Michael Boyne Department of Medicine Caribbean Institute for Health Research The UWI, Mona

1. Epidemiology of obesity in the Caribbean and its link with hypertension, diabetes and kidney disease Michael Boyne Department of Medicine Caribbean Institute for Health Research The UWI, Mona

3. Natural Progression of Weight Gain Eckel R H et al. JCEM 2011;96:1654-1663

4. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1998, 2007 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1998 1990 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

6. Global Burden of Obesity in 2005 and Projections to 2030 T. Kelly et al. International Journal of Obesity 32: 1431-37 (2008).

8. Age-adjusted prevalence of obesity in the African diaspora Obes Rev 1995; 3: 95-105S

9. Worsening adiposity in Jamaicans +6 kg in men +13 kg in women Annu Rev Nutr. 2001;21:47-71 West Indian Med J. 2011;60:422-8

10. Obesity is increasing:Barbados Fraser 1996

11. Mar 5, 2012 Health Minister Dr Fuad Khan concerned about the local obesity rate, which has risen from 25% to 55%. “Women in Trinidad and Tobago are becoming, sorry to say it ladies, fatter. And if you look at Carnival you will know what I’m talking about.”

12. Weight change in the African Diaspora BMC Public Health. 2008;8(1):133.

13. Diet has changed

14. 1-2% JHLSII 2008 >75% JHLSII 2008 N Engl J Med 2011 364: 2392-404

15. The largest Last Supper: depictions of food portions and plate size increased since 10th century Int J Obes 2010;34:943-4

16. Physical activity has changed Rural = urban

19. Y-Y Paradox:Limitations of BMI in individuals Y-Y-B Paradox:Limitations of BMI in individuals 18.8 21.5% 180 mins resistance 140 mins aerobic Yajnik CS and Yudkin JS. Lancet 2004: 363: 163

20. Boyne et al. Diabetes Res Clin Pract. 2010 ;90:e33-6.

22. Macrophages invade visceral adipose tissue when adipocytes die but with increased frequency in obesity Cinti, S. et al. J. Lipid Res. 2005;46:2347-2355

23. 1-2% JHLSII 2008 >75% JHLSII 2008 N Engl J Med 2011 364: 2392-404

24. Prevalence of hypertension and mean BMI among 7 populations of African diaspora Maywood Barbados St. Lucia Jamaica Cameroon urban Cameroon rural Nigeria Am J Public Health 1997;87:160-8

25. Prevalence of diabetes by mean BMI and sex in populations of West African origin Indian UK UK US US Caribbean African Caribbean West Africa West Africa

27. Obesity, diabetes, incidence and mortality in Cuba, 1980-2010 Franco M et al. BMJ 2013;346:bmj.f1515

28. Higher waist circumferences increase the risk of type 2 diabetes and hypertension in Jamaicans Obesity Rev 2002; 10: 792-8 Int J Obes 2000; 24: 180-6

29. Global Prevalence Rates of Undernourishment and Obesity Source: FAO for prevalence of undernourishment; G. Stevens, G et al. Population Health Metrics 10 (22): 1-16 (2012).

30. Estimated prevalence of SGA births (birth weight < 10th centile for GA) in LMIC • 32 million infants were born SGA in LMIC in 2010, ~ 27% of live births • ~ ½ of all low birth weight babies are SGA at full term and ½ are preterm • 2/3 are born in Asia Lancet Glob Health 2013;1:e26-36

32. Men Overweight Women High birth weight (via IGF-I) Low birth weight followed by rapid weight gain Infants Intergenerational cycle of overweight/ obesity ELDERLY PEOPLE overweight Tracking Metabolic syndrome ADOLESCENTS overweight Energy-dense diets and low levels of physical activity Reduced breastfeeding Tracking Earlier puberty Tracking CHILDREN overweight Women Poor nutrition Adapted from “Challenge of obesity in WHO European Region and strategies for response: Summary;” WHO 2007. BMJ. 1996; 312:156-60; Eur J Clin Nutr 2002; 56:506-11; J Clin Endocrinol Metab 2003; 88:1687-91; J Clin Endocrinol Metab 2010; 95: 3194-200.

33. What happens in stunting? % of children under age 5 yrs who are stunted (2005-2011) FAO (2013) COHORTS. Lancet 2013;382: 525 - 534

34. Principle components of body weight regulation in an obesogenic environment

36. Renal Adaptation to Obesity • Structural: renal hypertrophy as well as mesangial and podocyte abnormalities • Functional: ↑ GFR, ↑ RBF • Weisinger et al, 1974: severe obesity and nephrotic-range proteinuria in 4 women • proteinuria decreased with weight loss and reappeared with wt regain • Also described focal segmental glomerulosclerosis (FSGS) on histology which was different from other causes of proteinuria (e.g. diabetic nephropathy) Kidney Int 2001;59:1498-1509.5. Curr Opin Nephrol Hypertens 2011;20:44-49.

37. Obesity and CKD Outcomes • impaired pressure natriuresis • glomerular hypertension • endothelial dysfunction and vasoconstriction • matrix proliferation and expansion • microalbuminuria • obesity associated focal segmental glomerulosclerosis ↑ 10 x 1980s, as histologic changes appear to precede the clinical onset of microalbuminuria Weight loss and bariatric surgery helpful but not necessarily in ESRD Am J Transplant. 2010 ;10:2644-51 Mayo Clin Proc. 2010;85:991-1001

38. Relationship between number of risk factors at baseline and the odds of developing CKD • In the Framingham Offspring Study, obesity was associated with a 23% increase in CKD rates • OR 3.1 for developing ESRD patients with BMI > 30 (a risk ~ moderate degrees of proteinuria) CI indicates confidence interval. Risk factors considered included hypertension, diabetes, obesity (body mass index >30), and current tobacco use; results are age-adjusted and sex-adjusted. JAMA. 2004;291(7):844-850. JAMA 2004;291:844-850.3. Arch Intern Med 2009;169:342-350.

39. Mechanisms of obesity-induced renal injury and potential targeted treatments • Increased oxidative stress • Increased endoplasmic reticulum stress • Increased coagulability • impaired fibrinolysis Agrawal, V. et al.Nat. Rev. Nephrol. 2009 Sep;5(9):520-8.

40. Summary • Obesity epidemic continues! • Direct effects on incident hypertension and diabetes • Hypertension, adipocytokines, inflammation and oxidative stress can lead to renal disease • Need to prevent obesity using food policy, urban engineering and improving maternal-fetal care