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PREVENTION & DIABETES & OBESITY

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Ask not what your body can do for you. Ask what you can do for your body. (With apologies to JFK) * * * CVD risk factors: dyslipidemia, hypertension, smoking, a ... – PowerPoint PPT presentation

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Title: PREVENTION & DIABETES & OBESITY


1
PREVENTION DIABETES OBESITY
  • Ask not what your body can do for you. Ask what
    you can do for your body.
  • (With apologies to JFK)

2
3 Types of Prevention
  • Primary
  • Secondary
  • Tertiary
  • How does each apply to the present topics?

3
Diabetes
  • Is it a disease? What does labeling it a disease
    do?
  • Disempowers pts.
  • How about a lifestyle that does NOT match up
    with ones genetic make-up ?
  • People with famine genes do poorly with
    inactivity and an unhealthy diet

4
DIABETES Definitions
  • Diagnosis ?
  • Fasting
  • Random
  • OGTT
  • Prediabetes
  • IFG
  • IGT
  • Gestational

5
Is there PRIMARY prevention for Diabetes?
  • Natural Hx of Type 2 DM ?
  • Progression of this natural Hx occurs over a
    period of ______ ?
  • 7 10 years
  • Is there evidence that we can slow and/or stop
    this progression?
  • A definite YES!
  • HOW ?

6
How to Retard the progression to T2DM
  • Have to break the pathophysiology of T2DM
  • At present, the best way is ____ ?
  • Lifestyle Intervention
  • Of what does TLC in DM consist?
  • Weight Loss Tobacco Cessation (Why?)
  • Nutritional therapy
  • Exercise prescription
  • Sleep Hygiene
  • After that, we can do what?
  • Use pharmacotherapy

7
Initial Goal in Weight Reduction
  • 5 10 of initial body weight
  • Why ?

8
Nutritional Therapy
  • Foods that improve insulin sensitivity
  • Reduce Carbohydrate intake
  • More Fiber
  • More whole grains
  • Saturated fat lt 7 total calories
  • Minimize Trans fats
  • Reduce cholesterol to lt 200 mg/day

9
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10
Exercise
  • ___ minutes of moderate activity per ____
  • 150 per WEEK
  • At least 30 minutes per day for 5 days a week
  • No more than ___ hrs between periods of activity
  • 24
  • Perform _at_ ____ max predicted heart rate
  • 50 70
  • Does exercise work even w/o weight loss ?
  • A Cochrane

11
(No Transcript)
12
Lifestyle Intervention
  • Reduced RR for T2DM by 58
  • Works in all ages and with all BMIs and with all
    levels of IFG IGT
  • DM Prevention Program, 2000 NEJM

13
Meds in DM Prevention
  • Metformin
  • Pioglitazone
  • Exenatide

14
Metformin
  • Insulin sensitizer
  • Reduced RR of progression by 31
  • Can induce weight loss
  • Most effective in pts. lt 45 y.o. and with BMI gt
    35
  • Also most effective in those with IFG gt 110
  • No evidence for additive nor synergy when added
    to TLC
  • DM Prevention Program (NEJM, 2002) UKPDS

15
Metformin
  • Reduces inflammatory markers linked to CAD
    (Fibrinogen CRP)
  • Reduces TGs by 10 30
  • Reduces LDL by 5 10

16
Pioglitazone
  • Insulin sensitizer
  • Preserves beta cell fxn
  • Retards progression to T2DM
  • ACT NOW

17
Exenatide
  • Reduces hyperglucogonemia
  • Enhances satiety
  • Promotes weight loss
  • Promotes expansion of beta cell mass
  • Improves 1st phase insulin response

18
  • If all of the above fails, then what?
  • Bariatric Surgery is an option .

