Types | Costs | Prevalence | Treatment

Introduction
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose, triggered by defects in insulin production, insulin action, or occasionally both. Insulin is a hormone that is essential to convert sugar, starches and other food into energy needed for daily life.

Insulin is a hormone secreted by the islets of Langerhans in the pancreas and performs an important role in the metabolizing of carbohydrates. It regulates the amount of glucose in the blood, promotes glucose utilization, protein synthesis, and the formation and storage of lipids. Insufficient insulin results in glucose accumulations in the blood and urine, and the cells of the body are starved of energy.

Diabetes is sometimes associated with serious medical complications and premature death, nevertheless people with diabetes can take steps to control the disease and reduce the risk of complications.

According to the Centers for Disease Control (CDC), over 15 million Americans have been diagnosed with diabetes and the American Diabetes Association estimates that another 6.2 million individuals are diabetic but unfortunately unaware of the fact.

Additionally, the American Diabetes Association reports that there are 54 million people in the United States, ages 40 to 74, with pre-diabetes. Pre-diabetes, a condition where blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes, is generally a precursor to developing Type-2 diabetes.

The CDC estimated the economic cost of diabetes to be $132 billion in 2002, which is nearly one out of every ten health care dollars spent in the United States.

References
Centers for Disease Control and Prevention - National Diabetes Fact Sheet, United States, 2005.
American Diabetes Association -Total Prevalence of Diabetes & Pre-diabetes, All About Diabetes.

 

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Types of Diabetes

Type-1
Type-1 diabetes was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes. Type-1 diabetes develops when the body's immune system destroys pancreatic beta cells. These are the only cells in the body that make the hormone insulin. Insulin regulates blood glucose. This form of diabetes usually strikes children and young adults, although disease onset can occur at any age. Type-1 diabetes may account for 5% to 10% of all diagnosed cases of diabetes. Risk factors for Type-1 diabetes may include autoimmune, genetic, and environmental factors.
There are two forms of Type-1: immune-mediated diabetes and idiopathic diabetes.

Type-1A or Immune-Mediated Diabetes
Markers of beta cell autoimmune destruction include autoantibodies to insulin, islet cell autoantibodies, autoantibodies to glutamic acid decarboxylase and autoantibodies to the tyrosine phosphatases IA-2 and IA-2 beta. When fasting hyperglycemia is initially detected, one or more of these autoantibodies are exhibited in 85-90% of individuals.

The rate of beta cell destruction is variable in individuals; however, it tends to be rapid among infants and children, and slower in adults. In some patients, ketoacidosis may appear as the first manifestation of Type-1 diabetes mellitus. It is possible that some adults can maintain residual beta cell function sufficiently to prevent ketoacidosis for several years, although they will become insulin dependent at a later stage, when there is low or zero insulin secretion. This is exhibited through low or imperceptible level of plasma C-peptide.

Type-1B or Idiopathic Diabetes
Certain categories of Type-1 diabetes have no known etiologies, and are therefore considered a subclass. This subclass, idiopathic diabetes, is present in only a minute segment of the population. The majority of suffers tend to be of African or Asian ancestry.

Although Type-1B diabetes is genetic in nature, it lacks immunological evidence of beta cell autoimmunity and is not associated with Human Leukocyte Antigen (HLA). Patients exhibit permanent insulinopenia and are prone to ketoacidosis. They suffer from episodic ketoacidosis and show varying degrees of insulin deficiency between episodes. Consequently, total requirement for insulin replacement therapy in affected patients is variable.

Type-2
Type-2 diabetes was previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes. Type-2 diabetes may account for about 90% to 95% of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce insulin. Insulin secretion is insufficient to compensate for insulin resistance.

This diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. Many patients with Type-2 diabetes are obese; obesity in itself does cause certain degree of insulin resistance. In cases where patients are not classified obese by weight or BMI standards, they are likely to carry increased abdominal percentage of body fat.

