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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). PREVENTION & DIABETES & OBESITY. 3 Types of Prevention. Primary Secondary Tertiary How does each apply to the present topics?. Diabetes.
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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) PREVENTION &DIABETES & OBESITY
3 Types of Prevention • Primary • Secondary • Tertiary • How does each apply to the present topics?
Diabetes • Is it a disease? What does labeling it a disease do? • Disempowers pts. • How about : a lifestyle that does NOT match up with one’s genetic make-up ? • People with “famine” genes do poorly with inactivity and an unhealthy diet
DIABETES Definitions • Diagnosis ? • Fasting • Random • OGTT • “Prediabetes” • IFG • IGT • Gestational
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 ?
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
Initial Goal in Weight Reduction • 5 – 10 % of initial body weight • Why ?
Nutritional Therapy • Foods that improve insulin sensitivity • Reduce Carbohydrate intake • More Fiber • More whole grains • Saturated fat < 7% total calories • Minimize Trans fats • Reduce cholesterol to < 200 mg/day
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 @ ____ max predicted heart rate • 50 – 70 % • Does exercise work even w/o weight loss ? • ‘A’ Cochrane
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
Meds in DM Prevention • Metformin • Pioglitazone • Exenatide
Metformin • Insulin sensitizer • Reduced RR of progression by 31% • Can induce weight loss • Most effective in pts. < 45 y.o. and with BMI > 35 • Also most effective in those with IFG > 110 • No evidence for additive nor synergy when added to TLC • DM Prevention Program (NEJM, 2002) & UKPDS
Metformin • Reduces inflammatory markers linked to CAD (Fibrinogen & CRP) • Reduces TGs by 10 – 30 % • Reduces LDL by 5 – 10 %
Pioglitazone • Insulin sensitizer • Preserves beta cell fxn • Retards progression to T2DM • ACT NOW
Exenatide • Reduces hyperglucogonemia • Enhances satiety • Promotes weight loss • Promotes expansion of beta cell mass • Improves 1st phase insulin response
If all of the above fails, then what? • Bariatric Surgery is an option .
Screening Diabetes in Asymptomatic Adults Adults who are overweight (BMI >= 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)
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 > 9 lb or were diagnosed with GDM • hypertension (>=140/90 mmHg or on therapy for hypertension) • HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 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 acanthosisnigricans) • history of CVD
Screening for DM type II in Children • Screen those who are overweight (BMI >85th % for age and sex, weight for height >85%, or weight >120% 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
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
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)
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 24–28 weeks of gestation. • Low risk status, which does not require GDM screening, is defined as women with ALL of the following characteristics: • Age <25 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
Secondary Prevention in Diabetes • How do we do it? • TLC • Meds • Bariatric Surgery
Tertiary Prevention in DM • What are we trying to prevent ? • Microvascular Complications • Nephropathy • Neuropathy • Retinopathy • Macrovascular Complications • CAD • CVA
How Do We Screen in T2DM ? • Annual retinoscopy • Annual creatinine • Annual microalbuminuria • Annual lipids (if @ goal) • Annual feet neuro exam • Resting ECG ? • Stress Test ?
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
GOALS ? • Glycemia ? • Hgb A1C , 7 or 6.5 or 6.0 • BP ? • < 130/80 • Smoking? • Control Lipids • < 100 or < 70
Tertiary Preventive Meds in DM • ACEI or ARB • Statin • Aspirin • Immunizations • Pneumovax • Fluvax • tDap
Statin Therapy • Statin therapy added to LTM regardless of baseline lipid values for diabetic patients: • With overt cardiovascular disease (CVD) (A) OR • >40 yoa without CVD but one or more CVD risk factors. (A) • Consider adding statin in other patients (<40 yoa without overt CVD) if LDL>100 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.
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) • >40 years of age OR • Fmhx CVD, hypertension, dyslipidemia, smoking, or albuminuria.
Obesity Trends • Kids as young as 4 y.o. have “adult” illnesses : T2DM, HTN, CAD • > 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
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%
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, it’s 1.4 & 48 • This = 86 & 62 lbs of sugar
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”
For kids, the greatest predictor for obesity is having obese parents
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
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
What Can we Do ? • Assess patients and families : • //bms.brown.edu/nutrition/acrobat/REAP%206 • 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
What can we do? • At EVERY visit for EVERY patient, record a BMI : get a table or BMI calculator • Properly label the problem : • Underweight < 18.5 • Normal weight 18.5 - 25 • Overweight >25 to < 30 • Obese 30 to < 40 • Morbidly Obese 40 or more
BMI in Kids • Labels are based on BMI percentiles, not weight %-iles : • BMI //apps.nccd.cdc.gov/dnpabmi/calculator.aspx • > 75th to 84th Caution and close observe • 85th to 94th Overweight • 95th & more Obese
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
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 @ institutional & community levels
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