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Natural History of Obesity Leading to Type 2 Diabetes. Complications. Onset of diabetes. Disability. Genetic susceptibility Environmental factors Nutrition Physical inactivity. IGT. Ongoing hyperglycemia. Obesity Insulin resistance. Death. Risk for Disease. Metabolic Syndrome.

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natural history of obesity leading to type 2 diabetes
Natural History of Obesity Leading to Type 2 Diabetes

Complications

Onset ofdiabetes

Disability

Genetic susceptibility

Environmental factors Nutrition Physical

inactivity

IGT

Ongoing hyperglycemia

Obesity Insulin resistance

Death

Risk for

Disease

Metabolic

Syndrome

AtherosclerosisHyperglycemiaHypertension

RetinopathyNephropathyNeuropathy

BlindnessRenal failureCHDAmputation

prevalence of overweight among children and adolescents
Prevalence (%) of overweight among children and adolescents

Average 11 year old boy today is 11 pounds heavier than in 1973

national longitudinal survey of youth prospective cohort study of 8270 children 4 12 years old 1999
National Longitudinal Survey of Youth Prospective Cohort Study of 8270 Children (4-12 years old) - 1999

Risk of Overweight Overweight

> 85th %ile BMI > 95th %ile BMI

African American 38.4% 21.5%

Hispanics 37.9% 21.8%

Caucasian 25.8% 12.3%

Source: NHANES???

secular increases in relative weight and adiposity in children 5 14 years old bogalusa heart study
Secular Increases in Relative Weight and Adiposity in Children (5-14 years old)- Bogalusa Heart Study -

* Change adjusted for height, age, race, and sex

Source: Pediatrics 99:420-426, 1997

correlations of weight and bmi in youth at 7 7 and 23 6 years
Correlations of Weight and BMI in Youth at 7.7 and 23.6 Years

r=0.605

r=0.612

Source: Minneapolis Children’s BP Study, Circulation 99:1471, 1999

overweight children
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.

pediatric overweight aap policy statement
Pediatric Overweight AAP Policy Statement
  • Identify and track at risk youth
  • Calculate and plot BMI yearly
  • Promote health eating patterns
    • Fruits, vegetables, low-fat dairy, whole grains
    • Self-regulation of intake, limits on choices, modeling
  • Promote physical activity
  • Limit TV and video
  • Monitor changes in obesity-associated risk factors (BP, lipids, IGT, apnea, hyperinsulinism)

Source: Pediatrics 112, August 2003

metabolic syndrome prevalence in 12 19 year olds
Metabolic SyndromePrevalence 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 157:821-827, 2003

slide12

Number of Bariatric Surgeries 1992-2003

Surgery for Severe Obesity: US 1992 to 2003 NEJM March 11, 2004

slide13

GI Surgery for Severe Obesity

Risk and Complications:

  • 10-20% require follow-up surgery
  • Abdominal hernia
  • Break down of staple line
  • Gallstones
  • 30% develop nutritional deficiency

Cost: $20,000 to $50,000

Source: NIDDK

Highest Increase Rate of all Pediatric Surgeries

natural history of obesity leading to type 2 diabetes1
Natural History of Obesity Leading to Type 2 Diabetes

Complications

Onset ofdiabetes

Disability

Genetic susceptibility

Environmental factors Nutrition Physical

inactivity

IGT

Ongoing hyperglycemia

Obesity Insulin resistance

Death

Risk for

Disease

Metabolic

Syndrome

AtherosclerosisHyperglycemiaHypertension

RetinopathyNephropathyNeuropathy

BlindnessRenal failureCHDAmputation

type 2 diabetes a progressive disease
Type 2 DiabetesA Progressive Disease

Impaired

glucose tolerance (IGT)

Undiagnosed

diabetes

Known diabetes

Insulin resistance

Insulin secretion

Postprandial glucose

Fasting glucose

Microvascular complications

Macrovascular complications

Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789

burden of diabetes in usa
Burden of Diabetes in USA
  • 18.2 Million Americans Have Diabetes
  • 5.2 Million Unaware of Diagnosis
  • 40 Million Americans Have Prediabetes
  • 239,000 Diabetes-Related Deaths/year
  • 2-to-6-Fold More Likely to Have Heart Disease
  • 2-to-4-Fold More Likely to Have a Stroke
  • 75% of All Diabetes Related Deaths Associated With Cardiovascular Disease
  • Cost $132 Billion/2002
  • Mokdad, et al, JAMA 2001 286,1195
slide17

Diabetes and Gestational Diabetes Trends Among Adults in the United States, Behavioral Risk Factor Surveillance System, 1990, 1995 and 2001

1990

1993

2001

slide19

Diabetes Prevalence Among Minority Populations in the U.S.

