The Epidemic
of Diabesity –
How Will It
Change Your
Life?
Marshall Bouldin MD
Director, Diabetes and Metabolism Program
Associate Professor of Medicine
University of Mississippi Medical Center
The Burden of Diabetes
 16 million Americans
 22 million with impaired glucose tolerance




Leading cause of blindness
Leading cause of ESRD
Leading cause of limb amputations
2/3 die from coronary disease
 Per capita cost/pt 2x that of non-diabetic pt
 15% of all U.S. health costs; 25% of all Medicare costs
 40% of all costs are related to hospitalization
Cessna Jet
• $2.55 million
• Could purchase
44,000
Elton John
• $1.5 million
• He could perform
66,000 times
Epidemiology
“But wait a bit,” the Oysters cried
“Before we have our chat.
For some of us are out of breath,
And all of us are fat.”
- Lewis Carroll
Obesity in the prehistoric ages
Venus of Willendorf
c. 24,000-22,000 BCE
Oolitic limestone
4 3/8 inches (11.1 cm) high
(Naturhistorisches Museum,
Vienna)
Globesity/Diabesity
• Obesity is more prevalent than malnutrition
in the world
• Obesity is a stronger predictor of morbidity
than poverty or smoking
• Framingham: obesity = smoking in terms of
life lost (~7yrs)
• Prevalence of obesity/overweight –
skyrocketing globally
Natural History: Pandemic
 DM in 1897 – 2.8/100,000 prevalence
 Since 1958 5-fold increase in prevalence of DM2
 From 1991-2001, 49% increase in overall
prevalence, 76% increase in age 30-39, 10-fold
increase in pediatric DM2
 From 1991-2001, 61% increase in obesity
 From 2003 to 2005 13% increase in diabetes
 1 in 3 children born in 2000 will develop diabetes
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity* Trends Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity* Trends Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity and Diabetes Trends in the US
Obesity
No Data
Diabetes
No Data
1991
<10%
2001
10-14%
15-19%
1991
<4%
Mokdad. JAMA. 2003;289:76-79.
20-24%
25%
2001
4-6%
7-8%
9-10%
>10%
26
Obesity Syndrome
(“Syndrome X”, “Metabolic Syndrome”,
“Insulin Resistance Syndrome”)
Insulin
Resistance/
Hyperinsulinemia
Dyslipidemia
Obesity/
Overweight
Glucose
Intolerance
Atherosclerosis
Hypertension
Kidney Disease
Visceral Obesity Increases Risk for
Cardiovascular Disease and Metabolic Disorders
CVD/Metabolic Risk Factors:
• Hypertension
• Kidney Disease
• Insulin resistance
• Type 2 Diabetes
• Hypertriglyceridemia
• High dense LDL
• Low HDL Cholesterol
• Postprandial hyperlipidemia
• Microalbuminuria/Proteinuria
• Impaired fibrinolysis
• Low grade chronic inflammation
( IL-6, TNF, CRP)
Global CV Risk
Elevated cholesterol combined with other
risk factors markedly increases CVD risk*
Dyslipidemia
TC 260 mg/dL
 2.3
 3.5
Hypertension
SBP 150 mm Hg
 1.5
 6.2
 2.8
4
Glucose
Intolerance
 1.8
*Compared with risk for a 40-year-old male nonsmoker with total cholesterol=185 mg/dL,
Systolic BP=120 mm Hg, and no glucose intolerance, ECG-LVH negative, whose probability of
developing CVD is 15/1000 (1.5%) in 8 years.
Kannel. In: Genest et al (eds). Hypertension: Physiopathology and Treatment. New York, NY:
McGraw-Hill; 1977:888-910; Wilson et al. Arch Intern Med. 1999;159:1104-1109; Poulter. Am J
Hypertens. 1999;12:92S-95S; Fagot-Campagna et al. Diabetes. 2000;49 (suppl 1):A78-A79.
24
The Obesity Epidemic Has Reached America’s Pets.
August 16, 2004, AP Press Release
“The National Academy of
Science said that today that as
many as 40% of dogs and 12%
of cats presented at clinics are
either overweight or obese.”
“It seems as though
American’s bad lifestyle habits
have started to affect man’s
best friends.”
Background: Mississippi
•
•
•
•
•
Highest prevalence of diabetes and obesity in U.S.
