7. Age-adjusted Prevalence of Obesity and Diagnosed
Diabetes Among US Adults
Obesity (BMI ≥30 kg/m2)
No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%
No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
31. Thank You For Your Attention
Constance Brown-Riggs, MSEd,
RD, CDE, CDN
Nutrition Consultant – Certified
100 Veterans Blvd, Suite 15
Massapequa, NY 11758
2002 - The American Diabetes Association defines prediabetes as impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). IFG is defined as a fasting blood glucose of 100-125 mg/dl, and IGT is defined as a glucose level from 140 mg/dl – 199 mg/dl two hours after consuming a glucose-rich drink. Later, A1C levels of 5.7% to 6.4% are also used to identify individuals with prediabetes. - See more at: http://www.diabetes.org/research-and-practice/student-resources/history-of-diabetes.html#sthash.hMmwOYu8.dpuf
Development of diabetes from normal glucose tolerance is a continuous process. The first stage is characterized by insulin resistance accompanied by a compensatory increase in insulin secretion; this stage can last several years. Patients with both IFG and IGT have insulin resistance, but the site of their predominant insulin resistance differs. Those with IFG have predominantly hepatic insulin resistance, whereas those with IGT have predominantly muscle insulin resistance.
In 2012, 86 million Americans age 20 and older had prediabetes; this is up from 79 million in 2010. - See more at: http://www.diabetes.org/diabetes-basics/statistics/#sthash.MegjuhLC.dpuf
Criteria for the diagnosis of diabetes
1. A1C 6.5%. The test should be performed in a laboratory using a method that is NGSP
certified and standardized to the DCCT assay.*
2. FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
3. 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be
performed as described by the World Health Organization, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water.*
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random
plasma glucose 200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing.
Because of this unprecedented parallel rise of obesity and diabetes many experts refer to them as a single problem. In fact, Shape Up America—founded by former United States Surgeon General C. Everett Koop to raise awareness of the adverse health effects of obesity—trademarked the term diabesity to denote the causal link between obesity and type 2 diabetes.3
Diabesity is associated with the long-term complications of diabetes such as myocardial infarction, cerebrovascular stroke, end stage renal disease, a reduction in health-related functioning, decreased quality of life, and reduced overall life expectancy. Chronic stress, depression, and sleep disturbances also have been linked to diabesity.
Several randomized clinical trials have shown that individuals at high risk for developing diabetes (ie, those with impaired fasting glucose [IFG] or impaired glucose tolerance [IGT], or both) can be given interventions that significantly decrease rate of onset of diabetes
The encompassing theme of lifestyle intervention programs is to change the modifiable risk factors of prediabetes and diabetes by targeting obesity with increase in physical activity and dietary changes. The two largest diabetes prevention studies, the United States DPP and the Finnish Diabetes Prevention Study (DPS) have both shown beneficial effects of lifestyle interventions. World J Diabetes 2015 March 15; 6(2): 296-303
In 1986, the Da Qing study screened 110,660 adults from 33 health care clinics for impaired glucose tolerance (IGT) and type 2 diabetes mellitus
Using World Health Organization (WHO) criteria, 577 men and women were classified as having IGT and randomized by clinic to either a control group (n=138) or one of three lifestyle interventions (n=438)
The mean age of the control group was 46.6 years and included 79 men and 59 women; in the active treatment groups combined, mean age was 44.7 years and there were 233 men and 205 women
The goal of the diet only intervention was to increase vegetable intake and lower alcohol and sugar intake; those overweight or obese were also encouraged to lose weight by reducing total calorie intake
The goal of the exercise intervention was for participants to increase leisure time physical activity
Those in the diet + exercise group applied the goals from both the diet only and exercise only intervention groups
The effect of the intervention was assessed at 2-yearly intervals for 6 years to determine incidence of type 2 diabetes
At 6 years, the cumulative incidence of diabetes was significantly decreased in each of the active intervention groups compared with the control group
The percentage decrease in diabetes incidence and 95% confidence intervals are summarized in the Table
The diet + exercise lifestyle intervention led to the most significant decrease, followed by diet alone and then exercise alone
Control: 67.7% (95% CI, 59.8-75.2)
Diet + exercise: 46.0% (95% CI, 37.3-54.7)
Diet: 43.8% (95% CI, 35.5-52.3)
Exercise: 41.1% (95% CI, 33.4-49.4)
When data from each of the 33 clinics were analyzed, each active intervention group was found to differ significantly from those of the control clinic (P<0.05).
