“Diabesity: Potentially the Greatest

Epidemic in World History”

Paul Zimmet AODirector Emeritus

Baker IDI Heart and Diabetes InstituteMelbourne

Studies in Migrating Populations

• Opportunity to study the genetic and

environmental determinants of disease in

different ethnic groups in same & different

locations

• Demographic issues

• Nutrition

• Physical activity

• Socio-cultural issues

• Climatic & pollution issues

• Epigenetic determinants

UN launches global campaign to curb death toll from non-communicable diseases

Secretary-General Ban Ki-moon addresses high-level meeting on the prevention and control of non-communicable diseases19 September 2011 –

The United Nations today launched an all-out attack on non-communicable diseases (NCDs) such as cancer and diabetes with a summit meeting devoted to curbing the factors, like tobacco and alcohol use, behind the often preventable scourge that causes 63 per cent of all deaths.

Obesity is driving the escalating Diabesity epidemic: The biggest epidemic in human history

OECD Predictions for Future Overweight

Rates:1970s-2020

Global Projections for the Diabetes Epidemic: 2010-2030 (millions)

Shaw J. Diab Res & Clin Practice, 2009 IDF Atlas 2009 www.idf.org

World2010 = 285 million2030 = 438 million

Increase 54%

2011- a staggering 366 million2030 – 552 million

Modernization & High Diabetes Prevalence1966-1975

Pacific – Nauru

Phoenix Arizona:Pima Indians

Australia:Indigenous

New Zealand: Maori

The 10 Top Nations forDiabetes 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

Western Killer in Paradise“The Age”, May 1992

Diabetes Numbers:10 Highest Countries 2010 #

China now has over 90 million people with diabetes*

# Diabetes Atlas, 3rd edition, IDF 2006* Yang W et al NEJM April 2010

0 10 20 30 40 50

India

China

USA

Russia

Brazil

Germany

Pakistan

Japan

Indonesia

Mexico

Adult Diabetes: millions

60

Mauritius therefore became:

“the epitome of the struggle

between free labour and slavery

and the test scene for the success

of renewed Coolie immigration.”

I. M. Cumpston, Indians Overseas in British Territories, 1834-1854. Published 1969

William Wilberforce

Mauritius: Where it all started with the end of slavery

“As the first colony to undertake a

Government regulated importation of

indentured labour, Mauritius served as a

model for the Caribbean, Fiji, South Africa

and other territories which subsequently had

recourse to Indian immigrants for the

purposes of plantation production.”

S. Deerpalsingh and M. CarterSelected Documents on Indian Immigration Mauritius, 1834-1926 Mahatma Gandhi Institute 1994

Mauritius: Where it all started with the end of slavery

Mauritius: The Next Step in Predicting the Global Diabesity Epidemic

• The population consistsof Asian Indians, Blacks (Creoles) and Chinese

• These 3 ethnic groups constitute 66% of the world’s population

• Studies performed:1987, 1992, 1998, 2004 and 2009

62% increase from 1987 to 2009

Mauritius: Increase in DiabetesPrevalence over 22 yrs

Standardised to 2008 population structure of Mauritius

Prevalence of Diabetes %

0

5

10

15

20

25

30

1987 1992 1998 2004 2009

MenWomenTotal14.6%

17.4%

20.1%18.7%

23.6%

35

McDonald’s - Beijing“Coca-colonization”

Increasing Diabetes Prevalence 1980-2009: China

Life style changes

Ji Linong: Personal communication

0

2

4

6

8

10

1980 1994 1996 2002 2009

9.7

1

2.8 3.2

5.0

Coca-colonization in Jaipur, India

Prevalence of Diabetes in Urban India (Chennai)

Prevalence (%)

Prevalence 2000 – 13.9%Prevalence 2006 – 18.6%

Ramachandran et al. Diabetes Care 2008

0

10

20

30

40

50

60

20-24 25-34 35-44 45-54 55-64 65+

“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 ourNation's Sights for the Future

The Hon Kevin Rudd(Former) Prime Minister

April 2008

AusDiab

Aboriginal

TSI

0

10

20

30

40

50

60Prevalence %

Age group (years)

25-34 35-44 45-54 55-64 65-74 75+

Diabetes In Indigenous Australians:Age-Specific Prevalence (%)

Kerin O’Dea 2002

ATSI HAVE HIGHEST RATE OF ESRD DEATHS IN WORLD

Alice Springs has the largest dialysis unit in the

Southern Hemisphere!

ATSI HAVE ONE OF HIGHEST RATES OF DIABETES IN

WORLD

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

The Middle East – The World’s Diabetes Epicentre?

Diabetes prevalence for adults age 20-79

UAE

0

10

20

S. Arabia

0

10

20 16.8%

18.7%

Oman

0

10

2013.4%

Kuwait

0

10

2014.6%

Bahrain

0

10

20 15.4%

ENVIRONMENT

EARLY LIFE• Low birth weight

• Poor nutrition

ADULT LIFE• Sedentary lifestyle

• Dietary factors

CARDIOVASCULAR DISEASE

GENESDIABETES +/-

THE METABOLIC SYNDROME

Genetic-Environment Interactionfor Type 2 Diabetes

Epigenetics: Foetal Programming & Intergenerational Risk

Developmental Plasticity, Foetal Programming & Intergenerational Risk

Developmental plasticity is the process where a stimulus applied in utero establishes a permanent response in the foetus leading to enhanced susceptibility to later disease, eg type 2 diabetes and cardiovascular disease

Rotterdam, 1945

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 ofpregnancy delivered small babies.

• As adults, these babies (exposed tofamine in utero) had a higher prevalence: – Type 2 diabetes– Cardiovascular disease (heart attacks, strokes)– Hypertension– Obesity– Schizophrenia

Diabetes in Cambodia:(30 years after Pol Pot) regime)

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

Conclusions• Diabesity continues to rise exponentially globally • Ageing, lifestyle change & urbanisation have been targetted

as the main drivers but in developing nations & indigenous communities, the story may be very different

• A greater focus on epigenetics & early life risk factors eg maternal nutrition may lead to more effective strategies to halt this global “perfect storm” of Diabesity

• By 2020, Diabesity is set to bankrupt the economies of many nations unless action is taken

AcknowledgementsBaker IDI Epidemiology and key collaboratorsJonathan Shaw George Alberti Adrian Cameron

Dianna Magliano Richard Sicree David Dunstan

Stefan Soderberg Elizabeth Barr Jaakko Tuomilehto

Gary Dowse Max De Courten Jeremy Jowett

MauritiusSudhir Kowlessur

Pierrot Chitson

N Gopee

V Pauvaday

FundingNIH (USA) & NH&MRC (Australia)