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Cardiometabolic Risk: Evaluation & Treatment in Your Patient Population
--Insert Here—Speaker Titleand Affiliation
--Insert Here—Speaker Titleand Affiliation
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 CVD and diabetes
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 CVD and diabetes
Cardiometabolic Risk
Gives a comprehensive picture of a patient’s health and potential risk for future disease and complications
Is inclusive of all risks related to metabolic changes associated with CVD
Accommodates emerging risk factors as useful predictive tools
Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment
Supports an integrated approach to care
Gives a comprehensive picture of a patient’s health and potential risk for future disease and complications
Is inclusive of all risks related to metabolic changes associated with CVD
Accommodates emerging risk factors as useful predictive tools
Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment
Supports an integrated approach to care
Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the AmericanDiabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the AmericanDiabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.
2 out of 3 Americans are overweight or obese
More than 70 million (nearly 1 in 4) Americans have varying degrees of insulin resistance
There are an estimated 54 million (more than 1 in 6) Americans with prediabetes
Nearly 1 in 4 U.S. adults has high cholesterol
1 in 3 American adults has high blood pressure
2 out of 3 Americans are overweight or obese
More than 70 million (nearly 1 in 4) Americans have varying degrees of insulin resistance
There are an estimated 54 million (more than 1 in 6) Americans with prediabetes
Nearly 1 in 4 U.S. adults has high cholesterol
1 in 3 American adults has high blood pressure
Direct and Indirect Cost of CVD and Diabetes
$296 billion $152 billion
$116 billion $58 billion
$412 billion $210 billion
*Note: these figures may not account for potential overlap.Sources: 2008 statistics from the American Diabetes Association and American Heart Association.
Cardiovascular
Disease
Diabetes
TOTAL
Estimated DirectMedical Costs
Estimated Indirect Costs
(disability, work loss,
premature mortality)
Abnormal Lipid Metabolism
LDL ApoB HDL Trigly.
Abnormal Lipid Metabolism
LDL ApoB HDL Trigly.
Cardiometabolic Risk
Global Diabetes / CVD Risk
Overweight / ObesityOverweight / Obesity
Inflammation Hypercoagulation
Inflammation Hypercoagulation
HypertensionHypertension
SmokingPhysical InactivityUnhealthy Eating
SmokingPhysical InactivityUnhealthy Eating
Age, Race, Gender,
Age, Race, Gender,
Family HistoryFamily History
GlucoseGlucoseBPBP Lipids Lipids
AgeAge GeneticsGenetics
Insulin ResistanceInsulin Resistance?? Insulin Resistance Insulin Resistance
SyndromeSyndrome Insulin Resistance Insulin Resistance
SyndromeSyndrome
Cardiometabolic Risk - Graphic
Non-modifiableNon-modifiable
Age
Race/ethnicity
Gender
Family history
Age
Race/ethnicity
Gender
Family history
Overweight
Abnormal lipid metabolism
Inflammation, hypercoagulation
Hypertension
Smoking
Physical inactivity
Unhealthy diet
Insulin resistance
Overweight
Abnormal lipid metabolism
Inflammation, hypercoagulation
Hypertension
Smoking
Physical inactivity
Unhealthy diet
Insulin resistance
ModifiableModifiable
Case - Mr. Martin
47-year-old African American man, hasn’t seen doctor in years
Works as a truck driver, eats mostly fast food
Smokes 1 pack per day At health fair found to have BP = 146/86,
total cholesterol = 210 Weight = 230 lbs; BMI = 29 kg/m² Family history of HTN and diabetes
47-year-old African American man, hasn’t seen doctor in years
Works as a truck driver, eats mostly fast food
Smokes 1 pack per day At health fair found to have BP = 146/86,
total cholesterol = 210 Weight = 230 lbs; BMI = 29 kg/m² Family history of HTN and diabetes
Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetes
Overweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Yes Unhealthy diet Fast food diet
Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetes
Overweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Yes Unhealthy diet Fast food diet
Non-ModifiableRisk Factors
Nu
mb
erN
um
ber
Centers for Disease Control and Prevention. National diabetes fact sheet: general information and nationalestimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, 2005.
