Textbook definitions used to be that people with type 1 diabetes were younger people and children, were white European, and more likely to have lower a body mass index (BMI), while people with type 2 diabetes were likely to be older, non-white people with higher BMI, says Professor Nick Oliver of Imperial College London. “There was a distinct, ‘typical’ profile. But now there are challenges. For example, we’re more overweight as a population, even at a younger age.”

"There used to be distinct profiles for people with type 1 or type 2 diabetes but it's no longer that straight-forward."

There is also an emerging ethnic and demographic mix which doesn’t fit the classic type 1, type 2 descriptions. Oliver says it’s mostly straightforward if you have a five-year-old with high sugar levels, weight loss and no family history of diabetes, or an overweight 75-year-old, but the area in between is where challenges arise.

“First generation migrants who moved to the UK from India, for example, and developed diabetes in adulthood are most likely to have type 2 diabetes. But second and third generations have assimilated the European risk factors, so a 25-year-old non-white person with a BMI of 26, which is around average, is in a grey area and may have type 1 diabetes, type 2 diabetes, or another rare form.

“I work in multi-ethnic London, and I see a lot of young-onset diabetes which has frequently been allocated as type 1 when it’s actually a different sub-type.  It’s important to define the diabetes type to get the treatment right - some types don’t even require any treatment. We’re throwing out the textbook definitions and looking more to laboratory tests and genetics.”

 

Ensuring safe treatment

 

Genetic testing helps with identifying types such as mature-onset diabetes of the young (MODY), neonatal diabetes, and inherited monogenic diabetes. It’s important for clinicians to be educated and “vigilant” says Dr Oliver, as prognoses and treatments vary according to the type of diabetes involved.

What all patients need to know is that insulin treatment is safe, he stresses.

“Even if there’s some uncertainty about the type, insulin is a completely appropriate as a treatment while tests are carried out. Your doctor may later take you off insulin if that’s safe, but insulin always manages glucose safely during that period. If it turns out that someone doesn’t have classic diabetes and can manage their condition with a tablet instead of injections, it can make a huge difference to quality of life.”

 

Design meets device

 

With regard to technology in diabetes treatment, Dr Oliver believes that the next few years will see smaller and more accurate continuous glucose monitoring (CGM) devices. They will also be more precise – meaning accurate over time – longer-lasting and, hopefully, cheaper. He’s hoping that the need for patients to do their own calibration will also disappear in the next few years.

The other interesting new tech development, says Oliver, is disruption between the medical device world and the consumer world. “Medical devices used to be grey, functional things which had undergone a series of testing to ensure they were robust. It often took years for that testing to be completed.

“Now, we have Fitbits and other devices by fabulous designers, which are not subject to lengthy testing. Think of the complexity of the iPhone – can you imagine if that had to go through the same kind of testing as a traditional medical device? But you can now monitor your continuous glucose data via your smartphone, and this use of consumer devices in healthcare really meaningful for quality of life.”

Data can reduce the burden of decision-making for people with diabetes, says Dr Oliver. “We’re sharing data all the time: devices know how many steps you’ve walked today, that you’re in your favourite restaurant, and that you like chicken salad – your smartphone can give you decision-making support and advice on insulin dosage based on data it already has.

“A person with diabetes has to be highly numerate to manage their condition now. This is set to be eased considerably as the lines between consumer convenience and medical management continue to merge.”