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Reducing Cardiovascular Risk in Patients With Diabetes Robert J Bulgarelli DO FACC CMA Director Integrative Cardiology - MLHS CMO – the Habit Change Company.

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Presentation on theme: "Reducing Cardiovascular Risk in Patients With Diabetes Robert J Bulgarelli DO FACC CMA Director Integrative Cardiology - MLHS CMO – the Habit Change Company."— Presentation transcript:

1 Reducing Cardiovascular Risk in Patients With Diabetes Robert J Bulgarelli DO FACC CMA Director Integrative Cardiology - MLHS CMO – the Habit Change Company

2 The Cholesterol And Dietary Fat Obsession

3 United States: 1979–1998 mortality. American Heart Association Heart and Stroke Statistical Update Deaths (in thousands) MenWomen Years CVD Deaths: 1979– NCEP INCEP IINCEP III

4 Metabolic Syndrome Components: –Obesity –Insulin Resistance –Dyslipidemia –Hypertension

5 Metabolic Syndrome 34% of U.S. adults Diagnosis 3 or more of the following –Hypertension > 130/85 –Waist > 40 men, >35 women –HDL < 40 for men, < 50 in women –Triglycerides > 150 –Fasting glucose > 110

6 Cardiovascular Mortality Diabetes Care 2001;24:683 p < p < 0.001

7 Obesity Metabolic Syndrome (Met S) –Insulin resistance / Obesity / HTN / Dyslipidemia High association with development of DM Type II and CAD –11 year prospective study of Finnish men without CAD or DM but who met NCEP and or WHO criteria for Metabolic Syndrome 3.6X CHD Mortality 3.2X CVD Mortality 2.3X All Cause Mortality –JAMA Dec 4, 2002 Vol. 288 No. 21

8 Patterns of Body Fat Distribution Abdominal (android) Lower body (gynoid)

9 1998 Obesity Trends Among U.S. Adults (*BMI 30, or about 30 lbs. overweight for 54 person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

10 States had a prevalence of obesity less than 10% 0 States had prevalence equal to or greater than 15% States had prevalence less than 10% 7 States had a prevalence of obesity between 20-24% 0 States had prevalence equal to or greater than 25% State (Colorado) had a prevalence less than 20% 30 States had a prevalence equal to or greater than 25% 3 States (Alabama, Mississippi and Tennessee) had a prevalence of obesity equal to or greater than 30% States had a prevalence of obesity less than 10% 0 States had prevalence equal to or greater than 15% States had prevalence less than 10% 7 States had a prevalence of obesity between 20-24% 0 States had prevalence equal to or greater than 25% State (Colorado) had a prevalence less than 20% 30 States had a prevalence equal to or greater than 25% 3 States (Alabama, Mississippi and Tennessee) had a prevalence of obesity equal to or greater than 30%. Obesity Trends Among U.S. Adults (*BMI 30, or about 30 lbs. overweight for 54 person)

11 Recent Trends Type 2 DM in Children and Adolescents Obesity, low level of physical activity, as well as exposure to diabetes in utero, may be major contributors Generally between 10 and 19 years old, obese, have a strong family history for type 2 diabetes, and have insulin resistance and have poor glycemic control (A1C = 10% - 12%). CDC estimates that among new cases of childhood diabetes, the proportion of those with type 2 diabetes ranges between 8 percent and 43 percent.

12 Diet, Lifestyle, and Risk of Type 2 Diabetes Mellitus in Women Nurses Health Study (84,941) female nurses followed for 18 years 3300 new cases of type 2 diabetes mellitus Lack of exercise, poor diet also major risk factors BMI most important risk factor –BMI > RR –BMI RR Hu et al. NEJM 2001;345:790

13 + = moderately increased compared with nondiabetic population ++ = markedly increased compared with nondiabetic population – = not different compared with nondiabetic population Prevalence CAD Risk Factors in Type 1 vs. Type Type 1 Dyslipidemia Hypertriglyceridemia Low HDL Small, dense LDL Increased apo B Hypertension Hyperinsulinemia/insulin resistance Central obesity Family history of atherosclerosis Cigarette smoking Adapted from Chait A, Bierman EL. In: Joslins Diabetes Mellitus. Philadelphia: Lea & Febiger, 1994: Type 2 Risk Factor +–––+––––+–––+–––– ++ + –

14 Risk Factors for IHD* *Data from the Quebec Heart Study. Adapted from Lamarche B et al. JAMA. 1998;279:1955–1961. Odds RatioP Elevated fasting insulin Elevated triglycerides Elevated ApoB Small dense LDL Elevated LDL-C Reduced HDL-C1.6.15

