Natalie Alméras, Ph.D. Quebec Heart and Lung Institute

Department of Kinesiology, Faculty of Medicine, Université Laval Québec, CANADA

Preventive intervention in DiabetesWeight Loss Is Not the Optimal Target

Public Health 2014Canadian Public Health Association

Typical Profile of the Canadian Patient with Type 2 Diabetes Managed in Primary Care

Age: 63 yearsBMI:

Men=30.3 kg/m2

Women=31.4 kg/m2

HbA1c: 6.9%Blood pressure: 130/76 mmHgLDL-cholesterol: 1.9 mmol/LDyslipidemia: 55.4%Hypertension: 68.2%Sedentary lifestyle: 56.5% (reported!!!)Current or previous smoker: 32.7%

From Teoh H et al.Diabetes Obes Metab 2013;15:1093-1100

Typical Profile of the Canadian Patient with Type 2 Diabetes

Age: 63 yearsBMI:

Men=30.3 kg/m2

Women=31.4 kg/m2

HbA1c: 6.9%Blood pressure: 130/76 mmHgLDL-cholesterol: 1.9 mmol/LDyslipidemia: 55.4%Hypertension: 68.2%Sedentary lifestyle: 56.5% (reported!!!)Current or previous smoker: 32.7%

Adapted from Teoh H et al.Diabetes Obes Metab 2013;15:1093-1100

More drugs? More patients taking their meds!!! Only 12% achieved combined ABC Targets!!!

Typical Profile of the Canadian Patient with Type 2 Diabetes

Age: 63 yearsBMI:

Men=30.3 kg/m2

Women=31.4 kg/m2

HbA1c: 6.9%Blood pressure: 130/76 mmHgLDL-cholesterol: 1.9 mmol/LDyslipidemia: 55.4%Hypertension: 68.2%Sedentary lifestyle: 56.5% (reported!!!)Current or previous smoker: 32.7%

Adapted from Teoh H et al.Diabetes Obes Metab 2013;15:1093-1100

Diet? Physical activity?

Proportion of Patients with and without Type 2 Diabetes who Received Recommendations on Healthy Lifestyle Changes from their Primary Care Physicians

Adapted from Teoh H et al.Diabetes Obes Metab 2013;15:1093-1100

The Current Epidemic of Obesity, Type 2 Diabetesand CVD: Chronic Societal Metabolic Diseases

In the Québec Province…

720,000 with diabetes in Québec

Source : Diabète Québec 2014

Behaviors: Forgotten Componentsof Ideal Cardiovascular Health

4 ideal health behaviors: Nonsmoking BMI<25 kg/m2

Physical activity at goal levels (150 min. moderate/week) Healthy diet score

3 favorable health biological factors: Cholesterol (untreated) <200 mg/dL (5.2 mmol/L) Blood pressure (untreated) <120/<80 mm Hg Absence of diabetes and glucose <100 mg/dL (5.6 mmol/L)

Absence of clinical CVD

From Lloyd-Jones DM et al.Circulation 2010;121:586-613

Incidence Rate of Cardiovascular Disease According to the Number of Ideal Health Behaviors and Health Factors

01

23-4

0

5

10

15

20

25

30

35

Adapted from Folsom AR et al.

J Am Coll Cardiol 2011;57:1690-6

Number of ideal health factors=3

Number of ideal health factors=1

Number of ideal health factors=2

Number of ideal health factors=0

Ag

e, s

ex, a

nd

rac

e-ad

just

ed in

cid

ence

ra

te (

/1,0

00 p

erso

n-y

ear)

Number of ideal health behaviors

To optimally prevent CVD, it isas important, if not more, to target the

health behaviors (obesity, physical activity, nutritional quality, smoking)

than the biological risk factors (blood pressure, cholesterol, diabetes)

Risk of Obesity: More than an Excess of Body Fat

Fat mass: 19.8 kgIntra-abdominal fat: 155 cm2

Fat mass: 19.8 kgIntra-abdominal fat: 96 cm2

Our Initial Results…27 Years Ago!!!

((((

Pro-thromboticstate

Inflammatoryprofile

Atherogenicdyslipidemia

Hypertension

Insulinresistance

Endothelial dysfunction

Adapted from Després JP, Lemieux I. Nature 2006;444:881-887

Abdominal obesity is associated several abnormalities increasing risk of diabetes and cardiovascular disease

Smith JD et al. J Clin Endocrinol Metab 2012;97:1517-25

Visceral Adipose Tissue Measurement(n=4144 Men and Women)

L4-L5 intervertebral space

Vertebrae

Ribs

Visceral fatVisceral fatL4-L5

Subcutaneous fat

Muscle

Visceralfat

Vis. fat

Subcutaneous fat

Visceralfat

Subcutaneous fat

CTL: 79.4 HU

CTL: 14.8 HU

CTS: 60.7 HU

CTS: 59.6 HU

Subject B – Fatty liverCTL/CTS : 0.24

Liver fatCTL-Liver CTL-Spleen

Subject A – Lean liverCTL/CTS : 1.33

Liver Fat Measurement (Th12-L1)(n=4144 Men and Women)

Relationship Between Visceral Adipose Tissue and Liver Attenuation According to Glucose Tolerance Status in Women

The INSPIRE ME IAALi

ver a

tten

uatio

n (H

U)

Visceral adipose tissue area (cm2)0 50 100 150 200 250 300 350 400

0

10

20

30

40

50

60

70

80

90

NGTIFG/IGT

T2D

IGT/IFGT2D

NGTMean values

(r= -0.46, p<0.001)

Visceral Adiposity and Ectopic Fat (not Weight) Define the High-Risk Overweight/Obesity!

