1 Chronic Disease EpidemiologyDiabetes Chronic Disease Epidemiology https://www.youtube.com/watch?v=WvzIktiFY6k

2 Objectives Diabetes overview Type 1 Gestational diabetes Type 2

3 Diabetes: Definition Increased blood sugar as a result of insulin deficiency or resistance Type 1- Autoimmune disorder Type 2- Acquired insulin deficiency or resistance Gestational- Diabetes which develops during pregnancy

4 Diagnosis of Diabetes

5 Complications/Co-Morbid conditionsHeart disease and stroke: People with diabetes are twice as likely to have heart disease or a stroke as people without diabetes—and at an earlier age. Blindness/eye problems: retinopathy (damage to blood vessels in Kidney disease: High blood sugar levels can damage the kidneys long before a person has symptoms. Kidney damage can cause chronic kidney disease, and lead to kidney failure. Amputations: Diabetes damages blood vessels and nerves, particularly in the feet, and can lead to serious, hard-to-treat infections. Amputation is sometimes necessary to stop the spread of infection.

6 Type 1 Diabetes

7 Type 1 Diabetes Condition in which the body does not produce insulinAutoimmune disorder caused by genetic susceptibility and environmental triggers Usually begins in childhood 1% of population (5% of diabetes cases) Increasing in prevalence

8 Type 1 Diabetes: Cause Immune cells attack beta cells in the pancreas which produce insulin Slow manifestation as beta cells are gradually lost

9 Treatment Blood sugar monitoring Insulin therapy Diet Exercise

10 Type 1 Diabetes: Risk FactorsFamily history/genetic susceptibility White race Young age Viral infection Cow milk? Cold weather?

11 Genetic SusceptibilityMutations in Human Leukocyte Antigen (HLA) system 5-10% of people with mutation develop diabetes Inheritance pattern is unknown 5% of family members also have T1 diabetes Less than half of identical twins

12 Age Diagnoses spike around 4-7 and 10-14 years oldDiagnosis in adulthood is uncommon Often misdiagnosed as T2 diabetes

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15 Viral trigger? EnterovirusViral antigen resembles insulin/beta cell proteins? Seasonal diagnosis/association with cold weather Could also have a protective effect

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19 Research Transplantation of beta cells Stem cellsInhibiting immune response Vaccine?

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21 Gestational Diabetes

22 Gestational Diabetes Hormonal changes during pregnancy block insulin uptake which leads to hyperglycemia Usually develops in late pregnancy 9% of pregnancies

23 Risk factors Age Family history Non-white race Lifestyle factors

24 Complications Babies: Obesity T2 diabetes Preterm birth HypoglycemiaRespiratory distress Mothers: Hypertension/preeclampsia T2 diabetes in future Postnatal hypoglycemia C section

25 Type 2 Diabetes

26 Type 2 Diabetes Condition characterized by high blood glucose levels caused by either a lack of insulin or the body's inability to use insulin efficiently-insulin resistance. (ADA). Type 2 is the most common type of diabetes- 95% of cases. (NIH, ADA) Caused by several factors, including lifestyle factors and genes Type 2 diabetes develops most often in middle-aged and older adults but can appear in young people. Can be delayed or prevented. Diabetes made simple - https://www.youtube.com/watch?v=MGL6km1NBWE Type 1 and type 2 animation- https://www.youtube.com/watch?v=XfyGv-xwjlI Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas stops producing enough insulin

27 Type 2 Diabetes: Risk FactorsOverweight/Obese Age: More likely to develop if you’re age 45 or older Family history of diabetes Fat distribution Gestational Diabetes during pregnancy Depression Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue you have, the more resistant your cells become to insulin. However, you don't have to be overweight to develop type 2 diabetes. Age an important risk factor, but becoming more prevalent in children and young adults as obesity increases If your body stores fat primarily in your abdomen, your risk of type 2 diabetes is greater than if your body stores fat elsewhere, such as your hips and thighs. Gestational diabetes is a type of diabetes that develops during pregnancy. Most of the time, gestational diabetes goes away after your baby is born. if your gestational diabetes goes away, you still have a greater chance of developing type 2 diabetes within 5 to 10 years

28 Type 2 Risk Factors: PrediabetesPrediabetes- occurs blood glucose, levels are higher than normal, but not high enough to be called diabetes. If left untreated, prediabetes often progresses to type 2 diabetes. You won’t know if you have prediabetes unless you are tested. Estimated that 1 in 3 Americans (86 million) have prediabetes (CDC 2014) 9 out of 10 people don’t know they have it. Prediabetes is serious because it raises your chance of developing type 2 diabetes.