15 Glucose (mg/dL) 50 – 100 – 150 – 200 – 250 – 300 – 350 – Fasting Glucose Post meal Glucose 0 – 50 – 100 – 150 – 200 – 250 – Years of Diabetes *IFG = impaired fasting glucose. ©2000 International Diabetes Center, Minneapolis, Minnesota. Used with permission. Relative Function (%) Insulin Resistance -Cell Failure ObesityIFG*Diabetes Uncontrolled Hyperglycemia Natural History of Type 2 Diabetes

16 Over 90% of Type 2s are Insulin Resistant Hypertension Type 2 Diabetes Disordered Fibrinolysis Complex Dyslipidemia TG, sdLDL HDL Endothelial Dysfunction Systemic Inflammation Atherosclerosis Visceral Obesity Adapted from the Consensus Development Conference of the American Diabetes Association. Diabetes Care. 1998;21(2): Haffner SM, et al. Diabetes Care. 1999;22(4): Pradhan AD, et al. JAMA. 2001;286(3): The Importance of Targeting Insulin Resistance Insulin Resistance

17 CHF/CAD Deaths (%) Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; ch 11. Mortality in Patients With Diabetes Causes of Death DiabetesCancerStrokeInfection Other

18 Incidence of CHD* Events in Patients With and Without Diabetes *Coronary heart disease Haffner SM et al. N Engl J Med. 1998;339:229–234. Events per 100 Person-yr Incidence During 7-Year Follow-up (%) n= Non diabetics with no prior MI Non diabetics with prior MI Diabetics with no prior MI Diabetics with prior MI n=69n=890n= P<.001

19 Adapted from the United Kingdom Prospective Diabetes Study. Stratton IM, et al. BMJ. 2000;321(7258): The Need for Tight BG Control According to the United Kingdom Prospective Diabetes Study (UKPDS) 35, every 1% increase in A 1c resulted in: Increase in risk of microvascular complications Increase in any diabetes- related endpoint Increase in risk of MI Increase in risk of stroke 21% 14% 12% 37%

20 Diabetes Control and Complications Trial (DCCT) 1983 – ,441 pts. / 29 centers in US and Canada DM > 1yr and < 15yr ; no eye disease Standard care vs intensive management Intensive insulin therapy Diet and exercise Behavioral therapy Carotid intima-media thickness

21 Diabetes Control and Complications Trial (DCCT) Results 76% reduction in eye disease 6% reduction in neuropathy 54% reductions in urine albumin secretion 50% reduction in nephropathy Overall improvements in BP, Hgb A1c, HDL and LDL

22 Treatment of CAD Risk in DM: Are We Doing a Good Job? George PB et al. Am Heart J. 2001;142:857–863. Suboptimal Optimal Do We Reach Treatment Goals? 100%80%60%40%20%0%10%40%60%80%100% HbA 1c <7.0 HDL >45 (men) HDL >55 (women) LDL <100 Triglycerides <200 BP <130/85 BMI <25 Prospective observational study of 235 treated (oral or insulin) CAD patients with Diabetes

23 Treatment of CAD Risk in DM: Are We Doing a Good Job? George PB et al. Am Heart J. 2001;142:857–863. Do We Prescribe Optimal Cardiovascular Drug Therapy? % Patients Treated by Medication Lipid-lowering drugs -Blockers ACE inhibitors Aspirin Prospective observational study of 235 treated (oral or insulin) CAD patients with Diabetes

24 60% Type 2s Not At ADA HgbA 1c Goal <6% GOAL Survey % Of Subjects N = % >8% 59.4% >7% 26.5% 19.1% 40.6% 13.8% HgbA 1c Adults aged y with previously diagnosed diabetes who participated in the interview and examination components of the National Health Examination Survey (NHANES), Saydah et al. Diabetes. 2003;52(suppl 1):A228 (Abstract 979-P).

