SOCIOECONOMIC, ANTHROPOMETRIC AND BEHAVIORAL DIMENSIONS OF PRE-DIABETES IN AUCKLAND. Hannah Chisholm, in collaboration with the PREVIEW:NZ team

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2 SOCIOECONOMIC, ANTHROPOMETRIC AND BEHAVIORAL DIMENSIONS OF PRE-DIABETES IN AUCKLAND Hannah Chisholm, in collaboration with the PREVIEW:NZ team

3 OUTLINE Background: obesity, prediabetes and diabetes in PREVIEW New Zealand Overview of the PREVIEW Trial Outline of my rationale and hypotheses Methods Summary statistics Preliminary findings Conclusion

4 OBESITY IN NEW ZEALAND 1/3, 1/3, 1/3 NZ Ministry of Health Men & Women; All ethnicities % of popn nd in OECD 35 Overweight Obese Lean

5 PREDIABETES AND OBESITY IN NEW ZEALAND Obesity/overweight AND diabetes Obese groups within New Zealand have higher rates of prediabetes and diabetes (Coppell, 2013) Recent estimates of diabetes prevalence 7% and pre-diabetes prevalence 18.2% (Coppell, 2013) Diabetes and prediabetes particularly prevalent in Maori and Pacific peoples (Coppell, 2013) 1/4 of individuals with prediabetes develop diabetes (Knowler, 2002; Lindstrom, 2003; Tuomilehto, 2003; Nathan, 2007) This progression is amenable to weight loss intervention

6 PREVIEW: PREVENTION OF DIABETES THROUGH LIFESTYLE INTERVENTION IN NEW ZEALAND, AUSTRALIA AND EUROPE PREVIEW Prevention of diabetes in New Zealand, Australia and Europe Multinational clinical trial $10 million funding from European Union 2,500 adults and children Aims to inform policy and clinical recommendations for diabetes prevention Largest weight loss and diabetes prevention trial internationally over the next few years Most efficacious diet and exercise patterns for preventing diabetes through long term weight maintenance

7 PREVIEW:NZ TEAM Professor Sally D Poppitt Amy Liu Dr Anne-Thea McGill Dr Marta Silvestre, Wonjoo Lee, Hannah Chisholm

8 RATIONALE FOR PREVIEW Positive effect of weight loss on metabolic health Large body of evidence to support the effect of weight loss in lowering plasma glucose levels in obesity related adverse metabolic states (Knowler, W., Barrett, E., Fowler, S., Hamman, R., Lachlin, J., Walker, E., Nathan, D., 2002; Maruthur et al., 2013; Katula et al., 2013; Allende- Vigo, 2011; Bergman, 2012; Gillett et al., 2012; Moutzouri, Tsimihodimos, Rizos, & Elisaf, 2011; Yates, Davies, & Khunti, 2009; Ratner & Sathasivam, 2011) Protein or carbohydrate for weight loss and maintenance Diogenes study (Larsen et al., 2010) vs Finnish Diabetes Prevention Study (Lindstrom, J., Louheranta, A., Mannelin, M., Rastas, M., Salminen, V., Eriksson, J., Tuomilehto, J., 2003)

9 A STUDY WITHIN A STUDY Advertisement Recruitment Screening and baseline Low Energy Diet (LED) (8 weeks) Weight Maintenance Through Diet and Exercise (148 weeks) My Study PREVIEW Trial

10 PRE-DIABETES? (IMPAIRED FASTING GLUCOSE AND/OR IMPARIED GLUCOSE TOLERANCE) Fasting: Normal blood glucose levels: mmol/l Prediabetic glucose levels (impaired fasting glucose) : 5.6 to 6.9 mmol/l Diabetic glucose levels: 7.0 mmol/l Post Oral Glucose (OGTT): Normal blood glucose levels: 7.8 mmol/l Prediabetic glucose levels (impaired glucose tolerance) : mmol/l Diabetic glucose levels: 11.2mmol/L World Health Organisation, 2006

11 RATIONALE: WHY ARE SOICODOMOGRAPHIC, BEHAVIOURAL AND ANTHROMOMETIRC DIMENSIONS IMPORTANT? Biology: appetite and food as a potentially addictive substance Social and physical environment: OBESOGENIC Suboptimal diet and physical activity Obesity Obesity related pre-diabetes Diabetes

12 Diabetes is DIFFICULT and Sneaky Diabetes is VERY Expensive for the Health Care System Diabetes has Large Personal and Familial Costs Prediabetes Diabetes

13 RESEARCH QUESTIONS 1. Which characteristics (socioeconomic and ethnicity, anthropometry, eating behaviours) put individuals at increased risk of prediabetes in Auckland? 2. Is a controlled, short term low energy diet a potentially feasible method to reduce at risk individuals risk of type 2 diabetes mellitus in Auckland (prior to the 3 year diet and exercise coaching) study? 3. Which characteristics are associated with greater weight loss and lower OGGT results after a low energy diet?

