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Modifiable Risk Factors for Type 2 Diabetes 2009 Middle Eastern Region Epidemiology Supercourse Alexandria, Egypt

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Modifiable Risk Factors for Type 2 Diabetes 2009 Middle Eastern Region Epidemiology Supercourse Alexandria, Egypt. Edward Gregg, PhD Epidemiology and Statistics Branch Division of Diabetes Translation Centers for Disease Control and Prevention Atlanta, GA.

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slide1

Modifiable Risk Factors for Type 2 Diabetes2009 Middle Eastern RegionEpidemiology SupercourseAlexandria, Egypt

Edward Gregg, PhD

Epidemiology and Statistics Branch

Division of Diabetes Translation

Centers for Disease Control and Prevention

Atlanta, GA

key steps in the public health research leading to public health decision making
Key Steps in the Public Health Research Leading to Public Health Decision Making
  • Surveillance and Descriptive Epidemiology
    • Monitor health of the population
    • Identify public health problems and their magnitude
    • Evaluate levels of care
    • Identify high risk populations amenable to intervention
  • Analytic and Clinical Epidemiology:
    • Identify modifiable risk factors
    • Examine effectiveness of interventions in the clinical setting aimed at the individual
  • Health Services Research, Cost-Effectiveness, Translation Research
    • Examine the effectiveness of different health service, program, or policy-level interventions.
    • Examine the cost effectiveness of successful interventions
slide3
Range of Potential Priorities in the Public Health Response to Diabetes

Normal

IGT

Type 2 DM

Disability

Death

Complications

Primary Secondary Tertiary

prevention prevention prevention

  • Control of complications and management of disability.
  • Prevention of diabetes complications
  • Assure access to care
  • Prevention of diabetes among persons of high risk.
  • Prevention and management of risk factors in the whole population.
common study designs used in epidemiologic research
Common Study Designs Used in Epidemiologic Research
  • Observational Studies
    • Cross-sectional
    • Retrospective (case control)
    • Prospective (cohort studies)
    • Ecologic Studies
  • Intervention Studies
    • Quasi-experimental studies
    • Controlled intervention studies
      • Clinical
      • Health Service
      • Community
    • Cost-effectiveness studies

cross-sectional

Retrospective

cohort

Intervention

Yes

No

slide5
Risk factors: Characteristic of an individual or his/her environment that increases the chance of a health-related condition.
  • Major Types:
    • Causal vs non-causal
    • Modifiable vs non modifiable
    • Behavioral
    • Physiologic
    • Environmental
    • Contextual
how do we use risk factors
How do we use risk factors?
  • To contribute to understanding of etiology of disease.
  • To guide the development of effective interventions.
bradford hill criteria for evaluation of the evidence of causality
Bradford Hill Criteria for Evaluation of the Evidence of Causality
  • Strength of Association
  • Dose-response effect
  • Temporality
  • Consistency of evidence
  • Biological plausibility
  • Specificity of association
  • Experimentation
how do we use risk factors8
How do we use risk factors?
  • To contribute to understanding of etiology of disease.
  • To guide the development of effective interventions.
  • To assist in efficient identification of people who will benefit from intervention.
step 1 clinical observations impressions
Step 1: Clinical Observations/Impressions

“There are entirely too many diabetic patients in the country. Statistics for the last thirty years show so great an increase in the number that, unless this were in part explained by a better recognition of the disease, the outlook for the future would be startling.”

”The physician should take pride in the prevention of diabetes in his practice. Obese patients should be frankly told that they are candidates for diabetes”.

”But it is to the diabetic patient and his relatives that one can look most confidently for help in preventing diabetes. They should be encouraged to disseminate information about its prevention”.

Joslin EP. The Prevention of Diabetes Mellitus JAMA 1921; 76 (2):79-84.

slide12
Migration Studies: Association Between Westernization and Diabetes Prevalence in Susceptible Populations

New

Guinea

Nauru

Chinese

Indian

Australian

Aborigines

King, Diabetes Care, 1993; 1998; Diamond J, Nature, 2003

slide14
Natural Experiments

Franco et al.,

Am J Epidemiol, 2007

slide17
Diabetes Prevalence among U.S. Adults Aged 20 - 74

8.83%

5.03%

Age and sex adjusted

Gregg et al., Prev Med, 2007

slide18
Trends in the proportion of total intake devoted to macronuetriends (left x-axis) and mean total Energy Intake (right x-axis) among U.S. adults age 20-74, 1971 to 2000

Total Intake (kcals)

MMWR, 2004

slide19
Percentage of total carbohydrates obtained from whole grains

(smaller circles) and corn syrup (larger circles) in the United States

Gross et al., Am J Clin Nutr, 2004

slide20
Trends in % of Meals Eaten at Home and Trends in Total Kcal Intake in Meals and Snacks in the U.S., 1977-1996.

Nielsen and Popkin, JAMA, 2003

portion sizes for selected key foot items for americans aged 2 and older 1977 1996
Portion Sizes for Selected Key Foot Items for Americans Aged 2 and Older, 1977-1996.

