• DOI:10.1038/nm0106-75
• Corpus ID: 1042625

Diabetes and obesity: the twin epidemics

@article{Smyth2006DiabetesAO,
  title={Diabetes and obesity: the twin epidemics},
  author={Simon Smyth and Andrew Heron},
  journal={Nature Medicine},
  year={2006},
  volume={12},
  pages={75-80}
}

• S. Smyth, A. Heron
• Published 2006
• Medicine
• Nature Medicine

DIABETES The World Health Organization (WHO) has declared that a diabetes epidemic is underway. In 1985, an estimated 30 million people worldwide had diabetes. By 1995, this number had shot up to 135 million, and by 2005 reached an estimated 217 million. Alarmingly, the WHO predicts that this will increase to at least 366 million by 2030 (Fig. 1). Most of this growth is expected to occur in developing countries, where the number of people with diabetes is forecast to increase substantially over the next 25 years. India and China are predicted to show the largest increases in terms of prevalence, with the US ranking third. Of the two types of diabetes mellitus, most of this growth will be driven by the increasing prevalence of type 2 diabetes, whereas the prevalence of type 1 diabetes will remain relatively stable. The WHO attributes this growth to population growth, aging, unhealthy diets, obesity and increasingly sedentary lifestyles. Diabetes is considered one of the major causes of premature illness and death in most countries and imposes a substantial financial burden to society. The predicted increase in prevalence among the population is therefore a real health and economic concern. Diabetes costs. Primary diabetes and its complications are costly to manage, not only for affected individuals, but also for healthcare systems around the world. According to the International Diabetes Federation, diabetes already accounts for 5–10% of the total healthcare budget in many countries. In the US, the American Diabetes Association (ADA) has estimated that the total cost of diabetes in 2002 was $132 billion, with direct and indirect costs of $92 billion and $40 billion, respectively. Reflecting the projected increase in prevalence of the condition, total costs are predicted to rise further, to reach $156 billion in 2010 and $192 billion in 2020 (Fig. 2). Most of the costs associated with diabetes result from comorbidities and the management of diabetes-related complications. Diabetic individuals are three times more likely to require expensive hospitalization for complications such as heart disease, kidney failure, limb amputation and blindness. In the US in 2002, institutional care was estimated to represent $54.2 billion, or 41%, of total costs attributable to diabetes, with total prescription drug expenditure representing only 13% ($17.5 billion) of total costs. Various clinical trials, however, have shown that the long-term risk of complications can be reduced through optimal glycemic control, together with rigorous control of blood pressure and other lifestyle factors such as diet and physical activity. As the overall cost of diabetes management far outweighs the relative costs of drug therapy, there are powerful health and economic arguments in favor of using drugs that improve glycemic control, leading to a decline in rates of hospitalization and premature deaths. Current treatment of diabetes. The overall aim of treatment is to achieve the best possible glycemic control and to avoid disabling hypoglycemia. People with type 1 or type 2 diabetes may require an exogenous source of insulin to control blood-sugar levels. For individuals with type 1 diabetes who produce little or no endogenous insulin, administration of insulin is necessary. A long-acting basal insulin is typically used, supplemented at mealtimes with short-acting preparations. For individuals with type 2 diabetes, dietary control plus pharmacological intervention with oral antidiabetic drugs (OADs) is usually sufficient, although insulin may be required if glucose management cannot be achieved by these means. In these individuals, long-acting basal preparations are typically used. The treatment of individuals with ‘prediabetes’ (blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes) and metabolic syndrome (a cluster of conditions that occur together, including obesity, insulin resistance or type 2 diabetes, high blood pressure, high blood triglyceride levels and low blood high-density lipoprotein levels) is less established. However, it is principally aimed at reducing their risk of developing diabetes. Increasing physical activity and losing excess weight has been shown to significantly reduce the risk of developing type 2 diabetes in overweight people with prediabetes. Additional preventative measures such as reduction of blood pressure, control of cholesterol levels and smoking cessation are also advocated for many individuals. Insulin. First isolated in 1921, insulin revolutionized the treatment of type 1 diabetes and the prevention of its complications, transforming it from a fatal disease into one in which long-term survival became achievable. The first insulin products generated were derived from animals (porcine or bovine insulin), although these have now largely been superseded by recombinant human insulins. More recently, insulin analogs have been successfully launched into the market. These differ slightly in structure from human-derived insulin, typically by one or two amino acids, and change the molecule’s pharmacokinetic profile to resemble more closely that of endogenous insulin. Long-acting analogs offer a smoother (‘peakless’) and more predictable profile of action than conventional long-acting insulins, 0 100 200 300 400