800,000800,000
600,000600,000
400,000400,000
200,000200,000
00
Age GroupAge Group20-3920-39 40-5940-59 60+60+
0
5
10
15
20
25
30
35
40
45
0
5
10
15
20
25
30
35
40
45
Cardiovascular Risk Factor Trends Among U.S. Adults Aged 20-74Cardiovascular Risk Factor Trends Among U.S. Adults Aged 20-74
Centers for Disease Control & Prevention, Division for Heart Disease andStroke Prevention, "Addressing the Nation's Leading Killers: At A Glance 2007
33.6
28.2
27.2
19.017.0
30.8
33.1
26.3
14.9
39.2
36.0
29.3
26.4
1.8
3.5
3.4
4.65.0
14.8
DiagnosedDiabetesDiagnosedDiabetes
SmokingSmokingHigh BloodPressureHigh BloodPressure
High TotalCholesterolHigh TotalCholesterol
1960-19621960-1962
1971-19751971-1975
1976-19801976-1980
1988-19941988-1994
1999-20001999-2000
Centers for Disease Control and Prevention. National diabetes fact sheet: general information and nationalestimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, 2005.
Hispanic/Latino AmericansHispanic/Latino Americans
Non-Hispanic WhitesNon-Hispanic Whites
American Indians/Alaska NativesAmerican Indians/Alaska Natives
Non-Hispanic BlacksNon-Hispanic Blacks
00 664422 121288 1010 20201414 1616 1818
Insulin Resistance Insulin Resistance
Factors affectinginsulin resistance
• Overweight/ fat distribution• Age• Genetic predisposition• Activity level• Medications• Puberty• Pregnancy
• Overweight/ fat distribution• Age• Genetic predisposition• Activity level• Medications• Puberty• Pregnancy
IFG and IGT
• 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 (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).
Interpreting BloodGlucose Levels
Healthy BG FPG < 100 mg/dL
Pre-diabetes FPG 100–125 mg/dL
Diabetes FPG ≥126 mg/dL
Healthy BG FPG < 100 mg/dL
Pre-diabetes FPG 100–125 mg/dL
Diabetes FPG ≥126 mg/dL
Criteria for testing for type 2 diabetesin asymptomatic children50
Overweight (BMI > 85th percentile for age and sex, weight for height > 85th percentile, or weight
>120 percent of ideal for height) Plus any two of the following:
• Family history
• Race/ethnicity
• Signs of insulin resistance or conditions associated with insulin resistance
• Maternal history of diabetes or GDM
Overweight (BMI > 85th percentile for age and sex, weight for height > 85th percentile, or weight
>120 percent of ideal for height) Plus any two of the following:
• Family history
• Race/ethnicity
• Signs of insulin resistance or conditions associated with insulin resistance
• Maternal history of diabetes or GDM
Criteria for testing for diabetes in asymptomatic adult individuals50
1. Testing should be considered in all overweight adults (BMI ≥25 kg/m2*) and have additional risk factors:
Physical inactivity First-degree relative with diabetes Members of a high-risk ethnic population Women delivering baby weighing >9 lb or
were diagnosed with GDM Hypertension (≥140/90 mmHg)
1. Testing should be considered in all overweight adults (BMI ≥25 kg/m2*) and have additional risk factors:
Physical inactivity First-degree relative with diabetes Members of a high-risk ethnic population Women delivering baby weighing >9 lb or
were diagnosed with GDM Hypertension (≥140/90 mmHg)
ContinuedContinued
Criteria for testing for diabetes in asymptomatic adult individuals50
HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride 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
HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride 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
Criteria for testing for diabetes in asymptomatic adult individuals50
2. In the absence of the above criteria, testing for pre-diabetes and diabetes should begin at age 45 years
3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.
*At-risk BMI may be lower in some ethnic groups.
2. In the absence of the above criteria, testing for pre-diabetes and diabetes should begin at age 45 years
3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.
*At-risk BMI may be lower in some ethnic groups.
00
11
22
33C
HD
mo
rtal
ity,
per
100
0C
HD
mo
rtal
ity,
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100
0
Fontbonne AM, et al. Diabetes Care. 1991;14:461-469.
Quintiles (pmol) of fasting plasma insulinQuintiles (pmol) of fasting plasma insulin
P<.01P<.01
Insulin Sensitive Insulin ResistantInsulin Sensitive Insulin Resistant
(n=943)(n=943)
29 30-50 51-72 73-114 115 29 30-50 51-72 73-114 115
Insulin SensitivityInsulin Sensitivity
Insulin SecretionInsulin Secretion
Associated Risk FactorsAssociated Risk Factors• Hypertension• Hypertension• Dyslipidemia• Dyslipidemia
AtherogenesisAtherogenesis
MicrovascularMicrovascularComplicationsComplications
Type 2 Diabetes Type 2 DiabetesAge (years)Age (years)
Fasting Blood GlucoseFasting Blood Glucose
Cardiometabolic Risk Cardiometabolic Risk
Diabetes
Impaired Fasting GlucoseEuglycemia
Proposed Metabolic Observations in the Natural History of Type 2 DiabetesProposed Metabolic Observations in the Natural History of Type 2 Diabetes
Overweight/Obesity
Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management
Cardiometabolic Risk Factors
Desired Goals for Healthy Patients
Overweight/obesitySource: CDC , ADA
Prevention of overweight/obesity as measured by BMI
(normal = 18.5–24.9).
