The past 200 years in diabetes.

Copyright © 2012 Massachusetts Medical Society. Diabetes was first recognized around 1500 b.c.e. by the ancient Egyptians, who considered it a rare condition in which a person urinated excessively and lost weight. The term diabetes mellitus, reflecting the fact that the urine of those affected had a sweet taste, was first used by the Greek physician Aretaeus, who lived from about 80 to 138 c.e. It was not until 1776, however, that Matthew Dobson actually measured the concentration of glucose in the urine of such patients and found it to be increased.1 Diabetes was a recognized clinical entity when the New England Journal of Medicine and Surgery was founded in 1812. Its prevalence at the time was not documented, and essentially nothing was known about the mechanisms responsible for the disease. No effective treatment was available, and diabetes was uniformly fatal within weeks to months after its diagnosis owing to insulin deficiency. In the intervening 200 years, major fundamental advances have been made in our understanding of the underlying causes of diabetes and the approach to its prevention and treatment (see timeline, available with the full text of this article at NEJM.org). Although diabetes is still associated with a reduced life expectancy, the outlook for patients with this disease has improved dramatically, and patients usually lead active and productive lives for many decades after the diagnosis has been made. Many effective therapies are available for treating hyperglycemia and its complications. The study of diabetes and related aspects of glucose metabolism has been such fertile ground for scientific inquiry that 10 scientists have received the Nobel Prize for diabetes-related investigations since 1923 (Table 1). Thus, as a result of the efforts of the past 200 years, there is much good news to report regarding diabetes. Ironically, although scientific advances have led to effective strategies for preventing diabetes, the pathway to cure has remained elusive. In fact, if one views diabetes from a public health and overall societal standpoint, little progress has been made toward conquering the disease during the past 200 years, and we are arguably worse off now than we were in 1812. Two centuries ago, severe insulin deficiency dominated the clinical presentation of diabetes. Although it is possible that some people had milder forms of hyperglycemia at that time, they largely escaped clinical detection. In 2012, the commonly encountered spectrum of diabetes is quite different. Although severe insulin deficiency still occurs, it now accounts for only about 10% of cases overall and can be readily treated with insulin. The vast majority of patients with diabetes are overweight and have a combination of insulin resistance and impaired insulin secretion. The prevalence of this form of diabetes has been increasing dramatically, particularly in the past three to four decades, resulting in a worldwide epidemic that has made diabetes one of the most common and most serious medical conditions humankind has had to face. A timeline is available at NEJM.org