Nielsen and Popkin, JAMA, 2003

summary of secular trends in u s dietary behavior
Healthy Trends

Lower % of saturated fat

Lower % of total fat in diet

Higher % of carbohydrates

More fruits and vegetables

Unhealthy Trends

Increased portion sizes

Decreased quality of carbs

Increased total intake

More meals out of the home

Increased soda intake

Reduced breakfast frquency

Summary of Secular Trends in U.S. Dietary Behavior
slide25
Trends in Leisure-Time Physical Inactivity by Age, Sex, and

Race/Ethnicity - United States, 1994-2004

Centers for Disease Control and Prevention, MMWR, 2005

slide27
Body Mass Index and 1-year Risk of Diabetes

(Ford ES et al. AJE 1997;146:214-22)

%- Point

Absolute Increase

0

0.031

0.204

0.315

0.329

0.675

0.850

1.256

1.668

2.237

Increase per

100,000

0

31

204

315

329

675

850

1,256

1,668

2,237

Cumulative

Increase

BMI

<22

22-<23

23-<24

24-<25

25-<27

27-<29

29-<31

31-<33

33-<35

35+

1-y Risk (%)

0. 224

0. 255

0. 428

0. 539

0. 553

0. 899

1.074

1.480

1.892

2.461

RR

1

1.18

2.44

2.97

3.04

5.07

5.70

8.21

10.89

14.64

0

550

1,554

7,565

slide28
Relative risk of incident diabetes per standard deviation of BMI and

Waist circumference from a meta-analysis of 32 studies

Vasquez, Epidemiol Rev, 2007

slide29
Hu et al.,

Arch Intern Med, 2001

slide30
Potential Impact of Physical Activity on Diseases and Conditions:

Across the Life Span

Adolescent - Young Adult - Adult - Mid-aged - Older Adult -

10 20 30 40 50 60 70 80 90

Lifestyle forming, habituation, and maintenance

Obesity

Diabetes

CVD

Physical Function

Falls

Fracture

Stroke

Cancers

Quality of life / Mental health

dietary factors as independent diabetes risk factors
Dietary factors as independent diabetes risk factors
  • Characteristics of fat intake
  • Whole grain / cereal fibers
  • Dairy
  • Glycemic load
  • “Western diet”
  • Fast food intake
  • Soda intake
  • Alcohol intake
  • Coffee consumption
slide32
Diabetes OR per 1kg

Birth weight=0.78

slide33
Gestational Diabetes and the Incidence of Type 2 Diabetes:

A systematic review (Kim et al., Diabetes Care, 2002)

systematic review of the incidence of diabetes associated with various categories of glycemia
Systematic Review of the Incidence of Diabetes Associated with Various Categories of Glycemia

*extremely variable; 1-7% in

European pops; 23-34% in Asian pops.

Gerstein et al., Diab Res Clin Pract, 2007

upstream contextual factors as risk factors for obesity and diabetes
Upstream / Contextual Factors as Risk Factors for Obesity and Diabetes
  • Poverty
  • Education
  • Food insecurity
  • Food environment
  • Neighborhood factors
summary risk factors for type 2 diabetes
Age ↑

Family History ↑

Gestational Diabetes ↑

Obesity / fat distribution ↑

Physical Activity / fitness ↓

Smoking ↑

Very low birth weight ↑

Depression ↑

Antipsychotic medications ↑

Anti-Retrovial therapy ↑

Dietary Factors

Carbohydratess ↓

Fats ↑↓

Glycemic load ↑

Cereal fiber / whole grain ↓

Dairy products ↓

High fructose corn syrup ↑

Sugar-sweetened bevarages ↑

Alcohol ↓

Coffee ↓

Summary: Risk Factors for Type 2 Diabetes
major type 2 diabetes risk factors under new or renewed investigation
Major Type 2 Diabetes Risk Factors Under New (or Renewed) Investigation
  • Genetic markers
  • Insulin resistance biomarkers (inflammation markers, adipocytokines, hepatocytokines)
  • Sleep; sleep apnea
  • Depression; vital exhaustion
  • Vitamin D deficiency
  • Anti-retroviral treatment
  • New antipsychotic treatment
  • Fatty liver disease
  • Hepatitis
slide44
Proportion of Participants Developing Diabetes During the Finnish and U.S. Diabetes Prevention Studies

Finland

United States

Control

Control

Metformin

Lifestyle

Lifestyle

Tuomilehto, N Engl J Med, 2001; DPP Research Group, N Engl J Med, 2002

characteristics of controlled trials of lifestyle based interventions on diabetes incidence
Characteristics of Controlled Trials of Lifestyle-based Interventions on Diabetes Incidence

Pan et al., 1997; Tuomilehto et al., 2001, Knowler et al., 2002

slide47
Applications of Risk Scores to Diabetes Prevention in Finland And Germany

Schwarz, Horm Metab Res, 2008

discussion questions
Discussion Questions
  • Are the modifiable risk factors in your country and region likely to be different from these?
    • For the average individual?
    • As predictors of trends over time?
  • If yes, what would those risk factors be?
  • What major types of research are needed in your country to examine new and emerging risk factors?
  • What are the major candidate interventions for publication in your country and region?
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