In Type-2 diabetes ketoacidosis rarely occurs spontaneously, however if this happens, it is usually associated with other conditions such as infection.

As hyperglycemia develops gradually and is not severe in the early stages, Type-2 diabetes may remain undiagnosed in patients for several years. Later diagnosis increases the risk of developing macrovascular and microvascular complications.

Weight reduction or pharmacological treatment of hyperglycemia may improve insulin resistance but it is unlikely re-establish normal levels.

The probability of developing this form of diabetes increases with age, lack of physical activity and obesity.

Type-2 diabetes is more common among individuals with hypertension, dyslipidemia or women with prior Gestational Diabetes Mellitus. Its prevalence varies among population sub groups; African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Native Hawaiians or Other Pacific Islanders are at particularly high risk for Type-2 diabetes. Recently, Type-2 diabetes has been diagnosed in children and adolescents.

Although there is a strong genetic predisposition for Type-2 diabetes, its forms are complex and not clearly defined.

Gestational Diabetes Mellitus
Gestational diabetes is a form of glucose intolerance that is occasionally diagnosed in women during pregnancy. Gestational diabetes occurs more frequently among African Americans, Hispanic/Latino Americans, and American Indians. It is also more common among obese women and women with a family history of diabetes.

During pregnancy, gestational diabetes requires treatment to normalize maternal blood glucose levels to avoid complications in the infant. After pregnancy, 5% to 10% of women with gestational diabetes are found to have Type-2 diabetes. Women who have had gestational diabetes have a 20% to 50% chance of developing diabetes in the next 5-10 years.

 

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Economic Costs of Diabetes

Diabetes is the sixth leading cause of disease death in the United States and the economic costs are estimated to be greater than $132 billion, inclusive of medical expenditure and lost productivity according to the most recent survey for the year 2002.

Direct medical expenditures attributable to diabetes amounted to $92 billion and comprised $23.2 billion for diabetes care, $24.6 billion for chronic diabetes-related complications, and $44.1 billion for excess prevalence of general medical conditions.

Indirect costs resulting from lost workdays, restricted activity days, mortality, and permanent disability due to diabetes totaled $40.8 billion.

The per capita annual costs of health care for people with diabetes rose from $10,071 in 1997 to $13,243 in 2002, an increase of more than 30%. As a comparison, health care costs for people without diabetes amounted to $2,560 in 2002.
In a previous study conducted in 1997, the American Diabetes Association estimated the total economic costs of diabetes to be $98 billion, showing a 34% increase to 2002. The direct costs were estimated at $92 billion in 2002, compared to $44 billion in 1997, a 109% increase.

Even more starkly, diabetes represents 19% of total personal health care expenditures, even though the disease only accounts for 4% of the total U.S. population.

Hogan, Dall and Nikolov in their study for the American Diabetes Association state, “If diabetes prevalence rates remained constant over time, controlling for age, sex, race, and ethnicity, then based on Census Bureau population projections the number of people diagnosed with diabetes could increase to approximately 14.5 million by 2010 and to 17.4 million by 2020. The projected increase in the number of people with diabetes suggests that the annual cost in 2002 dollars of diabetes could rise to an estimated $156 billion by 2010 and to $192 billion by 2020. The actual cost in future years could be higher if the cost of health care outpaces the overall cost of living, and if current trends in obesity in the U.S. continue, with the resulting contribution to increased incidence of Type-2 diabetes.”

Patients spent 16.9 million days in hospital during 2002 resulting in $40.3 billion in costs; the cost of nursing home care for people with diabetes was $13.8 billion.

Rates of outpatient care were highest for physician office visits, which included 62.6 million visits to treat persons with diabetes.

Cardiovascular disease is the most costly complication of diabetes, accounting for more than $17.6 billion of the $91.8 billion annual direct medical costs for diabetes in 2002.

