Summary statement IV: Obesity and diabetes: opportunities for translation of basic research.

The worldwide epidemics of obesity and diabetes that have emerged in the 21st century are creating a major public heath problem, having struck developed countries as well as those still developing. With our present clinical tools, abilities, and understanding, we may not be prepared to respond adequately to the demands or be able to engage in effective prevention strategies. The underlying pathophysiological reasons for the increases in both obesity and diabetes may be closely related through abnormality in endothelial cells. Diverse expertise from within and outside the public health arena will be needed to explore the health implications from an "endothelium" perspective and identify those at risk for the development of chronic disease. Identification of new biological markers and better measures of current biological marker will both be critical in understanding and addressing the ongoing epidemic of chronic diseases.

Vascular endothelium summary statement VI: Research directions for the 21st century.

Effective translation of research advances from the bench to clinical and public health practice at the bedside and in the community at large represents an important step in the health research discovery enterprise. Increasingly, the gap in translating these advances into practice is being recognized. Successfully addressing this translational gap for the prevention and control of chronic diseases will require the development of novel, innovative, and, if necessary, nontraditional approaches. Participants in the 8th International Conference on Vascular Endothelium discussed a variety of novel approaches that have significant promise. Three of these approaches-vaccine development, genomics and proteomics, and tissue engineering-are highlighted in this position statement and strategies for public health practice and research are suggested.

Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002.

BACKGROUND: Progress of diabetes care is a subject of public health concern. OBJECTIVE: To assess changes in quality of diabetes care in the United States by using standardized measures. DESIGN: National population-based, serial cross-sectional surveys. SETTING: National Health and Nutrition Examination Survey (1988-1994 and 1999-2002) and the Behavioral Risk Factor Surveillance System (1995 and 2002). PARTICIPANTS: Survey participants 18 to 75 years of age who reported a diagnosis of diabetes. MEASUREMENTS: Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, annual cholesterol level monitoring, and annual foot and dilated eye examination, as defined by the National Diabetes Quality Improvement Alliance measures. RESULTS: In the past decade, the proportion of persons with diabetes with poor glycemic control (hemoglobin A1c > 9%) showed a nonstatistically significant decrease of 3.9% (95% CI, -10.4% to 2.5%), while the proportion of persons with fair or good lipid control (LDL cholesterol level < 3.4 mmol/L [<130 mg/dL]) had a statistically significant increase of 21.9% (CI, 12.4% to 31.3%). Mean LDL cholesterol level decreased by 0.5 mmol/L (18.8 mg/dL). Although mean hemoglobin A1c did not change, the proportion of persons with hemoglobin A(1c) of 6% to 8% increased from 34.2% to 47.0%. The blood pressure distribution did not change. Annual lipid testing, dilated eye examination, and foot examination increased by 8.3% (CI, 4.0% to 12.7%), 4.5% (CI, 0.5% to 8.5%), and 3.8% (CI, -0.1% to 7.7%), respectively. The proportion of persons reporting annual influenza vaccination and aspirin use improved by 6.8 percentage points (CI, 2.9 percentage points to 10.7 percentage points) and 13.1 percentage points (CI, 5.4 percentage points to 20.7 percentage points), respectively. LIMITATIONS: Data are self-reported, and the surveys do not have all National Diabetes Quality Improvement Alliance indicators. CONCLUSION: Diabetes processes of care and intermediate outcomes have improved nationally in the past decade. But 2 in 5 persons with diabetes still have poor LDL cholesterol control, 1 in 3 persons still has poor blood pressure control, and 1 in 5 persons still has poor glycemic control.

Chronic kidney disease: a public health problem that needs a public health action plan.

For a health problem or condition to be considered a public health issue, four criteria must be met: 1) the health condition must place a large burden on society, a burden that is getting larger despite existing control efforts; 2) the burden must be distributed unfairly (i.e., certain segments of the population are unequally affected); 3) there must be evidence that upstream preventive strategies could substantially reduce the burden of the condition; and 4) such preventive strategies are not yet in place. Chronic kidney disease meets these criteria for a public health issue. Therefore, as a complement to clinical approaches to controlling it, a broad and coordinated public health approach will be necessary to meet the burgeoning health, economic, and societal challenges of chronic kidney disease.

CDC/AHA Workshop on Markers of Inflammation and Cardiovascular Disease: Application to Clinical and Public Health Practice: report from the population science discussion group.

This article summarizes epidemiological studies of inflammation markers, particularly C-reactive protein, and cardiovascular disease as of early 2002. Gaps in the research and the public health practice implications are also discussed. Although considerable work has been published since this review was completed, the perspectives and issues presented are still useful in evaluating the use of inflammation markers for risk stratisfication and prevention.

