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Natalie Alméras, Ph.D . Quebec Heart and Lung Institute

Preventive intervention in Diabetes Weight Loss Is Not the Optimal Target. Natalie Alméras, Ph.D . Quebec Heart and Lung Institute Department of Kinesiology , Faculty of Medicine , Université Laval Québec, CANADA. Public Health 2014 Canadian Public Health Association.

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Natalie Alméras, Ph.D . Quebec Heart and Lung Institute

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  1. Preventive intervention in Diabetes Weight Loss Is Not the Optimal Target Natalie Alméras, Ph.D. QuebecHeart and Lung Institute Department of Kinesiology, Facultyof Medicine, Université Laval Québec, CANADA Public Health 2014 Canadian Public Health Association

  2. Typical Profile of the Canadian Patient with Type 2 DiabetesManaged in PrimaryCare • Age: 63 years • BMI: • Men=30.3 kg/m2 • Women=31.4 kg/m2 • HbA1c: 6.9% • Blood pressure: 130/76 mmHg • LDL-cholesterol: 1.9 mmol/L • Dyslipidemia: 55.4% • Hypertension: 68.2% • Sedentarylifestyle: 56.5% (reported!!!) • Current or previoussmoker: 32.7% From Teoh H et al. Diabetes ObesMetab 2013;15:1093-1100

  3. Typical Profile of the Canadian Patient with Type 2 Diabetes More drugs? More patients taking theirmeds!!! Only 12% achievedcombined ABC Targets!!! • Age: 63 years • BMI: • Men=30.3 kg/m2 • Women=31.4 kg/m2 • HbA1c: 6.9% • Blood pressure: 130/76 mmHg • LDL-cholesterol: 1.9 mmol/L • Dyslipidemia: 55.4% • Hypertension: 68.2% • Sedentarylifestyle: 56.5% (reported!!!) • Current or previoussmoker: 32.7% Adapted from Teoh H et al. Diabetes ObesMetab 2013;15:1093-1100

  4. Typical Profile of the Canadian Patient with Type 2 Diabetes Diet? Physicalactivity? • Age: 63 years • BMI: • Men=30.3 kg/m2 • Women=31.4 kg/m2 • HbA1c: 6.9% • Blood pressure: 130/76 mmHg • LDL-cholesterol: 1.9 mmol/L • Dyslipidemia: 55.4% • Hypertension: 68.2% • Sedentarylifestyle: 56.5% (reported!!!) • Current or previoussmoker: 32.7% Adapted from Teoh H et al. Diabetes ObesMetab 2013;15:1093-1100

  5. Proportion of Patients with and without Type 2 DiabeteswhoReceivedRecommendations on HealthyLifestyleChanges fromtheirPrimary Care Physicians Adapted from Teoh H et al. Diabetes ObesMetab 2013;15:1093-1100

  6. The CurrentEpidemicof Obesity, Type 2 Diabetes and CVD: ChronicSocietalMetabolicDiseases

  7. In the Québec Province… 720,000 withdiabetes in Québec Source : Diabète Québec 2014

  8. Behaviors: Forgotten Componentsof IdealCardiovascular Health 4 idealhealthbehaviors: • Nonsmoking • BMI<25 kg/m2 • Physicalactivityat goal levels (150 min. moderate/week) • Healthydiet score 3 favorable healthbiologicalfactors: • Cholesterol (untreated) <200 mg/dL (5.2 mmol/L) • Blood pressure (untreated) <120/<80 mm Hg • Absence of diabetes and glucose <100 mg/dL (5.6 mmol/L) Absence of clinical CVD From Lloyd-Jones DM et al. Circulation 2010;121:586-613

  9. Adapted from Folsom AR et al. J Am CollCardiol2011;57:1690-6 Incidence Rate of Cardiovascular Disease According to the Number of Ideal Health Behaviors and Health Factors Age, sex, and race-adjusted incidence rate (/1,000 person-year) Number of ideal health factors=0 Number of ideal health factors=1 Number of ideal health factors=2 Number of ideal health factors=3 Number of idealhealthbehaviors

  10. To optimallyprevent CVD, itisas important, if not more, to target the healthbehaviors (obesity, physicalactivity, nutritionalquality, smoking) than the biologicalriskfactors (blood pressure, cholesterol, diabetes)

  11. Risk of Obesity: More than an Excess of Body Fat

  12. Our Initial Results…27 YearsAgo!!! Fat mass: 19.8 kg Intra-abdominal fat: 155 cm2 Fat mass: 19.8 kg Intra-abdominal fat: 96 cm2

  13. Abdominal obesityisassociatedseveralabnormalitiesincreasingrisk of diabetes and cardiovasculardisease ( ( Endothelial dysfunction Atherogenic dyslipidemia Inflammatory profile Hypertension Insulin resistance Pro-thrombotic state AdaptedfromDesprés JP, Lemieux I. Nature 2006;444:881-887

  14. Smith JD et al. J Clin EndocrinolMetab 2012;97:1517-25

  15. Visceral Adipose Tissue Measurement(n=4144Men and Women) Vertebrae Ribs Visceral fat L4-L5 Muscle Vis. fat Subcutaneous fat Visceral fat Visceral fat Subcutaneous fat Subcutaneous fat L4-L5 intervertebral space

