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Reducing Cardiovascular Risk in Patients With Diabetes

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1 Reducing Cardiovascular Risk in Patients With Diabetes
Robert J Bulgarelli DO FACC CMA Director Integrative Cardiology - MLHS CMO – the Habit Change Company We would like to thank GlaxoSmithKline for sponsoring this. In regards to the CME credit that is being offered, I do need to let you know that the faculty have been asked to disclose any conflicts, use generic names whenever possible, and disclose if they’ll be talking about a product outside its labeling. So, let’s begin.

2 The Cholesterol And Dietary Fat Obsession

3 CVD Deaths: 1979–1998 520 500 480 460 440 420 NCEP I NCEP II NCEP III
Deaths (in thousands) 440 420 NCEP I NCEP II NCEP III 400 And one thing I think we should keep in mind as we’re thinking about approaching this. Despite our war on cholesterol, despite the national guidelines calling for aggressive detection and treatment of hyperlipidemia; if we look at the impact we’ve actually had on cardiovascular morbidity and mortality in this country age adjusted, since the release and application of these national guidelines, we see here in men no fall in cardiac mortality and actually a rise in women. And certainly when we look at what is behind this, we see the growing incidence of metabolic syndrome, diabetes accounting for much of this increased or failure to see a reduction in cardiovascular morbidity and mortality despite our guidelines calling for the application of pharmacologic approaches to control risk factors. It’s very important to keep that in mind as we go forward. 79 81 83 85 87 89 91 93 95 97 98 Years Men Women United States: 1979–1998 mortality. American Heart Association Heart and Stroke Statistical Update

4 Components: Metabolic Syndrome Obesity Insulin Resistance Dyslipidemia

5 Diagnosis Metabolic Syndrome 34% of U.S. adults
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 So you might think that this is the boring part, but in fact, I think this is the interesting part of the metabolic syndrome. And it is my opinion that the metabolic syndrome is the most important medical problem facing our society today for two reasons. Number one, it’s so prevalent, as we’ll talk about, and number two, the pathophysiologic manifestations of it are so broad and they really impact upon most of the diseases that kill us. Like I tell my patients that, you know, these days everybody reads the paper and they get paranoid about, you know, E.coli or dying in a plane crash or any number of bizarre and, you know, dramatic deaths. But, you know, the chances of those kinds of things happening are less than 1%, even car crashes are low. On the other hand, cardiovascular disease kills half of us, half of us in this room. Even, as Greg just pointed out, even with all we know about heart disease and how to prevent it and LDL cholesterol, you’d think that we have the answer to it. We don’t. Half of us still die from this disease. It’s endemic in our society, atherosclerosis. So clearly, it’s a major problem, yet clearly, we’re not addressing the underlying problem and the underlying problem is, for most people, for most of our society is the metabolic syndrome. There’s been a breakthrough in the metabolic syndrome, recently, and that is we’ve finally figured out what to call it. There have been, you know, a bunch of names for it for a lot of years and it’s fun to now have a name that we can all settle on, that’s the metabolic syndrome as described by the National Cholesterol Education Program about a year ago and you should memorize this. It’s three or more of the following, hypertension, that is blood pressures above 130 over 85. That’s a pretty low bar for the diagnosis of hypertension. Waist size, 40 inches in men and 35 in women and we might say that’s actually a pretty liberal criteria because in South Asians, people from India, for example, or a lot of other people, males in particular, can have the metabolic syndrome with excess abdominal obesity with a waist size a lot less than 40 inches. HDL of less than 40 for men and less than 50 for women, triglycerides over 150 and fasting glucose above 110, three or more of those.

6 Cardiovascular Mortality
p < 0.001 Diabetes Care large population with / without the metabolic syndrome six-fold higher CV mortality in the people that had the metabolic syndrome. Diabetes Care 2001;24:683

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 Lower body (android) (gynoid) female pattern - gynecoid obesity male pattern - android obesity. dramatically different effects on the metabolic syndrome

9 (*BMI 30, or about 30 lbs. overweight for 5’4” person)
Obesity Trends Among U.S. Adults (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1990 1998 2007 No Data <10% %–14% %–19% %–24% %–29% ≥30%

10 (*BMI 30, or about 30 lbs. overweight for 5’4” person)
Obesity Trends Among U.S. Adults (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1990 10 States had a prevalence of obesity less than 10% 0 States had prevalence equal to or greater than 15%. 1998 0 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%. 2007 1 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%.

