Diabetes and CVD burden in Asia population

National Center for Global Health and Medicine Tokyo, Japan Hiroshi Kajio, M.D., Ph. D/

Diabetes and CVD

Diabetes Population in 2010 and 2030

Europe 58.70 million + 20.0% 66.2 million

Med & Middle East SE Asia West pacific 26.6 million 58.7 million 76.7 million + 93.9% + 72.1% + 47.0% 51.7 million 101 million 112.8 million Africa 1210 + 98.1% 2390

North America 37.4 million + 42.4% 53.2 million

South and Central America 18 million + 65.1% 29.6 million

Total 28.46 million in 2010 43.84 million in 2030

+ 54.0% IDF Map in 2009

Prevalence of DM in 1970-1989 and in 1990-2005

Prevalence of Type 2 diabetes

Multiplication factor for increase prevalence

Relative Risk of CVD In Patients with IGT and DM The Hisayama Study
3.0

Cardiovascular

disease Ischemic heart disease and Stroke Relative risk adjusted for age

2.0

Relative risk adjusted for Age, sex, blood pressure, BMI, ECG abnormality, T-chol, HDL-C, tobacco and alcohol p0.05 vs Normal p0.01 vs Normal

Relative risk of CVD

1.0
Subject: 2,427 residents Age: 40 -79 yrs Previous history: stroke (-) MI (-) Follow-up period: 5 years

Normal n=1,693

IGT n=474

DM n=260
Fujishima M, et al: Diabetes, Vol.45 Suppl 3, S14-S16, 1996

Abnormality of glucose tolerance in patients with CHD

Caucasian AMI Japanese

Norhammar A. et al. Lancet 2002: 359, 2140-44. Satoh H. et al.: Heart 2005: 91: 731-36

Age-standardized death rates per 100 000 for stroke and CHD across countries in different regions of Asia in 2002
Stroke

CHD

Ueshima, H. et al. Circulation 2008;118:2702-2709

CVD Risk Factors

Association of risk factors with acute myocardial infarction in men and women after adjustment for age, sex, and geographic region

Yusuf S etal.: Lancet 2004; 364: 937 52

Risk of acute myocardial infarction associated with exposure to multiple risk factors
Smk=smoking. DM=diabetes mellitus. HTN=hypertension. Obes=abdominal obesity. PS=psychosocial. RF=risk factors.

Yusuf S etal.: Lancet 2004; 364: 937 52

Odds of myocardial infarction according to number of cigarettes smoked and ApoB/ApoA1 ratio

Yusuf S etal.: Lancet 2004; 364: 937 52

Reduced risk of acute myocardial infarction associated with various risk factors
Smk=smoking. Fr/vg=fruits and vegetables. Exer=exercise. Alc=alcohol. Note the doubling scale on the y axis. Odds ratios are adjusted for all risk factors

Yusuf S etal.: Lancet 2004; 364: 937 52

Risk of acute myocardial infarction associated with current or former smoking, overall and by region after adjustment for age and sex
W Eur=western Europe. CE Eur=central and eastern Europe. MEC=Middle East Crescent. Afr=Africa. S=South. HK=Hong Kong. SE=southeast. ANZ=Australia and New Zealand. N=North. Am=America

Yusuf S etal.: Lancet 2004; 364: 937 52

Risk of acute myocardial infarction associated with ApoB/ApoA1 ratio (top vs lowest quintile), overall and by region after adjustment for age, sex, and smoking
PAR is for the top four quintiles versus the lowest quintile

Yusuf S etal.: Lancet 2004; 364: 937 52

Risk of acute myocardial infarction associated with self-reported hypertension, overall and by region after adjustment for age, sex, and smoking

Yusuf S etal.: Lancet 2004; 364: 937 52

Risk of acute myocardial infarction associated with self-reported diabetes, overall and by region after adjusting for age, sex, and smoking

