Diabetes a Global Epidemic Sherry Dunbar Northern Arizona University

Abstract Type 2 Diabetes is major and growing global health concern, and the focus of this presentation. Included: Risk factors and stages of the disease Global, U.S., and European incidence and prevalence Data and measures utilized for diabetes are examined Health promotion and prevention, and global and economic impacts

Introduction Three types of Diabetes: Type 1 – childhood onset requiring genetic predisposition (Forouhi & Wareham, 2010) Gestational – usually in third trimester and temporary, but is considered predisposing factor for Type 2 (Nolan et. al. 2014) Type 2 – the focus of this presentation, is dominantly prevalent at 85% of total diabetes (Forouhi & Wareham, 2010) Someone dies every six second from diabetes (International Diabetes Federation, 2014b)

The Disease Diabetes: Chronic disease Complex metabolic disorder described as chronic hyperglycemia (Smuchkin and Vella, 2010) Secondary to insufficient production or uptake of insulin Resulting in elevated concentration of blood glucose (World Health Organization, 2014) Leading to vascular complications (Smuchkin & Vella, 2010)

Stage of susceptibility Significant determining risk factors Obesity Lack of sufficient physical activity Underlying risk factors Genetics Smoking Air pollution Psychosocial factors Metabolic pathway biomarkers (Tamayo et. al. 2014) Without risk factor mediation, 15-30% of pre-diabetic Americans will progress to diabetes within 5 years(American Diabetes Association, 2014)

Pre-symptomatic stage of disease Gestational diabetes = 9x more likely to have diabetes within 15 yrs (Nolan et.al 2011) Pre-metabolic syndrome: two are more of the following: Abdominal obesity: girth > 40” in men & 35” women Hypertension 140/90 or greater Triglyceride levels 200 or greater HDL 40 or less in men & 50 or less in women Fasting blood glucose 100-125 (Okosun et. al. 2009) Pre-metabolic syndrome is associated with 5 fold increase for Type 2 diabetes. (Okosun, et. al 2009)

The clinical stage Metabolic syndrome: Diabetes: abnormal glucose metabolism but not yet diagnosable as diabetes Diabetes: Fasting blood glucose: 126 or greater, or Random blood glucose: 200 (Sumshkin & Vella, 2010)

Recovery, disability, and death Insulin replacement is not enough Must act upon modifiable risks factors for control or reversal of disease 7% weight loss via diet & exercise = 58% incidence reduction after 3 years (Sumshkin & Vella, 2010) Diabetes complications secondary to vascular destruction: Blindness, heart disease, stroke, organ damage, amputation (Hussain et. al. 2007) American with diabetes at 50% greater risk of death (ADA, 2014)

Data and Measures Used Types of data Age, gender, ethnicity, geographical, genetic (Forouhi & Wareham, 2010) Fetal development, gestational diabetes (Hussain et la 2007) Correlations to agricultural, westernized, & transitional dietary patterns (Smushkin & Vella ,2010 and Oggioni et. al. 2014) Tracking and reporting (a few examples) World Health Organization, Centers for Disease Control American Diabetes Assoc., International Diabetes Federation Action for Health in Diabetes (Smushkin & Vella ,2010) Behavioral Risk Factor Surveillance System (Ryan et. al. 2010) U.S. National Center for Health Statistics (Okosun & Boltri, 2008) Metabolic and Endocrine Disorder Group Specialize Register (Wens et.al. 2008)

Worldwide rates in the last 10 years Incidence & Prevalence In 2003 - 194 million between ages 20 to 79 = 5.1% (IDF, 2003) In 2013 – 378 million = 8.3% (IDF, 2014a) (IDF, 2014b. Retrieved from http://www.idf.org/worlddiabetesday/toolkit/gp/facts-figures )

Worldwide rates in the last 10 years Mortality 2004 = 3.4 million (WHO, 2014) 2007 = 5.5% of global population (IDF, 2014b) 2010 = 6.8 % of global pop. (IDF, 2014b) 2011 = 4 million (IFD, 2014b) 2013 = 5.1 million (Diabetes Australia, Dec. 2013) WHO predicts by 2030 diabetes will be the worlds 7th largest cause of death. (2014)

Patterns of Diabetes in the U.S. Factors Sedentary lifestyle is primary contributing factor (Leahy, 2005) “Chronic over-nourishment” is main factor (Noland et.al. 2011) “high glycemic index, low fiber, sugar-sweetened foods” are highly damaging (Oggioni et. al. 2014) Overall prevalence 2010 = 25.8 million or 8.3% (7M undiagnosed) (ADA, 2014) 2014 = 29.1 million or 9.3% (8.1M undiagnosed) (ADA, 2014)