14 WHICH CHARACTERISTICS PUT INDIVIDUALS AT INCREASED RISK OF PREDIABETES IN AUCKLAND? : HYPOTHESES BMI SES Ethnicity Eating behaviour

15 STUDY DESIGN Cross Sectional Study: Sociodemographic Anthropometric & Metabolic markers At baseline Intervention: Weight loss over an 8 week period on a LED (low energy diet)

16 ¼ of the typical intake At Least 8% Weight loss required 3386KJ

17 VARIABLES OF INTEREST ANTHROMETRY Body weight (baseline and post LED) BMI (body mass index) (baseline and post LED) Waist circumference (baseline and post LED) BODY COMPOSTION DEXA (dual x-ray absorptiometry) (baseline and post LED) EATING BEHAVIOUR Eating behaviors measured by the three factor eating questionnaire (baseline) Demographics & SOCIOECONOMICS Area based socioeconomic deprivation (baseline) VERSUS METABOLIC or PreDiabetes Fasting plasma glucose OGTT (baseline and post LED) Post oral plasma glucose OGTT (baseline)

18 METHODS TFEQ QUESTIONNAIRES Prescreening BLOOD ANALYSIS Fasting plasma glucose Post oral plasma glucose ANTHROPOMETRY BMI DEXA Waist Weight

19 468 Respondents 107 screened 45 Eligible and enrolled 257 Not Yet Assessed 62 Ineligible 3 Withdrawal 42 Low Energy Diet 3 Withdrawal? Successful Completion (~60%)?Unsuccessful

20 468 Respondents 107 screened 45 Eligible and enrolled Prediabetic 257 Not Yet Assessed 62 Ineligible 3 Withdrawal Normoglyceamic Abnormal ECG 42 Low Energy Diet 3 Withdrawal? Successful Completion ~60%

21 SUMMARY STATISTICS: WHO ARE THESE PEOPLE? Characteristic Normoglyceamic Prediabetic Age Gender 81% Female 73% Female Ethnicity 67% NZEuropean 12% PI 53% NZEuropean 24% PI Area based socioeconomic status 3 (NZDep06 quintile) 3.2 (NZDep06 Quintile) BMI 38 kg/m2 (class 2 obesity) 38 kg/m2 (class 2 obesity) Weight 108kg 110kg Fasting Plasma Glucose Post Oral Plasma Glucose 5.1 mmol/l 5.8 mmol/l 5.7 mmol/l 6.6 mmol/l

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23 WHICH CHARACTERISTICS PUT INDIVIDUALS AT INCREASED RISK OF PREDIABETES IN AUCKLAND: BMI One way ANOVA of BMI categories (overweight, obese class 1, obese class 2, obese class 3) and fasting plasma glucose and post oral plasma glucose levels. No significant relationship between blood glucose (at fasting and post oral) and BMI. Independent samples T-test of BMI between Normoglyceamic and Prediabetic groups. No significant relationship between blood glucose (at fasting and post oral) and BMI category.

24 BUT A SIGNIFICANT CORRELATION BETWEEN PERCENT BODY FAT (DEXA) AND POST ORAL PLASMA GLUCOSE (R2=0.28) (P=0.000)

25 WHICH CHARACTERISTICS PUT INDIVIDUALS AT INCREASED RISK OF PREDIABETES IN AUCKLAND: SES One way ANOVA to test the differences in socioeconomic status in relation to fasting and post oral plasma glucose. No significant difference found Independent samples t-test to compare the area based socioeconomic status between prediabetic and normoglyceamic groups. There was no significant difference in the area based socioeconomic status scores for prediabetic and normoglyceamic groups.

