Epidemiology and Prevention of Type 2 Diabetes

Epidemiology and Prevention of Type 2 Diabetes

Epidemiology and Prevention of Type 2 Diabetes Edward Gregg, PhD Epidemiology and Statistics Branch Division of Diabetes Translation Centers for Disease Control and Prevention Atlanta, GA The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC. Prevalence Prevalence of of Total Total Diabetes Diabetes (Diagnosed (Diagnosed Diabetes Diabetes and and Undiagnosed Undiagnosed Diabetes) Diabetes) in in the the U.S. U.S. Adult Adult Population, Population, Age Age 20, 20, 2005-2006 2005-2006

According to Alternative Definitions of Undiagnosed According to Alternative Definitions of Undiagnosed Diabetes Diabetes 16 14 12 Diagnosed Undiagnosed 27.0 million 22.4 million 21.5 million 10 19.7 million 8 6

4 2 0 FPG (> 126 mg/dl) A1c (> 6.5%) FPG or A1c FPG or 2-hr (>126 mg/dl OR > 6.5%) (>126 mg/dl OR 2hPG > 200) Sources: Cowie et al., Diab Care, 2009; unpublished analyses, Bullard et al.; NIDDK, CDC Estimated Estimated lifetime lifetime risk risk of of developing developing diabetes diabetes for

for individuals individuals born born in in the the United United States States in in 2000 2000 60 Percent 50 Total Non-Hispanic Black Non-Hispanic White Hispanic 40 30 20 10 0

Men Narayan et al, JAMA, 2003 Women Projected Projected Total Total Number Number of of Adults Adults with with Diabetes Diabetes (Diagnosed (Diagnosed or or Undiagnosed) Undiagnosed) Under Under Scenarios Scenarios of of No No further further Increase Increase Continued Continued Increased Increased Incidence Incidence Rate

Rate 120 Current Trends No Further Increase Millions of Adults 100 80 60 40 20 2007 2010 2015 2020 2025 2030 2035 Year Boyle et al., Pop Health Metrics, 2010 2040 2045 2050 Projected Projected Prevalence

Prevalence of of Diabetes Diabetes (Diagnosed (Diagnosed or or Undiagnosed) Undiagnosed) Under Under Scenarios Scenarios of of No No further further Increase Increase Continued Continued Increased Increased Incidence Incidence Rate Rate 40 Prevalence (%) Current Trends No Further Increase 30

20 10 0 2007 2010 2015 2020 2025 2030 2035 2040 2045 2050 Year Boyle et al., Pop Health Metrics, 2010 Factors Factors Influencing Influencing Future Future Incidence Incidence and and Prevalence Prevalence Estimates Estimates Prevalence in year 2010 (number and proportion of adults with diagnosed and undiagnosed diabetes, pre-diabetes). Incidence (Rate of new cases into the future). Mortality rates Age distribution of the population. Census projection of population growth. Migration

Risk Factors for Type 2 Diabetes Types of Risk Factors Factors Causally Associated with Increased Diabetes Incidence in Individuals Modifiable and Prime Targets for Individual-Level Interventions Factors Explaining Population Trends in the Disease Prevalence Prevalence of of Total Total Diabetes Diabetes (Diagnosed (Diagnosed Diabetes Diabetes and and Undiagnosed Undiagnosed Diabetes) Diabetes) in in the the U.S. U.S. Adult Adult Population, Population, Age Age 20,

20, 2003-2006 2003-2006 25 Age Group 20 Undiagnosed Diagnosed 15 10 5 0 Total 20-39 yrs 40-59 yrs Prevalence (%) Sources: Cowie et al., Diab Care, 2010; NIDDK, CDC 60-74 yrs 75+ yrs

Estimated Estimated Age-Adjusted Age-Adjusted** Prevalence Prevalence of of Diagnosed Diagnosed Diabetes Diabetes in in People People Aged Aged 20 20 Years Years or or Older, Older, by by Race/Ethnicity, Race/Ethnicity, United United States, States, 2007 2007 American Indians/Alaska Natives Non-Hispanic blacks Hispanic/Latino Americans Asian Americans Non-Hispanic whites 0

5 10 15 Percent *Based on the 2000 US standard population CDC, National Diabetes Fact Sheet, 2007 20 Migration Migration Studies: Studies: Association Association Between Between Westernization Westernization and and Diabetes Diabetes Prevalence Prevalence in in Susceptible Susceptible Populations Populations 40

