The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC.

Epidemiology and Prevention

of Type 2 Diabetes

Epidemiology and Prevention

of Type 2 Diabetes

Edward Gregg, PhDEpidemiology and Statistics Branch

Division of Diabetes TranslationCenters for Disease Control and Prevention

Atlanta, GA

Edward Gregg, PhDEpidemiology and Statistics Branch

Division of Diabetes TranslationCenters for Disease Control and Prevention

Atlanta, GA

Prevalence of Total Diabetes (Diagnosed Diabetes and Undiagnosed Diabetes) in the U.S. Adult Population, Age ≥ 20, 2005-2006

According to Alternative Definitions of Undiagnosed Diabetes

Prevalence of Total Diabetes (Diagnosed Diabetes and Undiagnosed Diabetes) in the U.S. Adult Population, Age ≥ 20, 2005-2006

According to Alternative Definitions of Undiagnosed Diabetes

0

2

4

6

8

10

12

14

16

FPG A1c FPG or A1c FPG or 2-hr

Diagnosed Undiagnosed

0

2

4

6

8

10

12

14

16

FPG A1c FPG or A1c FPG or 2-hr

Diagnosed Undiagnosed

21.5 million

27.0 million

19.7 million

22.4 million

(> 126 mg/dl) (> 6.5%) (>126 mg/dl OR > 6.5%)

(>126 mg/dl OR 2hPG > 200)

Sources: Cowie et al., Diab Care, 2009; unpublished analyses, Bullard et al.; NIDDK, CDC

0

10

20

30

40

50

60

Men Women

Per

cen

t

Total Non-Hispanic WhiteNon-Hispanic Black Hispanic

0

10

20

30

40

50

60

Men Women

Per

cen

t

Total Non-Hispanic WhiteNon-Hispanic Black Hispanic

Narayan et al, JAMA, 2003

Estimated lifetime risk of developing diabetes for individuals born in the United States in 2000

Estimated lifetime risk of developing diabetes for individuals born in the United States in 2000

Projected Total Number of Adults with Diabetes (Diagnosed or Undiagnosed) Under Scenarios of No

further Increase Continued Increased Incidence Rate

Projected Total Number of Adults with Diabetes (Diagnosed or Undiagnosed) Under Scenarios of No

further Increase Continued Increased Incidence Rate

20

40

60

80

100

120

2007 2010 2015 2020 2025 2030 2035 2040 2045 2050

Year

Mill

ion

s o

f A

du

lts

Current Trends No Further Increase

20

40

60

80

100

120

2007 2010 2015 2020 2025 2030 2035 2040 2045 2050

Year

Mill

ion

s o

f A

du

lts

Current Trends No Further Increase

Boyle et al., Pop Health Metrics, 2010

Projected Prevalence of Diabetes (Diagnosed or Undiagnosed) Under Scenarios of No further

Increase Continued Increased Incidence Rate

Projected Prevalence of Diabetes (Diagnosed or Undiagnosed) Under Scenarios of No further

Increase Continued Increased Incidence Rate

0

10

20

30

40

2007 2010 2015 2020 2025 2030 2035 2040 2045 2050

Year

Pre

va

len

ce

(%

)

Current Trends No Further Increase

0

10

20

30

40

2007 2010 2015 2020 2025 2030 2035 2040 2045 2050

Year

Pre

va

len

ce

(%

)

Current Trends No Further Increase

Boyle et al., Pop Health Metrics, 2010

Factors Influencing Future Incidence and Prevalence Estimates

Factors Influencing Future Incidence and Prevalence Estimates

Prevalence in year 2010 (number and proportion of adults with diagnosed and undiagnosed diabetes, pre-diabetes).

Incidence (Rate of new cases into the future).

Mortality rates

Age distribution of the population.

Census projection of population growth.

Migration

Prevalence in year 2010 (number and proportion of adults with diagnosed and undiagnosed diabetes, pre-diabetes).

Incidence (Rate of new cases into the future).

Mortality rates

Age distribution of the population.

Census projection of population growth.

