1. Epidemiology of Diabetes EPID 624 – Epidemiology of Chronic Diseases Sadia Shah

2. Presentation Overview Historical Background Defining Diabetes Prevalence and Incidence Risk of Diabetes Screening/prediabetes Challenges for Public Health Prevention Interventions Research opportunities Questions

3. Historical Background Past 200 years in Diabetes First recognized around 1500 B.C.E by ancient Egyptians: rare condition, excessive urinating, weight loss Recognized clinically when NEJMS was founded in 1812 2 centuries ago it was severe insulin deficiency Now only 10 % of cases overall http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/200yrsofdiabet es_NEJM.pdf

4. Scientific Discoveries: Past 200 Years 1889-Mering and Minkowski found removing pancreas in dogs resulted in fatal diabetes 1910- Shafer described that deficiency of a single chemical; insulin, produced by beta cells in pancreas as cause of diabetes 1921-Banting and Best actually discovered insulin when they reversed induced diabetes in dogs http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/200yrsofdiabetes_NEJM.pdf

5. Defining Diabetes Mellitus A group of metabolic disorders characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both Chronic hyperglycemia is associated with long- term damage, dysfunction, and failure of various organs, eyes, kidneys, nerves, heart, and blood vessels DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004

6. Diabetes Related Serious Complications Heart disease Stroke Kidney disease Blindness Amputations of legs and feet Early death http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf

7. Type 1 versus Type 2 Type 1 (Juvenile previously) Usually diagnosed in children and young adults 5% of people have this form Pancreas is no longer capable of producing insulin Autoimmune pathologic process Type 2 Vast majority overweight Combination of insulin resistance/ impaired insulin secretion Worldwide epidemic Multiple genes and environmental factors contribute in its development DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004 http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/200yrsofdiabetes_NEJM.pdf

8. Type 1 Diabetes Among Youth No known way to prevent Type 1 Peak ages for diagnosis are in middle teen years Must have insulin delivered by injection or pump 167,00 US youth <20 years in 2009 18,000 new cases estimated Non-Hispanic white children and adolescents have highest rates of new cases http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf

9. Type 2 Among Youth >20,000 US youth younger than 20 had T2D in 2009 >5,000 new cases of T2D estimated to be diagnosed in youth younger than 20 years Rates of new cases higher in youth 10-19 Rates of T2D higher among youth of racial and minority groups than in non-Hispanic whites http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf

10. Consequences of Diabetes Increased risk of heart disease and stroke. In a multinational study, 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke) Combined with reduced blood flow, neuropathy (nerve damage) in the feet increases the chance of foot ulcers, infection and eventual need for limb amputation http://www.who.int/mediacentre/factsheets/fs312/en/

11. Consequences of Diabetes Diabetic retinopathy: an important cause of blindness, and occurs as a result of long-term accumulated damage to the small blood vessels in the retina. One percent of global blindness can be attributed to diabetes Diabetes is among the leading causes of kidney failure The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes- lowers life expectancy by 15 years http://www.who.int/mediacentre/factsheets/fs312/en/

12. BACKGROUND Prevalence/Incidence

13. Crude and Age-Adjusted Rates of Diagnosed Diabetes per 100 Adults Population, 1980-2014 http://www.cdc.gov/diabetes/statistics/prev/national/figageadult.htm

14. Rates of Diagnosed Diabetes per 100 civilian population, by age, US, 1980- 2014 http://www.cdc.gov/diabetes/statistics/prev/national/figbyage.htm

15. Age-Adjusted rates of Diagnosed Diabetes per 100 Civilian Population, US, 1980-2014 http://www.cdc.gov/diabetes/statistics/prev/national/figbyeducation.htm

16. Age-Adjusted rates of Diagnosed Diabetes per 100 Civilian Population by Sex, US 1980-2014 http://www.cdc.gov/diabetes/statistics/prev/national/figbysex.htm

17. Age-adjusted rated of diagnosed per 100 civilian population, by Race, US, 1980-2014 http://www.cdc.gov/diabetes/statistics/prev/national/figbyrace.htm

18. CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2013

19. Age-Specific Rates of Diagnosed Diabetes per 100 Civilian Population, by Race and Sex, US 2014 http://www.cdc.gov/diabetes/statistics/prev/national/fig2004.htm

20. Race and Ethnicity Racial and minority groups more likely to have diagnosed diabetes During their lifetime half of all Hispanic men and women are predicted to develop disease http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf

