Understanding diabetes is a complex affair. Thousands of researchers and medical doctors around the globe are daily working to achieve a better understanding of diabetes, which may help the prevention of it and offer novel treatment leading to maybe, who knows, a cure. Let us ask experts in the field of diabetes on their opinion in relation to a future cure. Will we ever see a cure for diabetes? >> Well, we already have a cure. So if you are normal weight, and you're eating healthy and you're doing exercises, it's very rare to see type 2 diabetes. But the problem is that many people are too obese and they exercise too little. >> I would say that we actually have a cure for diabetes. There might be people who disagree with me. We have the cure, now we just need all the people to take the pill. And the pill is eating the right diet and exercise. >> Will we ever see a society that doesn't have diabetes? >> If you look at experimental animals, if you look at rats and mice and follow them for a lifetime, particularly rats. And if you make them eat a little less they live longer. They get less metabolic disease just like we. So the answer to your question really implies that we should be able to make people eat less. And that is a problem because why are we here? If you think we are here to enjoy life, that implies eating and drinking. If you think we are here to suffer, that also implies that you're not supposed to eat and drink. And then you have to choose what life is really all about. That's my answer. >> It almost sounds too good to be true. And it is too good to be true in the sense that by cure the researchers mean that people can reverse type 2 diabetes through healthy eating and exercise, and thereby go off medication. But still, they have to follow a lifestyle program for the rest of their lives. Whether we can actually turn back time, so that it's like you've never had diabetes, is a different matter nd depends, among other things, on how severe the condition is, for how long you've had it, and on your genes. One of the leading scientists in the heritance of diabetes is professor Torben Hansen. So let's ask him to give us a look into the complexity of the genetics behind type 2 diabetes, and how an understanding of this complexity can hopefully lead to more personalized strategies in terms of treatment and prevention. I would like to ask you this because some researchers already state that we have a cure for diabetes, namely if we exercise and eat healthy then we can cure it, do you agree on this? >> I partly agree because we do have studies in pre-diabetics which show that we at least can delay the onset of diabetes. But I don't think the studies show that we can prevent them. But then also we know that there are subtypes of diabetes which are not type 1, which are not type 2, where you can not prevent diabetes even if you exercise and eat healthy because these subsets are monogenic and they are very important to identify, and they should have specific treatment. We know that there are, as I mentioned before, what we call monogenic forms of diabetes where a defect in one gene will cause, nearly always, diabetes. And these forms we can give specific treatment, unfortunately not prevention. So these are subtypes which are important, they are maybe 2% of all diabetes. So in Denmark it would be between 5 and 10,000 diabetics, which are not diagnosed the right way. >> So what are the consequences of those that are diagnosed wrongly? >> For the majority of diabetes, if you have a diagnosis for example of type two diabetes, there are guidelines on how to be treated. You should start, for example, with lifestyle intervention, and add on top of that you will have a medication called Metformin, which is an oral hypoglycemic agent, and then if that does not work you will have other medications on top of that. But for the monogenic forms of diabetes, we exactly know the defect in the genome, and also then the underlying pathophysiology. And some of the forms, that is only sensing defects in the glycemic level, when should these individuals start secreting insulin. And when the glucose reach a certain threshold, they secrete insulin as well as you and me. And they live a perfectly happy life just at a slightly elevated glycemic level. And these patients and these children should not be treated at all, because they are not in danger of late diabetic complications. Then there are other monogenic forms of diabetes where also often there's an early onset, maybe around 20 years old, or often with a very strong family history. So when we ask to the family history of diabetes they will tell us that these patients that we have diabetes in several generations in the family. And when we have these suspected forms, we can do genetic testing, identify the underlying pathophysiology and we can treat with other tablets. So some of these patients, even after 20 years of insulin treatment, they are better off with a tablet compared to insulin. So it has big, big consequences for these patients that we do the right diagnosis very early on. >> If genes play such an important role, is that what you're saying then we can't find a prevention? >> No, I do think that also genes might be able to help us. But most of the preventive initiatives which has been published so far, the diabetes preventions studies both in US and from Finland, they identify people who we know are at very high risk, they already have hyperglycemia. And when you do lifestyle intervention in these individuals then you can postpone the time of diabetes onset. But you'll only postpone this time with one or two years. So in my mind what we call prevention nowadays, that is not really prevention. You, by healthy lifestyle, postpone the onset. I believe and think that genetics might be able to tailor prevention much earlier in life. So it might be so that we have a point of no return in the development of diabetes, and that could be the early stages of hyperglycemia. And this is where we start nowadays. When we move it to before, people they actually start getting hyperglycemia. Then we might have much, much better chances to prevent. And then also when we start getting an idea of how the genes work, some genes work primarily on their ability to secrete insulin, others work maybe primarily on the insulin-sensitive side. Then we can maybe, at the individual level, say that you should do this form of prevention, and maybe I should put my focus on another kind of prevention. So if we are little bit lucky, then we can tailor the preventive initiative. And we can start much earlier in life. But I do think that we can be much better to prevent, and I also think that genetics might be one of the tools where we can do it much more focused. >> As we've heard, Torben Hanson and his colleague's study highlighted a number of genes directly involved in the development of type 2 diabetes, and point to both the challenges we face and to possible new ways to treat