1. Natural History of Obesity Leading to Type 2 Diabetes
Complications
Onset of diabetes
Disability
Genetic susceptibility
Environmental factors Nutrition Physical
inactivity
Obesity Insulin resistance
IGT
Ongoing hyperglycemia
Death
IGT = Impaired Glucose Tolerance
Risk for
Disease
Metabolic
Syndrome
Atherosclerosis Hyperglycemia Hypertension
Retinopathy Nephropathy Neuropathy
Blindness Renal failure CHD Amputation

2. Obesity Trends. Among U. S
Obesity Trends* Among U.S. Adults (BMI ≥ 30 or ≈ 30 lbs overweight for 5’4” woman)
F as in Fat: How Obesity Policies Are Failing in America. Trust for America’s Health Issue Report. October 2004.

3. Prevalence (%) of overweight among children and adolescents
Average 11 year old boy today is 11 pounds heavier than in 1973
This graph shows how childhood overweight has tripled since the 1960s. The epidemic of childhood obesity is a particular concern because it predicts much suffering from health problems starting at an earlier age than previously. It is estimated that this will be the first generation in the US to have a shorter lifespan than their parents.

4. National Longitudinal Survey of Youth Prospective Cohort Study of Children (4-12 years old)
Risk of Overweight Overweight
> 85th %ile BMI > 95th %ile BMI
African American 38.4% %
Hispanics % %
Caucasian % %
Showing that prevalence rates vary by ethnicity.
Source: NHANES???

5. Secular Increases in Relative Weight and Adiposity in Children (5-14 years old) - Bogalusa Heart Study -
Study years
Weight (kg)
Height (cm)
BMI (kg/m2)
35.9
140
17.6
41.0
142
19.5
Change*
+3.4
+1.6
+1.5
* Change adjusted for height, age, race, and sex
Source: Pediatrics 99: , 1997

6. Correlations of Weight and BMI in Youth at 7.7 and 23.6 Years
Source: Minneapolis Children’s BP Study, Circulation 99:1471, 1999

7. Relationship Between Prevalence of Overweight and Daily TV Hours
Gortmaker et al., 1996

8. Overweight Children Ate fewer fruits and vegetables (2.9 vs. 3.3/day)
Drank more sweetened beverages (1.3 vs. 1.1/day)
Ate more high-fat snacks (64 vs. 56 %; p=0.054)
Ate more fast food (1.4 vs. 1.1/week; p=0.051)
Spent more screen time (101 vs. 81 minutes)
Less likely take part in lessons on nutrition (50 vs. 64 percent).
Special Report on Policy Implications from the 1999 California Children’s Healthy Eating and Exercise Practices Survey. The California Endowment. Rev. August 2002.

9. Pediatric Overweight AAP Policy Statement
Identify and track at risk youth
Calculate and plot BMI yearly
Promote health eating patterns
Fruits, vegetables, low-fat dairy, whole grains
Self-regulation of intake, limits on choices, modeling
Promote physical activity
Limit TV and video
Monitor changes in obesity-associated risk factors (BP, lipids, IGT, apnea, hyperinsulinism)
AAP = American Academy of Pediatrics
Source: Pediatrics 112, August 2003

10. Metabolic Syndrome Prevalence in 12-19 Year Olds
Overall 4.2% (6.1% M, 2.1% F)
BMI  95th percentile 28.0%
BMI 85th-94th percentile 6.8%
BMI < 85th percentile 0.1%
Based on 1994 population estimates, 910,000 adolescents had metabolic syndrome.
Source: Cook et al., Arch Pediatr Adolesc Med 157: , 2003

11. Link Between Obesity and Type 2 Diabetes: Nurses’ Health Study

12. Number of Bariatric Surgeries 1992-2003
Surgery for Severe Obesity: US to NEJM March 11, 2004

13. GI Surgery for Severe Obesity
Risk and Complications:
10-20% require follow-up surgery
Abdominal hernia
Break down of staple line
Gallstones
30% develop nutritional deficiency
Cost: $20,000 to $50,000
Source: NIDDK
Highest Increase Rate of all Pediatric Surgeries

