gpsf annual conference 2018 non communicable diseases: an ... · age-adjusted prevalence of obesity...
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GPSF Annual Conference 2018 – Non
Communicable Diseases: An Overview
Of The Twin Epidemics of Diabetes and
Obesity - Diabesity
Kwabena O.M. Adubofour, MD, FWACP, FACP
Medical Director, East Main Clinic and Stockton
Diabetes Intervention Center
I would like to start
with my conclusions
“We should not wait until a patient comes in for orthopedic surgery before being worked up
or treated for a chronic non-communicable disease”
Prof Oheneba Boachie-Adjei
UN Secretary-General in his 2011 report to the UN General Assembly
Noncommunicable diseases are a global political priority
"A rapidly rising epidemic in developing countries with serious socio-economic impacts"
"Workable solutions exist to prevent most premature deaths from NCDs and mitigate the negative impact on development"
"These solutions need to be
mainstreamed into socio-economic
development programmes and
poverty alleviation strategies"
Halt the rise in diabetes
and obesity
A 10% relative reduction in prevalence of insufficient physical activity
At least a 10% relative reduction in the harmful use of alcohol
A 25% relative reduction in risk of premature mortality from cardiovascular disease, cancer, diabetes or chronic respiratory diseases
An 80% availability of
the affordable basic
technologies and essential
medicines, incl. generics,
required to treat NCDs
A 30% relative reduction in
prevalence of current tobacco
use
A 30% relative
reduction in mean
population intake of
salt/sodium
A 25% relative reduction in prevalence of raised blood pressure or contain the prevalence of raised blood pressure
At least 50% of eligible
people receive drug therapy and counselling to prevent
heart attacks and strokes
Where to focus: 9 global NCD targets to be attained by 2025 (against a 2010 baseline)
Best buys
Tobacco • Reduce affordability of tobacco products by
increasing tobacco excise taxes • Create by law completely smoke-free environments
in all indoor workplaces, public places and public transport
• Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns
• Ban all forms of tobacco advertising, promotion and sponsorship
Harmful use of alcohol • Regulate commercial and public availability of
alcohol • Restrict or ban alcohol advertising and promotions • Use pricing policies such as excise tax increases on
alcoholic beverages
WHO Global NCD Action Plan 2013-2020
Best buys
Diet and physical activity
• Reduce salt intake
• Replace trans fats with polyunsaturated fats
• Implement public awareness programmes on diet and physical activity
• Promote and protect breastfeeding
Cardiovascular diseases and diabetes
• Drug therapy and counselling to individuals who have had a heart attack or stroke and to persons with high risk of a cardiovascular event in the next 10 years
• Acetylsalicylic acid (aspirin) for people at risk of suffering an acute myocardial infarction (heart attack)
WHO Global NCD Action Plan 2013-2020
WHO Commission on Ending Childhood Obesity
who.int/end-childhood-obesity/final-report
Obesity and Diabetes – what I want
to share with you
• Review the married epidemics of obesity and
diabetes
• Review the global health and financial implications
of the twin epidemic.
• Review the nature of the problem in Ghana.
• Discuss different solutions to tackle the adverse
impact of this double epidemic.
Human Evolution
Body Mass Index (BMI)
Most commonly used method to
estimate body fat
Can be used to screen for both
overweight and obesity in adults
Calculation based on height and
weight, and is not gender-specific
BMI = weight (kg)/height squared (m2)
BMI: Normal, Overweight, Obesity
BMI
Normal 18.5 – 25%
Overweight 25 – 30%
Obesity >30%
Global Increase in Obesity
Overweight, BMI ≥25 kg/m2; obese, BMI >28 kg/m2 (Asian) or >30 kg/m2.
James WP. J Intern Med. 2008;263:336-352.
USA
UK
Australia
Finland
Sweden Norway Brazil Cuba
Japan
1970 1975 1980 1985 1990 1995 2000 2005
Pre
vale
nce o
f O
besit
y (
%)
35
30
25
20
15
10
5
0
2002 2007 2015
Obese 356 million 523 million 704 million
Overweight 1.4 billion 1.5 billion 2.3 billion
Magnitude of the Diabetes Epidemic
28.3 M
40.5 M
43.0%
16.2 M
32.7 M
102%
53.2 M
64.1 M
20%
67.0 M
99.4 M
48%
10.4 M
18.7 M
80%
46.5 M
80.3 M
73%
M=million; AFR=Africa; EMME=Eastern Mediterranean and Middle East; EUR=Europe; NA=North America;
SACA=South and Central America; SEA=South-East Asia; WP=Western Pacific.
