The discovery of insulin in 1921 by Frederick Banting and his team at the University of Toronto sparked a century of innovation in the treatment of diabetes — and continues to save millions of lives around the globe.
Now 100 years later, just how far have we come in helping people manage the challenges of the diabetes? And what is it like to be on the frontlines of care for this disease?
Healthing talked to Dr. Ronald Goldenberg, endocrinologist and diabetes expert at North York General Hospital in Toronto, and LMC Diabetes & Endocrinology in Thornhill, Ontario, about his thoughts on the Nobel prize-winning discovery of insulin, how patients have benefitted, and the possibilities of a cure.
What drove you to study medicine?
Goldenberg: I was always interested in medicine and science as a school-age child, and my father had type 1 diabetes. He died just before my eighth birthday. That was back in the day when the treatments were pretty crude. There was no self-monitoring of blood glucose. He actually died from a heart attack (heart disease can be a complication of diabetes). So I told my family when I was eight-years-old that I was going to be a doctor to try to cure diabetes.
Certainly 100 years feels like a long time to have a treatment for diabetes. But have we really come that far in terms of how people manage the disease?
I think the discovery of insulin is probably one of Canada’s biggest contributions to medicine and science ever…I started 32 years ago and my practice has changed dramatically, even in the last five years. We’ve come a long way, not just with insulin. Everybody with type 1 takes insulin and we use them often in type 2, but there are newer non-insulin therapies for type 2 that keep expanding.
With glucose monitoring, we’ve evolved from simple monitoring devices to state-of-the-art continuous glucose monitoring without any finger pricks. Insulin pumps have continued to improve even in the last couple of years. Now we have the hybrid closed loop pump that connects with the continuous glucose monitoring device to manage sugar levels at any given time, which is a step toward what we call the ‘artificial pancreas.’ So yes, with the innovation of insulin and other diabetes therapy, and pumps and other insulin delivery devices like pens and monitoring — innovation has come at incredible speed.
How is today’s insulin different from what Banting and Best discovered 100 years ago?
Initially, when insulin was rolled out to the population, it was derived from the pancreas of pigs and cows. It was refined over the years and made longer-acting so [patients] didn’t have to take as many injections. But it was really in the 1980s through the 2000s that technology allowed labs to mass produce human insulin. By inserting the human insulin gene into yeast or bacteria, we could actually mass produce human insulins, both meal-time — or what we call rapid-acting — insulins and slower-acting insulins (that your body absorb slowly and uses throughout the day).
Beginning in about 2010, [we started seeing] the newest generation. These are based on human insulin, so they match how insulin is normally secreted by the pancreas. They’re also much safer and patients are much happier because they control their glucose in a much more effective fashion with fewer attacks of hypoglycemia (where blood sugar level is lower than normal). It all improves the quality of life for people living with diabetes.
You’ve been at the forefront of diabetes education for healthcare providers. Why is that important?
I’ve been involved in medical education for 30 years now — educating physicians, pharmacists and nurses. Medicine is so complicated when it comes to interpreting studies and translating all the science into the practical issues at the bedside. I have an interest in trying to simplify this in the area of diabetes, just to make it much more practical so that a clinician with a patient can take this information and apply it in a practical way.
What are some of the most common challenges for your patients?
In type 1 diabetes, where there are different insulin regimens, it can be a bit complicated for the patient. There’s a big learning curve with all the complexities of managing the pump or multiple daily injections and making appropriate adjustments.
It can be a bit overwhelming at first, but fortunately, we have good support systems in place at all the diabetes education centres across the country. And a lot of professionals, including dieticians and certified diabetes educators, pharmacists and endocrinologists and primary care doctor teams can help support the individual to get over all of these issues and get organized.
Diabetes affects children, adolescents, younger adults, older adults and people in all economic strata, across all different levels of education. And people are people, they have their own lives separate from their diabetes. You don’t want their whole life to revolve around their diabetes. But it is a chronic disease that people live with and have to pay attention to on a daily basis or even every hour.
What innovations are coming down the pipeline?
Some of the big breakthroughs recently have been the newer classes of glucose lowering inhibitors for type 2 diabetes. The reason we’re all excited about these drug therapies is that they’ve been shown in clinical trials to prevent cardiovascular and kidney complications of diabetes.
In the insulin space, we’re eagerly awaiting a once-weekly basal insulin — that will make things much simpler for patients.
What do you think diabetes treatment will look like in five years? In 10?
Very exciting! There’s work on what’s called a smart insulin — known as glucose-sensitive insulin. So the insulin itself will sense the blood glucose level and deliver the amount of insulin that’s needed to lower the blood sugar. And then further in the future, for type 1 diabetes, would be stem cell transplants that will actually convert to insulin-secreting cells. That could be a potential cure for type 1 diabetes.
Also in type 1, further innovation for insulin pumps so that eventually, we’ll have an artificial pancreas. You wouldn’t have to do any monitoring or make any insulin decisions. It would all be done automatically. There is lots of research going on. If all goes well and [these techniques are] safe, possibly in the next five to 10 years we’ll see the first artificial pancreas rolled out to the mainstream.
What do you love most about your work?
With all the treatments, we really do help our patients. I find it very rewarding to initiate different treatments, provide counsel, and then see the results and rewards from the patient’s point of view.