griffin p. rodgers, m.d., m.a.c.p. director · 2019. 3. 8. · niddk griffin p. rodgers, m.d.,...
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NIDDK
Griffin P. Rodgers, M.D., M.A.C.P.Director
March 8, 2019
The Economic and Social Imperatives of Disease Prevention: The Obesity-Diabetes-Kidney Disease Paradigm
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Faculty Disclosure
In compliance with ACCME Guidelines, I hereby declare:
• I do not have financial or other relationships with the manufacturer(s) of any commercial services(s) discussed in this educational activity.
Griffin P. Rodgers, M.D., M.A.C.P.Director of the National Institute of Diabetes and Digestive and Kidney Diseases
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ObesityType 2
Diabetes
• Approx. 2/3 of U.S. adults overweight or obese
• Nearly 40% of U.S. adults obese
• Increasing in the young• Annual medical cost:
$147B
• Approx. 30.3 million U.S. cases (9.4% of population)—90-95% T2D
• Projected to ~50 million by 2050
• Increasing in the young• Annual total cost:
$327B
NIDDK’s Integrated Research Programs:Implications for Health Disparities
Chronic Kidney Disease
• Nearly 15% of the U.S. population have CKD
• Major causes: diabetes, hypertension
• Annual Medicare cost of CKD and kidney failure: $98B
Age-adjusted Diagnosed Diabetes:• 15.1% of AIAN• 12.1% of NH Black• 12.1% of Hispanic• 7.4% of White
ESRD prevalence, compared to U.S. white population:• 3 times higher
in NH Black• 1.3 times higher
in Hispanic
Obesity Disparities:47 % of Hispanics and 46.8% of NH Black(compared to 37.9% of Whites)
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Obesity Trends* Among U.S. AdultsBehavioral Risk Factor Surveillance System (BRFSS), 1985
No Data
<10%
10%-14%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
4
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No Data
<10%
10%-14%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1986
5
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No Data
<10%
10%-14%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1987
6
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No Data
<10%
10%-14%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1988
7
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No Data
<10%
10%-14%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1989
8
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No Data
<10%
10%-14%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1990
9
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No Data
<10%
10%-14%
15%-19%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1991
10
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No Data
<10%
10%-14%
15%-19%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1992
11
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No Data
<10%
10%-14%
15%-19%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1993
12
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No Data
<10%
10%-14%
15%-19%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1994
13
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No Data
<10%
10%-14%
15%-19%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1995
14
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No Data
<10%
10%-14%
15%-19%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1996
15
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No Data
<10%
10%-14%
15%-19%
20%-24%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1997
16
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No Data
<10%
10%-14%
15%-19%
20%-24%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1998
17
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No Data
<10%
10%-14%
15%-19%
20%-24%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 1999
18
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No Data
<10%
10%-14%
15%-19%
20%-24%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2000
19
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2001
20
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2002
21
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2003
22
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2004
23
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
≥30%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2005
24
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
≥30%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2006
25
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
≥30%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2007
26
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
≥30%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2008
27
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
≥30%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2009
28
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
≥30%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2010
29
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No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
≥30%
Source: CDC Behavioral Risk Factor Surveillance System.
*BMI ≥30 kg/m2 or 30 pounds overweight for 5’4” woman
Obesity Trends* Among U.S. AdultsBRFSS, 2011
30
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From: CDC NCHS Data Brief 288
Obesity Trends Continue Unabated
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The Public Health Problem of Obesity: Prevalence and Associated Health Conditions
Vein inflammation
Coronary heart diseaseLung disease
Gall bladder disease
Gout
Diabetes
Osteoarthritis
Nonalcoholic fatty liver disease
High blood pressure
Elevated fat in the blood
Cataracts
Skin
Pancreatitis
Cancerbreast, uterus, cervix, prostate, kidney, colon, esophagus, ovaries, liver, gall bladder, multiple myeloma, thyroid, pancreas
Gynecologic abnormalities
StrokeIntracranial pressure
Depression
Diabetes
2/3/19
17.0% of 2- to 19-year-old children/adolescents and 36.5% of adults are obese (prevalence data from 2011-14, NCHS Data Brief, No. 219. National Center for Health Statistics, CDC, 2015.
