1. Obesity and Diabetes: inter-relationship and impact José T. Montero, MD Director Division of Public Health Services

2. TOLL OF DIABETES IS RISING RAPIDLY; Death Rate for First Quarter of 1929 Was 23.8 a 100,000, Metropolitan Life Finds. INCREASE LAID TO RICH DIET. Only the Use of Insulin Has Kept Mortality From Being Much Higher, Experts Assert. Overindulgence in food and drink has raised the death rate from diabetes to a new high level for the first quarter of this year and is likely to drive it by the end of 1929 to the highest figure ever recorded, the Metropolitan Life Insurance Company reports in its current Statistical Bulletin, made available yesterday. [New York Times June 1929

3. NH Data: –2/3 Adults are overweight or obese –1/4 Teens are overweight or obese –1/3 Third graders are overweight or obese –1/3 Children in Head Start are overweight or obese (NH BRFSS, 2009) Obesity

4. Obesity Is A Fisk Factor For Many Chronic Conditions Such As: Heart disease, Type two (2) diabetes, Stroke, High blood pressure, and Some cancers

5. Obesity and Type 2 Diabetes Are Closely Related 87% Adults with diabetes in NH are overweight or obese (NH BRFSS, 2009) State with the highest prevalence of obesity also have the highest prevalence of diabetes Obese individuals are less able to use insulin properly (called insulin resistance) Over time, these individuals may also produce less and less insulin

6. Predicted Diabetes Rates If current trends continue, 1/3 individuals born in the year 200 will develop diabetes in their lifetime. The risk is higher for minorities, 2 out of 3 Hispanic children will develop diabetes. Narayan KMV, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA 2003 October 8;290(14):1884-1890. http://articles.latimes.com/2003/jun/15/nation/na-diabetes15 http://www.cdc.gov/diabetes/news/docs/lifetime.htm

17. 2007 Age-Adjusted Estimates of the Percentage of Adults † with Diagnosed Diabetes in New Hampshire

19. How Many People Have Diabetes? NH Adults – 7.1% (BRFSS 2009) NH Adults over 65 – 16.9% (BRFSS 2009) US Adults – 8.4% (BRFSS 2009) Increases with age and is higher in minorities, low socioeconomic status.

20. What Is Diabetes?? People with diabetes have trouble using the sugar in their blood for energy. Normally, insulin (a hormone made in the pancreas) unlocks the cell so sugar (energy) can get into the cell. People with diabetes either do not make enough insulin or they cannot use insulin well. Many people with diabetes have both problems. Because the sugar cannot get into the cells, it stays in the blood. The extra sugar may cause problems or “complications” such as: - Blindness- Loss of feeling in the hands and feet - Kidney failure- Dental problems - Infection- Increased risk for heart attack and stroke

21. Most Common Types Of Diabetes Are: Type 1 “insulin dependent” – 5-10% of all cases (autoimmune, genetic, or environmental) Type 2 – 90-95% of all cases (lifestyle, genetic) Prevention efforts focus on type 2 diabetes Pre-diabetes is when blood glucose levels are high, but Not high enough for a diagnosis of diabetes. About 57 Million Americans are living with this condition. With lifestyle changes, it is possible to prevent or delay the Progression to type 2 diabetes.

22. Diabetes Type 2 (cont.) A landmark study found that lifestyle intervention reduced the risk of developing type 2 diabetes in subjects with pre-diabetes by 58% over three years. In the study, lifestyle intervention (changes in diet and exercise) worked better than medication. This intervention is now being used in communities. According to CDC, lifestyle interventions are more cost effective than medication. Losing just 5-10% of your body weight can make a difference. Exercise helps the cells use insulin better http://diabetes.niddk.nih.gov/about/dateline/spr10/1.htm

25. Diabetes related problems

26. Cardiovascular System Cardiovascular disease is the leading cause of early death among people with diabetes. Adults with diabetes are two to four times more likely than people without diabetes to have heart disease or experience a stroke. At least 65% of people with diabetes die from heart disease or stroke. About 70% of people with diabetes also have high blood pressure People with type 2 diabetes have high rates of cholesterol and triglyceride abnormalities, obesity, and high blood pressure, all of which are major contributors to higher rates of cardiovascular disease. Many people with diabetes have several of these conditions at the same time. This combination of problems is often called metabolic syndrome (formerly known as Syndrome X). The metabolic syndrome is often defined as the presence of any three of the following conditions: 1) excess weight around the waist; 2) high levels of triglycerides; 3) low levels of HDL, or "good," cholesterol; 4) high blood pressure; and 5) high fasting blood glucose levels.

