more effective and easier way of controlling blood glucose levels.

I have heard that it is possible to get away from insulin injections either by using nasal insulin sprays or some form of insulin that is active when taken by mouth. Are these claims true and are we going to be able to get away from insulin injections in the future?

There is no doubt that a small proportion of any insulin delivered via the nose is absorbed through the membranes into the bloodstream and can lower the blood glucose. Unfortunately, only a small percentage of that which is put into the nose is ever absorbed and it is, therefore, an inefficient and expensive way of administering insulin. Because the absorption is erratic, the blood glucose is not very stable. Experiments have been done with insulin suppositories showing that they too can lower the blood glucose without the need for injections but, again, the absorption is only incomplete and the response erratic.

Regarding oral insulins, it is possible to prevent the stomach from digesting the insulin by incorporating it into a fat (lipid) droplet (liposome), which enables it to be absorbed from the gut without being broken down by the digestive juices. Unfortunately again, the absorption is erratic, the whole lipid droplet with the insulin is absorbed, and there is no way of knowing when the insulin will be released from the droplet and become active.

Inhale Therapeutic Systems Inc. is developing an insulin inhaler (using compressed air), that delivers an insulin powder deep into the lungs, where it is absorbed into the bloodstream, (a pulmonary drug delivery system). These new forms of insulin are taking a long time to come onto the market and we just have to wait and see how successful they will be. NovoNordisk and Aradigm Corporation is beginning further trials of their insulin inhaler. This is an electronic inhaler that releases a blister pack of liquid insulin deep into the lungs. Generex Biotechnology Corporation is developing an oral insulin spray administered by a device that looks like a small asthma inhaler. A pressurised container holding liquid insulin administers the drug into the mouth, and this is quickly absorbed through the cheeks into the blood-stream.

Oral insulin crystals are being used in capsule form in the Diabetes Prevention Trial in the US, but, although they are thought to be effective against the antibodies that destroy the insulin-producing cells, they cannot control diabetes after onset.

All these developments are exciting but there are various issues to be aware of when considering the effectiveness of inhaled and oral insulin:

• People must be confident of receiving an accurate dose of the insulin.

• Inhalers often use very large doses of insulin.

• We do not yet know the potential side effects of such large doses.

• The inhalers being developed so far do not totally eliminate the need for insulin injections.

• The devices need to be portable, compact and competitively priced.

We await the publication of the clinical trials with great interest. Diabetes UK is likely to keep people informed by articles in Balance, or on their website.

New technology

Will there be any benefits to people with diabetes from the computer and microelectronic revolution?

You will have already seen some of the benefits in the blood glucose monitoring devices currently available, and all the modern insulin pumps rely heavily on microchips to control the rate of infusion. We have microcomputer programs that help store and analyse home blood glucose monitoring records. It should be possible soon to simulate the blood glucose response to different insulin injections and in this way produce means of exploring the effect of different types and doses of insulin, and stimulating the body’s response. We are also using computers as a way of teaching people about diabetes and its management, as well as a way of testing people about their knowledge of diabetes. There is now a multimedia interactive CD ROM containing a great deal of excellent educational material but, as it is expensive at present, it is only suitable for diabetes clinic or practice use. Microcomputers are being used to help record and analyse information from the diabetes clinic as well as to help to plan and organize monitoring of diabetes care and to write letters. It is quite likely that this will lead to an improvement in the efficiency of the organization of diabetes clinics, as it has done to the organizing, for example, of airline tickets and flights. There are early experiments going on in the use of so-called ‘expert systems’ to transfer the expert knowledge and reasoning of specialists to general practitioners in order to facilitate their management of people with diabetes within general practice, without the need for them to attend hospital diabetes clinics so often.

It is not unreasonable to expect that the microelectronic revolution will produce a lot of benefits over the next 10 years.

Our local diabetes unit has just run a successful Christmas Fair to raise a lot of money for a mass spectrometer. What good is this going to do for diabetes research?

A mass spectrometer is a complicated machine, which can be used to measure minute amounts of very similar substances present in the bloodstream or in other body constituents. It is often used to measure the amounts of naturally occurring stable ‘isotopes’, which can be administered to people with diabetes to investigate their body’s metabolism in great detail. In the past, this type of study could be done only by injecting radioactive isotopes, which could then be followed in the body as they were metabolized. As their name implies, radioisotopes produce radiation, which can have harmful effects on cells in the body. As we know, even the smallest amount of radiation is best avoided: mass spectrometry allows even more detailed research into metabolism than radioisotopes with none of the risk. Your local researchers are lucky to have this facility


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