Migration

Risk Factors for Type 2 DiabetesRisk Factors for Type 2 Diabetes

Factors Causally Associated withFactors Causally Associated withIncreased Diabetes Incidence in IndividualsIncreased Diabetes Incidence in Individuals

ModifiableModifiable and and PrimPrime e Targets for Individual-Level Targets for Individual-Level InterventionsInterventions

Factors ExplainingFactors ExplainingPopulation Trends Population Trends in the Diseasein the Disease

Types of Risk Factors

Prevalence of Total Diabetes (Diagnosed Diabetes and Undiagnosed Diabetes)

in the U.S. Adult Population, Age ≥ 20, 2003-2006

Prevalence of Total Diabetes (Diagnosed Diabetes and Undiagnosed Diabetes)

in the U.S. Adult Population, Age ≥ 20, 2003-2006

Sources: Cowie et al., Diab Care, 2010; NIDDK, CDC

0

5

10

15

20

25

Total 20-39 yrs 40-59 yrs 60-74 yrs 75+ yrs

Prevalence (%)

Ag

e G

rou

p

Undiagnosed

Diagnosed

0

5

10

15

20

25

Total 20-39 yrs 40-59 yrs 60-74 yrs 75+ yrs

Prevalence (%)

Ag

e G

rou

p

Undiagnosed

Diagnosed

0 5 10 15 20

Non-Hispanic whites

Asian Americans

Hispanic/Latino Americans

Non-Hispanic blacks

American Indians/Alaska Natives

Percent

Estimated Age-Adjusted* Prevalence of Diagnosed Diabetes

in People Aged 20 Years or Older, by Race/Ethnicity,United States, 2007

Estimated Age-Adjusted* Prevalence of Diagnosed Diabetes

in People Aged 20 Years or Older, by Race/Ethnicity,United States, 2007

*Based on the 2000 US standard population

CDC, National Diabetes Fact Sheet, 2007

Migration Studies: Association Between Westernization and Diabetes Prevalence in Susceptible Populations

Migration Studies: Association Between Westernization and Diabetes Prevalence in Susceptible Populations

0

10

20

30

40

%

0

10

20

30

40

%

King, Diabetes Care, 1993; 1998; Diamond J, Nature, 2003

IndianAustralian Aborigines

ChineseNauru New

Guinea

BMI

<22

22-<23

23-<24

24-<25

25-<27

27-<29

29-<31

31-<33

33-<35

35+

1-y Risk (%)

0. 224

0. 255

0. 428

0. 539

0. 553

0. 899

1.074

1.480

1.892

2.461

RR

1

1.18

2.44

2.97

3.04

5.07

5.70

8.21

10.89

14.64

%- PointAbsolute Increase

0

0.031

0.204

0.315

0.329

0.675

0.850

1.256

1.668

2.237

Increase per100,000

0

31

204

315

329

675

850

1,256

1,668

2,237

Body Mass Index and 1-year Risk of Diabetes (Ford ES et al. AJE 1997;146:214-22)

CumulativeIncrease

550

1,554

7,565

0

Relative risk of incident diabetes per standard deviation of BMI and Waist circumference from a meta-analysis of 32 studies

Vasquez, Epidemiol Rev, 2007

1.57 1.28

1.5 2.5

1.05

2.260.56

1.42

0.4

1.37

0

2

4

6

8

10

1976-1980 1999-2004

Year

1.57 1.28

1.5 2.5

1.05

2.260.56

1.42

0.4

1.37

0

2

4

6

8

10

1976-1980 1999-2004

Year

Diabetes Prevalence among U.S. Adults Aged 20 - 74

BMI Category

Obese III (> 40)

Obese II (35-40)

Obese I (30 -35)

Overweight (25 -30)

Normal / underweight (<25)

Total

5.03%

8.83%

Age and sex adjustedGregg et al., Prev Med, 2007

Luckovich, Atlanta Journal Constitution

Hu et al.,Arch Intern Med, 2001

Dietary factors as independent diabetes risk factors

Dietary factors as independent diabetes risk factors

Characteristics of fat intake Whole grain / cereal fibers Dairy Glycemic load “Western diet” Fast food intake Soda intake Alcohol intake Coffee consumption

Characteristics of fat intake Whole grain / cereal fibers Dairy Glycemic load “Western diet” Fast food intake Soda intake Alcohol intake Coffee consumption

Trends in the proportion of total intake devoted to macronuetriends (left x-axis) and mean total Energy Intake (right x-axis) among U.S.

adults age 20-74, 1971 to 2000

Trends in the proportion of total intake devoted to macronuetriends (left x-axis) and mean total Energy Intake (right x-axis) among U.S.

adults age 20-74, 1971 to 2000

0

10

20

30

40

50

60

1971-1974 1976-1980 1988-1994 1999-20001000

1200

1400

1600

1800

2000

2200

2400

2600

2800

% Carbs

% fats

% saturated fats

% protein

Total Energy

0

10

20

30

40

50

60

1971-1974 1976-1980 1988-1994 1999-20001000

1200

1400

1600

1800

2000

2200

2400

2600

2800

% Carbs

% fats

% saturated fats

% protein

Total Energy

Total Intake (kcals)

MMWR, 2004

Percentage of total carbohydrates obtained from whole grains (smaller circles) and corn syrup (larger circles) in the United States

Gross et al., Am J Clin Nutr, 2004

Trends in % of Meals Eaten at Home and Trends in Total Kcal Intake in Meals and Snacks in the U.S., 1977-1996.

