Diabetes Mellitus Type 2 - Wikipedia, The Free Encyclopedia

10/8/2016
Diabetesmellitustype2Wikipedia,thefreeencyclopedia
Diabetesmellitustype2
FromWikipedia,thefreeencyclopedia
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Diabetesmellitustype2(alsoknownastype2diabetes)isalongtermmetabolicdisorderthatischaracterized
byhighbloodsugar,insulinresistance,andrelativelackofinsulin.[3]Commonsymptomsincludeincreased
thirst,frequenturination,andunexplainedweightloss.Symptomsmayalsoincludeincreasedhunger,feeling
tired,andsoresthatdonotheal.[4]Oftensymptomscomeonslowly.[3]Longtermcomplicationsfromhigh
bloodsugarincludeheartdisease,strokes,diabeticretinopathywhichcanresultinblindness,kidneyfailure,and
poorbloodflowinthelimbswhichmayleadtoamputations.[1]Thesuddenonsetofhyperosmolar
hyperglycemicstatemayoccurhowever,ketoacidosisisuncommon.[5][6]
Diabetesmellitustype2
noninsulindependentdiabetesmellitus
(NIDDM),adultonsetdiabetes[1]
Type2diabetesprimarilyoccursasaresultofobesityandnotenoughexercise.[1]Somepeoplearemore
geneticallyatriskthanothers.[3]Type2diabetesmakesupabout90%ofcasesofdiabetes,withtheother10%
dueprimarilytodiabetesmellitustype1andgestationaldiabetes.[1]Indiabetesmellitustype1thereisan
absolutelackofinsulinduetobreakdownofisletcellsinthepancreas.[7]Diagnosisofdiabetesisbybloodtests
suchasfastingplasmaglucose,oralglucosetolerancetest,orA1C.[4]
Type2diabetesispartlypreventablebystayinganormalweight,exercisingregularly,andeatingproperly.
Treatmentinvolvesexerciseanddietarychanges.[1]Ifbloodsugarlevelsarenotadequatelylowered,the
medicationmetforministypicallyrecommended.[8][9]Manypeoplemayeventuallyalsorequireinsulin
injections.[10]Inthoseoninsulin,routinelycheckingbloodsugarlevelsisadvised,howeverthismaynotbe
neededinthosetakingpills.[11]Bariatricsurgeryoftenimprovesdiabetesinthosewhoareobese.[12][13]
Ratesoftype2diabeteshaveincreasedmarkedlysince1960inparallelwithobesity.[14]Asof2013therewere
approximately368millionpeoplediagnosedwiththediseasecomparedtoaround30millionin1985.[15][16]
Typicallyitbeginsinmiddleorolderage,[3]althoughratesoftype2diabetesareincreasinginyoung
https://en.wikipedia.org/wiki/Diabetes_mellitus_type_2
Universalbluecirclesymbolfordiabetes[2]
Classificationandexternalresources
Pronunciation /dabitis/
Specialty
Endocrinology
ICD10
E11(http://apps.who.int/classificati
ons/icd10/browse/2016/en#/E11)
ICD9CM
250.00(http://www.icd9data.com/g
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people.[17][18]Type2diabetesisassociatedwithatenyearshorterlifeexpectancy.[19]Diabeteswasoneofthe
firstdiseasesdescribed.[20]Theimportanceofinsulininthediseasewasdeterminedinthe1920s.[21]
etICD9Code.ashx?icd9=250.00),
250.02(http://www.icd9data.com/g
etICD9Code.ashx?icd9=250.02)
OMIM
125853(http://omim.org/entry/125
853)
DiseasesDB
3661(http://www.diseasesdatabase.
