Diabetes mellitus has been present since antiquity. It was described in 400 B.C. as a disease of "well-fed people," and Bose wrote in 1895 "amongst the Zemindars and Talookdars, who consider it a pride and honor to lead an indolent life, diabetes is a common disorder" (1). It is a common disease that is now estimated to affect more than 16 million Americans and more than 100 million people worldwide (2, 3). It is most prevalent in countries such as India, China, and the U.S. (4). Its direct and indirect costs account for at least 15 percent of health-care expenditure in the U.S., which totals at least $100 billion annually (2, 5, 6). The annual estimated cost in other countries is just as formidable. The estimated annual health-care costs associated with diabetes in various developed countries in 1995 (4) are shown in Table 9.1.
A large portion of the costs of diabetes is associated with its complications (7). The University Group Diabetes Program, the earliest randomized clinical trial of the treatment of hyperglycemia in people with diabetes, failed to show a positive effect of glycemic control on the prevention of the development or progression of microvascular complications (8). However, the Diabetes Control and Complication Trial and the United Kingdom Prospective Diabetes Study clearly showed that strict control of blood glucose could positively affect the progression of diabetic complications (9). It has also been shown that elevated hemoglobin A1c (HbA1c), an indicator of poor glucose control, is associated with increased mortality in diabetic populations (9). The American Diabetes Association recommends a goal for HbA1c of < 7 percent, with the need for intervention when HbA1c is > 8 percent (10).
Type 1 diabetes mellitus comprises approximately 10 percent of diabetes incidence (11). Most cases of type 1 diabetes mellitus are sporadic, with only 10 percent to 15 percent of affected individuals having a first-degree relative with type 1 diabetes mellitus at the time of diagnosis (11). The risk of developing diabetes is 5 percent if a family member also has type 1 diabetes mellitus, in comparison to general population risk of 0.2 percent (11). Type 1 diabetes mellitus is characterized by T-lymphocyte mediated destruction of insulin-producing cells of the pancreatic islets of Langerhans (11). A majority of cases of type 1 diabetes mellitus result from proven beta-cell destruction and are classified as type 1a. Ten percent to 20 percent of cases are antibody negative and are classified as idiopathic (11).
Type 2 diabetes mellitus comprises approximately 90 percent of diabetes (11). Prevalence among ethnic groups in the U.S. include: 2 percent to 8 percent Caucasians; 4 percent to 12 percent African Americans; 4 percent to 19 percent Mexican Americans; 14 percent to 12 percent Asian Americans; and 35 percent to 50 percent Pima Native Americans, with Arizona having the highest diabetes incidence in the world among this group (Table 9.2) (11). In comparison, a Singapore national survey showed a prevalence of 13.1 percent among Mauritian Chinese, 2.7 percent in Asian Indians in Asia, and 1.6 percent in Chinese in China (12). It is estimated that diabetes
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