Type 2 Diabetes: Why We Are Winning the Battle but Losing the War? 2015 Kelly West Award Lecture

Diabetes is among the biggest of the 21st-century global health challenges. In the U.S. and other high-income countries, thanks to investments in science, dedication to implementing these findings, and measurement of quality of care, there have been improvements in diabetes management and declines in rate of diabetes complications and mortality. This good news, however, is overshadowed by the ever-increasing absolute numbers of people with diabetes and its complications and the unprecedented growth of diabetes in low- and middle-income countries of the world. To comprehensively win the war against diabetes requires 1) concerted attention to prevention and 2) expansion of global research to better inform population-level policies to curb diabetes but also to better understand individual- and population-level variations in pathophysiology and phenotypes globally so that prevention and treatment can be tailored. For example, preliminary data show that thin people in low- and middle-income countries such as India commonly experience type 2 diabetes. Global studies comparing these thin Asian Indians with other high-risk groups such as Pima Indians, a population with a high mean BMI, suggest that type 2 diabetes may not be a single pathophysiological entity. Pima Indians may represent the well-studied phenotype of poor insulin action (type 2A), whereas Asian Indians represent the grossly understudied phenotype of poor insulin secretion (type 2B). This has major implications for diagnosis, prevention, and treatment and highlights the mismatch between where diabetes burdens occur (i.e., low- and middle-income countries) and where research happens (i.e., high-income countries). Correcting this imbalance will advance our knowledge and arsenal to win the global war against diabetes.