diabetes - the global picture: the world’s … ndm ifg igt ngt 35% 18% 14% 22% 11% 65% of cvd...
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Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
1The screen versions of these slides have full details of copyright and acknowledgements
1
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Prof. Paul Zimmet AODirector EmeritusBaker IDI Heart and Diabetes InstituteAustralia
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“Diabetes is a public health emergency in slow motion”
Ban Ki-Moon,UN Secretary-General
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2006 UN general assembly resolution on diabetes
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
2The screen versions of these slides have full details of copyright and acknowledgements
4
5
Obesity is driving the escalating Diabesity epidemic:
the biggest epidemic in human history
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OECD predictions for future overweight rates: 1970s-2020
Past and projected future overweight rates in selected OECD countries
Prop
ortio
n ov
erw
eigh
t
Years
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
3The screen versions of these slides have full details of copyright and acknowledgements
7
The escalating diabetes epidemic:a historical perspective
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Modernization & high diabetes prevalence1966-1975
Zimmet: Pacific – Nauru
Bennett: Phoenix Arizona:Pima Indians
Wise: Australia:Indigenous
Ian Prior: New Zealand: Maori
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Age specific prevalence of diabetesNauru: 1994
Age group (years)
Prevalence %
0
10
20
30
40
50
60
25 - 34 35 - 44 44 - 54
MalesFemales
55 - 64 65+
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
4The screen versions of these slides have full details of copyright and acknowledgements
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The 10 top nations for diabetes prevalence: 2010
0% 5% 10% 15% 20% 25% 30% 35%
Nauru
UAE
Saudi Arabia
Mauritius
Bahrain
Réunion
Kuwait
Oman
Tonga
Malaysia
Prevalence %** For 20-79 year population
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Western killer in paradise “The Age”, May 1992
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On the basis of the Nauru studies, we predicted there would be a global epidemic
of type 2 diabetes
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
5The screen versions of these slides have full details of copyright and acknowledgements
13
Mauritius: the next step in predicting the global diabetes epidemic
• The population consistsof Asian Indians, Blacks (Creoles) and Chinese
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62% increase from 1987 to 2009
Mauritius: increase in diabetes prevalence over 22 yrs
Standardised to 2008 population structure of Mauritius
Prev
alen
ce o
f Dia
bete
s %
0
5
10
15
20
25
30
1987 1992 1998 2004 2009
MenWomenTotal14.6%
17.4%20.1%
18.7%23.6%
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• The 3 ethnic groups in Mauritius (see slide 13) constitute 66% of the world’s population
• Studies performed: 1987, 1992, 1998, 2004 and 2009
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Global projections for the diabetes epidemic: 2010-2030 (millions)
Shaw J. Diab Res & Clin Practice, 2009 IDF Atlas 2009 www.idf.org
World
2010 = 285 million2030 = 438 million
Increase 54%
2011 – a staggering 366 million2030 – 552 million
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
6The screen versions of these slides have full details of copyright and acknowledgements
16
Undiagnosed diabetes
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The top 10s (number of people with diabetes)
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Increasing diabetes prevalence 1980-2002: China
Life style changesJi Linong: Personal communication
0
2
4
6
8
10
1980 1994 1996 2002 2009
9.7
1
2.8 3.2
5.0
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
7The screen versions of these slides have full details of copyright and acknowledgements
19
20
Prevalence of diabetes in urban India (Chennai)
Prevalence 2000 – 13.9%
Prevalence 2006 – 18.6%
Ramachandran et al., Diabetes Care 2008
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The Middle-East – world diabetes hot-spot
DM prevalence for adults age 20-79
UAE
0
10
20
S. Arabia
0
10
20 16.8%