25 United Kingdom Prospective Diabetes Study (UKPDS) *Conventional=diet therapy. UK Prospective Diabetes Study (UKPDS 34) Group. Lancet. 1998;352: Traditional Therapies Do Not Maintain A 1c Control Over Time Median A 1c (%) Conventional* Insulin Glibenclamide (glyburide) Metformin Time from Randomization (Years) ADA goal

26 We have a lot of catching up to do!

27 2010 Now Primary Prevention: Status and 2010 Goals NCEP. Adult Treatment Panel III Report Moderate physical activity Vegetable intake of >3 servings Saturated fat <10% of calories

28 Primary Prevention: Status and 2010 Goals Fruit >2 servings/d Smoking cessation Healthy weight 2010 Now NCEP. Adult Treatment Panel III Report

29 Hard enough to get people to take their meds!

30 Same old thing Over and Over…

31 Whole new way of looking at things!

32 Lifestyle Management The 8 Essential Habit Areas Nutrition / Supplements Physical Fitness Affiliation Resilience (Stress Management) Spirituality Sleep Simplicity New Learning (Neuroplasticity)

33 Diet Healthy Eating

34 Early weight loss!

35 Your food shall be your remedy…… Hypocrites

36 Diet and Heart Disease Dietary intervention trials using morbidity / mortality endpoints 30 – 70% reduction events and death Dietary intervention trials using angiographic endpoints Decreased lesion progression and regression Brousseau etal Current Atherosclerosis Repots 2000 Diet and CAD: Clinical Trials

37 Atkins?

38 Ornish?

39 What do our kids think?

40 Healthy Eating and Heart Disease Good Fats / Mediterranean Lyon Diet Study 2 nd prevention trial Mediterranean vs. SAD 70% reduction in recurrent coronary events / cardiac death post MI! Maintained out to 4 years! Lorgeril etal Lancet 1994 ;343:

41 Mediterranean Diet Fiber Vitamin E Omega-3 fatty acids Folic Acid Monounsaturated fat Phytochemicals and antioxidants Calcium, magnesium, selenium

42 Healthy Eating and Diabetes The use of low-glycaemic index diets in diabetes control –British Journal of Nutrition Cambridge University Press Copyright © The Authors 2010D. E. Thomas a1 c1 and E. J. Elliott a1a2a3 a1 Centre for Evidence Based Paediatrics Gastroenterology and Nutrition (CEBPGAN), Sydney Medical School, The University of Sydney, c/o Research Building, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia –Meta-analysis – 12 RCTs (612 patients Type 1 & 2) Low Glycemic Index vs. High Glycemic Index Diet (Controvesial) –Statistically significant improvements in HgbA1c »Mean decrease of 0.4 % HbA1c, 95 % CI 0.7, 0.20 P = 0·001

43 Exercise Physical Fitness

44 Those who think they have no time for bodily exercise will sooner or later have to find time for illness. Edward Stanley ( ) The Conduct of Life

45 Move it or lose it!

46 …but really move it!

47 Physical Fitness and Heart Disease Exercise Many clinical trials: 40 – 50 % reduction in events compared with meds alone Improved Q.O.L.

48 Physical Fitness and Heart Disease A META-ANALYSIS OF PHYSICAL ACTIVITY IN THE PREVENTION OF CORONARY HEART DISEASE –American Journal of Epidemiology Vol. 132, No. 4: Copyright © 1990 by The Johns Hopkins University School of Hygiene and Public Health JESSE A. BERLIN 1,2, and GRAHAM A. COLDITZ 1,31 Technology Assessment Group, Harvard School of Public Health Boston, MA 2 University of Pennsylvania School of Medicine, Section of General Internal Medicine, Clinical Epidemiology Unit Philadelphia, PA 3 Channing Laboratory, Harvard Medical School Boston, MAThe Johns Hopkins University School of Hygiene and Public Health –Relative risk of death from coronary heart disease: 1.9 (95% confidence interval 1.6–2.2) Sedentary compared with Active

49 Physical Fitness and Heart Disease Exercise-based rehabilitation for patients with coronary heart disease: meta-analysis –American Journal of Medicine Volume 116, Issue 10, Pages (15 May 2004) Rod S Taylor, MSc; etalVolume 116Issue 10 –48 trials with a total of 8940 patients Reduced All-Cause mortality (odds ratio [OR] = 0.80; 95% confidence interval [CI]: 0.68 to 0.93) Reduced Cardiac mortality (OR = 0.74; 95% CI: 0.61 to 0.96) Reduced Total cholesterol (weighted mean difference, –0.37 mmol/L [– 14.3 mg/dL]; 95% CI: –0.63 to –0.11 mmol/L [–24.3 to –4.2 mg/dL Reduced Triglycerides (weighted mean difference, –0.23 mmol/L [–20.4 mg/dL]; 95% CI: –0.39 to –0.07 mmol/L [–34.5 to –6.2 mg/dL] Reduced Systolic blood pressure (weighted mean difference, –3.2 mm Hg; 95% CI: –5.4 to –0.9 mm Hg) Reduced rates of self-reported smoking (OR = 0.64; 95% CI: 0.50 to 0.83)