International Diabetes Federation. Diabetes Atlas. 3rd ed. Available at: http://www.eatlas.idf.org/index.asp.
World
2007=246 M
2025=380 M
54%
AFR
NA
SACA
EUR
SEA
WP 24.5 M
44.5 M
82%
EMME
2007
2025
Global Projections for the
Diabetes Epidemic: 2007-2025
Pathogenesis of Insulin ResistancePathogenesis of Insulin Resistance
Photo courtesy of Leonard Glass, San Antonio, 2003
US Obesity Epidemic • 17% of all US deaths from obesity
o approx. 300,000 deaths/year
o Obesity equals smoking as cause of preventable death
o Shortens life span 5 -22 years
• Extremely obese white male 20-30
o Lose 13 yrs of life
o Mortality 12x higher if BMI >40
Years of Life Lost Due to Obesity, JAMA January 8, 2003:89;2;187-193
Obesity Among US Immigrants Subgroups by Duration of Residence JAMA Dec 15, 2004.
Obesity • Greatest US health expenditure
• Social and ethnic differences in obesity o Greater in women x 2
o Greater among Black Americans
• Women>> men
o Greater among non-HS grads
o Largest increase in ages 19-28
• 75% of those with extreme obesity have a co-morbid disease
Age-adjusted Prevalence of Obesity and Diagnosed
Diabetes Among US Adults
Obesity (BMI ≥30 kg/m2)
Diabetes
1994
1994
2000
2000
No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9%
> 26.0%
No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9%
>9.0% CDC’s Division of Diabetes Translation. United States Surveillance System available at
http://www.cdc.gov/diabetes/data
2014
2014
Risk of Type 2 Diabetes as a
function of BMI
0
10
20
30
40
50
60
70
80
90
100
<22 22- 22.9
23- 23.9
24- 24.9
25- 26.9
27- 28.9
29- 30.9
31- 32.9
33- 34.9
>35
Adjusted relative risk of diabetes
Colditz GA et al. Ann Int Med, 1995 BMI Range
Pima Indian Transitions
1894 2000
Body shape – are you a
pear or an apple? Beer Belly is dangerous
Some of the alterations in the metabolic risk profile that have been found to be related to
abdominal obesity assessed by anthropometry and later to excess visceral adiposity/ectopic fat
assessed by imaging techniques.
Jean-Pierre Després Circulation. 2012;126:1301-1313
Copyright © American Heart Association, Inc. All rights reserved.
Man –Abdominal Obesity
Global Impact
of Obesity
What about back home in
Ghana?
Risk Factors for Obesity
• Obese parents
o Before age 3 parental weight predicts obesity more than
child’s weight
o If 1 parent is obese child’s risk x3
o If both obese odds ratio 10
• 10% chance normal weight
Whitaker NEJM 1997
Risk Factors for Obesity • Environmental Factors
o Portion size (market portions are 2-8 times larger than
recommended USDA and FDA recs)
o Sweetened beverages
• Increasing since 1970
o Socioeconomic status inversely related to obesity
o Energy density and food cost inversely related
o Increase in sedentary leisure time
• 26% watch more than 4 hours of TV time per day
• 67% watch more than 2 hours
Physicians Do not Address
Obesity Enough:
• Addressing obesity in the office
o Only 17.4% of 2-5 yr old
o 32.6% of 6-11 yr/old
o 39.6% of 12 -15 yr/old
o 51.6% of 16-19 yr/old
Diabesity prevention in
Those at Risk
Setting Goals for Weight Loss • Set reasonable goals
o 10% weight loss for first 6 months
o 500-1000 calories less/day
o Decrease 1-2 lb/week
o Most patients set goals 2-3 x higher
• Physical activity is important o More effective in maintaining weight than weight loss
• Resetting goals and diet/exercise is necessary at 6 months and plateaus in weight loss
• Preventing weight gain is an important long-term goal
NHLBI Obesity Education Initiative: A Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 2000.
