Griffin P. Rodgers, M.D., M.A.C.P. Acting Director, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Department of Health and Human Services
The research mission of the NIDDK was defined by the U.S. Congress when it established the Institute: “The general purpose of the National Institute of Diabetes and Digestive and Kidney Diseases...is the conduct and support of research, training, health information dissemination, and other programs with respect to diabetes mellitus and endocrine and metabolic diseases, digestive diseases and nutritional disorders, and kidney, urologic, and hematologic diseases.”
The NIDDK engages in and supports biomedical research ranging from basic studies of fundamental processes, to clinical trials of novel therapeutic agents and strategies, to the translation and dissemination of health information to health care providers, patients, and the public. Efforts include: Identification of health problem Epidemiologic & basic research to identify potential risk factors, mechanisms, & influences Clinical trials to determine efficacy of novel therapies on health outcomes Translation of research from the bench to the bedside, and back Dissemination of information through national education programs The Institute aims to move advances in basic science, achieved at the “bench,” into trial of novel therapies in patients at the “bedside.” The NIDDK also strives to use knowledge gained during such trials to fuel future laboratory studies.
The three extramural scientific divisions support research programs at facilities that include d iabetes, endocrinology, metabolic and genetic diseases; digestive diseases, nutritional disorders, and obesity; and kidney, urologic, and hematologic diseases. In addition to these extramural Divisions, the Division of Intramural Research conducts research and training within the Institute's laboratories and clinical facilities in Bethesda, Maryland, and at the Phoenix Epidemiology and Clinical Research Branch in Arizona. The Division of Extramural Activities provides administrative support and overall coordination. A fifth division, the Division of Nutrition Research Coordination, coordinates government nutrition research efforts across the NIH and with other Federal agencies.
In this presentation, I’d like to use obesity, type 2 diabetes, and kidney disease, to illustrate how the NIDDK works with the research community to investigate diseases, how they are connected, and approaches that we can take to address each one. Obesity is present at epidemic levels in the U.S. and many other nations. Being overweight or obese puts individuals at increased risk of developing a number of diseases. One of the more common diseases seen in obese people is type 2 diabetes, the incidence of which is also rising rapidly in the U.S. Type 2 diabetes is, in turn, the leading cause of kidney failure in the U.S. The NIDDK has vigorous research programs targeting each of these three conditions; let’s start by looking at obesity.
Obesity results from an imbalance in caloric intake relative to caloric expenditure. This imbalance causes fat to accumulate. Researchers usually define overweight and obesity in terms of an individual’s body mass index, or BMI. BMI is calculated by dividing a person’s weight in kilograms by his or her height in meters squared [kg/m 2 ]. A person with a BMI over 25 is classified as overweight, while a person with a BMI of 30 or above is considered obese. For example, a 6-foot (~1.8 m) tall man who weighs 180 pounds (~82 kg) has a BMI of about 24, which is at the upper end of the normal range. At 200 pounds (~91 kg), he has a BMI of about 27 and he is classified as overweight. At 225 pounds (~102 kg), he has a BMI of over 30, and he is obese. Overweight is defined somewhat differently in children and adolescents. After BMI is calculated, it is plotted on growth charts -- based on national surveys compiled before the recent increase in obesity -- to obtain a percentile ranking. If a child’s BMI is above the 85th percentile for his or her age, then he or she is at risk of becoming overweight. If a child’s BMI is above the 95th percentile, the child is overweight. There is no generally accepted definition for obesity, as distinct from overweight, in this age group. It is possible to have a high BMI and be healthy. For example, people who are athletic and have large amounts of muscle may have a BMI over 25, but are healthy. Also, BMI measurements cannot be used on pregnant women. Nevertheless, BMI is a useful tool.
13 13 Obesity is a problem in the U.S. for two main reasons. The first is that a large number of health problems are associated with obesity. They include high blood pressure, cardiovascular disease, stroke, arthritis, and many others. The multitude of co-morbidities associated with obesity reflects the complexity and diversity of systems that contribute to energy balance. Obesity is also associated with several diseases within the research mission of the NIDDK, including nonalcoholic fatty liver disease and type 2 diabetes. Image modified from one appearing in National Geographic magazine.