com/ddb3661.htm)
MedlinePlus
000313(http://www.nlm.nih.gov/m
edlineplus/ency/article/000313.htm)
eMedicine
article/117853(http://emedicine.me
dscape.com/article/117853overvie
w)
MeSH
D003924(https://www.nlm.nih.go
v/cgi/mesh/2016/MB_cgi?field=uid
&term=D003924)
Contents
1 Signsandsymptoms
1.1 Complications
2 Cause
2.1 Lifestyle
2.2 Genetics
2.3 Medicalconditions
3 Pathophysiology
4 Diagnosis
5 Screening
6 Prevention
7 Management
7.1 Lifestyle
7.2 Medications
7.3 Surgery
8 Epidemiology
9 History
10 References
11 Externallinks
Signsandsymptoms
Videoexplanation
Theclassicsymptomsofdiabetesarepolyuria(frequenturination),polydipsia(increasedthirst),polyphagia
(increasedhunger),andweightloss.[22]Othersymptomsthatarecommonlypresentatdiagnosisincludea
historyofblurredvision,itchiness,peripheralneuropathy,recurrentvaginalinfections,andfatigue.[7]Manypeople,however,havenosymptomsduringthefirst
fewyearsandarediagnosedonroutinetesting.[7]Peoplewithtype2diabetesmellitusmayrarelypresentwithhyperosmolarhyperglycemicstate(aconditionof
veryhighbloodsugarassociatedwithadecreasedlevelofconsciousnessandlowbloodpressure).[7]
Complications
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Type2diabetesistypicallyachronicdiseaseassociatedwithatenyearshorterlife
expectancy.[19]Thisispartlyduetoanumberofcomplicationswithwhichitisassociated,
including:twotofourtimestheriskofcardiovasculardisease,includingischemicheartdisease
andstrokea20foldincreaseinlowerlimbamputations,andincreasedratesof
hospitalizations.[19]Inthedevelopedworld,andincreasinglyelsewhere,type2diabetesisthe
largestcauseofnontraumaticblindnessandkidneyfailure.[23]Ithasalsobeenassociatedwith
anincreasedriskofcognitivedysfunctionanddementiathroughdiseaseprocessessuchas
Alzheimer'sdiseaseandvasculardementia.[24]Othercomplicationsincludeacanthosis
nigricans,sexualdysfunction,andfrequentinfections.[22]
Cause
Thedevelopmentoftype2diabetesiscausedbyacombinationoflifestyleandgenetic
factors.[23][25]Whilesomeofthesefactorsareunderpersonalcontrol,suchasdietandobesity,
otherfactorsarenot,suchasincreasingage,femalegender,andgenetics.[19]Alackofsleep
hasbeenlinkedtotype2diabetes.[26]Thisisbelievedtoactthroughitseffecton
metabolism.[26]Thenutritionalstatusofamotherduringfetaldevelopmentmayalsoplaya
role,withoneproposedmechanismbeingthatofalteredDNAmethylation.[27]Theintestinal
bacteriPrevotellacopriandBacteroidesvulgatushavebeenconnectedwithtype2
diabetes.[28]
Overviewofthemostsignificantsymptomsofdiabetes.
Lifestyle
Anumberoflifestylefactorsareknowntobeimportanttothedevelopmentoftype2diabetes,includingobesityandbeingoverweight(definedbyabodymass
indexofgreaterthan25),lackofphysicalactivity,poordiet,stress,andurbanization.[19][29]Excessbodyfatisassociatedwith30%ofcasesinthoseofChinese
andJapanesedescent,6080%ofcasesinthoseofEuropeanandAfricandescent,and100%ofcasesinPimaIndiansandPacificIslanders.[7]Amongthosewho
arenotobeseahighwaisthipratioisoftenpresent.[7]Smokingalsoappearstoincreasetheriskoftype2diabetesmellitus.[30]
Dietaryfactorsalsoinfluencetheriskofdevelopingtype2diabetes.Consumptionofsugarsweeteneddrinksinexcessisassociatedwithanincreasedrisk.[31][32]
Thetypeoffatsinthedietarealsoimportant,withsaturatedfatsandtransfattyacidsincreasingtherisk,andpolyunsaturatedandmonounsaturatedfatdecreasing
therisk.[25]Eatinglotsofwhitericeappearstoalsoplayaroleinincreasingrisk.[33]Alackofexerciseisbelievedtocause7%ofcases.[34]Persistentorganic
pollutantsmayalsoplayarole.[35]