21. Distribution of Duration of Diabetes, US Adults 18-79 Years, 2011 http://www.cdc.gov/diabetes/statistics/duration/fig1.htm

22. Annual Number (in thousands) of new cases of Diabetes Among Adults Aged 18-79 Years, US, 1980-2014 http://www.cdc.gov/diabetes/statistics/incidence/fig1.htm

23. Crude and Age-adjusted Incidence of Diagnosed Diabetes per 100 Population Aged 18-79 years, US 1980-2014 http://www.cdc.gov/diabetes/statistics/incidence/fig2.htm

24. Age-Adjusted Incidence of Diagnosed Diabetes per 100 Population Aged 18-79 Years by Race/Ethnicity, US, 1997-2014 http://www.cdc.gov/diabetes/statistics/incidence/fig6.htm

25. Number of Civilian, Non-Institutionalized Persons with Diagnosed Diabetes, United States, 1980-2014 http://www.cdc.gov/diabetes/statistics/prev/n ational/figpersons.htm

30. Increased Risk of Diabetes Age -45 years or older Obesity Sedentary lifestyle Family history Had diabetes while pregnant Giving birth to a baby that weighed more than 9 pounds Race and ethnicity http://www.commed.vcu.edu/Chronic_Disease/diabetes/diabetss&arsenic.pdf http://www.cdc.gov/diabetes/prevention/prediabetes-type2/index.html

31. Risk Of Diabetes Complex interplays among genetic, perinatal and lifestyle Worldwide the risk of diabetes and heart disease increasing Starting at a BMI as low as 20 Nutritional epidemiologic studies show associations of specific foods and nutrients or overall dietary patterns with diabetes http://www.commed.vcu.edu/Chronic_Disease/diabetes/2014/nejmriskfactsept13.pdf

32. Epigenetics and Type 2 Diabetes Evidence of familial aggregation More than 150 genetic loci associated with monogenic, syndromic or multifactorial of T2D or obesity http://www.ncbi.nlm.nih.gov/pubmed/23047653

33. Environmental Exposure to Arsenic Association between low-level arsenic exposure and prevalence of diabetes 3.6-fold increase in the odds of diabetes for participants with the highest total urinary arsenic concentrations as compared with participants with the lowest total urinary arsenic concentrations http://www.commed.vcu.edu/Chronic_Disease/diabetes/diabetss&arsenic.pdf

34. Gestational Diabetes First seen in pregnancy Can lead to problems for mother ; preeclampsia, C- section Baby born early, risk of hypoglycemia after birth Antenatal visits screen between 24 and 28 weeks Control through eating healthy foods and exercise Severe cases need insulin http://www.cdc.gov/pregnancy/diabetes-gestational.html

35. Maintaining Euglycemia Lifestyle changes Medication therapies Surgery http://www.commed.vcu.edu/Chronic_Disease/diabetes/2016/diabetesdscreen_USTFPS.pdf

36. Prediabetes 90% of the 86 million Americans with prediabetes are not aware of their condition ADA recommends screening all high risk for diabetes Initial treatment: lifestyle intervention followed by Metformin Metformin offers another approach to diabetes prevention (esp. with H/O gestational diabetes) If no intervention; progress to diabetes http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/whatsprevprevn.pdf http://annals.org/article.aspx?articleid=2246122

37. Prediabetes Prediabetes is defined as IFG, IGT or an increased average blood glucose level indicated by an increased hemoglobin A1c Incidence of T2D among prediabetes is 35.5 to 70.4 new diagnosis per 1000 person-years In 2014 36.4% of adults with T2D were undiagnosed.. http://www.commed.vcu.edu/Chronic_Disease/diabetes/2016/diabetesdscreen_USTFPS.pdf

38. Screening USPSTF guidelines recommend screening at age 40 Screen for glucose abnormalities every 3 years Use Hemoglobin A1c level, fasting plasma glucose level, or glucose tolerance test Family history of diabetes, polycystic ovary syndrome or racial ethnicity/minority- screen at lower BMI, or at younger age http://www.commed.vcu.edu/Chronic_Disease/diabetes/2016/diabetesdscreen_USTFPS.pdf

39. Behavioral Intervention IGF, IGT OR Type 2 diabetes patients to be offered intensive behavioral counselling interventions In 2011, intensive behavioral therapy for obesity became a covered preventive service by Medicare Parts A and B, From a health system perspective, reimbursement for 15-minute visits is low (approximately $25/session) http://www.commed.vcu.edu/Chronic_Disease/diabetes/2016/diabetesdscreen_USTFPS.pdf