Total Cost of Diabetes: 2002

Cost Component	Total Cost Attributable to Diabetes (in Millions of Dollars)	Components’ Proportion of Total Cost (%)
Healthcare Expenditure	$91,861	70
Institutional Care	54,215	41
Hospital inpatient care	40,337	31
Nursing home care	13,878	10
Outpatient Care	20,130	15
Physician office-based care	10,033	8
Emergency care	2,162	2
Ambulance services	146	0
Hospital outpatient care	3,315	3
Home healthcare	3,930	3
Hospice care	543	0
Outpatient Medication & Supplies	17,516	13
Outpatient medication	5,516	4
Insulin and delivery supplies	6,991	5
Oral agents	5,009	4
Indirect Costs Due to Lost Productivity	39,810	30
Lost work days	4,503	3
Restricted activity days	6,256	5
Mortality	21,558	16
Permanent Disability	7,494	6
Total Cost	$131,672	100

Reference:
Winning at Work - Diabetes Facts (American Diabetes Association)

 

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Prevalence of Diabetes

Every year diabetes is becoming more prevalent in the United States. From 1980 through 2002, the number of Americans with diabetes more than doubled (from 5.8 million to 13.3 million).

The American Diabetes Association estimates that an additional 5.2 million Americans have not yet been diagnosed with the disease and are consequently unaware that they are diabetic.

The prevalence of diabetes increases with age and is higher among certain racial and ethnic minority populations. The growth, aging, and increasing racial and ethnic diversity of the U.S. population signifies potentially a substantial increase in the size of the population with diabetes.

Prevalence of Diabetes 1990-2005

Year	People Diagnosed with Diabetes (millions)
1990	6.71
1991	7.03
1992	7.60
1993	7.81
1994	8.27
1995	8.25
1996	8.48
1997	10.30
1998	10.49
1999	11.14
2000	12.01
2001	12.88
2002	13.60
2003	14.3
2004	15.2
2005	15.8

The unusually large increase between 1996 and 1997 may have been partially a result of changes in the survey methods used to measure diagnosed diabetes.

The National Health Interview Survey was redesigned in 1997. In the redesigned survey, all sampled adults were asked whether a health professional had ever told them they had diabetes. To exclude gestational diabetes, women were asked whether they had been told they had diabetes other than during pregnancy. Also, parents of sampled children were asked whether their child had diabetes. Three-year averages were used to improve the precision of the annual estimates.

Prevalence of Diabetes by Age in the United States

Age   0–44 45–64 65–74 75+ Year Percentage Percentage Percentage Percentage 1980 0.6 5.5 9.1 8.9 1981 0.6 5.6 9.2 8.4 1982 0.6 5.8 8.6 8.3 1983 0.6 5.6 9.3 8.5 1984 0.6 5.4 9.8 9.1 1985 0.6 5.6 10.2 10.0 1986 0.7 5.7 9.9 10.1 1987 0.7 5.8 9.5 9.8 1988 0.7 5.6 9.4 9.0 1989 0.7 5.4 9.6 8.4 1990 0.7 5.5 9.9 8.6 1991 0.8 5.4 10.7 9.3 1992 0.8 5.8 10.6 10.1 1993 0.8 6.0 10.5 10.4 1994 0.8 6.3 11.1 10.8 1995 0.8 6.2 11.1 10.6 1996 0.8 6.6 12.5 11.1 1997 0.9 7.1 12.8 11.3 1998 1.0 7.8 14.0 12.1 1999 1.1 8.1 14.5 12.6 2000 1.2 8.6 15.4 13.0 2001 1.2 9.0 16.5 13.9 2002 1.2 9.3 17.1 14.6 2003 1.2 9.5 17.7 15.4 2004 1.3 9.9 18.2 15.6 2005 1.4 10.2 18.5 15.6

 
Source
Percentage of Persons with Diagnosed Diabetes by Age, United States, 1990-2005


Prevalence of Diabetes by Sex in the United States

Source
Percentage of Persons with Diagnosed Diabetes by sex, United States, 1990-2005
Number and Percent of U.S. Population with Diagnosed Diabetes

 

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Diabetes Treatments

Type-1 Diabetes
Type-1 is the type of diabetes that people most often get before 30 years of age. All people with Type-1 diabetes need to take insulin because their bodies do not make enough of it. Insulin helps turn food into energy for the body to work.

