7th DIETS/EFAD Conference Diabetes pandemic garda_25112013_website_final

1. 7th DIETS/EFAD Conference
Type 2 Diabetes:
the pandemic waiting to happen
Cathy Breen
EFAD ESDN Diabetes Lead/Irish Nutrition and Dietetic Institute/
Endocrine Unit, St Columcille’s Hospital, Loughlinstown, Co Dublin,
Ireland
Garda, Italy. November 8th, 2013
©, 2013

2. Type 2 Diabetes: the pandemic waiting
to happen?

Pandemic


Waiting to happen?
Extensively epidemic
(Steadmans Medical Dictionary, 28th Ed)

An infectious epidemic
occurring worldwide or
over a very wide area,
crossing international
boundaries, and usually
affecting a large number of
people (Wikipedia, 2013)
IDF, 2012

3. IDF, 2012

4. Prevalence: Europe

5. Diabetes Prevalence in 2000 vs. 2030
Over 430 million cases predicted by 2030

6. Age-Adjusted Prevalence of Diagnosed Diabetes Among
U.S. Adults Aged 18 Years or older
2000
1994
No Data
<4.5%
4.5-5.9%
6.0-7.4%
2010
7.5-8.9%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
>9.0%

7. Why the explosion?

8. Risk factors for Type 2 diabetes
WHO, 2011

9. Diabesity?


Type 2 diabetes ↔ Obesity
~80% of adults with T2 diabetes are overweight / obese (McLaughlin,
2007)

10. Age-Adjusted Prevalence of Obesity and Diagnosed
Diabetes Among U.S. Adults Aged 18 Years or older
Obesity (BMI ≥30 kg/m2)
1994
No Data
<14.0%
2010
2000
14.0-17.9%
18.0-21.9%
22.0-25.9%
>26.0%
Diabetes
1994
No Data
2010
2000
<4.5%
4.5-5.9%
6.0-7.4%
7.5-8.9%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
>9.0%

11. Diabesity

Adipose tissue drives insulin resistance and
hyperglycaemia
Rosen & Spiegelman, 2006

12. Type 2 diabetes: why worry?

Costs

Quality of life



Burden of diabetes
Complications / co-morbidities
Monetary

Overburdened health care
systems
IDF, 2012

13. Diabetes and quality of life/health status
AIHF, from AUSDiab Study 1999-2000
Solli, 2010

14. Diabetes complications

15. Monetary costs
Kanavos, 2012

16. Type 2 diabetes (dietary) management





Glycaemic control → carbohydrate quantity & quality
Weight loss → calories
Lipid management → saturated vs. unsaturated fat
Blood pressure management → salt / alcohol
Overall dietary quality → fruit & veg, fibre
Low calorie,
higher fibre
diet, lower
GL diet
Individualising
macronutrient
composition
Low fat diet
+ lipase
inhibitors
Meal
replacement
Very low
calorie
diets
CALORIE RESTRICTION
• Structured diabetes education + patient empowerment
• Individualised, supportive approach
• Intense review as part of a behavioural lifestyle intervention (MDT approach)
Bariatric
surgery

17. Dietary approaches in Type 2 diabetes

Evidence for:
Low fat diets, low carbohydrate diets, high protein diets
Low glycaemic index/load diets
Mediterranean diet
Meal replacements
Very low calorie diets

“The true application of research findings can usually be found in the
author’s description of the participants’ usual diet before randomization.
The red meats, salty snacks, and sweets participants typically ate were
replaced with lower-fat protein sources, lower-fat dairy, whole grains—
fewer empty-calorie foods in place of more nutrient-dense foods” (Perry,
2005)
 What do our patients want? Food based recommendations that can be easily
understood and translated into everyday life

18. It works!

Structured dietetic-led diabetes education programmes

ROMEO (Italy): Dietitian-led T2DM groups significantly improved
outcomes compared to a medically and pedagogically-led group
(Trento, 2008)