50 Physical Fitness and Diabetes Resistance Training in the Treatment of the Metabolic Syndrome: A Meta-Analysis –Sports Medicine, Volume 40, Number 5, 1 May 2010, pp (19) Strasser, Barbara 1 ; Siebert, Uwe; Schobersberger, Wolfgang 1 University for Health Sciences, Medical Informatics and Technology, Institute for Sport Medicine, Alpine Medicine and Health Tourism, Hall i. T., AustriaSports Medicine –Metabolic consequences of reduced muscle mass, as a result of normal aging or decreased physical activity, lead to a high prevalence of metabolic disorders Meta-Analysis – 13 RCTs – Effect of Resistance Training –HbA 1c by 0.48% (95% CI 0.76, 0.21; p = ) –Fat mass by 2.33 kg (95% CI 4.71, 0.04; p = 0.05) –Systolic blood pressure by 6.19 mmHg (95% CI 1.00, 11.38; p = 0.02) –No statistically significant effect of RT on: »total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride and diastolic blood pressure

51 Stay Active

52 Exercise Weight and Heart Health 22,000 Men / 8 years % body fat and exercise treadmill testing Thin / Fit = 1/3 cardiac related death c/w Thin / Un-Fit Fit / Obese men had lower death rates than Unfit / Thin men! Lee et al, Am J of Clin Nutrition 1999; 69: 373

53 Fitness / Fatness and Heart Health Lean <16.7% Relative Risk of CVD Mortality Body Fat Category (% Weight as Fat) Lee et al. Am J Clin Nutr 1999;69:373. Normal 16.7%-24.9% Obese >25% Aerobically fit Unfit

54 Pedometers: Taking the first steps! Great motivational tool Low upfront cost Healthcare cost savings Preliminary outcome data particularly in diabetics Problems: –No standards yet (10,000 steps/day) –First Step Program – US and Canada Tudor-Locke Dept. Exercise and Wellness ASU Presidents Council on Physical Fitness and Sports 2001

55 As a man thinketh in his heart, so shall his life be made Osler

56 You are what you…..believe!

57

58

59 Unresolved Anger / Grief Relationships Images / Beliefs Generalized Stress and Anxiety Values

60 Where does Stress come from? We often get so caught up in the drama of our lives that we forget that we are the ones who created the drama in the first place Matt Flickstein Journey To The Center

61 Is it you or them?

62 Dis-Stress Dis-Ease Disease

63 Stress and Heart Disease Psycho-social factors, particularly depression, negatively predict: –Adherence and outcomes of Cardiac Rehab –Adherence to Smoking cessation programs –Adherence to weight management programs Glazer et al, J of CardioPulm Rehab 2002; 22: Psychological predictors of adherence and outcomes among patients in cardiac rehab

64 Stress Management and Heart Disease Psycho-social interventions designed to modify these factors have been shown in large meta-analyses to reduce fatal and non fatal events by 30 – 50% Dusseldorp et al, Health Psych 1999; 18: Sustained effectiveness Compared to diet / exercise (temporary) Luskin et al. Alternative Therapies May 1998 A review of mind body approaches to CHD

65 Dis-stress and Diabetes In people with diabetes, dis-stress alters blood glucose levels – Direct: Stress-mediated production of: –Cortisol, Norepinephrine, Beta endorphin, Glucagon, and Growth hormone – Indirect: People when under stress often make poor health choices –Less physical activity –Poor meal choices –Check BG less frequently

66 Stress Management and Diabetes Stress management improves long-term glycemic control in type 2 diabetes –Surwit RS, Diabetes Care Jan;25(1): patients with type 2 diabetes –Five-session group diabetes education program with or without stress management training. HbA(1c) tests, questionnaires assessing perceived stress, anxiety, and psychological health were administered at regular intervals to evaluate treatment effects Stress management training was associated with a small (0.5%) but significant reduction in HbA(1c) CONCLUSIONS: The current results indicate that a cost-effective, group stress management program in a "real-world" setting can result in clinically significant benefits for patients with type 2 diabetes

67 Stress Management and DM Diabetes Care 25:30-34, 2002 Stress Management Improves Long-Term Glycemic Control in Type 2 Diabetes –Richard S. Surwit, PHD etal., Duke University Medical Center, Durham, North Carolina

68 Stress Management and Children with Diabetes Stress Management Training for Adolescents with Diabetes –Journal of Pediatric Psychology 18(1) pp , 1993 Ronald H. Boardway Wayne State University School of Medicine Effects of stress management training (SMT) for adolescents with diabetes 9-month controlled treatment-outcome study –Diabetes-specific stress decreased significantly for patients in the SMT group

