diabetes and obesity in nyc: shadi chamany, md, mph new york city department of health and mental...
TRANSCRIPT
Diabetes and Obesity in NYC:
Shadi Chamany, MD, MPHNew York City Department of Health
and Mental [email protected]
November 7, 2013 Edelstein Diabetes Conference
• General information about obesity and diabetes
• Epidemiology of obesity and diabetes in NYC
• Ways to approach obesity and diabetes
• General resources
Overview
Diabetes—What is It?
• A condition where the body either does not make enough insulin or the insulin it has does not work as well as it should (insulin resistance)
• Insulin moves sugar from the blood into the cells for energy • If there isn’t enough of it or it doesn’t work
right, too much sugar in the blood
• Sugar in the blood comes from food, your body changing other types of nutrients into sugar, and stores your body has
Diabetes—What Are the Complications?
• High sugar damages the blood vessels to certain parts of the body • Eye disease and blindness• Nerve damage• Infections and amputations• Kidney disease which may require dialysis
• Diabetes also increases the risk of heart disease and stroke and has been linked to some cancers• Adults with diabetes have heart disease deaths
rate~ 2-4 times higher than those without
Diabetes—What Are the Complications?
• Type 1 • Usually starts in childhood • Body attacks itself, damaging cells in the pancreas
that make insulin• Always requires insulin
• Type 2• Usually starts in adulthood but see in children now• May or may not need insulin
• Gestational diabetes • Comes during pregnancy and goes away but increases
risk of type 2 diabetes down the road
Common Types of Diabetes
• Type 1 • Environmental exposure??
• Type 2– Overweight/obesity - Age– Physical inactivity - Family history– High blood pressure - Race/ethnicity – High triglycerides - Hx gestational DM – Low HDL (bad cholesterol)
• Gestational diabetes • Overweight/obesity, certain race/ethnic groups,
older age
Risk Factors for Diabetes
• Type 1 • Environmental exposure??
• Type 2– Overweight/obesity - Age– Physical inactivity - Family history– High blood pressure - Race/ethnicity – High triglycerides - Hx gestational DM – Low HDL (bad cholesterol)
• Gestational diabetes • Overweight/obesity, certain race/ethnic groups,
older age
Risk Factors for Diabetes
Prevalence of Self-Reported Diabetes Among NYC Adults
Source: Behavioral Risk Factor Survey System 1993-2001, NYC Community
Health Survey (CHS) 2002-2012; Gupta and Olson. NYC DOHMH. Diabetes in New York City Epi Data Brief, April 2013, no. 26 and https://a816-healthpsi.nyc.gov/epiquery/
Level of Control Among Adults with Diagnosed Diabetes
(NYC data 2004)
Source: Thorpe LE et al. Diabetes Care 2009;32:57-62.
*includes individuals who were undiagnosed with HTN or hyperlipidemia
Level of Control Among Adults with Diagnosed Diabetes (national data 2007-2010)
Casagrande, Sarah Stark, et al. "The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010." Diabetes Care (2013).
Obesity—What is It? • A condition where a person has excess
adipose tissue • Defined using height and weight in the form is the
body mass index (BMI) which works for most1
• Overweight in adults 25-29.9 kg/m2
• Obese in adults 30+ kg/m2
• Obesity is associated with increased risk of certain conditions and mortality1
– Coronary heart disease, stroke, hypertension, dyslipidemia
– Type 2 diabetes (increases insulin resistance)2
– Cancer (endometrial, breast, colon)– Sleep apnea– Osteoarthritis
1. From CDC website http://www.cdc.gov/obesity/adult/causes/index.html 2. Steinberger and Daniels. Circulation 2003;107:1448-1453.