The Da Qing study concluded that among those with IGT, the lifestyle interventions of diet and/or exercise led to a significant decrease in the incidence of diabetes over a 6-year period 1
For the 1986-1992 period, incidence (per 100 person years per year) of diabetes was 14.1 (95% CI, 11.2-17.0) in the control group, compared with 7.9 (95% CI, 6.8-9.1) in the lifestyle intervention groups2
In the Finnish Diabetes Prevention Study, 522 overweight (BMI ≥25 kg/m2) men and women ages 40 to 65 years with impaired glucose tolerance (IGT, defined as plasma glucose concentration 140-200 mg/dL 2 hours following an oral glucose challenge) were randomly assigned to either a control group or to a lifestyle intervention group
In the control group, 91 men and 174 women were given general oral and written information about diet (a 2-page leaflet) and exercise at baseline and at annual visits - No specific individualized programs were offered - A 3-day food diary was completed at baseline and at each annual visit; nutrient intakes were computed
In the intervention group, 81 men and 176 women were given detailed advice about how to achieve the goals of the intervention, which were to
Reduce weight by 5% or more - Reduce total intake of fat to <30% and saturated fat to <10% of energy consumed - Increase fiber intake to at least 15 g/1,000 kcal
Moderate exercise for at least 30 minutes/day
Dietary advice was tailored to each subject on the basis of 3-day food records completed 4 times annually; participants had 7 sessions with a nutritionist during the first year of the study and 1 session every 3 months thereafter and received individual guidance on increasing level of physical activity
Primary end point was diagnosed diabetes: a FPG of 140 mg/dL or higher or a plasma glucose concentration of 200 mg/dL or higher 2 hours following an oral glucose challenge
The objective of the Finnish Diabetes Prevention Study was to determine the feasibility and effects of lifestyle changes designed to prevent or delay the onset of type 2 diabetes in those with IGT
Mean duration of study follow-up was 3.2 years
At the end of Year 1, weight loss was 0.8±3.7 kg (mean±SD) in the control group and 4.2±5.1 in the intervention group; at Year 2, weight loss was 0.8±4.4 kg in the control group and 3.5±5.5 in the intervention group (P<0.001 for both comparisons between groups)
After 4 years, the cumulative incidence of diabetes was 11% (95% CI, 6-15) in the intervention group compared with 23% (95% CI, 17-29) in the control group
Cox regression analysis of all person-years accumulated results in a cumulative incidence of diabetes that was 58% lower in the intervention group than in the control group (hazard ratio, 0.4; 95% CI, 0.3-0.7; P<0.001)
Among those in the intervention group, incidence of diabetes was 63% lower among men (95% CI, 18-79; P=0.01) and 54% lower among women (95% CI, 26-81; P=0.008)
The authors concluded that type 2 diabetes can be prevented by changes in the lifestyles of high-risk subjects, defined as those with impaired glucose tolerance, which represented an intermediate category between normal glucose tolerance and overt diabetes
Strong evidence suggests modifiable risk factors (eg, obesity, physical inactivity) are the primary nongenetic determinants of type 2 diabetes
Results of this study have found that to prevent 1 case of diabetes, 22 subjects with IGT must be treated with lifestyle intervention for 1 year, or 5 subjects for 5 years
From 1996-1999, the Diabetes Prevention Program Research Group randomly assigned 3,234 nondiabetic persons at high risk for diabetes (eg, with elevated fasting and postload plasma glucose concentrations) with a BMI ≥24 kg/m2 (or ≥22 kg/m2 in Asians) to
Standard lifestyle + placebo (n=1082)
Standard lifestyle + metformin (initiated at 850 mg orally once daily and, at one month, increased to twice daily)
Intensive lifestyle intervention (n=1079)
The study initially included a fourth intervention, troglitazone, which was discontinued in 1998 due to the potential for liver toxicity
“Standard lifestyle” included written information and an annual 20-30 minute individual session that emphasized the importance of a healthy lifestyle (eg, follow the food pyramid guide, reduce weight, and increase physical activity)
Primary outcome was diabetes, diagnosed on the basis of an annual oral glucose-tolerance test or a semiannual fasting plasma glucose test
The intensive lifestyle intervention is described on the next slide
This slide describes the goals of the intensive lifestyle intervention arm of the Diabetes Prevention Program study
Subjects were asked to lose 7% of their body weight and maintain it by keeping dietary fat to 25% of calories, which were calculated at 1200-1800 kcal/day based on a patient’s initial body weight, and to engage in physical activity at least 150 minutes weekly
The fat and calories goals were used to achieve weight loss, rather than as specific goals
A 16-lesson curriculum designed to help participants achieve their goals was taught on a one-to-one basis during the first 24 weeks following enrollment and was individualized
Subsequent individual (monthly) and group sessions helped to reinforce behavioral changes
