Presentation on theme: "Natural History of Obesity Leading to Type 2 Diabetes"— Presentation transcript:
1 Natural History of Obesity Leading to Type 2 Diabetes ComplicationsOnset of diabetesDisabilityGenetic susceptibilityEnvironmental factors Nutrition PhysicalinactivityObesity Insulin resistanceIGTOngoing hyperglycemiaDeathIGT = Impaired Glucose ToleranceRisk forDiseaseMetabolicSyndromeAtherosclerosis Hyperglycemia HypertensionRetinopathy Nephropathy NeuropathyBlindness Renal failure CHD Amputation
2 Obesity Trends. Among U. S Obesity Trends* Among U.S. Adults (BMI ≥ 30 or ≈ 30 lbs overweight for 5’4” woman)F as in Fat: How Obesity Policies Are Failing in America. Trust for America’s Health Issue Report. October 2004.
3 Prevalence (%) of overweight among children and adolescents Average 11 year old boy today is 11 pounds heavier than in 1973This graph shows how childhood overweight has tripled since the 1960s. The epidemic of childhood obesity is a particular concern because it predicts much suffering from health problems starting at an earlier age than previously. It is estimated that this will be the first generation in the US to have a shorter lifespan than their parents.
4 National Longitudinal Survey of Youth Prospective Cohort Study of Children (4-12 years old)Risk of Overweight Overweight> 85th %ile BMI > 95th %ile BMIAfrican American 38.4% %Hispanics % %Caucasian % %Showing that prevalence rates vary by ethnicity.Source: NHANES???
5 Secular Increases in Relative Weight and Adiposity in Children (5-14 years old) - Bogalusa Heart Study -Study yearsWeight (kg)Height (cm)BMI (kg/m2)35.914017.641.014219.5Change*+3.4+1.6+1.5* Change adjusted for height, age, race, and sexSource: Pediatrics 99: , 1997
6 Correlations of Weight and BMI in Youth at 7.7 and 23.6 Years Source: Minneapolis Children’s BP Study, Circulation 99:1471, 1999
7 Relationship Between Prevalence of Overweight and Daily TV Hours Gortmaker et al., 1996
8 Overweight Children Ate fewer fruits and vegetables (2.9 vs. 3.3/day) Drank more sweetened beverages (1.3 vs. 1.1/day)Ate more high-fat snacks (64 vs. 56 %; p=0.054)Ate more fast food (1.4 vs. 1.1/week; p=0.051)Spent more screen time (101 vs. 81 minutes)Less likely take part in lessons on nutrition (50 vs. 64 percent).Special Report on Policy Implications from the 1999 California Children’s Healthy Eating and Exercise Practices Survey. The California Endowment. Rev. August 2002.
9 Pediatric Overweight AAP Policy Statement Identify and track at risk youthCalculate and plot BMI yearlyPromote health eating patternsFruits, vegetables, low-fat dairy, whole grainsSelf-regulation of intake, limits on choices, modelingPromote physical activityLimit TV and videoMonitor changes in obesity-associated risk factors (BP, lipids, IGT, apnea, hyperinsulinism)AAP = American Academy of PediatricsSource: Pediatrics 112, August 2003
10 Metabolic Syndrome Prevalence in 12-19 Year Olds Overall 4.2% (6.1% M, 2.1% F)BMI 95th percentile 28.0%BMI 85th-94th percentile 6.8%BMI < 85th percentile 0.1%Based on 1994 population estimates, 910,000 adolescents had metabolic syndrome.Source: Cook et al., Arch Pediatr Adolesc Med 157: , 2003
11 Link Between Obesity and Type 2 Diabetes: Nurses’ Health Study
12 Number of Bariatric Surgeries 1992-2003 Surgery for Severe Obesity: US to NEJM March 11, 2004
13 GI Surgery for Severe Obesity Risk and Complications:10-20% require follow-up surgeryAbdominal herniaBreak down of staple lineGallstones30% develop nutritional deficiencyCost: $20,000 to $50,000Source: NIDDKHighest Increase Rate of all Pediatric Surgeries
14 Natural History of Obesity Leading to Type 2 Diabetes ComplicationsOnset of diabetesDisabilityGenetic susceptibilityEnvironmental factors Nutrition PhysicalinactivityObesity Insulin resistanceIGTOngoing hyperglycemiaDeathIGT = Impaired Glucose ToleranceRisk forDiseaseMetabolicSyndromeAtherosclerosis Hyperglycemia HypertensionRetinopathy Nephropathy NeuropathyBlindness Renal failure CHD Amputation
15 Type 2 Diabetes A Progressive Disease Impairedglucose tolerance (IGT)UndiagnoseddiabetesKnown diabetesInsulin resistanceInsulin secretionPostprandial glucoseFasting glucoseMicrovascular complicationsMacrovascular complicationsAdapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:
16 Burden of Diabetes in USA 18.2 Million Americans Have Diabetes5.2 Million Unaware of Diagnosis40 Million Americans Have Prediabetes239,000 Diabetes-Related Deaths/year2-to-6-Fold More Likely to Have Heart Disease2-to-4-Fold More Likely to Have a Stroke75% of All Diabetes Related Deaths Associated With Cardiovascular DiseaseCost $132 Billion/2002Mokdad, et al, JAMA ,1195
17 Diabetes and Gestational Diabetes Trends Among Adults in the United States, Behavioral Risk Factor Surveillance System, 1990, 1995 and 2001199019932001
19 Diabetes Prevalence Among Minority Populations in the U.S. Percentage of each population with diabetesNon-Hispanic WhitesLatinosAfrican Americans7.8% (11.4 million)10.2% (2 million)13% (2.8 million)15.1% (105,000)Native Americans & Alaska NativesCenters for Disease Control and Prevention (CDC)
21 The Changing Face of Diabetes in Youth 5101520253035% with type 287888990919293949596Cincinnati <19 yearsLittle Rock 8-21 yearsSan Antonio <19 yearsSource: Fagot-Campagna et al., J Pediatr 136: , 2000
22 Diabetes Projected Risks: For Babies Born in 2000 Girls: 38% lifetime riskIf diabetic before age 40, Lifespan shortened by 14 years (Quality of life by 19 years)Boys: 33% lifetime riskIf diabetic before age 40, Lifespan shortened by 12 years. (Quality of life by 22 years)V Narayan et al: JAMA 8 Oct 2003
23 Prevalence of Diabetes in Pregnancy in the United States of America 8%Non-diabetes92%More than 135,000 GDM + 200,000 T2DM +6,000 T1DM pregnancies annuallyAmerican Diabetes Association. Diabetes Care. 1998;21(Suppl. 2).