Yusuf S etal.: Lancet 2004; 364: 937 52

Risk of acute myocardial infarction associated with abdominal obesity measured as waist/hip ratio (upper tertile vs lowest tertile), overall and by region after adjusting for age, sex, and smoking
PARs are for top two tertiles vs lowest tertile

Yusuf S etal.: Lancet 2004; 364: 937 52

Risk of acute myocardial infarction associated with the composite psychosocial index, overall and by region

Yusuf S etal.: Lancet 2004; 364: 93752

Cardiovascular risk prediction tool for populations in Asia

Observed and predicted cardiovascular event rate according to deciles of predicted risk using the (A) Framingham risk equation, (B) other Asian risk equation and (C) recalibrated Framingham risk equation.

J Epidemiol Community Health. 2007 February; 61(2): 115121.

Smoking

Trends in smoking rate by sex and by selected Asian countries

Ueshima, H. et al. Circulation 2008;118:2702-2709

Hazard ratios (HRs) associated with a 2 kg/m2 higher body mass index for coronary heart disease events in current smokers and non-smokers, by sex, region, age and overall.
Analyses are adjusted by age and stratified by study and sex. The horizontal lines (or widths of diamonds for overall results) show 95% confidence intervals (CIs). The p values shown are for the test of interaction between body mass index and smoking status. The dashed and continuous lines represent current smokers and non-smokers, respectively. The Asia Pacific Cohort Studies Collaboration BMC Public Health 2009 9:294e

Smoking

Smoking

Hazard ratios (HRs) associated with a 2 kg/m2 higher body mass index for ischaemic stroke events in current smokers and non-smokers, by sex, region, age and overall.

Analyses are adjusted by age and stratified by study and sex. The horizontal lines (or widths of diamonds for overall results) show 95% confidence intervals (CIs). The p values shown are for the test of interaction between body mass index and smoking status. The dashed and continuous lines represent current smokers and non-smokers, respectively. The Asia Pacific Cohort Studies Collaboration BMC Public Health 2009 9:294e

Hazard ratios (HRs) associated with a 2 kg/m2 higher body mass index for haemorrhagic stroke events in current smokers and non-smokers, by sex, region, age and overall.
Analyses are adjusted by age and stratified by study and sex. The horizontal lines (or widths of diamonds for overall results) show 95% confidence intervals (CIs). The p values shown are for the test of interaction between body mass index and smoking status. The dashed and continuous lines represent current smokers and non-smokers, respectively. The Asia Pacific Cohort Studies Collaboration BMC Public Health 2009 9:294 a

Hypertension

Estimated Number of Individuals Aged >20 Years With Blood Pressure >140/90 mm Hg in 2000 and Predicted Number of Affected Individuals in 2025

Region

Prevalence 2000, Millions 239.5 114.3 93.1 73.8 181.6 118.2 71.4 79.8 971.7

Predicted Prevalence 2025, Millions 309.7 200.6 103.7 152.6 299.2 213.5 129.4 150.7 1559.4

Increase, Millions 70.2 86.3 10.6 78.8 117.6 95.3 58.0 70.9 587.7

Established market economies Latin America and the Caribbean Former socialist economies Middle East crescent China India Other Asia and islands Sub-Saharan Africa Total

Adapted from Kearney et al :Lancet 365: 217-22313

Associations between usual systolic blood pressure (SBP) and overall events by smoking status for: (A) coronary heart disease, (B) ischemic stroke, (C) hemorrhagic stroke, and (D) other strokes

Nakamura, K. et al. Stroke 2008;39:1694-1702

The higher risk of (A) fatal and nonfatal coronary heart disease and (B) stroke, associated with higher systolic blood pressure (SBP) levels by age and region in the Asia Pacific Cohort Studies Collaboration

Hypertension 2007;50;991-997

Coronary heart disease

Stroke

Hazard ratios (HRs) associated with a 10-mm Hg increase in usual systolic blood pressure for coronary heart disease (CHD), ischemic stroke, and hemorrhagic (Hem) stroke, in present smokers and non-smokers, by sex, region, age, and overall