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Genetics
Mostcasesofdiabetesinvolvemanygenes,witheachbeingasmallcontributortoanincreasedprobabilityofbecomingatype2diabetic.[19]Ifoneidenticaltwin
hasdiabetes,thechanceoftheotherdevelopingdiabeteswithinhislifetimeisgreaterthan90%,whiletheratefornonidenticalsiblingsis2550%.[7]Asof2011,
morethan36geneshadbeenfoundthatcontributetotheriskoftype2diabetes.[36]Allofthesegenestogetherstillonlyaccountfor10%ofthetotalheritable
componentofthedisease.[36]TheTCF7L2allele,forexample,increasestheriskofdevelopingdiabetesby1.5timesandisthegreatestriskofthecommongenetic
variants.[7]Mostofthegeneslinkedtodiabetesareinvolvedinbetacellfunctions.[7]
Thereareanumberofrarecasesofdiabetesthatariseduetoanabnormalityinasinglegene(knownasmonogenicformsofdiabetesor"otherspecifictypesof
diabetes").[7][19]Theseincludematurityonsetdiabetesoftheyoung(MODY),Donohuesyndrome,andRabsonMendenhallsyndrome,amongothers.[19]Maturity
onsetdiabetesoftheyoungconstitute15%ofallcasesofdiabetesinyoungpeople.[37]
Medicalconditions
Thereareanumberofmedicationsandotherhealthproblemsthatcanpredisposetodiabetes.[38]Someofthemedicationsinclude:glucocorticoids,thiazides,beta
blockers,atypicalantipsychotics,[39]andstatins.[40]Thosewhohavepreviouslyhadgestationaldiabetesareatahigherriskofdevelopingtype2diabetes.[22]Other
healthproblemsthatareassociatedinclude:acromegaly,Cushing'ssyndrome,hyperthyroidism,pheochromocytoma,andcertaincancerssuchas
glucagonomas.[38]Testosteronedeficiencyisalsoassociatedwithtype2diabetes.[41][42]
Pathophysiology
Type2diabetesisduetoinsufficientinsulinproductionfrombetacellsinthesettingofinsulinresistance.[7]Insulinresistance,whichistheinabilityofcellsto
respondadequatelytonormallevelsofinsulin,occursprimarilywithinthemuscles,liver,andfattissue.[43]Intheliver,insulinnormallysuppressesglucose
release.However,inthesettingofinsulinresistance,theliverinappropriatelyreleasesglucoseintotheblood.[19]Theproportionofinsulinresistanceversusbeta
celldysfunctiondiffersamongindividuals,withsomehavingprimarilyinsulinresistanceandonlyaminordefectininsulinsecretionandotherswithslightinsulin
resistanceandprimarilyalackofinsulinsecretion.[7]
Otherpotentiallyimportantmechanismsassociatedwithtype2diabetesandinsulinresistanceinclude:increasedbreakdownoflipidswithinfatcells,resistanceto
andlackofincretin,highglucagonlevelsintheblood,increasedretentionofsaltandwaterbythekidneys,andinappropriateregulationofmetabolismbythe
centralnervoussystem.[19]However,notallpeoplewithinsulinresistancedevelopdiabetes,sinceanimpairmentofinsulinsecretionbypancreaticbetacellsis
alsorequired.[7]
Diagnosis
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TheWorldHealthOrganizationdefinitionofdiabetes(both
type1andtype2)isforasingleraisedglucosereadingwith
symptoms,otherwiseraisedvaluesontwooccasions,of
either:[46]
fastingplasmaglucose7.0mmol/l(126mg/dl)
or
withaglucosetolerancetest,twohoursaftertheoral
doseaplasmaglucose11.1mmol/l(200mg/dl)
Condition
WHOdiabetesdiagnosticcriteria[44][45]
2hourglucose
Fastingglucose
HbA1c
Unit
mmol/l(mg/dl)
mmol/l(mg/dl)
mmol/mol DCCT%
Normal
<7.8(<140)
<6.1(<110)
<42
<6.0
Impairedfastingglycaemia
<7.8(<140)
6.1(110)&<7.0(<126)
4246
6.06.4
Impairedglucosetolerance
7.8(140)
<7.0(<126)
4246
6.06.4
Diabetesmellitus
11.1(200)
7.0(126)
48
6.5
Arandombloodsugarofgreaterthan11.1mmol/l
(200mg/dL)inassociationwithtypicalsymptoms[22]oraglycatedhemoglobin(HbA1c)of48mmol/mol(6.5DCCT%)isanothermethodofdiagnosing