Combination pharmacotherapy for cardiovascular disease prevention: threat or opportunity for public health?

In a series of three papers in the British Medical Journal (June 28, 2003), Wald et al. proposed that the Polypill can reduce the incidence of coronary heart disease by 88%, and stroke by 80%, if taken by all people aged > or = 55, as well as people of any age with existing cardiovascular disease or diabetes. We review the rationale and uniqueness behind this idea, identify the concerns and questions that need to be addressed, discuss whether this strategy is a threat or an opportunity for public health, and hope that this will stimulate further debate.

Prevention and control of coronary heart disease and stroke--nomenclature for prevention approaches in public health: a statement for public health practice from the Centers for Disease Control and Prevention.

Successful prevention and control of coronary heart disease and stroke requires extensive collaboration and strategic partnerships with many health and non-health-related organizations and agencies in the voluntary, public, and private sectors. To assure a common language and purpose and to facilitate communication in these multiple settings, a simplified classification of prevention levels for public health practice is essential. This statement proposes three levels of prevention (health promotion, primary prevention, and secondary prevention) as a guide for public health practice. This statement is also intended to inform the design, implementation, and evaluation of programs and research initiatives that address the prevention and control of coronary heart disease and stroke, and to enhance communication and dialogue among health professionals, policymakers, and the public.

A national progress report on diabetes: successes and challenges.

Over the last few decades, numerous public health agencies and other private and public organizations have sought to prevent and delay the disabling complications of diabetes by increasing the use of preventive care practices and reducing risk factors for complications among people with diabetes. Now, federal diabetes surveillance activities are yielding encouraging reports that progress is being made in increasing the use of preventive care practices, reducing risk factors for complications, and preventing or delaying diabetes complications. However, although several gains have been noted, levels of preventive care practices remain suboptimal, risk factors for diabetes complications are too prevalent, and diabetes complications are too pervasive. Furthermore, with compelling evidence that the onset of diabetes can be prevented or delayed among adults at high risk, prevention of diabetes has become a major new challenge. Additional efforts are needed to address the growing problems of obesity and physical inactivity, to identify the most efficacious and cost-effective prevention strategies and interventions, and to implement surveillance activities that allow us to gauge our success. Although progress has been made against diabetes complications, the current epidemic of diabetes increases the urgency of primary prevention efforts.

Primary prevention of type 2 diabetes mellitus by lifestyle intervention: implications for health policy.

More than 18 million Americans currently have diabetes mellitus. The economic and human cost of the disease is devastating. In the United States, diabetes is the most common cause of blindness among working-age adults, the most common cause of nontraumatic amputations and end-stage renal disease, and the sixth most common cause of death. For the cohort of Americans born in 2000, the estimated lifetime risk for diabetes is more than 1 in 3. In the next 50 years, the number of diagnosed cases of diabetes is predicted to increase by 165% in the United States, with the largest relative increases seen among African Americans, American Indians, Alaska Natives, Asian and Pacific Islanders, and Hispanic/Latino persons. Compelling scientific evidence indicates that lifestyle change prevents or delays the occurrence of type 2 diabetes in high-risk groups. This body of evidence from randomized, controlled trials conducted in 3 countries has definitively established that maintenance of modest weight loss through diet and physical activity reduces the incidence of type 2 diabetes in high-risk persons by about 40% to 60% over 3 to 4 years. The number of persons at high risk for type 2 diabetes is similar to the number of persons who have diabetes. This paper summarizes scientific evidence supporting lifestyle intervention to prevent type 2 diabetes and discusses major policy challenges to broad implementation of lifestyle intervention in the health system.

Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the U.S.

