type 2 diabetes – a global epidemic arya m sharma, md, frcp(c) professor of medicine research...
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Type 2 Diabetes – A Global Epidemic
Arya M Sharma, MD, FRCP(C)Professor of Medicine
Research Chair for Obesity Research & ManagementUniversity of Alberta
Medical DirectorEdmonton Weight Wise Program
Edmonton, AB, Canadawww.drsharma.ca
An estimated 285 million people worldwide are affected
by diabetes.
With a further 7 million people developing diabetes each
year, this number is expected to hit 438 million by 2030.
More than 3 million Canadians have diabetes and this number
is expected to reach 3.7 million by 2020.
Diabetes is a contributing factor in the deaths of approximately 41,500 Canadians each year.
50% of Canadians diagnosed with type 2 diabetes do not achieve the CDA Guidelines target level of blood glucose.
DICE Study
Abdominal obesity increases the risk of developing type 2 diabetes
<71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 >96.3
24
20
16
12
8
4
0
Rel
ativ
e ri
sk
Waist circumference (cm)
Carey V, 1997
Conventional treatment (n = 411)*
UKPDS 34. Lancet 1998:352:854; Kahn SE, et al. N Engl J Med 2006;355:2427
The Double-Edged Sword: Weight Gain With Diabetes Treatment
*Diet initially then sulphonylureas, insulin, and/or metformin if FPG > 15 mmol/LFPG = fasting plasma glucose
Ch
an
ge in
weig
ht
(kg
)
Years from randomization
0
1
5
0 3 6 9 12
8
7
6
4
3
2
Insulin (n = 409)Glyburide (n = 277)Metformin (n = 342)
UKPDSWeight gain up to 8 kg
over 12 years
DepressionPseudotumor cerebri
Obstructive sleep apnea
Coronary artery diseaseHeart failure
Fatty liver
Thrombosis
Osteoarthritis
Intertrigo
Incontinence
Gallbladder disease
Infertility
GE-Reflux disease
Hypertension
Diabetes
Gout
Cancer
Sharma 2006
Health Consequences of Obesity
Obesity Treatment Pyramid
DietDiet Physical ActivityPhysical Activity
Lifestyle ModificationLifestyle Modification
PharmacotherapyPharmacotherapy
SurgerySurgery
Placebo
Metformin
Lifestyle
Diabetes Prevention StudyMean Weight Change
The DPP Research Group, NEJM 346:393-403, 2002
0 1 2 3 4
0
10
20
30
40Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Plac)Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )
Percent developing diabetes
All participants
All participants
Years from randomization
Cum
ulat
ive
inci
denc
e (%
)
Placebo (n=1082)
Metformin (n=1073, p<0.001 vs. Placebo)
Lifestyle (n=1079, p<0.001 vs. Metformin , p<0.001 vs. Placebo)
Diabetes Prevention StudyDiabetes Prevention StudyIncidence of Diabetes Incidence of Diabetes
Risk reductionRisk reduction31% by metformin31% by metformin58% by lifestyle58% by lifestyle
The DPP Research Group, NEJM 346:393-403, 2002
The Dilemma
Kg
decades
Weight Curves in Obese and Never-Obese Rats
MacLean PS et al. Am J Physiol 2004
Isn’t Obesity Simple?
EnergyIn
EnergyOut
+/- +/-
Energy Regulation is Complex!
EnvironmentalDeterminants
EnvironmentalDeterminants
Sharma AM 2007
Genetics
Central Control of Energy Metabolism
Principal Sites of Synthesis of GI Peptides Implicated in the Regulation of Food Intake
Cummings & Overduin J Clin Invest. 2007;117:13
Phases of Obesity Treatment
Phase I(Weight Loss)
3-6 months
Phase II(Weight-Loss Maintenance)
Indefinitely
When you stop treatment,the disease comes back!
We
igh
t
Treatment SuccessC
han g
e in
We i
g ht
Years
Lifestyle (LS) ~ 3-5%
LS+Surgery ~ 20-30%
LS+Pharmacotherapy ~ 5-15%
Randomized Controlled Trial of Weight-Loss Maintenance
Svetky LP et al., JAMA 2008;299:1139
STORMSTORM Mean bodyweight changes duringMean bodyweight changes duringweight loss and weight maintenanceweight loss and weight maintenancephases over 2 yearsphases over 2 years
104
102
100
98
96
94
92
90
880 122 4 6 8 10 14 16 18 20 22 24
Month
Bod
yw
eig
ht
(kg
) Control
Sibutramine
Weight loss Weight maintenance
Same diet and exercise for both sibutramine and control
James WPT, Lancet 2001
Bariatric Surgery Reduces Mortality in Swedish Obese Subjects
(n=2010 vs. 2037)
Sjostrom L et al. NEJM 2007;357:741-52
30% Reduction in All Cause Mortality
Bariatric SurgeryEffect on Cardiovascular Risk
A Systematic Review and Meta-Analysis of 22,090 Patients
% r
eso
lved
62%70%
77%86%
Hypertension Dyslipidemia Diabetes Sleepapnea
Buchwald H, et al. JAMA 2004;292:1724
, 2004
Key Points
We currently have a “diabesity” epidemic in Canada
Conventional treatment of “diabesity” is limited and expensive
New thinking is required to better manage this epidemic
My Obesity Blog: www.drsharma.ca