At the end of April 2011, the World Health Organization (WHO) released its first Global Status Report on Non-Communicable Diseases (NCDs) that included cardiovascular disease, diabetes, cancer, and chronic respiratory disease. Following the release of this report, WHO director general Dr Margaret Chan stated in a press conference that “The rise in chronic non-communicable diseases presents an enormous challenge … For some countries, it is no exaggeration to describe the situation as an impending disaster; a disaster for health, for society, and most of all for national economies.” According to the executive summary by Dr Chan, the report is meant to provide countries with an overview of the current status of NCDs and what is being done to address these diseases worldwide. More importantly, the final two chapters of the report address steps that countries can take to address the epidemic. This initial report will have a follow-up report in 2013 to assess the progress countries are making in preventing NCDs. The report has particular focus on low-to-middle income countries, which are estimated to carry 80% of the burden from NCDs. In 2008, 63% of global deaths (36 million) were attributable to NCDs, and it is expected that these numbers will continue to increase unless steps are taken to prevent the development of NCDs and associated risk factors. Diabetes alone was estimated to have a global prevalence of approximately 10%, with higher prevalence in the Eastern Mediterranean region and the Region of the Americas (11% for both males and females), with the lowest prevalence in European and Western Pacific Regions (9% for both males and females).1 The report also reiterates the significant role that impaired glucose tolerance and impaired fasting glycemia have on the future development of cardiovascular disease, cerebrovascular disease, retinopathy, nephropathy, and neuropathy. What was particularly sobering to learn was that not only does diabetes account for up to 15% of national health budgets, but individuals with diabetes also require almost double to triple the amount of healthcare resources. NCDs impair economic development, and one study estimated that for every 10% increase in NCD, there was an associated 0.5% lower rate of annual economic growth. For example, in 2005 it was estimated that due to heart disease, stroke, and diabetes, losses in national income were US$18 billion in China, US$11 billion in the Russian Federation, US$9 billion in India, and US$3 billion in Brazil. These economic losses balloon to Interational$558 billion in China and I$237 billion in India when estimating national income losses from 2005–2015. When looking at obesity in China, it is estimated that the total direct and indirect cost will account for 9% of China’s gross national product by 2025.1 An important thing to keep in mind about NCDs is that they are preventable. The report identifies four main behavioral risk factors fueling the increasing prevalence of NCDs: tobacco, insufficient physical activity, harmful use of alcohol, and an unhealthy diet. In addition, these four behavioral risk factors were associated with four key metabolic/physiological changes: increased blood pressure, obesity, hyperglycemia, and hyperlipidemia. Of the four behavioral risk factors, insufficient physical activity and an unhealthy diet were the most relevant in preventing obesity and diabetes. Previous studies have demonstrated that engaging in 150 minutes of moderate physical activity each week reduces the risk of diabetes by 27%.1 Unsurprisingly, the regions with the highest percentage of insufficient activity, the Eastern Mediterranean Region and the Region of the Americas, also had a higher prevalence of diabetes. When comparing income, high-income countries had the highest prevalence of insufficient activity as well as the highest consumption of total fat, including processed foods, saturated fats, and trans-fats.1 At the moment, the prevalence of diabetes is relatively consistent across low-, middle-, and high-income countries, but an increase in diabetes continues to be seen in low- and middle-income countries. This trend does not bode well for the future, as the WHO report emphasized that individuals with an NCD who are in a lower social and economic position tend to get sicker and die sooner than their wealthier counterparts. With regards to obesity, in 2008 an estimated 205 million men and 297 million women over the age of 20 were obese (BMI > 30 kg/m2). Unlike diabetes, there was a significant difference in obesity prevalence between low-income countries (7%) and high-income countries (24%). A similar pattern was seen when looking at obesity prevalence in infants and children; however, what was particularly worrisome in the report was that the fastest increase in overweight