The Epidemic of Diabesity How Will It Change Your Life

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The Epidemic of Diabesity How Will It Change
Your Life?

• Marshall Bouldin MD
• Director, Diabetes and Metabolism Program
• Associate Professor of Medicine
• University of Mississippi Medical Center

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The Burden of Diabetes

• 16 million Americans
• 22 million with impaired glucose tolerance
• Leading cause of blindness
• Leading cause of ESRD
• Leading cause of limb amputations
• 2/3 die from coronary disease
• Per capita cost/pt 2x that of non-diabetic pt
• 15 of all U.S. health costs 25 of all Medicare
  costs
• 40 of all costs are related to hospitalization

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Cessna Jet

• 2.55 million
• Could purchase 44,000

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Elton John

• 1.5 million
• He could perform 66,000 times

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Epidemiology

• But wait a bit, the Oysters cried
• Before we have our chat.
• For some of us are out of breath,
• And all of us are fat.

- Lewis Carroll
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Obesity in the prehistoric ages Venus of
Willendorf c. 24,000-22,000 BCE Oolitic
limestone 4 3/8 inches (11.1 cm) high
(Naturhistorisches Museum, Vienna)
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Globesity/Diabesity

• Obesity is more prevalent than malnutrition in
  the world
• Obesity is a stronger predictor of morbidity than
  poverty or smoking
• Framingham obesity smoking in terms of life
  lost (7yrs)
• Prevalence of obesity/overweight skyrocketing
  globally

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Natural History Pandemic

• DM in 1897 2.8/100,000 prevalence
• Since 1958 5-fold increase in prevalence of DM2
• From 1991-2001, 49 increase in overall
  prevalence, 76 increase in age 30-39, 10-fold
  increase in pediatric DM2
• From 1991-2001, 61 increase in obesity
• From 2003 to 2005 13 increase in diabetes
• 1 in 3 children born in 2000 will develop diabetes

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Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI 30, or 30 lbs overweight for 5 4
person)
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs overweight for 5 4
person)
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs overweight for 5 4
person)
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Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI 30, or 30 lbs overweight for 5 4
person)
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs overweight for 5 4
person)
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs overweight for 5 4
person)
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs overweight for 5 4
person)
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Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2003
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2004
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity and Diabetes Trends in the US
Mokdad. JAMA. 200328976-79.
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Obesity Syndrome (Syndrome X, Metabolic
Syndrome, Insulin Resistance Syndrome)
Obesity/ Overweight
Glucose Intolerance
Dyslipidemia
Hypertension
Atherosclerosis
Kidney Disease
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Visceral Obesity Increases Risk for
Cardiovascular Disease and Metabolic Disorders

• CVD/Metabolic Risk Factors
• Hypertension
• Kidney Disease
• Insulin resistance
• Type 2 Diabetes
• Hypertriglyceridemia
• High dense LDL
• Low HDL Cholesterol
• Postprandial hyperlipidemia
• Microalbuminuria/Proteinuria
• Impaired fibrinolysis
• Low grade chronic inflammation
• (? IL-6, TNF?, CRP)

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Global CV Risk
Elevated cholesterol combined with otherrisk
factors markedly increases CVD risk
Compared with risk for a 40-year-old male
nonsmoker with total cholesterol185 mg/dL,
Systolic BP120 mm Hg, and no glucose
intolerance, ECG-LVH negative, whose probability
of developing CVD is 15/1000 (1.5) in 8 years.
Kannel. In Genest et al (eds). Hypertension
Physiopathology and Treatment. New York, NY
McGraw-Hill 1977888-910 Wilson et al. Arch
Intern Med. 19991591104-1109 Poulter. Am J
Hypertens. 19991292S-95S Fagot-Campagna et al.
Diabetes. 200049 (suppl 1)A78-A79.
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The Obesity Epidemic Has Reached Americas
Pets. August 16, 2004, AP Press Release
The National Academy of Science said that today
that as many as 40 of dogs and 12 of cats
presented at clinics are either overweight or
obese. It seems as though Americans bad
lifestyle habits have started to affect mans
best friends.
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Background Mississippi

• Highest prevalence of diabetes and obesity in
  U.S.
• Very high in all CV and diabetes complications
• Worst socioeconomic status in U.S.
• Very large at-risk population
• Very high in health disparities and poor access
  to care
• Half the average number of providers per capita

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Prevalence of Overweight/Obesity by Gender
(Mississippi BRFSS)
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Prevalence of Overweight/Obesity by Race
(Mississippi BRFSS)
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Prevalence of Overweight/Obesity in Men
(Mississippi BRFSS)
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Prevalence of Overweight/Obesity in Women
(Mississippi BRFSS)
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Childhood Obesity

