Diabetes - The Global Picture: The World’s … NDM IFG IGT NGT 35% 18% 14% 22% 11% 65% of CVD deaths over 5 years occurred in people with DM, IFG or IGT at baseline Barr et al.,Circulation

Diabetes - The Global Picture: The World’s Greatest Public Health Challenge

Paul Zimmet

1The screen versions of these slides have full details of copyright and acknowledgements

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Prof. Paul Zimmet AODirector EmeritusBaker IDI Heart and Diabetes InstituteAustralia

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“Diabetes is a public health emergency in slow motion”

Ban Ki-Moon,UN Secretary-General

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2006 UN general assembly resolution on diabetes


Paul Zimmet


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5

Obesity is driving the escalating Diabesity epidemic:

the biggest epidemic in human history

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OECD predictions for future overweight rates: 1970s-2020

Past and projected future overweight rates in selected OECD countries

Prop

ortio

n ov

erw

eigh

t

Years


Paul Zimmet


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The escalating diabetes epidemic:a historical perspective

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Modernization & high diabetes prevalence1966-1975

Zimmet: Pacific – Nauru

Bennett: Phoenix Arizona:Pima Indians

Wise: Australia:Indigenous

Ian Prior: New Zealand: Maori

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Age specific prevalence of diabetesNauru: 1994

Age group (years)

Prevalence %

0

10

20

30

40

50

60

25 - 34 35 - 44 44 - 54

MalesFemales

55 - 64 65+


Paul Zimmet


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The 10 top nations for diabetes prevalence: 2010

0% 5% 10% 15% 20% 25% 30% 35%

Nauru

UAE

Saudi Arabia

Mauritius

Bahrain

Réunion

Kuwait

Oman

Tonga

Malaysia

Prevalence %** For 20-79 year population

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Western killer in paradise “The Age”, May 1992

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On the basis of the Nauru studies, we predicted there would be a global epidemic

of type 2 diabetes


Paul Zimmet


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Mauritius: the next step in predicting the global diabetes epidemic

• The population consistsof Asian Indians, Blacks (Creoles) and Chinese

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62% increase from 1987 to 2009

Mauritius: increase in diabetes prevalence over 22 yrs

Standardised to 2008 population structure of Mauritius

Prev

alen

ce o

f Dia

bete

s %

0

5

10

15

20

25

30

1987 1992 1998 2004 2009

MenWomenTotal14.6%

17.4%20.1%

18.7%23.6%

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• The 3 ethnic groups in Mauritius (see slide 13) constitute 66% of the world’s population

• Studies performed: 1987, 1992, 1998, 2004 and 2009

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Global projections for the diabetes epidemic: 2010-2030 (millions)

Shaw J. Diab Res & Clin Practice, 2009 IDF Atlas 2009 www.idf.org

World

2010 = 285 million2030 = 438 million

Increase 54%

2011 – a staggering 366 million2030 – 552 million


Paul Zimmet


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Undiagnosed diabetes

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The top 10s (number of people with diabetes)

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Increasing diabetes prevalence 1980-2002: China

Life style changesJi Linong: Personal communication

0

2

4

6

8

10

1980 1994 1996 2002 2009

9.7

1

2.8 3.2

5.0


Paul Zimmet


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Prevalence of diabetes in urban India (Chennai)

Prevalence 2000 – 13.9%

Prevalence 2006 – 18.6%

Ramachandran et al., Diabetes Care 2008

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The Middle-East – world diabetes hot-spot

DM prevalence for adults age 20-79

UAE

0

10

20

S. Arabia

0

10

20 16.8%

18.7%

Oman

0

10

20 13.4%

Kuwait

0

10

20 14.6%

Bahrain

0

10

20 15.4%


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Diabetes prevalence in Qatar & Australia

0

5

10

15

20

25

30

35

20-29 30-39 40-49 50-59Age group (years)

QatarAustralia*

Prevalence (%)

*Australian data apply to 25-34; 35-44; 45-54; 55-64

Bener et al., DRCP 84; 2009: 99-106Dunstan et al., Diab Care 2002; 25: 829-834

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Prevalence of diabetes: Japan

7.4 million(16.2 million including pre-diabetic subjects)

1955 60 65 70 75 80 85 90 95 2002 (year)

35

30

25

20

15

10

5

0

31.5 fold

Rel

ativ

e ra

tio

1

Takashi Kadowaki: Personal communication

An explosive increase

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Time trends in type 2 diabetes incidence among Japanese children

Kitagawa T et al., Clin Pediatr 1998

Type 2 diabetes

Obesity

Type

2 d

iabe

tes

inci

denc

e / 1

00,0

00po

pula

tion

per y

ear

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

8.0

7.0

6.0

5.0

19951995198519801975

Prevalence of obesity (%)


Paul Zimmet


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Number (in millions) with diagnosed diabetes, USA, 1980–2009

http://www.cdc.gov/diabetes/surveillance/index.htm

Num

ber (

mill

ions

)

Year

26www.cdc.gov/diabetes

County-level estimates of diagnosed diabetes among adults aged ≥ 20 years: United States 2004 and 2008