diabetes.[19]In2009anInternationalExpertCommitteethatincludedrepresentativesoftheAmericanDiabetesAssociation(ADA),theInternationalDiabetes
Federation(IDF),andtheEuropeanAssociationfortheStudyofDiabetes(EASD)recommendedthatathresholdof48mmol/mol(6.5DCCT%)shouldbe
usedtodiagnosediabetes.[47]ThisrecommendationwasadoptedbytheAmericanDiabetesAssociationin2010.[48]Positivetestsshouldberepeatedunlessthe
personpresentswithtypicalsymptomsandbloodsugars>11.1mmol/l(>200mg/dl).[47]
Thresholdfordiagnosisofdiabetesisbasedontherelationshipbetweenresultsofglucosetolerancetests,fastingglucoseorHbA1candcomplicationssuchas
retinalproblems.[19]Afastingorrandombloodsugarispreferredovertheglucosetolerancetest,astheyaremoreconvenientforpeople.[19]HbA1chasthe
advantagesthatfastingisnotrequiredandresultsaremorestablebuthasthedisadvantagethatthetestismorecostlythanmeasurementofbloodglucose.[49]Itis
estimatedthat20%ofpeoplewithdiabetesintheUnitedStatesdonotrealizethattheyhavethedisease.[19]
Diabetesmellitustype2ischaracterizedbyhighbloodglucoseinthecontextofinsulinresistanceandrelativeinsulindeficiency.[50]Thisisincontrasttodiabetes
mellitustype1inwhichthereisanabsoluteinsulindeficiencyduetodestructionofisletcellsinthepancreasandgestationaldiabetesmellitusthatisanewonset
ofhighbloodsugarsassociatedwithpregnancy.[7]Type1andtype2diabetescantypicallybedistinguishedbasedonthepresentingcircumstances.[47]Ifthe
diagnosisisindoubtantibodytestingmaybeusefultoconfirmtype1diabetesandCpeptidelevelsmaybeusefultoconfirmtype2diabetes,[51]withCpeptide
levelsnormalorhighintype2diabetes,butlowintype1diabetes.[52]
Screening
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Nomajororganizationrecommendsuniversalscreeningfordiabetesasthereisnoevidencethatsuchaprogramimproveoutcomes.[53][54]Screeningis
recommendedbytheUnitedStatesPreventiveServicesTaskForce(USPSTF)inadultswithoutsymptomswhosebloodpressureisgreaterthan135/80mmHg.[55]
Forthosewhosebloodpressureisless,theevidenceisinsufficienttorecommendfororagainstscreening.[55]Thereisnoevidencethatitchangestheriskofdeath
inthisgroupofpeople.[56]Theyalsorecommendscreeningamongthosewhoareoverweightandbetweentheagesof40and70.[57]
TheWorldHealthOrganizationrecommendstestingthosegroupsathighrisk[53]andin2014theUSPSTFisconsideringasimilarrecommendation.[58]Highrisk
groupsintheUnitedStatesinclude:thoseover45yearsoldthosewithafirstdegreerelativewithdiabetessomeethnicgroups,includingHispanics,African
Americans,andNativeAmericansahistoryofgestationaldiabetespolycysticovarysyndromeexcessweightandconditionsassociatedwithmetabolic
syndrome.[22]TheAmericanDiabetesAssociationrecommendsscreeningthosewhohaveaBMIover25(inpeopleofAsiandescentscreeningisrecommending
foraBMIover23.[59]
Prevention
Onsetoftype2diabetescanbedelayedorpreventedthroughpropernutritionandregularexercise.[60][61]Intensivelifestylemeasuresmayreducetheriskbyover
half.[23][62]Thebenefitofexerciseoccursregardlessoftheperson'sinitialweightorsubsequentweightloss.[63]Highlevelsofphysicalactivityreducetheriskof
diabetesbyabout28%.[64]Evidenceforthebenefitofdietarychangesalone,however,islimited,[65]withsomeevidenceforadiethighingreenleafy
vegetables[66]andsomeforlimitingtheintakeofsugarydrinks.[31]Inthosewithimpairedglucosetolerance,dietandexerciseeitheraloneorincombinationwith
metforminoracarbosemaydecreasetheriskofdevelopingdiabetes.[23][67]Lifestyleinterventionsaremoreeffectivethanmetformin.[23]WhilelowvitaminD
levelsareassociatedwithanincreasedriskofdiabetes,correctingthelevelsbysupplementingvitaminD3doesnotimprovethatrisk.[68]