29 Type 2 Diabetes: Family History/Genetics RiskOccurs more often in: African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native Hawaiian, or Pacific Islander ethnic/racial groups With a family history of type 2 diabetes, it may be difficult to figure out whether diabetes status is due to lifestyle factors or genetic susceptibility. Most likely it is due to both. (ADA) Many genes are thought to be involved in type 2 diabetes. Uncertainty on how these genes variations interact and how environment affects those genes. (NIH) https://www.ncbi.nlm.nih.gov/books/NBK1665/ Genes also can increase the risk of type 2 diabetes by increasing a person’s tendency to become overweight or obese. Even if you have a family history, Studies show that it is possible to delay or prevent type 2 diabetes by exercising and losing weight. Type 2 diabetes has a stronger link to family history and lineage than type 1, although it too depends on environmental factors. When one twin has type 2 diabetes, the other's risk is at most 3 in 4

30 Type 2 Risk Factors: Race/Ethnicity & GeneticsWhen food is always abundant, a “thrifty” genetic makeup turns into a survival disadvantage. 20th century diabetes epidemic on remote Pacific island of Nauru The classic example of an epidemic of diabetes is found on an remote island in the Pacific Ocean, the island of Nauru. Before the turn of the 20th century, the lifestyle of Nauruans was harsh. The soil was poor, agriculture was difficult, and frequent episodes of starvation were common. Despite these adverse conditions, the islanders were noted to be “heavy”. In 1922, it was discovered that Nauru contained phosphate rock, which was then mined for use in fertilizer, and for which the islanders received royalties. Over several decades, the Nauruans became extremely wealthy, and with their new-found riches came major lifestyle changes. Food was now abundant and could be bought from stores. Instead of fishing and farming, Nauruans now led sedentary lives. By the 1950s, type 2 diabetes exploded from being non-existent in this population to affecting 2 of 3 adults over the age of 55 and becoming a common cause of death “Thrifty Gene theory”- genes that are metabolically thrifty give a survival advantage in times when there is a constant threat of famine and starvation. When food is abundant, these genes aid the efficient metabolism of the food, enabling rapid build up of fat stores

31 Diabetes by race/ethnicity

32 Type 2 Diabetes National OutlookTotal: 29.1 million people or 9.3% of the population have diabetes. Diagnosed: 21.0 million people. More than one-quarter of seniors (ages 65 and older) have diabetes (25.9 percent or 11 million seniors). Undiagnosed: 8.1 million people (27.8% of people with diabetes are undiagnosed or don’t know they have it).

33 Number and Percentage of U. SNumber and Percentage of U.S. Population with Diagnosed Diabetes, Methodology Number and percent of the U.S. population with diagnosed diabetes were obtained from the National Health Interview Survey (NHIS, available at of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC) for years. Conducted continuously since 1957, the NHIS is a health survey of the civilian, noninstitutionalized population of the United States. The survey provides information on the health of the United States population, including information on the prevalence and incidence of disease, the extent of disability, and the utilization of health care services. The multistage probability design of the survey has been described elsewhere (1,2,3). Estimates for years were obtained from published data (4) and estimates from 1980 forward were derived directly from the NHIS survey data. References 1. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the National Health Interview Survey, Hyattsville, MD: National Center for Health Statistics. Vital and Health Statistics 1989;2(110). 2. Botman SL, Moore TF, Moriarity CL, Parsons VL. Design and estimation for the National Health Interview Survey, 1995–2004. National Center for Health Statistics. Vital and Health Statistics 2000;2(130). 3. Parsons VL, Moriarity C, Jonas K, et al. Design and estimation for the National Health Interview Survey, 2006–2015. National Center for Health Statistics. Vital Health Stat Vital and Health Statistics 2014, 2(165). 4. Harris MI: Prevalence of noninsulin-dependent diabetes and impaired glucose tolerance. Chapter VI in Diabetes in America, Harris MI, Hamman RF, eds. NIH publ. no , 1985. CDC’s Division of Diabetes Translation. United States Diabetes Surveillance System available at

34 Trends in Incidence and Prevalence of Diagnosed Diabetes Among Adults Aged 20-79, United States, Source: National Diabetes Surveillance System, CDC 2016.

