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GLOBESITY / DIABESITY THE EPIDEMIC

This overview discusses the definitions, epidemiology, and importance of the global increase in overweight and obesity, particularly in relation to metabolic syndrome and diabetes. It also addresses controversial questions such as how to measure the problem and why we have this epidemic. The text outlines what healthcare providers can do to help change the course of this epidemic at both individual and global levels.

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GLOBESITY / DIABESITY THE EPIDEMIC

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  1. GLOBESITY / DIABESITYTHEEPIDEMIC DR. T. COOK FRCPC, MPH LCOL (RET’D)

  2. OVERVIEW DEFINITIONS EPIDEMIOLOGY / IMPORTANCE SOME CONTROVERSIAL QUESTIONS • How best to measure the problem? • Why do we have this epidemic? • What can HealthCare Providers do to help change the course of this epidemic? • With individual patients • “Globally”

  3. GLOBESITY Worldwide increase in overweight and obesity

  4. DIABESITY

  5. METABOLIC SYNDROME • WHO / IDF Must have Insulin Resistance (DM2, IFG, IGT) Includes additional risk factor - Urinary albumin • ATP III (Adult Treatment Panel US NCEP - 2001) Any 3 of : • Abdominal Obesity (WC) • HyperTG • Low HDL • Hypertension • Impaired FBG

  6. ALL INTERACT OBESITY MET SYN DIABETES RIP

  7. SCOPE OF PROBLEM • HUGE! • ESCALATING • BUT... PREVENTABLE & MANAGEABLE

  8. FIRST CONTROVERSY: HOW TO MEASURE OBESITY BMI = Wt (kg)/ Ht (m)2 BMI = 34 BMI = 34

  9. BMI PROS & CONS • Easy, consistent, reproducible • Applicability questioned • Very muscular • Young • Old • Doesn’t distinguish visceral obesity

  10. WAIST CIRCUMFERENCE WAIST:HIP RATIO • PROS & CONS • Identifies visceral obesity • May carry independent risk assoc • Difficult to standardize, low “Kappa”

  11. WC THRESHOLDS • Caucasian • Male 102 cm (40 in) • Female 88 cm (35 in) • S. Asian / Asian • Male 90 cm (36 in) • Female 80 cm (32 in)

  12. BMI vs WC

  13. MEASURING BODY FAT % Bioelectric Impedance Analyzer Calipers “BodPod” (Air Displacement) BEST GOOD BETTER

  14. GLOBAL EPIDEMIC of OBESITY

  15. OVERWEIGHT IN CANADA BY PROVINCE

  16. FRIGHTENING STATS on OBESITY • 1995 • 200 million adults obese worldwide • 18 million children • 2008 • 300 million adult females obese worldwide • 200 million adult males • 42 million children • 35 million of these children live in LDC (less developed countries) • 2030 • 1.5 billion obese worldwide! (WHO data)

  17. OBESITY Associated Conditions • Hypertension • Diabetes Mellitus • Dyslipidemia • Coronary Artery Disease • Malignancies • Breast • Uterus • Pancreas • Prostate • Colorectal • Psychological Disorders • depression • anorexia nervosa • bulimia • Obstructive Sleep Apnea • Susceptibility: AMS, Heat Illness, Gout, Urolithiasis, Hypogonadism

  18. DIABETES IN CANADA PHAC - 2009 • 2.4 million Cdn • 6.8% pop’n • 8.7% (1:11) of 20 yo + • 3.7 million by 2019 • Increasingly affects children / productive age grps

  19. DIABETES IN CANADA OVER TIME Doubled in 10 y, by 2050 1:3 adults AND 1:3 children PHAC 2009

  20. WORLDWIDE DIABETES WHO est Currently 350 Million (6.5% world’s pop’n) Increase by 60% by 2030

  21. PRE-DIABETES / MET SYN • Pre-Diabetes is IFG +/- IGT • Addt’l 5 million Cdn (over 20 yo) have • Progression to diabetes ~ 30% in 10 yrs if IFG or IGT • Progression to diabetes ~ 60% in 10 yrs if IFG AND IGT • 15% Cdn meet criteria for Metabolic Syndrome

  22. WHY CARE? • Obesity, Diabetes, Metabolic Syndrome all assoc with • Higher mortality • Higher morbidity • Lower longevity • Increased health care cost • Lower productivity

  23. DIABETES DM2 leading cause of blindness, CRF, Amputation, CVD

  24. StatsCan

  25. INTERHEART STUDY Landmark Case-Control Study Lancet Vol 364, 11 Sept 2004 Dr. S. Yusuf – McMaster U. one of PI 15152 cases of Acute Myocardial Infarction 14820 controls - matched Worldwide (52 countries incl. 450 Canadians)

  26. ABDOMINAL OBESITY: MAJOR UNDERLYING CAUSE OF ACUTE M.I. Cardiometabolic risk factors in the INTERHEART Study 60 49 Abdominal obesity predicts the risk of CVD beyond BMI 40 PAR (%)a 20 18 20 10 0 Abnormallipids Abdominal obesity Hypertension Diabetes aProportion of MI in the total population attributable to a specific risk factor; CVD: cardiovascular disease; BMI: body mass index; PAR: population attributable risk; MI: myocardial infarction Yusuf S et al, 2004

