Insulin Therapy in Type 2 Diabetes Mellitus

The worldwide burden of diabetes continues to increase at an alarming rate, with the latest statistics from the US Centers for Disease Control showing an 11.3% incidence of diabetesand35%for prediabetes in adult Americans. Also, the InternationalDiabetes Federation predicts that the global incidence will increase from 366 million currently to 552 million in 2030, with developing nations particularly affected. The increase is multifactorial:most obviousare thediet and lifestyle changes that accompanyWesternization, but genetic variances, inadequate prenatal care or childhood malnutrition predisposing to obesity or diabetes later in life, gastrointestinal microflora-related immunologic and metabolic effects, food additives, and environmental toxins are all active research topics. Furthermore, epidemiologic studies have shown that persons with type 2 diabetes have a higher incidence than the general population of numerous other serious health problems. So it is not a surprise that the worldwide threat posed by type 2 diabetes and other noncommunicable diseases is viewed as potentially cataclysmic. The strategy to counter the threat is to optimize health care through early diagnosis and treatment algorithms and standards of care. Although there has been considerable discussion of late about treatment guidelines because of recent disappointing highly publicized large clinical trials (see the review by Yuen and Riddle elsewhere in this issue), the consensus continues to be that there is compelling evidence for the benefits of intensive blood glucose control (usually defined by an A1c value of less than 7%) for prevention of diabetes complications in most patients with type 2 diabetes. One can argue that the legacy effect against macrovascular and microvascular complications still present many years after completion of the Steno 2 and United Kingdom Prospective Diabetes Study (UKPDS) trials in type 2 diabetes, and