1. Obesity, Metabolic Syndrome and Diabetes in Hispanics: implications on Cardiovascular Disease 2011 Eduardo de Marchena M.D., F.A.C.C., F.A.C.P. Professor of Medicine & Surgery Associate Dean for International Medicine & Director International Medicine Institute Director of Cardiovascular Center University of Miami Miller School of Medicine Eduardo de Marchena M.D., F.A.C.C., F.A.C.P. Professor of Medicine & Surgery Associate Dean for International Medicine & Director International Medicine Institute Director of Cardiovascular Center University of Miami Miller School of Medicine

3. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

4. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

5. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

6. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

7. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

8. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

9. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

10. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

11. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

12. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

13. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

14. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

15. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

16. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

17. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

18. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

19. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

20. (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

21. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

22. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

23. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

24. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

25. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

26. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

27. Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

28. “Globesity”“Globesity” Colombia and Brazil 40% women in 2001

29. Prevalence of Obesity in Males

30. Prevalence of Obesity in Females

31. “Globesity”“Globesity”

32. Alarming trend for Obesity in Children

33. Evolution of Man 2.5 million years 50 years Diet Exercise

34. 2050 New Concept of Ideal Body Type

35. Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008 CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

36. Source: International Diabetes Federation (IDF) (2009), “Diabetes Atlas, 4th edition”. Note: The data are age-standardised to the World Standard Population. However, the prevalence of chronic diseases such as diabetes is rising, due to population aging but also to changes in lifestyle Prevalence estimates of diabetes, adults aged 20-79 years, 2010

37. Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI ≥30 kg/m 2 ) Diabetes1994 1994 2000 2000 No Data 26.0% No Data 26.0% No Data 9.0% No Data 9.0% CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics 2008 2008

38. (*BMI 30) Hispanic State-specific Prevalence of Obesity* Among U.S. Adults, by Race/Ethnicity, 2006-2008 White non-Hispanic Black non- Hispanic

39. Prevalence of Physician Diagnosed Type 2 diabetes in Adults age 20+ by Race/Ethnicity, and Years of Education (NHANES: 2003-2006). Source: NCHS and NHLBI. NH – non- Hispanic.

40. Prevalence of Diabetes Today

41. Source: International Diabetes Federation (IDF) (2009), “Diabetes Atlas, 4th edition”. Note: The data are age-standardised to the World Standard Population. However, the prevalence of chronic diseases such as diabetes is rising, due to population aging but also to changes in lifestyle Prevalence estimates of diabetes, adults aged 20-79 years, 2010

42. Global projection for the Diabetes Epidemic: 2003 – 2025 (millions)

43. Diabetes Caused by Excessive Weight per Global Region

44. Atherosclerosis 100 200 150 300 250 350 -10-5 05101520 2530 0 100 200 50 150 Postprandial glucose Insulin resistance Years At risk for diabetes 250 Glucose (mg/dL) % Relative to Normal Insulin level b-cell dysfunction The Increased Atherosclerosis Risk in Type 2 Diabetes Begins in the Prediabetic State 200 mg/dl 126 mg/dl Fasting glucose Clinical Diagnosis

45. Interrelationship Between Insulin Resistance, Abdominal Obesity and Atherosclerosis Insulin Resistance H/T Hyper- glycemia Hypertri- glyceridemia Small LDL Low HDL HDL Atherosclerosis Endothel.dysfunctnPro-inflam-matory HyperinsulinemicmitogenesisObesityHyperco-agulability

46. Age-adjusted prevalence trends for high blood pressure in Adults age 20 and older by race/ethnicity and sex survey (NHANES: 1988-94, 1999-02 and 2003-06). Source: NCHS and NHLBI. NH- non-Hispanic.

47. Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity and Sex Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity and Sex (NHANES: 1999-2006). Source: NCHS and NHLBI.

48. Trends in mean total serum cholesterol among adolescents ages 12-17 by race, sex, and survey (NHANES: 1976-80, 1988-94, 1999-02, 2003-04, and 2005-06). Source: NCHS and NHLBI.