18.7%
Oman
0
10
20 13.4%
Kuwait
0
10
20 14.6%
Bahrain
0
10
20 15.4%
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
8The screen versions of these slides have full details of copyright and acknowledgements
22
Diabetes prevalence in Qatar & Australia
0
5
10
15
20
25
30
35
20-29 30-39 40-49 50-59Age group (years)
QatarAustralia*
Prevalence (%)
*Australian data apply to 25-34; 35-44; 45-54; 55-64
Bener et al., DRCP 84; 2009: 99-106Dunstan et al., Diab Care 2002; 25: 829-834
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Prevalence of diabetes: Japan
7.4 million(16.2 million including pre-diabetic subjects)
1955 60 65 70 75 80 85 90 95 2002 (year)
35
30
25
20
15
10
5
0
31.5 fold
Rel
ativ
e ra
tio
1
Takashi Kadowaki: Personal communication
An explosive increase
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Time trends in type 2 diabetes incidence among Japanese children
Kitagawa T et al., Clin Pediatr 1998
Type 2 diabetes
Obesity
Type
2 d
iabe
tes
inci
denc
e / 1
00,0
00po
pula
tion
per y
ear
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
8.0
7.0
6.0
5.0
19951995198519801975
Prevalence of obesity (%)
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
9The screen versions of these slides have full details of copyright and acknowledgements
25
Number (in millions) with diagnosed diabetes, USA, 1980–2009
http://www.cdc.gov/diabetes/surveillance/index.htm
Num
ber (
mill
ions
)
Year
26www.cdc.gov/diabetes
County-level estimates of diagnosed diabetes among adults aged ≥ 20 years: United States 2004 and 2008
Percent0 - 6.56.6 - 8.08.1 - 9.49.5 - 11.1> 11.2
2004 2008
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Prevalence of diabetes and IFG in rural Bangladesh: 1999 and 2004
Rahim et al., Diab Res Clin Prac 77, 2007, 300-305
0
1
2
3
4
5
6
7
8
Men Women Total Men Women Total
19992004
Prev
alen
ce (%
)
DM IFG
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
10The screen versions of these slides have full details of copyright and acknowledgements
28
Diabetes prevalence rates in selected nations: 1970-1989 & 1990-2005
B: Multiplication factor for increasedprevalence of Type 2 Diabetes
0
1
2
3
4
5
6
A: Prevalence of Type 2 Diabetes (%)
1970-1989
1990-2005
0
2
4
6
8
10
12
14
Yoon KH et al., Lancet 2006; 368: 1681-1688
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Economic development & prevalence of diabetes in selected Asian countries:
1981-2008
1981-19871988-19941995-20012002-2008
ChinaIndia Malaysia Singapore
B: Prevalence (%)
A: Real GDP per head (US$)
05000
100001500020000250003000035000
02468
101214161820
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Regional highlights
Africa: 78% of people with diabetes are undiagnosed
Europe: the highest prevalence of type 1 diabetes in children
Middle East and North Africa: 6 of the top 10 countries by diabetes prevalence
North America and Caribbean: 1 adult in 10 has diabetes
South and Central America: 12.3% of all deaths were due to diabetes
South-East Asia: almost one-fifth of the world’s people with diabetes live in just seven countries
Western Pacific: 132 million adults have diabetes, the largest number of any region
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
11The screen versions of these slides have full details of copyright and acknowledgements
31
Diabetes in Australia joining the global epidemic
Dunstan D et al., Diabetes Care 2002
Busselton1981
250,000
1983
400,000
1990
550,000
1995
725,000
2000
1,000,000
AU
SDIA
B
2010 >1,500,000
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Eligible participants9,303
CVD Mortality
124 (34%)
Non CVD mortality 244
(66%)
All-cause Mortality
368
2000
2006Median: 6.6 yrs
AusDiab mortality follow-up
Dunstan et al., Television viewing time and mortality: The AusDiab study; Circulation 2010; 121: 384-391
Adults ≥ 25 yrs participating in the baseline survey = 11,247
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AusDiab mortality: CVD deaths
KDM
NDM
IFG
IGT
NGT
35%
18%
14%
22%
11%
65% of CVD deaths over 5 years occurred in people with DM, IFG or IGT at baseline
Barr et al., Circulation2007; 116: 151-7
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
12The screen versions of these slides have full details of copyright and acknowledgements
34
“If current trends continue, by 2020, diabetes will be the leading cause of disease for men and the second
leading cause for women.”