Insulin
If your pancreas no longer makes enough insulin, then you need to take insulin as a shot. You inject the insulin just under the skin with a small, short needle.

Insulin is a protein/hormone. If you took insulin as a pill, your body would break it down and digest it before it got into your blood to lower your blood glucose.

Insulin lowers blood glucose by moving glucose from the blood into the cells of your body. Once inside the cells, glucose provides energy. Insulin lowers your blood glucose whether you eat or not. You should eat on time if you take insulin.

Most people with diabetes need at least two insulin shots a day for good blood glucose control. Some people take three or four shots a day to have a more flexible diabetes plan.

You should take insulin 30 minutes before a meal if you take regular insulin alone or with a longer-acting insulin. If you take a rapid-acting insulin, you should take your shot just before you eat.

There are six main types of insulin. They each work at different speeds. Many people take two types of insulin.

Types of Insulin

Rapid-acting
- Rapid-acting, insulin lispro (Humalog)
- Starts working in 5 to 15 minutes
- Lowers blood glucose most in 45 to 90 minutes
- Finishes working in 3 to 4 hours
- Rapid-acting, insulin aspart (Novolog)
- Starts working in 10 to 20 minutes
- Lowers blood glucose most in 1 to 3 hours
- Finishes working in 3 to 5 hours

Short-acting
- Short-acting, Regular (R) insulin
- Starts working in 30 minutes
- Lowers blood glucose most in 2 to 5 hours
- Finishes working in 5 to 8 hours

Intermediate-acting
- Intermediate-acting, NPH (N) or Lente (L) insulin
- Starts working in 1 to 3 hours
- Lowers blood glucose most in 6 to 12 hours
- Finishes working in 16 to 24 hours

Long-acting
- Long-acting, Ultralente (U) insulin
- Starts working in 4 to 6 hours
- Lowers blood glucose most in 8 to 20 hours
- Finishes working in 24 to 28 hours

Very long-acting
- Very long-acting, insulin glargine (Lantus)
- Starts working in 1 hour
- Lowers blood glucose evenly for 24 hours
- Finishes working in 24 hours and is taken once a day at bedtime
- Lantus should not be mixed together in a syringe with any other form of insulin before use

Premixed
- NPH and Regular insulin mixture
- Two types of insulins mixed together in one bottle
- Starts working in 30 minutes
- Lowers blood sugar most in 7 to 12 hours
- Finishes working in 16 to 24 hours

Type-2 Diabetes
If you have Type-2 diabetes, your pancreas usually makes plenty of insulin but your body cannot correctly use the insulin you make. You might get this type of diabetes if members of your family have or have had diabetes. You might also get Type-2 diabetes if you weigh too much or do not exercise enough.

After you have had Type-2 diabetes for a few years, your body may stop making enough insulin. You will then need to take diabetes pills or insulin.

Diabetes Pills
Many types of diabetes pills can help people with Type-2 diabetes lower their blood glucose. Each type of pill helps lower blood glucose in a different way. The diabetes pill (or pills) you take is from one of these groups.

- Sulfonylureas stimulate your pancreas to make more insulin.
- Biguanides decrease the amount of glucose made by your liver.
- Alpha-glucosidase inhibitors slow the absorption of the starches you eat.
- Thiazolidinediones make you more sensitive to insulin.
- Meglitinides stimulate your pancreas to make more insulin.
- D-phenylalanine derivatives help your pancreas make more insulin quickly.
- Combination oral medicines put together different kinds of pills.