% 30 20 10 0 Nauru New Guinea Australian Aborigines Chinese King, Diabetes Care, 1993; 1998; Diamond J, Nature, 2003 Indian Body Mass Index and 1-year Risk of Diabetes (Ford ES et al. AJE 1997;146:214-22) BMI 1-y Risk (%) <22 0. 224 22-<23 0. 255

23-<24 0. 428 24-<25 0. 539 25-<27 0. 553 27-<29 0. 899 29-<31 1.074 31-<33 1.480 33-<35 1.892 35+ 2.461 %- Point Increase per RR Absolute Increase 100,000 0 0 1 0.031 31 1.18 0.204 204

2.44 0.315 315 2.97 0.329 329 3.04 0.675 675 5.07 0.850 850 5.70 1.256 1,256 8.21 1.668 1,668 10.89 2.237 2,237 14.64 Cumulative Increase 0 550

1,554 7,565 Relative risk of incident diabetes per standard deviation of BMI and Waist circumference from a meta-analysis of 32 studies Vasquez, Epidemiol Rev, 2007 10 Diabetes Prevalence among U.S. Adults Aged 20 - 74 8.83% 1.37 8 BMI Category 6 Obese III (> 40) Obese II (35-40) Obese I (30 -35) Overweight (25 -30) Normal / underweight (<25) Total

Age and sex adjusted 4 2 0 1.42 5.03% 0.4 0.56 1.05 2.26 1.5 2.5 1.57 1.28 1976-1980 1999-2004

Year Gregg et al., Prev Med, 2007 Luckovich, Atlanta Journal Constitution Hu et al., Arch Intern Med, 2001 Dietary factors as independent diabetes risk factors Characteristics of fat intake Whole grain / cereal fibers Dairy Glycemic load Western diet Fast food intake Soda intake Alcohol intake Coffee consumption Trends Trends in in the the proportion proportion of of total total intake intake devoted

devoted to to macronuetriends macronuetriends (left (left x-axis) x-axis) and and mean mean total total Energy Energy Intake Intake (right (right x-axis) x-axis) among among U.S. U.S. adults adults age age 20-74, 20-74, 1971 1971 to to 2000 2000 60 Total Intake (kcals) 50

2800 2600 2400 40 2200 % Carbs 2000 30 % fats % saturated fats 1800 % protein Total Energy 20 1600 1400 10

0 1200 1971-1974 MMWR, 2004 1976-1980 1988-1994 1999-2000 1000 Percentage of total carbohydrates obtained from whole grains (smaller circles) and corn syrup (larger circles) in the United States Gross et al., Am J Clin Nutr, 2004 Trends Trends in in % % of of Meals Meals Eaten Eaten at at Home

Home and and Trends Trends in in Total Total Kcal Kcal Intake Intake in in Meals Meals and and Snacks Snacks in in the the U.S., U.S., 1977-1996. 1977-1996. Snac k s 75 Meals 1950 70 k c a ls /d a y

% Meals eaten at home 80 65 60 55 50 1800 1650 1500 1977- 1989- 1994- 78 91 96 Nielsen and Popkin, JAMA, 2003

1977- 1989- 199478 91 96 Portion Portion Sizes Sizes for for Selected Selected Key Key Foot Foot Items Items for for Americans Americans Aged Aged 22 and and Older, Older, 1977-1996. 1977-1996. Food intake per occasion, oz 25 20 15

10 5 0 Nielsen and Popkin, JAMA, 2003 1977-78 1989-91 1994-98 Promising Promising Targets Targets for for Population-Wide Population-Wide Food Food Policies Policies to to Influence Influence Diabetes Diabetes Diabetes OR per 1kg Birth weight=0.78 Serum Concentration ND Cases/n

<25% 25-50% 50-75% 75-90% 90-100% 2/643 34/505 53/527 65/275 63 / 246 Prevalence -- 0.4 6.7

10.1 23.6 25.6 Adjusted OR -- Referent 14.9 (3. 0 65.0) 14.7 (3.4 63.9) 38.2 (8.0 183.1) 37.7 (7.8 182.0) Adjusted OR

--- 0.07 (0.02 0.33) Ref 1.1 (0.6 1.7) 2.7 (1.5 4.9) 2.7 (1.5 4.8) Lee et al., Diab Care, 2007 Brownell et al., Gestational Diabetes and the Incidence of Type 2 Diabetes: A systematic review (Kim et al., Diabetes Care, 2002) Systematic Systematic Review Review of of the

the Incidence Incidence of of Diabetes Diabetes Associated Associated with with Various Various Categories Categories of of Glycemia Glycemia Number Regress to Progress to Relative Risk of of studies normal Diabetes Diabetes (median %) (median %) Impaired Glucose Tolerance 26 8% 7% 6.4 (4.9 7.8) IGT Isolated