14. Natural History of Obesity Leading to Type 2 Diabetes
Complications
Onset of diabetes
Disability
Genetic susceptibility
Environmental factors Nutrition Physical
inactivity
Obesity Insulin resistance
IGT
Ongoing hyperglycemia
Death
IGT = Impaired Glucose Tolerance
Risk for
Disease
Metabolic
Syndrome
Atherosclerosis Hyperglycemia Hypertension
Retinopathy Nephropathy Neuropathy
Blindness Renal failure CHD Amputation

15. Type 2 Diabetes A Progressive Disease
Impaired
glucose tolerance (IGT)
Undiagnosed
diabetes
Known diabetes
Insulin resistance
Insulin secretion
Postprandial glucose
Fasting glucose
Microvascular complications
Macrovascular complications
Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:

16. Burden of Diabetes in USA
18.2 Million Americans Have Diabetes
5.2 Million Unaware of Diagnosis
40 Million Americans Have Prediabetes
239,000 Diabetes-Related Deaths/year
2-to-6-Fold More Likely to Have Heart Disease
2-to-4-Fold More Likely to Have a Stroke
75% of All Diabetes Related Deaths Associated With Cardiovascular Disease
Cost $132 Billion/2002
Mokdad, et al, JAMA ,1195

17. Diabetes and Gestational Diabetes Trends Among Adults in the United States, Behavioral Risk Factor Surveillance System, 1990, 1995 and 2001
1990
1993
2001

18. Prevalence of Diabetes

19. Diabetes Prevalence Among Minority Populations in the U.S.
Percentage of each population with diabetes
Non-Hispanic Whites
Latinos
African Americans
7.8% (11.4 million)
10.2% (2 million)
13% (2.8 million)
15.1% (105,000) 
Native Americans & Alaska Natives
Centers for Disease Control and Prevention (CDC)

20. Age Specific Prevalence of DM 2002

21. The Changing Face of Diabetes in Youth5 10 15 20 25 30 35
% with type 2 87 88 89 90 91 92 93 94 95 96
Cincinnati <19 years
Little Rock 8-21 years
San Antonio <19 years
Source: Fagot-Campagna et al., J Pediatr 136: , 2000

22. Diabetes Projected Risks: For Babies Born in 2000
Girls: 38% lifetime risk
If diabetic before age 40, Lifespan shortened by 14 years (Quality of life by 19 years)
Boys: 33% lifetime risk
If diabetic before age 40, Lifespan shortened by 12 years. (Quality of life by 22 years)
V Narayan et al: JAMA 8 Oct 2003

23. Prevalence of Diabetes in Pregnancy in the United States of America8%
Non-diabetes
92%
More than 135,000 GDM + 200,000 T2DM +
6,000 T1DM pregnancies annually
American Diabetes Association. Diabetes Care. 1998;21(Suppl. 2).

24. Major Birth Defects: Preexisting Type I vs Type II Diabetes

25. ADA Goals for Glycemic Control
A1C < 7.0%*
Pre-prandial plasma mg/dl
glucose
Peak postprandial <180 mg/dl
plasma glucose
*Referenced to a non-diabetic range of % using a DCCT-based assay

26. Diabetes Care in the U.S. Improvement Needed
Data from NHANES III* and BRFSS**
Participants years with DM
Results: Percent at Goal
A1C < % (>9.5, 18%)
LDL < % (>130, 58%)
BP < 140/ %
Dilated eye exam 63%
Foot exam 55%
* Nat’l Health & Nutrition Exam Survey
** Behavioral Risk Factors Surveillance Study