Management
Managementoftype2diabetesfocusesonlifestyleinterventions,loweringothercardiovascularriskfactors,andmaintainingbloodglucoselevelsinthenormal
range.[23]Selfmonitoringofbloodglucoseforpeoplewithnewlydiagnosedtype2diabetesmaybeusedincombinationwitheducation,[69]howeverthebenefitof
selfmonitoringinthosenotusingmultidoseinsulinisquestionable.[23][70]Inthosewhodonotwanttomeasurebloodlevels,measuringurinelevelsmaybe
done.[69]Managingothercardiovascularriskfactors,suchashypertension,highcholesterol,andmicroalbuminuria,improvesaperson'slifeexpectancy.[23]
Decreasingthesystolicbloodpressuretolessthan140mmHgisassociatedwithalowerriskofdeathandbetteroutcomes.[71]Intensivebloodpressure
management(lessthan130/80mmHg)asopposedtostandardbloodpressuremanagement(lessthan140/85100mmHg)resultsinaslightdecreaseinstrokerisk
butnoeffectonoverallriskofdeath.[72]
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Intensivebloodsugarlowering(HbA1c<6%)asopposedtostandardbloodsugarlowering(HbA1cof77.9%)doesnotappeartochangemortality.[73][74]Thegoal
oftreatmentistypicallyanHbA1cofaround7%orafastingglucoseoflessthan7.2mmol/L(130mg/dL)howeverthesegoalsmaybechangedafterprofessional
clinicalconsultation,takingintoaccountparticularrisksofhypoglycemiaandlifeexpectancy.[75][59]Itisrecommendedthatallpeoplewithtype2diabetesget
regularophthalmologyexamination.[7]Treatinggumdiseaseinthosewithdiabetesmayresultinasmallimprovementinbloodsugarlevels.[76]
Lifestyle
Aproperdietandexercisearethefoundationsofdiabeticcare,[22]withagreateramountofexerciseyieldingbetterresults.[77]Aerobicexerciseleadstoadecrease
inHbA1candimprovedinsulinsensitivity.[77]Resistancetrainingisalsousefulandthecombinationofbothtypesofexercisemaybemosteffective.[77]Adiabetic
dietthatpromotesweightlossisimportant.[78]Whilethebestdiettypetoachievethisiscontroversial,[78]alowglycemicindexdietorlowcarbohydratediethas
beenfoundtoimprovebloodsugarcontrol.[79][80]Culturallyappropriateeducationmayhelppeoplewithtype2diabetescontroltheirbloodsugarlevels,forupto
sixmonthsatleast.[81]Ifchangesinlifestyleinthosewithmilddiabeteshasnotresultedinimprovedbloodsugarswithinsixweeks,medicationsshouldthenbe
considered.[22]ThereisnotenoughevidencetodetermineiflifestyleinterventionsaffectmortalityinthosewhoalreadyhaveDM2.[62]Vegetariandietsingeneral
havebeenrelatedtolowerdiabetesrisk,butdonotofferadvantagescomparedwithdietswhichallowmoderateamountsofanimalproducts.[82]
Medications
Thereareseveralclassesofantidiabeticmedicationsavailable.Metforminisgenerallyrecommendedasa
firstlinetreatmentasthereissomeevidencethatitdecreasesmortality[9][23][83]however,thisconclusionis
questioned.[84]Metforminshouldnotbeusedinthosewithseverekidneyorliverproblems.[22]
Asecondoralagentofanotherclassorinsulinmaybeaddedifmetforminisnotsufficientafterthree
months.[75]Otherclassesofmedicationsinclude:sulfonylureas,thiazolidinediones,dipeptidylpeptidase4
inhibitors,SGLT2inhibitors,andglucagonlikepeptide1analog.[75]Thereisnosignificantdifference
betweentheseagents.[75]Rosiglitazone,athiazolidinedione,hasnotbeenfoundtoimprovelongterm
outcomeseventhoughitimprovesbloodsugarlevels.[85]Additionallyitisassociatedwithincreasedratesof
heartdiseaseanddeath.[86]Angiotensinconvertingenzymeinhibitors(ACEIs)preventkidneydiseaseand
improveoutcomesinthosewithdiabetes.[87][88]Thesimilarmedicationsangiotensinreceptorblockers
(ARBs)donot.[88]A2016reviewrecommendedtreatingtoasystolicbloodpressureof140to150
mmHg.[89]
Metformin500mgtablets.
