Ten years ago, diabetes was a life sentence. Today, Imperial research is transforming the lives of diabetics through data, technology and public policy.
Words: Victoria James / Photography: David Gill / Styling: Vicky Lees
Obesity and diabetes, the headlines tell us, are a ‘national health emergency’ that will ‘bankrupt’ the NHS within a generation and ensure that today’s children ‘die earlier than their parents’. The figures – 422 million worldwide living with diabetes, which directly causes 1.6 million deaths annually – suggest a health disaster of catastrophic proportions; one that has come out of nowhere to overwhelm the world’s population. A trend we’ll never be able to reverse. A fight we won’t win.
Such pessimism would be challenged, however, by Imperial’s numerous diabetes researchers – many of whom have been working in the field since long before it came to international attention. Indeed, their shared hope is that their professional lifetime may yet see the battle won.
Professor Sir Steve Bloom, Imperial’s Head of Division for Diabetes, Endocrinology and Metabolism, now in his 70s, was born into the medical establishment’s fight against diabetes. “My father was a doctor and my mother a nurse, and my father specialised in diabetes. When I was a boy I remember him testing urine in the kitchen,” he recalls.
The use of insulin as a treatment for diabetes was pioneered in the 1920s by a team in Toronto, winning a Nobel Prize in 1923 for Frederick Banting and John Macleod. “Insulin was able to save lives,” Bloom says. “And by the time my father retired it was unusual for children to die from diabetes, as they had done when his career began.”
Bloom’s father’s small patients were living with type 1 diabetes (see box on page 18 for an explanation of the principal types), but today’s diabetes discussion is focused on type 2, which is acquired from numerous risk factors, many – though not all – of which are avoidable.
“Globally, most cases of diabetes in adults – between 85 and 95 per cent – are type 2,” says Professor Majid Ezzati, who holds Imperial’s Chair in Global Environmental Health and in 2016 co-authored a major study in The Lancet, ‘Worldwide trends in diabetes since 1980’.
That research, using data from 146 countries, laid bare the extraordinary advance of diabetes around the world. The number of adults living with the condition rose from 108 million in 1980 to 422 million by 2014.
“That’s the story everyone talks about,” says Ezzati. “Diabetes is going up.” And on the face of it, it’s a bleak story. One of the World Health Organisation (WHO)’s global targets for non-communicable diseases is, by 2025, to have held adult prevalence of diabetes at its 2010 level. Ezzati and his colleagues have found that even this modest goal looks unattainable. “If post-2000 trends continue,” their study concludes, “the probability of meeting the global target is lower than one per cent for men and is one per cent for women. Only nine countries for men and 29 countries for women, mostly in western Europe, have a 50 per cent or higher” chance of doing so.
The bigger picture revealed by their work, however, is far more complex – and in some ways more reassuring – than these stark predictions suggest. In part, the rise in diabetes incidence is due to healthcare successes. Yes, you read that right.
“You hear a lot about obesity and fast food,” Ezzati explains, “but the rise in population – and the ageing population – are actually the biggest drivers of rising diabetes costs to the NHS. In non-English speaking western Europe, diabetes is going up solely because of ageing. People are living longer. So, in many ways, that’s actually a success.”
Ezzati’s research reminds us to beware lazy thinking about the modern lifestyles so often blamed for that post-1980 acceleration of diabetes prevalence. Take urbanisation, accused of causing people to lead sedentary lifestyles and consume poorer-quality diets of processed foods. The evidence suggests otherwise. “Access to diverse foods can be greater in a city,” says Ezzati, “so that can be a benefit. Cities, rightly used, can be useful. Where we see westernisation and urbanisation, those countries are doing better.”
Better access to healthcare is a crucial part of that, and Ezzati’s Imperial team is working with WHO to look at coverage of treatment. “The sooner people are diagnosed, the sooner the chance of preventing complications. That’s currently done very well in tackling HIV and very poorly with diabetes,” he says.
Those fighting obesity and diabetes are now looking back, keen to learn lessons from past public health achievements and failures. Dr Jonathan Pearson-Stuttard (MSc Epidemiology 2016), a Public Health doctor and National Institute for Health Research Academic Clinical Fellow at Imperial, is currently seconded to England’s Chief Medical Officer (CMO), Professor Dame Sally Davies (herself an Emeritus Professor at Imperial). A recent paper on childhood obesity from the CMO and Pearson-Stuttard drew parallels with the public health response to smoking. Almost 70 years after a seminal study on smoking’s grave health impact, the paper states, “it remains a leading cause of premature deaths in England”. The fight against obesity, it concluded, must be “faster, and fairer, than our fight against smoking”.
“Look at how long it’s taken us with smoking,” says Pearson-Stuttard. “The response has had to be multifaceted and sustained: redesigning packaging, restricting availability by age, reducing acceptability (not smoking in cars with children nor in public spaces) and persistent taxation. Despite these efforts, inequalities still persist. And that’s the challenge for public health on obesity and diabetes – that it’s complex. You can’t take a pill and sort it. One’s risk of obesity and diabetes is influenced by family history and diet, all the way to your living conditions and economic circumstance – the environment around you is immensely important.”
Building an evidence base and communicating such messages takes time. “The link between being overweight and cancer has been around for many years,” says Pearson-Stuttard.
“But the link with diabetes is much more recent. We recently quantified the cancer burden – in 2012 – attributable to diabetes for the first time.”
