GPSF Annual Conference 2018 Non Communicable Diseases: An Overview Of The Twin Epidemics of Diabetes and Obesity - Diabesity Kwabena O.M. Adubofour, MD, FWACP, FACP Medical Director, East Main Clinic and Stockton Diabetes Intervention Center
I would like to start with my conclusions
We should not wait until a patient comes in for orthopedic surgery before being worked up or treated for a chronic noncommunicable disease Prof Oheneba Boachie-Adjei
Noncommunicable diseases are a global political priority UN Secretary-General in his 2011 report to the UN General Assembly "A rapidly rising epidemic in developing countries with serious socio-economic impacts" "Workable solutions exist to prevent most premature deaths from NCDs and mitigate the negative impact on development" "These solutions need to be mainstreamed into socioeconomic development programmes and poverty alleviation strategies"
Where to focus: 9 global NCD targets to be attained by 2025 (against a 2010 baseline) A 25% relative reduction in risk of premature mortality from cardiovascular disease, cancer, diabetes or chronic respiratory diseases At least a 10% relative reduction in the harmful use of alcohol A 10% relative reduction in prevalence of insufficient physical activity A 25% relative reduction in prevalence of raised blood pressure or contain the prevalence of raised blood pressure A 30% relative reduction in prevalence of current tobacco use Halt the rise in diabetes and obesity A 30% relative reduction in mean population intake of salt/sodium An 80% availability of the affordable basic technologies and essential medicines, incl. generics, required to treat NCDs At least 50% of eligible people receive drug therapy and counselling to prevent heart attacks and strokes
WHO Global NCD Action Plan 2013-2020 Best buys Tobacco Reduce affordability of tobacco products by increasing tobacco excise taxes Create by law completely smoke-free environments in all indoor workplaces, public places and public transport Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns Ban all forms of tobacco advertising, promotion and sponsorship Harmful use of alcohol Regulate commercial and public availability of alcohol Restrict or ban alcohol advertising and promotions Use pricing policies such as excise tax increases on alcoholic beverages
WHO Global NCD Action Plan 2013-2020 Best buys Diet and physical activity Reduce salt intake Replace trans fats with polyunsaturated fats Implement public awareness programmes on diet and physical activity Promote and protect breastfeeding Cardiovascular diseases and diabetes Drug therapy and counselling to individuals who have had a heart attack or stroke and to persons with high risk of a cardiovascular event in the next 10 years Acetylsalicylic acid (aspirin) for people at risk of suffering an acute myocardial infarction (heart attack)
WHO Commission on Ending Childhood Obesity who.int/end-childhood-obesity/final-report
Obesity and Diabetes what I want to share with you Review the married epidemics of obesity and diabetes Review the global health and financial implications of the twin epidemic. Review the nature of the problem in Ghana. Discuss different solutions to tackle the adverse impact of this double epidemic.
Human Evolution
Body Mass Index (BMI) Most commonly used method to estimate body fat Can be used to screen for both overweight and obesity in adults Calculation based on height and weight, and is not gender-specific BMI = weight (kg)/height squared (m 2 )
BMI: Normal, Overweight, Obesity BMI Normal 18.5 25% Overweight 25 30% Obesity >30%
Prevalence of Obesity (%) Global Increase in Obesity 35 30 2002 2007 2015 Obese 356 million 523 million 704 million Overweight 1.4 billion 1.5 billion 2.3 billion USA 25 20 Overweight, BMI 25 kg/m 2 ; obese, BMI >28 kg/m 2 (Asian) or >30 kg/m 2. James WP. J Intern Med. 2008;263:336-352. UK Australia Finland 15 Sweden 10 Norway Brazil 5 0 Cuba Japan 1970 1975 1980 1985 1990 1995 2000 2005
Magnitude of the Diabetes Epidemic
Global Projections for the Diabetes Epidemic: 2007-2025 NA 28.3 M 40.5 M 43.0% EUR 53.2 M 64.1 M 20% AFR EMME 24.5 M 44.5 M 82% SEA 46.5 M 80.3 M 73% WP 67.0 M 99.4 M 48% World 2007=246 M 2025=380 M 54% SACA 16.2 M 32.7 M 102% 10.4 M 18.7 M 80% 2007 2025 M=million; AFR=Africa; EMME=Eastern Mediterranean and Middle East; EUR=Europe; NA=North America; SACA=South and Central America; SEA=South-East Asia; WP=Western Pacific. International Diabetes Federation. Diabetes Atlas. 3rd ed. Available at: http://www.eatlas.idf.org/index.asp.
Pathogenesis of Insulin Resistance Photo courtesy of Leonard Glass, San Antonio, 2003
US Obesity Epidemic 17% of all US deaths from obesity o approx. 300,000 deaths/year o Obesity equals smoking as cause of preventable death o Shortens life span 5-22 years Extremely obese white male 20-30 o Lose 13 yrs of life o Mortality 12x higher if BMI >40 Years of Life Lost Due to Obesity, JAMA January 8, 2003:89;2;187-193 Obesity Among US Immigrants Subgroups by Duration of Residence JAMA Dec 15, 2004.
Obesity Greatest US health expenditure Social and ethnic differences in obesity o Greater in women x 2 o Greater among Black Americans Women>> men o Greater among non-hs grads o Largest increase in ages 19-28 75% of those with extreme obesity have a co-morbid disease
Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI 30 kg/m 2 ) 1994 2000 2014 Diabetes No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% 1994 2000 2014 No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% CDC s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data
Risk of Type 2 Diabetes as a function of BMI Adjusted relative risk of diabetes 100 90 80 70 60 50 40 30 20 10 0 <22 22-22.9 23-23.9 24-24.9 25-26.9 BMI Range 27-28.9 29-30.9 31-32.9 33-34.9 >35 Colditz GA et al. Ann Int Med, 1995
Pima Indian Transitions 1894 2000
Body shape are you a pear or an apple? Beer Belly is dangerous
Some of the alterations in the metabolic risk profile that have been found to be related to abdominal obesity assessed by anthropometry and later to excess visceral adiposity/ectopic fat assessed by imaging techniques. Jean-Pierre Després Circulation. 2012;126:1301-1313 Copyright American Heart Association, Inc. All rights reserved.