Image credit: Adapted from image created by Dr. Wei Shen and Dr. Steven Heymsfield, New York Obesity Research Center, St. Luke’s-Roosevelt Hospital, Columbia University, New York.
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A few examples of NIH obesity research areas
Bariatric surgery
Long-term risks & benefits? Underlying mechanisms?
Microbiome
Therapeutic targets?
Our gut companions: Effects on weight?
Potential target for obesity treatment: fat that burns itself
Brown & beige fat
Lifestyleenvironmental & behavioral
interventions
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1994 2000 2010
<14% 14-17.9% 18-21.9% 22-25.9% ≥ 26%
Obesity
Diabetes (diagnosed)
Age-adjusted Prevalence of Obesity and Diabetes Among U.S. Adults
<4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% ≥ 9.0%
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Type 2 Diabetes Clinical Studies
NormalPre-
diabetesType 2
DiabetesComplications
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Complications Common to Both Type 1 and Type 2 Diabetes
BRAIN
TEETH & GUMS
HEART & BLOOD VESSELS
FEET
LIVERKIDNEYS & LOWERURINARY TRACT
AIRWAYS
EARS
EYES
https://www.niddk.nih.gov/about-niddk/strategic-plans-reports/diabetes-in-america-3rd-edition
BONE
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The Financial Costs of Diabetes
www.diabetes.org/advocacy/news-events/cost-of-diabetes.html
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U.S. Diabetes30.3 million*23.1 million diagnosed; 7.2 million undiagnosed
U.S. Prediabetes84.1 million†
9.8 million aware of their prediabetes74.3 million unaware
Diabetes: The Tip of the Iceberg
*All ages, 2015
† Age 18 and older with IFG +/or A1c between 5.7 and 6.4 (2015)
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The DPP Study
LifestyleMetforminPlacebo
3234 participants (45% minority) with IGT who were overweight or obese
Compared 3 approaches to diabetes prevention for 3 years:
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Lifestyle Intervention
Intensive behavioral modification program with the following goals
7% weight loss
150 minutes/week physical activity
Intervention delivery
16 session core curriculum delivered one-on-one over 24 weeks
Monthly visits post core
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LifestyleMetforminPlacebo
0
4
8
12
Caucasian(n=1768)
African American
(n=645)
Hispanic(n=508)
American Indian (n=171)
Asian(n=142)
Cas
es/1
00
pe
rso
n-y
r
DPP Results
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0
3
6
9
12
15
25-44 (n=1000) 45-59 (n=1586) > 60 (n=648)
Cas
es/1
00
per
son
-yr
Lifestyle Metformin Placebo
DPP Interventions by Age Group
Effect of Age on Intervention Response
71% reduction
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Cumulative Incidence of Diabetes in DPPWomen without and with a History of GDM
0
5
10
15
20
25
30
35
40
45
50
0 1 2 3
Metformin(n=464)
Placebo (n=487)
Lifestyle(n=465)
Risk reduction vs. placebo
14% by metformin (p=0.280)
49% by lifestyle (p<0.001)
Risk reduction vs. metformin
41% by lifestyle (p=0.001)
without GDM with GDM
0
5
10
15
20
25
30
35
40
45
50
0 1 2 3
Risk reduction vs. placebo
51% by metformin (p=0.006)
55% by lifestyle (p=0.002)
Risk reduction vs. metformin
8% by lifestyle (p=0.781)
Cu
mu
lati
ve in
cid
ence
(%
)
Years from randomization
Metformin(n=110)
Placebo (n=122)
Lifestyle(n=117)
Adjusted for age
Years from randomization
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The Diabetes Prevention Program: Collaborative and Transformative
Diabetes Prevention Program (DPP)3,234 individuals at risk for type 2 diabetes
➢ Lifestyle modification lowered risk by 58% (modest weight loss, from exercise and reduced fat and caloric intake)
➢Metformin medication lowered risk by 31%
Percent Reduction in Diabetes Incidence Compared to Placebo
0
30
60
Metformin
IntensiveLifestyleIntervention
• Metformin cost-saving
Follow-up Research
31% 58%
DPPOS 15-year follow-up:0
30 MetforminIntensive Lifestyle Intervention
18% 27%
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Translating from Efficacy Research to Public Health
On July 7, 2016, the Centers for Medicare & Medicaid Services proposed changes to the Physician Fee Schedule to begin coverage of certain DPP adaptations in April, 2018.
