Introduction

1. Prevention of Diabetes and ObesityRobin S. Goland, MDNewYork-Presbyterian Hospital/Columbia University

2. Introduction • What’s important about diabetes and obesity? Definitions of type 1, type 2 diabetes, obesity, metabolic syndrome • Causes of diabetes and obesity • Treatments of diabetes and obesity • Prevention of diabetes and obesity

3. Diabetes in the U.S. and France • In US, ~17 million Americans have type 2 diabetes and 1 million have type 1 diabetes. • In US, diabetes is the seventh leading cause of death. Diabetes complications account for more than $190 billion in health care costs • In France, 1.8 million people have type 2 diabetes (prevalence 3%), incidence increasing at 3.2 % • In France, healthcare costs for people with diabetes are about 2x expense of nondiabetic people

4. What is Diabetes? • Diabetes is a disease of high blood sugar • Type 2 diabetes accounts for ~90%cases • Type 2 diabetes results from combination of resistance to effects of insulin and relative insulin deficiency • Type 1 diabetes results from insulin deficiency

5. Who Gets Diabetes? • Type 1 diabetes occurs in young, lean, non-minority. Peak age 12.8 but can occur at any age. 80% no family history but still genetic origin. 50% concordance in identical twins. • Type 1 diabetes has explosive onset • Type 2 diabetes incidence increases with age and weight; occurs frequently in minority populations; age of onset decreasing. Near 100% concordance in identical twins. • Type 2 diabetes has insidious onset and if often undiagnosed

6. How Type 1 Diabetes Develops Putative environmental trigger Genetic predisposition Insulitis b cell injury (autoantibodies) Pre-diabetes Impaired Glucose tolerance Clinicalonset Diabetes

7. How Type 2 Diabetes Develops

8. Poorly Controlled Diabetes Causes Vascular Complications

9. Taking care of Diabetes • Control of blood sugar prevents complications • Importance of self-monitoring and hemoglobin A1c • Type 1 diabetes mainly about blood sugar • Type 2 diabetes multi-factorial. A component of the metabolic syndrome. Insulin resistance accompanied by central obesity, inactivity, abnormal cholesterols, high blood pressure, vascular disease, inflammation

10. Management of Type 2 Diabetes in France • 1999 study of 4,119 patients with type 2 diabetes. • Over 50% of the patients were more than 67 years old; 73% diagnosed with diabetes during a visit not related to diabetes' symptoms or complications. • 42% of patients were obese, 46% had high blood pressure, 53% had high LDL-Cholesterol. • 33% of patients had at least one diabetic complication. • 40% had no HbA1c measured in the last 6 months. HbA1c level high in more than half who did have it done.

11. Metabolic Syndrome • Abdominal obesity • High insulin levels • High fasting glucose • Impaired glucose tolerance • High triglycerides • Low HDL-cholesterol • High blood pressure

12. Metabolic Syndrome Increases Risk for CHD and Type 2 Diabetes HighLDL-C MetabolicSyndrome Type 2Diabetes Coronary Heart Disease Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

13. Treatment of Metabolic Syndrome in Patients with Diabetes • 80-85% of diabetic subjects in North America and Europe have the metabolic syndrome • However, most subjects with the metabolic syndrome do not have diabetes • Importance of aspirin, statins, blood pressure control • What about exercise and weight loss?

14. Obesity: Impact of Genes and Environment

15. Obesity Is Caused by Long-Term Positive Energy Balance FatStores

16. Lifetime Food Intake Water 45,300 kg Fat 2300 kg 21 kcal* Cholesterol 8000 kg 31 kcal* Protein 1900 kg 7 kcal* *kcal in millions

17. Body Mass Index (BMI) BMI 18.5 - 24.9 = Normal weight BMI 25 - 29.9 = Overweight BMI >30 = Obese

18. Medical Complications of Obesity Lung disease Stroke Fatty liver disease Coronary heart disease Diabetes Abnormal Cholesterol High Blood Pressure Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Gynecologic abnormalities Arthritis Edema Skin Gout

19. <22 <23 23 - 23.9 24 - 24.9 25 - 26.9 27 - 28.9 29 - 30.9 31 - 32.9 33 - 34.9 35+ Preventing Obesity Would Prevent Much Type 2 Diabetes Age-Adjusted Relative Risk Body Mass index (kg/m2)

20. Diabetes in US

21. Obesity In US

22. Obesity in France

23. Obesity in France

24. Obesity in France in Children Ages 5-12

25. Obesity in France • Although France has one of the lowest obesity levels in Europe, still cause for concern • Obesity: 12% in France, 23% in Britain, 31% in US • Obesity in children has risen 17% in 20 years • One child in 10 is obese at age 10 • 19% children 10-11 are obese • Fewer than 10% of people in Paris are classified as obese -- but in France's Northeast, adult obesity exceeds 20%.

26. 1200 1000 800 600 400 200 It’s Difficult to Lose Weight with Exercise All out competitive sports Running 10 mph Energy Expenditure (kcal/h) Running 6 mph Climbing stairs Sexual intercourse Gardening Walking 4 mph Bicycling Walking 2 mph Chewing gum (11 kcal/h) Adapted from: Alpers. Undergraduate Teaching Project. Nutrition: energy and protein. American Gastroenterological Association, 1978.

27. Losing Weight and Keeping It Off • 90% of overweight people who lose weight gain it back • No short-term fixes work • Low carb vs low fat? • Common sense tips: Limit fast food, sodas, juices, highly processed foods • Exercise often the key to losing weight and keeping it off • Being fat associated with living longer, regardless of weight

28. Physical Activity is Good • Being fit associated with living longer, regardless of weight • Exercise often the key to losing weight and keeping it off • Decreasing sedentary behavior--tv watching, computer time---very important

29. Impact of Small Weight Loss on Health

30. Unrealistic Weight Loss Goals Common Foster et al. J Consult Clin Psychol 1997;65:79.

31. Why Is It So Easy to Gain Weight and So Hard to Lose Weight and Keep it Off? • Obesity is a chronic illness, not a character flaw • Many physiologic pathways to prevent starvation and ensure survival of the species; little to protect against weight gain: thrifty genotype hypothesis • Environment likely responsible for recent obesity epidemic: ready access to highly palatable, calorie-dense, highly advertised calories plus reduced need for physical activity

32. Why Is It So Easy to Gain Weight and So Hard to Lose Weight and Keep it Off?

33. Preventing Obesity and Diabetes • Preventing obesity will prevent ~70% type 2 diabetes. Prevention more successful than treatment. Importance of attention to pregnant women, children. • Small weight loss can have significant health benefit. Need to manage expectations. • Cause of obesity epidemic unclear but appears related to environmental “toxicity” with increased caloric intake and decreased physical activity • Weight loss requires reduced calories. A calorie is a calorie. Low-glycemic index diets may enhance satiety and reduce re-gain of weight. • Exercise important and helps with weight maintenance

35. Better Than “Eat Less and Exercise More”