19
Screening Diabetes in Asymptomatic Adults
  • Adults who are overweight (BMI gt 25) or obese
    AND who have one or more risk factors for DM.
    Otherwise testing should begin at age 45. (B)
  • If tests are normal, repeat testing at least at
    3-year intervals. (E)
  • In those identified with pre-diabetes, treat
    other CVD risk factors. (B)
  • Monitoring for development of DM in pre-diabetics
    is every year. (E)

20
Criteria for testing for pre-diabetes and
diabetes in asymptomatic adult individuals
  • Testing should be considered in all adults who
    are overweight (BMI _25 kg/m2) AND
  • have additional risk factors
  • physical inactivity
  • first-degree relative with diabetes
  • members of a high-risk ethnic population (e.g.,
    African American, Latino, Native
  • American, Asian American, and Pacific Islander)
  • women who delivered a baby weighing gt 9 lb or
    were diagnosed with GDM
  • hypertension (gt140/90 mmHg or on therapy for
    hypertension)
  • HDL cholesterol level lt35 mg/dl (0.90 mmol/l)
    and/or a triglyceride level gt250
  • mg/dl (2.82 mmol/l)
  • women with polycystic ovarian syndrome (PCOS)
  • IGT or IFG on previous testing
  • other clinical conditions associated with
    insulin resistance (e.g., severe obesity
  • and acanthosis nigricans)
  • history of CVD

21
Screening for DM type II in Children
  • Screen those who are overweight (BMI gt85th for
    age and sex, weight for height gt85, or weight
    gt120 of ideal for height)
  • AND 2 of the following risk factors (E)
  • Family hx of DM in 1st or 2nd degree relative.
  • Race/ethnicity (Native American, African
    American, Latino, Asian American, Pacific
    Islander)
  • Signs of insulin resistance (acanthosis nigrans,
    htn, dyslipidemia, or PCOS)
  • Maternal h/o DM or GDM

22
Detection and Diagnosis of GDM
  • Screen for GDM using risk factor analysis and, if
    appropriate, use of an OGTT. (C)
  • Women with GDM should be screened for DM at 6-12
    weeks postpartum and should be followed up with
    subsequent screening for the development of
    diabetes or pre-diabetes. (E)
  • TLC metformin both can prevent the future
    development of T2DM in women with a Hx of GDM

23
Screening for GDM
  • Carry out GDM risk assessment at the first
    prenatal visit.
  • Women at very high risk for GDM should be
    screened for diabetes as soon as possible after
    the confirmation of pregnancy.
  • Criteria for very high risk are
  • Severe obesity
  • Prior history of GDM or delivery of
    large-for-gestational-age infant
  • Presence of glycosuria
  • Diagnosis of PCOS
  • Strong family history of type 2 diabetes
  • Screening/diagnosis at this stage of pregnancy
    should use standard diagnostic testing (FPG, OGTT)

24
Screening for GDM
  • All women of higher than low risk of GDM,
    including those above not found to have diabetes
    early in pregnancy, should undergo GDM testing at
    2428 weeks of gestation.
  • Low risk status, which does not require GDM
    screening, is defined as women with ALL of the
    following characteristics
  • Age lt25 years
  • Weight normal before pregnancy
  • Member of an ethnic group with a low prevalence
    of diabetes
  • No known diabetes in first-degree relatives
  • No history of abnormal glucose tolerance
  • No history of poor obstetrical outcome

25
Secondary Prevention in Diabetes
  • How do we do it?
  • TLC
  • Meds
  • Bariatric Surgery

26
Tertiary Prevention in DM
  • What are we trying to prevent ?
  • Microvascular Complications
  • Nephropathy
  • Neuropathy
  • Retinopathy
  • Macrovascular Complications
  • CAD
  • CVA

27
How Do We Screen in T2DM ?
  • Annual retinoscopy
  • Annual creatinine
  • Annual microalbuminuria
  • Annual lipids (if _at_ goal)
  • Annual feet neuro exam
  • Resting ECG ?
  • Stress Test ?

