Lest We Forget: In Remembrance to Move Forward.

Poppies row on row… Following just a few days after Remembrance day is World Diabetes Day. When speaking about moving forward for anything, it is important we look back at history to learn from those before us. History has much to tell. Here’s a small trip back in time to recognize those who fought for us in the battle against this chronic condition:

1869, Paul Langerhans – a medical student in Berlin – identified some “little heaps of cells” scattered throughout the bulk of the pancreas. Little did Paul know at the time when studying the structure of the pancreas under a microscope that these clusters of cells he identified, later known as the “islets of Langerhans”, would have a regulatory role in digestion (1).

1889, Oskar Minowski in collaboration with Joseph von Mering removed the pancreas from a healthy dog to test its assumed role in digestion. Several days later, they observed flies feeding on the dog’s urine. On testing, they found sugar. Thereby coining the term “diabetes” from late Greek “excessive discharge of urine”; and “mellitis” from the classical Latin word “mellite” or sweetened with honey (2). They also identified that if the duct through which the pancreatic juices flowed to the intestine was surgically tied off, the dog developed minor digestive issues, but no diabetes. Thereby identifying two independent functions of the pancreas (1).

In 1901, Eugene Lindsay Opie identified that Diabetes mellitis is caused by destruction of the islets of Langerhans and occurs only when these bodies are in part or wholly destroyed (1).

Over the next two decades, researchers made various attempts to isolate the substance which the islets produced:  In 1906, George Ludwig Zuelzer; in 1911, EL Scott and in 1915, Israel Kleiner and in 1916, Nicolae Paulescu was able to inject a dog with diabetes with an aqueous pancreatic extract, successfully normalizing blood sugar levels … but World War I interrupted their work (1).

Summer of 1920, Frederick Banting approached Professor John Macleod at the University of Toronto, a leading figure in the study of diabetes in Canada at the time, to study his theory. Macleod provided Banting with a student, Charles Best and a few dogs for experimentation. His theory was that the pancreatic digestive juices could be harmful to the secretion of the pancreas produced by the islets of Langerhans. Therefore, he thought if he were able to ligate the pancreatic ducts and stop the flow of nutrients to the pancreas, the pancreas would degenerate, shrink and lose its ability to secrete digestive juices, which would then allow him to extract the cells that produced this “antidiabetic secretion” without harming the pancreas. And so the experiment began: they removed the pancreas from a dog, Marjorie: blood sugar rose, it became thirsty, drank lots of water, urinated frequently and grew weak – the dog had developed diabetes. On another dog, they surgically ligated the pancreas so that it had degenerated, and removed the pancreas, sliced up, froze and then filtered the substance, which they named “isletin”. The extract was injected into the dog with diabetes and glycemic control was achieved (1, 3, 4).

Insulin was discovered: the hormone that controls the amount of glucose (sugar) in the blood, crucial to the uptake of sugar into cells to be used as energy or to store as fat. It allowed people that otherwise would not have more than a few days to live, to survive, and now, thanks to science and those behind the research, to live well.

“Diabetes is a chronic, often debilitating and sometimes fatal disease, in which the body either cannot produce insulin or cannot properly use the insulin it produces. Insulin is a hormone that controls the amount of glucose (sugar) in the blood. Diabetes leads to high blood sugar levels, which can damage organs, blood vessels and nerves. The body needs insulin to use sugar as an energy source.” – Canadian Diabetes Association 

We know that if left untreated, diabetes can lead to harmful complications such as eye and kidney complications, cardiovascular disease, and nerve damage. For anyone living with diabetes, whether it be type 1, type 2, or gestational, we know that it can be consuming. On top of the everyday difficulties of life, one has to learn to adjust physical activity, food intake, and medication or insulin to achieve somewhat of an equilibrium… and as you can imagine, that equilibrium is highly sensitive to various factors – what we eat, how much we eat, our sleep schedules, whether we are happy or sad, or stressed – they could all be thrown off balance in the blink of an eye.

According to the WHO, today, more than 422 million people in the world have diabetes – that is approximately 1 in 11 persons, and is on the rise. In 2012, diabetes was the direct cause of some 1.5 million deaths, with more than 80% of them occurring in low- and middle-income countries. The projection is that diabetes will be the 7th leading cause of death by 2013 (5).

So whilst we remember the contributions those of us before us have made so that we can live better lives, let us be grateful and continue to pay it forward so that our future generations can continue to live better lives than ours. 

Lest we forget. In war, there is no victory. When lives are lost and blood is shed, nobody wins. During early 1900s, multiple researchers on the topic of diabetes had their studies interrupted by war, the expense was not only the soldiers in the frontline, but those who could have benefitted from the discoveries that were delayed. Let us remember Sir Frederick Banting, cofounder of insulin, served with distinction in the First World War (Cambrai, September 1918) and gave his life serving our country during the Second World War (February 1941) (6) – a sad loss of a brilliant mind.