In those who are overweight/obese, the goal is to lose 5–7% of body weight.
Abnormal lipid metabolismHigh LDL cholesterol
Low HDL cholesterol
High triglyceridesSource: NHLBI, ATP III Guidelines, ADA
Desirable levels are less than 100 mg/dL.
Desirable levels are greater than 40 mg/dL in men and
greater than 50 mg/dL in women.
Desirable levels are less than 150 mg/dL
HypertensionSource: NHLBI, JNC7
<140/90 mm/Hg or 130/80 mm/Hg for people with diabetes
(Ideal is less than 120/80 mm/Hg)
Fasting blood glucoseSource: ADA
Below 100 mg/dL
Physical inactivity Source: CDC At least 30 minutes of moderate activity most days
Smoking Source: ADA Quit or never start
Children Source: ADA Maintain healthy weight for age, sex, and height.
Measure BMI routinely at each regular check-up.
Classifications:
• BMI 18.5-24.9 = normal
• BMI 25-29.9 = overweight
• BMI 30-39.9 = obesity
• BMI ≥40 = extreme obesity
Measure BMI routinely at each regular check-up.
Classifications:
• BMI 18.5-24.9 = normal
• BMI 25-29.9 = overweight
• BMI 30-39.9 = obesity
• BMI ≥40 = extreme obesity
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health.
Measuring Waist CircumferenceMeasuring Waist Circumference
Large waist circumference (WC) can identify some at increased risk over BMI alone
If BMI and other cardiometabolic risk factors are assessed, currently there is insufficient evidence to:
– Substitute WC for BMI
– Measure WC in addition to BMI
Large waist circumference (WC) can identify some at increased risk over BMI alone
If BMI and other cardiometabolic risk factors are assessed, currently there is insufficient evidence to:
– Substitute WC for BMI
– Measure WC in addition to BMI
Klein, et al. Waist Circumference and Cardiometabolic Risk. Diabetes Care. 2007 0: dc07-9921v1-0.
PrimaryMetabolic
Disturbance
PrimaryMetabolic
Disturbance
Intermediate Vascular Disease
Risk Factor
Intermediate Vascular Disease
Risk Factor Intravascular
PathologyIntravascular
PathologyClinicalEvent
ClinicalEvent
Atherosclerosis
Hypercoagulability
• Coronary arteries• Carotid arteries• Cerebral arteries• Aorta• Peripheral arteries
Hypertension
Dyslipidemia
Hyperinsulinemia
Hyperglycemia
Inflammation
ImpairedFibrinolysis
Endothelial Dysfunction
Insulin Resistance
CVD
Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887.
Overnutrition
<100 110-129 130+ <110 110-129 130+<100 110-129 130+ <110 110-129 130+00
100100
150150
200200
250250
300300
5050
125125
200200
267267
105105121121 128128
*Metropolitan Relative Weight percent (percentage of desirable weight)
*Metropolitan Relative Weight percent (percentage of desirable weight)
Hubert HB et al. Circulation. 1983;67:968-977
MenMen WomenWomen
Incidence of CVD
per 1,000
Incidence of CVD
per 1,000
n=56 n=75 n=30 n=191 n=199 n=78 n=56 n=75 n=30 n=191 n=199 n=78
Lifestyle modification
• Reduce caloric intake by 500-1000 kcal/day (depending on starting weight)
• Target 1-2 pound/week weight loss
• Increase physical activity
• Healthy diet
• Diabetes Prevention Program
• DASH diet
Lifestyle modification
• Reduce caloric intake by 500-1000 kcal/day (depending on starting weight)
• Target 1-2 pound/week weight loss
• Increase physical activity
• Healthy diet
• Diabetes Prevention Program
• DASH diet
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:2165–2171, 2002. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH Publication No. 04-5230, August 2004
Consider pharmacologic treatment
• BMI 30 with no related risk factors or diseases, or
• BMI 27 with related risk factors or diseases
• As part of a comprehensive weight loss program incl. diet & physical activity
Consider surgery
• BMI 40 or
• BMI 35 with comorbid conditions
Consider pharmacologic treatment
• BMI 30 with no related risk factors or diseases, or
• BMI 27 with related risk factors or diseases
• As part of a comprehensive weight loss program incl. diet & physical activity
Consider surgery
• BMI 40 or
• BMI 35 with comorbid conditionsClinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:2165–2171, 2002
Abnormal Lipid MetabolismAbnormal Lipid Metabolism
Total Cholesterol Goals34Total Cholesterol Goals34
• Desirable — Less than 200 mg/dL
• Borderline high risk — 200–239 mg/dL
• High risk — 240 mg/dL and over
• Desirable — Less than 200 mg/dL