  27. Cardio- Metabolic Risk HyperTG Waist • IFG / IGT • Abdo obesity • TG Cardiometabolic Risk Adds to Traditional Risk

  28. CONTROVERSY 2 WHY DO WE HAVE THESE EPIDEMICS? Ethnicity + Income, Job, Education, Food security, Social support, Healthcare access SOCIAL GENETICS “Built” – urban vs rural plan, access to trails, ease of walking / activities Housing Food & Beverage marketing ENVIRONMENTAL

  29. OBVIOUS BUT... NOT SOLE EXPLANATIONS • Excessive consumption of calorie-dense but nutrient poor, highly processed food • $110 billion USD spent on fast food worldwide /y • Sedentary lifestyles • Aging populations

  30. GENETICS OF OBESITY / DM2 • Rapid development s since human genome project • Single-gene , “causal” • Diabetes • Familial MODY = Glucokinase mutations • Mitochondrial diabetes with deafness • Obesity • Leptin or leptin receptor gene mutations • Orexin hormone abnormalities • Prader-Willi syndrome • These are RARE

  31. GENE ASSOCIATIONS • Obesity – 30 + gene changes • FTO “Fat Mass” gene  Satiety • “Appetite” gene • Nutrigenomics – SNPs predict best diet and exercise regimen • Diabetes – 40 + gene changes • TCF7L2 – modulates pancreatic islet cell function • IRS1 – insulin receptor substrate • TBC1D3 CNV (Copy Number Variation) may be primary player in insulin resistance

  32. NEW GENOMIC RISK FACTORS • Telomere length / Telomerase levels • High correlation with biological age, metabolic disease (obesity / DM2), stress effects and CVD! • Use is controversial! • Test annually • If telomeres are shorter than avg or shortening over time  BAD NEWS • Lifestyle modification will lengthen

  33. HOW TO MANAGE DIABESITY • Population and individual based • Multi-sectoral • Multi-disciplinary • Integrative • Culturally relevant • “one size can’t fit all”

  34. RECOMMENDATIONS • Lifestyle Modification  Sustained Behaviour changes for better health is goal • Must address all factors • Nutrition • Fitness (physical) • Fitness (mental) • Barriers to change • Education • Experiential, guidance, practice

  35. CONTROVERSY: WHAT IS BEST DIET? • Many studies, many conclusions • Must be individualized, ?guided by genomics • Long-term adherence • Micro and macro nutrients must be sufficient • “Balance and Moderation” • Avoid excessive liquid • Avoid processed foods • Vegetables, nuts, legumes, fruit predominate

  36. CONTROVERSY: HOW MUCH EXERCISE? • WHO Guidelines • 5 – 17 yo • 60 min mod to vigorous intensity daily • mostly aerobic • vigorous intensity activity that strengthens muscles and bones 3 / wk • >17 yo • 150 min mod intensity / wk OR • 75 min vigorous intensity / wk OR • equivalent combination • strengthen major muscle groups at least 2 / wk

  37. WHAT ABOUT N.E.A.T.? • Non-Exercise Activity Thermogenesis • Orexin “fidget” hormone • Small muscle groups used subconsciously eg. Posture • Mimic Orexin • Stand as much as possible • Sit on a Yoga ball • Avoid conveyances (elevators, escalators, cars)

  38. ROLE OF STRESS MANAGEMENT • Critically important for all diabesity patients • Stress hormones contribute to weight gain and raise glucose • Regular induction of the “relaxation response” improves BP and lengthens telomeres (Dr. D. Ornish) • Contemplative practice > 15 min daily assoc with improved health, well-being • MB-EAT (Mindfulness Based Eating Awareness Training) • Learn to pay attention to body signals for hunger, satiety, control emotional eating • Effective weight management program

  39. CMAJ April 2007: CPG on Prevention and Management of Obesity in Children and Adults

  40. CONTROVERSY: WHAT ARE GLYCEMIA CONTROL TARGETS? • Intensive glycemic control reduces microvascular complications • BUT... No RCT has demonstrated improved macrovasc outcomes in DM2 with intensive Rx • ACCORD and ADVANCE trials showed incr risk • Other risk factors (esp lipids, HTN, smoking, stress) more important • Glycemic targets need to be individualized • HbA1 6.5 - 7% if no AE in avg DM2 • HbA1 7 - 8% in elderly, multcomorbidities • GLOBAL CV RISK MANAGEMENT IS CRUCIAL

  41. SUMMARY • Obesity, Metabolic Syndrome and DM2 all reflect a prevalent genetic, social and environmental interaction • Their prevalence is increasing dramatically throughout the world. • All are associated with adverse CV and other health outcomes • All can be prevented and managed at an individual and global level, though there remain many challenges and controversies

  42. QUESTIONS

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