• Rates continue to INCREASE, and overweight and
  obesity appears to DISCRIMINATE by race, sex, and
  geographic location
• Rates DOUBLED among children and TRIPLED among
  youth since 1980
• The greatest INCREASES in rates are among
• African-American girls
• Hispanic youth
• Those living in the south

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The Prevalence (overtime in the US)
American Obesity Association
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Percentage by Gender and Race
At risk of overweight BMI-for-age gt 85th
percentile, lt 95th percentile for gender Over
weight BMI-for-age gt 95th percentile for gender
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Percentage by Grade
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Percentage by Grade
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Childhood obesity over time
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How well do we take care of diabetes?
Mississippi 52nd out of 50 states in the quality
of diabetes care
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So What Is Diabetes?

• No, really

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Natural History of DM2
BA Ramlo-Halsted, SV Edelman, The Natural History
of Type 2 Diabetes Practical Points to Consider
in Developing Prevention and Treatment
Strategies , CLINICAL DIABETES, 18 (2) Spring
2000, pg 80-
Severity of Diabetes
Impaired Glucose Tolerance
Frank Diabetes
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Pre-diabetes

• IFG/IGT
• FBG gt100mg/dl, lt126mg/dl
• 30-60 become diabetic
• Weight loss and exercise prevent diabetes in
  these pts
• Drug therapy for prevention is much less
  effective

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Diabetes is very preventable!

• With loss of 7 of body weight and 150 min/week
  of moderate exercise, diabetes can be prevented
  about 58 of the time
• This was true for all subgroups age, sex, race,
  etc.
• Weight loss and exercise is twice as good at
  preventing diabetes as medicine

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Diabetes Prevention Program Intensive Lifestyle
Changes Reduce the Risk of Developing Type 2
Diabetes
N3,234 with IGT, mean age 51
-31
Change in RR
-58
Lifestyle Metformin
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Who would have thought the cure for Type 2
Diabetes would be a surgical procedure?

• All aspects of DM2 improve with exercise and
  weight loss
• Gastric Bypass (Pories et al.)
• n608, 146 w DM2
• Preop wt 304.4lb (198-615)
• 1 y p/op 192.2lb (104-466)
• 5 y p/op 205.4lb (107-512)
• 10 y p/op 206.5lb(130-388)
• 14 y p/op 204.7lb(158-270)
• 121 of 145(83) with DM2 nl FBG, A1c, insulin
  at 14 years
• 150 of 152(99) with IGT nl FBG, A1c,
  insulin at 14 years
• Multiple similar studies show normalization of
  FBG, insulin, A1c, insulin release, insulin
  resistance, glucose utilization w/i months p
  surgery

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But HOW did all this happen to us?

• The 2nd Law of Thermodynamics
• Total energy is ALWAYS conserved
• Calories in Calories burned

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BAGEL
20 Years Ago
Today
140 calories 3-inch diameter
350 calories 6-inch diameter
Calorie Difference 210 calories
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CHEESEBURGER
Today
20 Years Ago
590 calories
333 calories
Calorie Difference 257 calories
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SPAGHETTI AND MEATBALLS
20 Years Ago
Today
1,025 calories 2 cups of pasta with sauce and 3
large meatballs
500 calories 1 cup spaghetti with sauce and 3
small meatballs
Calorie Difference 525 calories
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Sedentary Lifestyle

• Average hours of TV viewing per household per
  day

Source Neilson Media Research
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COFFEE
20 Years Ago Coffee(with whole milk and sugar)
Today Mocha Coffee(with steamed whole milk and
mocha syrup)
45 calories 8 ounces
How many calories are in today's coffee?
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COFFEE
20 Years Ago Coffee(with whole milk and sugar)
Today Mocha Coffee(with steamed whole milk and
mocha syrup)
45 calories 8 ounces
350 calories 16 ounces
Calorie Difference 305 calories
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Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to walk in order to burn
those extra 305 calories?  
Based on 130-pound person
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Calories In Calories Out
If you walk 1 hour and 20 minutes, you will burn
approximately 305 calories.
Based on 130-pound person
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MUFFIN
20 Years Ago
Today
210 calories 1.5 ounces
How many calories are in todays muffin?
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MUFFIN
20 Years Ago
Today
210 calories 1.5 ounces
500 calories 4 ounces
Calorie Difference 290 calories
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Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to vacuum in order to burn
those extra 290 calories?
Based on 130-pound person
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Calories In Calories Out
If you vacuum for 1 hour and 30 minutes you will
burn approximately 290 calories.
Based on 130-pound person
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CHICKEN CAESAR SALAD
20 Years Ago
Today
How many calories are in todays chicken Caesar
salad?
390 calories 1 ½ cups
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CHICKEN CAESAR SALAD
20 Years Ago
Today
390 calories 1 ½ cups
790 calories 3 ½ cups
Calorie Difference 400 calories
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Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to walk the dog in order
to burn those extra 400 calories?  
Based on 160-pound person
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Calories In Calories Out
If you walk the dog for 1 hour and 20 minutes,
you will burn approximately 400 calories.
Based on 160-pound person
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But what about my genes?

