Tackling Diabesity in Asia: People, politics, and prevention. Paul Zimmet AO Director Emeritus Baker IDI Heart and Diabetes Institute Melbourne

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1 Tackling Diabesity in Asia: People, politics, and prevention Paul Zimmet AO Director Emeritus Baker IDI Heart and Diabetes Institute Melbourne

2 Diabetes is a public health emergency in slow motion Ban Ki-Moon, UN Secretary-General

3 2006 UN General Assembly Resolution on Diabetes

4 September 2011: The Next Step UN Resolution on NCDs

5 Where do nations rank in the global obesity stakes?

6 Japanese Health Minister Lead The Way in Obesity!

7 OECD Predictions for Future Overweight Rates

8 Obesity is driving the escalating Diabesity epidemic: The biggest epidemic in human history

9 Global Projections for the Diabetes Epidemic: (millions) World 2010 = 285 million 2030 = 438 million Increase 54% a staggering 366 million Shaw J. Diab Res & Clin Practice, 2009 IDF Atlas

10 Diabetes Prevalence Rates in Selected Nations: & A: Prevalence of Type 2 Diabetes (%) B: Multiplication factor for increased prevalence of Type 2 Diabetes USA Indonesia Korea China Thailand India Singapore Taiwan 0 USA Indonesia Korea China Thailand India Singapore Taiwan Yoon KH et al, Lancet 2006; 368:

11 Economic Development & Prevalence of Diabetes in Selected Asian Countries: A: Real GDP per head (US$) B: Prevalence (%) India China Malaysia Singapore

12 The 10 Top Nations for Diabetes Prevalence: 2010 Malaysia Tonga Oman Kuwait Réunion Bahrain Mauritius Saudi Arabia UAE Nauru 0% 5% 10% 15% 20% 25% 30% 35% Prevalence %* * For year population

13 Western Killer in Paradise The Age, May 1992

14 Mauritius: The Next Step in Predicting the Global & Asian Diabesity Epidemic The population consists of Asian Indians, Blacks (Creoles) and Chinese These 3 ethnic groups constitute 66% of the world s population Studies performed: 1987, 1992, 1998, 2004 and 2009

15 Mauritius: Increase in Diabetes Prevalence over 22 yrs Prevalence of Diabetes % 62% increase from 1987 to % % 17.4% 20.1% 18.7% Men Women Total Standardised to 2008 population structure of Mauritius

16 Prevalence of Diabetes*: Singapore National Study 2009** 25.0% 21.6% Prevalence % 20.0% 15.0% 10.0% 13.8% 11.5% 17.1% 5.0% 0.0% Total Chinese Indians Malays * Based on fasting plasma glucose ** Persons years Chiang PPC et al. IOVS 2011

17 Diabetes Numbers: 10 Highest Countries 2010 # Mexico Indonesia Japan Pakistan China now has 90 million people with diabetes* Germany Brazil Russia USA China India Adult Diabetes: millions 60 # Diabetes Atlas, 3rd edition, IDF 2006 * Yang W et al NEJM April 2010

18 McDonald s - Beijing Coca-colonization

19 Coca-colonization in Jaipur, India

20

21

22 Type 2 Diabetes in Children: Japan 8.0 Type 2 diabetes incidence / 100,000 population per year Type 2 diabetes Obesity Prevalence of obesity (%) Kitagawa T et al. Clin Pediatr 1998

23 The Tangled Web of Obesity

24

25 Foresight Report (UK): Tackling Obesities - Future Choices Project The key findings include: The obesity epidemic cannot be prevented by individual action alone & demands a societal approach. Tackling obesity requires far greater change than anything tried so far, and at multiple levels: personal, family, community & national. Preventing obesity is a societal challenge, similar to climate change. It requires partnership between government, science, business & civil society

26

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28 Australia: COAG Prioritises Diabetes Prevention: April 13 th 2007

