7th DIETS/EFAD Conference

Type 2 Diabetes:

the pandemic waiting to happen

Cathy Breen EFAD ESDN Diabetes Lead/Irish Nutrition and Dietetic Institute/

Endocrine Unit, St Columcille’s Hospital, Loughlinstown, Co Dublin, Ireland

Garda, Italy. November 8th, 2013

©, 2013

Type 2 Diabetes: the pandemic waiting

to happen?

Pandemic

Extensively epidemic (Steadmans Medical Dictionary, 28th Ed)

An infectious epidemic

occurring worldwide or

over a very wide area,

crossing international

boundaries, and usually

affecting a large number of

people (Wikipedia, 2013)

Waiting to happen?

IDF, 2012

IDF, 2012

Prevalence: Europe

Diabetes Prevalence in 2000 vs. 2030

Over 430 million cases predicted by 2030

Age-Adjusted Prevalence of Diagnosed Diabetes Among

U.S. Adults Aged 18 Years or older

1994 2000

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at

http://www.cdc.gov/diabetes/statistics

2010

Why the explosion?

Risk factors for Type 2 diabetes

WHO, 2011

Diabesity?

Type 2 diabetes ↔ Obesity

~80% of adults with T2 diabetes are overweight / obese (McLaughlin,

2007)

Age-Adjusted Prevalence of Obesity and Diagnosed

Diabetes Among U.S. Adults Aged 18 Years or older

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at

http://www.cdc.gov/diabetes/statistics

2010

2010

Diabesity

Adipose tissue drives insulin resistance and

hyperglycaemia

Rosen & Spiegelman, 2006

Type 2 diabetes: why worry?

Costs

Quality of life

Burden of diabetes

Complications / co-morbidities

Monetary

Overburdened health care

systems

IDF, 2012

Diabetes and quality of life/health status

Solli, 2010

AIHF, from AUSDiab Study 1999-2000

Diabetes complications

Monetary costs

Kanavos, 2012

Type 2 diabetes (dietary) management

Glycaemic control → carbohydrate quantity & quality

Weight loss → calories

Lipid management → saturated vs. unsaturated fat

Blood pressure management → salt / alcohol

Overall dietary quality → fruit & veg, fibre

Low calorie,

higher fibre

diet, lower

GL diet

• Structured diabetes education + patient empowerment

• Individualised, supportive approach

• Intense review as part of a behavioural lifestyle intervention (MDT approach)

Individualising

macronutrient

composition

Low fat diet

+ lipase

inhibitors

Meal

replacement Bariatric

surgery

Very low

calorie

diets

CALORIE RESTRICTION

Dietary approaches in Type 2 diabetes

Evidence for:

Low fat diets, low carbohydrate diets, high protein diets

Low glycaemic index/load diets

Mediterranean diet

Meal replacements

Very low calorie diets

“The true application of research findings can usually be found in the

author’s description of the participants’ usual diet before randomization.

The red meats, salty snacks, and sweets participants typically ate were

replaced with lower-fat protein sources, lower-fat dairy, whole grains—

fewer empty-calorie foods in place of more nutrient-dense foods” (Perry,

2005)

What do our patients want? Food based recommendations that can be easily

understood and translated into everyday life

It works!

Structured dietetic-led diabetes education programmes

ROMEO (Italy): Dietitian-led T2DM groups significantly improved

outcomes compared to a medically and pedagogically-led group (Trento, 2008)

X-PERT (UK): Improved HbA1c (-0.6 vs. -0.1%), weight (-0.5 vs.

1.1kg) + improved diabetes knowledge + fruit/veg intake (Deakin, 2006)

Intense lifestyle interventions

e.g. LookAhead

4 years:

Weight -6.2 v.s -0.88% (P <0.001)

Significantly better HbA1c, fitness,

BP, HDL, TAG

Gregg, 2012

EASD/ADA Guidelines

But

where is

the

emphasis

really?

Benefits of modest weight loss in Type 2

diabetes

1Anderson, 2001; 2Anderson, 2003

Key messages for clinical practice

1. Focus on calorie restriction, portion control + weight

management

2. Think more ‘algorithmically’ i.e. individualise approaches

and change the approach if it’s not working

Is it cost effective?

Lifestyle interventions? Yes, probably, at least in the shorter

term (Jacobs Van der Bruggen, 2009; DPP, 2012)

Report commissioned by the Dutch Association of Dietitians

in 2012 (ICAN Study):

For every €1 spend on dietary counseling, society gets a net €14 -

63 in return: €56 in terms of improved health, €3 net savings in

total health care costs and €4 in terms of productivity gains.

Need to gather more diverse data routinely

Less medication usage, improved dietary quality, improved quality of

life, less hospital admissions, less A&E visits, less hypoglycaemia, less

work absenteeism, reduced rates of progression to complications

IMAGE Work package 4 – Subgroup 3: Guideline Nutrition

Preventing Type 2 diabetes: the simple things

work

1. Weight loss (5-10%)

2. Reduce fat intake (<30%)

3. Reduce saturated fat intake

(<10%)

4. Increase fibre intake

(>15g/1000kcals)

5. Increase activity

(>4hrs/week)

Tuomilehto et al, NEJM, 2001

Dietitians as uniquely qualified leaders in

Type 2 diabetes treatment and prevention

Working in primary & secondary health care, public & private sector, industry, administrative, education & research settings

Unique knowledge and skill set relating to food and clinical nutrition

Uniquely qualified to match the approach to the client

Advanced behaviour change skills

Clinically effective

Inherent value placed on best practice that underpins all approaches

Code of professional practice

Commitment to CPD/LLL

Expertise in audit & research

Unified public health message

Unique insight & capacity to deliver high quality, evidence-based, patient-centred approaches to the management and prevention

of Type 2 diabetes

Dietitians know best!

We understand the complex challenges that our patients

face when trying to manage their diabetes within an

increasingly obesogenic environment and overburdened

health care systems.

Clinical ↔ public health

Health 2020

Health2020 makes the case for investment in health and aims

to support action across government and society to improve

the health and well-being of populations and strengthen public

health.

Tackling Europe’s major disease burdens, including diabetes, is a

priority area within the policy.

This will require coordinated public health action and health

care system interventions, which must be underpinned by

supportive environments.

Innovation and leadership for health are at the core of Health

2020, and it encourages all stakeholders to take on new

responsibility and accountability for population health.

What we can do This provides an opportunity for dietitians, as specialists with a

unique insight and professional expertise in the area, to take

leadership roles in developing local and national public health

policies that support the aims of Health2020 for a healthier

society that will reduce the burden of type 2 diabetes.

Local, national, international diabetes advocacy groups

Local / national diabetes service planning / steering committees

Global Diabetes Survey

We can be a strong voice about what needs to change…

Health in all policies approach

Environmental planning

Food marketing

Unhealthy food taxation vs. healthy food subsidies

We’ve been here before….

Plague

Matthews, 2011 Thanks to Illona Kickbush, OECD

“Bubonic plague could not

be stopped by wishing

that the population were

less degenerate”

“There is no public outrage that

governments legislate to protect

through legislation in other contexts

e.g. seatbelts, fire escapes, crash

barriers. Yet startlingly few public health

policies are in place to protect us from

excess calorie consumption ”