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Diabesity

Diabesity. Jay Shubrook DO FACOFP Associate Professor of Family Medicine Director, Diabetes Fellowship Ohio University Heritage College of Osteopathic Medicine. Obesity and Diabetes. Review the married epidemics of obesity and diabetes

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Diabesity

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  1. Diabesity Jay Shubrook DO FACOFP Associate Professor of Family Medicine Director, Diabetes Fellowship Ohio University Heritage College of Osteopathic Medicine

  2. Obesity and Diabetes • Review the married epidemics of obesity and diabetes • Review how diabetes can be prevented in obese individuals • Review how you can improve obesity and diabetes simultaneously • Discuss different treatments for different types of diabetes

  3. Human Evolution

  4. US Obesity Epidemic • 17% of all US deaths from obesity • approx. 300,000 deaths/year • Obesity equals smoking as cause of preventable death • Shortens life span 5 -22 years • Extremely obese white male 20-30 • Lose 13 yrs of life • Mortality 12x higher if BMI >40 Years of Life Lost Due to Obesity, JAMA January 8, 2003:89;2;187-193 Obesity Among US Immigrants Subgroups by Duration of Residence JAMA Dec 15, 2004.

  5. Obesity • Greatest US health expenditure • Social and ethnic differences in obesity • Greater in women x 2 • Greater among Black Americans • Women>> men • Greater among non-HS grads • Largest increase in ages 19-28 • 75% of those with extreme obesity have a co-morbid disease

  6. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1999 1990 2009 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  7. Risk of Type 2 Diabetes as a function of BMI Adjusted relative risk of diabetes 100 90 80 70 60 50 40 30 20 10 0 <22 22- 23- 24- 25- 27- 29- 31- 33- >35 22.9 23.9 24.9 26.9 28.9 30.9 32.9 34.9 BMI Range Colditz GA et al. Ann Int Med, 1995

  8. 2008 1994 2000 2008 1994 2000 <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0% <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0% Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI ≥30 kg/m2) Diabetes CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

  9. What about closer to home?

  10. Childhood Obesity in Ohio • 1/3 of 3rd graders were overweight or obese • Higher rates in • Hispanic and Non-Hispanic Black children • Children in Appalachian counties • Low income children • Children who watched at least 3 hours TV/day • Highest in kids who drank >1 sweetened beverage per day ODH 2009-2010 data

  11. Childhood Obesity in Ohio ODH 2009-2010 data

  12. Childhood Obesity in Ohio ODH 2009-2010 data

  13. Risk Factors for Obesity • Obese parents • Before age 3 parental weight predicts obesity more than child’s weight • If 1 parent is obese child’s risk x3 • If both obese odds ratio 10 • 10% chance normal weight Whitaker NEJM 1997

  14. Risk Factors for Obesity • Environmental Factors • Portion size (market portions are 2-8 times larger than recommended USDA and FDA recs) • Sweetened beverages • Increasing since 1970 • Socioeconomic status inversely related to obesity • Energy density and food cost inversely related • Increase in sedentary leisure time • 26% watch more than 4 hours of TV time per day • 67% watch more than 2 hours

  15. Obesity Related Co-morbidities • Glucose tolerance tests in obese children • ABnormal results in • 29% non-Hispanic white children • 41% of African American children • 50% of Hispanic children • 53% of Asian/Pacific Island children • 66% of American Indian children Weiss R Diabetes Care 2005

  16. Childhood Obesity Complications • Overall Diabetes Risk (children born in 2000) • 1 in 3 boys • 2 in 5 girls • 20% of children with DM have Type 2 • NAFLD/NASH • Steatosis in 40% of obese children (Guzzaloni 2000) • Elevated LFTs in 6% of overweight and 10% of obese kids (Rashid 2000)

  17. Physicians Do not Address Obesity Enough: • Addressing obesity in the office • Only 17.4% of 2-5 yr old • 32.6% of 6-11 yr/old • 39.6% of 12 -15 yr/old • 51.6% of 16-19 yr/old

  18. Diabetes Prevention in Those at Risk

  19. Case 1 • 28 year while male presents with knee pain • Bilateral knee pain, worse as day goes on • No previous workup • No regular PA, computer programmer • No med hx/ family hx of HTN, DM2, CAD • No meds • ROS: admits fatigue, admits weight gain 80 lbs since college

  20. Case 1 (cont’d) • Exam 5’ 10” weight 260 lbs • Stretch marks on abdomen • No synovitis, no swelling, normal ROM, • X-rays are normal • BP 138/88 • FSG 148 non fasting • HgA1c in office 6.0%

  21. Case Questions • What do you include in your problem list for this person? • Which do you address first? • What is your treatment plan?

  22. How would you address his weight • Nothing –he is here for knee pain • Recommend that he start a new diet • Refer him to medical nutrition therapy • Not address it today but get more labs and bring him back • Start him on a medication • Refer him for weight loss surgery

  23. Medications • Which medication would you start? • Phentermine/topiramate (QnexaR ) • Phentermine (AdipexR) • Topiramate (TopamaxR) • Orlistat (ALLIR) • Metformin • Amylin (SymlinR) • Exenatide (ByettaR)

  24. Weight Loss Surgery • What surgery would you recommend? • Lipoplasty • Lap-band • Roux-en-Y (gastric by pass) • Gastric sleeve • Biliarypancreatic diversion

  25. Diabetes Prevention

  26. Lifestyle Recommendations • Reduce total caloric intake • Increase physical activity • Stop sweetened beverages • What are the specifics and how do you decide which he does? • What is the motivation to make all of these changes?