• Borderline high risk — 200–239 mg/dL
• High risk — 240 mg/dL and over
American Diabetes Association. Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center
Increased:
TriglyceridesVLDLLDL and small
dense LDLApoB
Increased:
TriglyceridesVLDLLDL and small
dense LDLApoB
Decreased:
HDLApo A-I
Decreased:
HDLApo A-I
American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Major Risk FactorsAffecting Lipid Goals36
• Cigarette smoking• Hypertension (≥140/90 mm Hg or on
antihypertensive medication)• Low HDL-C (<40 mg/dL)• Family history of early heart disease• Age (men ≥45 years; women ≥55 years)
• Cigarette smoking• Hypertension (≥140/90 mm Hg or on
antihypertensive medication)• Low HDL-C (<40 mg/dL)• Family history of early heart disease• Age (men ≥45 years; women ≥55 years)
Statins (also called HMG-CoA reductase inhibitors) work by increasing hepatic LDL-C removal from the blood.
Resins (also called bile acid sequestrants) bind to bile acids in the intestines and prevent their reabsorption, leading to increased hepatic LDL-C removal from the blood.
Cholesterol absorption inhibitors help lower LDL-C by reducing the amount of cholesterol absorbed in the intestines; increases LDL receptor activity.
Statins (also called HMG-CoA reductase inhibitors) work by increasing hepatic LDL-C removal from the blood.
Resins (also called bile acid sequestrants) bind to bile acids in the intestines and prevent their reabsorption, leading to increased hepatic LDL-C removal from the blood.
Cholesterol absorption inhibitors help lower LDL-C by reducing the amount of cholesterol absorbed in the intestines; increases LDL receptor activity.
Fibrates (also called fibric acid derivatives) activate an enzyme that speeds the breakdown of triglyceriderich lipoproteins while also increasing HDL-C.
Niacin (also called nicotinic acid) reduces the liver’s ability to produce VLDL. When given at high doses, it can also increase HDL-C.
Fibrates (also called fibric acid derivatives) activate an enzyme that speeds the breakdown of triglyceriderich lipoproteins while also increasing HDL-C.
Niacin (also called nicotinic acid) reduces the liver’s ability to produce VLDL. When given at high doses, it can also increase HDL-C.
American Diabetes Association. Understanding Cardiometabolic risk: Broadening risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center
Cholesterol Management
For patients >20 years of age, cholesterol should be checked every 5 years
Ordering a fasting lipid panel is preferred to gauge the patient’s total cholesterol, LDL-C, HDL-C and triglycerides
Treatment priorities
For patients >20 years of age, cholesterol should be checked every 5 years
Ordering a fasting lipid panel is preferred to gauge the patient’s total cholesterol, LDL-C, HDL-C and triglycerides
Treatment priorities
Cholesterol Management
Category of risk LDL-C Goal
0-1 risk factor* < 160 mg/dL or lower
Multiple (2+) risk factors* < 130 mg/dL or lower
People with coronary heart disease or risk equivalent (e.g., diabetes)
< 100 mg/dL or lower
Known CAD and DM < 70 mg/dL or lower may be ideal
LDL-C-loweringLDL-C-lowering
Cholesterol Management
Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking cessation Dietary modifications including low saturated fat (fat
intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet
Pharmacologic treatment frequently necessary Risk factors include hypertension; HDL < 40; family
history of MI before age 55; male > 45 years old; female > 55 years old; smoking.
Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking cessation Dietary modifications including low saturated fat (fat
intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet
Pharmacologic treatment frequently necessary Risk factors include hypertension; HDL < 40; family
history of MI before age 55; male > 45 years old; female > 55 years old; smoking.
Risk of CHD by Triglyceride Level:Risk of CHD by Triglyceride Level:The Framingham Heart StudyThe Framingham Heart Study
MenMen WomenWomen
n=5,127n=5,127
Triglyceride Level, mg/dLTriglyceride Level, mg/dL
5050 100100 150150 200200 250250 300300 350350 400400
Rel
ativ
e R
isk
Rel
ativ
e R
isk
00
0.50.5
11
1.51.5
22
2.52.5
33
Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiology. 1992;70:3H-9H.
