Diabetes views 3
Further puzzles and uncertainties –
and some progress
Helmut R Henrichs This issue of Diabetes Voice takes us another step in the
is Professor of long quest to reveal the mysteries of type 2 diabetes. The
description by Colagiuri and Win Tin of the past century or
internal medicine
so of social and economic history in the tiny island nation
and diabetologist. of Nauru, with little more than 10,000 inhabitants, presents
He founded the a bleak example of the potentially disastrous marriage be-
Quakenbrück tween genetics and environmental factors in the causation
of type 2 diabetes. In the case of the Nauruans, thousands
Diabetes Centre
of years of a traditional Micronesian South Pacific lifestyle,
and the German fishing and gathering fruit and coconuts, ended when the
Diabetes phosphate wealth of the island was discovered in the early
Technology study 20th century. Their lifestyle was very suddenly replaced by
a westernized, sedentary one, including a high-energy diet
group, and served
(high in sugars, fats and salt) of imported food.
as president of the
German Diabetes The subsequent explosion in the number of people with
Association obesity-driven type 2 diabetes, to 34.4% by 1975, is a
major component in the same nightmarish paradigm of
and German
chronic ill-health that has blighted Indigenous communities
Diabetes Union. in other parts of the world – Aboriginal Australians and the
Pima Indians in Arizona, USA, for example. A disastrous
combination of genetic preconditioning and westernized
lifestyles in such ancient and for many hundreds of gen-
erations isolated populations has been explained in the
‘thrifty gene’ hypothesis.
According to this theory, certain human genes evolved that
allow hunter-gatherer populations to build up and store en-
ergy reserves quickly and effectively when food is plentiful,
enabling them to better survive times of famine. However,
with an abundance of food and sedentary behaviour, this
same genotype has become severely prejudicial, leading to
obesity and its complications. The cultural distinctions, low
socio-economic status and geographic isolation that character-
ize many such Indigenous communities hamper the provision
of adequate and appropriate care and education.
The diabetes educator Michael Porter, who travels with the
Royal Flying Doctor Service of Australia, describes an inno-
vative project that, by placing diabetes within a conceptual
framework that is familiar to Aboriginal people, delivers
culturally appropriate education to outlying communities.
The ‘Sugarman’ project uses traditional story-telling and an
active-learning approach which enable participants to walk
around the Sugarman´s body to demystify diabetes. Articles
from Canada highlight the efforts of the French- and English-
speaking diabetes associations and their excellent work to
promote research, raise awareness, provide education and
guidelines, and improve the rights of people with diabetes
– including First Nation people – in that vast country.
A report from the Netherlands by Judith Kuenen and Rikke
Borg, representing 11 study-centres from around the world,
deals with the remaining uncertainties around the measure-
ment and interpretation of HbA1c. In 2007, the results of the
global A1c-Derived Average Glucose (ADAG) study robustly
demonstrated that estimated average glucose, calculated
using the HbA1c assay, correlates very closely with blood
glucose readings obtained by repeated measurements
(using finger sticks and continuous glucose monitoring)
over the period of survival of haemoglobin-bearing red
blood cells – around 100 days, thus again justifying the
reliability of HbA1c in representing the metabolic memory
of the intermediate past.
This study was necessary and its results eagerly awaited
in the scientific diabetes community. It should be noted,
however, that the ADAG study was restricted to people
in stable metabolic control throughout the study period; in
people with fluctuating blood glucose levels, the ADAG
calculation may well lead to different results. The ADAG
findings support the reporting and interpretation of HbA1c
values as translated into average blood glucose values
that allow people with diabetes to better understand
their current metabolic condition. The respective recom-
mendations resulting from the study are laid out in the
2007 consensus statement (cited in the article) by the
leading diabetes organizations around the world – IDF,
the European Association for the Study of Diabetes and the
American Diabetes Association, the ‘Consensus Statement
on the Worldwide Standardization of the Hemoglobin
A1C Measurement’.
March 2009 | Volume 54 | Issue 1