infants and children was seen in low-middle-income countries. As Western lifestyles continue to be adopted by low- and middle-income countries, the NCD epidemic is likely to grow unless steps are taken to prevent these diseases from developing. In order to address the issue of prevention, the WHO report splits their discussion into population-based and individual-based strategies. The population-based strategies focused on preventing the four behavioral risks mentioned earlier. For encouraging physical activity, the WHO suggested promoting physical activity through mass media as the most cost-effective and feasible way. Other strategies, including supporting active transport, promoting physical activity at work and school, and offering counseling in a primary care setting, have not yet been shown to be as cost-effective. The most cost-effective strategies for a healthy diet included reducing salt intake, replacing trans-fats with polyunsaturated fats, replacing saturated fats with unsaturated fats, encouraging public awareness about a healthy diet, and restricting the marketing of food and beverages to children.1 For individual-based strategies for specific NCDs, the report includes the following measures to prevent and manage diabetes: Lifestyle interventions for high-risk individuals or individuals with type 2 diabetes Metformin for individuals at a high risk of developing type 2 diabetes Glycemic control in individuals with an HbA1c >9.0% to reduce microvascular disease Blood pressure control in individuals with a BP >130/80 mmHg to reduce macrovascular and microvascular disease Annual eye examinations to prevent serious vision loss Vigilant foot care to prevent serious foot disease Angiotensin-converting enzyme inhibitor use to prevent nephropathy and cardiovascular disease.1 Of the strategies listed, the report notes that blood pressure control, glycemic control, and foot care have also been shown to reduce healthcare costs. While many countries have improved their capacity to prevent NCDs, much of the health infrastructure is inadequately funded and not operational. Using comprehensive prevention strategies that are cost-effective and easily implemented will be important to prevent the development and progression of NCDs. We hope to see improvement on this front when the follow-up report comes out in 2013. The American Association of Clinical Endocrinologists (AACE) 20th annual meeting was held from 13–17 April in San Diego, CA, USA (http://am.aace.com, accessed April 2011). Although new research data were not a major part of this year’s conference, valuable updates were provided on numerous topics related to the clinical management of diabetes, the highlights of which are summarized below. On the second day of the conference, Dr Yehuda Handelsman, MD (Tarzana, CA), reviewed the new 2011 AACE diabetes guidelines,2 focusing on the recommendation for a comprehensive approach to managing diabetes. Some of the key changes he pointed out included the modified diagnostic criteria for diabetes: fasting plasma glucose (FPG) under 100 mg/dL and two-hour postprandial glucose (PPG) under 140 mg/dL are defined as normoglycemia; impaired fasting glucose (IFG) is defined as 100–125 mg/dL, while impaired glucose tolerance (IGT) is defined as a two-hour PPG reading of 140–199 mg/dL; diabetes is defined as FPG of 126 mg/dL or higher, two-hour PPG over 200 mg/dL, or A1c of ≥6.5%. According to the new guidelines, most people with diabetes should aim for A1c <6.5% (if it can be done safely). Young, newly diagnosed people with diabetes who are relatively healthy should aim for an A1c of <5.0–6.0%, while those who are sicker (multiple comorbidities, labile, short life expectancy) should aim for A1c >7.0%. Dr Handelsman elaborated on the AACE’s recommendations regarding A1c. The A1c should be considered as an additional optional diagnostic criterion, not as the primary criterion for diagnosis of diabetes. AACE/ACE suggest using traditional glucose criteria (oral glucose tolerance test and FPG) for diagnosis when feasible. A1c is not recommended for diagnosing type 1 diabetes or gestational diabetes, because they would catch patients much later in the diabetes continuum. In addition, A1c may be misleading in several ethnic populations, including African–American patients. It may also be misleading in a setting of various hemoglobinopathies, iron deficiency, hemolytic anemias, thalassemias, spherocytosis, and severe hepatic/renal disease. Dr Handelsman also discussed new gastrointestinal surgical recommendations for obesity and diabetes management. The new guidelines state that laparoscopic adjustable gastric banding could be considered for patients with type 2 diabetes with BMI >30 kg/m2 and Roux-en-Y gastric bypass could be considered for patients with type 2 