Health, Nutrition and Type 2 Diabetes A one-week unit exploring how… Most traits are determined by a combination of genetic and environmental factors, including complex diseases like type 2 diabetes. Type 2 diabetes is a growing concern and occurs frequently in our communities. Type 2 diabetes is a complex condition that is heavily influenced by environmental factors such as access to resources, personal choice, product marketing, public policy, socio-economic status, and stress. Type 2 diabetes is caused by the effects of high blood glucose levels over time. Glucose, the major energy source for all human cells, is released primarily through digestion of carbohydrates. Food choices impact blood glucose levels. Type 2 diabetes is a serious condition with negative health consequences if left untreated. Type 2 diabetes can be prevented: factors contributing to a person’s risk include good nutrition and exercise. Students can make a meaningful contribution to the prevention of type 2 diabetes. These are the enduring understandings for the unit.

Lesson One Genes Environment Alcohol Dependency Alzheimer’s Disease Gunshot wound Breast Cancer Huntington’s Disease Type 2 Diabetes Mental Illness Methamphetamine Addiction Malaria Stress Torn Knee Ligaments Type 1 Diabetes Ebola Small pox

Lesson One Fletcher & Houlston (2010) Nat Rev Cancer For complex diseases, variations in many genes may add to risk of getting that disease. Around and within the region of overlap of the two curves, environmental factors may tip the balance from a person not having the condition to having it. People without the condition People with the condition Low-risk variant High-risk variant Fletcher & Houlston (2010) Nat Rev Cancer

Lesson Two Obesity Diabetes The following PowerPoint from the CDC shows the percentage of adults who have been diagnosed with obesity and diabetes in the US between 1994 and 2015. These tables shows the color key for percentages you see in the next sides. Obesity Diabetes Color Percentage white No data cream <14 yellow 14.0-17.9 gold 18.0-21.9 orange 22.0-25.9 red > 26.0 Color Percentage white No data cream <4.5 yellow 4.5-5.9 gold 6.0-7.4 orange 7.5-8.9 red > 9.0

1994 Methodology The percent of U.S. adults who are obese or who have diagnosed diabetes was determined by using data from the Behavioral Risk Factor Surveillance System (BRFSS, available at http://www.cdc.gov/brfss). An ongoing, yearly, state-based telephone survey of the non-institutionalized adult population in each state, the BRFSS provides state-specific information on behavioral risk factors for disease and on preventive health practices. Respondents who reported that a physician told them they had diabetes (other than during pregnancy) were considered to have diagnosed diabetes. Self reported weight and height were used to calculate body mass index (BMI): weight in kilograms divided by the square of height in meters. A BMI greater than or equal to 30 was considered to be obese. Rates were age-adjusted using the 2000 U.S. Standard Population.

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Major changes to the survey method in 2011 more detail at http://www.cdc.gov/surveillancepractice/reports/brfss/brfss.html

2011

2012

2013

2014

2015

Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI ≥30 kg/m2) 1994 2000 2015 No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0% Diabetes 1994 2000 2015 No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0% CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data

Incidence and Prevention Types of Diabetes Incidence and Prevention Type Prevalence Possible Prevention Type 1 5% none Type 2 90-95% for most, lifestyle changes Gestational <1-2% for some, lifestyle changes other 1-5% Data from the CDC

Lesson 2 What is type 2 diabetes? Type 2 diabetes is the result of chronic high blood glucose levels and can develop over time as the mechanisms that maintain blood glucose levels fail. If left untreated, it has devastating effects on the body, including damage to the nervous and circulatory systems, the heart, eyes, hands and feet, and kidneys. Complications from type 2 diabetes can even lead to death.

Diabetes incidence in three populations Lesson 2 Diabetes incidence in three populations Effects of Traditional and Western Environments on Prevalence of Type 2 Diabetes in Pima Indians in Mexico and the U.S. Leslie O. Schulz, PHD1, et al. Diabetes Care 2006 Aug; 29(8): 1866-1871. https://doi.org/10.2337/dc06-0138 Slide is useful in discussing genetic/environmental aspects of t2d in Pima Indians These slides could be used in conjunction with segment from Unnatural causes showing Pima lifestyle in Mexico and USA and asking about environmental/lifestyle factors that might explain the differences. Schulz L O et al. Dia Care 2006;29:1866-1871

Lesson 3 Healthy Response to Glucose

Lesson 3 Extension

Genetic Risk Score vs. Body Weight (Case-control study from combined cohorts of more than 300,000 people) Cumulative risk of type 2 diabetes over 10 years (%) Recently a large cohort study demonstrated that the effect of a genetic risk profile on cumulative risk of T2DM could be measured, but was trivial compared to the effect of body weight. In fact, the study suggested that a genetic risk profile would produce inaccurate information: underestimating diabetes risk in many overweight and obese people and overestimating it in many people with normal body weight. Langenberg et al (2014) PLOS Medicine

Lesson 4 A B “A” represents a diet of foods that release glucose slowly into the blood stream after they are eaten. “B” represents a diet of foods that release glucose quickly into the blood stream after they are eaten. Hypothetical effect of feeding diets with a low (A) or high (B) glycemic index on gastrointestinal glucose absorption and postprandrial blood glucose ©2002 by American Society for Nutrition David JA Jenkins et al. Am J Clin Nutr 2002;76:266S-273S

Blood Glucose Curves of proteins, fats and carbohydrates Lesson 4 Blood Glucose Curves of proteins, fats and carbohydrates Does it matter what we eat?

Lesson 4 Extension Danger Zone low fat high fat low carb high carb Low Carb High Fat diet High Carb High Fat diet Low Carb Low Fat diet High Carb Low Fat diet Danger Zone People who follow strict diets at either end of the scale tend to lose weight, and you can find proponents (and data) to support both positions. The low carb/low fat diet may work for a while low carb high carb

1 Lesson 5 Where do muscles get the energy they need during exercise? Glucose! Where do muscles get the energy they need during exercise? Regular activity can lower blood glucose levels in a number of ways: 1 Skeletal muscles remove glucose from the blood to use as an energy source during exercise.

Lesson 5 2 During exercise, muscles are able to transport glucose into the cells without depending on insulin. This can last for several hours after exercise is completed.

Lesson 5 3 Building muscle provides more mass to store and use blood glucose. More muscles means a higher basal metabolic rate—which means a person will use more glucose, even when at complete rest. And muscle can take in about five times as much glucose as liver and fat can.

Lesson 5 4 Burning calories through exercise helps maintain or decrease weight, which are important factors in type 2 diabetes.

Lesson 5 The effects of exercise on glucose tolerance http://www.austincc.edu/apreview/EmphasisItems/Glucose_regulation.html