or prevent the disease. Professor Juleen Zierath is working on a different but equally important risk factor for developing diabetes, exercise and its effects on our epigenome. The epigenome includes chemical changes to the molecules regulating the expression of our DNA. Let us now ask how exercise can contribute to the treatment of diabetes even in persons who have a high genetic risk for developing the disease. Now you once said exercise is medicine, and it seems the means to alter our epigenomes for better health, may be only a jog away. What does that mean? >> Well, I think it's quite interesting that even if you have a high genetic risk score for the development of diabetes, if you exercise and if you can keep your weight down, you can prevent or delay diabetes. So you can actually exercise your way away from diabetes even if you have a high genetic risk. So exercise is like a medicine, and that's a proven fact. And one of the ways that you can use exercise is to remodel the muscle cells, and you can build up muscle mass, bigger muscles, and you can have muscles that can break down sugar and fat as a substrate more readily. So even with a genetic risk, exercise can kind of help rescue yourself from that course to becoming diabetic. So your DNA, your genetics are not your destiny. And I mentioned earlier some of the changes that happen in the muscle are these epigenetic marks. And exercise can somehow decorate the DNA with chemicals that can either prevent, or allow, transcription factors to bind to the DNA and reprogram the muscle. And essentially make the muscle a healthier organ to prevent diabetes. >> So does that actually mean that we can completely cure or reverse diabetes without medication? >> No, it doesn't mean that. I still believe that if you a have a genetic risk for diabetes eventually you probably will become diabetic. But the exercise and lifestyle modifications, diet, good habits in your life, can delay the onset of diabetes. So you can really push it further down the path. And I think that that's a good thing. >> Could you put a timeframe on that? >> I would hesitate to put a time frame on that, because it's probably very individual, but I think research has shown that you potentially could delay the onset of the disease by ten years or more. One thing that's really interesting is if you have a glucose tolerance test where you drink a sugar drink and clinicians they measure your blood sugar. And they can see the rise in blood sugar in response to drinking a sugar drink. There are certain parameters that if your sugar levels are too high you're classified as being impaired glucose-tolerant, you are at risk of developing diabetes. What we know, and our research has shown, if you undergo a lifestyle intervention with exercise or diet, you can improve this number, this glucose tolerance level. And you can actually convert from being at a very risk for diabetes to being normal glucose tolerant. And that's just some evidence that exercise or lifestyle can improve your glucose control and pull you away from the diabetic phenotype or the diabetic classification. >> How will your research be able to contribute to prevention and treatment of diabetes in the future? >> So I could tell you what we're doing now. And then I can tell you what we hope for. So right now we are really looking at different modalities of exercise. Either endurance exercise, or walking, or weight training, or high intensity exercise. And we're doing that in the clinic, okay. And we're trying to gauge how well individuals with diabetes, people with diabetes, respond to the different modality of training. And the idea is that not all sizes fit the same person. Not all exercise is going to be beneficial for the same person. So you may respond very well to an endurance exercise program. But my brother may respond much better to a weight training program with some cardiovascular fitness. So we're actually trying to figure out how the gloves are fitting. How the exercise might be best tailored to help different individuals. And we're also trying to understand what kind of metabolic outcomes we can achieve with different exercise programs. So what might be the best time of the day to exercise? People with diabetes are most vulnerable in the morning. Their blood sugars can be very high after their first meal. If you follow a blood sugar course over the day, blood sugar levels are very, very high in the morning. And based on what you do and what you eat, that might project out the curve of your glucose levels throughout the day. So we're trying to see whether exercising in the morning, where you stimulate the muscle to take sugar up and lower the blood sugar, is better than exercising late at night. So the timing of the exercise, the kind of exercise and then what you eat around the exercise may improve your overall health. And we think that might go with the idea of an exercise prescription that, of course, should be taken in consultation with your physician and maybe other medicines you need. But how can we dial in the best prescription for you to keep your blood sugar low and improve your overall health. >> Will we ever have a cure for diabetes? >> I am hopeful that we'll have best treatments for diabetes, and I am hopeful that we'll have better ways of preventing diabetes. And I think that that's what we should be focusing on, initially. I think we should certainly be looking for cure, and my view of that would probably be to think about the islets and the cells that produce the hormone insulin. For example, with type 1 diabetes, there's a situation where people with type 1 diabetes are not producing insulin. And I think we really need a cure there. I think we understand that there is a problem with that organ, we have to cure it. You could argue there's a treatment, insulin, but that's also complicated. For people with type 2 diabetes, I think that initially we need to work on prevention and best treatment. And then hopefully that'll get us to a cure. I don't think we still understand the complex physiology with type 2 diabetes well enough to know what to cure. So there's still much more for scientists to do to tackle this big problem. >> Current evidence states that we have indeed become better at treating diabetes. Decreasing mortality and morbidity numbers speak for themselves. And just to include one example, a perspective study led by Professor Olaf Petersen from the Metabolism Center, University of Copenhagen, demonstrated that people diagnosed with diabetes in Europe have regained 8 years of their life expectancy over the last 20 years, due to improved treatment and follow up. Several new drugs with improved tolerability and efficiency are emerging. Surgical treatment, such as gastric bypass surgery, are being implemented. And these initiatives inspire researchers to look for future treatment opportunities. With a special interest in how to control appetite to help ensure a healthy diet. [MUSIC]
