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Emerging Links Between Diabetes and Environmental Exposures to Arsenic and Dioxin


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

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

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

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

Why is it important?
High worldwide burden of disease, high projected
  • 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

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

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

Prevalence of Diabetes Among U.S. Adults,
1993-1994 (BRFSS)
lt4 46 gt6
Prevalence of Diabetes Among US Adults, 1999
lt4 46 gt6
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

What do we know about causes?
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

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

Gene-Environment Interactions
Biologically vulnerable
Barker hypothesis
B-cell defect
Environmental factors, exposures
Environmental Exposures
Arsenic Ingestion - DrinkingWater
  • Bangladesh
  • Elevated PRs for glucosuria from PR3 to 9 in one
  • 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.

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

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

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

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

Dioxin Exposures Other Industrial Workers
  • IARC cohort exposed to phenoxy herbicides and
  • 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

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

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.

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

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

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

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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