Will diabetes be cured in the 21st century?   (October 3, 2009)

A reader recently wrote: "I just wonder if a cure will ever happen in the 21st Century? What do you think as a doc with diabetes? Will it make the extinction list of diseases when the 21st Century is over? Your perspective as a doctor?"

Well, as a doctor with diabetes myself, I'll take the bait, and offer an opinion. But first things first: we'll have to define "cure" (and also define "remission" and "prevention") and also realize that any predictions inevitably will have to differentiate our guesses for type 1 vs. type 2 diabetes.

Cure, to me, would be a situation where a person previously diagnosed with diabetes, who had well-documented elevated blood glucose levels and elevated A1C levels, later has normal BG and A1C without ongoing medications, surgery, dietary adjustments, or devices, as a result of some transient intervention. The problem is that although there are lots of bright ideas about what transient intervention or interventions might be able to create a cure, they are more science fiction than science at this time. An example: someday perhaps physicians might somehow use stem cells to regenerate the beta cells that make insulin -- without using antirejection medications. Someday this might be able to cure type 1 diabetes, but we're a long way from using stem cells in humans for this purpose. And using stem cells would seem unlikely to cure type 2 diabetes, which is a disorder that has two components: beta cell malfunction and also insulin resistance.

Remission, to me, would be a situation where a person previously diagnosed with diabetes, who had well-documented elevated blood glucose levels and elevated A1C levels, later has normal BG and A1C while continuing to take medications, or make dietary adjustments, or using devices. An example: weight loss via gastric surgery to control type 2 diabetes should be able to create remissions. It's reasonable to assume that overweight people with type 2 diabetes can have better glucose control after decreasing obesity-related insulin resistance. However, weight loss is not, to my mind, a cure for diabetes, but rather, weight loss can induce a remission. The problem is that regaining the weight, or having other stress events (such as severe infection, or use of steroid medications) could cause the diabetes to reassert itself -- it wasn't really gone; it was very well controlled. Another example: transplantation of beta cells can normalize BG and A1C in people with type 1 diabetes, but require ongoing use of antirejection medications, and frequently the transplants eventually fail anyway: so I count beta-cell transplant as creating a remission, not a cure.

Prevention, to me, would be a situation where a person never previously diagnosed with diabetes, who had always had normal blood glucose levels and normal A1C levels, continues to have normal BG and A1C in circumstances where statistically they might have been expected to develop diabetes. An example: use of a hypothetical diabetes vaccine might somehow prevent type 1 diabetes from occurring in high risk populations (for example, relatives of people with type 1 diabetes who have the antibodies associated with diabetes). This idea has been pursued in the past (in the DPT trials for instance), but to date hasn't been successful.

Now, back to the question: Will diabetes be cured in the 21st century?

In my opinion, type 1 diabetes, which is usually considered a disorder caused by immune problems, will be preventable as a result of immune methods: perhaps a vaccine, or medications that prevent the immune destruction of the beta cells. There will also be methods to create long-lasting drug-free remissions of type 1 diabetes, perhaps based on better beta-cell transplantation techniques.

In my opinion, type 2 diabetes, which is a disorder with both beta cell malfunction and insulin resistance, will be preventable, by societal changes that de-emphasize overeating, meaning less middle-aged adults will be obese. Less obesity equals less insulin resistance. Type 2 diabetes, once established, will be able to go into remission by weight loss -- nothing new!

But somehow I suspect that established cases of diabetes (whether type 1 or type 2) will not be curable anytime in the foreseeable future. The closest I see is that someday physicians might somehow use stem cells to regenerate the beta cells that make insulin in people with type 1 diabetes -- without using antirejection medications. I really can't put a timeline on this, and it might never work. And curing type 2 diabetes would require interventions that tackle both the beta cell malfunction and the insulin resistance, and I doubt that this will be possible.

My standards for documentation of a diabetes cure are tough: I won't accept any purported cure until the scientists who figure it out win the Nobel Prize in Medicine. (By the way, this would be the second Nobel for diabetes -- the first being for the discovery of insulin).