Diabetes: Not so sweet

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A not so sweet disease

Diabetes is a chronic disease. Individuals with diabetes have high blood sugars, pass more urine, and get more thirsty. While urine is sweet and sugar in blood is high, disease is not so sweet. Individuals need to restrict their diets, exercise more, and take tablets or insulin injection for life. Diabetes has two major forms, type 1 who need insulin for survival, and type 2 who are mostly controlled on diet, physical activity and drugs. High sugar affects blood-vessels, eventually failing eyes, nerves, and kidneys. Heart attacks, Paralysis, gangrenes, and infections are also more frequent in them. Today every three of four individuals with diabetes belongs to a low or middle income country.

Ancient descriptions

Ancient physicians in Egypt, India, China and Greece knew that some individuals pass more urine. For Egyptians it was “passing plentiful urine”, and for Indians it was “honey like urine” or “madhumeya“. Chinese texts describe the condition as a “wasting thirst”, and the Greeks as “more urine”. Origin of the word “diabetes” is from Ancient Greece, “diabianen” meaning “passing through”. This is in reference to large amounts of Urine passed out by those who have the condition. Arateous of Cappadocia gave the term “diabetes” in about 150 AD.

Till 17th century AD, this was the only description of diabetes. Arateous further wrote: “the flow is incessant, as if from opening of the aqueducts. While disease takes a long time to form, but the patient is short-lived.... for the melting is rapid and death speedy.“

Awakening in Modern Era

Unaware about the ancient physicians who had already tested diabetes-urine to be sweet, Thomas Willis re-discovered this fact in 1674. It took another century for Matthew Dobson to report in 1776 that this sweetness is because of sugar. Till this time all considered Diabetes as a disease of the “Kidneys”.

In 1797 John Rollo and Cruickshank performed an interesting experiment. Captain Meredith had diabetes. Rollo made him eat different food items on different days. He would collect all his urine, boil it and extract all sugar he could. He could show that passage of more sugar in urine depends on what you eat. They concluded that diabetes is not because of kidneys, but due to a disease in “Stomach”.

Scientists performed extensive autopsy studies in mid 1800s, including in those who had died of diabetes. They found that in some pancreas was shrivelled and diseased, but in many others it was not. Apollinaire Bouchardat was a French pharmacist. He discovered that more exercise led to less urine in those with diabetes. He also recognised two forms “diabete maigre” and “diabete gras” – thin and a fat variety respectively.

Discovery of Insulin

Paul Langerhans was a final year medical student in 1869. He worked under Virchow and wrote a brief dissertation about anatomy of Pancreas. He described islands of cells in the Pancreas. Role of these cells was then unknown. Langerhans discovery was forgotten, but for Edouard Laguesse a French pathologist, who in 1893 suggested that these islands secrete some substances. He gave them a name – Islets of Langerhans. By 1906, scientists started calling this yet unknown substance as “Insulin”. This word originates from “insula” or island.

A few scientists were already working on Pancreatic extract to treat diabetes. Nicolae Paulescu was a Romanian scientist. In 1921, he reported that substance in pancreatic extract (which he called pancreine), reduced blood glucose levels in a dog. While he published his work, earlier than Banting and Best, he is not credited with discovery of Insulin. This may be because their preparation was quite impure, or because Paulescu had not tested his product in human.

Four scientists got together in Toronto, Canada in 1920. The story starts with Frederick Banting – a surgeon. He was in Canada to teach physiology. He convinced Macleod, a professor in Biochemistry to lend him lab space. In 1921, he and his graduate student Charles Best started working on a project to extract insulin from Dog Pancreas. Macleod assigned another researcher James Collip to help Banting and Best extract Insulin. George Walden from Eli-Lilly helped them with extraction. Walden worked for Eli-Lilly – a small pharmaceutical company at that time. This team would eventually extract Insulin in July 1921. On 11 January 1922, Leonard Thompson aged 14 was first person to receive Insulin.

Insulin Nobel 1923

In 1923 when Nobel Prize for discovery of Insulin was announced, it surprised many. Nobel committee jointly awarded the honour to Banting and Macleod. It left out Best and Collip. This omission is debated till date. Popular literature and philately attributes the discovery to Banting and Best. Postage stamps from Canada show first Insulin (1971 stamp), and the notes from Banting and Best (2021 stamp).

Beyond Insulin

Insulin is a life-saving medicine. We need to inject multiple doses in our. body every day, if we are not making enough of it ourselves. In 1921, Insulin was first drug to be used for diabetes. In next 40 years, we further refined insulin, could mix it with other compounds, and could determine its structure. Till 1970s it was sourced from animal pancreas. In 1982 we could synthesise insulin in laboratories using recombinant technology. Today all insulin and its analogues are synthetic.

First oral drug for treatment of Diabetes was carbutamide, manufactured in 1955. We have identified more oral drugs in the last sixty years. We developed home urine sugar testing strips in 1960s, and first home glucometer in 1970s. Today diet, physical activity, Insulin, oral medication, and self monitoring of blood glucose are cornerstone of diabetes treatment.

Diabetes comes to the developing world

For years, we considered diabetes as a problem of affluence. In 1990s we could identify enormity of the problem globally, especially in South Asia. Today about 8% of all Indians have diabetes. This makes it largest number of individuals with diabetes in any country.

International Diabetes federation (IDF) was formed in 1950s. IDF proposed World Diabetes day in 1991. 14th November is date of birth of Federick Banting. In 2007, the day was recognised by UN General assembly. Blue circle became logo for this day.