The second reason obesity is a big problem in the U.S. is that it is growing at an alarming rate. A quick look at these maps is all it takes to realize the scope of the obesity problem. Between 1991 and 2004, there was a dramatic increase in the number of people who were obese, and in many American states in 2004, more than a quarter of residents were obese. In fact, the problem may be even worse than it appears in these maps. Data published in 2006 indicate that 32 percent of adults are obese, and, ominously, 17 percent of children are overweight. Source: Behavioral Risk Factor Surveillance System, CDC. Ogden et al, JAMA 295:1549-1555, 2006.
Since the late 1970s, the rates of overweight among children and adolescents have risen dramatically. Recall that overweight is defined as BMI greater than or equal to the gender- and weight-specific 95th percentile from historic growth charts. Source: National Health Examination Surveys II (ages 6-11) and III (ages 12-17), National Health and Nutrition Examination Surveys I, II, III and 1999-2004, National Center for Health Statistics, CDC.
What is responsible for this sudden increase in the number of obese people in the U.S.? Obesity most likely results from an interplay between genes and the environment. However, the recent explosion in the prevalence of obesity has occurred too quickly to be explained solely by changes in our genes. One hypothesis is that, in the past, humans who were able to accumulate fat when food was plentiful were better able to survive during times of food scarcity. Now, however, in the U.S. and many other countries, food is plentiful and foods that are high in calories but often low in nutritional value tend to be relatively inexpensive. Furthermore, most people engage in far less physical activity than did previous generations. Ironically, the ability to accumulate fat during times of plenty – which was originally thought to confer a benefit – has become a detriment to our health. Research supported by the NIDDK has led to improved understanding of the factors contributing to this complex condition. G.S. Barsh, I.S. Farooqi, S. O’Rahilly. Nature 404: 644, 2000
Obesity is a major driving force in the development of type 2 diabetes. Type 2 diabetes was formerly known as “adult-onset” diabetes. As we shall see, though, it is no longer only adults who are at risk of developing this disease.
There are two major forms of diabetes. Type 1 diabetes, formerly known as “juvenile” diabetes, is the form of diabetes that has historically most likely to be detected in the young. On the other hand, type 2 diabetes, formerly known as “adult-onset” diabetes, is responsible for 90-95 percent of diabetes cases. It had historically been detected in older people. Ominously, however, as the obesity epidemic has reached alarming levels in children and adolescents, we are seeing more and more type 2 diabetes being diagnosed in young people. Fortunately, NIDDK-funded research has shown that type 2 diabetes can be prevented or delayed in adults, and an ongoing study is examining whether a similar approach can be used in children at risk of developing the disease.
Similar to the trends seen with obesity, diabetes has been increasing in the U.S. in recent years. Between 1994 and 2004, there was a dramatic increase in the number of people with diagnosed diabetes in the U.S. Over the past 25 years, the prevalence of diabetes has more than doubled. It is thought that the increase in diabetes is due largely to an increase in type 2 diabetes that is being driven by three major trends in the U.S. population: An aging population A growing number of racial and ethnic minorities A dramatic increase in overweight and obesity – serious risk factors for developing the disease Source: CDC National Diabetes Surveillance System, 2005.
Nearly 21 million American have either type 1 or type 2 diabetes, and the vast majority of these people have type 2. Minority ethnic groups such as African Americans, Hispanics, American Indians, and Native Hawaiians are disproportionately affected by diabetes. Almost 3 million deaths worldwide were attributable to diabetes in 2000 . Sources: Diabetes: Disabling, Deadly, and on the Rise, CDC, 2006. World Health Organization, Diabetes Care 28: 2130-2135, 2005.
