gpsf annual conference 2018 non communicable diseases: an ... · age-adjusted prevalence of obesity...

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