The ‘cardiometabolic dilemma’: Collaboration across specialties advances diabetes research
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More must be done across cardiology, endocrinology, obesity medicine and related specialties to build on a century of progress to improve the assessment and management of patients with diabetes, according to a speaker.
Despite decades of research and scientific discoveries, diabetes remains an expensive disease with no cure, Robert H. Eckel, MD, president of medicine and science for the ADA, said during an address at the virtual American Diabetes Association Scientific Sessions. The cost for health care for Americans with diabetes is approximately 2.3 times higher than those without diabetes, with an annual expenditure of $330 billion.
“Broken down, the person with diabetes will spend on average almost $14,000 per year on health care, with over half of that attributed to diabetes,” Eckel said. “Due in part to efforts by the ADA in their annual call to Congress, research for diabetes is strongly promoted, but we are still falling far short.”
Defying the odds
It was February 1953 when Eckel first became seriously ill as a child and was later hospitalized with diabetic ketoacidosis and new-onset type 1 diabetes. He does not recall life without the disease, he said. His diabetes regimen included glass syringes and needles, boiled daily before injections, and the use of Clinitest tablets, boiled for 15 seconds with two to five drops of urine plus 10 drops of water. The technique, a crude way to assess glycemic management, risked severe burns if the hot solution were spilled on the skin, Eckel recalled.
“I experienced multiple severe hypoglycemic events as a young child, which led to a more simplified insulin regimen — one injection daily of U80 unpurified pork globin insulin, with a duration of action of just 18 hours,” said Eckel, also professor emeritus of medicine in the division of endocrinology, metabolism and diabetes and the division of cardiology at the University of Colorado Anschutz Medical Campus. “There were no scout camping trips; no overnight stays with friends until mid-teenage years, and unfortunately, still too many memorable hypoglycemic events in sports, at school and during training as a medical house officer and endocrine fellow.”
Eckel has defied the data. Research from the Pittsburgh Epidemiology of Diabetes Complications Study cohort shows that less than 30% of people diagnosed with type 1 diabetes between 1950 and 1964 were alive at age 60 to 70 years, Eckel said.
“I recall so well while studying pathology in medical school that a member of the faculty asked me why I was studying to become a doctor,” Eckel said. “He implied I should not have even been admitted to medical school, because I would not live past my mid-40s.”
It was only while training as an endocrine fellow in Seattle that glucose test strips finally became available, which Eckel recalled cutting into quarters for use due to their expense. That development was followed later by the advances of blood glucose meters and sensors for continuous glucose monitoring.
“Thanks to all of this research and device development, here I am today all hooked up,” Eckel said. “The research has gone so much further than the management of glycemia. Just consider what we now know about how to assess and manage microvascular complications in the eyes, the kidney and the nervous system, and all of the recent CV outcomes trials, which provide new hope for the reduction of heart attack, heart failure, stroke and death from CV disease in patients with diabetes.”
Direction of diabetes research
Ongoing research is essential toward working for a cure for all types of diabetes, Eckel said. Preclinical work with animals continues to be an essential step, and advances in basic science promise there is much to come in diabetes science. Diagnostics, drug development, clinical trials and vaccines are constantly being developed, he said.
Still, many questions remain unanswered.
“How about the role of micro RNAs and exosomes on diabetes-related pathophysiology and therapeutics?” Eckel said. “How about understanding in more detail by what mechanisms metabolic surgery improves glycemia? What about how best to optimize cost-effective management of diabetes? Then there is the gut microbiome and the ability of gut microbes to produce organic metabolites that may serve to prevent or even treat diabetes, or studies that determine sex differences in the etiology and complications of diabetes.”
The list is longer still — research into islet transplantation, “smart” insulins, and the use of artificial intelligence to inform precision and personalized medicine in diabetes.
Eckel proposed two big targets for focused diabetes research. For type 1 diabetes, what are the potential environmental “triggers” for development of disease in human leukocyte antigen-predisposed children and adults? For type 2 diabetes, what is the mechanism for the beta-cell failure that results in defects in glucose sensing that leads to glucose intolerance, prediabetes and type 2 diabetes?
“This is a very ripe field needing intensive further and focused investigation,” he said.
New specialty proposed
The “cardiometabolic dilemma” is based on the increasing prevalence of three conditions: obesity, metabolic syndrome and type 2 diabetes, Eckel said. Today, more than 40% of the U.S. adult population is obese, and increasing obesity prevalence during the last 40 years predicts an alarming increase during the next decade, he said. Similarly, it is estimated that 34% of U.S. adults have metabolic syndrome and 10.5% of U.S. adults have type 2 diabetes, with many remaining undiagnosed. The overlap of these metabolic disorders contributes in a major way to reversing the decades-long trend downward of reduced CVD mortality, Eckel said.
Eckel, along with Michael J. Blaha, MD, MPH, director of clinical research and professor of medicine at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, recently designed a training program for a new medical subspecialty — cardiometabolic medicine — to provide the comprehensive care for such patients, he said.
“It would include components of preventive cardiology, metabolic aspects of endocrinology and hepatology, nephrology, lifestyle and obesity medicine,” Eckel said. The 3-year program would combine research and relevant clinical training after a 2- to 3-year residency in internal medicine, he added.
“Upfront, it is expected that such a training program would take 10 to 15 years to establish and initially will grow out from existing fellowship training programs in cardiology and endocrinology and metabolism,” Eckel said.
In the meantime, volunteers are needed to make the ADA’s vision of a life free of diabetes and all of its burdens a reality, Eckel said.
“We need you to volunteer, to serve and to give to the ADA, so that everything the ADA stands for, including standards of medical care, scientific and scholarly journals, and research, survive and expand,” he said.
Perspective
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Louis H. Philipson, MD, PhD, FACP
Dr. Eckel is one of the true heroes, both personally and professionally. His comments during his address were extraordinary both in terms of his personal experience with a lifetime of diabetes, his personal experience with both of his sons having type 1 diabetes, and his long history of spectacular contributions to the science and practice of diabetes and cardiometabolic disease. I hope everyone has a chance to listen to his talk, since it will be available on the website for this year, and will be inspired by it.
I’m sure Dr. Eckel would be touched if everyone who heard his comments made a donation to the American Diabetes Association in his honor.
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Eckel RH. Living lifelong with diabetes: So much accomplished, yet still so much to be done. Presented at: American Diabetes Association Scientific Sessions; June 12-16, 2020 (virtual meeting).
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