The problem of diabetes in the U.S. is likely to be even worse than it appears This graph reflects only diagnosed cases of diabetes. But, 1 in 3 people with diabetes is unaware that he or she has the disease. If you do not know that you have diabetes and you are not being treated, your diabetes is not controlled, and you are at even greater risk of developing complications such as heart disease, blindness, or kidney disease. The uptick in diagnosed cases between 2000-2004 may reflect an increase in the number of overall cases, possibly due to under-representation of Hispanics in earlier data sets, or it may reflect improvements in diagnosing diabetes in previously undiagnosed individuals. Predictions of future cases of diagnosed diabetes paint a sobering picture. The Centers for Disease Control and Prevention project that, by 2050, nearly 50 million Americans will have been diagnosed with diabetes. Source: Data for 1960-2004 from the National Health Interview Survey, NCHS, CDC. Projected data for 2005-2050 from Narayan KMV, et al, Diabetes Care 29:2114-2116, 2006.
As grim as the future may look, there is some good news to report regarding type 2 diabetes. NIH research has shown that type 2 diabetes can be delayed or prevented. This figure depicts disease development in the different racial and ethnic groups in the landmark Diabetes Prevention Program (DPP) clinical trial. The DPP compared three approaches -- lifestyle modification, treatment with metformin, and standard medical advice -- in 3,234 overweight people at high risk of developing diabetes. Patients who received standard medical advice and a sugar pill (placebo) developed diabetes at the highest rate (red bars). Patients in the metformin group also developed diabetes, but the overall rate was about 31 percent less than in the placebo group (yellow bars). Finally, the lifestyle intervention group, the individuals who lowered their caloric intake and walked about 30 minutes per day 5 times a week, showed the most dramatic improvement, with an overall 58 percent decrease of diabetes cases compared to placebo (blue bars). These improvements were seen across all racial and ethnic groups, and in participants of all ages. This study provides hope to all those prone to develop type 2 diabetes because it demonstrates that small changes in lifestyle could delay or prevent this disease. The NIDDK is currently following DPP participants to explore the durability of the interventions in preventing or delaying type 2 diabetes and cardiovascular disease. We are also vigorously disseminating the prevention message of the DPP, with the hope that more individuals will also benefit from these lessons learned.
For those who develop the disease, diabetes can damage nearly every organ system and is the leading cause of kidney failure, adult-onset blindness, lower limb amputations, and cardiovascular disease, including heart disease and stroke. Diabetes can also lead to liver disease, impaired wound healing and skin ulcers, periodontal disease, depression, pregnancy-related complications, and urologic complications. Illustration credit: F. Netter, MD, C. Machado, MD, and ICON Learning Systems. Netter medical illustration adapted with permission of Elsevier. All rights reserved.
One of the devastating complications of diabetes is kidney damage. Early kidney disease has no symptoms, and can progress to kidney failure with little or no warning if left undetected. Chronic kidney failure – so-called “end-stage renal disease” or ESRD -- occurs when the kidneys are no longer able to filter toxins from the blood. People with ESRD must receive either hemodialysis or a kidney transplant to survive. Diabetes is the number one cause of ESRD in the U.S.
These maps show the distribution of people with end-stage renal disease in the U.S. in 1993 and 2003. As was the case with obesity and type 2 diabetes, the prevalence of ESRD has risen dramatically in the past several years. However, there has been some recent, encouraging news that incidence rates are stabilizing, at least among some populations. This data is collected by the U.S. Renal Data System, or USRDS. The USRDS is a national data system that collects, analyzes, and distributes information about end-stage renal disease (ESRD) in the United States. The USRDS is funded directly by the NIDDK in conjunction with the Centers for Medicare & Medicaid Services. Note: Maps indicate December 31 point prevalent ESRD patients; rates adjusted for age, gender, and race.
Almost half a million Americans were treated for ESRD in 2004. Together, diabetes and high blood pressure account for about 70 percent of new cases of kidney failure. Minority ethnic groups such as African Americans, Hispanics, American Indians, and Native Hawaiians are disproportionately affected by ESRD. African Americans are nearly four times more likely to develop kidney failure than Caucasians.
