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Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body’s systems, especially the nerves and blood vessels.

Type 2 diabetes (formerly called non-insulin-dependent, or adult-onset) results from the body’s ineffective use of insulin. The majority of people with diabetes have type 2 diabetes and this type of diabetes is largely the result of excess body weight and physical inactivity. Symptoms may be similar to those of type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, after complications have already arisen (Sarwar, Seshasai, Gobin, Kaptoge & Angelantonio et al. Lancet. 2010; 26; 375:2215-2222).

 

Morbidity and mortality rates

The number of people with diabetes rose from 108 million in 1980 to 422 million in 2014 while the global prevalence of diabetes amongst adults over 18 years of age rose from 4.7% in 1980 to 8.5% in 2014. Between 2000 and 2016, there was a 5% increase in premature mortality from diabetes.

Diabetes prevalence has been rising more rapidly in low- and middle-income countries than in high-income countries. Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. In 2016, an estimated 1.6 million deaths were directly caused by diabetes. Another 2.2 million deaths were attributable to high blood glucose in 2012 (Sarwar, Seshasai, Gobin, Kaptoge & Angelantonio et al. Lancet. 2010; 26; 375:2215-2222).

New trends

A revolutionary endoscopic therapeutic procedure may lead to the discontinuation of insulin treatment in a significant number of people with type 2 diabetes. Researchers from the Netherlands tested a new, minimally obtrusive ablation procedure that reconstructs the lining of the duodenum in combination with daily doses of glucose-lowering drugs called glucagon-like peptide agonists (GLP-1 RAs) and mild lifestyle counselling (Health, 2020).

The participants in the study were previously insulin-dependent people with type 2 diabetes. The population were 75% and all treated with the ablation technique. The study found that all 75% of participants did not need insulin six months later, with HbA1c (a long-term parameter of glucose control) readings of 7.5% or below. HbA1c readings also fell to 6.7% at 12 months.

There were also significant reductions in the body mass index (BMI) of the patients who responded which were down from an average of 29.8 kg/m2 at the beginning of the research to 25.5 kg/m2 after 12 months. The percentage of fat in their livers also decreased from 8.1% to 4.6% at six months. Obesity and fatty liver are both important risk factors in the development of metabolic syndrome, a term that encompasses diabetes, high blood pressure (hypertension), obesity, and high triglycerides.

The patients, who did not respond, still needed insulin. The median insulin dose they required fell by more than half (from 35 units per day at study entry to 17 units per day at 12 months).

Another intervention is a minimally invasive technique, called duodenal mucosal resurfacing (DMR), which is performed in an outpatient setting and is delivered via an integrated over-the-wire catheter attached to a custom console that performs a synchronised lifting of the duodenal mucosa and then ablation of the treatment area. Although the process is not yet fully understood, mucosal cells are believed to undergo alterations in a response to unhealthy diets that are high in fat and sugar. This leads to changes in the production and signalling of key hormones that impact insulin resistance and diabetes. Resurfacing the lining appears to rejuvenate and reset this process.

Many patients with type 2 diabetes are very happy to be able to discontinue insulin therapy, since it comes with weight gain and hypoglycaemic events. Our earlier study, (Revita-1) with patients that used only oral medication for their diabetes type 2, showed that the effect of a single DMR was comparable to adding one glucose-lowering drug (Health, 2020).