The Diabetes Scourge

Patrick J. Mulrow, M.D.
Professor Emeritus
Department of Medicine

Secretary General
World Hypertension League

Medical University of Ohio
3120 Glendale Avenue
Toledo, OH 43614-5809


Type 2 diabetes, which occurs primarily in obese adults and accounts for 95% of the diabetic cases, has become a worldwide epidemic. In 1997 WHO estimated there were 135 million diabetics worldwide and that number was expected to rise to 300 million by 2025, with the largest increase in developing countries. In India the number of diabetic people will increase from 19 to 57 million by the year 2025. In the United States there are 17 million Americans with Type 2 diabetes, with a prevalence of about 6% in the general population and 14% in those 60 years and older. The prevalence is increasing at an alarming rate, especially in the adolescent population.(1)

What are some of the risk factors that predispose to the development of Type 2 diabetes? Obesity(2) is the major risk, especially visceral obesity defined by a waist circumference of greater than 102 cm in men and 88 cm in women. A sedentary lifestyle is an independent risk factor, but also contributes to the development of obesity. Certain races have a genetic predisposition for developing Type 2 diabetes. Afro-Americans, Hispanic Americans, and Native Americans have a two-fold greater prevalence than Caucasians. Age over 50 is also a significant risk factor.

The health consequences of Type 2 diabetes are serious. About 50-70%(3) of the diabetics have hypertension and the two diseases cause major cardiovascular complications,(4) such as coronary artery disease, myocardial infarction, congestive heart failure, strokes, and peripheral vascular disease. Diabetes is a major cause of blindness and renal failure. Many of these health complications are already present when the diagnosis is first made. In the United States, Type 2 diabetes may be present for over 7 years before it is diagnosed.

The financial cost to treat Type 2 diabetes and its cardiovascular complications places a burden on the health budget of a country and this burden is rapidly increasing. For optimal care of the diabetic patient, special diets and multiple drugs are required to reduce the blood glucose. Vigorous control of hypertension is needed to prevent many of the cardiovascular complications and this requires two to three drugs.(5) The goal blood pressure is less than 130/80 and one of the drugs should be an ACE inhibitor or angiotensin receptor blocker, usually combined with a thiazide diuretic. At least one drug is needed to treat dyslipidemia to reduce the development of coronary artery disease and myocardial infarction. The cost of these drugs is far over-shadowed by the cost of hospitalization, disability care, loss of income and many other expenses.

As is evident, the financial burden of treating diabetes and its health consequences is enormous and can bankrupt healthcare systems, especially in the developing countries.

There is one simple solution: Prevention! Obesity is at the heart of the problem. By preventing overweight and obesity the prevalence of Type 2 diabetes will decrease dramatically.(6) Even after diabetes has developed, small amounts of weight loss (5 @ 10 kg)(7) can improve the control of diabetes, hypertension and dyslipidemia. The methodology is cheap and universally applicable: Diet and Exercise!

However, establishment of a national weight control program is not easy. It requires a community effort: families, schools, the media, food industry, government and health professionals. These all need to be dedicated to the prevention of obesity. Each country will need to design its own action plan. The long-term emphasis should be on the young, to encourage them to develop healthy lifestyles to avoid the development of diabetes

References
  1. Rosenbloom AL, Young AS, Joe JR, et al. Emerging epidemic of type 2 diabetes in youth. Diabetes Care 1999; 22: 345-354.
  2. Moser M and Sowers J. Clinical management of cardiovascular risk factors in diabetes. 1st Edition Professional Communication, Inc., 2002, p 20.
  3. Hypertension in Diabetes Study group: Prevalence of hypertension in newly presenting type 2 diabetic patients and the association with risk factors for cardiovascular and diabetic complications. J Hypertens 1993; 11: 309-317.
  4. Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: an update. Hypertension 2001; 37: 1053-1059.
  5. United Kingdom Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications of Type 2 diabetes. Control of hypertension in diabetes. Br Med J 1998; 317; 703-713.
  6. Knowler WC, Barrett-Connor E, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention. N Engl J Med 2002; 346; 393-403.
  7. Stevens VJ, et al. Small amounts of weight loss improves diabetes mellitus, hypertension, long term weight loss and changes in blood pressure: Results of the trials of hypertension prevention phase II. Ann Intern Med 2001: 134(1); 1-11.
  8. Diabetes mellitus. WHO Fact Sheet. No. 138, September 1997.
  9. Global burden of diabetes. WHO Press Release WHO/63, September 1998.
  10. Dodson PM. Hypertension and diabetes. Curr Med Res Opin 2002: 18 Suppl 1: s48-57.
  11. Arauz-Pacheco C, Parrott MA, Raskin P. The treatment of hypertension in adult patients with diabetes. Diabetes Care 2002 (Jan.); 25: 134-147.
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