40. Diabetes Prevention Community Preventive Services task Force recommends: A weight loss goal Individual or group sessions (or both) about diet and exercise Meetings with a trained diet or exercise counselor (or both) Individual tailored diet or exercise plans http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf

41. Healthy People 2020: Glycemic control, adults with diabetes, 2005- 08 and 2009-12 http://www.healthypeople.gov/2020/topics-objectives/topic/diabetes/national-snapshot

42. Challenges for Public Health Improvement in outcomes for individual patients has not resulted in similar improvements from public health perspective From 1980 through 2014 the number of people diagnosed with diabetes has increased fourfold 5.5 million to 22 million http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/200yrsofdiabetes_NEJM.pdf

43. Challenges for Public Health Only 11% of patients with diabetes follow accepted dietary recommendations for saturated fat intake 18% of patients with heart disease continue to smoke http://www.commed.vcu.edu/Chronic_Disease/diabetes/lifestyle.pdf

44. Challenges for Public Health Although strong evidence of benefit of lifestyle interventions Most insurances do not cover for preventing Type 2 diabetes AFA requires CMS and private insurers to cover preventive medical services USPSTF has not issued a recommendation on diabetes prevention services Limited coverage for non-obese overweight persons with prediabetes http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/whatsprevprevn.pdf

45. Preventive Care Practices: BRFSS http://www.cdc.gov/diabetes/statistics/preventive/fAllPractices.htm

46. Mortality 7 th leading cause of death in US in 2010 based on 69,071 death certificates in which diabetes listed as underlying cause of death Underreported deaths from diabetes 35-40% of people with diabetes who died had diabetes listed anywhere on death certificate 10-15% listed as underlying cause of death Rates of death from all causes 1.5 times higher in adults with diabetes http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

47. COST OF DIABETES Costly implications do not appear immediately after onset Peak incidence of disease occurs between 50 and 60 years of age A decade or more later- results in enormous implications for Medicare Diabetes costs the United States $245 billion annually, including $176 billion from direct health care costs $69 billion in indirect costs from lost workdays, restricted activity, disability, and early death http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/whatsprevprevn.pdf http://annals.org/article.aspx?articleid=2246122

48. PREVENTION STRATEGIES Clinical trials show lifestyle modification can reduce prevalence of type 2 diabetes by 58% Weight reduction and physical activity: the cornerstone of diabetes prevention programs http://www.commed.vcu.edu/Chronic_Disease/diabetes/diabetss&arsenic.pdf

49. Changes in YMCA Afterschool Programs Harvard prevention research Center collaborated with YMCA to set several standards for nutrition and physical activity for the YMCA’s afterschool program Increase physical activity and Health Options http://www.cdc.gov/prc/prevention-strategies/YMCA-Harvard-Afterschool-Food-and-Fitness- Project.htm

50. Changes in YMCA Afterschool Programs In December 2011, the YMCA of the USA pledged to First Lady Michelle Obama and the Partnership for a Healthier America that 85% of YMCA Associations would adopt physical activity and healthy eating standards in early childhood and afterschool programs by 2015. The YMCA's pledge could impact the lives of 595,000 children across the United States http://www.cdc.gov/prc/prevention-strategies/YMCA-Harvard-Afterschool-Food-and- Fitness-Project.htm

51. Community-based Program on the US- Mexico Border Reduces Chronic Disease Risks Community health workers help tailor and lead a chronic disease prevention program for Mexican- Americans living on the U.S.-Mexico border Promotores deliver educational sessions targeting nutrition, physical activity, and other chronic disease and mental health risk factors, and form walking groups to promote activity Significant improvements in body mass index; blood pressure, total cholesterol, and glucose levels; health- related quality of life; and depression are sustained after the intervention ends http://www.cdc.gov/prc/prevention-strategies/chronic-disease-risks.htm

52. Future Research An average of 6.5 years of intensive blood glucose management dramatically reduced early signs of microvascular complications Effects on clinical events such as myocardial infarction and kidney failure emerged over decades. Such results demonstrate the importance of following patients to assess long-term outcomes in key clinical trials http://www.commed.vcu.edu/Chronic_Disease/diabetes/2013/whatsprevprevn.pdf

53. Future research Studies that examine the effects of screening large populations for abnormal blood glucose on hard outcomes, like mortality, are necessary http://www.commed.vcu.edu/Chronic_Disease/diabetes/2016/diabetesdscreen_USTFPS.pdf

54. Questions?