26 BUT.. CORRELATION: INCREASING BMI WAS SEEN WITH INCREASING NZDEP06 DECILE (R2=0.05) (P= 0.000)

27 WHICH CHARACTERISTICS PUT INDIVIDUALS AT INCREASED RISK OF PREDIABETES IN AUCKLAND: ETHNICITY One way ANOVA to test the differences in ethnicity* in relation to fasting and post oral plasma glucose. No significant difference found *Ethnicity output and analysis using multiple response

28 WHICH CHARACTERISTICS PUT INDIVIDUALS AT INCREASED RISK OF PREDIABETES IN AUCKLAND: EATING BEHAVIOUR: EMOTIONAL EATING Emotional Eating was correlated with post prandial plasma glucose. Increasing tendency towards emotional eating was correlated with higher BMI (n=45) (r=0.09) (p=0.05)

29 SUMMARY OF PRELIMINARY FINDINGS: LED INTERVENTION Total of kg lost Average of 8.6 kg per person

30 HOW ARE THEY FEELING NOW? A FEW REFLECTIONS FROM PARTICIPANTS: More energy for life: more family time and help around the house Better blood pressure Feeling and looking healthier Old clothes fit and people notice! Developing healthier relationships with food and getting to know their body s signals

31 Exclusion of the age group LIMITATIONS Participants were self selected (may be different to the rest of the population with respect to characteristics under study) New Zealand specific FPG + PPPG STRENGTHS

32 CONCLUSIONS Socioeconomic, behavioral and anthropometric influences on glucose metabolism are both plausible and complex (Literature) (Knowler, W., Barrett, E., Fowler, S., Hamman, R., Lachlin, J., Walker, E., Nathan, D., 2002; Maruthur et al., 2013; Katula et al., 2013; Allende-Vigo, 2011; Bergman, 2012; Gillett et al., 2012; Moutzouri, Tsimihodimos, Rizos, & Elisaf, 2011; Yates, Davies, & Khunti, 2009; Ratner & Sathasivam, 2011) Some common associations were mirrored (increasing emotional eating and increasing BMI, increasing body fat and plasma glucose concentration, BMI and SES) Others weren t (plasma glucose and ethnicity, BMI and plasma glucose) LED successful method for weight loss in a multicultural Auckland population (weight loss maintenance through lifestyle is the next step)

33 THANK YOU SUPER SUPERVISORS Prof. Sally D Poppitt Dr Anne-Thea McGill AND THE PREVIEW TEAM

34 References REFERENCES Allende-Vigo, M. Z. (2011). Diabetes mellitus prevention. American Journal of Therapeutics, Bergman, M. (2012). Treatments of prediabetes. Louvain Medical, 131(3), Coppell, K. J., Mann, J. I., Williams, S. M., Jo, E., Drury, P. L., Miller, J. C., & Parnell, W. R. (2013). Prevalence of diagnosed and undiagnosed diabetes and prediabetes in new zealand: Findings from the 2008/09 adult nutrition survey. The New Zealand Medical Journal, 126(1370), Gillett, M., Royle, P., Snaith, A., Scotland, G., Poobalan, A., Imamura, M.,... Waugh, N. (2012). Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation: A systematic review and economic evaluation. Health Technology Assessment, 16(33), Katula, J. A., Vitolins, M. Z., Morgan, T. M., Lawlor, M. S., Blackwell, C. S., Isom, S. P.,... Goff Jr., D. C. (2013). The healthy living partnerships to prevent diabetes study: 2-year outcomes of a randomized controlled trial. American Journal of Preventive Medicine, 44(4 Suppl 4), S

35 REFERENCES Knowler, W., Barrett, E., Fowler, S., Hamman, R., Lachlin, J., Walker, E., Nathan, D.,. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metaformin. New England Journal of Medicine, 346(6), Larsen, T. M., Dalskov, S., van Baak, M., Jebb, S., Kafatos, A., Pfeiffer, A.,... Astrup, A. (2010). The diet, obesity and genes (diogenes) dietary study in eight european countries a comprehensive design for long-term intervention. Obesity Reviews, 11(1), doi: /j x x Lindstrom, J., Louheranta, A., Mannelin, M., Rastas, M., Salminen, V., Eriksson, J., Tuomilehto, J.,. (2003). The finnish diabetes prevention study: Lifestyle intervention and 3-year results on diet and physical activity.. Diabetes Care, 26(12), Maruthur, N. M., Ma, Y., Delahanty, L. M., Nelson, J. A., Aroda, V., White, N. H.,... Clark, J. M. (2013). Early response to preventive strategies in the diabetes prevention program. Journal of General Internal Medicine, 1-8. Ministry of Health,. (2013). Mortality and demographic data 2010.Ministry of Health

36 REFERENCES Moutzouri, E., Tsimihodimos, V., Rizos, E., & Elisaf, M. (2011). Prediabetes: To treat or not to treat? European Journal of Pharmacology, 672(1-3), Ratner, R. E., & Sathasivam, A. (2011). Treatment recommendations for prediabetes. Medical Clinics of North America, 95(2), Yates, T., Davies, M., & Khunti, K. (2009). Preventing type 2 diabetes: Can we make the evidence work? Postgraduate Medical Journal, 85(1007),

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