However, we do have some good news to report about ESRD. Recently there has been a leveling off in the rate of new cases of ESRD. The green bars in this graph represent the rate of ESRD per million people in the U.S. The blue lines represent the percent change in ESRD from the previous year. The leveling of ESRD rates has occurred despite demographic factors -- such as increased diabetes and aging of the population -- that would tend to increase rates of ESRD. Rates adjusted for age, gender, & race. US Renal Data System 2005 Annual Report.
Credit for these recent gains likely goes to clinical strategies proven in the 1990s to significantly delay or prevent kidney failure. These include the use of angiotensin-converting enzyme inhibitors (ACE-inhibitors) and angiotensin receptor blockers (ARBs), which lower protein in the urine and are thought to directly prevent injury to the kidneys’ blood vessels; as well as careful control of diabetes and blood pressure. NIH research has demonstrated the value of these approaches in clinical trials. However, the overall improvement in the ESRD landscape is not seen in all Americans with the disease.
This graph illustrates the magnitude of the problem we still face in combating ESRD in the U.S. While incidence is dropping among Caucasians between the ages of 20 and 29, it continues at extremely high levels among African Americans in this age group. NIDDK-supported research programs are aimed at understanding the reasons for this disparity and closing this gap. Rates adjusted for age, gender, & race. US Renal Data System 2005 Annual Report
As we have seen with ESRD, it is possible – with insights gained from NIH-supported research – to successfully treat and prevent some complications of type 2 diabetes. I’d like to tell you a little about our successes in preventing some of the other complications of the disease. Damage to the small blood vessels at the back of the eye – microvascular damage – can lead to a condition called diabetic retinopathy. Diabetes is the leading cause of adult-onset blindness in the U.S. However, thanks to a landmark study of patients with type 1 diabetes, we know that tight control of blood glucose levels can prevent this damage and preserve eyesight. Damage to the larger blood vessels of the body – macrovascular damage – can lead to cardiovascular disease (CVD). We now know that tight control of blood glucose can dramatically lower the risk of heart disease and stroke. Finally, the Diabetes Prevention Program (DPP) clinical trial showed that development of type 2 diabetes could be prevented or delayed in high-risk individuals through either drug treatment or a lifestyle intervention that included reduced caloric intake and increased exercise.
NIH-supported clinical trials have shown that tight control of blood sugar levels prevents or delays the complications of diabetes. Here we see that tight control of blood sugar can prevent diabetic eye disease. This is data from the landmark Diabetes Control and Complications Trial (DCCT) was a clinical trial sponsored by the NIDDK between 1983 and 1993. In this trial, 1,441 patients with type 1 diabetes were randomized to either standard therapy or intensive control of blood glucose. This graph shows that, in patients who controlled their blood sugar aggressively, the risk of developing diabetic eye disease was 76 percent lower. The findings of this trial paved the way to studies that replicated these impressive results in type 2 diabetes patients.
Heart complications of diabetes can also be prevented with intensive treatment. The Epidemiology of Diabetes Interventions and Complications Study (EDIC) has continued to follow the participants in the DCCT. EDIC investigators recently reported that intensive control lowers the risk of heart disease and stroke by about 50 percent. These findings underscore the importance of good control of blood sugar in the short and long term. Again, these findings in type 1 diabetes patients have been replicated in type 2 diabetes patients as well, because both forms of the disease share the same possible complications in terms of damage to the kidneys, eyes, nerves, heart, and other organs. The results of this trial underscore the fact that because of pioneering research in type 1 diabetes, close control of blood glucose levels is now a keystone to the medical management of both forms of the disease. Moreover, this landmark trial in type 1 diabetes also established the value of hemoglobin A1c (HbA1c) levels -- a measurement of blood glucose levels over time -- as an outcome measure for future clinical trials in both type 1 and type 2 diabetes, dramatically shortening the cost and duration of new trials of new therapies and encouraging development of new therapies of diabetes. The use of HbA1c as an outcome measure was the basis for approval of improved forms of injected insulin, inhaled insulin, and several new classes of oral drugs for type 2 diabetes, which used in combination can delay the need for insulin therapy. Figure adapted from N Engl J Med 353: 2643-2653, 2005.
