PREVENTION & DIABETES & OBESITY

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PREVENTION DIABETES OBESITY

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

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3 Types of Prevention

• Primary
• Secondary
• Tertiary
• How does each apply to the present topics?

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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

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DIABETES Definitions

• Diagnosis ?
• Fasting
• Random
• OGTT
• Prediabetes
• IFG
• IGT
• Gestational

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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 ?

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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

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Initial Goal in Weight Reduction

• 5 10 of initial body weight
• Why ?

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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

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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

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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

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Meds in DM Prevention

• Metformin
• Pioglitazone
• Exenatide

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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

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Metformin

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

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Pioglitazone

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

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Exenatide

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

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

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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)

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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

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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

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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

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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)

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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

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Secondary Prevention in Diabetes

• How do we do it?
• TLC
• Meds
• Bariatric Surgery

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Tertiary Prevention in DM

• What are we trying to prevent ?
• Microvascular Complications
• Nephropathy
• Neuropathy
• Retinopathy
• Macrovascular Complications
• CAD
• CVA

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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 ?

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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

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GOALS ?

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

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Tertiary Preventive Meds in DM

• ACEI or ARB
• Statin
• Aspirin
• Immunizations
• Pneumovax
• Fluvax
• tDap

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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.

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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.

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OBESITY(Very closely related to DM)
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Obesity Trends
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Obesity Trends
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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

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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

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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

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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

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For kids, the greatest predictor for obesity is
having obese parents
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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

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Supersize It !
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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

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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

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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

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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

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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

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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

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Know Community Resources
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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

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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

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EXERCISE
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Exercise
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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

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The Exercise Prescription
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The Exercise Prescription
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WWayne Blount, superstar
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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
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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

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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

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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

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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

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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)