Obesity—How Does It Happen? Energy in > energy used → adipose tissue
– Genetic factors
– Physical inactivity and sedentary behavior• Possibly 2 minutes of stair climbing could prevent
1 lb/yr weight gain1
– Increased consumption of food• Degree of accessibility to certain types of food• Increasing portions sizes • Sugary drinks increase risk of weight gain in
children/adults with growing evidence of downstream effects (diabetes & heart disease) 2-4
1. Zimring AJPM 2005. 2. Malik AJCN 2006. 3. Malik Circulation 2010. 4. Fung ACJN 2009.
People Eat Out More
14
Portion Size Influences Consumption
• Numerous studies show people given larger portions eat more, without recognizing it1-8
– People given beverages 50% larger consumed 20% (women) to 33% (men) more, with no decrease in food eaten9
– People given larger portion sizes of food eat ~20-50% more, without completely reducing intake at subsequent meals4
1. Wansink and Cheney. JAMA 2005;293(14):1727-28. 2. Wansink B. Ann Review Nutr 2004;24:455-79. 3. Rolls BJ et al. J Amer Diet Assoc 2006;106(4):543-49. 4. Ledikwe JH et al. J Nutr 2005;135(4):905-9. 5. Diliberti N et al. Obes Rsrch 2004;12(3):562-68. 6. Rolls BJ et al. AJCN 2002;76(6):1207-13. 7. Wansink B et al. Obes Rsrch 2005;13(1): 93-100. 8. Flood JE et al. J Amer Diet Assoc 2006;106:1984-90. 9. Rolls BJ et al. Obesity 2007; 15:1535-43.
Sugary Drink Consumption Among NYC Adults
NYC CHS 2008-2012
Obesity contributes to conditions with significant years of “healthy”
life lostDALYS or disability adjusted life years
(years life lost + years lived w/ disability) YLL YLD
Ischemic Heart Disease 89,481 81,278 8,203
Major Depression 42,110 0 42,110
HIV 37,495 28,130 9,365
Alcohol Use 35,050 4,475 30,575
Osteoarthritis 29,330 94 29,236
Asthma 27,745 2,974 24,771
Diabetes 26,557 12,690 13,867
Lung Cancer 25,074 23,936 1,138
Cerebrovascular Disease 24,258 12,595 11,663
Hypertension 21,804 17,775 4,029
Source: Perlman and Driver. Disability adjusted life years in New York City. New York City Department of Health and Mental Hygiene. 2011 http://www.nyc.gov/html/doh/downloads/pdf/epi/datatable11.pdf
Obesity contributes to conditions with significant years of “healthy”
life lostDALYS or disability adjusted life years
(years life lost + years lived w/ disability) YLL YLD
Ischemic Heart Disease 89,481 81,278 8,203
Major Depression 42,110 0 42,110
HIV 37,495 28,130 9,365
Alcohol Use 35,050 4,475 30,575
Osteoarthritis 29,330 94 29,236
Asthma 27,745 2,974 24,771
Diabetes 26,557 12,690 13,867
Lung Cancer 25,074 23,936 1,138
Cerebrovascular Disease 24,258 12,595 11,663
Hypertension 21,804 17,775 4,029
Source: Perlman and Driver. Disability adjusted life years in New York City. New York City Department of Health and Mental Hygiene. 2011 http://www.nyc.gov/html/doh/downloads/pdf/epi/datatable11.pdf
• Pre-diabetes is a condition where blood sugar is elevated but not high enough to be considered to be diabetes• Increased risk of developing diabetes—over 5
years, 15-30% will develop diabetes1
• In NYC, 1.3 million adults in NYC have pre-diabetes2
• 72% (960,000) are overweight or obese
Pre-Diabetes
1. CDC. Pre-diabetes. http://www.cdc.gov/diabetes/consumer/prediabetes.htm2. NYC DOHMH. NYC HANES 2004 data analyzed by Bureau of Epidemiology
Services Jan 2012.
• Weight gain contributes to type 2 diabetes1
• For each 1 kg increase, there was a 4.5% increase in the risk of diabetes
• Intensive lifestyle modification has been shown to reduce the risk of developing T2DM in people who are overweight and have pre-diabetes 2
• Excess weight can make diabetes harder to manage• Modest weight loss in people who are overweight
with T2DM can improve insulin resistance, CVD risk factors, and can decrease number of medications3
