Too many notes: up and down the scales of diabetes therapy.

I N T R O D U C T I O N The World Health Organization estimates that 194 million people worldwide have diabetes and that this number will grow to 333 million by the year 2025-a 72% increase in the next 2 decades. The greatest increase in diabetes is predicted for developing count r ies-whereas the diabetic population of North America is predicted to grow by 57%, this population is predicted to increase by 79% to 10g% in Southeast Asian and West Pacific nations. 1 In parallel with the increase in diabetes is the explosion in the incidence of obesity and the metabolic syndrome. In the United States alone, an estimated 40% of adults have the metabolic syndrome (defined as an increase in abdominal girth of >35 inches in females and 40 inches in males, combined with triglycerides >150 mg/dL, high-density lipoprotein cholesterol [HDL-C] 130/g5 mm Hg. 2 By the time the average American is 65 years of age, it is estimated that he or she has a 50% chance of developing the metabolic syndrome. Although some argue that there is no such disease, none would deny that the constellation of features that comprise the metabolic syndrome increases the relative risk of macrovascular events by 1.65 and of diabetes by 2.99. 3 What is driving this dual epidemic? Clearly, there are major issues with regard to lifestyle or the "malnutrition of affluence," slothfulness, and gluttony. In the United States, 15% of our children are overweight, which translates to 6 million overweight kids! Type 2 diabetes mellitus (DM) now exceeds type 1 in children. Two of 3 children have one element of the metabolic syndrome and 10% have the syndrome in their teens. Of the children born today, 1 in 3 is destined to become diabetic and their life expectancy is <30 years; 47% of children with diabetes already have neuropathic complications. 4,5 The average American child watches television 4 hours per day, and while exercise has disappeared from the curriculum, McDonald's has opened stores in many schools, hospitals, and other public buildings. Food portions have been distorted by supersizing, a notion so successful that its popularity has led to the supersizing of the American population and, unfortunately, exporting this concept to the rest of the world. My son lives on a small island in the Pacific, which is reached by ferry from Hong Kong. At the dock of this little island, large neon signs light up the familiar names of McDonald's, Burger King, and 7-Eleven. There is no doubt that our newest weapons of mass destruction are spoons, forks, and knives-delivering "bombs" into the mouths of our children as well as to the rest of the world. The Diabetes Prevention Program (DPP) has taught us that with therapeutic lifestyle changes (TLC), we could reduce the conversion of impaired glucose tolerance (IGT) to diabetes by 58%, 6 and the Nurses' Health Study observed that over a lifetime, as little as a 3% increase in weight conferred a 21g% increase in the risk of developing diabetes. 7 Other authors have reported that for every kilogram gained over a lifetime, there is a doubling of the risk of developing diabetes, s Compounding the problem is a progressive reduction in physical activity, so that by 17 years of age, the average young black woman does no exercise at all. In the face of this deluge that is descending on us, what are we offering people with diabetes and those destined to develop it? Regretfully, we are failing miserably. The risk factors for developing diabetes are: (1) family history of diabetes (ie, parents or siblings with diabetes); (2) overweight; (3) habitual physical inac-