1. The Global Epidemics of Obesity & Diabetes Paul W. Ladenson, M.D. JHI Partners Forum 2012 October 2, 2012 Baltimore

2. The Obesity & Diabetes Epidemics Aims Describe relationship between overweight/obesity and diabetes from epidemiological and biological perspectivesDescribe relationship between overweight/obesity and diabetes from epidemiological and biological perspectives Review lifestyle, public policy, medical and surgical interventionsReview lifestyle, public policy, medical and surgical interventions Depict certain diabetes prevention and management programs currently offered by Johns Hopkins Medicine InternationalDepict certain diabetes prevention and management programs currently offered by Johns Hopkins Medicine International

3. Global Diabetes Prevalences Estimated 346 million individuals affected worldwide Highest diabetes prevalences -Nauru -United Arab Emirates -Saudi Arabia Lowest diabetes prevalences -Mongolia -Rwanda -Iceland Death rates from diabetes and its complications are higher in low- and middle-income countries

4. The Diabetes Epidemic Predisposing Factors ObesityObesity –Worldwide 500 million adults ≥20 years old obese –Highest worldwide prevalences: Nauru, Tonga, Cook Island, and Micronesia –U.S. ranked 5 th highest in male obesity (44%) and 12 th highest in female obesity (48%) Body fat distributionBody fat distribution Race/EthnicityRace/Ethnicity Environmental/LifestyleEnvironmental/Lifestyle

5. Diabetes Prevalence by Race/Ethnicity Percentage (%) 7% 8% 12% 13% 8% Cuban, Central, South American American 14% Mexican American 14% Puerto Rican American Centers for Disease Control, National Diabetes Fact Sheet, 2011

6. Heterogeneity in Diabetes Prevalences Among Asian-Americans Prevalence (%) ChineseFilipino AsianIndianJapanese Vietnamese Korean Other Asian NHOPI* *Native Hawaiian/Other Pacific Islander Narayan et al, J Am Coll Cardiol, 2010

7. In general, Asians develop diabetes at lower BMI than Caucasians In general, Asians develop diabetes at lower BMI than Caucasians Considerable variation among Asian groups Considerable variation among Asian groups KH, Yoon et al. Lancet. 2006; 368: 1681-1688. The Overweight-Diabetes Relationship Varies by Race/Ethnicity

8. Race/Ethnic Differences in Body Fat Distribution Asian Americans have more visceral fat at similar BMI and waist size circumference compared to non-Hispanic whitesAsian Americans have more visceral fat at similar BMI and waist size circumference compared to non-Hispanic whites

9. Biological Factors Obesity and body fat distributionObesity and body fat distribution Glucose metabolism and insulin resistance (compared to non-Hispanic whites)Glucose metabolism and insulin resistance (compared to non-Hispanic whites) –Greater insulin resistance in minority populations independent of adiposity –Asian Americans have lower insulin secretion –Glucose metabolic features may differ in Hispanic Americans depending on country of origin

10. Biological 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

11. Diabetes Care Publish Ahead of Print, published online September 17, 2012 Environmental/Lifestyle Factors Assessed impact of neighborhood walkability on diabetes incidence in 214,882 recent adult Canadian immigrants Assessed impact of neighborhood walkability on diabetes incidence in 214,882 recent adult Canadian immigrants Neighborhood walkability was strong predictor of diabetes regardless of age and income, particularly among recent immigrants (RR 1.58 for men; 1.67 for women). Neighborhood walkability was strong predictor of diabetes regardless of age and income, particularly among recent immigrants (RR 1.58 for men; 1.67 for women). Poverty accentuated effect, with 3-fold greater diabetes risk in recent immigrants living in low-income/low walkability areas Poverty accentuated effect, with 3-fold greater diabetes risk in recent immigrants living in low-income/low walkability areas

12. Acculturation: “process by which immigrants adopt the attitudes, values, customs, beliefs, and behaviors of a new culture”Acculturation: “process by which immigrants adopt the attitudes, values, customs, beliefs, and behaviors of a new culture” Socioeconomic Status: In U.S., lower income, education, and occupational status are all associated with increased diabetes riskSocioeconomic Status: In U.S., lower income, education, and occupational status are all associated with increased diabetes risk Health BehaviorsHealth Behaviors –Diet and Exercise –Access to healthcare for obesity, diabetes, and co- morbidities (i.e., hypertension and dyslipidemia) –Effective and affordable treatments and support Environmental/Lifestyle Factors

13. Maternal Factors and Intrauterine 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

14. Interventions for Diabetes Prevention & Reversal Lifestyle modification Public health mandates Medication Bariatric surgery

15. Interventions for Diabetes Prevention & Reversal

16. Ebbeling et al,. New Engl J Med, ePub Sept. 25, 2012 Sugar-sweetened beverage consumption declined from 1.7 to nearly 0 at 1 year with intervention and remained lower at 2 years Sugar-sweetened beverage consumption declined from 1.7 to nearly 0 at 1 year with intervention and remained lower at 2 years BMI (−0.57) and weight (−1.9 kg, P=0.04) were lower at 1 year, but not at 2 years BMI (−0.57) and weight (−1.9 kg, P=0.04) were lower at 1 year, but not at 2 years Hispanic participants responded better with BMI and weight declines at 1 and 2 years Hispanic participants responded better with BMI and weight declines at 1 and 2 years Diabetes Interventions Dietary and Lifestyle

