1. Ask not what your body can do for you. Ask what you can do for your body.

2. 3 Types of Prevention  Primary  Secondary  Tertiary  How does each apply to the present topics?

3. 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

4. DIABETES Definitions  Diagnosis ?  Fasting  Random  OGTT  “Prediabetes”  IFG  IGT  Gestational

5. 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 ?

6. 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 LossTobacco Cessation (Why?)  Nutritional therapy  Exercise prescription  Sleep Hygiene  After that, we can do what?  Use pharmacotherapy

7. Initial Goal in Weight Reduction  5 – 10 % of initial body weight  Why ?

8. 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

10. 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

12. 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

13. Meds in DM Prevention  Metformin  Pioglitazone  Exenatide

14. Metformin  Insulin sensitizer  Reduced RR of progression by 31%  Can induce weight loss  Most effective in pts. 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

15. Metformin  Reduces inflammatory markers linked to CAD (Fibrinogen & CRP)  Reduces TGs by 10 – 30 %  Reduces LDL by 5 – 10 %

16. Pioglitazone  Insulin sensitizer  Preserves beta cell fxn  Retards progression to T2DM  ACT NOW

17. Exenatide  Reduces hyperglucogonemia  Enhances satiety  Promotes weight loss  Promotes expansion of beta cell mass  Improves 1 st phase insulin response

18.  If all of the above fails, then what?  Bariatric Surgery is an option.

19. 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)

20. Criteria for testing for pre-diabetes and diabetes in asymptomatic adult individuals 1. 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 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

21. Screening for DM type II in Children  Screen those who are overweight (BMI >85 th % 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 1 st or 2 nd 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

22. 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

23. 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)

24. 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

25. Secondary Prevention in Diabetes  How do we do it?  TLC  Meds  Bariatric Surgery

26. Tertiary Prevention in DM  What are we trying to prevent ?  Microvascular Complications  Nephropathy  Neuropathy  Retinopathy  Macrovascular Complications  CAD  CVA

27. How Do We Screen in T2DM ?  Annual retinoscopy  Annual creatinine  Annual microalbuminuria  Annual lipids (if @ goal)  Annual feet neuro exam  Resting ECG ?  Stress Test ?

28. 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

29. GOALS ?  Glycemia ?  Hgb A1C, 7 or 6.5 or 6.0  BP ?  < 130/80  Smoking?  Control Lipids  < 100 or < 70

30. Tertiary Preventive Meds in DM  ACEI or ARB  Statin  Aspirin  Immunizations  Pneumovax  Fluvax  tDap

31. 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 ( 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.

32. 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.

33. OBESITY (Very closely related to DM)

34. Obesity Trends

36.  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 2 nd leading cause of death in US

37. 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%

38. 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

39. 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 Left on His Behind”

40. For kids, the greatest predictor for obesity is having obese parents

41. 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

42. Supersize It !

43. 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

44. 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

45. 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 weight18.5 - 25  Overweight>25 to < 30  Obese30 to < 40  Morbidly Obese40 or more

46. BMI in Kids  Labels are based on BMI percentiles, not weight %-iles :  BMI //apps.nccd.cdc.gov/dnpabmi/calculator.aspx  > 75th to 84 th Caution and close observe  85 th to 94 th Overweight  95 th & moreObese

47. 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3  Yet, only ___ % of obese patients are given such advice.  42

48. 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

49. Know Community Resources

50. 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

51. 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

52. EXERCISE

53. Exercise

54. 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 exerciseFrequency of exercise  Intensity of exerciseDuration of exercise  FlexibilityTechnique  Equipment Write an exercise prescription

55. The Exercise Prescription

57. 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

58. 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 y.o.  Increase active time to > 60 mins/day

59. 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.comwww.SuperSizedKids.com

60. 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

61. Bibliography  For caloric content of foods : www.annecollins.com/calories/ www.annecollins.com/calories/  Cochrane Collaboration  www.SuperSizedKids.com www.SuperSizedKids.com  Barlow SE. Pediatrics.2007;120:Supplement  Stenardo & Slusser. AAFP CME bulletin. Sept. 2008;7  “Readiness to Change” : www.aafp.org/20000301/1409www.aafp.org/20000301/1409. Fast Food & Families. DVD from NCAFP

62. 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)