Much NIH and NIDDK research is driven by a robust strategic planning process. These plans arise from a consultative, deliberative process that includes input from NIH staff, expert scientists and clinicians from outside the NIH, and community stakeholders.
The NIH has taken a proactive approach to the prevention and treatment of obesity. In April 2003, the NIH Director established the NIH Obesity Research Task Force. The Task Force is co-chaired by the Director of the NIDDK and by the Director of the National Heart, Lung, and Blood Institute. In 2004, the group developed a Strategic Plan for NIH Obesity Research with input from external scientists and the public. The Strategic Plan guides coordination of obesity research activities across the NIH and for enhances the development of new research efforts based on identification of areas of greatest scientific opportunity and challenge. The plan is available at http://obesityresearch.nih.gov The Strategic Plan represents a cohesive, multi-dimensional research agenda for addressing the problem of obesity. The Plan is organized around four major themes: Preventing and treating obesity through environmental changes, including lifestyle adjustments; Preventing and treating obesity using medical, surgical, and other interventions; Understanding and perhaps breaking the link between obesity and its associated health complications; and Cross-cutting topics.
The Diabetes Research Working Group (DRWG) was an independent panel composed of twelve scientific experts in diabetes and four representatives from the lay diabetes community. It developed a Strategic Research Plan that focused on five areas of “extraordinary research opportunity:” Genetics of Diabetes and Its Complications Autoimmunity and the Beta Cell Cell Signaling and Cell Regulation Obesity Clinical Research and Clinical Trials of Critical Importance Pictured above is the cover of an NIDDK report on progress made in implementing the recommendations of the DRWG. The full report is available at http://www.niddk.nih.gov/federal/dwg/2002/dwg02.htm
The NIDDK and the Council of American Kidney Societies have recognized the need to identify research priorities and the potential synergistic benefits of collaborating on a strategic plan. Led by the American Society of Nephrology (ASN), the Council and NIDDK sponsored Strategic Planning Conferences on Renal Research Priorities. Participants identified important scientific resources that would be needed to reach research goals, including: · Conducting More Epidemiological Studies; · Creating Centers and Cooperatives; · Creating New Ways to Study Renal Injury; · Focusing More on Genetic Susceptibility; · Developing a Renal Genomics Project; · Increasing Research on Treatments; and · Improving Grant Review at the National Institutes of Health. The full plan is available at http://www.niddk.nih.gov/fund/other/archived-conferences/1999-1997/wholeRDRC.pdf
The NIH and the NIDDK are taking steps to disseminate the knowledge gained from research studies to health care practitioners and to the public at large. Shown here is a small sample of the educational materials produced by various programs. Many of these items are available in multiple languages.
NIDDK’s Weight-control Information Network (WIN) provides the general public, health professionals, the media, and Congress with up-to-date, science-based information on weight control, obesity, physical activity, and related nutritional issues. It features publications and resources on nutrition, physical activity, and weight control. More information is available at http://win.niddk.nih.gov/index.htm
The National Diabetes Education Program is a U.S. Department of Health and Human Services program sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention. Over 200 public and private partners support the NDEP and help promote its messages. The goal of the NDEP is to translate scientific research into easy-to-understand materials to help both people with diabetes and people at risk for diabetes live longer, healthier lives. More information is available at http://www.ndep.nih.gov/
Education programs of the NDEP several aimed at encouraging people to take an active role in the management and treatment of their diabetes. Control Your Diabetes. For Life. promotes the importance of optimal blood glucose control. Based on findings from the landmark Diabetes Control and Complications Trial, the campaign has distilled essential information into easy-to-read materials for people with diabetes and their loved ones. Be Smart About Your Heart. Control the ABCs of Diabetes encourages people with diabetes to control not only their blood sugar, but also their blood pressure and cholesterol. The campaign also has been adapted to reach Hispanic/Latino audiences with the message, Si Tiene Diabetes. Cuide su Corazon (If you have diabetes, take care of your heart.) In addition, the campaign message has been adapted in 15 Asian and Pacific Islander languages using the theme, Take Care of Your Heart. Manage Your Diabetes. NDEP’s prevention initiative, Small Steps. Big Rewards. Prevent type 2 Diabetes , is the nation’s first comprehensive campaign to help stem the diabetes epidemic by reaching out to the 41 million Americans with pre-diabetes. Adapted for Hispanic /Latino audiences as Prevengamos la Diabetes tipo 2. Paso a Paso (Prevent type 2 Diabetes. Step by Step). The campaign is also available in 15 Asian and Pacific Islander languages.