OBJECTIVE: To examine trends in the prevalence of diagnosed and undiagnosed diabetes and the proportion of total cases previously diagnosed, according to obesity status in the U.S. over the past 40 years. RESEARCH DESIGN AND METHODS: We assembled data from five consecutive cross-sectional national surveys: National Health Examination Survey I (1960-1962), National Health and Nutrition Examination Survey (NHANES) I (1971-1974), NHANES II (1976-1980), NHANES III (1988-1994), and NHANES 1999-2000. Diagnosed diabetes was ascertained, and height and weight were measured in adults aged 20-74 years in all surveys. In NHANES II, NHANES III, and NHANES 1999-2000, a fasting glucose level > or =126 mg/dl was used to identify cases among individuals not reporting diabetes. Design-based analyses and Bayesian models estimate the probability that prevalence of diabetes increased within four BMI groups (<25, 25-29, 30-34, and > or =35 kg/m2). RESULTS: In the U.S. population aged 20-74 years between 1976-1980 and 1999-2000, significant increases in the prevalence of diagnosed diabetes (3.3-5.8%, probability >99.9%) were accompanied by nonsignificant increases in undiagnosed diabetes (2.0-2.4%, 66.6%). This resulted in an increase in total diabetes (5.3-8.2%, >99.9%) and a modest nonsignificant increase in the proportion of cases that were diagnosed (62-70%, 62.4%). However, these trends varied considerably by BMI level. In individuals with BMI > or =35 kg/m2, diagnosed diabetes increased markedly (from 4.9% in 1960, to 8.6% during 1976-1980, to 15.1% in 1999-2000; probability >99.9%), whereas undiagnosed diabetes declined considerably (12.5% during 1976-1980 to 3.2% in 1999-2000, probability of increase 4.5%) Therefore, the proportion of total diabetes cases that were diagnosed increased from 41 to 83% (probability 99.9%) among individuals with BMI > or =35 kg/m2. By comparison, changes in prevalence within BMI strata <35 kg/m2 were modest and there was no increase in the percent of total cases that were diagnosed. CONCLUSIONS: National surveys over the last several decades have found large increases in diagnosed diabetes, particularly in overweight and obese individuals, but this has been accompanied by large decreases in undiagnosed diabetes only among individuals with BMI > or =35 kg/m2. This suggests that improvements in diabetes awareness and detection are most prominent among this subgroup.

Community-based lifestyle interventions to prevent type 2 diabetes.

OBJECTIVE: To conduct a literature review of community-based interventions intended to prevent or delay type 2 diabetes. RESEARCH DESIGN AND METHODS: Recently published findings about the potential to prevent or delay type 2 diabetes with intensive lifestyle interventions prompted a literature search for community-based diabetes prevention interventions. The literature review design was a search of databases for publications in 1990-2001 that identified reports on community-based interventions designed to prevent or modify risk factors for type 2 diabetes. RESULTS: The search revealed 16 published interventions, 8 of which were conducted in the U.S. and involved populations disproportionately burdened by diabetes (e.g., American Indians, Native Hawaiians, Mexican Americans, and African Americans). Of the studies reporting results among youth, there were posttest improvements in intervention groups in knowledge, preventive behaviors, and self-esteem. Among studies reporting results among adults, most reported improvements in intervention groups in knowledge or adoption of regular physical activity. Several investigators offered important reflections about the process of engaging communities and sharing decision making in participatory research approaches, as well as insights about the expectations and limitations of community-based diabetes prevention research. Many of the studies reported limitations in their design, including the lack of control or comparison groups, low response rates or lack of information on nonresponders, or brief intervention periods. CONCLUSIONS: There is a critical need to conduct and publish reports on well-designed community-based diabetes prevention research and share information on the process, results, and lessons learned. Armed with recent positive findings about diabetes prevention and literature documenting community-based efforts, advocates at local, state, and national levels can collaborate to stem the rising tide of diabetes in communities.

Obesity, metabolic syndrome, and type 2 diabetes: emerging epidemics and their cardiovascular implications.

As we enter the twenty-first century, the burden of chronic diseases, such as obesity, type 2 diabetes, and CVDs, is expected to increase dramatically. These diseases are a consequence of several factors that include an aging population,changes in demographic composition, and an excess of contemporary lifestyle. The prevention and control of overweight, obesity, metabolic syndrome, and diabetes pose special challenges for clinical and public heath practice as well as for basic, clinical, and population science research.

Aging Americans and diabetes. A public health and clinical response.

Aging Americans experience normal age-related physiological changes and an increased burden of diabetes. Responding to the burden of diabetes will require a public health and clinical response. This article discusses how the Division of Diabetes Translation (DDT) at the Centers for Disease Control and Prevention (CDC) translates scientific findings into public health practice and introduces a 4-article series written by DDT and external partners that provides an overview of diabetes treatment guidelines among the aging; the role of psychosocial processes in diabetes management; implementation of diabetes treatment guidelines; and Identifying resources for patient education.

The psychosocial aspects of diabetes care. Using collaborative care to manage older adults with diabetes.

Diabetes is a chronic disease that requires managing medications, adhering to dietary requirements, and engaging in age- and abilities appropriate physical activity. This article addresses the need for a collaborative care management approach that emphasizes a partnership between older adults and health care professionals. Such an approach recognizes that patients are the experts about their lives and primary care providers are experts about diabetes. A collaborative care management approach can help primary care providers assist older adults to address psychosocial concerns, cognitive functioning, and depression. We conclude this article with a brief discussion regarding a transdisciplinary approach that takes the collaborative care management approach one step further.