69 Group Support Social connection decreases stress and depression Emotional quality > Structural quality Perceived low social support strongly associated with: –anger –depression

70 149 men and women with angina Questioned pre-catheterization regarding feeling loved and supported Those with the greatest perception of love and support had the least amount of CAD Seeman, TE and SL Syme, Psychosomatic Medicine, 1987;49(4): Group Support and CAD

71 Medicine and Faith in 1910: Immeasurable? Nothing in life is more wonderful than faith -- the one great moving force which we can neither weigh in the balance nor test in the crucible…mysterious, indefinable, known only by its effects, faith pours out an unfailing stream of energy while abating neither jot nor tittle of its potency. Sir William Osler (1910). The faith that heals, British Medical Journal, 1:

72 Ornish Pilot Project 10 patients with severe CAD 30 day residential study 62% increase in time on treadmill 90% reduction in anginal frequency improvements in myocardial perfusion as measured by exercise thallium scintigraphy Ornish, Gotto, Miller et al. Clin. Res.1979, 27:720A

73 The Lifestyle Heart Trial One-Year Data 48 patients with severe coronary artery disease Outpatient 1 year intervention extended to 4 –Percent diameter lesion stenosis improved in the experimental group and worsened in the control group (p = 0.001). Ornish, Brown, Scherwitz et al, Lancet. 1990, 336:

74 Ornish – 1 year Data Analysis Treatment 37% decrease – LDL 91% decrease - Angina 82% decrease - Stenosis Control LDL – Increase or same 165% - Increase Angina 53% - Progression

75 Ornish - Five-Year Data Continued angiographic improvement in the experimental group and continued progression in the control group PET scans showed improvement in myocardial perfusion –99% of patients stopped or reversed the progression of disease as measured by PET scan Changes in stenosis associated with –adherence to the intervention –Improved Lipid Profile The risk ratio for total cardiac events was 2.5 times greater in the control group than in the experimental group Ornish D, Scherwitz L, Billings J, et al. JAMA. 1998;280: Gould, Ornish, Scherwitz et al. JAMA. 1995, 274:

76 Finnish Diabetes Prevention Study Design –522 middle-aged overweight (BMI 31) –172 men and 350 women –Mean duration 3.2 years Intervention Group: Individualized counseling –Reducing weight, total intake of fat and saturated fat –Increasing uptake of fiber, physical activity Tuomilehto J et al. N Engl J Med 2001;344:

77 Finnish Diabetes Prevention Study Goals InterventionControls P value % of subjects Wt reduction >5% Fat intake < 30% energy Sat fat <10% energy Fiber >15 g/1000 kcal Exercise > 4 hr/wk Tuomilehto J et al. N Engl J Med 2001;344:

78 Finnish Diabetes Prevention Study Tuomilehto J et al. N Engl J Med 2001;344: InterventionControl After 4 years risk of diabetes reduced by 58% 11% 23% (6–15 CI) (17–29 CI) % with Diabetes

79 Diabetes Prevention Program 3,234 men and women with impaired glucose tolerance (fasting plasma glucose 95–125 mg/dL and 2-hr postload glucose 140–199 mg/dL) and BMI 24 45% from minority groups with increased prevalence of type 2 diabetes: African Americans, Hispanic Americans, Asian Americans, and American Indians 27 centers nationwide Randomization to lifestyle changes to include at least 7% weight loss and exercise 150 min/wk, metformin 850 mg b.i.d., or placebo Primary endpoint: development of diabetes Follow-up: designed for 3.5–5 years, but discontinued 1 year early because of conclusive results (mean 2.8 years) Diabetes Prevention Program. Diabetes Care 1999;22: Diabetes Prevention Program. Diabetes Care 2000;23:

80 Diabetes Prevention Program Lifestyle Patients Developing Diabetes in Mean 3-Year Follow-up (%) Trial was discontinued 1 year early because of clear results PlaceboMetformin 58% reduction 14 31% reduction 5-7% reduction in body weight; exercise 30 min/d 2229 Knowler WC, et al. N Engl J Med 2002;346:

81 Diabetes Prevention Program Cumulative incidence (%) Years from randomization Knowler WC, et al. N Engl J Med 2002;346: ©2002 Massachusetts Medical Society. 0 p< Placebo Lifestyle Metformin

82 Ready to take some new steps?

83 Whats at Risk?

84

85 When you look in the mirror what do you see?

86 The Bottom Line!

87 Only the thoughts of which you are unaware can control you!

88 You cant stop the waves, but you can learn to surf John Kabat-Zinn Wherever you go, there you are

89 The Wisdom of Children!


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