HeConnection-CauseResearchers are baffled by the worldwide increase in type 1 diabetes, the less common form of the disease.

For reasons that are completely mysterious, the incidence of type 1 diabetes has been increasing throughout the globe at rates that range from 3 to 5 percent a year. Although the second trend is less well publicized, it is still deeply troubling, because this form of the illness has the potential to disable or kill people so much earlier in their lives.

No one knows exactly why type 1 diabetes is rising. Solving that mystery—and, if possible, reducing or reversing the trend—has become an urgent problem for public health researchers everywhere. So far they feel they have only one solid clue.

“Increases such as the ones that have been reported cannot be explained by a change in genes in such a short period,” says Giu­seppina Imperatore, who leads a team of epidemiologists in the Division of Diabetes Translation at the U.S. Centers for Disease Control and Prevention. “So environmental factors are probably major players in this increase.”

A Challenge of Counting

The first strong signal that the incidence of type 1 diabetes was on the rise came in 2006, from a World Health Organization project known as DIAMOND (a combination of words in several languages for worldwide diabetes). That survey, which looked at 10 years of records from 112 diabetes research centers in 57 countries, found that type 1 had risen an average of 5.3 percent a year in North America, 4 percent in Asia and 3.2 percent in Europe.

Statistics from Europe—where the single-payer health care systems that care for residents throughout their lives generate rich stores of data—back up that first finding. In 2009 researchers from a second project called EURODIAB compared diabetes incidence across 17 countries and found not only that type 1 was rising—by 3.9 percent a year on average—but also that it was increasing most quickly among children younger than five. By 2020, they predicted, new cases of type 1 diabetes in that age group will nearly double, from 3,600 children to an estimated 7,076 children.

Competing Hypotheses

The challenge for explaining the rising trend in type 1 diabetes is that if the increases are occurring worldwide, the causes must also be. So investigators have had to look for influences that stretch globally and consider the possibility that different factors may be more important in some regions than in others.

The list of possible culprits is long. Researchers have, for example, suggested that gluten, the protein in wheat, may play a role because type 1 patients seem to be at higher risk for celiac disease and the amount of gluten most people consume (in highly processed foods) has grown over the decades. Scientists have also inquired into how soon infants are fed root vegetables. Stored tubers can be contaminated with microscopic fungi that seem to promote the development of diabetes in mice.

None of those lines of research, though, have returned results that are solid enough to motivate other scientists to stake their careers on studying them. So far, in fact, the search for a culprit resembles the next-to-last scene in an Agatha Christie mystery—the one in which the detective explains which of the many suspects could not possibly have committed the crime.

The last scene in the drama, unfortunately, still has not been written. Currently the suspects getting the closest scrutiny are infections with bacteria, viruses or parasites. The presumptive etiology: a version of the “hygiene hypothesis” that links clean modern lifestyles and allergies.

The diabetes version of the hygiene hypothesis proposes that when the immune system learns not to overreact to allergens, it also learns to tolerate compounds from the body’s own tissues—and therefore prevents the autoimmune attack that destroys the ability to make insulin.

Some circumstantial evidence supports that proposal. Children with multiple siblings—who might bring infections home from day care or school—are less likely to be hospitalized for type 1 diabetes (a proxy measure for incidence). The disease is also less common in children who attend day care themselves, and it is more common in specially bred mice that do not encounter infections because they are raised in a sterile environment.

Back to Fat

Recently the search for a cause behind the rise of type 1 diabetes has taken an unexpected turn. Some investigators are reconsidering the role of an old adversary: being overweight or obese.

This idea, called the accelerator or overload hypothesis, proposes that “if you have a kid who is chubby, that extra adiposity is going to challenge the pancreatic beta cells,” says Rebecca Lipton, an emeritus professor at the University of Chicago. “In a child who has already started the autoimmune process, those beta cells are just going to fail more quickly, because they are being forced to put out more insulin than in a thin child.”

Overweight makes a logical perpetrator. People are packing on the pounds in rich countries and poor ones. Of course, investigators want to do more than just to explain the rise of type 1 diabetes; they want to prevent it. Unfortunately, if excess weight is a major contributor to the problem, that task will not be easy. No one, so far, has been able to slow the global obesity epidemic. (By 2048, according to researchers from Johns Hopkins University, all American adults will be at least overweight if present trends continue.) Until societies can ensure that most children (not to mention adults) are more physically active, eat healthfully and maintain a normal weight, diabetes researchers will be in the position of detectives who, having solved a murder, realize they can do nothing to prevent the next one.

Health-e-Solutions comment: Lots of suspects, but alas, not enough clues to solve the mystery yet. Until the mystery is solved, we will continue to practice the diabetic-alkaline lifestyle in an effort to limit the environmental and dietary factors that may be involved.

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