Trends in % of Meals Eaten at Home and Trends in Total Kcal Intake in Meals and Snacks in the U.S., 1977-1996.

50

55

60

65

70

75

80

1977-

78

1989-

91

1994-

96

% M

ea

ls e

ate

n a

t h

om

e

50

55

60

65

70

75

80

1977-

78

1989-

91

1994-

96

% M

ea

ls e

ate

n a

t h

om

e

1500

1650

1800

1950

1977-

78

1989-

91

1994-

96

kc

als

/da

y

Snacks Meals

Nielsen and Popkin, JAMA, 2003

Portion Sizes for Selected Key Foot Items for Americans Aged 2 and Older, 1977-1996.

Portion Sizes for Selected Key Foot Items for Americans Aged 2 and Older, 1977-1996.

0

5

10

15

20

25

Food

inta

ke p

er o

ccas

ion,

oz

1977-78

1989-91

1994-98

0

5

10

15

20

25

Food

inta

ke p

er o

ccas

ion,

oz

1977-78

1989-91

1994-98

Nielsen and Popkin, JAMA, 2003

Promising Targets for Population-Wide Food Policies to Influence Diabetes

Promising Targets for Population-Wide Food Policies to Influence Diabetes

Diabetes OR per 1kgBirth weight=0.78

Serum Concentration

ND <25% 25-50% 50-75% 75-90% 90-100%

Cases/n 2/643 34/505 53/527 65/275 63 / 246

Prevalence -- 0.4 6.7 10.1 23.6 25.6

Adjusted OR

-- Referent 14.9 (3. 0 – 65.0)

14.7 (3.4 – 63.9)

38.2 (8.0 – 183.1)

37.7 (7.8 – 182.0)

Adjusted OR

--- 0.07 (0.02 – 0.33)

Ref 1.1 (0.6 – 1.7)

2.7 (1.5 – 4.9)

2.7 (1.5 – 4.8)

Lee et al., Diab Care, 2007

Brownell et al.,

Gestational Diabetes and the Incidence of Type 2 Diabetes: A systematic review (Kim et al., Diabetes Care, 2002)

Systematic Review of the Incidence of Diabetes Associated with Various Categories of GlycemiaSystematic Review of the Incidence of Diabetes Associated with Various Categories of Glycemia

Number of studies

Regress to normal (median %)

Progress to Diabetes (median %)

Relative Risk of Diabetes

Impaired Glucose Tolerance

26 8% 7% 6.4 (4.9 – 7.8)

IGT Isolated 3 n/a 6% 5.5 (3.1 – 7.9)

IFG 6 13 – 29% 5-20%* 4.7 (2.5 – 6.9)

IFG Isolated 3 n/a 7% 7.5 (4.6 – 10.5)

IGT and IFG 3 n/a 10-15% 12.1 (4.3 – 20)

Gerstein et al., Diab Res Clin Pract, 2007*extremely variable; 1-7% in European pops; 23-34% in Asian pops.

Summary: Risk Factors for Type 2 DiabetesSummary: Risk Factors for Type 2 Diabetes

Age ↑ Family History / genetics ↑ Gestational Diabetes ↑ Obesity / fat distribution ↑ Physical Activity / fitness ↓ Smoking ↑ Very low birth weight ↑ Depression ↑ Antipsychotic medications ↑ Anti-Retrovial therapy ↑

Age ↑ Family History / genetics ↑ Gestational Diabetes ↑ Obesity / fat distribution ↑ Physical Activity / fitness ↓ Smoking ↑ Very low birth weight ↑ Depression ↑ Antipsychotic medications ↑ Anti-Retrovial therapy ↑

Dietary Factors• Carbohydratess ↓• Fats ↑↓• Glycemic load ↑• Cereal fiber / whole grain ↓• Dairy products ↓• High fructose corn syrup ↑• Sugar-sweetened bevarages ↑• Alcohol ↓• Coffee ↓

Dietary Factors• Carbohydratess ↓• Fats ↑↓• Glycemic load ↑• Cereal fiber / whole grain ↓• Dairy products ↓• High fructose corn syrup ↑• Sugar-sweetened bevarages ↑• Alcohol ↓• Coffee ↓

Successes and Failures in the Public Health Response to Type 2 DiabetesSuccesses and Failures in the Public Health Response to Type 2 Diabetes

Diabetes Pyramid of Prevention?Diabetes Pyramid of Prevention?

