Precision medicine could transform the way we prevent and diagnose diabetes and its complications - offering the right care to the right person at the right time…
No two people experience diabetes the same.
The way diabetes develops, how complications potentially unfold, and how people respond to treatments is different for everyone. So, a ‘one size fits all’ approach to diabetes care doesn’t work.
Precision medicine offers a way forward. It uses detailed information about a person’s genes, environment, and individual health behaviours to tailor healthcare to them.
The phrase ‘precision medicine’ is new, but the idea has been used in healthcare for decades. Take blood transfusions. The donor’s blood type is precisely matched to the blood type of the person receiving it to prevent the immune system rejecting the donated blood.
More recently, advances in medical imaging and our ability to capture vast, detailed biological data have accelerated precision approaches. In cancer care, doctors can now use specific changes in tumour genes to guide which treatment works best for each person. In infectious disease, scientists can analyse every gene in a virus to make safer, better working vaccines that target these genes.
In diabetes, precision medicine is already transforming how we diagnose and treat Maturity onset diabetes of the young (MODY), a rare type of diabetes caused by a single gene change.
Ninety per cent of people with MODY are first mistakenly diagnosed with type 1 or type 2 diabetes. But scientists can now identify the exact gene that’s causing someone’s MODY to find their specific subtype. This is reducing misdiagnosis. Plus, it’s giving doctors the biological information they need to choose the MODY treatment that’s right for each person.
These advances show that we’re entering a new precision medicine era. And with NHS England’s new 10 Year Health Plan setting out a vision for more proactive and personalised care, driven by data and genetics, the momentum is only growing.
At Diabetes UK, we’ll be funding and driving the research that could unlock the full potential of precision medicine for everyone living with or at risk of diabetes. From personalised paths to type 2 prevention, to tailoring complications care, to advancing precision cures for type 1 diabetes – and more.
Type 2 diabetes
Personalised type 2 treatments are a very promising example of precision medicine.
In type 2 diabetes, the body doesn’t make enough insulin, or the insulin it makes doesn’t work properly. It’s a complex condition influenced by a wide range of risk factors, from genes to ethnicity to bodyweight…no single factor explains why people get the condition.
And this variation is reflected in differences in the condition’s biology once it develops. Some people’s type 2 is chiefly driven by insulin resistance, meaning their insulin no longer works effectively. For others, the biggest problem lies with their beta cells not making enough insulin.
As research reveals more about these biological differences, scientists are increasingly viewing type 2 diabetes as a collection of closely related conditions, rather than one. One key study identified the potential of at least five distinct type 2 subtypes, each with different biological drivers and different long-term outcomes.
This biological understanding is helping to explain why some people are more prone to complications or faster type 2 progression than others - and why people respond differently to the same treatments.
For example, early research suggests that people with type 2 diabetes whose beta cells don’t function as well may benefit less from GLP-1 receptor agonists, a class of type 2 drug, than those with better-working beta cells. And researchers are pinpointing biomarkers – measurable clues that show what’s going on in the body – that could help predict who is most likely to develop type 2 diabetes complications.
But there’s still more to understand. We need to nail down the biomarkers that define each type 2 subtype. And, adding to the complexity, a person’s type 2 diabetes can change over time - meaning they could shift between subtypes. As such, they may need different treatments at different times in life.
When it comes to type 2 prevention, whilst studies show that interventions focused on weight loss, increasing physical activity, and diet, are effective routes to preventing or delaying the condition, they don’t work for everyone. They fail to consider the spectrum of biological, environmental, and social factors which shape each person’s unique type 2 risk.
This is where precision medicine could be transformative.
A precision approach to type 2 prevention would consider these factors, tailoring prevention interventions to them - at the right time.
By creating the Type 2 Diabetes Prevention Research Challenge, we’re aiming to scale up investment in precision prevention research to make this vision a reality. We’ll build a deeper understanding of how type 2 diabetes varies between individuals and bring the research community together with people affected by type 2 to identify and tackle key questions.
