The Global EpidemicsThe Global Epidemicsof Obesity & Diabetesof Obesity & Diabetes

Paul W. Ladenson, M.D.Paul W. Ladenson, M.D.

JHI Partners Forum 2012JHI Partners Forum 2012October 2, 2012October 2, 2012

BaltimoreBaltimore

The Obesity & Diabetes EpidemicsThe Obesity & Diabetes Epidemics

AimsAims• Describe relationship between Describe relationship between

overweight/obesity and diabetes from overweight/obesity and diabetes from epidemiological and biological perspectivesepidemiological and biological perspectives

• Review lifestyle, public policy, medical and Review lifestyle, public policy, medical and surgical interventionssurgical interventions

• Depict certain diabetes prevention and Depict certain diabetes prevention and management programs currently offered by management programs currently offered by Johns Hopkins Medicine InternationalJohns Hopkins Medicine International

Global Diabetes PrevalencesGlobal Diabetes Prevalences

Estimated 346 million individuals affected worldwideEstimated 346 million individuals affected worldwide

Highest diabetes prevalencesHighest diabetes prevalences-NauruNauru-United Arab EmiratesUnited Arab Emirates-Saudi ArabiaSaudi Arabia

Lowest diabetes prevalencesLowest diabetes prevalences-MongoliaMongolia-RwandaRwanda-IcelandIceland

Death rates from diabetes and its complications Death rates from diabetes and its complications are higher in low- and middle-income countriesare higher in low- and middle-income countries

The Diabetes EpidemicThe Diabetes Epidemic

Predisposing FactorsPredisposing Factors• ObesityObesity

– Worldwide 500 million adults ≥20 years old obese Worldwide 500 million adults ≥20 years old obese

– Highest worldwide prevalences: Nauru, Tonga, Highest worldwide prevalences: Nauru, Tonga, Cook Island, and MicronesiaCook Island, and Micronesia

– U.S. ranked 5U.S. ranked 5thth highest in male obesity (44%) and highest in male obesity (44%) and 1212thth highest in female obesity (48%) highest in female obesity (48%)

• Body fat distributionBody fat distribution

• Race/Ethnicity Race/Ethnicity

• Environmental/Lifestyle Environmental/Lifestyle

Diabetes Prevalence by Race/EthnicityDiabetes Prevalence by Race/Ethnicity

0

2

4

6

8

10

12

14

Non-Hispanic White

Asian Americans Hispanic/Latino Non-Hispanic Black

Perc

en

tag

e (

%)

Perc

en

tag

e (

%)

7%7%8%8%

12%12% 13%13%

8% Cuban, Central, 8% Cuban, Central, South South AmericanAmerican14% Mexican American14% Mexican American14% Puerto Rican 14% Puerto Rican American American

Centers for Disease Control, National Diabetes Fact Sheet, 2011Centers for Disease Control, National Diabetes Fact Sheet, 2011

• In general, In general, Asians develop Asians develop diabetes at diabetes at lower BMI than lower BMI than Caucasians Caucasians

• Considerable Considerable variation variation among Asian among Asian groupsgroups

KH, Yoon et al. Lancet. 2006; 368: 1681-1688.

The Overweight-Diabetes Relationship The Overweight-Diabetes Relationship Varies by Race/EthnicityVaries by Race/Ethnicity

Race/Ethnic Differences Race/Ethnic Differences in Body Fat Distributionin Body Fat Distribution

• Asian Americans have more visceral fat at similar BMI and Asian Americans have more visceral fat at similar BMI and waist size circumference compared to non-Hispanic whiteswaist size circumference compared to non-Hispanic whites

Biological FactorsBiological Factors

• Obesity and body fat distributionObesity and body fat distribution

• Glucose metabolism and insulin resistance Glucose metabolism and insulin resistance (compared to non-Hispanic whites) (compared to non-Hispanic whites)

– Greater insulin resistance in minority Greater insulin resistance in minority populations independent of adipositypopulations independent of adiposity

– Asian Americans have lower insulin secretion Asian Americans have lower insulin secretion

– Glucose metabolic features may differ in Glucose metabolic features may differ in Hispanic Americans depending on country of Hispanic Americans depending on country of originorigin

Biological FactorsBiological Factors

• Obesity and body fat distribution

• Glucose metabolism and insulin resistance (compared to NHWs)

• Genetics– Type 2 diabetes susceptibility loci associated

in European populations also associated with increased risk in minority populations