Reduced risk of developing diabetes by 31%. Efficacy greater in those with higher baseline FPG and BMI and if younger
About 7.8% developed diabetes each year during the study, compared with 11% of the group receiving placebo
The DPP’s results indicate that millions of high-risk people can delay or avoid develop- ing type 2 diabetes by losing weight through regular physical activity and a diet low in fat and calories. Weight loss and physical activity lower the risk of diabetes by improving the body’s ability to use insulin and process glucose. The DPP also suggests that metformin can help delay the onset o
The Da Qing study 20-year follow-up assessed the long-term effect of interventions
Primary outcomes: diabetes and CVD incidence, mortality, all-cause mortality
Compared with the control arm, combined lifestyle intervention resulted in a 51% lower incidence of diabetes during active intervention and a 43% lower incidence over 20 years, which translated to 3.6 fewer years with diabetes
The 20-year cumulative incidence of diabetes was 93% in the controls vs 80% among those who received the combined lifestyle intervention
After an average of 10 years follow up treatment with metformin
Reduced rate of developing type 2 diabetes by 18% vs placebo
Delayed type 2 diabetes by approx 4 years compared with placebo
Reduced cardiovascular risk factors
To date, the focus of diabetes prevention has been placed on lifestyle interventions to modify adult behaviour, particularly obesity related unhealthy diets and physical inactivity. But a compelling body of evidence now indicates that many of the risks leading to type 2 diabetes originate in the very early stages of life, influenced by maternal under- or over-nutrition, diabetes in the mother and the fetal and post-natal environment.
A combination of epidemiology studies in human populations and a better understanding of the epigenetic process now indicates that diabetes may be triggered by events in the womb. Early life influences, such as maternal under- or over-nutrition, low birthweight and newborn over- feeding, increase the risk of obesity and associated diseases such as diabetes and cardiovascular disease in the offspring later in life.
Therefore, the prevention of diabetes must start with a healthy pregnancy. The health of mothers before and during pregnancy, and nutrition and growth in fetal and early postnatal life, have profound effects on vulnerability to diabetes later in life.
Consistent with this modern science, the 2015 Dietary Guidelines Advisory Committee Report emphasizes food-based, healthful diet patterns as a primary recommendation to address obesity.
For example, the intake of yogurt, but not milk, is consistently associated with lower incidence of diabetes mellitus, whereas the intake of cheese, which has high calorie, fat, and saturated fat content, is also associated with lower diabetes risk in several although not all studies. Although total milk intake is generally unassociated with diabetes mellitus, fermented milk is linked to lower risk, suggesting a potential influence of fermentation, particularly in light of the separate findings for cheese.
Just as the science of cardiovascular risk is moving away from theories based on single-nutrient components and single-surrogate outcomes toward empirical evidence on foods and dietary patterns and clinical events, the science of obesity is moving away from simplistic ideas of energy balance, will power, and calorie counting toward the elucidation of effects of foods and diet patterns on the complex physiological determinants of long-term weight regulation.
In people without diabetes, theDASH eating plan has been shown to help control blood pressure and lower risk for CVD and is frequently recommended as a healthful eating pattern for the gen- eral population (104–106). Limited evidence exists on the effects of the DASH eating plan on health outcomes specifically in individuals with diabetes; however, one would expect similar results to other studies using the DASH eating plan. In one small study in people with type 2 diabetes, the DASH eating plan, which included a sodium restriction of 2,300 mg/day, improved A1C, blood pressure, and other cardiovascular risk factors (46).
Includes abundant plant food (fruits, vegetables, breads, other forms of cereals, beans, nuts and seeds); minimally processed, seasonally fresh, and locally grown foods; fresh fruits as the typical daily dessert and concentrated sugars or honey consumed only for special occasions; olive oil as the principal source of dietary lipids; dairy products (mainly cheese and yogurt) consumed in low to moderate amounts; fewer than 4 eggs/week; red meat consumed in low frequency and amounts; and wine consumption in low to moderate amounts generally
Evidence-based dietary priorities for cardiometabolic health. The placement of each food/factor is based on its net effects on cardiometabolic health, across all risk pathways and clinical end points, and the strength of the evidence, as well. For dietary factors not listed (eg, coffee, tea, cocoa), the current evidence remains insufficient to identify these as dietary priorities for either increased or decreased consumption (see Table 3).