27. Vision In diabetic eye disease, high blood glucose and high blood pressure cause small blood vessels to swell and leak liquid into the retina of the eye, blurring the vision and sometimes leading to blindness. People with diabetes are also more likely to develop cataracts – a clouding of the eye’s lens, and glaucoma – optic nerve damage. Laser surgery can help these conditions. Not reversible

28. Kidneys In diabetic kidney disease (also called diabetic nephropathy), cells and blood vessels in the kidneys are damaged, affecting the organs’ ability to filter out waste. If it build up this can lead to kidney failure. When the kidneys fail, a person has to have his or her blood filtered through a machine (a treatment called dialysis) several times a week, or has to get a kidney transplant.

29. Nerve Endings (Diabetic Neuropathy) Having high blood glucose for many years can damage the blood vessels that bring oxygen to some nerves, as well as the nerve coverings. Damaged nerves may stop sending messages, or send messages too slowly or at the wrong times. Numbness, pain, and weakness in the hands, arms, feet, and legs may develop. Problems may also occur in various organs, including the digestive tract, heart, and sex organs. The most common type is peripheral neuropathy, which affects the arms and legs. An estimated 50% of those with diabetes have some form of neuropathy, but not all with neuropathy have symptoms. People with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the greater the risk. The highest rates of neuropathy are among people who have had the disease for at least 25 years. Diabetic neuropathy also appears to be more common in people who have had problems controlling their blood glucose levels, in those with high levels of blood fat and blood pressure, in overweight people, and in people over the age of 40.

30. Feet Nerve damage, circulation problems, and infections can cause serious foot problems for people with diabetes. Sometimes nerve damage can deform or misshape your feet, causing pressure points that can turn into blisters, sores, or ulcers. Poor circulation can make these injuries slow to heal. Sometimes this can lead to amputation of a toe, foot, or leg.

31. Digestion Gastroparesis, otherwise known as delayed gastric emptying, is a disorder where, due to nerve damage, the stomach takes too long to empty itself. Symptoms of gastroparesis include heartburn, nausea, vomiting of undigested food, an early feeling of fullness when eating, weight loss, abdominal bloating, erratic blood glucose levels, lack of appetite, gastroesophageal reflux, and spasms of the stomach wall

32. Oral health Because of high blood glucose, people with diabetes are more likely to have problems with their teeth and gums. Like all infections, dental infections can make your blood glucose go up. Sore, swollen, and red gums that bleed when you brush your teeth are a sign of a dental problem called gingivitis. Another problem, called periodontitis, happens when your gums shrink or pull away from your teeth. People with diabetes can have tooth and gum problems more often if their blood glucose stays high. Also, smoking makes it more likely for you to get a bad case of gum disease, especially if you have diabetes and are age 45 or older. People with diabetes are also prone to other mouth problems, like fungal infections, poor post-surgery healing, and dry mouth.

33. Sexual response Many people with diabetic nerve damage have trouble having sex. Men can have trouble maintaining an erection and ejaculating. Women can have trouble with sexual response and vaginal lubrication. Both men and women with diabetes can get urinary tract infections and bladder problems more often than average.

34. Mood Diabetes doubles the risk of depression, although it’s still unclear why. The psychological stress of having diabetes may contribute to depression, but diabetes’ metabolic effect on brain function may also play a role. At the same time, people with depression may be more likely to develop diabetes. The risk of depression increases as more diabetes complications develop. When you are depressed, you do not function as well, physically or mentally; this makes you less likely to eat properly, exercise, and take your medication regularly. Psychotherapy, medication, or a combination of both can treat depression effectively. In addition, studies show that successful treatment for depression also helps improve blood glucose control.

35. Response to flu Being sick by itself can raise your blood glucose. Moreover, illness can prevent you from eating properly, which further affects blood glucose. Diabetes can make the immune system more vulnerable to severe cases of the flu. People with diabetes who come down with the flu may become very sick and may even have to go to a hospital.

36. For People Who Already Have Diabetes, Proper Care Can Help Prevent Or Delay Complications Control ABCS (Hemoglobin A1c, blood pressure, cholesterol, and smoking) –**Smoking may increase risk of developing diabetes AND can make complications worse** Take medications as prescribed Have regular exams Get enough sleep Eat healthy foods Stay physically active Seek support from family members

38. State programs Healthy eating active leaving Obesity prevention strategy Diabetes control Role of health care reform

39. Questions........

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