28
How do we do tertiary prevention in DM ?
  • Control the glycemia
  • Control BP
  • Smoking Cessation
  • Control Lipids
  • Education
  • Screen for the complications
  • Early treatment of complications
  • Meds

29
GOALS ?
  • Glycemia ?
  • Hgb A1C , 7 or 6.5 or 6.0
  • BP ?
  • lt 130/80
  • Smoking?
  • Control Lipids
  • lt 100 or lt 70

30
Tertiary Preventive Meds in DM
  • ACEI or ARB
  • Statin
  • Aspirin
  • Immunizations
  • Pneumovax
  • Fluvax
  • tDap

31
Statin Therapy
  • Statin therapy added to LTM regardless of
    baseline lipid values for diabetic patients
  • With overt cardiovascular disease (CVD) (A)
  • OR
  • gt40 yoa without CVD but one or more CVD risk
    factors. (A)
  • Consider adding statin in other patients (lt40 yoa
    without overt CVD) if LDLgt100 OR w/ mult CVD risk
    factors.(E)
  • CVD RF including dyslipidemia, hypertension,
    smoking, a positive family history of premature
    CAD, or presence of micro or macroalbuminuria.

32
Antiplatelet Agents
  • Use Aspirin (ASA) 75-162 mg/day as a secondary
    prevention in DM with h/o CVD. (A).
  • Use ASA (75-162 mg/day) as a primary prevention
    in those w/ type I or type II DM with increased
    CVD risk (A)
  • gt40 years of age OR
  • Fmhx CVD, hypertension, dyslipidemia, smoking, or
    albuminuria.

33
OBESITY(Very closely related to DM)
34
Obesity Trends
35
Obesity Trends
36
Obesity Trends
  • Kids as young as 4 y.o. have adult illnesses
  • T2DM, HTN, CAD
  • gt 25 of growth of health care spending is
    caused by obesity
  • Obese kids are 5-10 X more likely to be depressed
  • Obesity is the 2nd leading
  • cause of death in US

37
Obesity Trends
  • 14 of cancer deaths in men 20 in women are
    due to obesity
  • Each MONTH, SSA pays 77 million for
    obesity-related disability
  • For each 2 hrs of TV/day
  • for a woman, her risk
  • for obesity grows
  • 23 for T2DM, 14

38
Obesity Trends
  • The most popular vege eaten by kids 19-24 m.o. is
  • French Fries
  • Avg teen boy drinks __ 12 oz sodas/day which __
    gals/yr
  • 2 68
  • For girls, its 1.4 48
  • This 86 62 lbs of sugar

39
Obesity Trends
  • Due to law, No Child Left Behind, schools have
    cut out P.E. recess.
  • BUT, P.E. results in better school btest
    performance
  • How about a new law,
  • No Child Left
  • on His Behind

40
For kids, the greatest predictor for obesity is
having obese parents
41
Obesity Trends
  • Supersize it!
  • From 1977 to 1998, the following growth occurred
  • Avg soda from 13 oz to 20
  • Avg cheeseburger from 397
  • Kcal to 533
  • Salty snacks from 132 kcal
  • to 225

42
Supersize It !
43
Preventing Obesity ?
  • What can we do?
  • Know the above facts
  • Get involved
  • Apply these facts to your patients,
    individually, by family, by population.
  • Implement means to attack the problem,
    individually and population-based

44
What Can we Do ?
  • Assess patients and families
  • //bms.brown.edu/nutrition/acrobat/REAP206
  • Eating activity assessmen
  • //bms.brown.edu/nutrition/acrobat/wave
  • Wgt, activity variety Excess
  • Offer counseling all kids ref behaviors that can
    prevent excessive wgt gain
  • Educate parents
  • No studies on effects of particular behaviors on
    wgt management, but
  • Counseling is the KEY component