27. Majority of Patients with Diabetes are Not at ADA HbA1c Goal <7%

28. Census Bureau Projections 2000-2050
Census Bureau projects population will grow 47% by 2050
By 2050, there will be 112% more diagnosed cases of diabetes
Serious diabetes complications are projected to increase % by 2050
Diabetes 50 (Suppl 2): A205, 2001

29. GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions)
World
2003 = 194 million
2025 = 333 million
Increase 72%

30. Age Adjusted Prevalence of CVD

31. End Stage Renal Disease 1984-2001

32. Coronary Heart Disease Mortality in Type 2 Diabetes
Men
Women 60 60
Diabetes
Diabetes 50 50
No Diabetes
No Diabetes 40 40
Mortality Rate per 1000
Mortality Rate per 1000 30 30 20 20 10 10
0-3
4-7
8-11
12-15
16-19
20-23
0-3
4-7
8-11
12-15
16-19
20-23
Duration of Follow-up (yr)
Duration of Follow-up (yr)
Krowlewski AS, et al Am J Med 1991; 90 (suppl2A):56S-61S.

33. A1C Predicts CV Risk in Type 2 Diabetes Kuusisto et al
229 Finnish Patients Followed for 3.5 Years
CHD mortality
All CHD events
Incidence (%)
over 3.5 years 5 10 15 20 25 5 10 15 20 25 † *
Low <6%
Middle 6.0%–7.9%
High >7.9%
Low <6%
Middle 6.0%–7.9%
High >7.9%
A1C tertile
CHD=coronary heart disease
*P<0.01 vs lowest tertile; †P<0.05 vs lowest tertile
Kuusisto J et al. Diabetes. 1994;43:

34. UKPDS - Glycemic Control Risk Reductions
Lancet 1998; 352:

35. UKPDS - BP Control Risk Reductions
Any Diabetes Related Endpoint
Deaths Related to Diabetes
24%
Risk Reduction
32%
Risk Reduction
Events/ 1000 pt-years
p=0.0046
p=0.0019
n=1148
UKPDS. BMJ :

36. 4S Study: Effect of Simvastatin on Coronary Events - 6 years
Diabetic Patients
n=201, p=0.002
Nondiabetic Patients
n=4242, p<
55%
Risk Reduction
32%
% of Patients with a Major Coronary Event
Pyorala et al, Diabetes Care 1997; 20: 614

37. Incidence of diabetes reduced 58% (p=.0003).
Prevention of T2D with Lifestyle Intervention (N=523 with IGT, mean age 55, BMI 31)
Weight Loss (kg)
Cases
1st year
2nd year
4th year
Intervention*
-4.2
-3.5
26 (10%)
Control**
-0.8
57 (22%)
Incidence of diabetes reduced 58% (p=.0003).
* diet, exercise, frequent visits ** yearly advice
Source: Tuomilehto et al., ADA 2000

38. Type 2 Diabetes Prevention
Percent developing diabetes
All participants
All participants
Risk reduction
31% by metformin
58% by lifestyle
Placebo 40 30
Metformin
Cumulative incidence (%) 20
Lifestyle 10 1 2 3 4
Years from randomization
The DPP Research Group, NEJM 346: , 2002

39. School-based Program to Decrease Soda Consumption
644 children (7-11 years old), 6 schools
Program to decrease regular and diet soda intake delivered in 1-hour sessions 4 times per year
# Glasses of Soda Per Day
% Overweight and Obese
Intervention
 0.6
 0.2
Control
 0.2
 7.5
Source: James et al., Brit Med J 328:1237, 2004

40. Natural History of Obesity Leading to Type 2 Diabetes
Complications
Onset of diabetes
Disability
Genetic susceptibility
Environmental factors Nutrition Physical
inactivity
Obesity Insulin resistance
IGT
Ongoing hyperglycemia
Death
IGT = Impaired Glucose Tolerance
Risk for
Disease
Metabolic
Syndrome
Atherosclerosis Hyperglycemia Hypertension
Retinopathy Nephropathy Neuropathy
Blindness Renal failure CHD Amputation