Weight, Pre-Diabetes, and Type 2 Diabetes
1. Ford et al, AJE 1997;146:214. 2. DPP Research Group, NEJM 2002. 3. ADA. Standards of Medical Care in Diabetes 2013.
Prevalence of Self-Reported Overweight/Obesity Among NYC
Adults
Source: NYC CHS 2002-2012 (age-adjusted)
Prevalence of Self-Reported Overweight/Obesity Among NYC
Adults
Source: NYC CHS 2002-2012 (age-adjusted)
Prevalence of Self-Reported Overweight/Obesity Among NYC
Adults
Source: NYC CHS 2002-2012 (age-adjusted)
Shift in the Distribution of Body Mass Index Among Adults
(nat’l data)
Adapted from : Ogden Cl et al. Obesity among adults in the United States. NCHS Data Brief No. 1, November 2007
ObeseOver-weight
Prevalence of Self-Reported Obesity 2002 vs. 2012 in Adults
NYC CHS 2002 & 2012 age-adjusted; * denotes differences where confidence interval do not overlap
Prevalence of Overweight/Obesity in Public School K-8
Source: NYC FITNESSGRAM data, school years 2008-09, 2009-10, and 2010-11 for NYC public schools students in districts 1-32, grades K-8, and ages 5-14.Prepared by: NYC Department of Health and Mental Hygiene, Bureau of Epidemiology Services
Prevalence of Overweight/Obesity in Public School K-8
Source: NYC FITNESSGRAM data, school years 2008-09, 2009-10, and 2010-11 for NYC public schools students in districts 1-32, grades K-8, and ages 5-14.Prepared by: NYC Department of Health and Mental Hygiene, Bureau of Epidemiology Services
Physical InactivityAdults with no physical activity in past 30 days
NYC CHS 2000-2012 age adjusted; * no data collected for that year
So Now What?
• Decrease access & consumption of unhealthy food
• Increase access & consumption of healthy food
• Increase physical activity and decrease sedentary behavior
• Ensure effective quality of care for diabetes and obesity
Four Goals to Address Obesity and Diabetes
• Decrease access & consumption of unhealthy food
• Increase access & consumption of healthy food
• Increase physical activity and decrease sedentary behavior
• Ensure effective quality of care for diabetes and obesity
1. Maintain healthy weight
2. Modest weight loss if overweight; at a minimum, don’t gain more weight
3. Benefits of physical activity regardless of weight
Four Goals to Address Obesity and Diabetes
NYC DOHMH Activities and Programs We Promote
Promoting Healthier Eating Decreasing access to unhealthy food
• Trans Fat Restriction– Food service establishments
• National Salt Reduction Initiative– Packaged & restaurant foods– 90+ partners and nearly 30
companies have committed to targets
• New York City Food Standards• City agencies and daycare centers
required; other institutions and organizations are adopting on voluntary basis (hospitals, CBOs, FBOs)
• Portion cap rule– Sugary drinks in food service
establishments
Promoting Healthier Eating Increasing access to healthy food
• Green Carts– Permits for mobile vendors in low-
income areas, ~ 500 active permits, ~80 of which accept EBT
• Shop Healthy– Promote healthy food in corner stores
and supermarkets/community outreach (currently in South Bronx
but expanding)
• Farmers Markets– Nutrition workshops and cooking
demos at 20 markets– Health Bucks: $2 coupons for F/V at all
farmers’ markets (EBT accepted); for every $5 customer spends using SNAP, get a $2 coupon
Promoting Physical Activity (run by Dept of Parks and Recreation)
• Shape Up New York
– Free aerobic classes in underserved neighborhoods in parks and community centers and schools
• BeFitNYC– A website with search
engine to find low-cost fitness opportunities across NYC
Promoting Physical Activity
• Active Design Guidelines
– Developers, city planners, and community groups can use; build places and spaces to promote activity
• Play Streets (community and school)
– Increase the frequency of single blocks of streets being closed to cars on a daily or weekly basis for children to play
• Stair prompts
- Facilitate stair use through outreach to building owners, stair access and signage in City Buildings, and better stair designs
Promoting Physical ActivityMove to Improve
• Curriculum developed by DOHMH and Department of Education used to train K-5 teachers with goal of getting kids moving during the day and include academic integration
• Teachers get a manual and equipment
• Thousands of teachers have been trained across hundreds of schools (DOE run)
