rhTSH Study Lecture by jgIFZJL3


									The Global Epidemics
of Obesity & Diabetes

   Paul W. Ladenson, M.D.

   JHI Partners Forum 2012
       October 2, 2012
     The Obesity & Diabetes Epidemics
• Describe relationship between
  overweight/obesity and diabetes from
  epidemiological and biological
• Review lifestyle, public policy, medical
  and surgical interventions
• Depict certain diabetes prevention and
  management programs currently offered
  by Johns Hopkins Medicine International
 Global Diabetes Prevalences

      Highest diabetes prevalences
      -United Arab Emirates
      -Saudi Arabia

      Lowest diabetes prevalences

      Death rates from diabetes and its complications
      are higher in low- and middle-income countries

Estimated 346 million individuals affected worldwide
            The Diabetes Epidemic
        Predisposing Factors
• Obesity
   – Worldwide 500 million adults ≥20 years old obese
   – Highest worldwide prevalences: Nauru, Tonga,
     Cook Island, and Micronesia
   – U.S. ranked 5th highest in male obesity (44%) and
     12th highest in female obesity (48%)
• Body fat distribution
• Race/Ethnicity
• Environmental/Lifestyle
                 Diabetes Prevalence by Race/Ethnicity
                                                  8% Cuban, Central, South
                                                  14% Mexican American
                 14                               14% Puerto Rican American
                                                                12%                 13%
Percentage (%)

                  8      7%
                      Non-Hispanic    Asian Americans Hispanic/Latino          Non-Hispanic
                         White                                                    Black

                      Centers for Disease Control, National Diabetes Fact Sheet, 2011
     The Overweight-Diabetes Relationship
           Varies by Race/Ethnicity

• In general,
  Asians develop
  diabetes at lower
  BMI than
• Considerable
  variation among
  Asian groups

             KH, Yoon et al. Lancet. 2006; 368: 1681-1688.
            Race/Ethnic Differences
            in Body Fat Distribution

• Asian Americans have more visceral fat at similar BMI and
  waist size circumference compared to non-Hispanic whites
          Biological Factors
• Obesity and body fat distribution
• 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
          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
     Environmental/Lifestyle Factors

• 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
• Poverty accentuated effect, with 3-fold greater diabetes
  risk in recent immigrants living in low-income/low
  walkability areas
     Diabetes Care Publish Ahead of Print, published online September 17, 2012
    Environmental/Lifestyle Factors
• 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 risk
• Health Behaviors
  – Diet and Exercise
  – Access to healthcare for obesity, diabetes, and co-
    morbidities (i.e., hypertension and dyslipidemia)
  – Effective and affordable treatments and support
           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
• Epigenetic changes in cellular gene expression:
  fetal adaptation to adverse intrauterine

              Kuzawa et al, Am J Hum Biol, 2009
Interventions for Diabetes
  Prevention & Reversal

• Lifestyle modification
• Public health mandates
• Medication
• Bariatric surgery
Interventions for Diabetes
  Prevention & Reversal
               Diabetes Interventions
            Dietary and Lifestyle

• 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
• Hispanic participants responded better with BMI and
  weight declines at 1 and 2 years

         Ebbeling et al,. New Engl J Med, ePub Sept. 25, 2012
              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.
• At 24 mos, weight loss was -4.6 kg with remote support,
  -5.1 kg in-person support, & -0.8 kg self-directed

                 Appel et al. N Engl J Med 2011: 365
 Diabetes Interventions
  Bariatric Surgery

                                        Control +


Carlsson et al. N Engl J Med 2012: 367:695-704
               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.
• 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 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.
              Knowler et al. N Engl J Med 2002: 346:393-403
       JHI Diabetes Programs
• Build professional capacity & expertise
• Characterize state of diabetes patients and
  their care
• Use data to improve quality of care delivery
• Implement point-of-care laboratory technologies
• Develop diabetic retinopathy screening program
• Heighten public awareness & prevention

        Johns Hopkins Diabetes
        International Programs
• The Johns Hopkins Diabetes Guide
  (Trinidad & Tobago, Kuwait, & India)
• Trinidad & Tobago Olympic Committee
  collaboration for diabetes risk detection
  and prevention in children
• Diabetes database and care performance
  monitoring system (Trinidad)
      TTHSI Diabetes Outreach Program
Diabetes Care Performance Improvement

          TTHSI Diabetes Outreach Program
 Diabetes Care Performance Improvement

• Sustainable Continuous Quality Improvement
  based on data collected and dashboard reporting

          Johns Hopkins Diabetes
          International Programs

• Health Professional education & empowerment
  • Academy of Diabetes Clinicians of Trinidad &
  • Nurse diabetes education and empowerment
    (Kuwait and Trinidad)
• Medical second opinion service (Kuwait)
• Inpatient diabetes management service
• Johns Hopkins Diabetes Center affiliations
            Obesity & Diabetes
          International Solutions
• Epidemics of chronic metabolic disorders represent
  threats to health and challenges for healthcare
• Research is revealing the biological and
  environmental factors responsible
• Solutions are being developed and implemented—
  from lifestyle to medication and surgery
• JHI currently offers a set of interventions and
  experience implementing them internationally

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