Very high in all CV and diabetes complications
Worst socioeconomic status in U.S.
Very large at-risk population
Very high in health disparities and poor access to
care
• Half the average number of providers per capita
Percent of Population
Trend in Percent of Mississippi Population
Overweight or Obese, Age 18 and Above
40.0
35.0
30.0
Overweight
Linear (Obese)
Obese
25.0
20.0
15.0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
BRFSS Interview Year
Prevalence of Overweight/Obesity by Gender
(Mississippi BRFSS)
Total
75.0
70.0
65.0
M
60.0
F
55.0
T
50.0
45.0
40.0
2000 2001 2002 2003 2004 2005
Prevalence of Overweight/Obesity by Race
(Mississippi BRFSS)
By Race
75.0
70.0
65.0
W
60.0
NW
55.0
T
50.0
45.0
40.0
2000 2001 2002 2003 2004 2005
Prevalence of Overweight/Obesity in Men
(Mississippi BRFSS)
Males
75.0
70.0
65.0
WM
60.0
NWM
55.0
M
50.0
45.0
40.0
2000 2001 2002 2003 2004 2005
Prevalence of Overweight/Obesity in Women
(Mississippi BRFSS)
Fem ales
75.0
70.0
65.0
WF
60.0
NWF
55.0
F
50.0
45.0
40.0
2000 2001 2002 2003 2004 2005
Childhood Obesity
• Rates continue to INCREASE, and overweight
and obesity appears to DISCRIMINATE by race,
sex, and geographic location
• Rates DOUBLED among children and TRIPLED
among youth since 1980
• The greatest INCREASES in rates are among:
– African-American girls
– Hispanic youth
– Those living in the south
The Prevalence
(overtime in the US)
Prevalence at 95th Percentile
16
14
12
10
Ages 6-11
8
Ages 12-19
6
4
2
0
1976-1980
1988-1994
1999-2000
American Obesity Association
Percentage by Gender and Race
Percent
CAYPOS
50
45
40
35
30
25
20
15
10
5
0
Overweight
At Risk
White males
Nonwhite males
White females
Nonwhite
females
At risk of overweight = BMI-for-age > 85th percentile, < 95th percentile for gender
Over weight = BMI-for-age > 95th percentile for gender
Percentage by Grade
CAYPOS
Percent
35
30
At Risk
25
Overweight
20
15
10
5
0
First
Second
Third
Fourth
Fifth
Sixth
Seventh Eighth
Percentage by Grade
CAYPOS
50
Overweight
Percent
40
At Risk
30
20
10
0
First
Second
Third
Fourth
Fifth
Sixth Seventh Eighth
Childhood obesity over time
Prevalence at 95th Percentile
30
25
20
Ages 6-11
15
Ages 12-19
10
YRBSS 6 - 8
5
CAYPOS 6 - 8
0
1
67
9
80
9
1
1
88
9
94
9
1
1
99
9
00
0
2
03
0
2
How well do we take care of
diabetes?
Mississippi: 52nd out of 50 states
in the quality of diabetes care
So What Is Diabetes?
No, really…
Natural History of DM2
BA Ramlo-Halsted, SV Edelman, The Natural History of Type 2 Diabetes: Practical Points to Consider in
Developing Prevention and Treatment Strategies , CLINICAL DIABETES, 18 (2) Spring 2000, pg 80-
Severity of Diabetes
Impaired Glucose Tolerance
Frank Diabetes
Insulin Resistance
Hepatic Glucose Production
Endogenous Insulin
Postprandial Blood Glucose
Fasting Blood Glucose
Microvascular Complications
Macrovascular Complications
Time
Years to
Decades
Typical Diagnosis of Diabetes
Pre-diabetes
•
•
•
•
IFG/IGT
FBG – >100mg/dl, <126mg/dl
30-60% become diabetic
Weight loss and exercise prevent diabetes in
these pts
• Drug therapy for prevention is much less
effective
Diabetes is very preventable!
 With loss of 7% of body weight and 150
min/week of moderate exercise, diabetes
can be prevented about 58% of the time
 This was true for all subgroups – age, sex,
race, etc.