The only battle where there might just be victory is this battle we are currently in against diabetes. A battle where lives can be saved instead of lost. A battle where people from all genders, age, ethnic, and socioeconomic backgrounds are united. 

“The blue circle is the universal symbol for diabetes. Until 2006, there was no global symbol for diabetes. The purpose of the symbol is to give diabetes a common identity. It aims to:

  • Support all existing efforts to raise awareness about diabetes
  • Inspire new activities, bring diabetes to the attention of the general public
  • Brand diabetes
  • Provide a means to show support for the fight against diabetes”

– International Diabetes Federation 

Lest we forget – how far we have come. From the term “diabetic” to “living with diabetes”. We’ve become more conscious of word choices when talking about people with diabetes. Diabetes is a serious and chronic disease, yes, but it is not what defines a person. And the terminology we use most definitely should not be encouraging discrimination. From a feared disease that undeniably led to death, to highly restrictive diets that bought patients a few extra years at the expense of starvation and related complications (3), to “living with diabetes for over 50 years”. Since 1922, we’ve had many advances in insulin, such as production of long-acting insulins, the purification of insulin and the production of how human insulin and now insulin analogues. We have a variety of oral hypoglycemic agents and diabetes associations in various countries regulating clinical practice guidelines with evidence-based science to better guide clinicians. By no means are we close to a cure, but we most definitely have come a long way. From pork insulin extract to controlled glucose monitoring and now looking at islet cell transplants. After more than 80 years, we are still unable to mimic the workings of the human pancreas adequately, though we are much closer than we were initially.

Leonard Thompson. 1922, the first boy to receive insulin therapy, without which he would only have had a couple of days to live. (Photo from: Truman Library)

Today, we are looking at 11 million Canadians living with diabetes or prediabetes. Every three minutes, another Canadian is diagnosed (6). Even more alarming news from the International Diabetes Federation is that 1 in 2 adults with diabetes is left undiagnosed. Highlighting the urgent need to screen, diagnose and provide appropriate treatment to people with diabetes. Wouldn’t it be nice to see blue circles row on row instead one day? But as Dr. Shaukat Sadikot, President of IDF says, “If we are to win the battle against diabetes, we have to empower health professionals so that they are best equipped to address all aspects of diabetes”.

In order to be effective against this researchers, family physicians, endocrinologists, nurse educators, dietitian, psychologists and patients need to come together to share knowledge. Scientists in their own expertise to disseminate their knowledge with the interdisciplinary team. Family physicians to be more quick to pick up risk factors and screen. For the public to be more aware and to live a life reducing the risk factors for the development of type 2 diabetes, and to be more aware of those around us who may already be living with diabetes. For those already living with diabetes to step up and share barriers to health behaviour change so that we can learn to cater our recommendations to help you most effectively, and to share strategies that you have found to be helpful in managing your diabetes so that it could possibly benefit others just as it had you. For healthcare professionals, to stop sending people who are newly diagnosed home with a prescription to “lose weight” or “go on a diet”, because we know that it is not effective. Be compassionate and redirect if needed to services to help coping with a new chronic disease diagnosis, be sensitive in terminology and talk about weight management rather than loss, discuss the role of food and how it affects hunger, satiety and blood sugars rather than prescribing a diet. Be client-centered in our approach, be culturally sensitive and build efficacy for self management. Make it a collaborative process.

Clearly World Diabetes Day not just a one-day event. Every day, new diagnosis are being made, researchers are pouring their hearts and souls into understanding this condition, scientists are formulating new ways to manage and combat it. But this November, the global diabetes community is uniting to promote earlier screening and diagnosis. The earlier the diagnosis, the earlier interventions can be initiated to provide durable effects on harmful and costly complications of diabetes.

It might not be long before we see “for 75 years with diabetes”.

For more information on diabetes risk:

 

 

 

References 

  1. “The Discovery of Insulin”. Nobelprize.org.Nobel Media AB 2014. Web. 14 Nov 2016. <http://www.nobelprize.org/educational/medicine/insulin/discovery-insulin.html&gt;
  2. Oxford English Dictionary. diabetes. Retrieved 2011-06-10.
  3. “History of Insulin”. J Community Hosp Intern Med Perspect. 2012; 2(2): 10.3402/jchimp.v212.18701.
  4. “The History of Insulin”. Diabetes Care. 1993; 16(Supplement 3): 4 http://dx.doi.org/10.2337/diacare.16.3.4
  5. “World Diabetes Day” Press Release. Piemonte. 2016. Web. 14 Nov 2016. http://www.idf.org/news/world-diabetes-day-1-2-adults-diabetes-undiagnosed
  6. “5 Things you didn’t know about Sir Frederick Banting”. Canada Diabetes Association. 2015. Web. 14 Nov 2016. https://www.diabetes.ca/publications-newsletters/diabetes-current-newsletter/diabetes-current-archive/diabetes-current-january-2015/news/5-things-you-didn-t-know-about-sir-frederick-banti

 

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