International symposium of Endocrinology and Metabolism 2019 - Diabetes and Obesity in Asia - Taipei, Taiwan November 2, 2019.

1. Obesity from Home:
The Story of the ASEAN
Metabolic Diaspora
International Symposium on Endocrinology & Metabolism 2019
Diabetes and Obesity in Asia
November 2, 2019 - Chang Yung-Fa Foundation
International Convention Center, Conference Room 1001, Taiwan (ROC)
Jeremy F. Robles, MD, FPCP, FPSEDM
President, Philippine Society of Endocrinology, Diabetes & Metabolism
Scientific Chair, 20th ASEAN Federation of Endocrine Society Congress (Manila)

2. ASEAN
Association of Southeast Asian Nations (ASEAN) is
a regional organization of 10 Southeast Asian and
Pacific Rim countries whose governments
collaborate to promote socio-cultural, economic,
and political advancement in the region.

3. Understanding ASEAN
• Ten member states form an economic powerhouse.
• ASEAN is not a monolithic market. Complex and diverse.
• Macroeconomic stability has provided a platform for growth.
• ASEAN is a growing hub of consumer demand.
• ASEAN is well positioned in global trade flows.
• Intraregional trade could significantly deepen with implementation
of the ASEAN Economic Community, but there are hurdles.
• ASEAN is home to many globally competitive companies.

4. June 2017 March 2018
Realities of ASEAN Obesity

5. Overweight & Obese in the ASEAN Region
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on
Food Innovation for Improved Nutrition

6. Overweight & Obese in the ASEAN Region
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

7. Overweight & Obese in the ASEAN Region
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

8. What’s driving the Philippine Economy Forward?
External Factors keep the Philippine Economy Afloat

9. Overweight & Obese in the Philippines
DOST - FNRI EXPANDED NATIONAL NUTRITIONAL SURVEY 2018

10. Overweight & Obese in the Philippines
DOST - FNRI EXPANDED NATIONAL NUTRITIONAL SURVEY 2018

11. Diabetes & Pre-diabetes in the Philippines
DOST - FNRI EXPANDED NATIONAL NUTRITIONAL SURVEY 2018

14. Almost double the healthcare spending between 2017 to 2025 . . .

15. Clustering of patients of concern beyond the age of 65 . . .

19. GLOBALIZATION
is the word used to describe the growing
interdependence of the world’s economies,
cultures, and populations, brought about by cross-
border trade in goods and services, technology,
and flows of investment, people, and information.

20. IMMIGRANT
"any person who lives temporarily or permanently in
a country where he or she was not born, and has
acquired some significant social ties to this
country.”

21. Asian American Population
• Asian American population in the United States is
approximately 20 million. (5.6% of the total population)
• Growth of 72% between 2000 and 2015 (11.9 million to
over 20 million) - 2nd largest immigrant population
www.worldpopulationreview.comwww.pewresearch.org

22. Asian American Population
www.worldpopulationreview.com

23. ASEAN Americans and Immigration
www.usasean.org

24. ASEAN Americans and Immigration
www.usasean.org
Last updated: 23 July 2019

25. • N: 2967 Asian Americans 2013-2014 California Health Interview Survey.
• BMI >25 (overweight) & 30 (obese) for non-Asians
• BMI >23 (overweight) for >27.5 (obese) for Asians
• Methodology: Survey - Multiple logistic regression analyses
• Results: 23.3% Asian population was obese, 40% overweight
• 1st Gen lower odds of obesity compared to Whites (OR = 0.34, 95% CI
= 0.26–0.45).
• 2nd Gen (OR = 1.69, 95%CI = 1.10–2.60) and 3rd generation (OR =
2.33, 95%CI = 1.29–4.22) Asians had higher odds of being obese
compared to 1st generation Asians
PLoS One. 2019 Feb 22;14(2)
The influence of Immigrant Generation on Obesity among
Asian Americans in California from 2013 to 2014

26. PLoS One. 2019 Feb 22;14(2)
The influence of Immigrant Generation on Obesity among
Asian Americans in California from 2013 to 2014
• Asian immigrants are less likely to be obese.
• Obesity rate seems to increase the longer Asian immigrants remain in the U.S.
• Acculturation of native born population to the cultural lifestyle and behaviors of
the host country appear to be detrimental.

