Diabetes and Obesity in Women
Judith Fradkin, M.D.
Director, Division of Diabetes,
Endocrinology, and Metabolic Diseases
National Institute of
Diabetes and Digestive
and Kidney Diseases
Diabetes:
Scope of the Problem
• >17 million Americans
• Leading cause of:
– Kidney failure, adult blindness, amputations
• Cardiovascular disease: main cause of death
• Estimated $132 billion health care costs
Prevalence of Diagnosed Diabetes in the United States
Diagnosed (1960-1998) and Projected Diagnosed (2000-2050) Cases
30
People (millions)
25
20
Diagnosed cases
15
10
Projected diagnosed cases
5
0
Year
Data for 1960-1998 from the National Health Interview Survey, NCHS, CDC.
Projected data for 2000-2050 from Boyle JP, et al, Diabetes Care 24:1936-40, 2001.
Estimated Growth in Type 2 Diabetes
and US Population From 2000-2050
120
Type 2 DM
Percent increase
100
General population
80
Working age population (20-59)
60
40
20
Year
Bagust A, et al. Diabetes 50, Suppl 2 A205, 2001
2050
2045
2040
2035
2030
2025
2020
2015
2010
2005
2000
0
Prevalence of Diabetes by
Race/Ethnicity and Sex
Gender Specific Effects of Diabetes
• Health risk to woman
• Health risk to offspring
• Prevention is possible
Cardiovascular Mortality: Wome
Diabetes vs Nondiabetes
Chicago Ht
Framing
Rancho
NHANES
Nurses
Adventist
1
2
3
4
5
Relative Risk
6
7
Diabetes and Atherosclerosis
• DM a CAD Risk Equivalent
• Lose gender protection: equal age adjusted rates MI, stroke
claudication
• Claudication increased 3.5-fold men and 8.6-fold women
(Framingham)
• Mortality post MI double in diabetes
• Mortality increased 1.4-fold for men and 1.9-fold women
(Italy) and 1.6-fold for men and 2.6-fold for women
(Finland)
• CAD mortality decreasing in general population, steady in
men with DM and increasing in women with DM
(NHANES)
Aspirin Therapy*: Persons with Diabetes,
Age 40 years and Over, 1988-94
Age-adjusted percent
35
2010
Target
30
25
20
15
10
5
0
Total
Black, not White, not Mexican
Hispanic Hispanic American
Females
*Took aspirin at least 15 times in past month. I 95% confidence interval.
Source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Males
The ABC’s of Diabetes
Know Your Numbers
A is for A1C
B is for Blood Pressure
C is for Cholesterol
Gender Specific Effects on Acute
Complications of T1D
• Adolescent girls had 2-3 fold increased risk
DKA compared to boys or younger girls
• Adolescent girls had rates of hypoglycemia
like DCCT conventional group while boys
were similar to intensive group
• Hypothesis that girls skip insulin for fear of
weight gain
Gestational Diabetes
•
•
•
•
14% of pregnancies
135,000 women in U.S. annually
GDM has same risk factors as type 2 diabetes
Fetal macrosomia risk related to postprandial
glycemia
• Increased diabetes in offspring
• 60-90% risk of recurrence
• risk of type 2 diabetes after pregnancy 30% over
10 years
Diabetes in Pregnancy and Offspring:
The Vicious Cycle
Mother with
Diabetes
Woman with
Diabetes
Pettitt & Knowler,
J Obes Wt Reg
Infant of
Diabetic Mother
Prevalence (%)
Diabetes in Offspring By Maternal
Diabetes in Pregnancy
60
Mother
40
nondiabetic
prediabetic
diabetic
20
0
5-9
10-14
15-19
Age (years)
20-24
25-29
Birth Weight and Risk for Gestational
Diabetes
• U shaped curve with increased risk at low
birth weight and high birth weight
• Effect of high birth weight disappears with
adjustment for maternal diabetes
• Susceptibility to diabetes and insulin
resistance may be programmed in utero
Prevalence of Diabetes
in Pima Indians by Infant Feeding
Breast Fed
Prevalence (%)
30
>2 mo.
20
Never
Adj. OR = 0.38 (0.16 – 0.89)
10
0
Pettitt: Lancet, 1997
10-19
20-29
Age (years)
30-39
Overweight Prevalence by Race/Ethnicity
for Adolescent Boys and Girls
Boys Aged 12-19 years
P =<.001
Percentage
30
P =<.001
Girls Aged 12-19 years
NHANES III
1988-1994
NHANES
1999-2000
P =.002
P =.08
25
20
P =.35
P =.10
15
10
5
0
Non-Hispanic
White
Non-Hispanic
Black
Mexican
American
Non-Hispanic
White
Non-Hispanic
Black
Mexican
American
SOURCES: National Health and Nutrition Examination Survey,
National Center for Health Statistics, CDC
Obesity and Women
• Major determinant of health related quality of life
in women throughout the lifespan
• 34% of women vs 27.7% of men were obese in
NHANES 1999-2000
• 6.3% of women vs 3.1% of men with class 3
obesity
• 15% of black women have class 3 obesity– 3-fold
increase compared to non-Hispanic white women
and Mexican American women
The Toll of Obesity
• Premature mortality: 280,000 deaths in U.S.
annually
• Increased type 2 diabetes, CVD, arthritis, cancer
• Strong correlation with low SES particularly in
women
• Strong correlation with sedentary activities (TV
watching in women) and inverse correlation with
physical activity
The Diabetes Prevention
Program
A U.S. Randomized Clinical Trial
to Prevent Type 2 Diabetes
in Persons at High Risk
Weight Change (Kg)
Mean Weight Change from Baseline
+1
0
-1
-2
-3
-4
-5
-6
-7
-8
Placebo
Metformi
n
Lifestyle
0
6
12
18
24
Months
30
36
42
Percent Developing Diabetes
Cumulative incidence (%)
All participants
Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Placebo )
Metformin (n=1073, p<0.001 vs. Placebo)
Placebo (n=1082)
40
30
20
10
0
0
1
2
3
Years from randomization
4
Small Steps. Big Rewards.
What’s Your Game Plan?