Eduardo de Marchena M.D., F.A.C.C., F.A.C.P. Professor of Medicine & Surgery

Obesity , Metabolic Obesity , Metabolic Syndrome and Diabetes Syndrome and Diabetes

in Hispanics: implications in Hispanics: implications on Cardiovascular on Cardiovascular

Disease 2011Disease 2011

Obesity , Metabolic Obesity , Metabolic Syndrome and Diabetes Syndrome and Diabetes

in Hispanics: implications in Hispanics: implications on Cardiovascular on Cardiovascular

Disease 2011Disease 2011Eduardo de Marchena M.D., F.A.C.C., F.A.C.P.Eduardo de Marchena M.D., F.A.C.C., F.A.C.P.

Professor of Medicine & SurgeryProfessor of Medicine & SurgeryAssociate Dean for International Medicine & Associate Dean for International Medicine &

Director International Medicine InstituteDirector International Medicine InstituteDirector of Cardiovascular Center Director of Cardiovascular Center

University of Miami Miller School of MedicineUniversity of Miami Miller School of Medicine

Eduardo de Marchena M.D., F.A.C.C., F.A.C.P.Eduardo de Marchena M.D., F.A.C.C., F.A.C.P.Professor of Medicine & SurgeryProfessor of Medicine & Surgery

Associate Dean for International Medicine & Associate Dean for International Medicine & Director International Medicine InstituteDirector International Medicine Institute

Director of Cardiovascular Center Director of Cardiovascular Center University of Miami Miller School of MedicineUniversity of Miami Miller School of Medicine

Obesity Trends* Among U.S. AdultsBRFSS, 1985

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1986

Obesity Trends* Among U.S. AdultsBRFSS, 1986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1987

Obesity Trends* Among U.S. AdultsBRFSS, 1987

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1988

Obesity Trends* Among U.S. AdultsBRFSS, 1988

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1989

Obesity Trends* Among U.S. AdultsBRFSS, 1989

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1990

Obesity Trends* Among U.S. AdultsBRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1991

Obesity Trends* Among U.S. AdultsBRFSS, 1991

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1992

Obesity Trends* Among U.S. AdultsBRFSS, 1992

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1993

Obesity Trends* Among U.S. AdultsBRFSS, 1993

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1994

Obesity Trends* Among U.S. AdultsBRFSS, 1994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1995

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%

Obesity Trends* Among U.S. AdultsBRFSS, 1996

Obesity Trends* Among U.S. AdultsBRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1997

Obesity Trends* Among U.S. AdultsBRFSS, 1997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 1998

Obesity Trends* Among U.S. AdultsBRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 1999

Obesity Trends* Among U.S. AdultsBRFSS, 1999

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 2000

Obesity Trends* Among U.S. AdultsBRFSS, 2000

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 2001

Obesity Trends* Among U.S. AdultsBRFSS, 2001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. AdultsBRFSS, 2002

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2003

Obesity Trends* Among U.S. AdultsBRFSS, 2003

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2004

Obesity Trends* Among U.S. AdultsBRFSS, 2004

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2005

Obesity Trends* Among U.S. AdultsBRFSS, 2005

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2006

Obesity Trends* Among U.S. AdultsBRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2007

Obesity Trends* Among U.S. AdultsBRFSS, 2007

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2008

Obesity Trends* Among U.S. AdultsBRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2009

Obesity Trends* Among U.S. AdultsBRFSS, 2009

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% 15%–19% 20%–24% 25%–29% ≥30%

““Globesity” Globesity” ““Globesity” Globesity”

Colombia and BrazilColombia and Brazil40% women in 200140% women in 2001

Prevalence of Obesity Prevalence of Obesity in Malesin Males

Prevalence of Obesity Prevalence of Obesity in Malesin Males

Prevalence of Obesity Prevalence of Obesity in Femalesin Females

Prevalence of Obesity Prevalence of Obesity in Femalesin Females

““Globesity”Globesity”““Globesity”Globesity”

Alarming trend for Alarming trend for Obesity in ChildrenObesity in ChildrenAlarming trend for Alarming trend for Obesity in ChildrenObesity in Children