27. • Average Female and Male immigrants enter the US with BMIs
that are approximately 2% and 5% points lower than native-
born women and men, respectively
• Declining health of immigrants the longer they remain in the US.
• Female immigrants converge to American BMI within 10 years of arrival.
• Male immigrants close a third of the gap within 15 years.
Demography, Volume 43–Number 2, May 2006: 337–360
Unhealthy Assimilation: Why do immigrants converge to
American Health Status Levels?
(National Health Interview Survey)

28. Demography, Volume 43–Number 2, May 2006: 337–360
Unhealthy Assimilation: Why do immigrants converge to
American Health Status Levels?
Overweight
National Health Interview Survey
Obese

29. • Selective Immigration
• Health Care Access
• Income Assimilation
• Acculturation
Demography, Volume 43–Number 2, May 2006: 337–360
Unhealthy Assimilation: Why do immigrants converge to
American Health Status Levels?
Immigrants enter
healthier but then
converge toward health
levels of natives.
Americans are getting
less healthy over time
irrespective of gender and
the health measure
analyzed
“Healthy Immigrant Effect”

30. Asian Americans in the US
• Asian Americans are 3X less likely to be obese compared to Non-
Hispanic Whites.
• Filipinos are 70% more likely to be obese than the overall Asian
American population.
• Lower body mass index (BMI) cutoff as proposed by the World Health
Organization may be more appropriate to use in Asian populations.
• Prevalence of obesity should be placed in the larger context of
immigration and globalization through cross-national comparisons
and examination of acculturation-related factors
Osong Public Health Res Perspect 2013 4(4), 187e193
Prev Med. 2015 April ; 73: 6–9

31. Appropriate BMI for Asian populations & its implications for
policy & intervention strategies
• WHO expert consultation concluded that Asians generally have a higher
percentage of body fat than white people of the same age, sex, and BMI.
• Available data do not necessarily indicate one clear BMI cut-off point for
all Asians for overweight or obesity.
• Observed risk in different Asian populations varies from 22 kg/m2 to 25
kg/m2 ; for high risk it varies from 26 kg/m2 to 31 kg/m2 .
• The consultation identified public health action, points (23.0, 27.5, 32.5,
and 37.5 kg/m(2)) along the continuum of BMI, and proposed methods
by which countries could make decisions about the definitions of
increased risk for their population.
THE LANCET • Vol 363 • January 10, 2004
WHO working group currently reviewing and assessing available data on
the relation between waist circumference and morbidity and the
interaction between BMI, waist circumference, and health risk. www.assessmentpsychology.com (WHO)

32. Using appropriate body mass index cut points for
overweight and obesity among Asian Americans
J. Jih et al. / Preventive Medicine 65 (2014) 1–6
Asian BMI cut points of 23 kg/m2 for overweight & 27.5 kg/m2 for obesity may better
correspond to the public health impact of overweight/obesity among Asian
Americans

33. Body Mass Index Values
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

34. INTERVENTION
"The act or fact of becoming involved
intentionally in a difficult situation”

36. General Interventions
• Target food intake show high promise in terms of impact
(reducing obesity) at both the individual and population
level.
• Physical activity plays an important role in preventing and
reducing obesity, and governments can positively influence
people’s access to exercise facilities.
• Food labelling that can have a greater impact on
consumers and help them make informed choices.
• Alliances between government, the health community and
the food and beverage industry are being trialled globally
and will be critical to success.

37. General Interventions
• Early child-focused obesity measures.
• Emphasis on Education campaigns targeting cultural
challenges, including the presence of unhealthy ingredients
in national dishes and social norms that consider fat a sign
of health in children. Simple educational campaigns and
more effective food labelling can help to tackle
complacency and promote healthier choices.
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

38. General Interventions
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
Body of evidence for Anti-obesity drugs is strong but medium magnitude of population.

39. Specific Interventions
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

40. WEIGHT
A1C

41. The Look AHEAD (Action for Health in Diabetes) Trial
• Showed that we could produce modest weight loss and improve
physical activity over time in these individuals with type 2 diabetes.
• Improvements noted on lipids, blood pressure, sleep apnea,
renal disease, fitness, depression
• Did not show was a reduction in cardiovascular events and
death. (PRIMARY OUTCOME)
• Even with the relative maintenance of weight losses in the study,
A1C levels worsened through the follow-up period.

42. General Interventions
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

43. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Non Pharmaceutical Management of Obesity
A variety of dietary approaches that differ widely in macronutrient composition, can lead to weight loss provided
they induce an adequate energy deficit. The guidelines recommended potential contribution to the
management of obesity-related coexisting disorders (e.g., type 2 diabetes and hypertension).

44. ADA Recommendations for Obesity & Diabetes
Diabetes Care 2019;42(Suppl. 1):S46–S60
Diabetes Care 2019;42(Suppl. 1):S81–S89
• Diet - food restriction effective if leads to energy deficit ; consider meal replacements
• Intensive behavioral lifestyle - >/= 16 sessions on diet/first 6 mos, activities, strategies
• Pharmacotherapy - consider DM meds with weight loss effect as adjunct
• Metabolic Surgery - surgical candidates with BMI >/= 40 kg/m2 (BMI >/= 37.5 kg/m2 in
Asian Americans) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian
Americans) ; done in high volume centers, multidisciplinary team with long term support.

45. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Medical Management of Obesity
Medications Approved by the Food and Drug Administration for Long-Term Weight Management.

46. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
Peptides 100 (2018) 61–67
Medical Management of Obesity (GLP-1)
GLP-1 and Cardiovascular Trials
GLP-1 Clinical and Structural Characteristics

47. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Medical Management of Obesity
The median percentages of participants who had a weight loss of at least 5% or 10% with each of five medications
approved for long-term weight management are from a meta-analysis by Khera et al. Data on the percentage of
participants with weight loss at 1 year of at least 15% of their initial weight were available for the Look AHEAD study
(16%), the DPP trial (11%), liraglutide (14%), phentermine–topiramate (32%), and naltrexone–bupropion (14%).

48. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Medical vs Surgical Management of Obesity
Weight Loss at 1 Year with Bariatric Surgery and Lifestyle Interventions as Compared with
Lifestyle Interventions Alone.
laparoscopic adjustable gastric banding (LAGB); medical therapy and a lifestyle
intervention (MT/LI), Roux-en-Y gastric bypass (RYGB), vertical-sleeve gastrectomy (VSG).

49. DIABESITY
"obesity associated with diabetes :
the state of being very overweight or obese and of
having type 2 diabetes or one of the conditions
(such as insulin resistance) that precedes it”

50. Congestive Heart Failure/ Stroke/
Chronic Kidney Disease
Adiposity to Major Risk Factors
and Common Chronic Disease
NEJM 376:3 January 19, 2017
Diabesity

51. INTERPLAY OF HORMONES
Am J Physiol Heart Circ Physiol 288: H2031–H2041, 2005
INSULIN RESISTANCE ENDOTHELIAL DYSFUNCTION

52. INTERPLAY OF HORMONES
Am J Physiol Heart Circ Physiol 288: H2031–H2041, 2005
It’s a bit more
complicated.

53. IDF DIABETES ATLAS
Eighth edition 2017
EXECUTIVE SUMMARY
9
South & Central
America
Colour palette // Regions Colour palette // 6 colour way 3 colour way // Tables in Appendices Brand Colours
Africa
South
East Asia
Western
Pacific
increase
35%
increase
110%
North America
& Caribbean
2045
62million
46million
2017
Europe
Middle East
& North Africa
Number of people with diabetes worldwide and per region in 2017 and 2045 (20-79 years)
Diabetes by age (20-79 years)
2045
82 million
39million
2017
increase
16%
2045
67million
58million
2017
increase
15%
increase
84%
2045
183million
159million
2017
2045
151million
82million
2017
increase
156%
increase
62%
2045
41million
16million
2017
2045
42million
26million
2017
WORLD
2045
629million
425million
2017
increase
48%
2017
327 million
20-64 years
98 million
65-79 years
2045
438 million
20-64 years
191 million
65-79 years

54. • The ASEAN region consist of culturally diverse countries with
distinct profiles. Economically presenting with extremes of the
spectrum.
• Migration patterns are driven by need to improve social standing.
This presents opportunities and risk for the migrating and
receiving communities.
• Asian American immigrants adopt to native-born lifestyle
behaviours that have important health implications. Lower BMI
cutoff as proposed by the World Health Organization may be
more appropriate to use in Asian populations.
• Health issues centered on obesity are on the rise. Prevalence of
obesity should be placed in the larger context of immigration and
globalization.
Summary

55. • Obesity increases the risk for cardio-metabolic disease. This
increases the financial burden due to greater health care
consumption and/or productivity loss.
• International Diabetes guideline now target obesity management.
2 key drugs used are GLP-1 agonists and SGLT-2 inhibitors.
• International Diabetes guideline now target Obesity
management. 2 key drugs used are GLP-1 agonists and SGLT-2
inhibitors.Surgical management of obesity may be effective and
curative for some diabetic patients. Limited centers and
prohibitive costs in the Philippines.
• Combination of non-pharmacologic, pharmacologic and surgical
procedures may be warranted in severe cases.
Summary

56. Summary
• Fat cells play a central role in the pathophysiology of
diabetes and obesity. Key mechanisms include insulin
resistance and endothelial dysfunction.
• Diet and exercise still play an important role in the
management. Weight loss can be sustained but
diabetes progression continues.
• Behavioral lifestyle intervention is a powerful tool to
initiate weight loss and maintenance. ( Individual and
peer intervention)
• Dietary goal of 500 - 750 kcal/day energy deficit with
caloric limits adjusted to baseline BMI.

57. November 21-23, 2019 Philippine International Convention Center, Manila

61. Obesity from Home:
The Story of the ASEAN
Metabolic Diaspora
International Symposium on Endocrinology & Metabolism 2019
Diabetes and Obesity in Asia
November 2, 2019 - Chang Yung-Fa Foundation
International Convention Center, Conference Room 1001, Taiwan (ROC)
Jeremy F. Robles, MD, FPCP, FPSEDM
President, Philippine Society of Endocrinology, Diabetes & Metabolism
Scientific Chair, 20th ASEAN Federation of Endocrine Society Congress (Manila)