Australia 2020: setting our nation's sights for the future
The Hon Kevin Rudd(Former) Prime Minister
April 2008
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Australian Indigenous people have one of the highest rates
of diabetes in the world
They have the highest rateof end-stage renal deaths
in the world
Alice Springs has the largest renal dialysis unit in the Southern Hemisphere!
Alice Springs
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Diabetes in indigenous Australians:age-specific prevalence (%)
AusDiabAboriginal TSI
0
10
20
30
40
50
60Prevalence %
Age group (years)25-34 35-44 45-54 55-64 65-74 75+
K O’Dea 2002
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
13The screen versions of these slides have full details of copyright and acknowledgements
37
Diabetes in indigenous communities: competing “causation” of type 2 diabetes
“Western” view
• Bad behaviours
• Bad choices
• Lazy
• Obesity
Indigenous view
• Dispossession
• Social disharmony
• Poverty
• Socio-cultural change
• ‘Toxic’ external pressures
• Transgenerational trauma
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Type 1 diabetes in the young
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Criteria:• Diagnosed as type 1 diabetes
• On Insulin at first hospital discharge
• Diagnosed between 1/1/90 and 31/12/99
• Age at onset 0-14
• Member of a defined community
Diabetes Mondial – DiaMond: establishment of population based registries for 1990
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
14The screen versions of these slides have full details of copyright and acknowledgements
40
Incidence and trends of childhood type 1 diabetes worldwide 1990-1999, The DIAMOND project group
Incidence (per 100,000/year)
Incidence (per 100,000/year)
Incidence (per 100,000/year)
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The DIAMOND study: high incidence countries during 1990-1999
Incidence (per 100,000/year)
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The trend in the incidence of Type 1 diabetes in Finnish children aged 14 or under
0.0
10.0
20.0
30.0
40.0
50.0
60.0
1963 1968 1973 1978 1983 1988 1993 1998
Year
Tuomilehto et al., Diabetologia 1999
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
15The screen versions of these slides have full details of copyright and acknowledgements
43
Age-specific annual incidence of type 1 diabetes per 100,000/year; Finnish children
aged 1-14 years between 1965 and 1996
0
10
20
30
40
50
60
1963 1968 1973 1978 1983 1988 1993 1998
Year
1-45-910-14
Tuomilehto J, Karvonen M et al. Diabetologia 1999; 42 (6): 655-60
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Diabetes is very complicated
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0
100
200
300
400
500
600
700
800
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 040
500
1000
1500
2000
2500Type 2 (Ins Requiring)
Type 2 (Non Insulin)
Type 1
Total New Patients
Year of Entry
Number of Diabetics Number of New Patients
Incidence of diabetes in end-stagerenal failure: Australia 1980-2004
R Atkins 2005
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
16The screen versions of these slides have full details of copyright and acknowledgements
46
0
10
20
30
40
50
60
70
80
90
100
1971-1980 1981-1990 1991-2000
GeneralDiabetes
Age at death in Japan:general population versus diabetes - males
Hotta N: Personal communication
Life Expectancy (Years)
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• To explore the relationship between diabetes (newly diagnosed (NDM) and known diabetes (KDM), impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) and all-cause, CVD, and cancer mortality
• To explore the relationship between hypertension, obesity and other risk factors for all-cause and CVD mortality
Mauritius surveillance study: aims
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• This is the first study in a developing country of the impact of glucose intolerance on mortality in an African population, and one of the first studies of a South Asian population
• It shows that the impact on mortality in these populations in Mauritius is comparable to that seen in developed countries
• These results are important in a global context for future health policy in the light of the impact of the rapid increase in prevalence of diabetes, especially in developing nations
Conclusion
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
17The screen versions of these slides have full details of copyright and acknowledgements