49. 0 1 2 3 CHD mortality (per 1,000) Fontbonne AM et al. Diabetes Care. 1991;14:461- 469.  29 30-50 51-72 73-114  115 Quintiles (pmol) of fasting plasma insulin P<0.01 CHD Mortality and Hyperinsulinemia: Paris Prospective Study (n=943)

50. National Diabetes Data Group. Diabetes in America. 2nd ed. NIH;1995. Atherosclerosis in Diabetes  ~80% of all diabetic mortality  75% from coronary atherosclerosis  25% from cerebral or peripheral vascular disease  >75% of all hospitalizations for diabetic complications  >50% of patients with newly diagnosed type 2 diabetes have CHD  ~80% of all diabetic mortality  75% from coronary atherosclerosis  25% from cerebral or peripheral vascular disease  >75% of all hospitalizations for diabetic complications  >50% of patients with newly diagnosed type 2 diabetes have CHD

51. Framingham Heart Study 30-Year Follow-Up: CVD Events in Patients With Diabetes (Ages 35-64) 0 2 4 6 8 10 Age-adjusted annual rate/1,000 MenWomen Total CVD CHDCardiac failure Intermittent claudication Stroke Risk ratio P<0.001 for all values Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular Disease. Ruderman N et al, eds. Oxford; 1992. Rate in non-diabetic population *P<0.05

52. Haffner SM et al. N Engl J Med. 1998;339:229-234. 012345678 0 20 40 60 80 100 Nondiabetic subjects without prior MI (n=1,304) Diabetic subjects without prior MI (n=890) Nondiabetic subjects with prior MI (n=69) Diabetic subjects with prior MI (n=169) Survival (%) Year Same Survival in Patients With Type 2 Diabetes and No Prior MI vs Nondiabetic Subjects With Prior MI

53.  2 - 4-fold increase in the risk of CAD  7-year incidence of MI or death:  3.5% non-DM versus 20% DM  In those with previous history of MI  18.8% in non-DM versus 45% in DM  DM carry the same level of risk for subsequent ACS as non-DM with prior MI subsequent ACS as non-DM with prior MI  ATP III established diabetes as a CAD risk equivalent mandating aggressive anti- atherosclerotic therapy Diabetes Increases Greatly Risk of Coronary Artery Disease

54. Kannel WB. Am Heart J. 1985;110:1100-1107. Abbott RD et al. JAMA. 1988;260:3456-3460. Women, Diabetes, and CHD  Diabetic women are at high risk for CHD  Diabetes eliminates relative cardioprotective effect of being premenopausal  risk of recurrent MI in diabetic women is three times that of nondiabetic women  Age-adjusted mean time to recurrent MI or fatal CHD event is 5.1 yr for diabetic women vs 8.1 yr for nondiabetic women  Diabetic women are at high risk for CHD  Diabetes eliminates relative cardioprotective effect of being premenopausal  risk of recurrent MI in diabetic women is three times that of nondiabetic women  Age-adjusted mean time to recurrent MI or fatal CHD event is 5.1 yr for diabetic women vs 8.1 yr for nondiabetic women

55. SMC=smooth muscle cell. Adapted from Bierman EL. Arterioscler Thromb. 1992;12:647-656. Potential Mechanisms of Atherogenesis in Diabetes  Abnormalities in apoprotein and lipoprotein particle distribution  Glycosylation and advanced glycation of proteins in plasma and arterial wall  “Glycoxidation” and oxidation  Procoagulant state  Insulin resistance and hyperinsulinemia  Hormone-, growth-factor–, and cytokine- enhanced SMC proliferation and foam cell formation  Abnormalities in apoprotein and lipoprotein particle distribution  Glycosylation and advanced glycation of proteins in plasma and arterial wall  “Glycoxidation” and oxidation  Procoagulant state  Insulin resistance and hyperinsulinemia  Hormone-, growth-factor–, and cytokine- enhanced SMC proliferation and foam cell formation