  16. Liver Fat Measurement (Th12-L1)(n=4144 Men and Women) Subject A – Lean liver CTL/CTS : 1.33 Liver fat CTL-Spleen CTL-Liver CTL: 79.4 HU CTS: 59.6 HU Subject B – Fatty liver CTL/CTS : 0.24 CTL: 14.8 HU CTS: 60.7 HU

  17. Relationship Between Visceral Adipose Tissue and Liver Attenuation According to Glucose Tolerance Status in Women The INSPIRE ME IAA (r= -0.46, p<0.001) IGT/IFG T2D NGT Mean values NGT IFG/IGT T2D Liver attenuation (HU) Visceral adipose tissue area (cm2)

  18. Visceral Adiposity and Ectopic Fat (not Weight) Define the High-Risk Overweight/Obesity! From Després JP. Circulation 2012;126:1301-13

  19. Beyond Weight Loss!!!Key Lifestyle Therapeutic Targets to Reduce Cardiometabolic Risk •  Cardiorespiratory • fitness Lifestyle modification program with regular physical activity/exercise + healthy eating/drinking •  Cardiometabolic • risk profile  CVD risk •  Visceral adipose • tissue •  Liver fat and other • ectopic fat depots From Després JP Circulation 2012;126:1301-13

  20. NUTRITIONAL QUALITY PHYSICAL ACTIVITY HABITS • Fruits and vegetables: ≥4.5 cups/day • Fish: ≥2 servings of 3.5 oz/week • Whole grain fibers(≥1.1 g fibers/10 oz carbohydrates): ≥3 servings of 1 oz/day • Sodium: <1500 mg/day • Soft drinks: ≤450 kcal (<1 liter/week) • Etc. • Reduce inactivity • Increaseoverallphysicalactivities • Increase vigorous physical activity/exercise • Increase activetransportation • Etc. TARGETED BEHAVIORS ( ) ABDOMINAL OBESITY CARDIORESPIRATORY FITNESS ASSESS EMERGING CARDIOMETABOLIC RISK FACTORS ↓ CARDIOMETABOLIC RISK Després JP, Alméras N, Gauvin L. ProgCardiovasc Dis, 2014;56:484-492 .

  21. Proportion of patients remaining free from type 2 diabetes Intervention group Cumulative probability of remaining free of diabetes Control group Study year Subjectsatrisk Total no. Cumulative no. withdiabetes: Intervention group Control group 27 27 59 507 5 16 471 15 37 374 22 51 167 24 53 53 27 57 Adapted from TuomilehtoJ et al NEJM (2001) 344:1343-1350

  22. THE GRAND CORPORATE CHALLENGEExperience of a Mobile CMR Unit

  23. The Workplace: AnotherEpicenter to Assess/Target Key Behaviors? Clinical assessment/management of cardiometabolic risk Abdominal obesity Cardiorespiratory fitness Nutritional quality Physical activity habits

  24. Stop smoking Eat better Be more active 1 “Action cube” = 1 day without smoking Bonus 1 “Action cube” = 1 daily or weekly nutrition target 1 “Action cube” = 15 min of continuous physical activity 500 “Action cubes” = 91 smoke-free days 50 “Action cubes” = 1 cm waist girth lost The 3-Month GDE Challenge Win the Grand Prize More cubes... more chances to win!

  25. Baseline Characteristics of Participants

  26. Nutritional Quality Index (NQI) +9.2‡ Baseline 3-month ↓61% NQI ↑131% Employees (%) Average of 2.9 nutrition targets achieved per day Elevated risk ˂60 Moderate risk 60-74 Low risk ≥75 NQI ‡p˂0.0001

  27. Blood Pressure and Heart Rate at Submaximal Exercise (3.5 mph at 2% slope) -6‡ -4‡ SBP (mmHg) DBP (mmHg) Baseline 3 months Baseline 3 months -4‡ Heart Rate (bpm) Baseline 3 months ‡p˂0.0001

  28. Mean Changes in Waist Circumference -4.2‡ Waist circumference (cm) Baseline 3 months ‡p˂0.0001

  29. Classification of Resting Blood Pressure Baseline ↑ 86% 3 months ↓ 47% Employees (%) SBP ≥160 or DBP ≥100 SBP ˂120 and DBP ˂80 SBP 120-139 or DBP 80-89 SBP 140-159 or DBP 90-99

  30. Changes in HbA1c Levels in Each Subgroups of Diabetes Mellitus Classification Baseline 3 months Normal T2D untreated T2D treated Prediabetes -0,1† +0,1† -0,7* -0,7*

  31. Prevention/Treatment of Obesity, Diabetes and Cardiovascular Disease • Target behaviors... and not weight • Improve nutritional quality!!! • Reduce sedentary behaviors • Increasephysicalactivity/exercise • Reduce the waistline • Improvecardiorespiratoryfitness

  32. Acknowledgement

  33. The GDE Health Team!

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