Type 2 Diabetes: A Long-Ignored Epidemic

▪ 2008

       Diabetes mellitus is a public health threat that rivals HIV/AIDS in its reach and deadly toll. The International Diabetes Federation (IDF), an alliance of diabetes associations in more than 160 countries, has described diabetes mellitus as a “global epidemic with devastating humanitarian, social, and economic consequences.” The most prevalent form of the disease—accounting for 90% to 95% of diabetes cases—is type 2 diabetes mellitus (T2DM), formerly known as non-insulin-dependent diabetes. At least 7 million people develop T2DM each year, and 3.8 million people die from complications of the disease. “Yet awareness of the global scale of the diabetes threat,” the IDF contends, “remains pitifully low.”

      Once mainly a disease that affected older adults in wealthy countries, T2DM now strikes all populations. Urbanization, sedentary lifestyles, and high rates of obesity are major contributing factors to the upsurge in cases. The IDF estimates that worldwide among adults 20–79 years old, 246 million persons (5.9% of the population) had T2DM in 2007—with about 80% of them living in less-developed countries (LDCs)—and that by 2025, 380 million (7.1% of the population) would have it. In the United States T2DM prevalence has more than doubled since 1990, and minorities are disproportionately affected. The disease is increasingly diagnosed in children and adolescents, in both developed countries and LDCs—a trend closely tied to epidemic rates of childhood obesity. The U.S. Centers for Disease Control and Prevention has predicted that about one-half of all African American and Hispanic American children born in 2000 will develop T2DM.

      T2DM is a metabolic disorder in which the body is unable to utilize the hormone insulin properly. Insulin is normally secreted by the beta cells of the pancreas in response to food intake; its role is to “unlock” cells so that glucose, the simple sugar into which food is broken down, can enter the cells and be converted into energy. When glucose cannot get into cells, it builds up in the bloodstream, which sets the stage for diabetes and its many serious complications such as kidney disease, potentially blinding eye disease, damage to the nerves of the feet and lower limbs that can necessitate amputation, and cardiovascular disease, which is the cause of premature death in more than one-half of diabetes cases.

      The vast majority of persons who develop T2DM first experience insulin resistance, a condition in which the body's cells are resistant to the action of insulin. Excess body fat (especially in the area of the abdomen), a sedentary lifestyle, and genetics are all thought to contribute to its development. In the early stages of insulin resistance, people are likely to have glucose levels that are elevated but not high enough to be classified as diabetes. This intermediate condition is often called prediabetes. The IDF estimates that 308 million people had prediabetes in 2007 and has predicted that the number will rise to 418 million by 2025.

      Fortunately, progression from prediabetes to diabetes is not inevitable. A three-year landmark clinical trial completed in 2001 called the Diabetes Prevention Program demonstrated that overweight people with prediabetes who lost a moderate amount of weight and exercised regularly reduced their risk of developing diabetes by 58%. Even persons with a genetic predisposition that more than doubled their chance of getting T2DM were able to overcome their risk with lifestyle interventions, medication, or both together. Unfortunately, at least one-third of those who are headed toward developing full-blown diabetes are not aware of their deteriorating health. They may not learn that they have T2DM until they develop one of its serious complications, at which point irreversible damage has already been done.

      The key to managing T2DM and thwarting or delaying the onset of devastating complications is what is termed “tight glycemic control”—keeping blood glucose levels as close to normal as possible. Proper diet, exercise, and weight loss are the foundation of T2DM management, but as the disease progresses, most people also need medication. There are currently eight classes of drugs for T2DM on the market and dozens of promising new agents in the pipeline. All regulate glucose, but they do so by targeting different metabolic defects. Medications that lower blood pressure or modify cholesterol levels are often critical components of T2DM-management regimens, since the majority of people with T2DM have high blood pressure, elevated levels of “bad” cholesterol (LDL), and low levels of “good” cholesterol (HDL).

      Because T2DM is a progressive disease in which the pancreatic beta cells can stop producing insulin entirely, some patients eventually need insulin. (Insulin is the mainstay of treatment of type 1 diabetes, in which the body's immune system destroys the insulin-producing beta cells, usually in childhood.) Advances in the understanding of insulin physiology and in recombinant DNA technology have enabled the production of highly refined insulin formulations. In 2006 the first inhaled insulin product, Exubera, was approved for persons with type 1 or 2 diabetes. Initially, it was touted as a major breakthrough, but only carefully selected patients could use it, and few physicians prescribed it. One year after Exubera's launch, Pfizer, the company that made the drug, announced that it was discontinuing the product.

      Diabetes and its complications are unfathomably costly. Unless there are momentous changes, the countries with the fewest resources, where the prevalence is rising fastest, will bear the brunt of the diabetes burden. The effort to slow the epidemic received important support on Dec. 20, 2006, when the United Nations passed a resolution that officially recognized the seriousness of the global T2DM threat. The resolution called upon all UN member states to develop national policies for preventing and treating T2DM and to observe World Diabetes Day (November 14) to raise awareness of diabetes. In 2007 the day was marked by such activities as walkathons and free glucose testing, and more than 200 buildings—from the Empire State Building in New York City and the World Trade Centre Tower in Dubai, U.A.E., to a clock tower in Tirana, Alb., and a cinema in Asmara, Eritrea—were lit up in blue, the colour chosen to signify a unified global response to a long-ignored epidemic.

Ellen Bernstein

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