Reaven GM, et al. J Clin Invest. 1993;92:141-146.
Association Between Small, Association Between Small, Dense LDL and Insulin ResistanceDense LDL and Insulin Resistance
Me
an
Ste
ad
y S
tate
Pla
sm
a G
luc
os
e (
mm
ol/L
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t Id
en
tic
al P
lasm
a In
sulin
Me
an
Ste
ad
y S
tate
Pla
sm
a G
luc
os
e (
mm
ol/L
)a
t Id
en
tic
al P
lasm
a In
sulin
AALarger LDL particle
pattern
AALarger LDL particle
patternIntermediate
patternIntermediate
pattern
BSmall LDL particle
pattern
BSmall LDL particle
pattern
0
2
6
10
12
8
4
LDL-Size PhenotypeLDL-Size Phenotype
(n=52)(n=52)
(n=19)(n=19)
(n=29)(n=29)
Low HDL-C: Independent Predictor of CHD Risk, Even When LDL-C is LowLow HDL-C: Independent Predictor of CHD Risk, Even When LDL-C is Low
0.0
1.0
2.0
3.0
100 160 220 8565
4525
LDL-C (mg/dL)LDL-C (mg/dL)
HDL-C (m
g/dL)
HDL-C (m
g/dL)
Ris
k o
f C
HD
Ris
k o
f C
HD
.
Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High density lipoprotein as a protective factor against coronary heart disease. The Framingham Study. American Journal of Medicine. 1977;62:707-14.
Screening for DyslipidemiaScreening for Dyslipidemia
Persons without DiabetesPersons without Diabetes
Test at least every 5 years, starting at age Test at least every 5 years, starting at age 20, including adults with low-risk values 20, including adults with low-risk values
Persons with DiabetesPersons with Diabetes
In adults, test at least annuallyIn adults, test at least annually
Lipoproteins: measure at after initial blood Lipoproteins: measure at after initial blood glucose control is achieved as hyperglycemia glucose control is achieved as hyperglycemia may alter resultsmay alter results
Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for The American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255. American Diabetes Association. Standards of Medical Care in Diabetes 2007. Available at: http://care.diabetesjournals.org/cgi/reprint/30/suppl_1/S4
Healthy Lipid GoalsHealthy Lipid GoalsTargets for Patients Without DM or CVDTargets for Patients Without DM or CVD
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. NIH Publication No. 01-3670, May 2001
Total <200 mg/dL
LDL <70 mg/dL
HDL >40 men mg/dL
>50 women mg/dL
Triglycerides < 150 mg/dL
Risk ManagementRisk ManagementAbnormal LipidsAbnormal Lipids
Lifestyle modification• Increased physical activity
• Diet: reduced saturated fat, trans fat, and cholesterol
• Weight loss, if indicated
Lifestyle modification• Increased physical activity
• Diet: reduced saturated fat, trans fat, and cholesterol
• Weight loss, if indicated
American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Pharmacologic treatment: primary goal is LDL lowering
• Without overt CVD: If over 40, statin therapy recommended to achieve 30-40% LDL reduction
• With overt CVD: All patients should receive statin therapy to achieve 30-40% LDL reduction
• Lowering triglycerides and raising HDL with a fibrate is associated with fewer cardiovascular events in patients with clinical CVD, low HDL, and near-normal LDL
Pharmacologic treatment: primary goal is LDL lowering
• Without overt CVD: If over 40, statin therapy recommended to achieve 30-40% LDL reduction
• With overt CVD: All patients should receive statin therapy to achieve 30-40% LDL reduction
• Lowering triglycerides and raising HDL with a fibrate is associated with fewer cardiovascular events in patients with clinical CVD, low HDL, and near-normal LDL
American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Risk ManagementRisk ManagementAbnormal LipidsAbnormal Lipids
Persons without Diabetes
BP should be measured at each regular visit or at least once every 2 years if BP <120/80 mmHg
BP measured seated after 5 min rest in office
Persons without Diabetes
BP should be measured at each regular visit or at least once every 2 years if BP <120/80 mmHg
BP measured seated after 5 min rest in office
Persons with Diabetes BP should be measured
at each regular visit BP measured seated
after 5 min rest in office Patients with ≥130 or
≥80 mmHg should have BP confirmed on a separate day
Persons with Diabetes BP should be measured
at each regular visit BP measured seated
after 5 min rest in office Patients with ≥130 or
≥80 mmHg should have BP confirmed on a separate day
Preventing Cancer, Cardiovascular Disease, and Diabetes A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255. American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Non-pharmacologic DASH diet