Type 1 Diabetes
Precision medicine is already improving how we diagnose type 1 diabetes.
Researchers can now look for type 1, type 2, or MODY biomarkers – like genes or proteins – that help distinguish between each type. And diabetes tech, like CGM, is becoming more personalised because its algorithms are being trained on each person’s specific blood sugar level patterns.
Precision medicine is also starting to help us diagnose type 1 much earlier, or identify who is at higher risk of it, to guide the right support at the right time.
Genetic screening can identify children and adults who have genes that increase their risk of developing type 1. Meanwhile, screening for type 1 autoantibodies in the blood can detect whether the immune attack at the root of the condition has already begun – telling us if someone is already in the early stages of type 1, before symptoms develop.
Luckily, we’re entering the era of type 1 immunotherapies.
Last summer saw the licensing of the first ever type 1 immunotherapy, teplizumab, in the UK, for people in the early stages of type 1 diabetes. Immunotherapies reprogramme the immune system and weaken its attack on beta cells. This can delay type 1’s full development - and in future, may prevent it altogether.
However, type 1 diabetes develops and progresses differently for each person, shaped by their unique genetic, immune, and environmental drivers.
Because of this complexity, the same immunotherapy might not work equally well for everyone. This presents a further opportunity for precision prevention.
Understanding how the biological pathways to type 1 differ between people could inform new immunotherapies targeting a person’s specific immune response, making them more effective at holding back or preventing type 1.
Personalised immunotherapies could also help to treat, and even cure, type 1 diabetes in people already living with it.
To cure type 1, we need to replace the beta cells that have been destroyed. Our scientists are developing beta cell therapies designed to do just this. But the immune system will attack newly transplanted cells - unless they’re protected. Combining beta cell replacement with targeted immunotherapies to hold off the attack sounds sci-fi - but our Type 1 Diabetes Grand Challenge scientists are on the case.
Elsewhere, researchers are using ‘genetic scissors’ – a molecular tool called CRISPR – to make precise edits to DNA. One exciting use of this technology is to genetically engineer lab-grown beta cells so they can hide from the immune system, evading its attack.
Looking ahead, there’s big potential to design the right beta cells for the right person. For instance, by customising gene-edited beta cells to evade an individual’s specific immune response. While much more research is needed, there’s real hope for a transformative precision cure for type 1 diabetes.
Diabetes complications
Diabetes complications can affect many parts of the body and impact major organs like the eyes, heart, or kidneys. They’re caused by high blood sugar, blood lipid, and blood pressure levels damaging the body’s blood vessels and nerves.
But not everyone with diabetes gets complications. Even among people who do, the way complications present and progress in the body, varies. This means that strategies to prevent or manage diabetes complications need to be tailored to the individual.
For instance - there’s lots of evidence that shows keeping blood sugar levels in range significantly reduces the risk of diabetes complications. But it isn’t the only risk factor. In people with type 1, for example, blood sugar levels are thought to account for about 50% of their overall complications risk. Things like genes, high blood pressure, cholesterol, or socio-economic background, also contribute.
Let’s zoom in on genes.
Some people with type 1 diabetes may carry genes that make their blood vessels, including in the heart, less responsive to the protective effects that come from tight blood sugar management. As such, keeping their blood sugar levels in range might not offer the same level of heart damage protection as it does for others with type 1.
To build a richer understanding of why complications develop, researchers are identifying additional biomarkers, alongside genetic differences, that influence a person’s risk.
This could help doctors tailor care to the specific biological processes driving an individual’s complications risk, better protecting people from the harm diabetes can cause.
As scientists reveal how our genes, biology and environments influence diabetes, care is beginning to shift away from blanket approaches to something more personalised. The foundations are now in place for a new era of smarter prevention, earlier diagnosis, and treatments shaped around each individual.