Pearson-Stuttard was the lead author of a June 2018 paper in The Lancet Diabetes & Endocrinology that, for the first time, estimated the global cancer burden attributable to diabetes and high body-mass index combined – and also isolated that caused by diabetes alone. Examining the 12 cancers known to be linked to high Body Mass Index (BMI), it found that 804,100 new cases were attributable to the combined effect, with nearly 300,000 cases due to diabetes alone. “We’re only just beginning to see what a complex condition diabetes is as a risk factor for other chronic illnesses and the implications for management and prevention measures,” he says.
And there are further startling new insights to come from Imperial’s network of diabetes researchers. While it may seem unsurprising that a patient’s diabetes will influence their health in other ways, striking evidence is emerging of how one type – gestational diabetes, experienced during pregnancy – affects not only the mother’s own health but also that of their child, even after birth.
“Diabetes in pregnancy is associated with a number of risks to the mother and baby, including a greater risk of pre-term labour, stillbirth and congenital malformations,” explains Dr Karen Logan (PhD Clinical Medicine Research 2016), Honorary Research Associate at Imperial’s Department of Medicine. “More recently, associations have been demonstrated between diabetes in pregnancy and longer-term health risks in offspring. Our research showed that diabetes in pregnancy is associated with greater fat deposits in early infancy.”
The mothers in Logan’s study all had their condition well controlled during their pregnancy, but the study’s findings showed that diabetes in the mother can trigger changes in the baby at a very early stage. And that’s worrying, because it throws the problem forward to the next generation. “Long-term health can be influenced in the womb and in early infancy, and diabetes in pregnancy may contribute to the worldwide epidemic of obesity and diabetes,” Logan says.
This deepened understanding of the complex causes and consequences of diabetes only heightens the urgency around effective intervention and prevention. Indeed, the two go hand in hand. And this is where Imperial’s network of expertise is leading the way in delivering a whole new range of diabetes interventions, arising from interdisciplinary collaborations.
For example, Gary Frost, Professor of Nutrition and Dietetics, is working on clinical trials of a cheap food ingredient that works in the same way that appetite-supressing legumes do, and has the potential to prevent weight gain in adults who wouldn’t naturally eat peas and beans by becoming part of their everyday diet. He is also working with clinician and Professor of Practice, Anne Dornhorst, on innovative approaches to gestational diabetes. “Using novel food supplements, we hope to offer women new ways to improve their pregnancy outcomes and long-term health,” says Dornhorst. The sort of interdisciplinary working enabled by Imperial’s collective expertise is, she says, “quite simply essential”.
Professor Bloom enthuses about the range of work being conducted across the university’s departments. “We have a division that looks at metabolic engineering which developed small artificial pancreases; a bariatric arm that can predict who will respond to surgery; a wing studying complications of diabetes; nutritionists looking at the kind of food that will protect us from diabetes; and geneticists working out who’s susceptible. We cover everything from the most basic biology to translational use, doing patients good here and now.”
‘Patients’, however, isn’t a word you’ll hear Professor Chris Toumazou using often. Toumazou is Regius Professor of Engineering, and among his innovations are an artificial pancreas for type 1 diabetics and an intelligent neural stimulator that provides a drug alternative for obesity. His latest venture, though, is taking diabetes intervention out of the realm of hospitals, research labs and policy makers’ offices. Instead, Toumazou and colleague Dr Maria Karvela are the co-founders of a spin-out company, DNA Nudge, that is taking diabetes prevention and intervention into supermarkets and high streets – and directly to ‘consumers’ via their smartphones.
“We now have the ability to sequence DNA on a microchip,” Toumazou explains. “And we know that a DNA-based diet will improve health.” The device offering the help is a blue plastic disc the size of a compact mirror, from which juts a microchip. “This replaces an entire lab,” Toumazou says. “It removes the stigma of it being anything medical.” Karvela adds: “The test helps glucose management, and hypertension goes down. So, the idea is to help people use their genetics to nudge their eating decisions for them.”
The consumer provides a saliva sample from which the chip sequences their DNA and creates a profile of their body’s particular susceptibilities – how well it processes fat, sugar and salt, what foodstuffs are craved, and how the body manages weight and appetite. It then empowers them to go and do something about it. The chip’s results are uploaded into a smartphone app and a wearable smartband that lets shoppers scan any grocery barcode and get an instant thumbs up or down as to whether it’s a suitable purchase for them.
It assists consumers in the course of their everyday life, ‘nudging’ them to make healthier choices that can prevent obesity and diabetes before they ever arise. “It’s not about telling people to eat grapes instead of biscuits,” says Toumazou. “It’s about what biscuits are better for you.”
Imperial expertise is opening up a new front in diabetes prevention, using cutting-edge technology to solve the oldest conundrum of public health: how to reach ‘consumers’ before they become ‘patients’. The future of the fight against diabetes just got personal.
Understanding diabetes
Type 1 – an autoimmune disease that prevents the body from producing enough insulin to regulate blood glucose levels.
The cause is believed to be a combination of genetic predisposition and potentially an environmental ‘trigger’. Usually diagnosed in childhood but may start in adulthood.
Type 2 – a metabolic disorder in which the body either uses insulin inefficiently or is unable to produce enough to regulate blood glucose. Risk factors include being overweight/obesity, unhealthy diet, physical inactivity, smoking, genetics and ethnic predisposition.
Gestational diabetes – usually develops around weeks 24-28 of pregnancy, caused by insulin-resistant hormones made by the placenta, coupled with foetal growth. The condition occurs in 3-5% of pregnancies and typically disappears after the baby is born.
Prediabetes – a metabolic condition closely connected to obesity, in which blood glucose is higher than normal but not yet classifiable as diabetes. An estimated one in three people in England live with prediabetes, which can be prevented from developing into type 2 with intervention.
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