U.S. Prevalence Gender 2007 to 2010 Race/ethnicity 2012 Women = 10.1% + 7.7% undiagnosed Men = 13% + 8.5% undiagnosed (CDC, May 2013) Race/ethnicity 2012 Am. Indians & Native Alaskans = 15.9% Blacks = 13.2% Hispanics = 12.8% Asian Am. = 9.0% Whites = 7.6% (ADA, 2014)

U.S. Prevalence (cont.) Age Geographic Location Under 20 in 2008/09 = 5,089 (ADA, 2014) 20 to 44 in 2013 = 3.4% (CDC, 2013) 45 to 65 in 2013 = 15% (CDC, 2013) > 65 = 25.9% (ADA, 2014) Geographic Location Southern states greatest incidence with Mid-northern region least 2010 = 5 states at 10%, 11 states at 6.0-6.9% 2012 = 12 states at 15.2%, only 3 at 6.0-6.9% (CDC, Jan. 2014)

Diabetes in Europe Variance as broad as socioeconomic, ethnic, and cultural differences of the 56 countries of the IDF European Region (Tamayo et. al. 2014) Prevalence varies greatly between and within countries, and within ethnicities and between gender among countries and regions (Tamayo et. al. 2014) (IDF, 2014a. Adapted from http://www.idf.org/atlasmap/atlasmap)

Prevalence in Europe Overall in ages 20 – 79 2013 - 8.5% = 56 million Undiagnosed – 29.3% in poor countries, 36.6% in affluent (Tamayo et. al. 2014) Gender – in > 25 yr.olds Men = 10.3% Women = 9.6% (WHO, 2014) Race/Ethnicity Prevalence is as heterogeneous the Europe is ethnically/racially A note: South Asians & African-Caribbean descendents in Europe are 6 and 3 times as, respectively, likely to have diabetes (WHO, 2014)

Prevalence in Europe (cont.) Age 20 to 79 yr. olds as previously reported No data for children and adolescents A note: 1to 4 % of children are obese and 25% are at risk for diabetes secondary to having impaired glucose tolerance (IDF, 2007) Geographic location Western part of Europe has higher prevalence 2003 - Iceland at 2% , Turkey at 8%, Germany at 10% (IDF, 2003) 2014 – Turkey at 14.8%, Russian Federation at 10.9%, Montenegro, Macedonia, Serbia, Bosnia, & Herzegovina at 10% (IDF, 2014)

Other data for Europe Annual incidence rate = 1 in 1000 (Forouhi & Wareham, 2010) Mortality – 2013 at > 6 million 329,500 women 289,100 men 28.2% under the age of 60 IDF estimates 22.4% increase in diabetes by 2035 (IDF, 2014c)

Health Promotion and Prevention IDF(2014b), WHO & ADA (2014) and others support education, care, and prevention grassroots movements, policy development, and political influence Modifiable risk factors addressed at three levels Upstream = policy & environment – has most potential Midstream = aimed at these w/ increased risk – young & special sup-groups Downstream = for those w/ impaired glucose tolerance – education, increased physical activity & improved diet (Hussain et. al. 2014)

Impact of Globalization Western lifestyle exposure Sedentary, urbanized, improved economy = increased prevalence (Oggioni et. al 2014) Global dietary patterns influence prevalence Agricultural – primarily cereals & starchy foods Transitional – similar to western in produce & sugar consumption Westernized - high in meat, animal fats, veg. oil, alcohol consumption Agricultural patterns = lower prevalence for obesity & diabetes Those in Transition no different than those already Westernized

Economic Impact Monetary costs Social and emotional costs Other U.S. = 253 billion (IDF Atlas, 2013) 2.3 greater medical expenses for those with diabetes (ADA, 2014) Europe = 137 billion (IDF Atlas, 2013) 10% of total health care dollars (IDF Europe, 2014) Social and emotional costs Co-morbidities & discrimination, personal loss = decreased work productivity, employment interruption = decreased quality of life, welfare, and security (WHO, 2014) Other Design & implementation of prevention & management programs (Tamayo et. al. 2014)

Insights, Discoveries, and Conclusions Majority of diabetes is preventable with increased physical activity and improved diet (Oggioni et. al 2014) Diabetes is present an average of 4 –7 yrs before onset of symptoms or diagnosis 33 to 50 percent remain undiagnosed (Forouhi & Wareham, 2010) Today, the increase in incidence of diabetes has exceeded IDF 2003 global projections for 2025 by 50 million (IDF, 2003) Given we have exceeded that prediction 10 yrs early, the term Epidemic is undeniable.

