The future of diabetes management: GLPs, new technologies and the ongoing quest for a cure

Robert A. Gabbay, MD, PhD, FACP

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Diabetes has been a massive problem not just in the U.S. but also around the world. Much of the focus on treating the disease to date has focused on glucose control, but new options are emerging that broaden that perspective. Let’s explore.

The state of diabetes

Today, 38 million people are living with diabetes. About a quarter of them don’t know they have it, and those with Type 2 diabetes often show no symptoms, only presenting once they are in the hospital with their first complication.

A common prediction among those of us in the field is that in 30 years, 50% of people will have diabetes — with the numbers anticipated to be particularly high among certain racial and ethnic groups. Realistically, our health care system cannot handle that great of an influx of new cases.

Diabetes continues to be the leading cause of amputations, blindness and kidney failure. While we’ve made some strides, amputations are actually on the rise. Additionally, cardiovascular disease increases two- to four-fold in individuals with diabetes, and it’s become the No. 1 killer of people with diabetes. It should come as no surprise, then, that the costs associated with diabetes are staggering — one in every four health care dollars spent in the U.S. is related to diabetes care.

That’s the bad news. The good news is that we now know how to prevent the complications that drive up costs and harm patients. Herein lies the opportunity.

The obesity link

Obesity is often a precursor to Type 2 diabetes. Because of this, it stands to follow that weight reduction decreases the chance of developing Type 2 diabetes, which is why there is so much enthusiasm around GLP-1-based therapies. Not only do these therapies help balance blood sugar, but patients also average 15% to 22% body weight reduction — a much greater percentage than with previous therapies.

GLP-1s (as glucagon-like peptide-1 agonists are known) have advanced significantly in recent years, with new combinations continuing to move through clinical trials to expand treatment possibilities. There is real promise they can be effective in obesity management, but access to the medications and high costs remain an issue. Hopefully, with a new influx of therapies and production continuing to ramp up, costs will drop and availability will increase.

But even with drugs in hand, patients still require support and education with these therapies. They must learn things like how to adopt a slower eating pace, letting their brains catch up to their stomachs, and the importance of adequate protein intake to preserve muscle mass, as well as the benefit of adding even light strength training to their routine.

Positive impact of technology on diabetes care

In addition to drug therapies, patients are finding success in managing diabetes with technology. Continuous glucose monitors (CGMs) make it simple for people to monitor their blood sugar levels. CGMs measure glucose levels automatically every five minutes, allowing patients and clinicians to view patterns and trends. These readings can be used to make informed decisions on things like managing blood sugar, adjusting treatment, the role of foods and exercise, and reducing hypoglycemia risk. Now, data from CGMs can be integrated with insulin pumps, which is an exciting development as we inch toward the creation of fully automated insulin delivery systems that adjust and respond even to meals and exercise (currently, patients still need to input some information).

Additionally, the rise of digital health tools and electronic health records (EHRs) has facilitated remote monitoring, personalized care, and improved engagement between physicians and patients. These tools can play a critical role in identifying and ultimately addressing patients’ social determinants of health — things like access to nutritious food and insight into lifestyle, such as how much a patient moves in a day. Health care providers can then use this information to bridge gaps in care plans.

There is certainly room for artificial intelligence (AI) to make an impact as well. AI might create personalized “behavioral phenotypes” for users, adjusting prompts and recommendations based on individual responses and patterns. This adaptive approach could make diabetes management more intuitive and responsive to patients’ unique needs while reducing the burden on health care providers.

Innovative research inspires hope for a cure

Still, the ultimate goal of diabetes research is to develop a cure. While significant progress has been made, there are reasons we have not yet succeeded in this regard. One of the primary obstacles is simply the body’s immune system. It attacks and destroys insulin-producing cells in the pancreas. But tremendous work is being done to overcome this challenge.

Islet cell transplantation involves transplanting insulin-producing cells into a patient. Although a shortage of these cells has limited its spread, recent breakthroughs enable scientists to convert blood cells into stem cells, which can then be developed into an unlimited supply of beta cells and other islet cells necessary for insulin production.

Beyond the typical need to prevent an immune attack of transplanted cells, because Type 1 diabetes is an autoimmune condition, the body’s immune system will still attack transplanted cells even if they are autologous. Many current trials rely on immunosuppressive drugs to protect these cells, though this approach has risks, including susceptibility to infections. Researchers are exploring alternative solutions to overcome immune rejection, including immunotherapy, which targets specific immune cells or molecules to create a tolerant environment for transplanted or newly generated cells.

Two other novel approaches could also prove successful:

1. Microencapsulation: This technique encloses islet cells within a small capsule, protecting them from immune cells. The challenges associated with this approach include preventing capsules from clogging due to fibrosis or foreign body reactions. Additionally, there can be oxygen supply issues within the capsules, but researchers are now using bioelectronic processes to generate localized oxygen, which can improve cell viability.
2. CRISPR genetic modification: Using CRISPR technology, scientists can alter cell surfaces to evade immune detection, potentially enabling transplantation without immunosuppression. By modifying the cell surface markers that trigger immune attacks, researchers hope to achieve tolerance.

Progress in islet cell technology and genetic modification not only reflects the commitment of scientists to curing diabetes and the opportunity to reduce the strain diabetes places on the health care system but also offers renewed hope to patients seeking relief.

A brighter vision for the future of diabetes care

With ongoing advancements in medication, technology and research, significant improvements in the lives of people with diabetes are on the way. We are moving beyond glucose control to truly address the complexities of the disease.

The health care ecosystem is successfully collaborating to benefit our patients, embracing new options. By working together, we can help people with diabetes achieve optimal health outcomes.

Robert A. Gabbay, M.D., Ph.D., FACP, is chief medical officer and senior vice president at Joslin Diabetes Center and associate professor at Harvard Medical School. His research concentrates on improving health care delivery models to enhance diabetes outcomes and patients’ experiences. He is dedicated to creating a model for the patient-centered medical neighborhood for diabetes to ensure patient-centered coordinated care between the team of health professionals that are required to meet the patient’s needs. To improve quality, Dr. Gabbay has traversed many arenas, including better patient communication tools and care management, behavior change using motivational interviewing, self-management support, decision support and leveraging technology.

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