17. Appel et al. N Engl J Med 2011: 365 Diabetes Interventions Dietary and Lifestyle Assessed weight-loss interventions over 24 mos. in 415 obese patients with >1 CV risk factor: 1) Weight-loss support remotely by phone, website, and e-mail; 2) in-person group and individual sessions + remote support; or 3) self-directed weight loss. Assessed weight-loss interventions over 24 mos. in 415 obese patients with >1 CV risk factor: 1) Weight-loss support remotely by phone, website, and e-mail; 2) in-person group and individual sessions + remote support; or 3) self-directed weight loss. At 24 mos, weight loss was -4.6 kg with remote support, -5.1 kg in-person support, & -0.8 kg self-directed At 24 mos, weight loss was -4.6 kg with remote support, -5.1 kg in-person support, & -0.8 kg self-directed

18. Carlsson et al. N Engl J Med 2012: 367:695-704 Diabetes Interventions Bariatric Surgery Surgery Control + Guidance

19. Carlsson et al. N Engl J Med 2012: 367:695-704 Diabetes Interventions Bariatric Surgery Surgery Control + Guidance

20. Knowler et al. N Engl J Med 2002: Knowler et al. N Engl J Med 2002: 346:393-403 Diabetes Interventions The Diabetes Prevention Program 3,234 overweight or obese adults with impaired glucose tolerance (prediabetes) assigned to receive: 1) lifestyle intervention aimed at modest weight loss through diet and exercise, 2) metformin treatment, or 3) placebo. 3,234 overweight or obese adults with impaired glucose tolerance (prediabetes) assigned to receive: 1) lifestyle intervention aimed at modest weight loss through diet and exercise, 2) metformin treatment, or 3) placebo. Lifestyle intervention and metformin reduced conversion to diabetes by 58% and 31%, respectively, over 3 years. Lifestyle intervention and metformin reduced conversion to diabetes by 58% and 31%, respectively, over 3 years. Lifestyle intervention was effective in both sexes, across racial and ethnic groups, and with genetic predisposition Lifestyle intervention was effective in both sexes, across racial and ethnic groups, and with genetic predisposition Lifestyle intervention worked best in participants 60 or older, a group in which metformin did not benefit. Lifestyle intervention worked best in participants 60 or older, a group in which metformin did not benefit. Metformin worked well among younger participants, esp. women with history of gestational diabetes. Metformin worked well among younger participants, esp. women with history of gestational diabetes.

21. Build professional capacity & expertise Build professional capacity & expertise Characterize state of diabetes patients and their care Characterize state of diabetes patients and their care Use data to improve quality of care delivery Use data to improve quality of care delivery Implement point-of-care laboratory technologies Implement point-of-care laboratory technologies Develop diabetic retinopathy screening program Develop diabetic retinopathy screening program Heighten public awareness & prevention Heighten public awareness & prevention JHI Diabetes Programs Aims 21

22. Johns Hopkins Diabetes International Programs The Johns Hopkins Diabetes Guide (Trinidad & Tobago, Kuwait, & India)The Johns Hopkins Diabetes Guide (Trinidad & Tobago, Kuwait, & India) Trinidad & Tobago Olympic Committee collaboration for diabetes risk detection and prevention in childrenTrinidad & Tobago Olympic Committee collaboration for diabetes risk detection and prevention in children Diabetes database and care performance monitoring system (Trinidad)Diabetes database and care performance monitoring system (Trinidad)

23. 23 TTHSI Diabetes Outreach Program Diabetes Care Performance Improvement

24. Sustainable Continuous Quality Improvement based on data collected and dashboard reporting 24 TTHSI Diabetes Outreach Program Diabetes Care Performance Improvement

25. Johns Hopkins Diabetes International Programs Health Professional education & empowermentHealth Professional education & empowerment Academy of Diabetes Clinicians of Trinidad & TobagoAcademy of Diabetes Clinicians of Trinidad & Tobago Nurse diabetes education and empowerment (Kuwait and Trinidad)Nurse diabetes education and 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 affiliationsJohns Hopkins Diabetes Center affiliations

26. Epidemics of chronic metabolic disorders represent threats to health and challenges for healthcare systemsEpidemics of chronic metabolic disorders represent threats to health and challenges for healthcare systems Research is revealing the biological and environmental factors responsibleResearch is revealing the biological and environmental factors responsible Solutions are being developed and implemented— from lifestyle to medication and surgerySolutions are being developed and implemented— from lifestyle to medication and surgery JHI currently offers a set of interventions and experience implementing them internationallyJHI currently offers a set of interventions and experience implementing them internationally Obesity & Diabetes International Solutions Obesity & Diabetes International Solutions