‘DIABETYPING’: A NEW APPROACH TO DIABETES CARE

Every week, almost a thousand people in the Netherlands are told that they have type 2 diabetes. More than a million Dutch people now have the condition and another 1.1 million have prediabetes [1].

One in three Dutch people aged 45 and older has type 2 diabetes or will suffer from it in the future.

Beyond the challenges for the healthcare industry, type 2 diabetes has far-reaching consequences for patients. Usually it means starting medication, which often turns into injections later on. Worse, patients with type 2 diabetes face a significantly higher risk of other conditions such as cardiovascular disease, metabolic health issues, respiratory conditions and eye disorders [2]. The life expectancy of someone with type 2 diabetes is 4 years lower than average.

Fighting the growing diabetes epidemic plaguing many Western countries is fraught with challenges. This explains surge of interest in research work done by, among others, TNO, into the causes of type 2 diabetes. As the condition develops differently in each patient, different ‘styles’ of type 2 diabetes can be identified, which is why pharmacist and diabetes researcher Anne-Margreeth Krijger -Dijkema launched the term ‘diabetyping’ [3].

With diabetyping, doctors can better plan the treatment for each individual by adapting it to the specific sub-type they have.

Expert interview

Researchers Suzan Wopereis of TNO and José Castela Forte of Ancora Health talk about the possibilities and challenges of diabetyping.

Suzan Wopereis (SW): “Diabetes type 2 involves various organs, including the liver, pancreas and muscles. These organs may include insulin resistance of the liver or muscles or reduce the ability of the pancreas to produce insulin. Either way, the insulin system in the body is disrupted, resulting in too much glucose in the blood – which leads to negative health consequences. We investigate the causes of diabetes in each patient.”

SW: “Because depending on the sub-type, different interventions are needed. For example, in a large Spanish study, we analyzed the effectiveness of two long-term lifestyle interventions on type-2 diabetes outcomes. We found that certain diets were much more successful depending on the person’s underlying causes of their diabetes. For example, if someone had muscle insulin resistance [where their muscles had become less sensitive to insulin], a Mediterranean diet appeared to be able to help. If the problems were mainly in the liver, patients benefited more from a low-fat diet.”

SW: “We have now identified 12 types, in response to the question of whether the pancreas functions normally, is affected but has residual capacity, or is affected in such a way that recovery is no longer possible. If you combine that with whether or not you have liver insulin resistance and muscle insulin resistance, you get 12 sub-groups. This has huge consequences for how doctors should be treating type 2 diabetes. Right now, patients are usually given drugs that increase the amount of insulin in the blood. But if the pancreas is functioning just fine, medication is not necessary. In fact, it can be counterproductive.”

SW: “Insulin is an anabolic hormone. It usually results in an increase in the amount of fat mass. That makes it extremely difficult, for example, to lose weight or to tackle a fatty liver.”

SW: “We recommend physicians to do an expanded version of the glucose tolerance test looking at glucose and insulin levels over multiple points in time. I know these are time-consuming procedures. That is why I am pleased that TNO is working together with Ancora Health, which can offer such a service.”

SW: “Another important issue is that diabetyping has yet to be established in medical protocols and thus is not reimbursed by health insurers. The insurers want to gather sufficient research evidence before they do that. TNO and Ancora are working together on this.”

José Castela Forte (JCF): “At Ancora we advise and coach people in improving their health. But you can only do this properly if you know the underlying cause of their complaints. It matters a lot whether someone has a poorly or well-functioning pancreas. If you know the causes, lifestyle adjustments are much more successful.”

JCF: “With lifestyle changes you can often reduce or even reverse type 2 diabetes. But this requires people to make big adjustments such as changing their diet and exercising more. Therefore, it’s crucial for doctors to know that the approach they recommend will have the greatest chance of success. Knowing more about the causes of a patient’s diabetes will help. And if you combine that with a 360-degree approach, in which you also look at the patient’s social environment and wellbeing, you can arrive at a personalized remission plan that will be effective over the long term.”

JCF: “First, we need to get the diagnostics in order. Some patients will need more extensive testing than others. An algorithm that TNO is developing will help doctors make their treatment choices. Yet the related interventions mainly revolve around lifestyle changes, and healthcare is not always ready to deal with that. Lifestyle interventions that can be deployed on a large scale will play an important role.”

JCF: “Small successful studies have already been carried out, including in the Netherlands by TNO itself [4]. The next step is a larger study on diabetes typing and lifestyle interventions. At Ancora we are preparing a multi-year study involving hundreds of patients in multiple regions. In that study, we want to show that diabetyping increases the chance of success in reversing type 2 diabetes in patients.”

JCF: “Definitely. We will learn to better control diabetes, and diabetyping plays a major role in this. More generally, to be able to properly help people with their health, a personalized approach is needed, where we have specific data about patients and how they respond to the treatment. That’s not just the future of diabetes care – it’s the future of healthcare in general.”

[1] Nivel https://www.nivel.nl/nl/publicatie/diabetes-mellitus-nederland-prevalentie-en-incidentie-heden-verleden-en-toekomst

[2] Diabetes Fund https://www.diabetesfonds.nl/over-diabetes/diabetes-in-het-algemeen/diabetes-in-cijfers

[3] Interview Anne-Margreeth Krijger-Dijkema on Your Lifestyle As Medicine https://jeleefstijlalsmedicijn.nl/diabetypering-de-uniforme-diabetes-2-patient-bestaat-niet/

[4] Stevenshof Pilot Study https://pubmed.ncbi.nlm.nih.gov/34202194/