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3 Types of Prevention. PrimarySecondaryTertiaryHow 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
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1. PREVENTION &DIABETES & OBESITY Ask not what your body can do for you. Ask what you can do for your body.
(With apologies to JFK)
2. 3 Types of Prevention Primary
Secondary
Tertiary
How does each apply to the present topics?
3. 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
4. DIABETES Definitions Diagnosis ?
Fasting
Random
OGTT
Prediabetes
IFG
IGT
Gestational
5. 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 ?
6. 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
7. Initial Goal in Weight Reduction
5 10 % of initial body weight
Why ?
8. 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
10. 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
12. 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
13. Meds in DM Prevention Metformin
Pioglitazone
Exenatide
14. 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
15. Metformin Reduces inflammatory markers linked to CAD (Fibrinogen & CRP)
Reduces TGs by 10 30 %
Reduces LDL by 5 10 %
16. Pioglitazone Insulin sensitizer
Preserves beta cell fxn
Retards progression to T2DM
ACT NOW
17. Exenatide 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 .
19. 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)
20. 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 acanthosis nigricans)
history of CVD
21. 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
22. 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
23. 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)
24. 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 <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
25. Secondary Prevention in Diabetes
How do we do it?
TLC
Meds
Bariatric Surgery
26. Tertiary Prevention in DM What are we trying to prevent ?
Microvascular Complications
Nephropathy
Neuropathy
Retinopathy
Macrovascular Complications
CAD
CVA
27. How Do We Screen in T2DM ? Annual retinoscopy
Annual creatinine
Annual microalbuminuria
Annual lipids (if @ goal)
Annual feet neuro exam
Resting ECG ?
Stress Test ?
28. 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
29. GOALS ? Glycemia ?
Hgb A1C , 7 or 6.5 or 6.0
BP ?
< 130/80
Smoking?
Control Lipids
< 100 or < 70
30. Tertiary Preventive Meds in DM ACEI or ARB
Statin
Aspirin
Immunizations
Pneumovax
Fluvax
tDap
31. 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. CVD risk factors: dyslipidemia, hypertension, smoking, a positive family history of premature CAD, presence of micro or macroalbuminuria.
Based on trials showing sig priamry and secondary prevention of CVD events (CHD death and nonfatal MI) in diabetic populations
Table 10 Reduction in 10 year risk of major CVD end pionts.
CVD risk factors: dyslipidemia, hypertension, smoking, a positive family history of premature CAD, presence of micro or macroalbuminuria.
Based on trials showing sig priamry and secondary prevention of CVD events (CHD death and nonfatal MI) in diabetic populations
Table 10 Reduction in 10 year risk of major CVD end pionts.
32. 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.
33. OBESITY(Very closely related to DM)
34. Obesity Trends
35. Obesity Trends
36. 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
37. 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%
38. 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
39. 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
40. For kids, the greatest predictor for obesity is having obese parents
41. 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
42. Supersize It !
43. 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
44. 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
45. 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
46. 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
47. 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
48. 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
49. Know Community Resources
50. 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
51. 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
52. EXERCISE
53. Exercise
54. 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
55. The Exercise Prescription
56. The Exercise Prescription
58. 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 < 2 y.o.
< 2 hrs/day for kids > 2 y.o.
Increase active time to > 60 mins/day
59. What to do @ 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
60. What About Pharmacotherapy? 2 meds approved
Sibutramine (Meridia)
Approved for age > 16 y.o.
Orlistat (Alli, Xenical)
Approved for age > 12 y.o.
No data on bariatric surgery in kids/teens
61. Bibliography For caloric content of foods : www.annecollins.com/calories/
Cochrane Collaboration
www.SuperSizedKids.com
Barlow SE. Pediatrics.2007;120:Supplement
Stenardo & Slusser. AAFP CME bulletin. Sept. 2008;7
Readiness to Change :
www.aafp.org/20000301/1409.
Fast Food & Families. DVD from NCAFP
62. Goals of Treatment Primary goal of LDL < 100 without overt CVD. (A)
Optional goal of LDL <70 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)