29 Preventative Health Task Force: Key Action Areas

30 Modern Society: minimising daily muscular activity! Then Now Transport Domestic Work

31 Urban Planning: Address Physical Activity & Sedentary Behaviour

32 Environmental Issues in Diabesity Prevention Thanks to Professor Ari Friedman: Magill University

33 Environmental Issues in Diabetes Prevention

34

35 An Environmentally Friendly Solution to the Obesity Epidemic

36 TV Viewing & Diabesity

37 Television Viewing Time and Mortality The Australian Diabetes, Obesity and Lifestyle Study (AusDiab) David W Dunstan, Elizabeth LM Barr, Genevieve N Healy, Jo Salmon, Jonathan E Shaw, Beverley Balkau, Dianna J Magliano, Adrian J Cameron, Paul Z Zimmet, Neville Owen Circulation :

38 Odds Ratio For Obesity: TV Viewing Versus Physical Activity: AusDiab Physical activity time tertiles Dunstan et al Diabetes Care 2003 TV viewing time tertiles

39 AusDiab: TV time and all-cause mortality (hazard ratios) 3.0 Hazard ratios all-cause mortality < 2 >=2 to <4 > = 4 TV time (hours/day) Adjusted for age, sex, smoking, education ( 12 years), total energy intake, diet quality index, leisure-time exercise, waist circumference, hypertension (blood pressure 140/90 mmhg or anti-hypertensive medication use), total plasma cholesterol, HDL-cholesterol (mmol/l), serum-triglycerides (mmol/l, log), lipid-lowering medication use, previously reported cardiovascular disease (angina, myocardial infarction or stroke), glucose tolerance status).

40 Address advertising, food supply & quality

41 James and Zimmet Report

42 The Jamie Oliver School Lunch Program

43 Prevention Of Diabesity: The New Paradigm

44 Genetic-Environment Interaction for Type 2 Diabetes ENVIRONMENT EARLY LIFE Low birth weight Poor nutrition ADULT LIFE Sedentary lifestyle Dietary factors DIABETES +/- THE METABOLIC SYNDROME GENES CARDIOVASCULAR DISEASE

45 Foetal Programming & Intergenerational Risk

46 The Dutch Winter Famine At the end of WW2, West Netherlands population suffered an acute famine Allocated rations were 400 to 800 calories/day Women exposed to this during the 2nd and 3rd trimester of pregnancy delivered small babies. As adults, these babies (exposed to famine in utero) had a higher prevalence: Type 2 diabetes CVD (heart attacks, strokes) Hypertension Obesity Rotterdam, 1945

47 Diabetes in Cambodia (30 years after Pol Pot) regime)

48 Policies and processes influencing the prevalence of obesity International Factors National/ Regional Community Locality Work/School/ Home Individual Population Globalisation of markets Transport Urbanisation Public Transport Public Safety Leisure Activity/ Facilities Labour Energy Expenditure Health Health Care Infections % Obese Development Media programs & advertising Social Services Media & Culture Education Food & Nutrition Sanitation System Manufactured/ Imported Food Agriculture/ Gardens/ Local Markets Worksite Food & Activity Family & Home School Food & Activity Food Intake : Nutrient Density Or Underweight National Perspective Source: Population-Based Prevention of Obesity. Kumanyika et al DOI:

49 Asia: the global epicentre of diabesity and under-nutrition!

50 The Metabolic Syndrome ( Deadly Quartet or Awesome Foursome ) A cluster of risk factors for diabetes & cardiovascular disease consisting of: IGT, IFG & Diabetes Abdominal obesity Hypertension Dyslipidaemia

51 Sleep Apnea & Diabesity: A New Epidemic

52 Conclusions Diabesity continues to rise exponentially in Asia & globally Ageing, lifestyle change & urbanisation have been targetted as the main drivers but in Asian nations, the story may be very different A greater focus on early life risk factors eg maternal nutrition may lead to more effective strategies to halt this global perfect storm of diabesity By 2020, diabesity is set to bankrupt the economies of many Asian nations unless action is taken

53 The End

54 Diabetes Prevalence in Cambodia 8.0% 7.0% 7.1% 7.4% 7.3% Urban 6.0% Rural Prevalence (%) 5.0% 4.0% 3.0% 2.0% 2.9% 3.5% 3.2% 1.0% 0.0% Males Females Total King H et al Lancet 2005

55 New Confounding Disorders Accelerating the Diabesity Epidemic Obesity Diabetes Insulin Resistance Dyslipidaemia Sleep Apnoea HIV/AIDS Therapy Non-alcoholic Steatohepatitis (Primary NASH)

56

57 Prevalence of overweight and obesity in 10yr old girls & boys in selected nations

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