Global Impact of Obesity
What about back home in Ghana?
Risk Factors for Obesity Obese parents o Before age 3 parental weight predicts obesity more than child s weight o If 1 parent is obese child s risk x3 o If both obese odds ratio 10 10% chance normal weight Whitaker NEJM 1997
Risk Factors for Obesity Environmental Factors o Portion size (market portions are 2-8 times larger than recommended USDA and FDA recs) o Sweetened beverages Increasing since 1970 o Socioeconomic status inversely related to obesity o Energy density and food cost inversely related o Increase in sedentary leisure time 26% watch more than 4 hours of TV time per day 67% watch more than 2 hours
Physicians Do not Address Obesity Enough: Addressing obesity in the office o Only 17.4% of 2-5 yr old o 32.6% of 6-11 yr/old o 39.6% of 12-15 yr/old o 51.6% of 16-19 yr/old
Diabesity prevention in Those at Risk
Setting Goals for Weight Loss Set reasonable goals o 10% weight loss for first 6 months o 500-1000 calories less/day o Decrease 1-2 lb/week o Most patients set goals 2-3 x higher Physical activity is important o More effective in maintaining weight than weight loss Resetting goals and diet/exercise is necessary at 6 months and plateaus in weight loss Preventing weight gain is an important long-term goal NHLBI Obesity Education Initiative: A Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 2000.
Lifestyle changes makes a difference in diabetes prevention
Diabetes Prevention Diabetes Prevention program Finnish Diabetes Trail Da Qing trial
Diabetes Prevention: Lifestyle Trial Intervention Population Results Da Qing IGT study Diet, PA or both Chinese m/w 45y/o IGT Each arm decreased DM 31-46% Finnish DM Prevention Study Diet counseling + PA w/m 55y/o IGT D + PA decreased DM 58% Diabetes Prevention Trial Wt loss + PA w/m 51y/o IGT decreased DM 58%
The Finnish Diabetes Prevention Study: Lifestyle Incidence of diabetes (cases/1000 person-years) Modifications Control (n=250) Diet intervention (n=256) 80 60 40 58% 20 0 Tuomilehto et al. N Engl J Med. 2001;344:1343.
The Finnish Diabetes Prevention Study: Lifestyle Modifications 522 overweight individuals with IGT randomized to o Control: diet instruction at the onset of study o Individualized advice given 7 times in the first year and every 3 months thereafter with goals of Weight loss 5% Reducing fat intake to <30% of energy consumption Increasing fiber intake to 15 g/1000 kcal Exercising at a moderate level for 30 min/d Primary end point: Prevention of diabetes, as assessed by annual OGTT Tuomilehto et al. N Engl J Med. 2001;344:1343.
The Finnish Diabetes Prevention Study: Lifestyle Change from baseline Modifications (cont d) Control (n=250) Diet intervention (n=256) 0-1 -2-3 -4-5 -6 Weight (kg) Waist (cm) SBP (mm Hg) DBP (mm Hg) P<0.001 P<0.001 P=0.007 P=0.02 Tuomilehto et al. N Engl J Med. 2001;344:1343.
The Diabetes Prevention Program A Randomized Clinical Trial to Prevent Type 2 Diabetes in Persons at High Risk Sponsored by the NIDDK, NIA, NICHD, NIH, IHS, CDC, ADA, and other agencies and corporations
Diabetes Prevention Program: Primary Objectives Compare safety and efficacy of 4 interventions for preventing or delaying development of diabetes o Standard lifestyle recommendations + masked metformin titrated to 850 mg bid or troglitazone 400 mg/d o Standard lifestyle recommendations + masked placebo o Intensive lifestyle intervention by case managers with goals of 7% weight reduction through healthy eating and physical activity 150 min/wk moderate intensity physical activity The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623.
Diabetes Prevention Program: Achievement of Study Goals Average follow-up of 2.8 years Goal % Achieving Goal Lifestyle modifications Week 24 Last visit Weight loss 7% 50% 38% Physical activity 150 74% 58% (min/wk) Pharmacologic intervention Placebo Metformin Compliance 80% 77% 72% Full dose 2 tablets/d 97% 84% The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.
Cases/100 person-years Diabetes Prevention Program: Progression to Type 2 Diabetes 12 10 8 6 4 2 0 Average follow-up of 2.8 years 31%* 58%* Placebo Metformin Intensive lifestyle *All pairwise comparisons significantly different by group; sequential log-rank test. The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.
Summary Based on demographic changes alone: The numbers of persons with diabetes in the world will more than double in the next 30 years In developed countries they will increase by 30-70% (mostly in older persons) In developing countries they will increase by c. 250% (mostly in 45-64y age group) These projections do not take into account any increase that is attributable to future increases in obesity
Summary Because of the current epidemic of diabetes, reflected in increasing age specific prevalence, the proportion of the diabetic population with complications will increase. This will result in a greater relative increase in complications than in diabetes prevalence. Because serious complications e.g. ESRD, typically develop after 15-20 years duration, the incidence of ESRD due to diabetes will continue to increase for at least the next 20 years
Promising Targets for Population-Wide Food Policies to Influence Diabetes