Diabetes and Obesity- The Way Diabetes and Obesity- The Way Forward?Forward?

Dr A K GuptaFeb 17, 2005

Structure of the sessionStructure of the session

Diabetes- The Problem– Extent of the problem– Twin epidemic of obesity and diabetes– Cost to the individual and society

Risk factors for diabetes– Role of obesity

Evidence so far– Primary prevention –focus on obesity

Group work: Discussion of few questions and issues

What Is Diabetes?What Is Diabetes?

Definition: Diabetes Mellitus is a group of metabolic diseases characterised by hyperglycaemia resulting from defects in insulin secretion, insulin action, or both.

Associated with damage to:– Eyes– Kidneys– Vascular system– Nervous system

Diabetes- The EpidemicDiabetes- The Epidemic

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1995 2000 2005 2010 2015 2020 2025 2030

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150

300

350

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200

250

Diabetes – Prevalence

Year 2000:177 million

Year 2030:370 million.

equivalent to 2/3rd of europe population

ObesityObesityObesity worldwide prevalence

– 1995-200 million– 2000-300 million

Developed world– US – prevalence estimates

1994:22.9%1999: 30.5%2008: 40%

– UK: similar rates, tripling of prevalence between 1980 - 1997

Copyright restrictions may apply.

Mokdad, A. H. et al. JAMA 2001;286:1195-1200.

Prevalence of Obesity Among US Adults

Copyright restrictions may apply.

Mokdad, A. H. et al. JAMA 2001;286:1195-1200.

Prevalence of Diagnosed Diabetes Among US Adults

Diabetes caused by excessive weightDiabetes caused by excessive weight

Diabetes : A dangerous diseaseDiabetes : A dangerous disease

Diabetes : The ProblemsDiabetes : The ProblemsDiabetes : The ProblemsDiabetes : The Problems

RetinopathyRetinopathyCommon cause of Common cause of blindness in peopleblindness in people

of working age in Westof working age in West

NephropathyNephropathy20% of all ESRD20% of all ESRD

Erectile DysfunctionErectile DysfunctionMay affect up to 50%May affect up to 50%

Macrovascular Macrovascular 2–4 x increased risk 2–4 x increased risk

of CVD, 75% have of CVD, 75% have hypertensionhypertension

Foot ProblemsFoot Problems15% develop 15% develop

foot ulcers; 5–15% need foot ulcers; 5–15% need amputationamputation

The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.

Mortality in DiabetesMortality in Diabetes

Diabetic patients without previous MI have as high a risk of MI as non-diabetic patients with previous MI

New England Journal of Medicine 1998;339:229–234.

Without previousMI previous MIWith previousMIprevious MI

7-ye

ar i

nci

den

ce o

f M

I (%

)

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5

10

15

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25

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45

non-diabetic with diabetes

7 year follow-up

Costs- Fact FileCosts- Fact File

Studies have shown that diabetes is a costly disease

Type 2 diabetes accounted for between 3% and 6% of total healthcare expenditure in eight European countries

Hospital in-patient costs are the largest single contributor to direct healthcare costs

Estimated total direct healthcare costs of diabetes in selected European

countriesCountry

General healthcare cost per patient (US$)

Additional cost due to presence of diabetes

(US$)

Annual cost per patient with type 2 diabetes (US$)

Belgium 1,495 1,647 3,142

France 1,979 1,009 2,988

Italy 1,259 1,611 2,870

Sweden 1,710 855 2,565

United Kingdom

1,144 881 2,025

Source: Diabetes Atlas, International Diabetes Federation

Risk Factors for Type 2 DMRisk Factors for Type 2 DM Non Modifiable

– Age (?40 or more)– First degree relative with Type 2 DM– Ethnicity– History of GDM

Modifiable – BMI (?25 or more)– Habitual physical inactivity– ? Previously identified glucose intolerance

Best single predictor– Presence of other “Syndrome X” abnormalities– ? Psychosocial Stress /and presence of major depressive episodes

Obesity and type 2 diabetesObesity and type 2 diabetes

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50

100

<22 23-23.9

25-26.9

29-30.9

>35

Body Mass Index

Age

adj

uste

d R

elat

ive

Ris

k of

D

iabe

tes

MenWomen

Chan et al (1994) and Colditz et al (1995)