X-PERT (UK): Improved HbA1c (-0.6 vs. -0.1%), weight (-0.5 vs.
1.1kg) + improved diabetes knowledge + fruit/veg intake (Deakin, 2006)
Intense lifestyle interventions
e.g. LookAhead

4 years:


Weight -6.2 v.s -0.88% (P <0.001)
Significantly better HbA1c, fitness,
BP, HDL, TAG
Gregg, 2012

19. EASD/ADA Guidelines
But
where is
the
emphasis
really?

20. Benefits of modest weight loss in Type 2
diabetes
1Anderson, 2001; 2Anderson, 2003

21. Key messages for clinical practice
1.
2.
Focus on calorie restriction, portion control + weight
management
Think more ‘algorithmically’ i.e. individualise approaches
and change the approach if it’s not working

22. Is it cost effective?



Lifestyle interventions? Yes, probably, at least in the shorter
term (Jacobs Van der Bruggen, 2009; DPP, 2012)
Report commissioned by the Dutch Association of Dietitians
in 2012 (ICAN Study):
 For every €1 spend on dietary counseling, society gets a net €14 63 in return: €56 in terms of improved health, €3 net savings in
total health care costs and €4 in terms of productivity gains.
Need to gather more diverse data routinely

Less medication usage, improved dietary quality, improved quality of
life, less hospital admissions, less A&E visits, less hypoglycaemia, less
work absenteeism, reduced rates of progression to complications

23. IMAGE Work package 4 – Subgroup 3: Guideline Nutrition

24. Preventing Type 2 diabetes: the simple things
work
1.
2.
3.
4.
5.
Weight loss (5-10%)
Reduce fat intake (<30%)
Reduce saturated fat intake
(<10%)
Increase fibre intake
(>15g/1000kcals)
Increase activity
(>4hrs/week)
Tuomilehto et al, NEJM, 2001

26. Dietitians as uniquely qualified leaders in
Type 2 diabetes treatment and prevention









Working in primary & secondary health care, public & private sector,
industry, administrative, education & research settings
Unique knowledge and skill set relating to food and clinical nutrition
 Uniquely qualified to match the approach to the client
Advanced behaviour change skills
Clinically effective
Inherent value placed on best practice that underpins all approaches
Code of professional practice
Commitment to CPD/LLL
Expertise in audit & research
Unified public health message
Unique insight & capacity to deliver high quality, evidence-based,
patient-centred approaches to the management and prevention
of Type 2 diabetes

27. Dietitians know best!


We understand the complex challenges that our patients
face when trying to manage their diabetes within an
increasingly obesogenic environment and overburdened
health care systems.
Clinical ↔ public health

28. Health 2020




Health2020 makes the case for investment in health and aims
to support action across government and society to improve
the health and well-being of populations and strengthen public
health.
Tackling Europe’s major disease burdens, including diabetes, is a
priority area within the policy.
This will require coordinated public health action and health
care system interventions, which must be underpinned by
supportive environments.
Innovation and leadership for health are at the core of Health
2020, and it encourages all stakeholders to take on new
responsibility and accountability for population health.

29. What we can do

This provides an opportunity for dietitians, as specialists with a
unique insight and professional expertise in the area, to take
leadership roles in developing local and national public health
policies that support the aims of Health2020 for a healthier
society that will reduce the burden of type 2 diabetes.
 Local, national, international diabetes advocacy groups
 Local / national diabetes service planning / steering committees
 Global Diabetes Survey

We can be a strong voice about what needs to change…
 Health in all policies approach
 Environmental planning
 Food marketing
 Unhealthy food taxation vs. healthy food subsidies

30. We’ve been here before….

Plague
Matthews, 2011
Thanks to Illona Kickbush, OECD

31. “There is no public outrage that
governments legislate to protect
through legislation in other contexts
e.g. seatbelts, fire escapes, crash
barriers. Yet startlingly few public health
policies are in place to protect us from
excess calorie consumption ”
“Bubonic plague could not
be stopped by wishing
that the population were
less degenerate”