The National Kidney Disease Education Program (NKDEP) aims to raise awareness of the seriousness of kidney disease, the importance of testing those at high risk (those with diabetes, high blood pressure, or a family history of kidney failure), and the availability of treatment to prevent or slow kidney failure. More information is available at http://www.nkdep.nih.gov/
I hope that these few examples of NIDDK-funded research convey the vigor and progress of our many research efforts. While it is not possible to list every initiative or program the Institute supports, I believe that the integrated and complementary research and education programs I have outlined illustrate how the Institute, and the NIH, seek to address the serious public health burdens facing the U.S. today. Griffin P. Rodgers, M.D., M.A.C.P. Acting Director, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Department of Health and Human Services
National Institute of Diabetes and Digestive and Kidney Diseases
Research Highlights from the National Institute of Diabetes and Digestive and Kidney Diseases Griffin P. Rodgers, M.D., M.A.C.P. Acting Director
National Institute of Diabetes and Digestive and Kidney Diseases <ul><li>Diabetes, Endocrinology, and Metabolic Diseases; </li></ul><ul><li>Digestive Diseases and Nutrition; and </li></ul><ul><li>Kidney, Urologic, and Hematologic Diseases. </li></ul>The NIDDK conducts and supports basic and applied research and provides leadership for a national program in:
NIDDK’s Research and Dissemination Spectrum “ Bench to Bedside and Beyond”
Organizational Structure of NIDDK’s Three Extramural Scientific Divisions NIDDK KUH Division of Kidney, Urologic, and Hematologic Diseases DDN Division of Digestive Diseases and Nutrition DEM Division of Diabetes, Endocrinology, and Metabolic Diseases
A Paradigm of NIDDK’s Integrated Research Programs Obesity Type 2 Diabetes Kidney Disease
Overweight and Obesity <ul><ul><li>BMI below 18.5 – Underweight </li></ul></ul><ul><ul><li>BMI between 18.5 and 24.9 – Healthy weight </li></ul></ul><ul><ul><li>BMI between 25 and 29.9 – Overweight </li></ul></ul><ul><ul><li>BMI 30 and above – Obese </li></ul></ul><ul><ul><li>BMI below 5th percentile – Underweight </li></ul></ul><ul><ul><li>BMI between 5th and less than 85th – Healthy weight </li></ul></ul><ul><ul><li>BMI between 85th and less than 95th – At Risk of Overweight </li></ul></ul><ul><ul><li>BMI 95th percentile and above – Overweight </li></ul></ul>For Adults For Children and Adolescents
Health Complications of Obesity Phlebitis venous stasis Coronary heart disease Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Gall bladder disease Gout Diabetes Osteoarthritis Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Hypertension Dyslipidemia Cataracts Skin Pancreatitis Cancer breast, uterus, cervix, prostate, kidney colon, esophagus, pancreas, liver Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Stroke Idiopathic intracranial hypertension
Obesity Trends Among U.S. Adults No Data <10% 10-14% 15-19% 20-24 % ≥ 25% 2004 1991
Trends in U.S. Child and Adolescent Overweight 0 5 10 15 20 0 5 10 15 20 Percent Percent 6-11 years old 12-19 years old 1963-1967 1999-2000 2001-2002 2003-2004 1971-1974 1976-1980 1988-1994
Obesity: Gene/Environment Interactions Current environment Past environment Genetic susceptibility Adipocity phenotype (e.g., body mass index)
A Paradigm of NIDDK’s Integrated Research Programs Obesity Type 2 Diabetes Kidney Disease