Evolution of ManEvolution of ManEvolution of ManEvolution of Man

2.5 million years 50 years

DietDiet

ExerciseExercise

2050 New Concept of Ideal Body

Type

2050 New Concept of Ideal Body

Type

0

1

2

3

4

5

6

7

1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06

Year

Per

cen

t w

ith

Dia

bet

es

0

2

4

6

8

10

12

14

16

18

20

Nu

mb

er w

ith

Dia

bet

es (

Mil

lio

ns)Percent with Diabetes

Number with Diabetes

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

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 lifestylePrevalence estimates of diabetes, adults aged 20-79 years, 2010

Age-adjusted Percentage of U.S. Adults Who Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Were Obese or Who Had Diagnosed Diabetes

Obesity (BMI ≥30 kg/mObesity (BMI ≥30 kg/m22))

DiabetesDiabetes

19941994

19941994

20002000

20002000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >>26.0%26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >>9.0%9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statisticsavailable at http://www.cdc.gov/diabetes/statistics

20082008

20082008

(*BMI 30)

Hispanic

State-specific Prevalence of Obesity* State-specific Prevalence of Obesity* Among U.S. Adults, by Race/Ethnicity, Among U.S. Adults, by Race/Ethnicity,

2006-20082006-2008White non-Hispanic

Black non-Hispanic

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.

9.2

13.4 12.8

6.2

9.6

5.8

11.013.0

15.3

02468

1012141618

NH Whites NH Blacks Mexican Americans

Per

cen

t o

f P

op

ula

tio

n

Less than high school High school More than high school

Prevalence of Diabetes Prevalence of Diabetes TodayToday

Prevalence of Diabetes Prevalence of Diabetes TodayToday

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 lifestylePrevalence estimates of diabetes, adults aged 20-79 years, 2010

Global projection for the Global projection for the Diabetes Epidemic: Diabetes Epidemic:

2003 – 2025 (millions)2003 – 2025 (millions)

Global projection for the Global projection for the Diabetes Epidemic: Diabetes Epidemic:

2003 – 2025 (millions)2003 – 2025 (millions)

Diabetes Caused by Excessive Diabetes Caused by Excessive Weight per Global Region Weight per Global Region

Diabetes Caused by Excessive Diabetes Caused by Excessive Weight per Global Region Weight per Global Region

Atherosclerosis100

200150

300250

350

-10 -5 0 5 10 15 20 25 300

100

200

50

150

Postprandial glucose

Insulin resistance

Years

At risk fordiabetes

250

GlucoseGlucose(mg/dL)(mg/dL)

%%RelativeRelative

to Normalto NormalInsulin levelb-cell dysfunction

The Increased Atherosclerosis Risk in Type The Increased Atherosclerosis Risk in Type 2 Diabetes Begins in the Prediabetic State2 Diabetes Begins in the Prediabetic StateThe Increased Atherosclerosis Risk in Type The Increased Atherosclerosis Risk in Type 2 Diabetes Begins in the Prediabetic State2 Diabetes Begins in the Prediabetic State

200 mg/dl

126 mg/dl

Fasting glucose

Clinical Diagnosis

Interrelationship Between Interrelationship Between Insulin Resistance, Abdominal Insulin Resistance, Abdominal

Obesity and AtherosclerosisObesity and Atherosclerosis

Interrelationship Between Interrelationship Between Insulin Resistance, Abdominal Insulin Resistance, Abdominal

Obesity and AtherosclerosisObesity and Atherosclerosis

Insulin Resistance Insulin Resistance

H/TH/THyper-Hyper-glycemiaglycemia

Hypertri-Hypertri-glyceridemiaglyceridemia

SmallSmall LDL LDL

LowLow

HDLHDL

AtherosclerosisAtherosclerosis

Endothel.Endothel.dysfunctndysfunctn

Pro-inflam-Pro-inflam-matorymatory

HyperinsulinemicHyperinsulinemicmitogenesismitogenesis

ObesityObesity

Hyperco-Hyperco-agulabilityagulability

Age-adjusted prevalence trends for high blood pressure in Age-adjusted prevalence trends for high blood pressure in Adults age 20 and older by race/ethnicity and sex survey Adults age 20 and older by race/ethnicity and sex survey

(NHANES: 1988-94, 1999-02 and 2003-06).(NHANES: 1988-94, 1999-02 and 2003-06). Source: NCHS and Source: NCHS and NHLBI. NH- non-Hispanic.NHLBI. NH- non-Hispanic.

