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Ask not what your body can do for you. Ask what you can do for your body.
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 individuals1. 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
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(Very closely related to
DM)
Obesity Trends
Obesity Trends
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 Lefton 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
Supersize It !
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
observe85th to 94th Overweight95th & 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
Know Community Resources
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
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
EXERCISE
Exercise
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
The Exercise Prescription
The Exercise Prescription
Walk 10 minutes at a time, 3 times per day, 5 days per week. Get heart rate to 90 to 125 beats per minute.
WWayne Blount, superstar 40
XX
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
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
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
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
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)
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