24 Major Birth Defects: Preexisting Type I vs Type II Diabetes
25 ADA Goals for Glycemic Control A1C < 7.0%*Pre-prandial plasma mg/dlglucosePeak postprandial <180 mg/dlplasma glucose*Referenced to a non-diabetic range of % using a DCCT-based assay
26 Diabetes Care in the U.S. Improvement Needed Data from NHANES III* and BRFSS**Participants years with DMResults: Percent at GoalA1C < % (>9.5, 18%)LDL < % (>130, 58%)BP < 140/ %Dilated eye exam 63%Foot exam 55%* Nat’l Health & Nutrition Exam Survey** Behavioral Risk Factors Surveillance Study
27 Majority of Patients with Diabetes are Not at ADA HbA1c Goal <7%
28 Census Bureau Projections 2000-2050 Census Bureau projects population will grow 47% by 2050By 2050, there will be 112% more diagnosed cases of diabetesSerious diabetes complications are projected to increase % by 2050Diabetes 50 (Suppl 2): A205, 2001
29 GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions) World2003 = 194 million2025 = 333 millionIncrease 72%
32 Coronary Heart Disease Mortality in Type 2 Diabetes MenWomen6060DiabetesDiabetes5050No DiabetesNo Diabetes4040Mortality Rate per 1000Mortality Rate per 10003030202010100-34-78-1112-1516-1920-230-34-78-1112-1516-1920-23Duration of Follow-up (yr)Duration of Follow-up (yr)Krowlewski AS, et al Am J Med 1991; 90 (suppl2A):56S-61S.
33 A1C Predicts CV Risk in Type 2 Diabetes Kuusisto et al 229 Finnish Patients Followed for 3.5 YearsCHD mortalityAll CHD eventsIncidence (%)over 3.5 years510152025510152025†*Low <6%Middle 6.0%–7.9%High >7.9%Low <6%Middle 6.0%–7.9%High >7.9%A1C tertileCHD=coronary heart disease*P<0.01 vs lowest tertile; †P<0.05 vs lowest tertileKuusisto J et al. Diabetes. 1994;43:
34 UKPDS - Glycemic Control Risk Reductions Lancet 1998; 352:
35 UKPDS - BP Control Risk Reductions Any Diabetes Related EndpointDeaths Related to Diabetes24%Risk Reduction32%Risk ReductionEvents/ 1000 pt-yearsp=0.0046p=0.0019n=1148UKPDS. BMJ :
36 4S Study: Effect of Simvastatin on Coronary Events - 6 years Diabetic Patientsn=201, p=0.002Nondiabetic Patientsn=4242, p<55%Risk Reduction32%% of Patients with a Major Coronary EventPyorala et al, Diabetes Care 1997; 20: 614
37 Incidence of diabetes reduced 58% (p=.0003). Prevention of T2D with Lifestyle Intervention (N=523 with IGT, mean age 55, BMI 31)Weight Loss (kg)Cases1st year2nd year4th yearIntervention*-4.2-3.526 (10%)Control**-0.857 (22%)Incidence of diabetes reduced 58% (p=.0003).* diet, exercise, frequent visits ** yearly adviceSource: Tuomilehto et al., ADA 2000
38 Type 2 Diabetes Prevention Percent developing diabetesAll participantsAll participantsRisk reduction31% by metformin58% by lifestylePlacebo4030MetforminCumulative incidence (%)20Lifestyle101234Years from randomizationThe DPP Research Group, NEJM 346: , 2002
39 School-based Program to Decrease Soda Consumption 644 children (7-11 years old), 6 schoolsProgram to decrease regular and diet soda intake delivered in 1-hour sessions 4 times per year# Glasses of Soda Per Day% Overweight and ObeseIntervention 0.6 0.2Control 0.2 7.5Source: James et al., Brit Med J 328:1237, 2004
40 Natural History of Obesity Leading to Type 2 Diabetes ComplicationsOnset of diabetesDisabilityGenetic susceptibilityEnvironmental factors Nutrition PhysicalinactivityObesity Insulin resistanceIGTOngoing hyperglycemiaDeathIGT = Impaired Glucose ToleranceRisk forDiseaseMetabolicSyndromeAtherosclerosis Hyperglycemia HypertensionRetinopathy Nephropathy NeuropathyBlindness Renal failure CHD Amputation