Diabetes and ObesityDiabetes and Obesity

Females of BMI >35 has 93 times the risk of developing diabetes compared to those with BMI<21

Increase in mean weight by one kg increase the risk of diabetes by 4.5% ( recent data - 9%)

Ethnic populations e.G. Pima Indians, Samoans- changed lifestyles, become more obese- diabetes

Not all obese have diabetes, but most of people with diabetes have excess weight

““58%of Diabetes 58%of Diabetes Cases Globally Can Be Cases Globally Can Be Attributed to Body Attributed to Body Mass Index Above 21 Mass Index Above 21 Kg/m2”Kg/m2”

Source: IDF Press Release August 25, 2003Source: IDF Press Release August 25, 2003

Type 2 Diabetes: Fatness Vs FitnessType 2 Diabetes: Fatness Vs Fitness

Source: Wei et al 1999

‘Obesity and physical activity are the most preventable risk factors for diabetes, and could potentially lead to more than 50% reduction in prevalence of the diabetes’

Criteria for Undertaking Community-Criteria for Undertaking Community-based Interventionsbased Interventions

Common and serious disease Strong causal relationships between risk factor

levels and disease risk Predominantly social factors which determine risk

levels e.g. lifestyle behaviours Established benefit and safety of interventions Potential for community control exists Added value to “community” based rather than

individual based approach

Natural History of IGTNatural History of IGT

IGT

Normal

25%

IGT

25%

Diabetes

50%After 10 yearsAfter 10 years

Prevention Studies in People with IGT: Prevention Studies in People with IGT: Downstream strategiesDownstream strategies

Lifestyle interventions – Da Qing : Diet and Exercise– Malmo study : Diet and exercise– Finish Diabetes Prevention Study Lifestyle– DPP (Diabetes Prevention Study) Lifestyle, MF (Glitazone)

Lifestyle interventions with pharmacological agents– FHS (Fasting Hyperglycaemia Study) Healthy Living and

SU– EDIT (Early Diabetes Intervention Study): Acarbose and

MF– STOP NIDDM : Acarbose

DA QING - DA QING - 1997, Diabetes Care, Pan et al1997, Diabetes Care, Pan et al

Screened 110,660 Men and women in 33 health centres in China (all population > 25yrs)

577 IGTDiet / Exercise / Both / ControlMean Age 45 yrsMean BMI 25.8 Kg/m26 yr FU, OGTT every 2 yrs

02468

101214161820

per

100

pers

on y

ears

Control Diet Exercise Diet andexercise

Overweight

Lean

Total

Incidence of diabetes at or Incidence of diabetes at or before 6-year evaluationbefore 6-year evaluation

Xiao-Ren et al, 1997

DA QING ResultsDA QING Results

Reduction in risk of developing diabetes– Diet 31%– Exercise 46%– Both 42%

Other results Lean group with exercise decreased risk with weight

increase BMI overall- no change, but in BMI>25 it decreased

by 1 Kg ? apply to European Population : older, more obese, socio-cultural issues, statistical issues Importance of physical activity apart from the weight

control

Finish Diabetes Prevention Finish Diabetes Prevention StudyStudy

522 - IGT BUT older and more obese– Aged 40-65– Family History of diabetes /

overweight– Age 55 yrs– BMI 31

Tuomilehto et al, NEJM, May 2001

Finish Diabetes Prevention Finish Diabetes Prevention StudyStudy

Dietary and Exercise Intervention Goals

– 5% weight loss– Total fat intake < 30%– Saturated fat intake <10%– Fibre >15gm per 1000 kcal– Moderate exercise for 30 mins every day

Seven sessions in first year,1 session nutritionalist every 3 months throughout 4 year study

Success in achieving the goals of the intervention by Success in achieving the goals of the intervention by one year according to treatment groupone year according to treatment group

