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Emerging Links Between Diabetes and Environmental Exposures to Arsenic and Dioxin

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Emerging Links Between Diabetes and Environmental Exposures to Arsenic and Dioxin ... Retrospective cohort study: OR 8.6 to 10 in dose response fashion. ... – PowerPoint PPT presentation

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Title: Emerging Links Between Diabetes and Environmental Exposures to Arsenic and Dioxin


1
Emerging Links Between Diabetes and Environmental
Exposures to Arsenic and Dioxin
  • J. Jina Shah, MD, MPH
  • Lynn Goldman, MD, MPH
  • Johns Hopkins School of Public Health

2
Diabetes Definitions
  • a group of heterogeneous disorders with the
    common elements of hyperglycemia and glucose
    intolerance, due to insulin deficiency, impaired
    effectiveness of insulin action, or both
  • other elements in its fully developed form
    (Fajans, 1971, cited in Welborn, 1984)
  • microvascular complications
  • accelerated atherogenesis

3
Classification Criteria in Evolution but Most
Still Type II
  • More recent classifications separate etiology
    from severity
  • Increasing genetic, immunological expertise
    allows for more specific diagnoses
  • However, majority are classified by clinical and
    blood glucose criteria
  • 90 of diabetes in the world is classified Type
    II

4
Why is it important?
5
High worldwide burden of disease, high projected
increase
  • 1997 120-147 million people, 2.1 of population
  • 66 million in Asia
  • 22 million in Europe
  • 13 million in North and Latin America
  • 8 million in Africa
  • 1 million in Oceana
  • 2010 213 to 215 million people (3)
  • Asia and Africa to have greatest (2 to 3X)
    potential to increase
  • Asia likely to have 61 of total

6
US Prevalence
  • 1998 NHIS data
  • 10.5 million diabetics
  • 5.4 million undiagnosed
  • 13.4 million with impaired fasting glucose
  • Even more with impaired glucose tolerance

7
Prevalence of Diabetes Among Adults,1990 (BRFSS)
lt4 46 gt6
8

Prevalence of Diabetes Among U.S. Adults,
1993-1994 (BRFSS)
lt4 46 gt6
9
Prevalence of Diabetes Among US Adults, 1999
(BRFSS)
lt4 46 gt6
10
High Cost to Individual and Society
  • Costs estimated for US 92 billion in 1997
  • 11,000 per capita
  • Direct medical and productivity costs
  • Some costs, such as suffering of patients and
    families, not quantifiable though people try to
    incorporate quality of life into calculations

11
What do we know about causes?
12
Biological Determinants
  • Age
  • Genetics
  • Obesity
  • Family history
  • Ethnicity
  • People of color greater prevalence and severity
  • There is more data on African Americans and
    Hispanics than on Asian and Native Americans

13
Environmental Determinants
  • Diet, physical activity (obesity)
  • Globalization, modernization, westernization
  • Exposures such as arsenic and dioxin
  • Other environmental exposures

14
Gene-Environment Interactions
Biologically vulnerable
Diabetes
Barker hypothesis
B-cell defect
Environmental factors, exposures
15
Environmental Exposures
16
Arsenic Ingestion - DrinkingWater
  • Bangladesh
  • Elevated PRs for glucosuria from PR3 to 9 in one
    study.
  • PR 1 to 3 in another study
  • Both with dose-response patterns
  • Taiwan
  • Prospective cohort study RR 2.1, RR 1.03 for
    every mg-L/year in arsenic exposure.
  • Mortality study non significantly elevated SMRs.
  • Retrospective cohort study OR 8.6 to 10 in dose
    response fashion.

17
Arsenic Inhalation Occupational
  • Swedish mortality studies
  • Glass workers
  • OR nonsignificant
  • Copper Smelter workers
  • OR 2 to 7, dose response pattern

18
Arsenic Conclusions
  • Evidence of an association between arsenic and
    diabetes in 5 separate studies
  • Further study is warranted, along with
    consideration of precautionary steps to avoid
    exposure

19
Dioxin Exposures-Environmental Releases
  • Residential exposures
  • Seveso , Italy
  • mortality increased, not statistically
    significant
  • Jacksonville, AK Superfund site
  • for high insulin concentration, ORs9 to 56

20
Dioxin Exposures-Veterans
  • Veterans
  • Ranch Hands
  • increased mean insulin, diabetes prevalence,
    glucose and insulin abnormalities
  • Those with background levels of exposure did not
    have significantly increased risk
  • Army chemical corps sprayers, increased risk

21
Dioxin Exposures Other Industrial Workers
  • IARC cohort exposed to phenoxy herbicides and
    chlorophenols
  • RR 2.25 for diabetes as underlying cause of death
    in exposed vs. non exposed
  • Other occupational cohorts with mixed findings,
    no clear dose-response pattern

22
Dioxins Conclusions
  • Limited but suggestive evidence of association
    for dioxin (finding could be due to chance, bias,
    or confounding) per the IOM

23
How much of a contribution are the exposures?
  • Unknown, but probably small relative to other
    known risk factors
  • IOM, VAO, Update 2000
  • These studies indicate that the increased risk,
    if any, from herbicide or dioxin exposure appears
    to be small. The known predictors of diabetes
    risk-family history, physical inactivity and
    obesity continue to greatly outweigh any
    suggested increase from exposure to herbicides.

24
Recommendations
  • Better studies regarding environmental exposures
  • standard case definition for diabetes
  • good exposure measurements
  • prospective study design
  • adequate control for confounding variables

25
How do we get better exposure and outcome
measures?
  • Better tracking of exposures
  • Better tracking of chronic diseases for specific
    populations and in specific localities

26
Risk reduction of known factors
  • Encourage policy initiatives to increase physical
    activity and promote a more sound diet for
    individuals and society
  • Address globalization, modernization,
    westernization, which lead to more sedentary
    lifestyles and higher fat diets
  • Take steps to reduce exposure to arsenic and
    dioxins

27
Acknowledgements and Contact Info
  • On this project, I was supervised by Lynn
    Goldman, at Johns Hopkins Bloomberg School of
    Public Health and supported by Physicians for
    Social Responsibility.
  • This project was not done under the Centers for
    Disease Control, but I am currently working at
    CDC. I can be contacted at zat5_at_cdc.gov.
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