PREVENTION DIABETES OBESITY

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 one�s 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 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

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, it�s 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 gov�t. 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)