Diabetes

Undiagnosed DM

Adult Prevalence Goal / Intervention Tier

7.6%

2.6%

Prevent MorbidityDetect Early

Classic Levers in the Public HealthResponse to Diabetes

Classic Levers in the Public HealthResponse to Diabetes

Clinical Services

Promotion of Behaviors

Population-TargetedPolicies

Glycemic control BP control Lipid testing and management

Annual eye examinationsFoot care for high risk persons Kidney disease testing Flu immunization Preconception care Diabetes education Case Management Targeted Screening

Education and awareness for:• Physical activity• Reduced Tobacco• Healthy diet• Regular doctor visits• Self monitoring• Self mgt education

• Health care access legislation• Drug and supply reimbursement policies• Population registry and feedback systems

Prevalence of CVD risk factors among U.S. adults with diabetes aged 20-74, according to income group, 1971 to 2006

(* red=low income; green=middle income; yellow=high income)

Prevalence of CVD risk factors among U.S. adults with diabetes aged 20-74, according to income group, 1971 to 2006

(* red=low income; green=middle income; yellow=high income)

High Blood Pressure High Cholesterol

High A1c LevelSmoking

80

70

60

50

40

30

20

4.0

3.0

2.0

Eve

nts

Per

10,

000

Amputation

End Stage Renal Disease

Hyperglycemic Death

Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. diabetic population, 1990-2006.

Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. diabetic population, 1990-2006.

Gregg and Albright, JAMA, 2009

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC.

Women

Men

Gregg et al., Ann Intern Med, 2007

What has worked in secondary prevention?What has worked in secondary prevention?

Health Services:Health Services:• Acute care and major medical interventionsAcute care and major medical interventions• Diffusion of new science of risk factor management Diffusion of new science of risk factor management • Emphasis on quality of careEmphasis on quality of care• Health system adaptation and CQIHealth system adaptation and CQI

Health Promotion and Health ProtectionHealth Promotion and Health Protection• Improved education/awareness of diabetes control.Improved education/awareness of diabetes control.• Improved CVD risk factor education and awareness. Improved CVD risk factor education and awareness. • Reduced Tobacco / tobacco legislation• Less directly atherogenic food supplyLess directly atherogenic food supply

Health Services:Health Services:• Acute care and major medical interventionsAcute care and major medical interventions• Diffusion of new science of risk factor management Diffusion of new science of risk factor management • Emphasis on quality of careEmphasis on quality of care• Health system adaptation and CQIHealth system adaptation and CQI

Health Promotion and Health ProtectionHealth Promotion and Health Protection• Improved education/awareness of diabetes control.Improved education/awareness of diabetes control.• Improved CVD risk factor education and awareness. Improved CVD risk factor education and awareness. • Reduced Tobacco / tobacco legislation• Less directly atherogenic food supplyLess directly atherogenic food supply

Failures in the Public Health Response to Diabetes

Failures in the Public Health Response to Diabetes

Levels of care and preventive health behaviors are still suboptimal. Improvements in blood pressure may have stalled. Disparities remain in renal disease, amputation, acute complications,

and costs. Major differences in morbidity remain between people with and

without diabetes. Diabetes is economically disabling for people and their families. While the average person with diagnosed diabetes has better control

and lower risk of complications, the risk of diabetes or a diabetes complication for the average person in the total population has increased.

Levels of care and preventive health behaviors are still suboptimal. Improvements in blood pressure may have stalled. Disparities remain in renal disease, amputation, acute complications,

and costs. Major differences in morbidity remain between people with and

without diabetes. Diabetes is economically disabling for people and their families. While the average person with diagnosed diabetes has better control

and lower risk of complications, the risk of diabetes or a diabetes complication for the average person in the total population has increased.

Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. population, 1990-2006.

Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. population, 1990-2006.