11 Type 2 DM in Children and Adolescents
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 > 35  RR BMI  RR U.S Nurses’ Health Study that showed the power of obesity. 39-fold increased risk of Type 2 diabetes in people who had a BMI above 35 and a relative risk of 39, huge. 20 million Type 2 diabetes in American today, 19 million are obese Hu et al. NEJM 2001;345:790

13 Prevalence CAD Risk Factors in Type 1 vs. Type
Dyslipidemia Hypertriglyceridemia Low HDL Small, dense LDL Increased apo B Hypertension Hyperinsulinemia/insulin resistance Central obesity Family history of atherosclerosis Cigarette smoking + ++ + Prevalence of Cardiovascular Risk Factors in Diabetic Subjects Relative to Nondiabetics Compared with nondiabetics, patients with type I diabetes tend to have more hypertension and more hypertriglyceridemia but they do not have many of the disorders that are characteristic of patients with type 2 diabetes, such as low HDL cholesterol concentration, small dense LDL particles, increased apolipoprotein (apo) B concentration, and central obesity. Type 2 diabetics have more multiple metabolic abnormalities. While CHD rate is increased in both types of diabetes, the reason for the increase with type 1 diabetes is not clear. Reference: Chait A, Bierman EL. Pathogenesis of macrovascular disease in diabetes. In: Kahn CR, Weir GC, eds. Joslin's Diabetes Mellitus. 13th ed. Philadelphia: Lea & Febiger, 1994: + = moderately increased compared with nondiabetic population ++ = markedly increased compared with nondiabetic population – = not different compared with nondiabetic population Adapted from Chait A, Bierman EL. In: Joslin’s Diabetes Mellitus. Philadelphia: Lea & Febiger, 1994:

14 Risk Factors for IHD* Odds Ratio P Elevated fasting insulin 5.5 .001
Elevated triglycerides Elevated ApoB Small dense LDL Elevated LDL-C Reduced HDL-C And, in fact, in a later paper from that study, this group said, let's get beyond LDL; because, if your LDL is elevated, you have a 2.5-fold increase in cardiac events, but if you're insulin resistant, you've a 5.5-fold increase. The reason for the independent risk factor, of course, is the effect on the endothelium. And endothelial function can be improved by lowering insulin resistance. *Data from the Quebec Heart Study. Adapted from Lamarche B et al. JAMA. 1998;279:1955–1961.

15 Natural History of Type 2 Diabetes
Uncontrolled Hyperglycemia Obesity IFG* Diabetes 350 – Post meal Glucose 300 – 250 – Glucose (mg/dL) Fasting Glucose 200 – 150 – 100 – 50 – 250 – Insulin Resistance Relative Function (%) 200 – 150 – 100 – -Cell Failure 50 – 0 – -10 -5 5 10 15 20 25 30 Years of Diabetes *IFG = impaired fasting glucose. ©2000 International Diabetes Center, Minneapolis, Minnesota. Used with permission.

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

17 Mortality in Patients With Diabetes Causes of Death
Deaths (%) We need to be very aggressive in these patients in lowering the risk. CHF/CAD Diabetes Cancer Stroke Infection Other Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; ch 11.

18 Incidence of CHD* Events in Patients With and Without Diabetes
7-Year Follow-up (%) Incidence During n=1304 18.8 Non diabetics with no prior MI Non diabetics with prior MI Diabetics with no prior MI Diabetics with prior MI n=69 n=890 n=169 0.5 3.0 3.2 7.8 3.5 45.0 20.2 P<.001 Incidence of Fatal or Nonfatal MI During a 7-Year Follow-up in Relation to History of MI in Nondiabetic vs Diabetic Subjects: East-West Study In the East-West Study, diabetics with prior myocardial infarction had a higher incidence of myocardial infarction than diabetics without prior myocardial infarction, but more importantly, diabetics without prior myocardial infarction had a 20.2% incidence of myocardial infarction at 7-year follow-up, compared with an 18.8% incidence in nondiabetics with prior myocardial infarction. These results were important in establishing diabetes as a CHD risk equivalent. Although this study was criticized because it was conducted in a relatively high-risk population for CHD, namely Finland in the early 1980s, a subsequently published analysis of the Organization to Assess Strategies for Ischemic Syndromes (OASIS) Registry, which included prospective data from 6 countries (Australia, Brazil, Canada, Hungary, Poland, and the United States), also found that diabetic patients without prior cardiovascular disease had the same event rates as nondiabetic patients with prior cardiovascular disease. References: Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998;339: Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, Piegas L, Calvin J, Keltai M, Budaj A. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation 2000;102: Keywords: coronary heart disease, diabetes, myocardial infarction, secondary prevention Slide type: graph Events per Person-yr *Coronary heart disease Haffner SM et al. N Engl J Med. 1998;339:229–234.

