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Diabetes 1

Cardiometabolic Risk

1

Learning ObjectivesDefine cardiometabolic risk and assess the non-modifiable and modifiable risk factors

Describe methods for early identification and management of the following risk factors:ObesityDyslipidemiaHypertension

Speaker Notes2

Why Focus on Cardiometabolic Risk?A comprehensive approach to patient care

Multiple disease pathways and risk factors are considered to facilitate earlier intervention

Early assessment and targeted intervention are needed to treat and prevent all risk factors associated with cardiovascular diseases (CVD) and diabetes Daly A, Power MA. Medical Nutrition Therapy. Diabetes Mellitus and Related Disorders; Medical Management of Type 2 Diabetes, 7th Edition. American Diabetes Association, 2012.

Speaker Notes

References: SlideDaly A, Power MA. Medical Nutrition Therapy. Diabetes Mellitus and Related Disorders. Medical Management of Type 2 Diabetes, 7th Edition. American Diabetes Association, 2012.

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What is Cardiometabolic Risk?A comprehensive picture of a patients health and potential risk for future disease and complications

All risks related to metabolic changes associated with CVD

Accommodates emerging risk factors Focuses clinical on evaluation, education, disease prevention and treatment

Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-304.

Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.

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Indonesian Cardiometabolic Risk: CVD EpidemiologyCVDs are responsible for over 17.3 million deaths/year and are the leading causes of death in the world

Indonesian statistics:CVD Mortality Rates: 363-443/100 000 for males and 181-281/100 000 for femalesBurden of CVD (Disability-adjusted Life Year): 3315-4228/100000 for males and 2584-3438/100000 females

WHO. Global atlas on cardiovascular disease prevention and control. 2011

WHO. Global atlas on cardiovascular disease prevention and control. 2011

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Direct and Indirect Cost of CVD and Diabetes (USD)*2008 statistics from the American Diabetes Association and American Heart Association.*Note: These figures may not account for potential overlapEstimated Direct Medical CostsEstimated Indirect Costs (disability, work loss, premature mortality)CVD$296 billion$152 billionDiabetes$116 billion$58 billionTOTAL$412 billion$210 billion

Cardiometabolic Risk

Global Diabetes/CVD Risk

Overweight / ObesityAbnormal Lipid Metabolism LDL ApoB HDL Trigly. Age, Race, Gender, Family History

Inflammation HypercoagulationHypertensionSmokingPhysical InactivityUnhealthy Eating

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GlucoseBP LipidsAgeGeneticsInsulin Resistance

Insulin Resistance Syndrome

Cardiometabolic risk identifies individuals at high risk for cardiovascular disease (CVD)

Risk factors include traditional CVD risk factors such as abnormal LDL cholesterol but also include metabolic factors such as abdominal adiposity, insulin resistance, metabolic dyslipidemia (hypertriglyceridemia, low levels of HDL, small dense LDL), hypertension, prothrombic state and proinflammatory state

Identification of these components helps patients make lifestyle changes needed to decrease their risk of developing CVD and diabetes

Reference: ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition, 2009.

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Risk FactorsNonmodifiableAgeRace/EthnicityGenderFamily history

ModifiableOverweightAbnormal lipid metabolismInflammation, hypercoagulationHypertensionSmokingPhysical inactivityUnhealthy dietInsulin resistance

From ADA slide8

Insulin Resistance

Overweight/ Fat distributionAgeGenetic predispositionActivity levelMedicationsPregnancy

Factors Affecting Insulin Resistance

Impaired Fasting Glucose (IFG): A condition in which the blood glucose level is between 100 mg/dL to 125mg/dL after an 8- to 12-hour fast.

Impaired Glucose Tolerance (IGT): A condition in which the blood glucose level is between 140 and 199 mg/dL at 2 hours during an oral glucose tolerance test (OGTT).

Impaired Fasting Glucose & Glucose Tolerance

Proposed Metabolic Observations in the Natural History of T2DMAtherogenesis

Euglycemia Impaired Fasting GlucoseDiabetes

Insulin SensitivityInsulin Secretion Hypertension DyslipidemiaMicrovascularComplicationsAge (years) Type 2 Diabetes

Cardiometabolic RiskADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition, 2009.