1990 1995 2000 2005 2010

Excess Risk of Complications in the Diabetic Population

1990 1995 2000 2005 2010

Excess Risk of Diabetes in the General Population

Proportion of Participants Developing Diabetes During the Finnish and U.S. Diabetes Prevention Studies

Proportion of Participants Developing Diabetes During the Finnish and U.S. Diabetes Prevention Studies

Tuomilehto, N Engl J Med, 2001; DPP Research Group, N Engl J Med, 2002

0

10

20

30

40

50

0 0.5 1 1.5 2 2.5 3 3.5 4

Study Year

%

Control

Lifestyle

Metformin

0

10

20

30

40

50

0 1 2 3 4 5 6

Study Year

%

Control

Lifestyle

Finland United States

Longer-term Impact? Magnitude of Incidence Reduction in Long-term Diabetes Prevention Legacy Studies

Longer-term Impact? Magnitude of Incidence Reduction in Long-term Diabetes Prevention Legacy Studies

Primary Outcome(RR Reduction)

Extended Outcome

Finnish DPS (Lifestyle) 58% at 3 yr 43% at 7 years

Da Qing Study (Lifestyle) 51% at 6 yr 43% at 20 years

DPP- OS (Lifestyle) 58% at 2 yr 24% at 10 years

DPP-OS (Metformin) 31% at 2 yr 18% at 10 years

Lindstrom, et al. 2006; Li et al. 2008; DPPOS; 2009

Drug Duration(yrs)

Dose / day RR Reduction

Side Effects

DPP, 2002 Metformin 2 1700 mg 31% GI

Stop NIDDM Acarbose 3 300 mg 25% GI

IDPP, 2006 Metformin 2.5 500 mg 26% GI; Hypo

DREAM Rosiglitazone 3 8 mg 60% CHF; wt gain;

NAVIGATOR Nateglinide 5 90mg NS hypo

CANOE Rosi + Metformin

4 4mg;1000mg

69% Diarrhea 16% vs 6%

Chiasson 2002; Ramachandran 2006; Knowler, 2002; Navigator, 2010; Zinman, 2010; Gerstein, 2006

Characteristics of Successful Lifestyle Interventions

Characteristics of Successful Lifestyle Interventions

Intensive: small group, or 1:1; For 6 –12 months Extended: > 2 years Multi-component

• Reduced total intake, reduced fat intake• Exercise• Increased fiber intake• Strongly integrated behavioral principles

Moderate weight loss: • 5-7% weight loss, • 3-4% long-term weight loss maintenance

Intensive: small group, or 1:1; For 6 –12 months Extended: > 2 years Multi-component

• Reduced total intake, reduced fat intake• Exercise• Increased fiber intake• Strongly integrated behavioral principles

Moderate weight loss: • 5-7% weight loss, • 3-4% long-term weight loss maintenance

Current Dilemmas in Diabetes Prevention PolicyCurrent Dilemmas in Diabetes Prevention PolicyCurrent Dilemmas in Diabetes Prevention PolicyCurrent Dilemmas in Diabetes Prevention Policy

High risk vs population approachHigh risk vs population approach Whom to Target?Whom to Target?

• Imminent risk based on glycemia vs broad risk factors vs Imminent risk based on glycemia vs broad risk factors vs everyone?everyone?

Is “screening” for pre-diabetes good policy?Is “screening” for pre-diabetes good policy?• And if so, how should we screen? And if so, how should we screen?

What interventions to apply? What interventions to apply? • Structured and tied to clinical services?Structured and tied to clinical services?

• Broad health promotion?Broad health promotion?

• Population-targeted policies?Population-targeted policies?

High risk vs population approachHigh risk vs population approach Whom to Target?Whom to Target?

• Imminent risk based on glycemia vs broad risk factors vs Imminent risk based on glycemia vs broad risk factors vs everyone?everyone?

Is “screening” for pre-diabetes good policy?Is “screening” for pre-diabetes good policy?• And if so, how should we screen? And if so, how should we screen?

What interventions to apply? What interventions to apply? • Structured and tied to clinical services?Structured and tied to clinical services?

• Broad health promotion?Broad health promotion?

• Population-targeted policies?Population-targeted policies?

Diabetes Pyramid of PreventionDiabetes Pyramid of PreventionDiabetes Pyramid of PreventionDiabetes Pyramid of Prevention

Diabetes

Very High Risk(A1c > 5.7%; IGT; GDM)

Undiagnosed DM

Moderate Risk

Low Risk

Adult Prevalence Goal / Intervention Tier

7.6%

2.6%

~12-15%

~15-20%

~57%

Prevent Morbidity

Detect Early

High Risk (FPG > 100);Central Obesity; HTN, age

What type of intervention for what level of risk?