19 The Need for Tight BG Control
According to the United Kingdom Prospective Diabetes Study (UKPDS) 35, every 1% increase in A1c 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% Adapted from the United Kingdom Prospective Diabetes Study. Stratton IM, et al. BMJ. 2000;321(7258):

20 Diabetes Control and Complications Trial (DCCT)
1983 – 1993 11,441 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?
Do We Reach Treatment Goals? Suboptimal Optimal HbA1c <7.0 HDL >45 (men) HDL >55 (women) LDL <100 Triglycerides <200 BP <130/85 BMI <25 100% 80% 60% 40% 20% 0% 10% 40% 60% 80% 100% George PB et al. Am Heart J. 2001;142:857–863. 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?
Do We Prescribe Optimal Cardiovascular Drug Therapy? % Patients Treated by Medication Lipid-lowering drugs -Blockers ACE inhibitors Aspirin George PB et al. Am Heart J. 2001;142:857–863. Prospective observational study of 235 treated (oral or insulin) CAD patients with Diabetes

24 60% Type 2’s Not At ADA HgbA1c Goal <6%
GOAL Survey HgbA1c 26.5% 40.3% >8% 59.4% >7% 13.8% % Of Subjects N = 371 19.1% Abstract Title Control of Risk Factors for Vascular Disease in US Adults with Diabetes Abstract Information Abstract Number: 979-P Authors: SHARON H. SAYDAH, JUDITH FRADKIN, CATHERINE C. COWIE Institution: Silver Spring, MD; Bethesda, MD Results: Individuals with diabetes are at increased risk of vascular diseases. Control of blood glucose, blood pressure and cholesterol levels can help reduce this risk. We examined national data on treatment and control of these risk factors in adults age years with previously diagnosed diabetes who participated in the interview and examination components of the Third National Health Examination Survey (NHANES III, , n=999) and the NHANES (n=371). Participants with diabetes were similar by age and sex in the two surveys, however the percent who were nonHispanic white decreased significantly from 72.5% to 59.6%, p<.05. Age at diagnosis of diabetes decreased during the decade (from mean 47.8 to 44.3 yrs, p<.05) and duration of diabetes increased (from mean 8.7 to 11.3 yrs, p<.05). Only 40.6% of adults with diabetes in the NHANES have HbA1c levels <7.0%, the goal recommended by the American Diabetes Association, with 40.3% having levels >8.0% and 26.5% having levels >9.0%. These percentages did not change significantly over the past decade. Diabetes treatment shifted to greater use of oral medications either alone (from 43.9% to 51.0%) or in combination with insulin (from 4.1% to 11.1%, p<.05). The percent with systolic blood pressure [ge]140 mmHg and/or diastolic blood pressure [ge]90 mmHg increased from 22.1% in the NHANES III to 36.3% in the NHANES , p<.05. Treatment for blood pressure (e.g., use of antihypertensive medication, weigh t or exercise control) did not change significantly during this period. No change occurred in total cholesterol levels during the decade (mean mg/dl, 54.6% with levels [ge]200 mg/dl in NHANES ), despite an increase in the report of total cholesterol being checked and use of medication to reduce cholesterol (from 26.0% to 55.4%, p<.001). The percent who smoke significantly decreased from 23.1% to 16.2%, p<.05. Mean body mass index significantly increased from 30.9 to 33.1, p<.05. Expanded efforts are needed to improve control of blood glucose, blood pressure, lipids and other risk factors for vascular disease in US adults with diabetes. Category: Epidemiology 40.6% 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 Traditional Therapies Do Not Maintain A1c Control Over Time
United Kingdom Prospective Diabetes Study (UKPDS) 9 8 Conventional* Insulin Median A1c (%) Glibenclamide (glyburide) 7 ADA goal Metformin 6 3 6 9 10 Time from Randomization (Years) *Conventional=diet therapy. UK Prospective Diabetes Study (UKPDS 34) Group. Lancet. 1998;352:

26 We have a lot of catching up to do!

27 Primary Prevention: Status and 2010 Goals
Now 2010 Moderate physical activity Vegetable intake of >3 servings Primary prevention: status and goals in 2010 This slide compares current findings for several lifestyle variables with the goals for 2010 set forth in Healthy People To reach the goal for healthy weight, more Americans will need to increase their physical activity and eat better. Reference: National Cholesterol Education Program. Adult Treatment Panel III Report Saturated fat <10% of calories NCEP. Adult Treatment Panel III Report