• After all, I didnt pick my parents

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Prevalence of Diabetes in US by Ethnic GroupsAge
45-74 years
Harris et al, Diabetes 198736523 Flegal et al,
Diabetes Care 1991 14628 Fujimoto et al,
Diabetes 1987 36721 Knowler et al, Diabetes
Care, 1993 16216
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Diabetes trends in US by Race (1990-1998)
Adapted from Mokdad A. et al, Diabetes Care,
200023(9)1278-1283
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Genes or Lifestyle?Arizona Pimas vs Mexican Pimas
Ravusin et al, Diabetes Care 171067, 1994
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Our fate, dear Brutus, is not in our stars, but
in ourselves
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Type 2 diabetes - Its not our genes, its our
blue jeans!
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So What is Diabetes Care?

• Controlling complications
• - blood sugar
• - blood pressure
• - lipids
• Losing weight!
• Becoming more active
• If you smoke, STOP!

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Guidelines the Short Form

• BG, BP, Lipid control
• Sceening eyes, kidneys, feet
• ASA use
• Smoking cessation

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Monitoring Goals in a Nutshell

• A1c (lt7goal, gt8action required)
• BP control (lt130/80)
• Lipids (1 LDLlt100, 2 HDLgt40, 3 TGlt200)
• Retinal exams yearly
• Nephropathy screening (Microalbumin) - yearly
• Foot screening yearly and as indicated
• ASA therapy basically, if over 30 and not
  contraindicated
• Smoking Cessation

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Lifetime Microvascular Events in Type 2 Diabetes
Eastman, RC et al Model of Complications of
NIDDM, Diabetes Care, May 1997, 20(5), 735-744.
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Hypoglycemia

• The only diabetic emergency you may routinely see
  on the farm
• Signs and symptoms he aint actin right,
  agitation, sweats, shakes, heart rate, confusion
• Cause blood sugar too low
• Cure EAT SOMETHING RIGHT NOW!

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Diabetes What To Do?

• Prevention
• - prevent obesity
• - in those already overweight, prevent
  diabetes
• Decrease the cost of existing disease
• - decrease complications
• - improve the quality of care

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But How Do We Do It???

• System of care reforms a new approach to this
  disease is needed
• Education - for patients and providers
• Population strategies
• - Children Mothers
• - Schools
• - Regulatory efforts
• Research
• - Basic
• - Translational

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The Big Picture

• The burden of both type 2 diabetes and obesity is
  rapidly increasing, and shows no sign of
  stopping. If our society does not change this,
  diabetes alone will bankrupt our medical system.
• We can prevent most of the misery and cost, but
  we arent. Diabetes is highly preventable for
  those with diabetes, its complications are highly
  preventable.
• Systematic approaches (e.g. guidelines, disease
  management, ) to diabetes FAR exceed the results
  of traditional care and enhance provider
  effectiveness.

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DHA/UMMC Delta Diabetes Project Model

• Multidisciplinary, chronic disease model CBPR
• Non-traditional features
• Resource sparing
• A service to primary care providers
• Two arms education and management patient
  self-management is the key
• 4500 patients, 800 visits/mo
• Data and outcomes driven novel applications of
  teleinformatics
• Excellent quality of care, outcome, and patient
  satisfaction results
• Successfully reproduced in community settings

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DDP Outcomes

• Average patient has had diabetes for 10 years
  36 no-pay 70 African-American
• Mean A1c on presentation 10.0 mean decrease
  in A1c 1.92
• Improvement in blood pressure, lipids
• Outcomes are durable
• The model and its outcomes are easily
  reproducible in community practice
• Outcomes independent of race and gender
• High quality of care measures 90
• High patient satisfaction measures 97
• Resource utilization 4 management and 2
  education visits (year 1)

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Delta Diabetes Project

• Regional system of diabetes care improvement for
  Mississippi Delta
• Community-based participatory research
  collaboration sustainability
• 6 sites
• Integral provider education
• Duplicating or exceeding UMMC results in all
  outcomes
• Diabetes is only a test case chronic disease
  CHF, CV mortality, HTN, asthma, etc.
• Foothold for regional prevention programs in
  diabetes, obesity, and CV mortality

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