• Dietary Approaches to Stop Hypertension• High in whole grains, fruits, vegetables,
and low-fat dairy• Low in saturated and trans fat, cholesterol
Physical Activity Weight loss, if applicable
Non-pharmacologic DASH diet
• Dietary Approaches to Stop Hypertension• High in whole grains, fruits, vegetables,
and low-fat dairy• Low in saturated and trans fat, cholesterol
Physical Activity Weight loss, if applicable
The Dash Diet. http://dashdiet.org. American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Management of HypertensionManagement of Hypertension
Pharmacologic Drug therapy indicated if BP ≥140/ ≥90 mm Hg Combination therapy often necessary Treatment should include ACE or ARB Thiazide diuretic may be added to reach goals Monitor renal function and serum potassium
Pharmacologic Drug therapy indicated if BP ≥140/ ≥90 mm Hg Combination therapy often necessary Treatment should include ACE or ARB Thiazide diuretic may be added to reach goals Monitor renal function and serum potassium
The Dash Diet. http://dashdiet.org. American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Microvascular Renal disease Autonomic
neuropathy Eye disease
(glaucoma, retinopathy with potential blindness)
Microvascular Renal disease Autonomic
neuropathy Eye disease
(glaucoma, retinopathy with potential blindness)
Macrovascular Cardiac disease Cerebrovascular
disease Reduced survival and
recovery rates from stroke
Peripheral vascular disease
Macrovascular Cardiac disease Cerebrovascular
disease Reduced survival and
recovery rates from stroke
Peripheral vascular disease
American Diabetes Association. Diabetes Care. 2007;30:S4-41..
Physical InactivityPhysical Inactivity
35% of coronary heart disease deaths in the US can be attributed to an inactive lifestyle*
Consistent exercise can reduce CVD risk*
Exercise, combined with healthy diet and weight loss, is proven to prevent/delay onset of type 2 diabetes
35% of coronary heart disease deaths in the US can be attributed to an inactive lifestyle*
Consistent exercise can reduce CVD risk*
Exercise, combined with healthy diet and weight loss, is proven to prevent/delay onset of type 2 diabetes
* American Diabetes Association. Diabetes Care. 2007;30:S4-41. Diabetes Prevention Program Diabetes Care 25:2165–2171, 2002.
Physical ActivityPhysical Activity
Guidelines Fit into daily routine Aim for at least 150 minutes/week of moderate
aerobic exercise Start slowly and gradually build intensity Wear a pedometer (10,000 steps) Encourage patients to take stairs, park further
away or walk to another bus stop, etc.
Guidelines Fit into daily routine Aim for at least 150 minutes/week of moderate
aerobic exercise Start slowly and gradually build intensity Wear a pedometer (10,000 steps) Encourage patients to take stairs, park further
away or walk to another bus stop, etc.
American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Physical ActivityPhysical Activity
Benefits of Exercise Increased insulin sensitivity Improved lipid levels Lower blood pressure Weight control Improved blood glucose control Reduced risk of CVD Prevent/delay onset of type 2 diabetes
Benefits of Exercise Increased insulin sensitivity Improved lipid levels Lower blood pressure Weight control Improved blood glucose control Reduced risk of CVD Prevent/delay onset of type 2 diabetes
American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Exercise Precautions Related to Complications of DiabetesExercise Precautions Related to Complications of Diabetes
Peripheral neuropathy can cause loss of sensation in feet; educate about preventive care measures for foot protection
Pre-existing CVD can cause arrhythmias, myocardial ischemia, or infarction during exercise
In presence of PDR or severe NPDR, vigorous exercise or resistance training may be contraindicated because of risk of vitreous hemorrhage or retinal detachment
Peripheral neuropathy can cause loss of sensation in feet; educate about preventive care measures for foot protection
Pre-existing CVD can cause arrhythmias, myocardial ischemia, or infarction during exercise
In presence of PDR or severe NPDR, vigorous exercise or resistance training may be contraindicated because of risk of vitreous hemorrhage or retinal detachment
American Diabetes Association. Diabetes Care. 2007;30:S4-41.
SmokingSmoking
R C Turner, H Millns, H A W Neil, I M Stratton, S E Manley, D R Matthews, and R R Holman. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS: 23) BMJ. 1998;316:823-828.
