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Worldwide, the estimated prevalence of diabetes for all age groups was 2.8% in the year 2000 and will be 4.4% in the year 2030.1 As a consequence, the total number of people affected from this condition is expected to double during the same period, from 171 million to 366 million. Within the United States, according to the American Diabetes Association (ADA), diabetes affected 20.6 million people in 2005, corresponding to 9.6% of all individuals older than 20 years of age.2 In that same year, 1.5 million new cases of diabetes were diagnosed. Importantly, in approximately one third of affected individuals, the condition remains unrecognized.2 With respect to gender, half of those affected are women.3 In 2004, the U.S. Department of Health and Human Services (USDHHS) estimated that approximately 40% of U.S. adults aged 40 to 74 years, or 41 million people, had prediabetes, a glucose metabolic disturbance predisposing to overt diabetes, heart disease, and stroke.3 Diabetes was the sixth leading cause of death listed on U.S. death certificates in 2002.2 Most likely, this number greatly underestimates the impact of this condition, because it has been demonstrated that diabetes is rarely reported as the cause of death. Adults with diabetes have a two- to fourfold higher CV death rate than nondiabetic individuals. With respect to gender, the adjusted risk of CV death among men is three times higher than in nondia-betic individuals, while in diabetic women the risk is up to six times higher.4 Whereas the U.S. age-adjusted mortality rates of other major multifactorial diseases (e.g., heart disease, stroke, cancer) have declined or remained stable over the last 20 years, the diabetes "epidemic" has led to a 30% increase in diabetes-related deaths in the same time span (Fig. 2-1).5 The total estimated cost of diabetes in the United States in 2002 was $132 billion, comprising $92 billion for direct medical costs and $40 billion for indirect costs (e.g., disability, work loss, premature mortality). Total health care costs associated with this condition are expected to rise to $192 billion by the year 2020.6

The diagnostic criteria for diabetes recommended by the ADA are presented in Table 2-1. In the absence of unequivocal hyperglycemia, one of these criteria must be confirmed on a subsequent day to establish the diagnosis. Although the plasma level of hemoglobin A1c (HbA1c) reflects mean plasma glucose concentrations over the preceding 2 to 3 months, the use of this parameter for the diagnosis of diabetes is currently not recommended.7 Before the development of diabetes, subjects pass through a stage of impaired glucose metabolism characterized by impaired fasting glucose (IFG) levels or impaired glucose tolerance (IGT) (see Table 2-1). These two metabolic disturbances predispose to diabetes and CVD and were recently grouped in the term prediabetes. A cluster of lipid and non-lipid risk factors of metabolic origin mediated by insulin resistance, such as pathologic glucose metabolism, obesity, hypertension, and dyslipidemia, was designated the metabolic

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1980 1982 1984 1986 1988 1990 1992 1994 1996

Figure 2-1. Increase in age-adjusted diabetes mellitus-related mortality in the United States between 1980 and 1996. (From McKinlay J, Marceau L: US public health and the 21st century: Diabetes mellitus. Lancet 2000;356:757-761.)

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1980 1982 1984 1986 1988 1990 1992 1994 1996

Figure 2-1. Increase in age-adjusted diabetes mellitus-related mortality in the United States between 1980 and 1996. (From McKinlay J, Marceau L: US public health and the 21st century: Diabetes mellitus. Lancet 2000;356:757-761.)

syndrome. Several organizations have proposed definitions of the metabolic syndrome that differ not only in the set of criteria included but also in the cutoff values used to define the presence or absence of an individual component of the syndrome (Table 2-2). However, both the concept and the clinical utility of the metabolic syndrome were recently critically appraised.8

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