Professor Bertrand Canivet at CHU-Nice speaks to the Riviera Reporter about Diabetes
What is Diabetes?
Definition: chronic dysregulation of the blood sugar (glucose) level, which becomes elevated.
Type-1 diabetes (formerly “insulin-dependent diabetes mellitus”) occurs mainly in young people (80-90% before age of 30). It is caused by selective destruction of the site of production of insulin (beta-cells in the pancreas). In fact, it is not really a pancreatic disease, it is a miss-targeted reaction of the immune system against the pancreas (precisely against the beta cells of the pancreas; the remaining structures of the pancreas are intact).
Type-2 diabetes (formerly “non insulin-dependent diabetes mellitus”) occurs mainly in overweight, older people (after the age of 40). It has a genetic basis (“a familial disease”) but genes are not sufficient to induce the disease. Factors like obesity, sedentary, and ageing play a part in its development. This explains why two individuals with same bad genes (best example, twins in a Type 2 diabetic family) may have variable evolution. The one who is sedentary and gains weight will become diabetic at age 45 while the other, who is physically active and remains lean, will avoid or delay the onset of diabetes. The mechanism of elevated blood glucose is somewhat different from that in Type 1 diabetes. Here, the beta cells of the pancreas are not destroyed but the secretion of insulin is qualitatively altered. Moreover, the action of insulin is reduced in the body (insulin-resistance).
Are there specific symptoms?
About the size of a cellphone, a computerised insulin pump belt continuously delivers insulin through a catheterType 1 D onset induces symptoms (thirst, frequent urine emission even at night, weight loss and tiredness) leading to a rapid (in a few days or weeks) diagnosis.
Type 2 D is usually not symptomatic. A subject may live without knowing that he is diabetic for many years, leading to unsuspected damages in the body. Therefore, Type 2 diabetes is, for health professionals, a matter of screening.
Consequences and prognosis
Keeping elevated blood glucose level over time (either in Type 1 or 2 diabetes) is deleterious for small vessels (for instance, the kidney or eye) and for the cardio-vascular system. The “toxic” effect of long standing high glucose level leads to the development of diabetic complications which may be severe: retinal damage, alteration in kidney function, coronary heart disease, stroke, arteritis, neuropathy with risk of foot ulcers. “Fair” blood glucose control prevents these complications. At the opposite end, there are a number of worsening factors that accelerate the occurrence of complications: blood glucose remaining high, elevated blood pressure, smoking, high lipid (fat) levels ... Life expectancy of diabetics has been considerably improved over the last three decades. It is nowadays evaluated as minus 4 years, compared to general population (8 to 12 years shorter in the 1980s).
Number of people with diabetes in France: over 3,000,000 in 2014.
According to diverse area: there are many more cases in the north than south (and even two fold more in overseas departments (Réunion, Antilles); much more in urban zones than in rural countries.
Repartition among subtypes: • 92% Type 2 (3 million people vs (1.5 million 1997) • 6-7% Type 1 (180,000 people) • 1-2% rare forms of atypical or so-called “secondary diabetes”
Can we put a cost on the disease?
Diabetes is an economical health nightmare for the Sécurité sociale. Expenses attributed to diabetes have shot up from €6.5 billion (2000) to €9 billon (2004) to €14 billion (2010). These are partly linked to hospital costs, 48% versus 52% for private care, but hospitals are in charge of only 10% of diabetic patients (of course, the more severe cases). The cost of an individual with diabetes is, statistically, twice as much as an individual in the rest of the population; the cost is highly variable in diabetic patients, according to complications. The cost of the treatment represented €1.8 billion in 2010. The fear, in front of this economic analysis, is the risk of decreasing an individual’s reimbursement by Sécurité sociale in the future.
Medical care of diabetic patients
Well, 80% to 90% of Type 2 diabetic patients are under the care of their GP.
More than 50% of Type 1 diabetic patients are followed by specialists, either paediatricians or endocrinologists, in private offices or bigger institutions (clinics or hospitals). Indeed, patients with Type 1 diabetes need a lot of information in order to self-manage their treatment (“the patient is his first own doctor”). There are technical aspects regarding insulin injections, insulin pumps, home blood glucose monitoring … and also theoretical aspects regarding the dose of insulin according the day-to-day life. The GP is not always comfortable delivering this “specialised” education.
Diabetes care in the South of France
As in other parts of the country, there are highly specialised institutions usually located in the university hospitals of the area (CHU de Marseille, CHU de Montpellier, CHU de Nice …) and in other “secondary” hospitals or some private clinics. Many patients are under the care of private endocrinologists, as they do not (or not yet) need the highly specialised structures mentioned above.
The density of doctors including endocrinologists is rather favourable in the South of France. In recent years, the ministry of health and the Sécurité sociale have made an effort of to promote “diabetes education”, especially outside the hospital (access is easier for patients). It consists of a teaching program for diabetics to make them aware of the impact of the disease on their lifestyle, the respect of treatment and the crucial importance of the medical follow up in order to detect possible damages induced by diabetes (long before they are at a non-reversible stage).