History of Diabetes Mellitus and a way of Life.
Diabetes Mellitus has been known for thousands of years and we will try to relate the essence and the discoveries through the ages which have led to today’s understanding of the disease and the fear of the diabetic patient to try new methods of treatment.
Physicians and researchers have documented this condition known as Diabetes Mellitus for centuries. The first to talk about it is believed to be Heys-Ra, an Egyptian physician in 1552 B.C. when he observed frequent urination as a striking symptom of a mysterious disease. He already knew that ancient healers noted that ants were attracted to the urine of such patient. Many manuscripts in the ancient Egypt mentioned about this disease.
We believe that Hippocrates did not mention much about Diabetes because it looks like this disease represented a death sentence during his time. Areataeus, also a Greek physician from Cappadocia in the first century did mention that Life with Diabetes was short and “disgusting” with a poor prognosis. He described the disease as a “Melting down of flesh and limbs into urine”. Similarly, Indian physicians identified the disease also and called it “madhumeha” or honey urine. The Chinese named the disease “tang niao bing” meaning “sugar urine disease”. Koreans and Japanese did also used the term.
Mention of the disease is done by Galen during the time of the Roman Empire while he claimed having only seen 2 cases. In Medieval Persia, Avicenna (800-1037) provided us with a description of the disease in the “Canon of Medicine”, insisting on the fact that such patients have abnormal appetite, poor sexual functions but were always associated to a urine with sweet taste.
We discovered, centuries later that people known as “Water Tasters” were able to diagnose the disease by tasting the urine of the suspected person. If the urine was found “sweet”, the diagnosis was made. Therefore, the disease was named “Mellitus” meaning honey by Thomas Willis in the late 1600’s, but later in the beginning of the 19th century, chemical test started to look for sugar in the urine. As physicians learned over time, they started managing the disease with exercises like horseback riding in the thinking that such sport will facilitate urination. The term “Diabetes” was coined by the Greek Apollonius of Memphis in 250 BC. Later in 400-500, Sushruta and Charaka, two Indian physicians associated the disease with the young patient while also the obese was found to suffer equally. They called type them Type one and Type 2 Diabetes , as two distinct entities.
We realized soon that dietary changes were essential to the well-being of such patients, so it was imperative to avoid sugar but eat more meat. Apollinaire Bouchardat, during the Franco-Prussian war, applied that principle and added less sugar to the military rations of the soldiers and people started insisting on “fat diet”, “starvation diet”.” potato therapy” to improve the conditions of patients suffering from the disease. In 1776 Matthew Dobson reported that “glucose” was identified in the urine and was found to be responsible for the sweet taste.
Earlier in the 20th century, Elliot Joslin, a scientist from Boston became a world expert in the treatment of this disease and wrote the first textbook “The treatment of Diabetes Mellitus” in which a fasting diet combined with exercises was able to eliminate complications from the disease, principles that we are still advocating for patients with this condition. The pathogenesis of Diabetes was understood around the early 1900’s and it is only in 1921 that Frederick Banking and Charles Best. two Canadians scientists first used “Insulin” in the treatment of Diabetes Mellitus after the fact that Paul Langerhans associated the gland Pancreas with the production of such substance Insulin (From the Latin: Insula=island) originated from the islets. Insulin was found to control the glucose level in the body. Refinement and purification of the hormone was pursued at the University of Toronto allowing modern physicians to use the drug in injections. Pharmaceutical companies like All Lilly, commercialized the product to treat thousands of patients in Canada and the USA.
Other medications like “Metformin” (1922), Insulin NPH (1940). Sulfonylureas (1942), Phenformin (1977), Thiazolidinedione (1990) were produced to help supplementing a variation in the treatment of different type of Diabetes. Now biosynthetic insulin is available, isolated from genetically altered bacteria. More, the advent of Insulin Analog (1996) has improved absorption and distribution. The FDA approved in 2005 a new drug derived from the venom of the Gila monster in the treatment of Diabetes Mellitus.
Each of us has lost somebody battling this disease. I still remember individual closed to me like my ex-father-in-law who will crave for sweet or a glass of alcohol against physician’s orders. You would believe that offering him the forbitten candy would ease his suffering. I have seen kids with juvenile diabetes refusing to keep a strict diet and one I remember the most in my practice in Coffeyville KS, after surgical treatment of a calcaneal fracture. The daily life is often part of their misery and they are tired of controlling all food they consume. Nowadays, many have found new ways to modify their gear in controlling their own destiny.
