1. Natalie Alméras, Ph.D. Quebec Heart and Lung Institute Department of Kinesiology, Faculty of Medicine, Université Laval Québec, CANADA Preventive intervention in Diabetes Weight Loss Is Not the Optimal Target Public Health 2014 Canadian Public Health Association

2. Typical Profile of the Canadian Patient with Type 2 Diabetes Managed in Primary Care  Age: 63 years  BMI:  Men=30.3 kg/m 2  Women=31.4 kg/m 2  HbA1c: 6.9%  Blood pressure: 130/76 mmHg  LDL-cholesterol: 1.9 mmol/L  Dyslipidemia: 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

3. Typical Profile of the Canadian Patient with Type 2 Diabetes  Age: 63 years  BMI:  Men=30.3 kg/m 2  Women=31.4 kg/m 2  HbA1c: 6.9%  Blood pressure: 130/76 mmHg  LDL-cholesterol: 1.9 mmol/L  Dyslipidemia: 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!!!

4. Typical Profile of the Canadian Patient with Type 2 Diabetes  Age: 63 years  BMI:  Men=30.3 kg/m 2  Women=31.4 kg/m 2  HbA1c: 6.9%  Blood pressure: 130/76 mmHg  LDL-cholesterol: 1.9 mmol/L  Dyslipidemia: 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?

5. 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

6. The Current Epidemic of Obesity, Type 2 Diabetes and CVD: Chronic Societal Metabolic Diseases

7. In the Québec Province… 720,000 with diabetes in Québec Source : Diabète Québec 2014

8. Behaviors: Forgotten Components of Ideal Cardiovascular Health 4 ideal health behaviors:  Nonsmoking  BMI<25 kg/m 2  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

9. Incidence Rate of Cardiovascular Disease According to the Number of Ideal Health Behaviors and Health Factors 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 Age, sex, and race-adjusted incidence rate (/1,000 person-year) Number of ideal health behaviors

10. To optimally prevent CVD, it is as important, if not more, to target the health behaviors (obesity, physical activity, nutritional quality, smoking) than the biological risk factors (blood pressure, cholesterol, diabetes)

11. Risk of Obesity: More than an Excess of Body Fat

12. Fat mass: 19.8 kg Intra-abdominal fat: 155 cm 2 Fat mass: 19.8 kg Intra-abdominal fat: 96 cm 2 Our Initial Results…27 Years Ago!!!

13. ( ( ( ( Pro-thrombotic state Inflammatory profile Atherogenic dyslipidemia Hypertension Insulin resistance 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

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

15. Visceral Adipose Tissue Measurement (n=4144 Men and Women) L4-L5 intervertebral space Vertebrae Ribs Visceral fat L4-L5 Subcutaneous fat Muscle Visceral fat Vis. fat Subcutaneous fat Visceral fat Subcutaneous fat

16. CTL: 79.4 HU CTL: 14.8 HU CTS: 60.7 HU CTS: 59.6 HU Subject B – Fatty liver CTL/CTS : 0.24 Liver fat CTL-Liver CTL-Spleen Subject A – Lean liver CTL/CTS : 1.33 Liver Fat Measurement (Th12-L1) (n=4144 Men and Women)

17. Relationship Between Visceral Adipose Tissue and Liver Attenuation According to Glucose Tolerance Status in Women The INSPIRE ME IAA Liver attenuation (HU) Visceral adipose tissue area (cm 2 ) NGT IFG/IGT T2D IGT/IFG T2D NGT Mean values (r= -0.46, p<0.001)

18. Visceral Adiposity and Ectopic Fat (not Weight) Define the High-Risk Overweight/Obesity! From Després JP. Circulation 2012;126:1301-13

19. 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

20. 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. ABDOMINALOBESITYABDOMINALOBESITYCARDIORESPIRATORYFITNESSCARDIORESPIRATORYFITNESS ( )  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.

21. Proportion of patients remaining free from type 2 diabetes Adapted from Tuomilehto J et al NEJM (2001) 344:1343-1350 Adapted from Tuomilehto J et al NEJM (2001) 344:1343-1350 Study year Cumulative probability of remaining free of diabetes Intervention group Control group Subjects at risk Total no. Cumulative no. with diabetes: Intervention group Control group 507 5 16 471 15 37 374 22 51 167 24 53 27 57 27 59

22. THE GRAND CORPORATE CHALLENGE Experience of a Mobile CMR Unit

24. Clinical assessment/management of cardiometabolic risk of cardiometabolic risk Clinical assessment/management of cardiometabolic risk of cardiometabolic risk Nutritional quality Nutritional quality Physical activity habits Abdominal obesity Cardiorespiratory fitness The Workplace: Another Epicenter to Assess/Target Key Behaviors?

25. The 3-Month GDE Challenge Be more active Be more active Bonus Stop smoking Stop smoking Eat better 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 days 50 “Action cubes” = 1 cm waist girth lost Win the Grand Prize More cubes... more chances to win!

26. Baseline Characteristics of Participants VariableTotal(n=749)Men(n=603)Women(n=146) Age (years)44.5±10.045.2±10.041.8±9.6 Weight (kg)82.6±15.986.0±14.468.3±13.7 BMI (kg/m 2 )27.5±4.527.9±4.225.6±4.9 Waist circumference (cm)96.3±12.598.0±11.689.1±13.5 Fat (%)26.6±7.725.0±6.733.1±7.9 FFM (kg)60.1±10.063.8±7.044.8±4.5 Smokers (n,%)264 (35%)208 (34%)56 (38%)

27. Nutritional Quality Index (NQI) NQI +9.2 ‡ Elevated risk ˂ 60 Moderate risk 60-74 Low risk ≥75 ↓61% ↑131% Employees (%) NQI Average of 2.9 nutrition targets achieved per day ‡ p ˂ 0.0001 3-month Baseline

28. Blood Pressure and Heart Rate at Submaximal Exercise (3.5 mph at 2% slope) -6 ‡ SBP (mmHg) Baseline3 months -4 ‡ DBP (mmHg) Baseline3 months -4 ‡ Heart Rate (bpm) Baseline3 months ‡ p ˂ 0.0001

29. Mean Changes in Waist Circumference -4.2 ‡ Waist circumference (cm) Baseline 3 months ‡ p ˂ 0.0001

30. Classification of Resting Blood Pressure Employees (%) SBP ˂ 120 and DBP ˂ 80 SBP 120-139 or DBP 80-89 SBP 140-159 or DBP 90-99 SBP ≥160 or DBP ≥100 ↑ 86% ↓ 47% 3 months Baseline

31. Changes in HbA1c Levels in Each Subgroups of Diabetes Mellitus Classification Normal Prediabetes T2D untreated T2D treated -0,1† -0,7* +0,1† Baseline 3 months

32. 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

33. Acknowledgement

34. The GDE Health Team!