Promoting Physical Activity and Healthy EatingEat Well Play Hard
• Nutrition workshops for children and caregivers & promotion of physical activity
– Child care centers
– Pre-K-1st grade
– Includes train the trainer model in child care centers
• Thousands reached each year
SOME GENERAL TIPS AND RESOURCES FOR YOU AND
YOUR CLIENTS
(more to come from Lorraine Drago)
General Guidance on Diet (assuming basic nutrition needs are met)
– Little to no sugary drinks (alcohol and mixers count)
– Limit fried foods, desserts, salty chips and snacks
– Less red meat, more fish and chicken– Low fat dairy – Whole grains instead of refined grains– More fruits and vegetables– Avoid seconds and save “half for later”
http://www.nyc.gov/html/doh/downloads/pdf/csi/obesity-plate-planner-13.pdf
CalCutter App (FREE)
• CalCutter has 3 main functions:
– Helps cooks figure out how many calories are in meals
– Offers ways for cooks to reduce calorie counts
• Suggests alternative ingredients, different cooking methods and/or smaller portion sizes
– Displays how many calories from their 2,000 daily allowance remain for other side dishes/meals
http://www.nyc.gov/html/doh/downloads/pdf/csi/obesity-flipchart-15.pdf
http://www.nyc.gov/html/doh/downloads/pdf/csi/obesity-flipchart-15.pdf
http://www.nyc.gov/html/doh/downloads/pdf/csi/obesity-flipchart-15.pdf
http://www.nyc.gov/html/doh/downloads/pdf/csi/obesity-flipchart-15.pdf
General Guidance on Activity (assuming no medical contraindications & tailored to individual)
– Some is better than none
– More benefit accrues with more activity and higher intensity
– Aerobic activity goals• Aerobic:
– Moderate activity totaling 150 min/week, such as brisk walking for 30 minutes
– Vigorous activity totaling 75 min/week– In either situation, using short bouts of activity, OK if
at least 10 minutes at a time
– Muscle-strengthening goals– Moderate or high intensity– Involving two or more muscle groups on 2+ days/week
Source: 2008 Physical Activity Guidelines for American http://www.health.gov/paguidelines/guidelines/summary.aspx
Resources
Healthy Diet ResourcesFarmers Markets https://a816-healthpsi.nyc.gov/DispensingSiteLocator/mainView.do (query system to find a market near you)http://www.nyc.gov/html/doh/downloads/pdf/cdp/farmers-market-map.pdf (map of markets noting which have cooking demonstrations)
Reading labels http://www.nyc.gov/html/doh/downloads/pdf/csi/hyperkit-pt-readlabel-fact.pdf
Salt and sugary drinkshttp://www.nyc.gov/html/doh/downloads/pdf/public/dohmhnews9-07.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/public/dohmhnews8-06.pdf
Green Cartshttp://www.nyc.gov/html/doh/html/diseases/green-carts.shtml
Shop Healthyhttp://www.nyc.gov/html/doh/html/living/shophealthy.shtml
CalCutter apphttp://www.nyc.gov/html/doh/html/media/apps.shtml
Physical Activity Resources
Shape Up NYC
For free classes that you can join across the city, go to http://www.nycgovparks.org/programs/recreation/shape-up-nyc or call 311 and ask for locations
BeFitNYChttp://www.nycgovparks.org/befitnyc
Active Design GuidelinesFor architects and urban designershttp://www.nyc.gov/html/ddc/html/design/active_design.shtml
For community groupshttp://www.nyc.gov/html/doh/downloads/pdf/environmental/active-design-community-guide.pdf
Medication Resource (NYC)
Big Apple Rx A discount program for all New Yorkers to use regardless of insurance status http://www.nyc.gov/html/doh/html/bigapplerx/index.shtml --can save up to 47% on prescriptions
Two steps to access this resource:1)Find a participating pharmacy—either on the website http://www.bigapplerx.com/findpharmacy or calling 800 697 6974
2)Print out a card to use at the pharmacy—either on the website http://www.bigapplerx.com/findpharmacy
or just use this information below
BIN:# 011677, Group: # NYC12, Cardholder ID: 69530
Medication Resource (NYS)
Prescription saver
–A discount program if low income* AND 50-64 years of age or with a disability https://nyprescriptionsaver.fhsc.com/
–Can save up to 60% on generics and 30% on brand name
–Complete an application on line, mail one in, or call 1-800-788-6917
*annual household income <$35,000 if single and <$50,000 if married
Quitting Tobacco
NYS Quit line 1-866-NYQUITS--Free counseling by phone --Smoking cessation medication if eligible
NYC Quits websitehttps://a816-nycquits.nyc.gov/pages/homepage.aspx