Lifestyle changes makes
a difference in diabetes
prevention
Diabetes Prevention • Diabetes Prevention program
• Finnish Diabetes Trail
• Da Qing trial
Diabetes Prevention: Lifestyle
Trial Intervention Population Results
Da Qing
IGT study
Diet, PA or
both
Chinese
m/w 45y/o
IGT
Each arm
decreased
DM 31-
46%
Finnish DM
Prevention
Study
Diet
counseling
+ PA
w/m 55y/o
IGT
D + PA
decreased
DM 58%
Diabetes
Prevention
Trial
Wt loss +
PA
w/m 51y/o
IGT
decreased
DM 58%
The Finnish Diabetes Prevention Study: Lifestyle
Modifications
0
20
40
60
80
Control (n=250) Diet intervention (n=256)
Inc
ide
nc
e o
f d
iab
ete
s
(ca
se
s/1
00
0 p
ers
on
-ye
ars
)
Tuomilehto et al. N Engl J Med. 2001;344:1343.
58%
The Finnish Diabetes Prevention Study:
Lifestyle Modifications
• 522 overweight individuals with IGT randomized to
o Control: diet instruction at the onset of study
o Individualized advice given 7 times in the first year and every 3 months thereafter with goals of
• Weight loss 5%
• Reducing fat intake to <30% of energy consumption
• Increasing fiber intake to 15 g/1000 kcal
• Exercising at a moderate level for 30 min/d
• Primary end point: Prevention of diabetes, as assessed by annual OGTT
Tuomilehto et al. N Engl J Med. 2001;344:1343.
The Finnish Diabetes Prevention Study: Lifestyle
Modifications (cont’d)
-6
-5
-4
-3
-2
-1
0Weight (kg) Waist (cm) SBP (mm Hg) DBP (mm Hg)
Control (n=250) Diet intervention (n=256)
Ch
an
ge f
rom
baselin
e
Tuomilehto et al. N Engl J Med. 2001;344:1343.
P<0.001 P<0.001
P=0.007 P=0.02
The Diabetes Prevention Program
Sponsored by the NIDDK, NIA, NICHD, NIH, IHS, CDC,
ADA, and other agencies and corporations
A Randomized Clinical Trial
to Prevent Type 2 Diabetes
in Persons at High Risk
Diabetes Prevention Program:
Primary Objectives
• Compare safety and efficacy of 4 interventions for preventing or delaying development of diabetes o Standard lifestyle recommendations + masked
metformin titrated to 850 mg bid or troglitazone 400 mg/d
o Standard lifestyle recommendations + masked placebo
o Intensive lifestyle intervention by case managers with goals of
– 7% weight reduction through healthy eating and physical activity
– 150 min/wk moderate intensity physical activity
The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623.
Diabetes Prevention Program:
Achievement of Study Goals
Average follow-up of 2.8 years
Goal % Achieving Goal
Lifestyle modifications Week 24 Last visit
Weight loss 7% 50% 38%
Physical activity 150 74% 58%
(min/wk)
Pharmacologic intervention Placebo Metformin
Compliance 80% 77% 72%
Full dose 2 tablets/d 97% 84%
The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.
Diabetes Prevention Program:
Progression to Type 2 Diabetes
0
2
4
6
8
10
12
Placebo Metformin Intensive
lifestyle
Ca
se
s/1
00
pe
rso
n-y
ea
rs
Average follow-up of 2.8 years
31%*
58%*
*All pairwise comparisons significantly different by group; sequential log-rank test.
The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.
Summary
• Based on demographic changes alone: The numbers of persons with diabetes in the world will more than double in the next 30 years
• In developed countries they will increase by 30-70% (mostly in older persons)
• In developing countries they will increase by c. 250% (mostly in 45-64y age group)
• These projections do not take into account any increase that is attributable to future increases in obesity
Summary
• Because of the current epidemic of diabetes, reflected in increasing age specific prevalence, the proportion of the diabetic population with complications will increase.
• This will result in a greater relative increase in complications than in diabetes prevalence.
• Because serious complications e.g. ESRD, typically develop after 15-20 years duration, the incidence of ESRD due to diabetes will continue to increase for at least the next 20 years
Promising Targets for Population-Wide Food Policies to Influence Diabetes