2002 paper
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Proportion of Type 1 and Type 2 DM by Race/Ethnicity in Youth Aged 10-19 Years
95.6%
4.4%
NHW
71.0%
29.0%
NHB
72.8%
27.2%
Hispanic
73.7%
26.3%
ASPI
31.8%
68.2%
AIAN
Type 1 Type 2
Hamman et al. ADA 2012
NHW: non-Hispanic white; NHB: non-Hispanic black; API: Asian or Pacific Islander; AIAN: American Indian or Alaska Native
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Rationale:• Increased youth T2D• Adult drugs not tested/approved in youth• Adolescent effects on glycemia/metabolism
• 20% White• 32% NHB• 41% Hispanic• 6% AI
Cohort:• Age 10-17 years (avg 14)• BMI >85th p’tile (avg 35.7)• T2D <2 yr (avg 8 months)• 35% male
Treatment Options for type 2 Diabetesin Adolescents and Youth
Treatmentgroups:
*Use of rosiglitazone was investigational under FDA IND
• Metformin• Metformin + rosiglitazone*• Metformin + intensive lifestyle
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Time-to-outcome Analyses
Cohort Overall NH Black
Treatment failure rates: Treatment failure rates:
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RISE Pediatric Medication Study
Though uncommon in young people, pediatric T2D is occurring more often, especially in minority groups.
• T2D occurs when long-term insulin resistance leads to eventual loss of proper insulin secretion from pancreas
• Restoring Insulin Secretion (RISE) studies ask if glucose-lowering treatment can reduce loss of insulin response in those with prediabetes, or restore some function in those with recent onset T2D
• RISE Pediatric Medication Study in 91 10-19 y.o. participants compared treatment with long-acting insulin followed by metformin with metformin alone.
• Neither treatment either preserved or restored insulin secretion. Insulin and metformin are the only drugs FDA-approved for treating pediatric T2D
• Substudies found that participants in this study had better insulin secretion, but more profound insulin resistance than do adults at a similar stage of T2D progression.
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ObesityType 2
Diabetes
NIDDK’s Integrated Research Programs:Implications for Health Disparities
Chronic Kidney Disease
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Increased Kidney Disease Risk Among African AmericansMostly Explained by APOL1 Gene Mutation
0 copies 1 copy
2 copies
African Americans 42% 46% 12%
FSGS risk (lifetime) 0.2% 0.3% 4% (25-fold increase)
Hypertensive kidney disease risk
-- -- ~5-10% (5-fold increase)
Lifetime risk for ESRD
Whites ~2%
Blacks ~7.5%
Apolipoprotein L1 (APOL1): kidney risk copies
ESRD rates by race
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(Re)Building a Kidney Consortium seeks to optimize approaches for the isolation, expansion, and differentiation of appropriate kidney cell types and their integration into complex structures that replicate human kidney function.
