What it will take to defeat Diabetes

When K.M. Venkat Narayan first began studying type 2 diabetes in the early 1990s, it was considered a disease of adults in affluent countries. Today diabetes has spread to every country in the world, to both urban and rural areas. It afflicts the poor as much as if not more than the rich and strikes children and teens as well as adults. A possible new phenotype of type 2 diabetes has emerged that is affecting younger, thinner people.

The number of people with diabetes has quadrupled from 1980 to 2014, and 415 million adults in the world now have diabetes, according to Rollins researchers. Globally, it was estimated that diabetes accounted for 12 percent of health expenditures in 2010, or at least $376 billion—a figure expected to hit $490 billion in 2030.

"In the years since I began working in this field, diabetes has grown to become one of the biggest public health threats we face," says Narayan, Ruth and O.C. Hubert Professor of Global Health. "The spread of some of the ills of a modern lifestyle—sedentary behaviors, a diet of processed and unhealthy foods, and an increase in obesity—has made diabetes a worldwide crisis. And at least in its most common form, it is substantially preventable."

Narayan and his team of researchers in the Emory Global Diabetes Research Center are looking at what needs to be done to reach a world free of diabetes.

Mohammed Ali, left, and Ralph DiClemente collaborate in the translation research center. K.M. Venkat Narayan, right, heads the Emory Global Diabetes Research Center.

First-world problems

In the U.S. and other high-income countries, diabetes is a good news, bad news scenario. On one hand, people who have diabetes today fare better than they did 20 years ago. They are living longer and suffering fewer complications, such as heart disease, kidney disease, amputations, strokes, and blindness.

On the other hand, more people are developing diabetes than experts even projected, with some 29 million people in the U.S. living with the disease today. One in four people with diabetes remains unaware and almost 90 percent with prediabetes don't know their blood sugar is elevated. And the drop in complications is not enjoyed equally. Minorities, people with low incomes, and younger adults tend to suffer more than their white, affluent, and older counterparts.

"We have gotten very good at caring for and controlling diabetes, but we are lagging in prevention," says Narayan. "The science is there. We know exercise, a healthy diet, and weight loss are extremely effective in preventing diabetes in people at high risk, but we haven't been able to figure out how to translate and scale up the implementation of that knowledge into population-wide interventions that work. We also need to find ways to improve outcomes for disenfranchised populations."

Narayan and his team will be tackling these issues through the newly established Georgia Center for Diabetes Translation Research. The center is funded by a grant from National Institute of Diabetes and Digestive and Kidney Diseases that was awarded to a partnership of Emory University (Rollins as well as the schools of medicine, nursing, and business), Georgia Institute of Technology, and Morehouse School of Medicine. Narayan is the principal investigator of the center.

Narayan and his team are borrowing the expertise Rollins has built in HIV prevention by bringing in Ralph DiClemente, Howard Candler Professor of Public Health in behavioral sciences and health education. DiClemente has decades of experience working to prevent risky sexual behavior among populations vulnerable to HIV, and he will repurpose these strategies to prevent diabetes. "One of the key things we've learned in our HIV work is that knowledge of the disease and what it takes to prevent it, while necessary, are not enough to promote adoption or maintenance of behavior change," says DiClemente. "We need to do much more than letting people know they are at risk. We have to be able to motivate people to adopt healthy behaviors."

That task may prove even more difficult for diabetes than it is for HIV. "The risk for both lie in lifestyle behaviors—sexual behavior for HIV and diet and exercise for diabetes," says DiClemente. "Changing HIV risk behavior was pretty challenging, but sexual behavior is episodic. However, you eat meals three times a day, so you have more opportunities to succeed or fail each day."

Technologies such as text messaging apps have proven helpful in providing needed reminders and motivation in HIV interventions, and the center plans to deploy similar strategies to fight diabetes. Community strategies can provide another layer of support. Coaches at YMCAs, churches, and community groups could be trained to offer diet and exercise interventions.

The center will also focus on eliminating disparities in diabetes management and complications, for which its Georgia location is ideally suited. The prevalence of diabetes in the Southeast is much higher than in other parts of the country—running 13 percent to 15 percent as compared to 9 percent for the nation. It also strikes some groups harder than others, particularly afflicting African Americans, people with lower incomes, and those with lower education levels. Not only do these groups have a higher incidence of diabetes, they have higher complication rates and incur higher costs.

Once again, the center will benefit from the expertise of the larger institution. "We have a lot of experience in disparities we can draw from," says Mohammed Ali, associate professor of global health and epidemiology and associate director of the center. "The school of medicine has a recently awarded American Heart Association Cardiovascular Center for Health Equity, and our epidemiology department has a training grant that focuses on disparities in cardiovascular diseases. These centers will collaborate, as their missions are similar, and the hope is that, together, the impacts will be larger than the sum of their individual actions."

Ali and his team have also identified another high-risk group—young adults. People with diabetes between 18 and 44 routinely have the worst outcomes in terms of controlling glucose, blood pressure, and cholesterol. That's largely because this group is not good at getting the care they need. "You know how the young never show up to vote? The young also don't show up for diabetes care," says Ali. "We're not sure why. Maybe they are working three jobs, or raising a young family, or just think they are immortal. Whatever the reasons, this age group does not manage the disease well, which means they develop complications earlier in life and spend a longer portion of their life dealing with morbidity and disability. We must counter this."

Burden in low-income countries

Despite the great strides in treating diabetes in high-income countries, much about the disease in low- to middle-income countries remains a mystery. Can interventions that have been proven effective in places like the U.S. be successfully translated in poorer countries? Why are thinner and younger people in some countries developing diabetes, and how does this form of the disease differ from the more common type that occurs in overweight people?