– Genome-wide association studies have identified additional diabetes-associated single-nucleotide polymorphisms in South and East Asians and in non-Hispanic blacks

Diabetes Care Publish Ahead of Print, published online September 17, 2012

Environmental/Lifestyle FactorsEnvironmental/Lifestyle Factors

• Assessed impact of neighborhood walkability on Assessed impact of neighborhood walkability on diabetes incidence in 214,882 recent adult diabetes incidence in 214,882 recent adult Canadian immigrantsCanadian immigrants

• Neighborhood walkability was strong predictor of Neighborhood walkability was strong predictor of diabetes regardless of age and income, diabetes regardless of age and income, particularly among recent immigrants (RR 1.58 particularly among recent immigrants (RR 1.58 for men; 1.67 for women).for men; 1.67 for women).

• Poverty accentuated effect, with 3-fold greater Poverty accentuated effect, with 3-fold greater diabetes risk in recent immigrants living in low-diabetes risk in recent immigrants living in low-income/low walkability areasincome/low walkability areas

• Acculturation:Acculturation: “process by which immigrants “process by which immigrants adopt the attitudes, values, customs, beliefs, and adopt the attitudes, values, customs, beliefs, and behaviors of a new culture”behaviors of a new culture”

• Socioeconomic StatusSocioeconomic Status: In U.S., lower income, : In U.S., lower income, education, and occupational status are all education, and occupational status are all associated with increased diabetes riskassociated with increased diabetes risk

• Health BehaviorsHealth Behaviors– Diet and ExerciseDiet and Exercise

– Access to healthcare for obesity, diabetes, and co-Access to healthcare for obesity, diabetes, and co-morbidities (i.e., hypertension and dyslipidemia)morbidities (i.e., hypertension and dyslipidemia)

– Effective and affordable treatments and supportEffective and affordable treatments and support

Environmental/Lifestyle FactorsEnvironmental/Lifestyle Factors

Maternal Factors and Maternal Factors and Intrauterine EnvironmentIntrauterine Environment

• Fetal under-nutrition and stress, maternal stress, maternal obesity modification of offspring’s gene expression and developmental biology

• Low birth weight insulin resistance, diabetes, abdominal adiposity, CVD risk, elevated cortisol reactivity

• Epigenetic changes in cellular gene expression: fetal adaptation to adverse intrauterine environment

Kuzawa et al, Am J Hum Biol, 2009

Interventions for Diabetes Interventions for Diabetes Prevention & ReversalPrevention & Reversal

• Lifestyle modification

• Public health mandates

• Medication

• Bariatric surgery

Interventions for Diabetes Interventions for Diabetes Prevention & ReversalPrevention & Reversal

Ebbeling et al,. New Engl J Med, ePub Sept. 25, 2012

• Sugar-sweetened beverage consumption Sugar-sweetened beverage consumption declined from 1.7 to nearly 0 at 1 year with declined from 1.7 to nearly 0 at 1 year with intervention and remained lower at 2 yearsintervention and remained lower at 2 years

• BMI (−0.57) and weight (−1.9 kg, P=0.04) were BMI (−0.57) and weight (−1.9 kg, P=0.04) were lower at 1 year, but not at 2 years lower at 1 year, but not at 2 years

• Hispanic participants responded better with BMI Hispanic participants responded better with BMI and weight declines at 1 and 2 yearsand weight declines at 1 and 2 years

Diabetes InterventionsDiabetes Interventions

Dietary and LifestyleDietary and Lifestyle

Appel et al. N Engl J Med 2011: 365Appel et al. N Engl J Med 2011: 365

Diabetes InterventionsDiabetes Interventions

Dietary and LifestyleDietary and Lifestyle

• Assessed weight-loss interventions over 24 mos. Assessed weight-loss interventions over 24 mos. in 415 obese patients with in 415 obese patients with >>1 CV risk factor: 1) 1 CV risk factor: 1) Weight-loss support remotely by phone, website, Weight-loss support remotely by phone, website, and e-mail; and e-mail; 2) in-person group and individual sessions + 2) in-person group and individual sessions + remote support; or 3) self-directed weight loss. remote support; or 3) self-directed weight loss.