49
50
Adjusted all-cause mortality hazard ratios (95% CI) for IFG, IGT, NDM and KDM compared to NGT in Mauritians
according to ethnic group: the Mauritius surveillance study
0
1
2
3
4
HR (95% CI) for mortality
NGT IFG IGT NDM KDM NGT IFG IGT NDMKDM NGT IFG IGT NDMKDM
Categories of glucose metabolism
Indian Creole Chinese
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Predictors for CVD deaths
Variable Level HR and 95% CI
Glucose tolerance NGT 1.00
IFG 1.01 (0.68–1.50)
IGT 1.31 (1.03–1.67)
NDM 2.01 (1.60–2.53)
KDM 2.94 (2.35–3.67)
Adjusted for ethnicity, sex, physical activity, education, smoking, lipids, hypertension, creatinin, BMI, waist, previous CVD
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
18The screen versions of these slides have full details of copyright and acknowledgements
52
Sleep Apnoea
• Obesity• Diabetes• Insulin Resistance• Dyslipidaemia
Non-alcoholic Steatohepatitis(Primary NASH)
HIV/AIDS Therapy
New confounding disorders accelerating the diabetes & metabolic syndrome epidemic
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Prevention of diabetes: the new paradigm
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Environment
EARLY LIFE
• Low birth weight
• Poor nutrition
ADULT LIFE
• Sedentary lifestyle
• Dietary factors
Cardiovascular disease
GenesDiabetes +/-The Metabolic Syndrome
Genetic-environment interaction for type 2 diabetes
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
19The screen versions of these slides have full details of copyright and acknowledgements
55
Epigenetics: a new paradigm for prevention
• The study of heritable changes in gene function that occur without a change in the sequence of the DNA
• Epigenetics - how we eat and live can change the way our genes behave
• The maternal environment may be the key to stemming the epidemic
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The Dutch winter famine
• At the end of WW2, West Netherlands population suffered an acute famine
• Allocated rations were 400 to 800 calories/day
• Women exposed to this during the 2nd and 3rd trimester of pregnancy delivered small babies
• As adults, these babies (exposed to famine in utero) had a higher prevalence:
Type 2 diabetes
CVD (heart attacks, strokes)
Hypertension
Obesity
57
Developmental plasticity, foetal programming & intergenerational risk
Developmental plasticity:
The process where a stimulus applied in utero establishes a permanent response in the foetusleading to enhanced susceptibility to later disease, e.g. type 2 diabetes and cardiovascular disease
Mother – 1st generation
Fetus – 2nd generation
Reproductive cells –3rd generation
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
20The screen versions of these slides have full details of copyright and acknowledgements
58
Diabetes in Cambodia (30 years after Pol Pot regime)
Dr. Hilary King
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Diabetes prevalence in Cambodia
7.3%
2.9%3.5%
3.2%
7.1%7.4%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
Males Females Total
Urban
Rural
Prev
alen
ce (%
)
King H et al., Lancet 2005
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Poverty & diabetes: issues for preventionin developing nations
• Prenatal and perinatal factors
• Most cases undiagnosed
• Socioeconomic status
• Education
• Unemployment
• Environment
• Access to care
• Chronic diseases enhance poverty
Cockram C 2006
Diabetes - The Global Picture: The World’s Greatest Public Health Challenge
Paul Zimmet
21The screen versions of these slides have full details of copyright and acknowledgements
61
Conclusions
• Diabetes continues to rise exponentially globally
• Ageing, lifestyle change and urbanisation have been targeted as the main drivers but in developing nations, the story may be very different
• A greater focus on maternal & child health may lead to more effective strategies to halt this global epidemic of diabetes and associated complications and co-morbidities
• By 2020, diabetes is set to bankrupt many national economies, both developed and developing
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Acknowledgements
Baker IDI Epidemiology and key collaborators
Jonathan Shaw George Alberti Adrian Cameron
Dianna Magliano Richard Sicree David Dunstan
Stefan Soderberg Elizabeth Barr Jaakko Tuomilehto
Gary Dowse Max De Courten
Mauritius
Sudhir Kowlessur
Pierrot Chitson
N Gopee
V Pauvaday
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