diabetes with BMI >35 kg/m2. This latest development reflects the recent shift towards wider acceptance of bariatric surgery as a treatment option for obesity and diabetes, following on the heels of the expanded indication in the US for Allergan’s LAP-BAND and the recent International Diabetes Federation (IDF) position statement on bariatric surgery.3 As a reminder, the IDF position paper stated that bariatric surgery should be accepted in people who have diabetes and a BMI of ≥35 kg/m2, and in people with diabetes with a BMI between 30 kg/m2 and 35 kg/m2 who have failed other therapies and have one or more comorbidity. One last important topic Dr Handelsman covered was the new goals for comprehensive care of diabetes and cardiovascular disease. The new guidelines suggest that people at the highest CV risk should target LDL levels of <70 mg/dL while those at high CV risk should target LDL levels of <100 mg/dL. Those at the highest risk should target non-HDL cholesterol levels of <100 mg/dL, while those at high risk should target non-HDL levels of <130 mg/dL. Injecting his opinion, Dr Handelsman asserted that non-HDL cholesterol should be <82–84 mg/dL for the highest risk patients. Men should target HDL levels >40 mg/dL, while women should target HDL levels >50 mg/dL. All should target blood pressure <130/80 mmHg. Aspirin use is appropriate for secondary prevention of cardiovascular disease, and for primary prevention for extremely high-risk patients. On the technology side, Irl Hirsch, MD (University of Washington, Seattle, WA, USA), reviewed the AACE consensus statement on continuous glucose monitoring (CGM) that was first released in October 2010.4 Looking at the bigger picture, Dr Hirsch noted that CGM is not an end, but rather, a component of the artificial pancreas as we “patiently await its further development”. He asserted that in the meantime, we need a smart insulin pen device with a memory chip, bolus calculator, and downloading capacity integrated into CGM. In summary, Dr Hirsch stated that: (i) CGM has a steep learning curve for clinical endocrinologists; (ii) the technology is still young and far from perfect (with regards to accuracy and lag times); (iii) due to a lack of reimbursement, there is a lack of widespread adoption of the technology and many patients who could benefit have not been able to get access to the technology; and (iv) as reimbursement improves, it is thought that more widespread use will occur. Dr Hirsch noted that reimbursement for the technology itself was in fact improving, but reimbursement for the clinician’s time has not been. The AACE consensus statement provides excellent recommendations for the best reimbursement, but coverage is “patchy at best”; it provides many resources, including a link to the JRDF’s resource on CGM payer larger health plan coverage (http://www.jdrf/org/index.cfm?page_id=111282). Dr Hirsch noted that in the future, he would like to see trials with longer follow-up (three to five years) documenting the efficacy of CGM, improved accuracy (mean absolute relative difference <10%), and greater attention to the economic analysis of CGM. Interestingly, in a separate session, Bruce Bode, MD, FACE (Atlanta Diabetes Association, Atlanta, GA, USA), mentioned that “game-changing” data on CGM in type 2 diabetes would be presented at the American Diabetes Association’s 71st Scientific Sessions this summer in San Diego, CA, in a late-breaking abstract, which, in his view, could “change the entire course of CGM in diabetes”. After providing various definitions for prediabetes (IFG, IGT, A1c between 5.7–6.4%), Alan Garber, MD, PhD (Baylor College of Medicine, Houston, TX, USA), outlined AACE’s two-track approach for the management of prediabetes, emphasizing that clinicians should aim to lower glucose to prevent microvascular complications and address cardiovascular disease risk factors. Notably, Dr Garber stated that for those with prediabetes for whom lifestyle intervention is not able to revert prediabetes, pharmacotherapies (weight-loss agents and/or antidiabetic agents) could be considered, including orlistat (alli/Xenical), metformin, and acarbose. In high-risk patients with prediabetes, thiazolidinediones and incretins could also be considered. Dr Garber highlighted the recently published ACT NOW trial in which pioglitazone was shown to prevent 72% of the progression to diabetes.5 Similarly, in a trial examining the effects of the glucagon-like peptide (GLP)-1 agonist liraglutide (Novo Nordisk’s Victoza) on body weight, 63% of people with prediabetes at baseline normalized their glycemic control with the highest doses of liraglutide tested (2.4 mg and 3.0 mg), compared to only 32% with orlistat.6 In conclusion, Dr Garber stressed that preventing the progression of prediabetes to diabetes is cost