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Injectionsofinsulinmayeitherbeaddedtooralmedicationorusedalone.[23]Mostpeopledonotinitiallyneedinsulin.[7]Whenitisused,alongacting
formulationistypicallyaddedatnight,withoralmedicationsbeingcontinued.[22][23]Dosesarethenincreasedtoeffect(bloodsugarlevelsbeingwell
controlled).[23]Whennightlyinsulinisinsufficient,twicedailyinsulinmayachievebettercontrol.[22]Thelongactinginsulinsglargineanddetemirareequally
safeandeffective,[90]anddonotappearmuchbetterthanneutralprotamineHagedorn(NPH)insulin,butastheyaresignificantlymoreexpensive,theyarenot
costeffectiveasof2010.[91]Inthosewhoarepregnantinsulinisgenerallythetreatmentofchoice.[22]
Surgery
Weightlosssurgeryinthosewhoareobeseisaneffectivemeasuretotreatdiabetes.[92]Manyareabletomaintainnormalbloodsugarlevelswithlittleorno
medicationsfollowingsurgery[93]andlongtermmortalityisdecreased.[94]Therehoweverissomeshorttermmortalityriskoflessthan1%fromthesurgery.[95]
Thebodymassindexcutoffsforwhensurgeryisappropriatearenotyetclear.[94]Itisrecommendedthatthisoptionbeconsideredinthosewhoareunabletoget
boththeirweightandbloodsugarundercontrol.[96][97]
Epidemiology
Globallyasof2010itwasestimatedthattherewere285millionpeoplewithtype2diabetesmakingupabout90%ofdiabetescases.[19]Thisisequivalenttoabout
6%oftheworld'sadultpopulation.[98]Diabetesiscommonbothinthedevelopedandthedevelopingworld.[19]Itremainsuncommon,however,inthe
underdevelopedworld.[7]
Womenseemtobeatagreaterriskasdocertainethnicgroups,[19][99]suchasSouthAsians,PacificIslanders,Latinos,andNativeAmericans.[22]Thismaybedue
toenhancedsensitivitytoaWesternlifestyleincertainethnicgroups.[100]Traditionallyconsideredadiseaseofadults,type2diabetesisincreasinglydiagnosedin
childreninparallelwithrisingobesityrates.[19]Type2diabetesisnowdiagnosedasfrequentlyastype1diabetesinteenagersintheUnitedStates.[7]
Ratesofdiabetesin1985wereestimatedat30million,increasingto135millionin1995and217millionin2005.[15]Thisincreaseisbelievedtobeprimarilydue
totheglobalpopulationaging,adecreaseinexercise,andincreasingratesofobesity.[15]Thefivecountrieswiththegreatestnumberofpeoplewithdiabetesasof
2000areIndiahaving31.7million,China20.8million,theUnitedStates17.7million,Indonesia8.4million,andJapan6.8million.[101]Itisrecognizedasaglobal
epidemicbytheWorldHealthOrganization.[102]
History
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Diabetesisoneofthefirstdiseasesdescribed[20]withanEgyptianmanuscriptfromc.1500BCEmentioning
"toogreatemptyingoftheurine."[103]Thefirstdescribedcasesarebelievedtobeoftype1diabetes.[103]
Indianphysiciansaroundthesametimeidentifiedthediseaseandclassifieditasmadhumehaorhoneyurine
notingthattheurinewouldattractants.[103]Theterm"diabetes"or"topassthrough"wasfirstusedin
230BCEbytheGreekApolloniusOfMemphis.[103]ThediseasewasrareduringthetimeoftheRoman
empirewithGalencommentingthathehadonlyseentwocasesduringhiscareer.[103]
Type1andtype2diabeteswereidentifiedasseparateconditionsforthefirsttimebytheIndianphysicians
SushrutaandCharakain400500ADwithtype1associatedwithyouthandtype2withbeing
overweight.[103]Theterm"mellitus"or"fromhoney"wasaddedbytheBritonJohnRolleinthelate1700sto
separatetheconditionfromdiabetesinsipiduswhichisalsoassociatedwithfrequenturination.[103]Effective
treatmentwasnotdevelopeduntiltheearlypartofthe20thcenturywhentheCanadiansFrederickBanting
andCharlesBestdiscoveredinsulinin1921and1922.[103]Thiswasfollowedbythedevelopmentofthelong
actingNPHinsulininthe1940s.[103]
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Prevalenceofdiabetesworldwidein2000.World
averagewas28per1000inhabitants.
nodata
4552.5
7.5
52.560
7.515
6067.5
1522.5
67.575
22.530
7582.5
3037.5
82.5
37.545
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CentersforDiseaseControl(Endocrinepathology)(http://www.cdc.gov/diabetes/)
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