Summary and Recommendations:Summary and Recommendations:Related to Screening and IdentificationRelated to Screening and Identification

Summary and Recommendations:Summary and Recommendations:Related to Screening and IdentificationRelated to Screening and Identification

• Encourage identification of pre-diabetes and undiagnosed diabetes in adults in clinical settings and established clinical/community partnerships.

o Risk scores most appropriate first stage screening.o More efficient in “integrated” manner, connected to lipid, BP.o Ideal thresholds for referral ultimately depend upon resources.Ideal thresholds for referral ultimately depend upon resources.

• Discourage :o Population-wide blood screening in the absence of risk factor

assessment or in low-risk populations.o Screening in community settings (health fairs, retail stores, etc.)

that lack a direct connections to health care provider.o Screening of youth and adolescents .

• Encourage identification of pre-diabetes and undiagnosed diabetes in adults in clinical settings and established clinical/community partnerships.

o Risk scores most appropriate first stage screening.o More efficient in “integrated” manner, connected to lipid, BP.o Ideal thresholds for referral ultimately depend upon resources.Ideal thresholds for referral ultimately depend upon resources.

• Discourage :o Population-wide blood screening in the absence of risk factor

assessment or in low-risk populations.o Screening in community settings (health fairs, retail stores, etc.)

that lack a direct connections to health care provider.o Screening of youth and adolescents .

Potential Barriers to Effective Clinical-System Based Lifestyle Intervention Programs

Potential Barriers to Effective Clinical-System Based Lifestyle Intervention Programs

Clinical health systems lack structure and expertise to change lifestyle.

Too expensive and not “scalable”. Previous models of clinical based / lifestyle change

have not achieved sustainable reimbursement. Waiting until people have elevated glucose is too late. Diabetes is a common-source epidemic rooted in

culture and society.

Clinical health systems lack structure and expertise to change lifestyle.

Too expensive and not “scalable”. Previous models of clinical based / lifestyle change

have not achieved sustainable reimbursement. Waiting until people have elevated glucose is too late. Diabetes is a common-source epidemic rooted in

culture and society.

Macro-Level Determinants Obesity and Diabetes: Current Debates Over Policy

Strategies

Macro-Level Determinants Obesity and Diabetes: Current Debates Over Policy

Strategies

Physical environment

Food environment Social environment Economy and

poverty

Physical environment

Food environment Social environment Economy and

poverty

Policy Options to Influence Diabetes RiskPolicy Options to Influence Diabetes Risk

Taxation Food and Menu labeling Engage Private Industry Crop subsidy policies Incentives/promotion for community availability and

affordability of foods. Incentives/promotion for community support for

physical activity. Regulation of foods in public areas. School food and physical education policies.

Taxation Food and Menu labeling Engage Private Industry Crop subsidy policies Incentives/promotion for community availability and

affordability of foods. Incentives/promotion for community support for

physical activity. Regulation of foods in public areas. School food and physical education policies.

Summary:Summary:

Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence.

Diabetes prevention requires a multi-tiered public health response, that includes • Efficient identification and referral of high

risk people to structured lifestyle programs using clinical-community partnerships.

Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence.

Diabetes prevention requires a multi-tiered public health response, that includes • Efficient identification and referral of high

risk people to structured lifestyle programs using clinical-community partnerships.

Summary:Summary:

Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence.

Diabetes prevention requires a multi-tiered public health response, that includes • Efficient identification and referral of high risk

people to structured lifestyle programs using clinical-community partnerships.

• Broad population –targeted approaches aimed at food, social, and economic environment to ultimately change trends in the epidemic.

Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence.

Diabetes prevention requires a multi-tiered public health response, that includes • Efficient identification and referral of high risk

people to structured lifestyle programs using clinical-community partnerships.

• Broad population –targeted approaches aimed at food, social, and economic environment to ultimately change trends in the epidemic.

Thank youThank you

http://www.cdc.gov http://www.cdc.gov/diabetes/statistics/index.htm http://www.cdc.gov/diabetes/statistics/didit/index.htm

Edward Gregg, PhD: edg7@cdc.gov

http://www.cdc.gov http://www.cdc.gov/diabetes/statistics/index.htm http://www.cdc.gov/diabetes/statistics/didit/index.htm

Edward Gregg, PhD: edg7@cdc.gov