28 Primary Prevention: Status and 2010 Goals
Now Fruit >2 servings/d Smoking cessation Primary prevention: status and goals in 2010 (continued) This slide continues the comparison of current findings for several lifestyle variables with the goals for 2010 set forth in Healthy People 2010. Reference: National Cholesterol Education Program. Adult Treatment Panel III Report Healthy weight 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……

36 Dietary intervention trials using morbidity / mortality endpoints
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 2nd 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. Thomasa1 c1 and E. J. Elliotta1a2a3 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 RCT’s (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. BERLIN1,2, and GRAHAM A. COLDITZ1,31Technology Assessment Group, Harvard School of Public Health Boston, MA2University of Pennsylvania School of Medicine, Section of General Internal Medicine, Clinical Epidemiology Unit Philadelphia, PA3Channing Laboratory, Harvard Medical School Boston, MA 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; etal 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, Barbara1; Siebert, Uwe; Schobersberger, Wolfgang1 University for Health Sciences, Medical Informatics and Technology, Institute for Sport Medicine, Alpine Medicine and Health Tourism, Hall i. T., Austria 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 RCT’s – Effect of Resistance Training HbA1c by 0.48% (95% CI −0.76, −0.21; p = 0.0005) 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
Aerobically fit Unfit Relative Risk of CVD Mortality Fatness, fitness and cardiovascular disease mortality In addition to the beneficial effects of physical activity on body weight, aerobic fitness can independently modify the risk of developing cardiovascular disease. This figure illustrates the data obtained from a large observational cohort study involving more than 20,000 men, aged 30 to 83 years, who were followed for an average of 8 years [1]. The results show that increasing adiposity is associated with an increased risk of cardiovascular mortality. However, among each category of body fatness, those who were fit, defined by their maximal ability to consume oxygen during exercise, had a lower incidence of cardiovascular mortality than those who were unfit. Moreover, participants who were obese and fit had a lower risk of cardiovascular death than participants who were lean but unfit. Aerobic fitness, independent of body fatness, also is associated with a decreased risk of developing diabetes [2]. Lee CD, Blair SN, Jackson AS. Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men. Am J Clin Nutr 1999;69: Wei M, Gibbons L, Mitchell T, et al. The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men. Ann Intern Med 1999;130:89-96. Keywords: fitness, cardiovascular disease mortality, CVD, relative risk, body fat Lean <16.7% Normal 16.7%-24.9% Obese >25% Body Fat Category (% Weight as Fat) Lee et al. Am J Clin Nutr 1999;69:373.

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 President’s 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!



59 Generalized Stress and Anxiety
Unresolved Anger / Grief Relationships Images / Beliefs 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):30-4 108 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 Social connection decreases stress and depression
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
Group Support and CAD 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):341-54

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 Control 37% decrease – LDL 91% decrease - Angina 82% decrease - Stenosis 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 ;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 Does treating the metabolic syndrome make a difference? Finnish Diabetes Prevention Study This slide describes the Finnish Diabetes Prevention Study, which looked at 522 middle-aged overweight men and women with glucose intolerance. Subjects were randomized to two groups. The intervention group had individualized counseling. Reference: Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344: Tuomilehto J et al. N Engl J Med 2001;344:

77 Finnish Diabetes Prevention Study
Goals Intervention Controls P value % of subjects Wt reduction >5% 43 13 0.001 Fat intake < 30% energy 47 26 Sat fat <10% energy 11 Fiber >15 g/1000 kcal 25 12 Exercise > 4 hr/wk 86 71 Treating the metabolic syndrome The results were striking. The intervention group achieved significant improvements in five lifestyle behavioral areas as contrasted with the control group. Reference: Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344: Tuomilehto J et al. N Engl J Med 2001;344:

78 Finnish Diabetes Prevention Study
After 4 years — risk of diabetes reduced by 58% 23% 11% Benefit of treating the metabolic syndrome The benefits were highly signficant, as after 4 years the risk of diabetes mellitus was reduced by 58%. This suggests that lifestyle change can reduce risk for CHD, as diabetics are assumed to have as high a risk for coronary events as nondiabetics with CHD. Reference: Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344: (6–15 CI) (17–29 CI) Intervention Control % with Diabetes Tuomilehto J et al. N Engl J Med 2001;344:

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) The Diabetes Prevention Program (DPP) studied the onset of diabetes in 3,234 men and women with impaired glucose tolerance, defined as fasting plasma glucose 95–125 mg/dL (125 mg/dL or less in American Indian centers) and 2-hour postload glucose 140–199 mg/dL. Patients were 25 years of age or older and had body mass index (BMI) of 24 kg/m2 or higher (22 kg/m2 or higher in Asian Americans). Patients were randomized to intensive lifestyle intervention (reduction in body weight of at least 7% through diet and exercise, physical activity of moderate intensity for at least 150 min/week), metformin 850 mg twice daily plus standard lifestyle recommendations (diet, weight reduction, exercise), or placebo plus standard lifestyle recommendations. The primary endpoint was development of diabetes. The study was conducted in 27 centers nationwide and was designed to have a follow-up period of 3.5–5 years. More than 45% of patients were racial or ethnic minorities: 20% were African American, 16% Hispanic, 5% American Indian, and 4% Asian American. The patient population was 68% female, and 20% of patients were aged 60 years or older (overall mean age at baseline, 51±11 years). Mean baseline BMI was 34.0±6.7 kg/m2; BMI was 30 kg/m2 or greater in 68% of patients (57% of men and 73% of women). Mean fasting plasma glucose was 106.5±8.3 mg/dL, and mean postload glucose was 164.6±17.0 mg/dL. Diabetes Prevention Program. Diabetes Care 1999;22: Diabetes Prevention Program. Diabetes Care 2000;23:

80 Diabetes Prevention Program
Trial was discontinued 1 year early because of clear results 31% reduction 58% reduction Patients Developing Diabetes in Mean 3-Year Follow-up (%) The study was stopped 1 year early (mean follow-up 2.8 years) because the data were already conclusive. Compared with placebo, patients randomized to intensive lifestyle intervention had a 58% reduction in onset of type 2 diabetes (by 1997 American Diabetes Association criteria), which was significantly greater than the 31% reduction in the metformin group. Mean weight loss with intensive lifestyle intervention was 12 lb; 50% achieved the weight loss goal of 7% by the end of the 24-week instruction period, and 74% met the physical activity goal at that time. Daily calorie intake in this group was reduced by 450 kcal (vs. 296 kcal in the metformin group and 249 kcal in the placebo group), and total fat intake was reduced by 6.6% (vs. 0.8% in both the metformin and placebo groups). 14 22 29 Lifestyle Metformin Placebo 5-7% reduction in body weight; exercise 30 min/d Knowler WC, et al. N Engl J Med 2002;346:

81 Diabetes Prevention Program
40 p<0.001 Placebo 30 Metformin 20 Cumulative incidence (%) Lifestyle 10 Diabetes developed in 14% of the intensive lifestyle intervention group, 22% of the metformin group, and 29% of the placebo group; based on these rates, an estimated 7 patients would need to be treated with intensive lifestyle intervention for 3 years to prevent 1 case of diabetes, compared with 14 patients treated with metformin. Treatment effects on incidence rates and risk reductions did not differ significantly among subgroups categorized by sex or ethnicity. However, intensive lifestyle intervention had a significantly greater effect in older patients, reducing the incidence of diabetes among patients older than 60 years by 69% compared with metformin and 71% compared with placebo. Intensive lifestyle intervention was also significantly more effective in patients with lower postload glucose levels at baseline and in patients with a lower BMI. An estimated 10 million Americans are at high risk for type 2 diabetes, which accounts for 95% of the 16 million cases of diabetes in the United States. Prevalence of the disease is almost 20% in individuals aged 60 and older, and is 60% higher in blacks and 90% higher in Hispanics than in whites. The dramatic threefold increase in prevalence in the past 30 years is due in large part to the increase in obesity; individuals with BMI of 30 kg/m2 or greater have a fivefold greater risk for diabetes than individuals with BMI of 25 kg/m2 or less. The results of the DPP are encouraging because they indicate that this trend can be reversed through intensive lifestyle intervention aimed at reducing obesity, and that this intervention works particularly well in older patients, who are at high risk for developing diabetes. References Diabetes Prevention Program Research Group. The Diabetes Prevention Program: design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care 1999;22: Diabetes Prevention Program Research Group. The Diabetes Prevention Program: baseline characteristics of the randomized cohort. Diabetes Care 2000;23: Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346: 1 2 3 4 Years from randomization Knowler WC, et al. N Engl J Med 2002;346: ©2002 Massachusetts Medical Society.

82 Ready to take some new steps?

83 What’s at Risk?

84 What’s at Risk?

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 can’t 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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