Two Major Forms of Diabetes <ul><ul><li>Usually diagnosed in childhood, adolescence, or young adulthood </li></ul></ul><ul><ul><li>Body’s immune defense system mistakenly destroys insulin-producing cells in the pancreas (autoimmunity) </li></ul></ul><ul><ul><li>Results in lack of insulin to control blood sugar levels; insulin therapy lifesaving but not a cure </li></ul></ul><ul><ul><li>Historically diagnosed in adults; now in children and adolescents </li></ul></ul><ul><ul><li>Body has reduced sensitivity to insulin </li></ul></ul><ul><ul><li>Therapy increases insulin release/sensitivity; some insulin administration may be required </li></ul></ul><ul><ul><li>Obesity is a serious risk factor </li></ul></ul><ul><ul><li>Can be prevented or delayed by diet and exercise as shown in NIH clinical trials </li></ul></ul>Type 1 Type 2
Estimates of Diagnosed Diabetes Among Adults in the U.S. No Data <4% 4-4.9% 5-5.9% ≥ 6% 1994 2004
Diabetes: Burden of Disease <ul><li>20.8 million Americans ( 7 percent of the U.S. population) have diabetes </li></ul><ul><li>90-95 percent of cases are type 2 diabetes </li></ul><ul><li>Minorities are disproportionately affected by type 2 diabetes </li></ul><ul><li>1 in 3 Americans born in 2000 is predicted to develop diabetes during his or her lifetime (for Hispanic females: 1 in 2 ) </li></ul>
0 10 20 30 40 50 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 People (millions) Year Diagnosed Diabetes in the U.S. Diagnosed (1960-2004) and Projected Diagnosed (2005-2050) Cases Diagnosed cases Projected diagnosed cases
Results from the Diabetes Prevention Program Substantial Reduction in Diabetes in All Race-Ethnic Groups Lifestyle Metformin Placebo/Standard care Cases per 100 person-years 0 3 6 9 12 15 All participants Caucasian African American Hispanic American Indian Asian
Complications Common to Both Type 1 and Type 2 Diabetes Blindness Kidney Disease Stroke Heart Disease Atherosclerosis Foot Ulcers and Amputations Acute complications Chronic complications <ul><li>Dangerously high or low blood glucose </li></ul><ul><li>-> c oma, death </li></ul><ul><li>Affect all major organs </li></ul><ul><li>Develop over time/ exposure to high blood glucose </li></ul><ul><li>Tight control of blood glucose can prevent or delay </li></ul>
A Paradigm of NIDDK’s Integrated Research Programs Obesity Type 2 Diabetes Kidney Disease
End-stage Renal Disease in the U.S. Number of Patients per Million Population 1993 2003
End-stage Renal Disease in the U.S. All Values are for Calendar Year 2004 <ul><li>Prevalence: 472,099 patients were undergoing treatment </li></ul><ul><li>Mortality: 84,252 deaths in patients undergoing treatment for ESRD </li></ul><ul><li>Primary cause: </li></ul><ul><ul><li>Diabetes: 45,871 </li></ul></ul><ul><ul><li>High blood pressure: 28,132 </li></ul></ul><ul><li>Primary treatment: </li></ul><ul><ul><li>Dialysis: 335,963 patients received dialysis </li></ul></ul><ul><ul><li>Kidney Transplant: 16,905 performed </li></ul></ul><ul><li>Minorities are disproportionately affected </li></ul>
End-stage Renal Disease in the U.S. Adjusted Incident Rates & Annual Percent Change
Progress in Combating the U.S. ESRD Epidemic <ul><li>After 20 years of annual increases from 5 to 10 percent, rates for new cases of kidney failure have stabilized </li></ul><ul><li>Better disease prevention methods appear to be responsible </li></ul><ul><ul><li>Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers </li></ul></ul><ul><ul><li>Better glycemic control </li></ul></ul><ul><ul><li>Better blood pressure control </li></ul></ul><ul><li>NIH research has established the value of these interventions </li></ul><ul><li>But, progress has not yet been realized across all U.S. populations </li></ul>
Incident Diabetic End-stage Renal Disease in the U.S. Age 20 to 29 Years 0 5 10 15 20 25 30 35 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year Per million population Caucasian African American
More Insights into Preventing Complications of Diabetes <ul><li>Microvascular damage – retinopathy </li></ul><ul><li>Macrovascular damage – CVD </li></ul><ul><li>Preventing complications by preventing diabetes - DPP </li></ul>