Diabetic bodies do not produce Insulin or if patients are lucky, the body can produce a little. So, the need to be constantly aware of their carbohydrate intake and their glycemia allowing them to adjust the insulin intake to control the breakdown of the sugar ingested. They are at risk because of so many complications starting by heart disease, kidney failure, peripheral vascular disease. Blindness. Often the diabetic, not controlling his diet, may fall in a coma with serious complications and even death. A little more than 50 % of diabetic will end up with a below knee amputation.
Diabetic patients can be ingenious, like the one who invented a system called “Dexdrip” linking a glucometer to a cell phone via Bluetooth and hooking herself to an online community to render better life to many diabetic patients. Because of the chronicity of the symptoms, diabetic patients found themselves in a constant mood for improvement of their care. The FDA recently approved the first closed loop system with automatic administration of insulin to type one diabetic patients based on a reading from the glucometer.
Physicians and Nutritionists instruct patients on the basics, leaving them free to the choice of foods or even to the use of Insulin, encouraging them to face errors. Hopefully, a new technology as the Continuing Glucose Meter (CGM) has made Diabetes maintenance easier through automatic insulin pumps, delivering insulin that can be raised or lower by tapping on a button.
The FDA also approved the first “Artificial Pancreas” that read the glucose level and infuses insulin as needed. The glucose is measured from fluid, fat or muscle but not from the blood and as such it may take a delay in the automatic response to treat the glycemia, endangering the life of the patient. Other personal health monitors as wrist bands will control sweat or control pain. Tubing in their insulin pumps need to be changed periodically in order to avoid infections. Apple watches can help in monitoring the amount of insulin to be injected.
Diabetics found out that the FDA is slow to bringing help to diabetic patients because the population became a so big source of income when insulin, testing strips, sugar pills, glucometers are constantly used. Uninsured are easily rejected by new insurances based on a pre-existing condition. Medicare is also terrible. Diabetic patients are losing hope because for so many years, a cure for Diabetes was offered. They have taken in hand their destiny in becoming more technically involved in their care. One parent, John Costik, created a code allowing him to check on his son glucose level while he was physically at his day care, leading to an open source software “Nightscout” able to deliver insulin.
In 2013, Leibrand and Lewis used a system called Raspberry Pi, creating a computer closed loop system which feeds information from the continuous glucose meter (CGM) into an algorithm to send command to an insulin pump. Two organizations Diasend and Tidepool are creating software to facilitate data storage. Others are even working on a generic insulin production like the one already available in Europe.
Most diabetic patients are reluctant to check a new system on themselves, the same way the FDA is hesitative to approve them. They are afraid of the consequences. Interest in the involvement of mental health expert in the care of the Diabetic is growing. There is a proliferation of information linking health and behavior. It is said that seven to ten leading causes of death in the USA are related to behaviors such as Smoking, Overeating, and Excessive alcohol consumption. Evidence has demonstrated the importance of psychological, behavioral, and social in Diabetes. Non-adherence to treatment does not appear to be itself an evidence of a psychological problem.
Patient coping with Diabetes Mellitus have learned to gain better control of their blood sugar levels with the choice of food and an easy lifestyle. They have better conditioning to keep them fit, allowing their body to increase muscle mass, reduce stress and often to minimize the use of insulin. Many “Apps” became available to manage glucose. They lose weight and stay in shape lowering their blood sugar. I encourage all to take advantages of the multiple options and try to enjoy life while the Diabetes is under control.
Maxime Coles MD
References:
1- Principles of Diabetes Mellitus, New York Springer (2nd edition) p 3
2- Dobson, M (1776) “Nature of the urine in Diabetes” Medical Observations and Inquiries. 5 298-310.
3- Pattack, M (December 2002) “New weapons to combat an ancient disease, treating diabetes”. The FASEB Journal 16 (14) 1853.
4- Mediver, Victor Cornelius (1993) The history of clinical endocrinology CK UK Parthenon Pub Group pp 23-34
5- Bryan, Jenny (2004) Just the Facts Diabetes. Chicago, Il Heinemann library, a Division of Reed Elsevier Inc. p 7
6- Pollack, Andrew (2005-04-30).” Lizard-Derived Diabetes Drug is approved by the FDA” The New-York Times
7- Crow, James Mitchell. “Venomous drugs: The Diabetes-busting lizard” (2014-08-23)
8- Polonsky, K, S “The Past 200 Years in Diabetes” New England Journal of Medicine, 367 (14): pp 1332-1340
9- Harris, Michael: Lustman, Patrick: Psychologist in the Diabetic care.