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Diabetes: we cannot wait any longer, we must act now!

The renowned endocrinologist Prof. Bernhard Böhm from Ulm, like many of his colleagues, is of the opinion that diabetes is a problem that concerns society as a whole. The following interview with the head of endocrinology at the University Hospital of Ulm shows why the USA invests 50 times more money into diabetes research and Böhm tells us about the three wishes he would ask of a “diabetes fairy”.

Germany is the European champion of diabetes type 2; more than 7 million German citizens have been treated for diabetes. And nowhere in the EU are there so many overweight and adipose people than in Germany. Is Europe's leading economic power guilty of underestimating diabetes?

The statistics underestimate the true figures. Studies carried out in Augsburg have confirmed that in many cases there is one undiscovered case of diabetes for every known case. Recently, another project was carried out in Baden-Württemberg, in which we participated. Diabetes is not only getting more and more common, but it is also affecting more and more young people. People who do not recognise or do not want to recognise the danger, underestimate the effects on the national economy.  

Diabetes mellitus is regarded as prime example of the complex interactions between genes, nutrition and physical activity. How does the University Hospital of Ulm deal with this phenomenon?

For Bernhard Böhm, 50, diabetes care means teamwork involving diabetes advisors and nutritionists. © University Hospital Ulm

Diabetes is one of the most frequent causes of death. Statistics ignore the effect of diabetes on cardiovascular diseases. Numerous investigations have dealt with this issue in the USA where they have succeeded in reducing the number of cardiovascular diseases. They have also succeeded in reducing the number of people suffering from diabetes, particularly men. At the same time, no real progress has been achieved for women over the last 10 to 15 years. Women are at particularly high risk of contracting diabetes.

Diabetes is a disease that needs to be diagnosed very early, as it gives rise to so many secondary diseases and because the clinical signs remain undiscovered for a long time. It is necessary to seek out these hidden cases of diabetes. Here in Ulm, testing is systematically done on patients who have a high risk of contracting diabetes - people with high blood pressure, people who have diabetes type 2 sufferers in their family and in cardiac infarction patients. The early detection and treatment of the disease helps to reduce the risk for such patients.

We have been using the new WHO recommendations on diabetes screening for quite some time already. For example, we have been training employees who have an elevated risk of contracting metabolic diseases. They go through a structured nutrition and physical activities programme, which has proven to be successful.

If you include associated secondary diseases, diabetes accounts for more than 30 percent of our patients. We therefore work closely with all other disciplines. We hold a joint consultation hour with the Department of Cardiology. We never shy away from working with any other departments. In the case of the treatment of diabetic feet, which is very expensive, diabetologists, angiologists, orthopaedists and experts from many other disciplines work together in a team.

We have been working in teams for a long time, a practice we have learnt from patient care, where treatment is not centred on a specific physician, but is a result of the cooperation between nutritionists and diabetes advisors. We have no other choice because the basic problem is that the causes are very complex - bad nutrition and lack of physical activity. This requires advisors who provide permanent help. We are fighting a lifelong battle in a diabetogenic environment.

We recently learnt that German endocrinology research and education lags way behind other countries. Is this really true?

I think that Baden-Württemberg has a very special role. All Baden-Württemberg universities are very much focused on research and education. I am sure that Baden-Württemberg has a very high profile in this area.

With regard to common diseases such as thyroid gland disorders, osteoporosis, diabetes, and adiposity, the subject is very much underrepresented in the area of academic medicine. I'd say the subject has been starved out over the last years.

Now that the problem is becoming very common, we often find that we lack skilled people in research and clinical treatment. This is a huge problem, and will probably become worse in the future. We have actively tried to do something to combat this problem and, together with universities in London, Barcelona and Rome we have established education concepts on a European level.

So, yes, what you say is true: endocrinology and diabetology are not recognised as an indispensable cross-sectional discipline.

Would you say that there is too little money for research?

In 2006, a paper in "Nature Medicine" compared the expenditure for this type of research in the USA and the European Union (including Germany). The result was 50:1 for the United States, although we have about the same population and overall research expenditure. This explains a lot. It is a shame that diabetes sufferers do not receive the empathy they need and deserve. They are not given proper support. The situation is quite different in the USA, where a lot more focus is put on this topic and it is also dealt with far more aggressively. This is how it should be.