The gap in knowledge has a straightforward explanation. About 75 percent of the burden of diabetes is borne in low- and middle-income countries, but more than 95 percent of the research is being conducted in high-income countries. Narayan and his team have been working to build up the research base in low- and middle-income countries, particularly in India and Pakistan.

Mary Beth Weber, assistant professor of global health, partnered with the Madras Diabetes Research Foundation in Chennai, India, on a study that showed the interventions that have proven successful in the U.S. and elsewhere in preventing prediabetes from advancing to diabetes can work as well in India in some segments of the population. After three years, the study group that got the recommended intervention—lifestyle education plus the glucose-lowering drug metformin if needed—was 30 percent less likely to develop diabetes than the control group.

Weber is now planning an implementation study to see if this type of diabetes prevention program can be implemented at worksites in India. She and her team are modifying the educational curriculum and training peer educators to provide the interventions where they might have the most impact.

Some participants, however, did not respond as well to Weber's intervention, and this group seems to represent a different phenotype of the disease. These people were thinner—some with BMIs as low as 18.5—and younger than the typical person with type 2 diabetes, and their disease characteristics were different from those in obesity-related type 2 diabetes.

Classically, in type 2 diabetes, the pancreas beta cells initially have no problem producing insulin. The trouble is that the body's cells become resistant and thus there is a problem regulating glucose, which builds up in the blood. Over years, the beta cells become exhausted as they have to work hard to produce more insulin to regulate higher glucose levels, and then they begin to fail. This type of diabetes, generally associated with obesity, responds well to weight loss interventions and metformin.

However, when Weber and Lisa Staimez, assistant professor of global health, looked at blood samples of Asian Indians with prediabetes, they found that there had already been dramatic change in their beta cell function. "This suggests that poor beta cell function might happen much earlier in this group as compared with those with typical type 2 diabetes," says Staimez. "But we don't know why."

Some hypothesize that this early beta cell dysfunction may stem from historic undernutrition. Their bodies may be programmed by food scarcity to store fat differently and perhaps secrete less insulin. Indeed, thin Asian people actually have more body fat than a similarly sized person in the U.S., but in Asian individuals fat is stored around organs. This type of fat storage has been linked to higher risk for cardiometabolic diseases like diabetes.

This thin group does not respond well to traditional interventions, such as weight loss. "In the other groups, you are trying to improve insulin's action, whereas here you might have to improve insulin secretion, which we don't know how to do yet," says Narayan. "There is a huge gap in the research in this form of diabetes."

Staimez is starting one study on this group. She wants to know the impact on the child of a mother who is underweight or malnourished. She will look at infants of both normal weight and underweight mothers and compare their beta cell function at six months of age. "Understanding the way type 2 diabetes develops in this group could lead to some really innovative pharmacologic and lifestyle interventions," says Staimez. "By understanding early life factors, this study may provide new insight on how to globally improve the worsening reality of diabetes."

Lisa Staimez, left, and Mary Beth Weber, middle, are studying diabetes in India. Felipe Lobelo, right, is working to incorporate exercise into health care.

Just do it

If you want to prevent diabetes, which is better—popping a pill or jogging around the park? A hint—it's the path of most resistance. People who are at high risk for developing diabetes can reduce their risk by about 30 percent by taking metformin, the current gold standard medication. However, they can cut their risk by about 58 percent with 150 minutes of brisk walking per week in combination with diet changes.

"We know the best intervention is lifestyle, but it's been difficult to standardize it," says Felipe Lobelo, associate professor of global health. "Doctors routinely prescribe metformin but not enough prescribe exercise, partially because it is typically not a covered benefit."

He is working to change that as director of the Exercise is Medicine (EIM) Global Research Collaboration Center. The center, a partnership between the American College of Sports Medicine and Rollins, is the academic hub in charge of evaluating the EIM initiative, in collaboration with partnering health care systems, community organizations, and fitness and technology companies.

The center recently hosted a conference and "think tank" focusing on developing standards for wearable devices, such as FitBit and Garmin, so they can be better integrated into health care delivery. "We looked into developing standards regarding the validity for devices' measurement of physical activity, a minimal standard for appropriate behavior change strategies, and a standard for integration so that it can be easily transmitted to a physician or health care professional in a way that is clinically useful," says Lobelo. "The conference was a first step. A working group will compile the findings and continue working toward developing these standards."

Lobelo is also launching a pilot project in collaboration with Sharon Bergquist at the Emory Clinic. The clinic will integrate physical activity as a vital sign in the electronic medical record. Patients who say they are inactive will be given a printed exercise prescription, educational material, and the option of downloading an app that will allow them to share physical activity data with the clinic.

In the second phase of the project, the group will select 50 to 100 inactive patients with at least one cardiovascular risk factor and give them each a wearable activity monitor, along with a list of vetted community programs and places that offer safe physical activity options. For 12 weeks, patients' activity data will be monitored and a system of personalized messages implemented to help them achieve and sustain behavior change. The group will follow them for another 12 weeks to see if they stick with any exercise program they adopted.

Lobelo recently finished a similar program with 230 hypertensive patients served by Mexico's Social Security System primary care clinics. The study demonstrated that the EIM model linking counseling by the health care provider and referral to community exercise programs was effective in improving patients' physical activity levels.

"We'll see how much this group of Emory patients with the access to the wearable devices and messaging system increases their physical activity and if their health outcomes improve as a result," says Lobelo. "This is a proof of concept project intended to show that this is feasible to do at Emory and other U.S. health care systems without a lot of resources, and then we'll try to refine and roll it out on a bigger scale. Hopefully five years from now, every time you interact with your primary care physician, he or she will have information about your physical activity and incorporate that into your care."