CHD

Ischemic stroke

Hem. stroke

Nakamura, K. et al. Stroke 2008;39:1694-1702

Map showing the estimated age- and sex-standardized prevalence of hypertension in each region of China

High Prevalence

Low Prevalence

Wu, Y. et al. Circulation 2008;118:2679-2686

The effects of a perindopril-based blood pressurelowering regimen on the risk of subsequent stroke among Asian and Caucasian participants in the Perindopril Protection Against Recurrent Stroke Study.
Reproduced from Rodgers et al.J Hypertens. 2004;22: 653-659

Metabolic abnormality

Joint effects of SBP and total cholesterol levels on stroke and CHD in the Asia Pacific Region
Circulation 2005;112;3384-3390

Hazard ratio vs SBP level for 4 strata of total cholesterol

P = 0.001

Hazard ratio vs both SBP and total cholesterol

P = 0.002

Mean levels of risk factors by 10 yr age interval group in men and women from Asia and ANZ.
Triglyceride Systemic Blood Pressure

Total Cholesterol

Diabetes

HDL Cholesterol

Body Mass Index

Cigarette Smoking

Int. J. Epidemiol. 2006;35:1025-1033

Serum total cholesterol levels (Serum T-CHOL) for men among Asian populations in 1980 to 2000 and in the United States in 1960 to 1991

USA

Japan

China

Ueshima, H. et al. Circulation 2008;118:2702-2709

Obesity and Change of nutrition

Prevalence of obesity/overweight and diabetes

Prevalence of obesity/ overweight

Prevalence of diabetes

Trends in the prevalence of overweight and obesity (BMI25 kg m2) in Australian, Chinese and Japanese adult populations

BMI and Body fat percent of Dutch and Indonesian

Prevalence of diabetes in adults in Singapore

1975 Total 1984 Total 1992 Total 1998 Total 1998 males 1998 Females

Chinese (%) Maley (%)

1.55 2.43

4 7.6

8 9.3

8 11.3

7.7 8.2

8.4 14.3

Indian (%)
Total (%)

6.07
1.99

8.9
4.7

12.8
8.6

15.8
9

16.7
8.5.

14.9
9.6

Prevalence of obesity in adults in Singapore (BMI30 kg/m2)

1992 Total 1998 Total 1998 Males 1998 Females

Chinese (%) Maley (%) Indian (%) Total (%)

3.5 11.1 11.2 5.1

3.8 16.2 12.2 6

4.6 8.8 7.4 5.8

3.1 23.7 17.5 12.2

DRCP 50Suppl 2: S35-S39, 2000

Insulin sensitivities in Indian and Caucasian

Indian Caucasian

Prevalence of diabetes in China

In 1985-1994 and 1995-2003

Changes of Percent Poor and GDP in India and China

GDP=gross domestic product

Food consumption in China and India

China
Lipid

India

Urban

Rural Lipid

Energy source in China(A) and India(B)

CarbohydrateProteinLipid

Young Generation

million

Developed countries
In 2000 In 2030

20-44

45-64

>65

The number of the patients with diabetes

million
150

Devloping countries

100

20-44
million
150

45-64

> 65

Total

100

20-44

45-64

>65

Wild S. et al. Diabetes care 27: 1047-1-53, 2004

Risk factors for lifestyle-related diseases

China and India in 1995 and 2025

Overweight

Low Body Weight

Age, study and year of birth adjusted HRs (95% CIs) for each outcome by height quarters in all participants.

males, females

Lee C M Y et al. Int. J. Epidemiol. 2009;38:1060-1071

The influence of early life factors on the burden of type 2 diabetes and other non-communicable diseases
Current concept of the Developmental Origins of Health and Disease (DOHaD)

Metabolic Syndrome

Population-based Study in Asian countries China

1246460
Beijing Taiyung

1213

1516
Ragama community
Kelaniya University Hanoi

Vietnam

3012

Sri Lanka

Tea Factory Nuwara Eliya

Thai Binh

403

2000

Metabolic Syndrome
Waist Circumference

Accumulation of risk factors

Onset of disease
Follow-up Study

Cross-sectional Study

Definition of the state of risk-factor clustering NCEP-ATP except for waist circumference

Triglycerides 150mg/dl

Systolic blood pressure

130mmHg or Diastolic blood pressure 85mmHg

HDL cholesterol Fasting plasma glucose <40mg/dl in men 110mg/dl <50mg/dl in women

Subjects with two or more risk factors Having multiple risk factors
a history of hyperlipidemia, hypertension,or diabetes were deemed as having the respective risk factors,regardless of the biochemical values.