Eye Disease: Intensive Diabetes Treatment Reduces Risk 0 25 50 75 100 Study Years 0 1 2 3 4 5 6 7 8 9 Cumulative Percent Cumulative Incidence of > 3-Step Change Conventional p = 0.001 Intensive
Cumulative Incidence of Nonfatal Myocardial Infarction, Stroke, or Death from Cardiovascular Disease 0.00 0.02 0.04 0.06 Years Since Entry into DCCT/EDIC Study 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Heart Disease: Intensive Diabetes Treatment Reduces Risk Conventional Intensive
Strategic Plan for NIH Obesity Research <ul><li>Research Toward Preventing and Treating Obesity Through Behavioral and Environmental Approaches to Modify Lifestyle, with an Emphasis on Childhood Obesity </li></ul><ul><li>Research Toward Preventing and Treating Obesity Through Pharmacologic, Surgical, or Other Medical Approaches </li></ul><ul><li>Research Toward Understanding the Relationship Between Obesity and Its Associated Health Conditions </li></ul><ul><li>Cross-cutting Topics – Technology, Multidisciplinary/Interdisciplinary Research Teams, Translational Research, Training, Education/Outreach </li></ul>Developed by the NIH Obesity Research Task Force with critical input from external scientists and the public Although listed separately, the first two themes are interdependent. We seek to create an interdisciplinary approach in which lifestyle interventions are informed by an understanding of the basic biological and genetic factors and vice versa.
Conquering Diabetes: A Scientific Progress Report on The Diabetes Research Working Group’s Strategic Plan <ul><li>Genetics </li></ul><ul><li>Autoimmunity and the Beta Cell </li></ul><ul><li>Cell Signaling and Cell Regulation </li></ul><ul><li>Obesity </li></ul><ul><li>Clinical Research and Clinical Trials of Critical Importance </li></ul>Highlights of Program Efforts, Research Advances and Opportunities related to:
Progress and Priorities: Renal Disease Research Plan <ul><li>Important scientific resources needed to reach research goals include: </li></ul><ul><li>Conducting More Epidemiological Studies </li></ul><ul><li>Creating Centers and Cooperatives </li></ul><ul><li>Creating New Ways to Study Renal Injury </li></ul><ul><li>Focusing More on Genetic Susceptibility </li></ul><ul><li>Developing a Renal Genomics Project </li></ul><ul><li>Increasing Research on Treatments </li></ul>
Examples of NIH and NIDDK Education and Outreach Programs
The Weight-control Information Network (WIN) is an information service of the NIDDK. WIN was established in 1994 to provide the general public, health professionals, the media, and Congress with up-to-date, science-based information on obesity, weight control, physical activity, and related nutritional issues. WIN produces, collects, and disseminates materials on obesity, weight control, and nutrition. Weight-control Information Network
National Diabetes Education Program The National Diabetes Education Program (NDEP) is a federally funded program sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, working together to reduce the morbidity and mortality associated with diabetes.
Components of the National Diabetes Education Program <ul><li>Control Your Diabetes. For Life. - To promote the importance and benefits of diabetes control </li></ul><ul><li>Be Smart About Your Heart. Control the ABCs of Diabetes - Encourages control of blood sugar, blood pressure, and cholesterol </li></ul><ul><li>Small Steps. Big Rewards. Prevent type 2 Diabetes - Translate and promote the Diabetes Prevention Program (DPP) clinical trial findings </li></ul>
National Kidney Disease Education Program The National Kidney Disease Education Program (NKDEP) is an initiative of the National Institutes of Health, designed to reduce the morbidity and mortality caused by kidney disease and its complications. N KD EP