The longer term goal is to stabilize, reverse, or restore lost kidney function
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Human Kidney Precision Medicine Project
• Human CKD is mixture of multiple diseases (CKDs)
• Molecular mechanisms of human CKDs not well known
relative paucity of CKD therapeutics
• Recent genetics, epidemiology, and animal models have validated only two CKD targets (ApoL1 and FGF23)
• Nephrologists have performed few kidney biopsies for 40 years, as unlikely to change care. Self-fulfilling prophecy
• Need human biopsy tissue
• New methods to understand each cell types contribution to disease are now available– Kidney is anatomically complex; many cell types
– Can now work at individual cell level
• Goal: Understand subgroups, mechanisms of disease,
and lead to new therapeutics, earlier treatment
and patient-specific prevention
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Kidney Precision Medicine Project
Goals of 10-15 year project
Understand and treat human kidney disease• Ethically obtain kidney biopsies from participants with
AKI or CKD• Find disease subgroups to stratify patients• Find disease pathways in key cells• Devise individualized treatments• Improve scientific knowledge base• Improve pipeline
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Training and Outreach Programs
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NIDDK and Our Partners Invest Heavily in Workforce Development
HS/Undergraduate Graduate/Medical School Postdoctoral Transition/Jr. Faculty Faculty/Tenured
$4.3 M
$61.4 M
$67.9 M
$4.4 M $6.1 M
R03
K01, K08, K23, K12, K99
T35, T32, F30, F31, F32
R25
K24
$144.1 Million – FY18(7.3% of total DK budget)
F/T to K K to R R renewal
Intramural
Professional Societies/Foundations
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NIDDK Works To Preserve this Investment
T35, T32, F30, F31, F32R25
Transition/Jr. Faculty
LRP
Independent
Faculty
Graduate
Medical School
HS
Undergraduate Postdoctoral
“Life after K”Workshop
R03
K01, K08, K23, K12, K99
“New PI”Workshop
ESI bonus
ESI renew bonus
Maximize payline
www.niddk.nih.gov
STEP-UP&
DSRTP
&Med Student DiabSummer Res Prog
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STEP-UP in the Pacific
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HS STEP-UP Puerto Rico
Hometown of 2018 STEP-UP ParticipantPrimary Research Sites
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109 Aspirnaut™ Undergraduates
2009-2018
from 25 universities:
1
41
45
2
1
1
45
CT - 2
1
1
11
79 graduated college29 still in college
1 left college
Aspirnaut™K-20 STEM Pipeline
*all schools one student attended
unless otherwise noted
44
27
12Russia - 1
83% in advanced STEM degree/ STEM workforce:
Dual M.D./Ph.D.
2
Gap Year7
Masters (6 were M.P.H.)7
STEM Workforce15
Grad School – Ph.D.12
Medical School19
Dental School
3Pharm.D.
1Other Workforce
5
2
3 2
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NIDDK Medical Student
Research Program in Diabetes
• Tenth summer (2009-2018)
• 4-10 students/Diabetes Center
• Over 1000 students from >120 medical schools
• Funding
– Supplement to T32s at Diabetes Centers
– Diabetic Complications Consortium
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http://nmri.niddk.nih.gov/
NIDDK’s Network of Minority Health Research Investigators
Goals:
• Encourage underrepresented minority investigators to choose a career in NIDDK mission areas
• Facilitate mentoring of junior investigators by experienced and accomplished researchers
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http://nmri.niddk.nih.gov/
NIDDK’s Network of Minority Health Research Investigators
• Current Membership ~ 200, 20% are senior members (Associate Professor or higher)
• Over 700 have attended the annual meetings in the past 10 years
• Numerous Grants, publications and poster presentations at national and international conferences.
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http://win.niddk.nih.gov/index.htm
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NDEP Resources: Prevention
Available to download at www.ndep.nih.gov
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National Kidney Disease Education Program
nkdep.nih.gov
Health Care ProfessionalsCommunity
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Follow @NIDDKgov on Twitter
• Healthy Moments radio program reaches over 60 million listeners.
• Airs weekly in• WMMJ Majic 102.3 FM Washington, DC • WWIN Magic 95.9 FM Baltimore, MD • KMJQ Majic 102.1 FM Houston, TX • WAMJ Majic 107.5 FM Atlanta, GA • WHHL Hot 104.1 FM St. Louis, MO• WENZ Z 107.9 FM Cleveland, OH• Get Up! Mornings with Erica Campbell Network (38
stations)
• Airs nationally 10 times a year in 10 additional cities on a celebrity morning radio show.