45
What can we do?
  • At EVERY visit for EVERY patient, record a BMI
    get a table or BMI calculator
  • Properly label the problem
  • Underweight lt 18.5
  • Normal weight 18.5 - 25
  • Overweight gt25 to lt 30
  • Obese 30 to lt 40
  • Morbidly Obese 40 or more

46
BMI in Kids
  • Labels are based on BMI percentiles, not weight
    -iles
  • BMI //apps.nccd.cdc.gov/dnpabmi/calculator.as
    px
  • gt 75th to 84th Caution and close observe
  • 85th to 94th Overweight
  • 95th more Obese

47
React to the Problem
  • Educate and Advise patients ref obesity and
    weight loss use Readiness to Change phases to
    guide advice
  • With a health professional recommending to them
    weight loss, there is a ___ fold increase in the
    odds the patient will try.
  • 3
  • Yet, only ___ of obese patients are given such
    advice.
  • 42

48
What Is our Reaction?
  • Know good nutritional and weight loss programs.
  • Know Community Resources
  • Call Ann Dunlop
  • Know what to advise your patients
  • Set the example for your patients and co-workers
  • Get involved _at_ institutional community levels

49
Know Community Resources
50
Patient Advice
  • Diet
  • For T2DM, remember earlier slide
  • For non DM, Which weight loss program has had the
    greatest success?
  • Weight Watchers
  • Which single diet plan has just recently been
    shown to effect more weight loss?
  • Low Carb
  • Exercise

51
For Growing Kids
  • Advice on weight maintenence, slowing of wgt
    gain, or weight loss depends on the age of child
    and the BMI percentile
  • See Bibliography for a table that presents these
    options

52
EXERCISE
53
Exercise
54
Patient Advice on Exercise
  • Refer to previous slide w.r.t. goal heart rate
    and duration and frequency.
  • How many variables are there to consider in an
    exercise regimen and preventing injury?
  • 7
  • Type exercise Frequency of exercise
  • Intensity of exercise Duration of exercise
  • Flexibility Technique
  • Equipment
  • Write an exercise prescription

55
The Exercise Prescription
56
The Exercise Prescription
57
WWayne Blount, superstar
40
Walk 10 minutes at a time, 3 times per day, 5
days per week. Get heart rate to 90 to 125
beats per minute.
XX
58
What Other Advice ?
  • Plan healthy snacks
  • Minimize sugar-sweetened beverages
  • Limit meals away from home
  • Serve appropriate portion sizes
  • Limit screen time
  • Zero for kids lt 2 y.o.
  • lt 2 hrs/day for kids gt 2 y.o.
  • Increase active time to gt 60 mins/day

59
What to do _at_ other levels ?
  • Educate your community
  • Get the junk food vending machines out of schools
    and institutions
  • Start a weight loss program
  • Get involved with PTA and communnity govt.
  • Get help from those who know and have succeeded
    www.SuperSizedKids.com

60
What About Pharmacotherapy?
  • 2 meds approved
  • Sibutramine (Meridia)
  • Approved for age gt 16 y.o.
  • Orlistat (Alli, Xenical)
  • Approved for age gt 12 y.o.
  • No data on bariatric surgery in kids/teens

61
Bibliography
  • For caloric content of foods
    www.annecollins.com/calories/
  • Cochrane Collaboration
  • www.SuperSizedKids.com
  • Barlow SE. Pediatrics.2007120Supplement
  • Stenardo Slusser. AAFP CME bulletin. Sept.
    20087
  • Readiness to Change
  • www.aafp.org/20000301/1409.
  • Fast Food Families. DVD from NCAFP

62
Goals of Treatment
  • Primary goal of LDL lt 100 without overt CVD. (A)
  • Optional goal of LDL lt70 with overt CVD using
    high dose statin therapy (E).
  • Alternative therapeutic goal of LDL reduction of
    40, if above LDL goal not achieved with maximal
    therapy. (A)
  • LDL cholesterol targeted statin therapy remains
    the preferred strategy. (C)
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