  27. Setting Goals for Weight Loss • Set reasonable goals • 10% weight loss for first 6 months • 500-1000 calories less/day • Decrease 1-2 lb/week • Most patients set goals 2-3 x higher • Physical activity is important • More effective in maintaining weight than weight loss • Resetting goals and diet/exercise is necessary at 6 months and plateaus in weight loss • Preventing weight gain is an important long-term goal NHLBI Obesity Education Initiative: A Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 2000.

  28. Is there any evidence that lifestyle changes makes a difference to prevent diabetes?

  29. Diabetes Prevention • Diabetes Prevention program • Finnish Diabetes Trail • Da Qing trial

  30. Diabetes Prevention: Lifestyle

  31. The Finnish Diabetes Prevention Study: Lifestyle Modifications  58% Incidence of diabetes (cases/1000 person-years) Tuomilehto et al. N Engl J Med. 2001;344:1343.

  32. The Finnish Diabetes Prevention Study:Lifestyle Modifications • 522 overweight individuals with IGT randomized to • Control: diet instruction at the onset of study • Individualized advice given 7 times in the first year and every 3 months thereafter with goals of • Weight loss 5% • Reducing fat intake to <30% of energy consumption • Increasing fiber intake to 15 g/1000 kcal • Exercising at a moderate level for 30 min/d • Primary end point: Prevention of diabetes, as assessed by annual OGTT Tuomilehto et al. N Engl J Med. 2001;344:1343.

  33. The Finnish Diabetes Prevention Study: Lifestyle Modifications (cont’d) Change from baseline P<0.001 P<0.001 P=0.007 P=0.02 Tuomilehto et al. N Engl J Med. 2001;344:1343.

  34. The Diabetes Prevention Program A Randomized Clinical Trial to Prevent Type 2 Diabetes in Persons at High Risk Sponsored by the NIDDK, NIA, NICHD, NIH, IHS, CDC, ADA, and other agencies and corporations

  35. Diabetes Prevention Program: Primary Objectives • Compare safety and efficacy of 4 interventions for preventing or delaying development of diabetes • Standard lifestyle recommendations + masked metformin titrated to 850 mg bid or troglitazone400 mg/d • Standard lifestyle recommendations + masked placebo • Intensive lifestyle intervention by case managers with goals of • 7% weight reduction through healthy eating and physical activity • 150 min/wk moderate intensity physical activity The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623.

  36. Average follow-up of 2.8 years Goal % Achieving Goal Lifestyle modifications Week 24 Last visit Weight loss 7% 50% 38% Physical activity 150 74% 58% (min/wk) Pharmacologic intervention Placebo Metformin Compliance 80% 77% 72% Full dose 2 tablets/d 97% 84% Diabetes Prevention Program:Achievement of Study Goals The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.

  37. Lifestyle Placebo Met Inter. P Value Wt change (kg) -0.1 -2. -5.6 <0.001 Change in fat intake* (% of total calories) -0.8 -0.8 -6.6 <0.001 Change in energy intake (kcal/d) at 1 year -249 -296 -450 <0.001 Diabetes Prevention Program:Effects on Weight and Dietary Intake *Baseline fat intake was 34.1% of total calories. The goal of intensive lifestyle modification was <25% of total calories. The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.

  38. Diabetes Prevention Program:Progression to Type 2 Diabetes Average follow-up of 2.8 years  31%* Cases/100 person-years  58%* Placebo Metformin Intensive lifestyle *All pairwise comparisons significantly different by group; sequential log-rank test. The Diabetes Prevention Program Research Group. NEngl J Med. 2002;346:393.

  39. Diabetes Treatment in Obese Adults

  40. Look AHEAD Trial • Randomized trial 5,145 obese adults diagnosed with type 2 DM • Randomized to intensive lifestyle intervention • Goal >7% initial weight loss • 175 minutes per week physical activity • Outcomes • Fatal MI, CVA, non fatal MI • 11.5 years of follow up

  41. LOOK AHEAD Results • One year results • Weight loss 8.6% vs 0.7% (p<0.001) • Fitness improved 20.9% vs 5.8% (p<0.001) • A1c improved 0.7% vs 0.1% (p<0.001) • Lipids, bp, urine albumin/creatinine ratio all improved (p<0.01) Look AHEAD: Diabetes Care 2007. 30(6):1374-1383

  42. Medications to Prevent Diabetes • Diabetes Prevention Program • Tripod trial/Pipod trial • Stop NIDDM • Xenidos Study

  43. Diabetes Prevention: Medications

  44. What works better to treat diabetes and obesity-medications or surgery?

  45. Surgery vs Meds in obese adults with T2DM • 150 obese adults with type 2 DM • Intensive medical therapy • Roux-en-Y • Sleeve gastrectomy • Primary outcome • % patients with HgA1c < 6% • Secondary outcomes • Weight loss • Lab values Schauer et al NEJM March 2012

  46. Surgery vs Meds Results • Primary outcome achieved at 1 year • 12% of medication group (p=0.008 vs surgeries) • 37% of sleeve gastectomy • 42% of Roux-en-Y • Secondary outcomes • Weight loss surgery groups better (p<0.01) • 24.7-27.5% vs 5.2% (p <0.001) • Reduced medications • Surgery better (p<0.01) Schauer et al NEJM March 2012

  47. Surgical Therapies for Obesity • Restrictive Procedures • Laparoscopic Adjustable Gastric Banding • Vertical Banded Gastroplasty • Silastic Ring Gastroplasty • Roux-en-Y Gastric Bypass* • Malabsorptive Procedures • Biliopancreatic Diversion • Duodenal Switch • Roux-en-Y Gastric Bypass* *Considered both restrictive and malabsorptive Primary Care Perspective on Bariatric Surgery Mayo Clinic Proceedings, 2004.

  48. Weight Loss Surgeries

  49. Treatment of Combined Obesity and Diabetes

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