Title: PREVENTION & DIABETES & OBESITY
1PREVENTION DIABETES OBESITY
- Ask not what your body can do for you. Ask what
you can do for your body. -
- (With apologies to JFK)
23 Types of Prevention
- Primary
- Secondary
- Tertiary
- How does each apply to the present topics?
3Diabetes
- 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
4DIABETES Definitions
- Diagnosis ?
- Fasting
- Random
- OGTT
- Prediabetes
- IFG
- IGT
- Gestational
5Is 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 ?
6How 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
7Initial Goal in Weight Reduction
- 5 10 of initial body weight
- Why ?
8Nutritional 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
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10Exercise
- ___ 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
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12Lifestyle 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
13Meds in DM Prevention
- Metformin
- Pioglitazone
- Exenatide
14Metformin
- 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
15Metformin
- Reduces inflammatory markers linked to CAD
(Fibrinogen CRP) - Reduces TGs by 10 30
- Reduces LDL by 5 10
16Pioglitazone
- Insulin sensitizer
- Preserves beta cell fxn
- Retards progression to T2DM
- ACT NOW
17Exenatide
- 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 .
19Screening 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)
20Criteria 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
21Screening 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
22Detection 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
23Screening 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)
24Screening 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
25Secondary Prevention in Diabetes
- How do we do it?
- TLC
- Meds
- Bariatric Surgery
26Tertiary Prevention in DM
- What are we trying to prevent ?
- Microvascular Complications
- Nephropathy
- Neuropathy
- Retinopathy
- Macrovascular Complications
- CAD
- CVA
27How Do We Screen in T2DM ?
- Annual retinoscopy
- Annual creatinine
- Annual microalbuminuria
- Annual lipids (if _at_ goal)
- Annual feet neuro exam
- Resting ECG ?
- Stress Test ?
28How 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
29GOALS ?
- Glycemia ?
- Hgb A1C , 7 or 6.5 or 6.0
- BP ?
- lt 130/80
- Smoking?
- Control Lipids
- lt 100 or lt 70
30Tertiary Preventive Meds in DM
- ACEI or ARB
- Statin
- Aspirin
- Immunizations
- Pneumovax
- Fluvax
- tDap
31Statin 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.
32Antiplatelet 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.
33OBESITY(Very closely related to DM)
34Obesity Trends
35Obesity Trends
36Obesity 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
37Obesity 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
38Obesity 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
39Obesity 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
40For kids, the greatest predictor for obesity is
having obese parents
41Obesity 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
42Supersize It !
43Preventing 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
44What 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
45What 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
46BMI 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
47React 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
48What 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
49Know Community Resources
50Patient 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
51For 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
53Exercise
54Patient 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
55The Exercise Prescription
56The Exercise Prescription
57WWayne 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
58What 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
59What 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
60What 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
61Bibliography
- 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
62Goals 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)