Percentage of each population with diabetes

Non-Hispanic Whites

Latinos

African Americans

7.8% (11.4 million)

13% (2.8 million)

10.2% (2 million)

15.1% (105,000)

Native Americans & Alaska Natives

Centers for Disease Control and Prevention (CDC) 1999 www.cdc.gov/diabetes

slide21

The Changing Face of Diabetes in Youth

35

30

25

20

% with type 2

15

10

5

0

87

88

89

90

91

92

93

94

95

96

Cincinnati <19 years

Little Rock 8-21 years

San Antonio <19 years

Source: Fagot-Campagna et al., J Pediatr 136:664-672, 2000

diabetes projected risks for babies born in 2000
Diabetes Projected Risks:For Babies Born in 2000

Girls: 38% lifetime risk

  • If diabetic before age 40, Lifespan shortened by 14 years (Quality of life by 19 years)

Boys: 33% lifetime risk

  • If diabetic before age 40, Lifespan shortened by 12 years. (Quality of life by 22 years)

V Narayan et al: JAMA 8 Oct 2003

prevalence of diabetes in pregnancy in the united states of america
More than 135,000 GDM + 200,000 T2DM +

6,000 T1DM pregnancies annually

Diabetes

8%

Non-diabetes

92%

Prevalence of Diabetes in Pregnancyin the United States of America

American Diabetes Association. Diabetes Care. 1998;21(Suppl. 2).

slide25

ADA Goals for Glycemic Control

  • A1C < 7.0%*
  • Pre-prandial plasma 90-130 mg/dl

glucose

  • Peak postprandial <180 mg/dl

plasma glucose

*Referenced to a non-diabetic range of 4.0-6.0% using a DCCT-based assay

diabetes care in the u s improvement needed
Diabetes Care in the U.S.Improvement Needed
  • Data from NHANES III* and BRFSS**
  • Participants 18-74 years with DM
  • Results: Percent at Goal
    • A1C < 7.0 43% (>9.5, 18%)
    • LDL < 100 11% (>130, 58%)
    • BP < 140/90 66%
    • Dilated eye exam 63%
    • Foot exam 55%
  • * Nat’l Health & Nutrition Exam Survey
  • ** Behavioral Risk Factors Surveillance Study
census bureau projections 2000 2050
Census Bureau Projections 2000-2050
  • Census Bureau projects population will grow 47% by 2050
  • By 2050, there will be 112% more diagnosed cases of diabetes
  • Serious diabetes complications are projected to increase 137-189% by 2050

Diabetes 50 (Suppl 2): A205, 2001

slide29

GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions)

World

2003 = 194 million

2025 = 333 million

Increase 72%

slide32

Coronary Heart Disease

Mortality in Type 2 Diabetes

Men

Women

60

60

Diabetes

Diabetes

50

50

No Diabetes

No Diabetes

40

40

Mortality Rate per 1000

Mortality Rate per 1000

30

30

20

20

10

10

0

0

0-3

4-7

8-11

12-15

16-19

20-23

0-3

4-7

8-11

12-15

16-19

20-23

Duration of Follow-up (yr)

Duration of Follow-up (yr)

Krowlewski AS, et al Am J Med 1991; 90 (suppl2A):56S-61S.

a1c predicts cv risk in type 2 diabetes kuusisto et al

25

25

20

20

15

15

10

10

5

5

0

0

A1CPredicts CV Risk in Type 2 DiabetesKuusisto et al

229 Finnish Patients Followed for 3.5 Years

CHD mortality

All CHD events

Incidence (%)

over 3.5 years

*

Low<6%

Middle6.0%–7.9%

High>7.9%

Low<6%

Middle 6.0%–7.9%

High>7.9%

A1C tertile

CHD=coronary heart disease

*P<0.01 vs lowest tertile; †P<0.05 vs lowest tertile

Kuusisto J et al. Diabetes. 1994;43:960-967

ukpds bp control risk reductions
UKPDS - BP Control Risk Reductions

Any Diabetes Related Endpoint

Deaths Related to Diabetes

24%

Risk Reduction

32%

Risk Reduction

Events/ 1000 pt-years

p=0.0046

p=0.0019

n=1148

UKPDS. BMJ 1998 317: 703-713

slide36

% of Patients with a Major Coronary Event

55%

Risk Reduction

32%

Risk Reduction

Nondiabetic Patients

n=4242, p<0.00001

Diabetic Patients

n=201, p=0.002

Pyorala et al, Diabetes Care 1997; 20: 614

4S Study: Effect of Simvastatin on Coronary Events - 6 years

prevention of t2d with lifestyle intervention n 523 with igt mean age 55 bmi 31
Prevention of T2D withLifestyle Intervention(N=523 with IGT, mean age 55, BMI 31)

Incidence of diabetes reduced 58% (p=.0003).

* diet, exercise, frequent visits ** yearly advice

Source: Tuomilehto et al., ADA 2000

slide38

Type 2 Diabetes Prevention

Percent developing diabetes

All participants

All participants

Risk reduction

31% by metformin

58% by lifestyle

Placebo

40

30

Metformin

Cumulative incidence (%)

20

Lifestyle

10

0

0

1

2

3

4

Years from randomization

The DPP Research Group, NEJM 346:393-403, 2002

school based program to decrease soda consumption
School-based Program to Decrease Soda Consumption
  • 644 children (7-11 years old), 6 schools
  • Program to decrease regular and diet soda intake delivered in 1-hour sessions 4 times per year

Source: James et al., Brit Med J 328:1237, 2004

natural history of obesity leading to type 2 diabetes2
Natural History of Obesity Leading to Type 2 Diabetes

Complications

Onset ofdiabetes

Disability

Genetic susceptibility

Environmental factors Nutrition Physical

inactivity

IGT

Ongoing hyperglycemia

Obesity Insulin resistance

Death

Risk for

Disease

Metabolic

Syndrome

AtherosclerosisHyperglycemiaHypertension

RetinopathyNephropathyNeuropathy

BlindnessRenal failureCHDAmputation