Type 2 diabetes – a reversible condition?
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Diabetes prevalence being on the rise globally, we expect a growing impact of the disease on re/insurance portfolios throughout different lines of business. Whereas type 2 diabetes is significantly driven by genetics, there are many behavioural factors that influence the onset, development and exacerbation of the disease.
Exploring type 2 diabetes and its implications for the insurance industry
In order to better understand actual and future diabetes prevention and management tools, and to explore ways to engage with patients to support them in adapting sustainably healthier lifestyles, Life & Health R&D has organised an Expert Forum on Diabetes for Swiss Re stakeholders and selected clients. On 10 October, the Expert Forum on diabetes: genetics, nutrition and the future of diabetes management took place at the Swiss Re Institute in Rüschlikon. An expert event at which 70 experts and industry leaders shared their expertise, exchanged ideas and discussed medical and insurance challenges facing the diabetes epidemic.
Russell Higginbotham, Head Life & Health Products Reinsurance, started the day on the theme of resilience, a core theme for Swiss Re. According to Russell's experience, it all starts with providing individuals with the necessary information to take an informed decision. Information allows them to take preventive action, which is urgently needed and very effective with type 2 diabetes. But since the mitigation measures have to be sustainable, the insurance industry needs to know what motivates people to make personal choices that have a long-term positive effect.
Molecular markers tracing disease progression of this highly dynamic condition
The opening keynote by Hannelore Daniel (see interview), Professor of Physiology of Human Nutrition at the Technical University of Munich, provided a deep dive into the latest understanding of the metabolic footprint of type 2 diabetes. It was surprising to hear that there is evidence for the branch chain amino acids Valine, Leucine and Isoleucine, to be the metabolic markers that fluctuate the most between healthy and type 2 diabetic patients. Additional markers that show a similarly strong association are the Acetylcarnitines.
Interestingly, we are not talking of sugars here. Having said this, type 2 diabetes is highly complex, involving more than insulin resistance and glucose metabolism; much still needs to be explored.
The next speaker, Vincent Moser (see interview), Professor, Head Clinical Chemistry CHUV at the University of Lausanne, provided us with more insight into type 2 diabetes risk scores and their performance. While type 2 diabetes is 72% heritable, over 100 genetic risk factors found in genome-wide association studies showed only minor improvement rates of the traditional risk factors. Additionally, 10% of the genetic variances found in large studies could explain only a fraction of the genetic risk.
Now, we asked ourselves where this genetic inheritance is concealed. Is it simply too complex or have the study groups not been phenotypically characterized enough?
Adding the latest metabolic markers also only improved the predictive value by 5% - much more research is needed here.
Francisco Verdeguer, Assistant Professor, Department of Molecular Mechanisms of Disease at the University of Zurich, gave some further insight into epigenetics, a heritable modification of the genome that does not change the DNA sequence. He talked about histone modifications and DNA methylations and the enzymes involved in epigenetic modification. Interestingly, some of these enzymes have been shown to be involved in type 2 diabetes. Not surprisingly, the most frequently prescribed drug in type 2 diabetes, Metformin, leads to demethylation of the DNA, which leads to changes in gene expression.
Luc Sterkman, CEO of Caelus Health, then explored the role of the microbiome. Another hot topic in type 2 diabetes. There are some promising aspects in the microbiota approach and once more, the microbiome represents a subset of the complexity of type 2 diabetes. For microbial interventions to reach the market in type 2 diabetes, it may take another decade, according to the expert.
The concluding morning panel moderated by Urs Widmer, Senior Life Guide Medical Officer at Swiss Re, further explored the novel predictive factors for type 2 diabetes.
Panel discussion moderated by Urs Widmer
What we learned is that the metabolic response shows a huge dynamic plasticity, which is important for our bodies to be maintained by experiencing continuous catabolic and anabolic stress. The metabolic response is also strongly personalized and proves to be very stable over time.
Are we ready for measuring these dynamic changes and develop personalized risk profiles? If so, maybe a continuous glycemic index is a good measure to start with and explore further.
Behavioural lifestyle change as a mean to significantly reduce type 2 diabetes disease burden
In the afternoon, the event switched gear and started to explore various preventive and curative measures for type 2 diabetes, focusing on behaviour rather than on drug treatment.
Aseem Malhotra (see interview), Honorary Consultant Cardiologist, Academy of Medical Royal Colleges, Obesity Steering Group, provided us with insights into the clinical aspect of type 2 diabetes and the adjunctive cardiovascular complications. Dr Malhotra concludes that with prescription drugs becoming the third leading cause of death, it becomes evident that we have to start reducing drug use in clinical practice.
With Peter Voshol, Senior Scientist at the Louis Bolk Institute, we started to explore what it takes to revert type 2 diabetes. Primarily, this requires a lifestyle change of the patients. In order to achieve this, modern food consumption needs to be adapted. Providing the right information and incentives to affected individuals is key. According to Peter it is clear that the consumption of fresh, unprocessed and satiating food, in addition to exercise and stress management efficiently reduces the diabetes disease burden.
David Unwin (see interview), Fellow of the Royal College of General Practitioners (FRCGP) and Senior Partner of the Norwood Surgery, took it a step further and reported the success he had in his clinical practice, where he was able to revert 26% of his type 2 diabetic patients. The key to his success is that he lets patients define their own goals (such as being able to play basketball with the kids) and provides them with choices for action, which are based on information that is easy to understand. He translated meals into the number of corresponding teaspoons of sugar, a concept that is easy to communicate and appeals to patients. Having reached their goals, patients are proud of their achievements, which is a pre-condition for sustainable life-style change.
David reported that behavioural change significantly reduces the diabetes burden but also leads to weight loss, improved liver function, lipids, and blood pressure; in all greatly reducing the risk of cardiovascular disease.
Arjun Panesar and Charlotte Summers (see interview) of Diabetes.co.uk, showed us how powerful diabetes communities can be. With 250'000 participants, they are the largest low carbohydrates programme-provider, and the numbers speak for themselves. Their key to success are feedback, customisable feedback loops and personalised messaging. Their solution is available in different languages and takes into account diversity of communities and ethnic backgrounds.
The closing panel moderated by Alison McLean, Head of Behavioural Research, addressed what it takes to achieve successful and sustainable change. Some of the experienced success factors are: hope, definition of intrinsically motivated and realistic goals, personalisation of programmes, frequent feedback loops, contextualisation, use of the EAST framework (easy, attractive, social and timely), gamification and social networks, simulating experience and praise for milestone achievements.
A new growing risk pool that requires innovative solutions
In conclusion, we gained manifold insights from the experts, panel discussions and the interactive workshops. While diabetes is highly complex and the underlying mechanisms are not yet fully understood, there are clear indications on what works to reduce the individual disease burden. The subsequent effects on society, health care systems and insurance portfolios look promising.
Looking back on a successful day, our task does not stop here. If type 2 diabetes is a growing risk pool, the insurance industry needs to consider whether and how to access it with innovative solutions. Having said that, understanding strategies in diabetes management is key for us to team up and develop future solutions that are attractive to consumers. Providing technology solutions for end consumers by partnering with providers is part of this. And last but not least, we need to understand and stay up to date with medical and technological trends to be able to provide insurance solutions that are of benefit to the diabetic community.
Christoph Nabholz, Head R&D Life & Health, Swiss Re
Séverine Rion, Head Life & Health R&D Europe, Swiss Re
Summary of the Swiss Re Institute's Expert Forum on diabetes in October 2017.