Associated Risk FactorsFasting Blood Glucose

As prediabetes develops into T2DM, the continued output of glucose and glucose from the intestinal tract leads to hyperglycemia (increased FBG). Simultaneously, insulin resistance is increased (decreased insulin sensitivity) and insulin secretion is reducedT2DM is an independent risk factor for CVD in addition to coexisting conditions like hypertension, dyslipidemia and obesity which are risk factors in themselves

Reference: ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition, 2009.

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Prediabetes and Diabetes Prevention

Prediabetes Pre-diabetes is an important risk factor for future diabetes and CVD

Recent studies have shown that lifestyle modifications can reduce the rate of progression from pre-diabetes to diabetes

Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT)ADA Consensus Statement:Treat IFG and IGT with intensive lifestyle modification

For certain patients with both IFG & IGT and risk factor(s), consider addition of metformin

Nathan D, et al. Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for Care. Diabetes Care 2007;30:753-9.

Lifestyle modification:5-10% weight loss and moderate intensity physical activity approx 30 mins/day

Risk factors include:6.0%

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Relative Effectiveness of Interventions in Diabetes Prevention

Cumulative Incidenceof Diabetes (%)Years40302010000.51.01.52.02.53.03.54.0Placebo

Knowler WC, et al. NEJM. 2002;346:393-403.MetforminLifestyle

METHODS:3234 andomly assigned nondiabetic persons with elevated FBG and PPG to placebo, metformin (850 mg twice daily), or a lifestyle-modification program Goals: at least 7 percent weight loss and at least 150 minutes of physical activity/week.RESULTS:The average follow-up was 2.8 years. The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively. The lifestyle intervention reduced the incidence by 58% and metformin by 31%, as compared with placebo Lifestyle intervention was significantly more effective than metformin. To prevent one case of diabetes during a period of three years, 6.9 persons would have to participate in the lifestyle-intervention program, and 13.9 would have to receive metformin.CONCLUSIONS:Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high riskLifestyle intervention was more effective than metformin.

Reference: Knowler WC, et al. NEJM. 2002;346:393-403

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Prevention of T2DM: Recent Randomized Trial ResultsStudySubjectsInterventionRelative Risk ReductionBehaviorFinnish DPSUS DPPIGTLifestyle58%IGTLifestyle58%MedicationUS DPPSTOP- NIDDMTRIPODXENDOSDREAMIGTMetformin31%IGTAcarbose25%Prior GDMTroglitazone55%IGTOrlistat45%IGTRosiglitazone/Ramipril61% NS

Screening Screening is conducted on those who have diabetes risks, but do not show any symptoms of DM.

Screening seeks to capture undiagnosed DM or prediabetes so it can be managed earlier and more appropriately.

Mass screening is not recommended considering the costs (usually abnormal results are not followed-up with an action plan).

PERKENI Guidelines. Diabetes Mellitus National Clinical Practice Guidelines. 2011

Perkeni Guidelines. Diabetes Mellitus National Clinical Practice Guidelines. 2011

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Standard Values of Random BG and FBG for Screening and Diagnosis of DMNote: For high-risk groups which show no abnormal results, the test should be done every year. For those aged > 45 years without other risk factors, screening can be done every 3 years.Non DMUncertain DMDMRandom Blood Glucose Level (mg/dL)Venous Plasma 90 cmInternational Diabetes Federation. Consensus worldwide definition of the metabolic syndrome. www.idf.org

Abdominal Obesity is Associated With Increased Risk of CHDWaist circumference is independently associated with increased age-adjusted risk of CHD, even after adjusting for BMI and other CV risk factors.

0.00.51.01.52.02.53.0

1 2 3 4 51.272.082.312.44P for trend = .007 (women)P for trend = .001 (men)Relative RiskQuintiles of Waist Circumference1.00

1.011.341.261.601.00

Rexrode KM, et al. JAMA. 1998;280:1843-8.Rexrode KM, et al. Int J Obes (Lond). 2001;25:1047-56.

Rexrode KM, et al. JAMA. 1998;280:1843-1848. p 1847, T3, model 1. (women) from the Nurses Health Study:During 8 years of follow-up 320 CHD events (251 myocardial infarctions and 69 CHD deaths) were documented. Higher WHR and greater waist circumference were independently associated with a significantly increased age-adjusted risk of CHD. After adjustment for reported hypertension, diabetes, and high cholesterol level, a WHR of 0.76