Electron microscope picture of an islet cell. The black spots are insulin granules (insulin and zinc). Zinc is the cement for granules and should also be the cement for diabetologists, because the zinc transporter is an autoantigen (type 1 diabetes), the SNP of the zinc transporter is a biomarker of diabetes type 2.
Electron microscope picture of an islet cell. The black spots are insulin granules (insulin and zinc). Zinc is the cement for granules and should also be the cement for diabetologists, because the zinc transporter is an autoantigen (type 1 diabetes), the SNP of the zinc transporter is a biomarker of diabetes type 2. © Bernhard Böhm, University Hospital Ulm

Have the causes and the pathogenesis of diabetes been sufficiently understood?

A lot is understood, but not always in precise detail. We have gained a basic understanding of the risks and risk factors that lead to diabetes. We actually know where the problem lies. Far too little physical activity and bad nutrition are the major causes of diabetes. Of course, genetic factors play a certain role, but they are not the dominant factors. Far more important is the interaction with genes that previously represented a survival advantage, but which are now turning against us in the environment of modern societies.

So, what is the problem?

We have some concepts. For example, if we were to get rid of the buses that take students from the city centre to Eselsberg where the university is located, and do the same with parking lots and get people to use bikes, this would be a huge health benefit.

It is also a social question, and we might need a bonus system in order to turn it into reality. These suggestions might sound quite naïve, but the USA are pursuing this concept very aggressively. In California, schools have to provide safe ways for children to get to and from school, and they only receive government funding if they do away with school buses, and make children either walk or cycle to school. But there is a lot of work to be done before people see the effect of such measures. It seems easy to achieve, but in reality it is not so easy.

In the British Medical Journal, an important paper was recently published on how to prevent a diabetes pandemic. The paper concluded that in view of uncertainties in diagnostics and in the concepts of disease prevention we must not leave it any longer, we must take action now, even if it means having to live with some uncertainties.

In view of the growing cost pressure in the health sector, it is necessary to move from treating diseases to promoting health. In the case of diabetes mellitus - what are the opportunities and risks of such a paradigm change?

The biggest problem is hospital costs. The situation in the USA is different from Europe. In the USA, one in three dollars is invested in diabetes, both in direct and indirect costs of the disease. We are talking in billions, which is also the case in Germany. The NICE institute (National Institute for Health and Clinical Excellence) has already published figures on how much systematic prevention costs and the ways in which it helps.

There is no doubt: prevention would be an ideal investment in cost reduction. And prevention would also alleviate a lot of suffering. You only have to think of the large number of diabetes patients on dialysis. Prevention can only be achieved by health protection on all levels; health education has to start early, in the family, in schools, universities, at work.

I hope that Baden-Württemberg will soon initiate traditional prevention concepts on the same lines as back schools for back pain and diabetes prevention schools, as well as concepts that focus on metabolism and food (lifestyle). If these preventive measures show that a lot of money can be saved, maybe even more will be done.

It is worth investing in prevention. In the case of diabetes, this has not only been shown in the model, but also quite convincingly in practice. In England, investigations have been carried out on larger patient groups; in Germany similar investigations involved only small groups. I hope that the "Helmholtz cohort" initiative will provide us with a large patient collective, potentially over 30,000. Metabolism will become a big topic here.

If a fairy could grant you three wishes, what would you wish with regard to diabetes?

First: that the public develops a greater awareness for the topic. The media could help to increase public awareness.

Why aren't there information campaigns, maybe twice a year, where all population groups receive easy to understand information on the topic?

I remember a campaign in Great Britain that explained that if you are thirsty at night, it is not necessarily because you are craving for whisky, but that the thirst might also be the result of diabetes. This campaign led to the diagnosis of a large number of people at an early stage of diabetes.

Second: In the discussion about cost savings one should focus more on the people concerned and their difficulties. This would help orient the development of products and services (how can I control my metabolism? How can I improve my life that is restricted through my diabetes?).

Third: I would wish for the same thing to happen here as has happened in the USA, and that it also leads to a paradigm change in research funding here. But this requires a lot of courage. It is actually quite simple: everybody with positions of political responsibility should have their blood glucose level checked. This was done in the USA Senate and led to a surprising result: the number of senators who suddenly developed an interest in diabetes due to their own suffering shot up. From that day onwards, funding for diabetes research increased and a number of programmes have been established - both from basic to clinical research.

The standard concepts in the therapy of diabetes type 1 and 2 are mainly due to the funding of diabetes research in the USA. Germany has a very low profile in this regard, despite its large population. The profile has remained low because the topic was ignored and the courage to do the right thing at the right time appeared to be lacking.

Dr. Böhm was interviewed by Walter Pytlik.


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