3 n/a 6% 5.5 (3.1 7.9) IFG 6 13 29% 5-20%* 4.7 (2.5 6.9) IFG Isolated 3 n/a 7% 7.5 (4.6 10.5)

IGT and IFG 3 n/a 10-15% 12.1 (4.3 20) Gerstein et al., Diab Res Clin Pract, 2007 *extremely variable; 1-7% in European pops; 23-34% in Asian pops. Summary: Summary: Risk Risk Factors Factors for for Type Type 22 Diabetes Diabetes

Age Family History / genetics Gestational Diabetes Obesity / fat distribution Physical Activity / fitness Smoking Very low birth weight Depression Antipsychotic medications Anti-Retrovial therapy Dietary Factors

Carbohydratess Fats Glycemic load Cereal fiber / whole grain Dairy products High fructose corn syrup Sugar-sweetened bevarages Alcohol Coffee Successes and Failures in the Public Health Response to Type 2 Diabetes Diabetes Diabetes Pyramid Pyramid of of Prevention? Prevention? Goal / Intervention Tier Adult Prevalence 7.6% 2.6% Diabetes Undiagnosed DM

Prevent Morbidity Detect Early Classic Classic Levers Levers in in the the Public Public Health Health Response Response to to Diabetes Diabetes Glycemic control BP control Lipid testing and management Clinical Services Promotion of Behaviors Annual eye examinations Foot care for high risk persons Kidney disease testing

Flu immunization Preconception care Diabetes education Case Management Targeted Screening Education and awareness for: Population-Targeted Policies Physical activity Reduced Tobacco Healthy diet Regular doctor visits Self monitoring Self mgt education Health care access legislation Drug and supply reimbursement policies Population registry and feedback systems Prevalence Prevalence of of CVD CVD risk risk factors

factors among among U.S. U.S. adults adults with with diabetes diabetes aged aged 20-74, 20-74, according according to to income income group, group, 1971 1971 to to 2006 2006 (* (* red=low red=low income; income; green=middle green=middle income; income; yellow=high yellow=high income) income) High Blood Pressure Smoking

High Cholesterol High A1c Level Incidence Incidence of of lower lower extremity extremity amputation, amputation, end end stage stage renal renal disease, disease, and and hyperglycemic hyperglycemic death death in in the the U.S. U.S. diabetic diabetic population, population, 1990-2006. 1990-2006. 80 70

Amputation Events Per 10,000 60 50 40 End Stage Renal Disease 30 20 4.0 3.0 2.0 Gregg and Albright, JAMA, 2009 Hyperglycemic Death Men Women The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC. Gregg et al., Ann Intern Med, 2007 What

What has has worked worked in in secondary secondary prevention? prevention? Health Services: Acute care and major medical interventions Diffusion of new science of risk factor management Emphasis on quality of care Health system adaptation and CQI Health Promotion and Health Protection Improved education/awareness of diabetes control. Improved CVD risk factor education and awareness. Reduced Tobacco / tobacco legislation Less directly atherogenic food supply Failures in the Public Health Response to Diabetes Levels of care and preventive health behaviors are still suboptimal. Improvements in blood pressure may have stalled.

Disparities remain in renal disease, amputation, acute complications, and costs. Major differences in morbidity remain between people with and without diabetes. Diabetes is economically disabling for people and their families. While the average person with diagnosed diabetes has better control and lower risk of complications, the risk of diabetes or a diabetes complication for the average person in the total population has increased. Incidence Incidence of of lower lower extremity extremity amputation, amputation, end end stage stage renal renal disease, disease, and and hyperglycemic hyperglycemic death death in

in the the U.S. U.S. population, population, 1990-2006. 1990-2006. Excess Risk of Complications in the Diabetic Population 1990 1995 2000 2005 2010 Excess Risk of Diabetes in the General Population 1990 1995 2000

2005 2010 Proportion Proportion of of Participants Participants Developing Developing Diabetes Diabetes During During the the Finnish Finnish and and U.S. U.S. Diabetes Diabetes Prevention Prevention Studies Studies Finland 50 40 50 40 Control

30 United States Control Metformin % % 30 20 Lifestyle 20 Lifestyle 10 10 0 0

0 1 2 3 Study Year 4 5 6 0 0.5 1 1.5 2 2.5 3 3.5 4 Study Year Tuomilehto, N Engl J Med, 2001; DPP Research Group, N Engl J Med, 2002 Longer-term Longer-term Impact? Impact? Magnitude Magnitude of of Incidence Incidence Reduction Reduction in in

