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)