1. Diabetes a Global Epidemic
Sherry Dunbar
Northern Arizona University

2. 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

3. 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)

4. 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)

5. 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)

6. 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 (Okosun et. al. 2009)
Pre-metabolic syndrome is associated with 5 fold increase for Type 2 diabetes. (Okosun, et. al 2009)

7. 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)

8. 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)

9. 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)

10. Worldwide rates in the last 10 years
Incidence & Prevalence
In million between ages 20 to 79 = 5.1%
(IDF, 2003)
In 2013 – 378 million = 8.3% (IDF, 2014a)
(IDF, 2014b. Retrieved from )

11. 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)

12. 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)

13. 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)

14. 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 %
2012 = 12 states at 15.2%, only 3 at % (CDC, Jan. 2014)

15. 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

16. Prevalence in Europe Overall in ages 20 – 79
% = 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)

17. 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
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)

18. 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)

19. 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)

20. 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

21. 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)

22. 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.

23. References
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