Long-term Long-term Diabetes Diabetes Prevention Prevention Legacy Legacy Studies Studies Primary Outcome (RR Reduction) Extended Outcome Finnish DPS (Lifestyle) 58% at 3 yr 43% at 7 years Da Qing Study (Lifestyle) 51% at 6 yr 43% at 20 years DPP- OS (Lifestyle) 58% at 2 yr

24% at 10 years DPP-OS (Metformin) 31% at 2 yr 18% at 10 years Lindstrom, et al. 2006; Li et al. 2008; DPPOS; 2009 Drug Duration (yrs) Dose / day RR Reduction Side Effects DPP, 2002 Metformin 2 1700 mg

31% GI Stop NIDDM Acarbose 3 300 mg 25% GI IDPP, 2006 Metformin 2.5 500 mg 26% GI; Hypo

DREAM Rosiglitazone 3 8 mg 60% NAVIGATOR Nateglinide 5 90mg NS CHF; wt gain; hypo CANOE Rosi + Metformin

4 4mg; 1000mg 69% Diarrhea 16% vs 6% Chiasson 2002; Ramachandran 2006; Knowler, 2002; Navigator, 2010; Zinman, 2010; Gerstein, 2006 Characteristics of Successful Lifestyle Interventions Intensive: small group, or 1:1; For 6 12 months Extended: > 2 years Multi-component Reduced total intake, reduced fat intake Exercise Increased fiber intake Strongly integrated behavioral principles Moderate weight loss: 5-7% weight loss, 3-4% long-term weight loss maintenance

Current Current Dilemmas Dilemmas in in Diabetes Diabetes Prevention Prevention Policy Policy High risk vs population approach Whom to Target? Imminent risk based on glycemia vs broad risk factors vs everyone? Is screening for pre-diabetes good policy? And if so, how should we screen? What interventions to apply? Structured and tied to clinical services? Broad health promotion? Population-targeted policies? Diabetes Diabetes Pyramid Pyramid of of Prevention Prevention Adult Prevalence 7.6%

Diabetes 2.6% Undiagnosed DM ~12-15% Very High Risk (A1c > 5.7%; IGT; GDM) ~15-20% ~57% Goal / Intervention Tier Prevent Morbidity Detect Early High Risk (FPG > 100); Central Obesity; HTN, age Moderate Risk Low Risk What type of

intervention for what level of risk? Summary Summary and and Recommendations: Recommendations: Related Related to to Screening Screening and and Identification Identification Encourage identification of pre-diabetes and undiagnosed diabetes in adults in clinical settings and established clinical/community partnerships. o Risk scores most appropriate first stage screening. o More efficient in integrated manner, connected to lipid, BP. o Ideal thresholds for referral ultimately depend upon resources. Discourage : o Population-wide blood screening in the absence of risk factor assessment or in low-risk populations.

o Screening in community settings (health fairs, retail stores, etc.) that lack a direct connections to health care provider. o Screening of youth and adolescents . Potential Potential Barriers Barriers to to Effective Effective Clinical-System Clinical-System Based Based Lifestyle Lifestyle Intervention Intervention Programs Programs Clinical health systems lack structure and expertise to change lifestyle. Too expensive and not scalable. Previous models of clinical based / lifestyle change have not achieved sustainable reimbursement. Waiting until people have elevated glucose is too late. Diabetes is a common-source epidemic rooted in culture and society. Macro-Level Determinants Obesity and Diabetes: Current Debates Over Policy

Strategies Physical environment Food environment Social environment Economy and poverty Policy Options to Influence Diabetes Risk Taxation Food and Menu labeling Engage Private Industry Crop subsidy policies Incentives/promotion for community availability and affordability of foods. Incentives/promotion for community support for physical activity. Regulation of foods in public areas. School food and physical education policies. Summary:

Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence. Diabetes prevention requires a multi-tiered public health response, that includes Efficient identification and referral of high risk people to structured lifestyle programs using clinical-community partnerships. Summary: Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence. Diabetes prevention requires a multi-tiered public health response, that includes Efficient identification and referral of high risk people to structured lifestyle programs using clinical-community partnerships. Broad population targeted approaches aimed at food, social, and economic environment to

ultimately change trends in the epidemic. Thank you http://www.cdc.gov http://www.cdc.gov/diabetes/statistics/index.htm http://www.cdc.gov/diabetes/statistics/didit/index.htm Edward Gregg, PhD: [email protected]

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