BOSTON — The role of the endocrinologist in diabetes management has changed dramatically over the past 50 years, and will continue to change rapidly in the years to come.
A special symposium held at the American Diabetes Association (ADA) 75th Scientific Sessions highlighted how much physicians and researchers have learned about diabetes management and how the lives of patients have changed during the past 5 decades.
“The endocrinologist’s role has evolved over the past 50 years from a glucose-centric to a patient-centric approach. Management of diabetes is a pharmacophysiologic approach to a chronic disease that requires attention beyond glycemic control,” Farhad Zangeneh, MD, who is an assistant clinical professor of medicine at George Washington University School of Medicine in Sterling, Virginia, told Endocrinology Advisor.
“Today, the barriers are real but visible and many we share with other chronic illnesses. We must find effective ways to translate the advances made in our clinical science into daily clinical practice. Our role as endocrinologists is as an orchestra director responsible for the metabolic symphony of homeostasis.”
From how people test their glucose levels to how long they can expect to live has changed significantly over the past 50 years for Americans with diabetes.
When Fred Whitehouse, MD, Division Head Emeritus at the Henry Ford Health System in Detroit, first started seeing patients about 5 decades ago, the only treatment option for type 1 diabetes was to inject animal insulin, which came from cows or pigs and sometimes caused adverse reactions, according to a press release.
Today, Whitehouse noted, patients with diabetes are benefiting dramatically from long-acting and rapid-acting insulins and a variety of new delivery systems, including insulin pumps and other novel technologies.
In the coming years, endocrinologists will be playing an even greater and more hands-on role, according to Zangenah.
“Knowing our patients, and connecting our patients to the right therapeutic plan, is what we do on a daily basis. The endocrinologists are chronic disease managers equipped with excellent command of the pathophysiology of type 2 diabetes,” Zangeneh said.
“Management of people with diabetes is individualized. Hypoglycemia and weight gain remain the Achilles heel of HbA1c reduction. Fortunately we have had great success recently with glucose-dependent therapies to mitigate these risks while achieving a targeted 5% weight loss and beyond.”
Basic Research Advances
While dramatic improvements in diabetes management have occurred, there is still no cure. Nevertheless, the advances in basic research have furthered understanding of the disease.
Daniel Porte Jr., MD, who has been conducting diabetes research for more than 50 years, recalled when the endocrine and nervous systems were considered completely unrelated. Now, it is known that insulin sent to the central nervous system not only feeds back to the brain, but it also affects glucose production. Porte noted that it regulates the islet cells so there is a complete integration of the endocrine system and the nervous system.
Although it took 40 years to make this discovery, he said these findings are important and may have implications for other diseases as well. For example, Porte, who is a professor at the University of California, San Diego, mentioned the connection between impaired insulin action in the central nervous system and behavioral changes seen in Alzheimer’s disease patients.
Areas of Focus
Michael Brownlee, MD, who has experienced life as a person with diabetes, said the changes in diabetes management are astounding.
When he applied to medical school, only half of people with type 1 diabetes were expected to live into their 40s or 50s, Brownlee said. Some schools were even reluctant to admit him because they were unsure he would be able to practice medicine for a full lifetime. Brownlee, who is now associate director for Biomedical Sciences at the Albert Einstein College of Medicine’s Diabetes Research Center in New York, said the feeling then was that they should give the spot to someone believed to have a normal lifespan.
Brownlee’s research on the mechanisms that cause diabetic complications has created a paradigm shift in the field. He said the adverse effects of early high blood glucose levels have been shown to persist for many years after HbA1c levels are improved, a phenomenon called metabolic memory. A major focus of his current research is identifying the mechanisms responsible for metabolic memory.
Robert Ratner, MD, Chief Scientific and Medical Officer for the American Diabetes Association, said despite the enormous growth in the understanding of diabetes and its complications, there is still much to be accomplished.
“The next 50 years must elucidate the mechanisms by which both type 1 and type 2 diabetes occur, along with those critical steps at which we might intervene to prevent disease,” he said in the release. “Treatments must provide optimal glucose and metabolic control, without the risk of hypoglycemia, and complications diabetes should become historical memories.”
- Ratner RE. Session 3-CT-SY16: Fifty Years of Diabetes Research and Treatment. Presented at: American Diabetes Association (ADA) 75th Scientific Sessions; June 5-9, 2015; Boston.