From Després JP. Circulation 2012;126:1301-13

Beyond Weight Loss!!!Key Lifestyle Therapeutic Targets to Reduce

Cardiometabolic Risk

Lifestyle modification

program with regular

physical activity/exercise

+ healthy eating/drinking Visceral adipose tissue Liver fat and other ectopic fat depots

Cardiorespiratory fitness

Cardiometabolic risk profile

CVD risk

From Després JP Circulation 2012;126:1301-13

TARGETED BEHAVIORS

ASSESS EMERGING CARDIOMETABOLIC RISK FACTORS

NUTRITIONAL QUALITY PHYSICAL ACTIVITY HABITS

Fruits and vegetables: ≥4.5 cups/day Fish: ≥2 servings of 3.5 oz/week Whole grain fibers (≥1.1 g fibers/10 oz

carbohydrates): ≥3 servings of 1 oz/day Sodium: <1500 mg/day Soft drinks: ≤450 kcal (<1 liter/week) Etc.

ABDOMINAL OBESITY

CARDIORESPIRATORY FITNESS

( )

Reduce inactivity Increase overall physical activities Increase vigorous physical

activity/exercise Increase active transportation Etc.

↓ CARDIOMETABOLIC RISK

Després JP, Alméras N, Gauvin L. Prog Cardiovasc Dis, 2014;56:484-492 .

Proportion of patients remaining free from type 2 diabetes

Adapted from Tuomilehto J et al

NEJM (2001) 344:1343-1350

0 1 2 3 4 5 60.4

0.5

0.6

0.7

0.8

0.9

1.0

Study year

Cu

mu

lati

ve p

rob

abil

ity

of

rem

ain

ing

fre

e o

f d

iab

etes

Intervention group

Control group

Subjects at riskTotal no.Cumulative no. with diabetes: Intervention group Control group

507

516

471

1537

374

2251

167

2453

53

2757

27

2759

THE GRAND CORPORATE CHALLENGEExperience of a Mobile CMR Unit

Clinical assessment/management of cardiometabolic risk

Nutritionalquality

Physical activity habits

Abdominal obesity

Cardiorespiratory fitness

The Workplace: Another Epicenter toAssess/Target Key Behaviors?

The 3-Month GDE Challenge

Be moreactive

Bonus

Stopsmoking

Eat better

1 “Action cube” = 1 day without smoking

1 “Action cube” = 15 min of continuous physical activity

1 “Action cube” = 1 daily or weekly nutrition target

500 “Action cubes” = 91 smoke-free days50 “Action cubes” = 1 cm waist girth lost

Win the Grand PrizeMore cubes... more chances to

win!

Baseline Characteristics of Participants

Variable Total (n=749)

Men (n=603)

Women(n=146)

Age (years)44.5±10.0

45.2±10.0

41.8±9.6

Weight (kg)82.6±15.9

86.0±14.4

68.3±13.7

BMI (kg/m2)27.5±4.5

27.9±4.2

25.6±4.9

Waist circumference (cm)96.3±12.5

98.0±11.6

89.1±13.5

Fat (%)26.6±7.7

25.0±6.7

33.1±7.9

FFM (kg)60.1±10.0

63.8±7.0

44.8±4.5

Smokers (n,%) 264 (35%) 208 (34%) 56 (38%)

Nutritional Quality Index (NQI)

Series154.0

59.0

64.0

69.0

74.0

60.6

69.9

Series10

10

20

30

40

50

60

48.9

35.1

16.218.9

43.737.4

NQ

I

+9.2‡

Elevated risk˂60

Moderate risk60-74

Low risk≥75

↓61% ↑131

%

Em

plo

yees (

%)

NQI

Average of 2.9 nutrition targets achieved per day

‡p˂0.0001

3-month

Baseline

Blood Pressure and Heart Rate at Submaximal Exercise (3.5 mph at 2% slope)

Series1145.0

148.0

151.0

154.0

157.0

154 148

Series168.0

70.0

72.0

74.0

73 69

Series1109.0

111.0

113.0

115.0

113 110

-6‡

SB

P (

mm

Hg

)

Baseline 3 months

-4‡

DB

P (

mm

Hg

)

Baseline3 months

-4‡

Heart

Rate

(b

pm

)

Baseline3 months‡p˂0.0001

Mean Changes in Waist Circumference

Series190.0

92.5

95.0

97.5

96.3

92.2

-4.2‡W

ais

t cir

cu

mfe

ren

ce (

cm

)

Baseline 3 months

‡p˂0.0001

Classification of Resting Blood Pressure

Normal Pre-hypertension Stage 1 Stage 20

10

20

30

40

50

60

17.0

52.4

23.9

6.7

31.7

52.1

12.9 3.2

Em

plo

yees (

%)

SBP ˂120and DBP ˂80

SBP 120-139or DBP 80-89

SBP 140-159or DBP 90-99

SBP ≥160or DBP ≥100

↑ 86% ↓

47%

3 months

Baseline

Changes in HbA1c Levels in Each Subgroups of Diabetes Mellitus Classification

5.0

5.5

6.0

6.5

7.0

7.5

8.0

5.4

5.9

7.1

7.6

5.55.8

6.4

6.9

HbA

1c %

Normal Prediabetes T2Duntreated

T2Dtreated

-0,1†

-0,7*

-0,7*

+0,1†

Baseline3 months

Prevention/Treatment of Obesity, Diabetes and Cardiovascular Disease

Target behaviors... and not weight Improve nutritional quality!!! Reduce sedentary behaviors Increase physical activity/exercise Reduce the waistline Improve cardiorespiratory fitness

Acknowledgement

The GDE Health Team!