Goal Interventiongroup

Controlgroup

PValue

% of subjects

Weight reduction >5% 43 13 0.001

Fat intake<30% energyintake

47 26 0.001

Saturated fat intake<10% ofenergy intake

26 11 0.001

Fibre intake>=15g/1000 kcal 25 12 0.001

Exercise > 4 hr / wk 86 71 0.001

Tuomilehto et al 2001

Finish Diabetes Prevention Finish Diabetes Prevention StudyStudy

Risk of developing diabetes reduced by 58% after 4 years

11% vs 23%

Cumulative risk of developing diabetes

NNT = 8

Diabetes Prevention Programme Diabetes Prevention Programme (DPP)(DPP)

27 centres 3234 participants > Or = 25 years BMI > or = 24 (22 for indo Asian) IGT 45%

– American Indian, African American, Hispanic American, Asia American, pacific islanders

DPPDPPAverage Age 51 Years

BMI 34

Lifestyle intervention

Weight reduction 7% Low fat diet Exercise for 150 mins per

week

OR metformin 850mgs BD

DPPDPPTrial stopped 1 year early, after 2.8 yr of

follow-up

• 29% Diabetes in controls

• 14% in Diet and exercise

• 22% in Metformin

3 year Data Risk Reduction

• 58% whole group

• 71% those aged >60yrs

• 31% Metformin (less effect in older and less obese)

Cost of PreventionCost of PreventionTotal cost $174.3 million Diet and exercise prevented diabetes in 162

people Metformin prevented diabetes in 77 people

(237 people did not develop diabetes over 3 yrs)

NNT = 7 for life style intervention

NNT= 14 for MetforminCosts per person over 3 yr excluding research cost

Metformin $2542

Life style intervention $2780

Obesity and IGTObesity and IGT

Total 136 subjects with IGT and mean BMI of 48 27 controls 109 bariatric surgery

Control group 22.2% developed diabetes Surgical group 0.91% developed diabetes

25-30 fold reduction in risk of diabetes

Long et al Diabetes Care 1994

ObesityObesity

Swedish Obese Subjects (SOS) 845 controls 845 bariatric surgery

2 yr FU Mean Age 48 yrs BMI 40-42

Sjostrom et al Obesity Research 1999

Weight Loss in SOSWeight Loss in SOS

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% w

eig

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Controls

Banding

VBG

G.bypass

Sjostrom et al, 1999

months

XENDOSXENDOS

3300 patients, BMI>30Xenical or placebo for 4 years

– With diet / exercise advice 2 weekly for 6/12, then monthly

Xenical group lost 6.9kg, control 4.1kgXenical group 37% less likely to develop

DMNNT = 36

Other interventionsOther interventions

Midstream intervention– Obese patients- pound for pound ( treatment group monthly

newsletter and 4 session of couselling- 12 mths)– Children– Gestational diabetes

Upstream intervention – Best – North Karelia study– Stanford five city project

Group WorkGroup Work

Briefly discuss the following questionsYour abstract/article: read the abstract,and

if possible, share the evidence during discussion

Provide the examples from your practice wherever possible.

Question 1Question 1

Given a perfect world, what ‘ideally’ should be done to reduce the twin burden of diabetes and obesity.

What will be an ‘ideal’ programme in our setting ( think there are no constraints)

5 min

Question 2Question 2

List possible constraints in implementation of the ideal programme in our setting e.g. Attitudes of people concerned- health care professionals and general population

Any solutions to those constraints?

Customer Profiles - Driving Customer Profiles - Driving ChangeChange

Lifestyle

Technology

Economics

Type 2 Yesterday

Low motivation

moderatelymobile

Average Age: 60

overweight

not well informed

lowawareness

Type 2 +10 years

Average Age: 45

physically inactive

obese

Aware but indifferent

better informed/“connected”

consumer power

“quick-fix”remedies

Current ScenarioCurrent Scenario

Focus on treatment and prevention of complications – secondary prevention ( mainly individual based)

Needs a ‘paradigm’ shift- from secondary prevention to primary prevention

Three strategies for primary prevention- – Upstream- whole population – Midstream- special high risk groups eg children,

elderly etc– Downstream- high risk ‘individuals’

Question-3Question-3

Pros and Cons of various primary prevention focus groups?

Primary prevention vs secondary prevention

Primary Prevention – why?

The way forwardThe way forward

Structured programme geared towards prevention Commitment of more resources- Costs need to be

considered as investment More Education to the users especially the socially

deprived Implementation of the intensive programmes of

management to curtail the costs.