• At 24 mos, weight loss was -4.6 kg with remote At 24 mos, weight loss was -4.6 kg with remote support, -5.1 kg in-person support, & -0.8 kg self-support, -5.1 kg in-person support, & -0.8 kg self-directeddirected

Carlsson et al. N Engl J Med 2012: 367:695-704Carlsson et al. N Engl J Med 2012: 367:695-704

Diabetes InterventionsDiabetes Interventions

Bariatric SurgeryBariatric Surgery

Surgery

Control +Guidance

Knowler et al. N Engl J Med 2002: Knowler et al. N Engl J Med 2002: 346:393-403

Diabetes InterventionsDiabetes Interventions

The Diabetes Prevention ProgramThe Diabetes Prevention Program• 3,234 overweight or obese adults with impaired 3,234 overweight or obese adults with impaired

glucose tolerance (prediabetes) assigned to glucose tolerance (prediabetes) assigned to receive: 1) lifestyle intervention aimed at modest receive: 1) lifestyle intervention aimed at modest weight loss through diet and exercise, 2) weight loss through diet and exercise, 2) metformin treatment, or 3) placebo.metformin treatment, or 3) placebo.

• Lifestyle intervention and metformin reduced Lifestyle intervention and metformin reduced conversion to diabetes by 58% and 31%, conversion to diabetes by 58% and 31%, respectivelyrespectively, over 3 years., over 3 years.

• Lifestyle intervention was effective in both sexes, Lifestyle intervention was effective in both sexes, across racial and ethnic groups, and with genetic across racial and ethnic groups, and with genetic predispositionpredisposition

• Lifestyle intervention worked best in participants Lifestyle intervention worked best in participants 60 or older, a group in which metformin did not 60 or older, a group in which metformin did not benefit. benefit.

• Metformin worked well among younger Metformin worked well among younger participants, esp. women with history of participants, esp. women with history of gestational diabetes. gestational diabetes.

• Build professional capacity & expertiseBuild professional capacity & expertise

• Characterize state of diabetes patients and Characterize state of diabetes patients and their caretheir care

• Use data to improve quality of care Use data to improve quality of care deliverydelivery

• Implement point-of-care laboratory Implement point-of-care laboratory technologiestechnologies

• Develop diabetic retinopathy screening Develop diabetic retinopathy screening programprogram

• Heighten public awareness & preventionHeighten public awareness & prevention

JHI Diabetes Programs JHI Diabetes Programs AimsAims

2121

Johns Hopkins Diabetes Johns Hopkins Diabetes International ProgramsInternational Programs

• The Johns Hopkins Diabetes Guide The Johns Hopkins Diabetes Guide (Trinidad & Tobago, Kuwait, & India)(Trinidad & Tobago, Kuwait, & India)

• Trinidad & Tobago Olympic Trinidad & Tobago Olympic Committee collaboration for diabetes Committee collaboration for diabetes risk detection and prevention in risk detection and prevention in childrenchildren

• Diabetes database and care Diabetes database and care performance monitoring system performance monitoring system (Trinidad)(Trinidad)

23

TTHSI Diabetes Outreach ProgramTTHSI Diabetes Outreach Program

Diabetes Care Performance ImprovementDiabetes Care Performance Improvement

• Sustainable Continuous Quality Improvement based on data collected and dashboard reporting

24

TTHSI Diabetes Outreach ProgramTTHSI Diabetes Outreach Program

Diabetes Care Performance ImprovementDiabetes Care Performance Improvement

Johns Hopkins Diabetes Johns Hopkins Diabetes International ProgramsInternational Programs

• Health Professional education & Health Professional education & empowermentempowerment

• Academy of Diabetes Clinicians of Academy of Diabetes Clinicians of Trinidad & TobagoTrinidad & Tobago

• Nurse diabetes education and Nurse diabetes education and empowerment (Kuwait and Trinidad)empowerment (Kuwait and Trinidad)

• Medical second opinion service (Kuwait)Medical second opinion service (Kuwait)

• Inpatient diabetes management serviceInpatient diabetes management service

• Johns Hopkins Diabetes Center affiliations Johns Hopkins Diabetes Center affiliations

• Epidemics of chronic metabolic disorders Epidemics of chronic metabolic disorders represent threats to health and challenges for represent threats to health and challenges for healthcare systemshealthcare systems

• Research is revealing the biological and Research is revealing the biological and environmental factors responsibleenvironmental factors responsible

• Solutions are being developed and implementedSolutions are being developed and implemented—from lifestyle to medication and surgery—from lifestyle to medication and surgery

• JHI currently offers a set of interventions and JHI currently offers a set of interventions and experience implementing them internationallyexperience implementing them internationally

Obesity & DiabetesInternational Solutions

Obesity & DiabetesInternational Solutions