effective, and, in some cases, even cost saving. Outside of the discussions on AACE’s new diabetes guidelines, there were also several interesting presentations on recent research developments. Douglas Muchmore, MD (Halozyme Therapeutics, San Diego, CA, USA), presented data from Halozyme’s first pump study with its synthetic hyaluronidase (PH20). PH20 acts locally and transiently to depolymerize subcutaneous hyaluronate, allowing bulk free flow in the interstitial and subcutaneous space. In previous trials, the subcutaneous injection of PH20 was shown to accelerate the absorption and action of co-injected insulin glulisine, insulin aspart, and insulin lispro.7 The study presented by Dr Muchmore compared the co-administration of insulin aspart and PH20 (insulin aspart–PH20) to insulin aspart alone via an insulin pump in 18 patients with diabetes over a 72-hour period. Overall, the study found insulin aspart–PH20 to have faster-in and faster-out profiles compared to insulin aspart alone. Insulin aspart–PH20 increased insulin absorption by 64% in the first hour following a bolus (P < 0.0001), and decreased insulin exposure beyond two hours by 42% (P = 0.0003). While insulin aspart–PH20 was generally well tolerated, there was a higher rate of nervous system disorders (headache, dizziness) with this combination (four events) compared to insulin aspart alone (zero events). In conclusion, Dr Muchmore noted that the current pump study results show that the PK and glucodynamic findings previously demonstrated with subcutaneous injections of PH20 are also observed with pump therapy. Finally, Robert Henry, MD (University of California San Diego School of Medicine, San Diego, CA, USA), presented the results from a meta-analysis on seven phase 3 clinical trials (the six LEAD studies plus the 1860 study) for liraglutide to compare the effectiveness of this drug to other commonly used anti-diabetic agents across a range of baseline A1c values. Overall, each anti-diabetic therapy was observed to improve glycemic control across all baseline A1c groups, with increasing effectiveness as the baseline A1c increased. Average A1c reductions achieved with liraglutide 1.8 mg, however, were generally significantly greater than those observed with thiazolidinediones, sulfonylurea, and sitagliptin. Liraglutide 1.8 mg was only found to be significantly more effective than exenatide in the group of patients with a baseline A1c of >9.0% and insulin glargine in patients with a baseline A1c <7.5%. Additionally, a greater proportion of individuals within each group achieved an A1c of <6.5% with liraglutide than the other therapies (except for insulin glargine in the >9.0% group). Altogether, Dr Henry argued that the results from this analysis indicate that liraglutide could be an effective therapy to improve blood glucose control, regardless of the A1c level. 2–5 June 2011, Shanghai, China: 1st Asia Pacific Congress on Controversies to Consensus in Diabetes, Obesity, and Hypertension (CODHy) (http://www.codhy.com/AP/2011) With the prevalence rates of diabetes and obesity in Asia already high and predicted to grow at alarming rates over the next several decades, we are glad to see more concentrated efforts focused on combating these epidemics in the region. The 1st Asia Pacific Congress on Controversies to Consensus in Diabetes, Obesity, and Hypertension (CODHy) will cover topics varying from the role of insulin, GLP-1 agonists, and dipeptidyl peptidase-4 inhibitors in the treatment of type 2 diabetes in Asia, to discussions on the merits of self-monitoring of blood glucose and CGM in diabetes management. In addition, the conference will include sessions on current hot topics in diabetes, such as sodium-glucose linked transporter-2 inhibitors, the implications of the Food and Drug Administration cardiovascular risk assessment requirements on clinical research in China, and bariatric surgery as a potential option early on in the treatment of obesity. 31 August–2 September 2011, Manila, Philippines: 6th Asia–Oceania Conference on Obesity (AOCO 2011) (http://www.obesity.org/ph) Centered around the theme “The Growing Problem of Obesity and Metabolic Syndrome: The Asia–Oceania Perspective”, the 6th Asia–Oceania Conference on Obesity (AOCO 2011) will include plenary talks on: (i) the hypothalamus, inflammation, and obesity; (ii) diet and central nervous system inflammation; (iii) inflammation, endoplasmic reticulum stress and metabolic control; (iv) adipocyte biology; and (v) the genetics of obesity. While it seems that the plenary talks will focus heavily on basic science and research, numerous symposia will focus on more immediate aspects of obesity management, including sessions on physical activity intervention programs, controversies in dietary management, and behavioral strategies.