 Weight loss and exercise is twice as good at
preventing diabetes as medicine
Diabetes Prevention Program: Intensive Lifestyle
Changes Reduce the Risk of Developing Type 2
Diabetes
% Change in RR
N=3,234 with IGT, mean age 51
0
-10
-31
-20
-30
-40
-50
-60
-70
-58
Lifestyle
Metformin
Who would have thought the cure for Type 2
Diabetes would be a surgical procedure?


All aspects of DM2 improve with exercise and weight loss
Gastric Bypass (Pories et al.):
n=608, 146 w DM2
Preop wt:
304.4lb (198-615)
1 y p/op:
192.2lb (104-466)
5 y p/op:
205.4lb (107-512)
10 y p/op:
206.5lb(130-388)
14 y p/op:
204.7lb(158-270)
121 of 145(83%) with DM2: nl FBG, A1c, insulin at 14 years
150 of 152(99%) with IGT: nl FBG, A1c, insulin at 14 years

Multiple similar studies show normalization of FBG, insulin, A1c,
insulin release, insulin resistance, glucose utilization w/i months p
surgery
But HOW did all this happen to us?
The 2nd Law of Thermodynamics
Total energy is ALWAYS conserved
Calories in = Calories burned
BAGEL
20 Years Ago
140 calories
3-inch diameter
Today
350 calories
6-inch diameter
Calorie Difference: 210 calories
CHEESEBURGER
20 Years Ago
Today
333 calories
590 calories
Calorie Difference: 257 calories
SPAGHETTI AND MEATBALLS
20 Years Ago
500 calories
1 cup spaghetti with sauce
and 3 small meatballs
Today
1,025 calories
2 cups of pasta with sauce
and 3 large meatballs
Calorie Difference: 525 calories
Sedentary Lifestyle
• Average hours of TV viewing per
household per day:
1950
1960
1970
1980
2003
4 hours,
5 hours,
6 hours,
6 hours,
8 hours
43 minutes
7 minutes
2 minutes
45 minutes
Source: Neilson Media Research
COFFEE
20 Years Ago
Today
Coffee
(with whole milk and sugar)
Mocha Coffee
(with steamed whole milk and
mocha syrup)
45 calories
8 ounces
How many calories
are in today's coffee?
COFFEE
20 Years Ago
Today
Coffee
(with whole milk and sugar)
Mocha Coffee
(with steamed whole milk and
mocha syrup)
45 calories
8 ounces
350 calories
16 ounces
Calorie Difference: 305 calories
Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to walk in order
to burn those extra 305 calories?*
*Based on 130-pound person
Calories In = Calories Out
If you walk 1 hour and 20 minutes, you
will burn approximately 305 calories.*
*Based on 130-pound person
MUFFIN
20 Years Ago
210 calories
1.5 ounces
Today
How many calories are
in today’s muffin?
MUFFIN
20 Years Ago
210 calories
1.5 ounces
Today
500 calories
4 ounces
Calorie Difference: 290 calories
Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to vacuum in
order to burn those extra 290 calories?*
*Based on 130-pound person
Calories In = Calories Out
If you vacuum for 1 hour and 30 minutes you
will burn approximately 290 calories.*
*Based on 130-pound person
CHICKEN CAESAR SALAD
20 Years Ago
390 calories
1 ½ cups
Today
How many calories are in
today’s chicken Caesar
salad?
CHICKEN CAESAR SALAD
20 Years Ago
390 calories
1 ½ cups
Today
790 calories
3 ½ cups
Calorie Difference: 400 calories
Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to walk the dog in
order to burn those extra 400 calories?*
*Based on 160-pound person
Calories In = Calories Out
If you walk the dog for 1 hour and 20 minutes,
you will burn approximately 400 calories.*
*Based on 160-pound person
But what about my genes?
After all, I didn’t pick my parents…
Prevalence of Diabetes in US by
Ethnic Groups
Age 45-74 years
% with Diabetes
60
50
40
30
20
10
0
European
AsianAmerican
JapaneseAmerican
AfricanAmerican
MexicanAmerican
CubanAmerican
Harris et al, Diabetes 1987;36:523
Flegal et al, Diabetes Care 1991; 14:628
Fujimoto et al, Diabetes 1987; 36:721
Knowler et al, Diabetes Care, 1993; 16:216
Pima
Diabetes trends in US by Race
(1990-1998)
% Increase
40
30
20
10
0
Caucasian
African-American
Hispanic
Adapted from: Mokdad A. et al, Diabetes Care, 2000;23(9):1278-1283
Genes or Lifestyle?