Hazards Ratio (95% CI)
Never Smoked 1
Ex-Smoker 1.08 (0.75 - 1.54)
Current Smoker 1.58 (1.11 - 2.25)
Hazards Ratio (95% CI)
Never Smoked 1
Ex-Smoker 1.08 (0.75 - 1.54)
Current Smoker 1.58 (1.11 - 2.25)
Obtain documentation of history of tobacco use Ask whether smoker is willing to quit
– If no, initiate brief, motivational discussion regarding:
• the need to stop using tobacco• risks of continued use• encouragement to quit, as well as support
when ready– If yes, assess preference for and initiate either
minimal, brief, or intensive cessation counseling.
Obtain documentation of history of tobacco use Ask whether smoker is willing to quit
– If no, initiate brief, motivational discussion regarding:
• the need to stop using tobacco• risks of continued use• encouragement to quit, as well as support
when ready– If yes, assess preference for and initiate either
minimal, brief, or intensive cessation counseling.
American Diabetes Association. Diabetes Care. 2004;27:S27:S74-S75.
Set a Plan Offer counseling and referrals Offer medication assistance Offer combined pharmacologic and
behavioral intervention Online guide to quitting: SmokeFree.gov
Set a Plan Offer counseling and referrals Offer medication assistance Offer combined pharmacologic and
behavioral intervention Online guide to quitting: SmokeFree.gov
American Diabetes Association. Diabetes Care. 2004;27:S27:S74-S75.
InflammationInflammation
Inflammation / HypercoagulationInflammation / Hypercoagulation
Proinflammatory/prothrombotic factors underlie cardiometabolic risk
Inflammation is a major component of atherogenesis and other cardiometabolic problems
Obesity is associated with inflammation
Proinflammatory/prothrombotic factors underlie cardiometabolic risk
Inflammation is a major component of atherogenesis and other cardiometabolic problems
Obesity is associated with inflammation
Ross R. Atherosclerosis: an inflammatory disease. N Engl J Med. 1999;340:115-126. Ballantyne CH, Nambi V. Markers of inflammation and their clinical significance. Atherosclerosis suppl 2005; 6: 21-9. McLaughlin T et al. Differentiation between obesity and insulin resistance in the association with C-reactive protein. Circulation. 2002;106:2908-2912.
High-sensitivity CRP tests may be used to further evaluate underlying risk Relative risk categories
• Low risk <1 mg/L• Average risk 1-3 mg/L• High risk >3 mg/L
Aspirin and statins reduce CRP levels
Unclear whether CRP should be a treatment target
Reduce weight
High-sensitivity CRP tests may be used to further evaluate underlying risk Relative risk categories
• Low risk <1 mg/L• Average risk 1-3 mg/L• High risk >3 mg/L
Aspirin and statins reduce CRP levels
Unclear whether CRP should be a treatment target
Reduce weight
Ross R. Atherosclerosis: an inflammatory disease. N Engl J Med.1999;340:115- 126. Ballantyne CH.
Pre-Diabetes and Pre-Diabetes and Diabetes PreventionDiabetes Prevention
Pre-DiabetesPre-Diabetes
Pre-diabetes is an important risk factor for future diabetes and cardiovascular disease
Recent studies have shown that lifestyle modification can reduce the rate of progression from pre-diabetes to diabetes
Pre-diabetes is an important risk factor for future diabetes and cardiovascular disease
Recent studies have shown that lifestyle modification can reduce the rate of progression from pre-diabetes to diabetes
American Diabetes Association, Diabetes Care. 2007:30:S4-41..
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2004; Supplement 1
Fasting PlasmaGlucose
Fasting PlasmaGlucose
126 mg/dL126 mg/dL
Normal
2-hour Plasma Glucose On OGTT
2-hour Plasma Glucose On OGTT
200 mg/dL 200 mg/dL
140 mg/dL 140 mg/dL
Diabetes Mellitus
Impaired GlucoseTolerance
Normal
Diabetes Mellitus
Any abnormality must be repeated and confirmed on a separate day*
Any abnormality must be repeated and confirmed on a separate day*
* One can also make the diagnosis of diabetes based on unequivocal symptoms and a random glucose >200 mg/dL* One can also make the diagnosis of diabetes based on unequivocal symptoms and a random glucose >200 mg/dL
“Pre-Diabetes”
100 mg/dL100 mg/dL
Impaired FastingGlucose
ADA Consensus Conference ADA Consensus Conference on IFG and IGT: on IFG and IGT:
Implications for Diabetes Care Implications for Diabetes Care October 16-18, 2006October 16-18, 2006
Results: Treat IFG and IGT with aggressive
lifestyle modification For certain patients with both IFG and
IGT consider metformin
Results: Treat IFG and IGT with aggressive
lifestyle modification For certain patients with both IFG and
IGT consider metformin
Nathan D, et al. Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for Care. Diabetes Care. 2007 30: 753-759.
