The Global Epidemics
of Obesity & Diabetes
Paul W. Ladenson, M.D.
JHI Partners Forum 2012
October 2, 2012
Baltimore
The Obesity & Diabetes Epidemics
Aims
• Describe relationship between
overweight/obesity and diabetes from
epidemiological and biological
perspectives
• 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
-Nauru
-United Arab Emirates
-Saudi Arabia
Lowest diabetes prevalences
-Mongolia
-Rwanda
-Iceland
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
American
14% Mexican American
14% Puerto Rican American
14
12%
Percentage (%)
12
10
8
7%
13%
8%
6
4
2
0
Non-Hispanic
White
Asian Americans Hispanic/Latino
Non-Hispanic
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
Caucasians
• 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
origin
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
women).
• 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 comorbidities (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
reactivity
• Epigenetic changes in cellular gene expression:
fetal adaptation to adverse intrauterine
environment
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 +
Guidance
Surgery
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
Aims
• 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
21
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
23
TTHSI Diabetes Outreach Program
Diabetes Care Performance Improvement
• Sustainable Continuous Quality Improvement
based on data collected and dashboard reporting
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Johns Hopkins Diabetes
International Programs
• Health Professional education & empowerment
• Academy of Diabetes Clinicians of Trinidad &
Tobago
• 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
systems
• 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