22.9

37.5 38.2

26.925.025.6

27.0

41.4

27.8

38.5

25.424.827.6

30.3

40.341.9

23.726.4

0

10

20

30

40

50

NH WhiteMen

NH WhiteWomen

NH BlackMen

NH BlackWomen

MexicanAmerican

Men

MexicanAmericanWomen

Pe

rce

nt

of

Po

pu

lati

on

1988-94 1999-02 2003-06

Extent of Awareness, Treatment and Control of High Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity and Sex Blood Pressure by Race/Ethnicity and Sex

(NHANES: 1999-2006). Source: NCHS and NHLBI.

76.6

71.8

61.8

41.9

76.9

68.1

40.0

70.1

59.6

34.1

85.3

43.8

57.7

41.8

25.6

69.9

57.9

31.9

0

10

20

30

40

50

60

70

80

90

Awareness Treatment Controlled

Pe

rce

nt

of

Po

pu

lati

on

W

ith

Hy

pe

rte

ns

ion

NH White Men NH White Women NH Black Men

NH Black Women Mexican-American Men Mexican-AmericanWomen

76.6

71.8

61.8

41.9

76.9

68.1

40.0

70.1

59.6

34.1

85.3

43.8

57.7

41.8

25.6

69.9

57.9

31.9

0

10

20

30

40

50

60

70

80

90

Awareness Treatment Controlled

Pe

rce

nt

of

Po

pu

lati

on

W

ith

Hy

pe

rte

ns

ion

NH White Men NH White Women NH Black Men

NH Black Women Mexican-American Men Mexican-AmericanWomen

Trends in mean total serum cholesterol among adolescents ages Trends in mean total serum cholesterol among adolescents ages 12-17 by race, sex, and survey 12-17 by race, sex, and survey

(NHANES: 1976-80, 1988-94, 1999-02, 2003-04, and 2005-06). Source: NCHS and NHLBI.

163161

172171170

166

163165

174

166168

155

163164

156

161 161

157 158

151

161163

160158

135140145150155160165170175180

WhiteMales

BlackMales

WhiteFemales

BlackFemales

Mex.Am.

Males

Mex.Am.

Females

Me

an

To

tal

Blo

od

Ch

ole

ste

rol

1976-80 1988-94 1999-02 2003-04 2005-06

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 CHD Mortality and Hyperinsulinemia:Hyperinsulinemia:

Paris Prospective Study (n=943) Paris Prospective Study (n=943)

CHD Mortality and CHD Mortality and Hyperinsulinemia:Hyperinsulinemia:

Paris Prospective Study (n=943) Paris Prospective Study (n=943)

National Diabetes Data Group. Diabetes in America. 2nd ed. NIH;1995.

Atherosclerosis in Atherosclerosis in DiabetesDiabetes

Atherosclerosis in Atherosclerosis in DiabetesDiabetes

~80% of all diabetic mortality75% from coronary atherosclerosis25% 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 mortality75% from coronary atherosclerosis25% from cerebral or peripheral

vascular disease>75% of all hospitalizations for

diabetic complications>50% of patients with newly

diagnosed type 2 diabetes have CHD

Framingham Heart Study 30-Year Follow-Up:Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes CVD Events in Patients With Diabetes

(Ages 35-64)(Ages 35-64)

Framingham Heart Study 30-Year Follow-Up:Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes CVD Events in Patients With Diabetes

(Ages 35-64)(Ages 35-64)

0

2

4

6

8

10

Age-adjusted annual rate/1,000

Men Women

Total CVD

CHD Cardiac failure

Intermittent claudication

Stroke

Riskratio

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