Cu
mu
lati
ve I
nci
den
ceo
f D
iab
etes
(%
)C
um
ula
tive
In
cid
ence
of
Dia
bet
es (
%)
YearsYears
4040
3030
2020
1010
0000 0.50.5 1.01.0 1.51.5 2.02.0 2.52.5 3.03.0 3.53.5 4.04.0
PlaceboPlacebo
MetforminMetformin
LifestyleLifestyle
Knowler WC, et al. NEJM. 2002;346:393-403.
Beh
avio
r M
edic
atio
n
Results of Recent Randomized TrialsResults of Recent Randomized Trials
58%
58%
58%
58%
31%
25%
55%
45%
61%/NS
31%
25%
55%
45%
61%/NS
Metformin
Acarbose
Troglitazone
OrlistatRosiglitazone/Ramipril
Metformin
Acarbose
Troglitazone
OrlistatRosiglitazone/Ramipril
IGT
IGT
Prior GDM
IGT
IGT
IGT
IGT
Prior GDM
IGT
IGT
US DPP
STOP-NIDDM
TRIPOD
XENDOS
DREAM
US DPP
STOP-NIDDM
TRIPOD
XENDOS
DREAM
Lifestyle
Lifestyle
Lifestyle
Lifestyle
IGT
IGT
IGT
IGT
Finnish DPS
US DPP
Finnish DPS
US DPP
Relative RiskReduction
Relative RiskReductionInterventionInterventionSubjectsSubjectsStudy Study
<180 mg/dL<180 mg/dLPostprandial plasma glucosePostprandial plasma glucose
90-130 mg/dL90-130 mg/dLPreprandial glucose Preprandial glucose
<7.0%<7.0%A1C*†A1C*†
* For non-pregnant individuals† As close to normal (<6%) as possible without significant hypoglycemia
American Diabetes Association. Diabetes Care. 2007:30:S4-41..
Goals for Glycemic Control
Fasting plasma glucose at least every 3 yrs starting at age 45
Consider at younger age, or more frequently, if patient is overweight and has one or more of the following risk factors (or two if not overweight):
• Family history of diabetes • Overweight (BMI 25 kg/m2)• Habitual physical inactivity (continued)
Fasting plasma glucose at least every 3 yrs starting at age 45
Consider at younger age, or more frequently, if patient is overweight and has one or more of the following risk factors (or two if not overweight):
• Family history of diabetes • Overweight (BMI 25 kg/m2)• Habitual physical inactivity (continued)
American Diabetes Association. Diabetes Care. 2007:30:S4-41..
Screening For DiabetesScreening For Diabetes
Additional risk factors:
• Race/ethnicity (e.g., African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, and Pacific Islanders)
• Previously identified IFG or IGT
• Hypertension (140/90 mmHg in adults)
• HDL cholesterol (35 mg/dl [0.90 mmol/l] and/or a triglyceride level 250 mg/dl [2.82 mmol/l])
• History of GDM or delivering baby weighing >9 lbs
• Polycystic ovary syndrome (PCOS)
Additional risk factors:
• Race/ethnicity (e.g., African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, and Pacific Islanders)
• Previously identified IFG or IGT
• Hypertension (140/90 mmHg in adults)
• HDL cholesterol (35 mg/dl [0.90 mmol/l] and/or a triglyceride level 250 mg/dl [2.82 mmol/l])
• History of GDM or delivering baby weighing >9 lbs
• Polycystic ovary syndrome (PCOS)
American Diabetes Association. Diabetes Care. 2007:30:S4-41..
Screening For DiabetesScreening For Diabetes
Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetes Overweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Sedentary Unhealthy diet Fast food diet
Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetes Overweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Sedentary Unhealthy diet Fast food diet
Identify at-risk patients by evaluating a spectrum of predisposing risk factors
The existence of any one risk factor is an alert to evaluate patient for others
Integrate evidence-based risk management strategies to target modifiable risk factors
Identify at-risk patients by evaluating a spectrum of predisposing risk factors
The existence of any one risk factor is an alert to evaluate patient for others
Integrate evidence-based risk management strategies to target modifiable risk factors
Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the AmericanDiabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005;28 (9)2289-2304.
What Should We Do?What Should We Do?
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