35 Distribution of Age at Diagnosis for Incident CasesIn 2011, 63% of the adult (aged 18–79 years) incident cases of diabetes were between the ages of 40 and 64 years. About 16% were diagnosed at age 18–39 years, and about 21% were diagnosed at age 65–79 years

36 Diagnosed Diabetes, Age-Adjusted Percentage, Adults with Diabetes-Total, 2014 Source: Disclaimer: This is a user-generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC. National Center for Chronic Disease Prevention and Health Promotion Division of Diabetes Translation

37 State Highlights Mississippi has the highest rate of diabetes at 14.7 percent. Ten of the 12 states with the highest type 2 diabetes rates are in the South. Virginia ranked 22nd with rate of 10.3 percent Utah, Colorado were 2 lowest at 7.0 and 6.8 percent respectively Nationwide, diabetes rates have nearly doubled in the past 20 years — from 5.5 percent (1994) to 9.3 percent in 2012

38 Diabetes Mortality Diabetes was the 7th leading cause of death in the United States Number of deaths: 76,488 Deaths per 100,000 population: 24.0 Diabetes may be underreported as a cause of death Studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on the death certificate (ADA) https://www.cdc.gov/nchs/fastats/diabetes.htm

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40 Estimated Economic Cost$245 billion total costs of diagnosed diabetes in the United States in 2012 (CDC) $176 billion for direct medical costs $69 billion in indirect cost (reduced productivity) Medical cost for individual with diabetes 2x higher than individual without

41 Type 2 Diabetes: PreventionWeight loss (5-7% of your starting weight). Regular physical activity (30 mins 5x/week) Healthy diet/eating lifestyle Weight loss (5-7% of your starting weight. For instance, if you weigh 200 pounds, your goal would be to lose about 10 to 14 pounds. Lose weight and keep it off. You may be able to prevent or delay diabetes by losing 5 to 7 percent of your starting weight.1 For instance, if you weigh 200 pounds, your goal would be to lose about 10 to 14 pounds. Move more. Get at least 30 minutes of physical activity 5 days a week. If you have not been active, talk with your health care professional about which activities are best. Start slowly to build up to your goal. Eat healthy foods most of the time. Eat smaller portions to reduce the amount of calories you eat each day and help you lose weight. Choosing foods with less fat is another way to reduce calories. Drink water instead of sweetened beverages.

42 Type 2 Diabetes InterventionsCDC- National Diabetes Prevention Program https://www.youtube.com/watch?v=mRVZ9lkubag Richmond YMCA one of many common community organizations that host the program nationwide Year-long program focused on long-term changes and lasting results a structured program—in person or online—developed specifically to prevent type 2 diabetes. It is designed for people who have prediabetes or are at risk for type 2 diabetes, but who do not already have diabetes. A trained lifestyle coach leads the program to help you change certain aspects of your lifestyle, like eating healthier, reducing stress, and getting more physical activity. The program also includes group support from others who share your goals and struggles.

43 Type 2 Diabetes Management & TreatmentHealthy Eating Physical Activity Blood Sugar Monitoring Diabetes Medication & Insulin Therapy Metformin Sulfonylureas GLP-1 receptor agonists SGLT2 inhibitors Healthy eating- fruits, vegetables, whole grains. Contrary to popular perception, there's no specific diabetes diet. However, it's important to center your diet on these high-fiber, low-fat foods: metformin is the first medication prescribed for type 2 diabetes. It works by improving the sensitivity of your body tissues to insulin so that your body uses insulin more effectively Sulfonylureas. These medications help your body secrete more insulin (side effect: weight gain) GLP-1 receptor agonists. These medications slow digestion and help lower blood sugar levels, (helps with weight loss). Isnt usually used by itself. Also bariatric surgery has been seen to lead to lower blood sugar levels https://www.youtube.com/watch?v=qSpAF-JUKEA https://www.youtube.com/watch?v=FPddG1w9luo

44 Type 2: Current Research EffortsConnection between stress and type 2 diabetes. E.g., Richmond Stress and Sugar Study, an ongoing longitudinal cohort study of the role of stress reactivity and glucose metabolism among individuals with pre-diabetes (Dr. Briana Mezuk) Investigations on Diabetes and Psychosocial Care Investigations on genetic defect in beta cells which may underlie both forms of diabetes. - When cortisol levels are consistently high but there’s no physical activity to buffer the effects of chronic stress, the consequences may contribute to type 2 diabetes. Higher cortisol results in higher insulin resistance, for example, forcing the pancreas to produce more insulin to get a response. With ongoing insulin resistance, the insulin-producing beta cells wear out, causing type 2 diabetes. - By following them over time, she hopes to find out if their cortisol levels and other measures of stress are connected to higher rates of type 2 diabetes. “If there are ethnic differences in the stress pathways, that could help guide our intervention,

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