Tuesday, July 16, 2019

Diagnosing diabetes risk early

I've been following the saga of Michael Snyder, a geneticist at Stanford, for some time. Snyder participated in a genetic study in which his own DNA was analyzed, and in the process he discovered that he had a gene linked with increased risk of type 2 diabetes. Then a viral infection made his blood glucose (BG) levels soar high enough that he was told he had type 2 diabetes.

Snyder modified his diet and increased his exercise and slowly brought his BG levels back to normal ranges within 6 months. When I mentioned this in a blogpost, I wrote as if bringing his BG levels back to normal meant that he could escape chronic type 2 diabetes as long as he maintained his diet and exercise regimen.

I was wrong. A recent story in the New York Times states that although he was able to maintain normal BG levels for three years after the initial diagnosis, they eventually increased enough that he was again told he was diabetic. He said it seems he's slow to release insulin.

In fact, almost everyone with type 2 diabetes lacks the rapid phase 1 insulin release that knocks down BG levels quickly, but we still have the slower phase 2 insulin release. When I was in a clinical study at the Joslin Diabetes Center, I showed almost zero phase 1 insulin release. Interestingly, when I took high-dose aspirin (actually an aspirin-like drug used in the study), my phase 1 insulin response increased to almost 70% of normal.

The classic description of type 2 diabetes is that it's caused by insulin resistance, but more and more research is showing that different people get type 2 diabetes (perhaps better called non-autoimmune diabetes) for different reasons. For some, the insulin resistance may be the strongest factor, but for others, factors like poor insulin secretion may be more important. Not all people with type 2 are overweight and some overweight people are insulin sensitive.

“We learned that people are Type 2 diabetic in very different ways,” said Snyder in the New York Times article.

In one study, "nine of the cohort members developed diabetes during the study. But it appears their health followed different paths to reach that state. Two people gained weight before their diagnosis, but seven developed the condition without substantial weight gain. The subjects also showed differences in how much insulin they produced. Some made very little insulin, while others produced enough insulin, but not sufficient to lower their glucose levels and forestall diabetes."

So a treatment that is best for people with one subtype of type 2 may not be best for people with another. This is not big news, but it's always nice to see some scientific validation of what we've observed.

Snyder is still trying to control his BG levels without drugs, and he's still getting a lot of lab tests. Perhaps this intense scrutiny of the physiology of one type 2 diabetes patient will give hints about the process that will help us all.

And what Snyder's story means for you is that if your diabetes progresses even though you are doing all you can to control it, don't blame yourself. Your genes may be responsible