References American Diabetes Association, (1995-2014) Diabetes Basics, Statistics. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/ Centers for Disease Control, (2013). Publications and information products, Health, United States, 2013, Table 46. pg.1. Retrieved from http://www.cdc.gov/nchs/data/hus/2013/046.pdf Centers for Disease Control, (January 23, 2014). Diabetic public health resource, Diabetes interactive atlas. Retrieved from http://www.cdc.gov/diabetes/atlas/obesityrisk/atlas.html Diabetes Australia (December 20, 2013), Understanding Diabetes, Diabetes Globally, Retrieved from http://www.diabetesaustralia.com.au/Understanding-Diabetes/Diabetes-Globally/ Forouhi, N. G., & Wareham, N. J. (2010). Epidemiology of diabetes. Medicine, 38(11), 602-606. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.mpmed.2010.08.007 Hussain, A., Claussen, B., Ramachandran, A., & Williams, R. (2007). Prevention of type 2 diabetes: A review. Diabetes Research and Clinical Practice, 76(3), 317-326. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.diabres.2006.09.020 International Diabetes Federation (2003), IDF Diabetes Atlas, 2nd ed. http://www.idf.org/sites/default/files/IDF_Diabetes_Atlas_2ndEd.pdf International Diabetes Federation, (2007). DiabetesVoice global perspective on diabetes, Diabetes in young people. Vol. 52, p 15. Retrieved from http://www.idf.org/sites/default/files/attachments/issue_50_en.pdf International Diabetes Federation (2014a), IDF Diabetes Atlas, 6th ed. Retrieved from http://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf International Diabetes Federation (2014b), About Diabetes, Facts and Figures. Retrieved from http://www.idf.org/worlddiabetesday/toolkit/gp/facts-figures

International Diabetes Federation Europe (2014c), Diabetes, the policy puzzle. Retrieved from http://www.idf.org/regions/EUR/policypuzzle Leahy, J. L. (2005). Pathogenesis of type 2 diabetes mellitus. Archives of Medical Research, 36(3), 197-209. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.arcmed.2005.01.003 Nolan, C. J., Damm, P., & Prentki, M. (2011). Type 2 diabetes across generations: From pathophysiology to prevention and management. The Lancet, 378(9786), 169-181. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/S0140-6736(11)60614-4 Oggioni, C., Lara, J., Wells, J. C. K., Soroka, K., & Siervo, M. (2014). Shifts in population dietary patterns and physical inactivity as determinants of global trends in the prevalence of diabetes: An ecological analysis. Nutrition, Metabolism and Cardiovascular Diseases, 24(10), 1105-1111. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.numecd.2014.05.005 Okosun, I. S., Boltri, J. M., Davis-Smith, M., & Ndirangu, M. (2009). Premetabolic syndrome and clustering of cardiometabolic risk factors in white, black and mexican american adults. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 3(3), 143-148. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.dsx.2009.07.006 Ryan, J. G., Brewster, C., DeMaria, P., Fedders, M., & Jennings, T. (2010). Metabolic syndrome and prevalence in an urban, medically underserved, community-based population. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 4(3), 137-142. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.dsx.2010.07.002 Smushkin, G., & Vella, A. (2010). What is type 2 diabetes? Medicine, 38(11), 597-601. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.mpmed.2010.08.008

Tamayo, T. , Rosenbauer, J. , Wild, S. H. , Spijkerman, A. M. W Tamayo, T., Rosenbauer, J., Wild, S. H., Spijkerman, A. M. W., Baan, C., Forouhi, N. G., Rathmann, W. (2014). Diabetes in europe: An update. Diabetes Research and Clinical Practice, 103(2), 206-217. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.diabres.2013.11.007 Wens, J., Vermeire, E., Hearnshaw, H., Lindenmeyer, A., Biot, Y., & Van Royen, P. (2008). Educational interventions aiming at improving adherence to treatment recommendations in type 2 diabetes: A sub-analysis of a systematic review of randomized controlled trials. Diabetes Research and Clinical Practice, 79(3), 377-388. doi:http://dx.doi.org.libproxy.nau.edu/10.1016/j.diabres.2007.06.006 World Health Organization Europe (2014). Health Topics, Diabetes, Data and statistics. Retrieved from http://www.euro.who.int/en/health-topics/noncommunicable-diseases/diabetes/data-and-statistics World Health Organization, (2014). Health topics, Diabetes. Retrieved from   http://www.who.int/topics/diabetes_mellitus/en/