Arizona Pimas vs Mexican Pimas
Arizona Pimas
Mexican Pimas
Height (cm)
164
160
BMI (kg/m2)
33.4
24.9
Hours of hard work
per week
3
>40
% Diabetic
54%
6.3%
Ravusin et al, Diabetes Care 17:1067, 1994
Our fate, dear Brutus, is
not in our stars, but in
ourselves…
Type 2 diabetes It’s not our genes, it’s
our blue jeans!
So What is Diabetes Care?
 Controlling complications
- blood sugar
- blood pressure
- lipids
 Losing weight!
 Becoming more active
 If you smoke, STOP!
Guidelines – the Short Form
1. BG, BP, Lipid control
2. Sceening: eyes, kidneys, feet
3. ASA use
4. Smoking cessation
Monitoring Goals in a Nutshell
•
•
•
•
•
•
•
A1c (<7=goal, >8=‘action required’)
BP control (<130/80)
Lipids (1: LDL<100, 2: HDL>40, 3: TG<200)
Retinal exams – yearly
Nephropathy screening (Microalbumin) - yearly
Foot screening – yearly and as indicated
ASA therapy – basically, if over 30 and not
contraindicated
• Smoking Cessation
Lifetime Microvascular Events in
Type 2 Diabetes
HbA1c 7.2%
Percent
Change
Blindness
HbA1c
10%
19%
5%
-72
Renal failure
17%
2%
-87
Symptomatic
Neuropathy
Amputation
31%
10%
-68
15%
5%
-67
Eastman, RC et al Model of Complications of NIDDM, Diabetes Care, May 1997, 20(5), 735-744.
Hypoglycemia
• The only diabetic emergency you may
routinely see on the farm
• Signs and symptoms: “he ain’t actin’ right”,
agitation, sweats, shakes, heart rate,
confusion
• Cause: blood sugar too low
• Cure: EAT SOMETHING RIGHT NOW!
Diabetes: What To Do?
 Prevention
- prevent obesity
- in those already overweight, prevent
diabetes
 Decrease the cost of existing disease
- decrease complications
- improve the quality of care
But How Do We Do It???
 System of care reforms – a new approach to this
disease is needed
 Education - for patients and providers
 Population strategies
- Children & Mothers
- Schools
- Regulatory efforts
 Research
- Basic
- Translational
The Big Picture
 The burden of both type 2 diabetes and obesity is rapidly
increasing, and shows no sign of stopping. If our society
does not change this, diabetes alone will bankrupt our
medical system.
 We can prevent most of the misery and cost, but we aren’t.
Diabetes is highly preventable; for those with diabetes, its
complications are highly preventable.
 Systematic approaches (e.g. – guidelines, disease
management, …) to diabetes FAR exceed the results of
traditional care and enhance provider effectiveness.









DHA/UMMC Delta Diabetes Project
Model
Multidisciplinary, chronic disease model; CBPR
Non-traditional features
Resource sparing
A service to primary care providers
Two arms: education and management – patient
self-management is the key
4500+ patients, 800+ visits/mo
Data and outcomes driven; novel applications of
teleinformatics
Excellent quality of care, outcome, and patient
satisfaction results
Successfully reproduced in community settings
DDP Outcomes
 Average patient has had diabetes for 10 years;
36% no-pay; 70% African-American
 Mean A1c on presentation = ~10.0%; mean
decrease in A1c –1.92%
 Improvement in blood pressure, lipids
 Outcomes are durable
 The model and its outcomes are easily
reproducible in community practice
 Outcomes independent of race and gender
 High quality of care measures: ~90+%
 High patient satisfaction measures: 97+%
 Resource utilization: 4 management and 2
education visits (year 1)
Delta Diabetes Project
 Regional system of diabetes care improvement for
Mississippi Delta
 Community-based participatory research
collaboration; sustainability
 6 sites
 Integral provider education
 Duplicating or exceeding UMMC results in all
outcomes
 Diabetes is only a test case chronic disease – CHF,
CV mortality, HTN, asthma, etc.
 Foothold for regional prevention programs in
diabetes, obesity, and CV mortality