Sensitivity and Specificity for having multiple risk factors

All
1.200

Sensitivity

1.000
0.800 0.600

0.400
0.200 0.000 0.0 20.0 40.0 60.0 80.0 100.0 120.0

WC Waist circumference (WC)

All
1.200 1.000 0.800 0.600 0.400 0.200 0.000 0.0 20.0 40.0 60.0 80.0 100.0 120.0

Specificity

WC Waist circumference (WC)

Hanoi, Vietnam
Male Female
Maximal sensitivity 72.2 cm

Sensitivity

80% sensitivity 75.4 cm Maximal sensitivity 81.8 cm

Sensitivity

80% sensitivity 72.4 cm

1-Specificity

1-Specificity

Sensitivity plus Specificity for having multiple risk factors

Figure 1
1.400

Men

1.350

Hanoi

1.300

Thai Binh

Sensitivity + Specificity

1.250

1.200

1.150

1.100

1.050

1.000

0.950 0.000 20.000 40.000 60.000 80.000 100.000 120.000 140.000 160.000 180.000 200.000

WC Waist circumference (WC)

Women
1.400 1.350 1.300

Sensitivity + Specificity

1.250 1.200 1.150 1.100 1.050 1.000 0.950 0.000 20.000

Hanoi Thai Binh

40.000

60.000

80.000

100.000

120.000

140.000

160.000

180.000

200.000

WC Waist circumference (WC)

Cut-off Points of Waist Circumference Cross-sectional Study

Beijin g
Male Max 85.1 Sensitivity + Female 82.0 Speificity Male 84.2 80% Sensitivity Female 80.0 Taiyuag Sri

Hanoi Japan 81.8 72.2 75.4 72.4 unit cm 85 80

Lanka 82.5 76.5 77.5 72.5 83.3 84.7 81.9 79.0

IDFstandardMale Female

Accumulation of the people with multiple risk factors

in Men
Men
60 50 40 30 20 10 0 60 62 64 66 68 70 72 74 clustering of metabolic risk factors

Thai Binh Mean = 74.3

33.6% 30.0%

Hanoi Mean = 79.0

76 78 80 82 84 86 88 90 92 94 96 98 100 102 WC Waist circumference (WC)

Accumulation of the people with multiple risk factors

in Women Rural
60 clustering of metabolic risk factors 50

Urban

Women

40

Thai Binh Mean = 71.4

37.9% 35.4%

30

20

10

Hanoi Mean = 76.3

60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 100 102

Waist circumference (WC)

WC

Accumulation of the people with multiple risk factors in Men

Men
60

50 clustering of metabolic risk factors

Aging

40

Thai Binh 55-69

Hanoi 55-69
36.8% 33.7% 31.3% 27.3%

30

20

10

Thai Binh 30-54

60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96

Hanoi 30-54
98 100 102

Waist circumference (WC)

WC

Accumulation of the people with multiple risk factors

in Women

Aging
60 clustering of metabolic risk factors 50

Thai Binh Women 55-69

Hanoi 55-69
36.8% 33.7%

Rural

Urban

40

30

31.3% 27.3%

20

10

Thai Binh 30-54

60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96

Hanoi 30-54
98 100 102

WC

Waist circumference (WC)

Diabetes and CVD in Asia

Genetic factors Environment factors factors

Accumulation of risk factors

Onset of disease
Follow-up Study

Cross-sectional Study

Thank you for your attention!