Percent0 - 6.56.6 - 8.08.1 - 9.49.5 - 11.1> 11.2

2004 2008

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Prevalence of diabetes and IFG in rural Bangladesh: 1999 and 2004

Rahim et al., Diab Res Clin Prac 77, 2007, 300-305

0

1

2

3

4

5

6

7

8

Men Women Total Men Women Total

19992004

Prev

alen

ce (%

)

DM IFG


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Diabetes prevalence rates in selected nations: 1970-1989 & 1990-2005

B: Multiplication factor for increasedprevalence of Type 2 Diabetes

0

1

2

3

4

5

6

A: Prevalence of Type 2 Diabetes (%)

1970-1989

1990-2005

0

2

4

6

8

10

12

14

Yoon KH et al., Lancet 2006; 368: 1681-1688

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Economic development & prevalence of diabetes in selected Asian countries:

1981-2008

1981-19871988-19941995-20012002-2008

ChinaIndia Malaysia Singapore

B: Prevalence (%)

A: Real GDP per head (US$)

05000

100001500020000250003000035000

02468

101214161820

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Regional highlights

Africa: 78% of people with diabetes are undiagnosed

Europe: the highest prevalence of type 1 diabetes in children

Middle East and North Africa: 6 of the top 10 countries by diabetes prevalence

North America and Caribbean: 1 adult in 10 has diabetes

South and Central America: 12.3% of all deaths were due to diabetes

South-East Asia: almost one-fifth of the world’s people with diabetes live in just seven countries

Western Pacific: 132 million adults have diabetes, the largest number of any region


Paul Zimmet


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Diabetes in Australia joining the global epidemic

Dunstan D et al., Diabetes Care 2002

Busselton1981

250,000

1983

400,000

1990

550,000

1995

725,000

2000

1,000,000

AU

SDIA

B

2010 >1,500,000

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Eligible participants9,303

CVD Mortality

124 (34%)

Non CVD mortality 244

(66%)

All-cause Mortality

368

2000

2006Median: 6.6 yrs

AusDiab mortality follow-up

Dunstan et al., Television viewing time and mortality: The AusDiab study; Circulation 2010; 121: 384-391

Adults ≥ 25 yrs participating in the baseline survey = 11,247

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AusDiab mortality: CVD deaths

KDM

NDM

IFG

IGT

NGT

35%

18%

14%

22%

11%

65% of CVD deaths over 5 years occurred in people with DM, IFG or IGT at baseline

Barr et al., Circulation2007; 116: 151-7


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“If current trends continue, by 2020, diabetes will be the leading cause of disease for men and the second

leading cause for women.”

Australia 2020: setting our nation's sights for the future

The Hon Kevin Rudd(Former) Prime Minister

April 2008

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Australian Indigenous people have one of the highest rates

of diabetes in the world

They have the highest rateof end-stage renal deaths

in the world

Alice Springs has the largest renal dialysis unit in the Southern Hemisphere!

Alice Springs

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Diabetes in indigenous Australians:age-specific prevalence (%)

AusDiabAboriginal TSI

0

10

20

30

40

50

60Prevalence %

Age group (years)25-34 35-44 45-54 55-64 65-74 75+

K O’Dea 2002


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Diabetes in indigenous communities: competing “causation” of type 2 diabetes

“Western” view

• Bad behaviours

• Bad choices

• Lazy

• Obesity

Indigenous view

• Dispossession

• Social disharmony

• Poverty

• Socio-cultural change

• ‘Toxic’ external pressures

• Transgenerational trauma

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Type 1 diabetes in the young

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Criteria:• Diagnosed as type 1 diabetes

• On Insulin at first hospital discharge

• Diagnosed between 1/1/90 and 31/12/99

• Age at onset 0-14

• Member of a defined community

Diabetes Mondial – DiaMond: establishment of population based registries for 1990


Paul Zimmet


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Incidence and trends of childhood type 1 diabetes worldwide 1990-1999, The DIAMOND project group

Incidence (per 100,000/year)



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The DIAMOND study: high incidence countries during 1990-1999


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The trend in the incidence of Type 1 diabetes in Finnish children aged 14 or under

0.0

10.0

20.0

30.0

40.0

50.0

60.0

1963 1968 1973 1978 1983 1988 1993 1998

Year

Tuomilehto et al., Diabetologia 1999


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Age-specific annual incidence of type 1 diabetes per 100,000/year; Finnish children

aged 1-14 years between 1965 and 1996

0

10

20

30

40

50

60

1963 1968 1973 1978 1983 1988 1993 1998

Year

1-45-910-14

Tuomilehto J, Karvonen M et al. Diabetologia 1999; 42 (6): 655-60

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Diabetes is very complicated

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0

100

200

300

400

500

600

700

800

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 040

500

1000

1500

2000

2500Type 2 (Ins Requiring)

Type 2 (Non Insulin)

Type 1

Total New Patients

Year of Entry

Number of Diabetics Number of New Patients

Incidence of diabetes in end-stagerenal failure: Australia 1980-2004

R Atkins 2005


Paul Zimmet


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0

10

20

30

40

50

60

70

80

90

100

1971-1980 1981-1990 1991-2000

GeneralDiabetes

Age at death in Japan:general population versus diabetes - males

Hotta N: Personal communication

Life Expectancy (Years)

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• To explore the relationship between diabetes (newly diagnosed (NDM) and known diabetes (KDM), impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) and all-cause, CVD, and cancer mortality

• To explore the relationship between hypertension, obesity and other risk factors for all-cause and CVD mortality

Mauritius surveillance study: aims

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• This is the first study in a developing country of the impact of glucose intolerance on mortality in an African population, and one of the first studies of a South Asian population

• It shows that the impact on mortality in these populations in Mauritius is comparable to that seen in developed countries

• These results are important in a global context for future health policy in the light of the impact of the rapid increase in prevalence of diabetes, especially in developing nations

Conclusion


Paul Zimmet


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Adjusted all-cause mortality hazard ratios (95% CI) for IFG, IGT, NDM and KDM compared to NGT in Mauritians

according to ethnic group: the Mauritius surveillance study

0

1

2

3

4

HR (95% CI) for mortality

NGT IFG IGT NDM KDM NGT IFG IGT NDMKDM NGT IFG IGT NDMKDM

Categories of glucose metabolism

Indian Creole Chinese

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Predictors for CVD deaths

Variable Level HR and 95% CI

Glucose tolerance NGT 1.00

IFG 1.01 (0.68–1.50)

IGT 1.31 (1.03–1.67)

NDM 2.01 (1.60–2.53)

KDM 2.94 (2.35–3.67)

Adjusted for ethnicity, sex, physical activity, education, smoking, lipids, hypertension, creatinin, BMI, waist, previous CVD


Paul Zimmet


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Sleep Apnoea

• Obesity• Diabetes• Insulin Resistance• Dyslipidaemia

Non-alcoholic Steatohepatitis(Primary NASH)

HIV/AIDS Therapy

New confounding disorders accelerating the diabetes & metabolic syndrome epidemic

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Prevention of diabetes: the new paradigm

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Environment

EARLY LIFE

• Low birth weight

• Poor nutrition

ADULT LIFE

• Sedentary lifestyle

• Dietary factors

Cardiovascular disease

GenesDiabetes +/-The Metabolic Syndrome

Genetic-environment interaction for type 2 diabetes


Paul Zimmet


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Epigenetics: a new paradigm for prevention

• The study of heritable changes in gene function that occur without a change in the sequence of the DNA

• Epigenetics - how we eat and live can change the way our genes behave

• The maternal environment may be the key to stemming the epidemic

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The Dutch winter famine

• At the end of WW2, West Netherlands population suffered an acute famine

• Allocated rations were 400 to 800 calories/day

• Women exposed to this during the 2nd and 3rd trimester of pregnancy delivered small babies

• As adults, these babies (exposed to famine in utero) had a higher prevalence:

Type 2 diabetes

CVD (heart attacks, strokes)

Hypertension

Obesity

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Developmental plasticity, foetal programming & intergenerational risk

Developmental plasticity:

The process where a stimulus applied in utero establishes a permanent response in the foetusleading to enhanced susceptibility to later disease, e.g. type 2 diabetes and cardiovascular disease

Mother – 1st generation

Fetus – 2nd generation

Reproductive cells –3rd generation


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Diabetes in Cambodia (30 years after Pol Pot regime)

Dr. Hilary King

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Diabetes prevalence in Cambodia

7.3%

2.9%3.5%

3.2%

7.1%7.4%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Males Females Total

Urban

Rural

Prev

alen

ce (%

)

King H et al., Lancet 2005

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Poverty & diabetes: issues for preventionin developing nations

• Prenatal and perinatal factors

• Most cases undiagnosed

• Socioeconomic status

• Education

• Unemployment

• Environment

• Access to care

• Chronic diseases enhance poverty

Cockram C 2006


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Conclusions

• Diabetes continues to rise exponentially globally

• Ageing, lifestyle change and urbanisation have been targeted as the main drivers but in developing nations, the story may be very different

• A greater focus on maternal & child health may lead to more effective strategies to halt this global epidemic of diabetes and associated complications and co-morbidities

• By 2020, diabetes is set to bankrupt many national economies, both developed and developing

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Acknowledgements

Baker IDI Epidemiology and key collaborators

Jonathan Shaw George Alberti Adrian Cameron

Dianna Magliano Richard Sicree David Dunstan

Stefan Soderberg Elizabeth Barr Jaakko Tuomilehto

Gary Dowse Max De Courten

Mauritius

Sudhir Kowlessur

Pierrot Chitson

N Gopee

V Pauvaday

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Documents

Diabetes - The Global Picture: The World’s … NDM IFG IGT NGT 35% 18% 14% 22% 11% 65% of CVD deaths over 5 years occurred in people with DM, IFG or IGT at baseline Barr et al.,Circulation