Lifestyle Medicine. This presentation will:

Transcription

1 Lifestyle Medicine This presentation will: Present the biological and environmental factors contributing to the obesity epidemic Discuss the lifestyle modification therapy for patients with obesity, prediabetes, and diabetes Outline the model for care of the overweight or obese patient, based on the comprehensive diabetes algorithm Explain the implications of lifestyle modification on the prevention of prediabetes and diabetes

2 Obesity Conceptual Framework Obesity directly and indirectly promotes, and/or causes, adverse health consequences. Current evidence indicates that obesity must be treated as a chronic, relapsing disease. 2 Seger JC et al. Obesity Algorithm, presented by the American Society of Bariatric Physicians, (Access = April 6, 2015). Jensen MD et al. Circulation. 2014;129(25 suppl 2):S102 S138.

3 Adverse Health and Social Consequences Associated With Obesity Physical Psychosocial Functional Cancer Depression Absenteeism from school or work Cardiovascular disease Discrimination Disability Cholestasis Low self-esteem Disqualification from active military/fire/police services Dyslipidemia Negative body image Low physical fitness level Gallbladder disease Negative stereotyping Mobility limitations Glucose intolerance and insulin resistance Social marginalization Reduced academic performance Hepatic steatosis Teasing and bullying Reduced productivity Hypertension Hyperuricemia and gout Menstrual abnormalities Orthopedic problems Reduction of cerebral blood flow Sleep apnea T2DM Unemployment 3 American Academy of Family Physicians. obesity-diagnosis-management.pdf. Accessed April 15, 2015.

4 Age-adjusted Relative Risk Relationship Between BMI and Risk of T2DM 100 Men Women <22 < BMI = body mass index. Chan JM et al. Diabetes Care. 1994;17(9): Colditz GA et al. Ann Intern Med. 1995;122(7): BMI (kg/m 2 )

5 Δ Blood Pressure (mm Hg) Δ Triglycerides (mg/dl) Δ A1C (%) Δ HDL Cholesterol (mg/dl) Weight Loss Reduces Cardiometabolic Risk Factors in Patients With Type 2 Diabetes Intensified Lifestyle Intervention, 8.6% Weight Loss Diabetes Support and Education, 0.7% Weight Loss 4 3 * * Systolic Diastolic * Randomized, controlled trial; n = 5145; Patients with type 2 diabetes, age >18 y; Mean ± SE Intensified lifestyle intervention (n = 2496) vs. diabetes support and education (n = 2463) therapy; *P<0.001 between groups Look AHEAD Research Group. Diabetes Care. 2007;30: * *

6 Obesity Classification: BMI B Patients with overweight/obesity = increased body fat (adiposity) Overweight and obesity classification: Body Mass Index (BMI) in kg/m 2 ACTION ITEM: Normal weight Overweight Class I obesity Class II obesity For all patients, calculate BMI at annual visits or more ( ) ( ) ( ) ( ) frequently and identify body weight classification. Class III obesity ( 40.0) 6 Seger JC et al. Obesity Algorithm, presented by the American Society of Bariatric Physicians, (Access = April 6, 2015).

7 Identification and Screening: BMI Is the Starting Point 2013 AHA/ACC/TOS Obesity Guidelines identify patients who need to lose weight Measure height and weight and calculate BMI at annual visits or more frequently for all patients Use BMI cut points to classify patients with overweight or obesity BMI is used as an estimate of increased adverse health consequences 7 ACC = American College of Cardiology; AHA = American Heart Association; TOS = The Obesity Society. Jensen MD et al. Circulation. 2014;129(25 suppl 2):S102 S138.

8 Obesity Classification: Waist Circumference (WC) B Patients with overweight/obesity = increased body fat (adiposity) Overweight and obesity classification: Waist Circumference (WC) ACTION ITEM: Measure Men abdominal WC at annual obesity visits or more Women frequently abdominal in obesity patients 40 in. ( 102 cm)* 35 in. ( 88 cm)* with overweight or obesity. 8 *Different WC abdominal obesity cutoff points may be appropriate for different races, such as 90 cm for Asian men and 80 cm for Asian women. Seger JC et al. Obesity Algorithm, presented by the American Society of Bariatric Physicians, (Access = April 6, 2015).

9 Treatment: Modest Weight Loss = Major Health Benefits B 5% weight loss 10% weight loss 15% weight loss 9 T2DM prevention With T2DM: better glycemic control/ medication reduction Improvement in urinary stress incontinence, mobility, joint pain, weight-related QOL Improvements in CVD risk factors (HDL-C, TG, BP) Previous improvements Sleep apnea Blackburn G. Obes Res. 1995;3(suppl 2):211s-216s. Foster GD et al. Arch Intern Med. 2009;169(17): Gregg EW et al. JAMA. 2012;308(23): Sjostrom L et al. J Intern Med. 2013;273(3): Christou NV et al. Surg Obes Relat Dis. 2008;4(6): Diabetes remission? Previous improvements CVD mortality All-cause mortality and reduction in cancer risk (with surgical weight loss) ACTION ITEM: Consider the benefits that a 5% to 10% weight loss will have on your patients with overweight or obesity.

10 Reduction in Mortality with Modest Weight Loss Effects of Weight Loss in Type 2 Diabetes Every kg of weight loss is associated with 3 to 4 months of improved survival In a prospective analysis of 5000 people with type 2 diabetes, 35% reported intentional weight loss; this subgroup experienced a 25% reduction in mortality over 12 years Alternately, a 5-kg weight gain increases coronary heart disease risk by 30% Lean ME, et al. Diabet Med. 1990;7: ; Williamson DF, et al. Diabetes Care. 2000;23: Anderson JW et al. J Am Coll Nutr. 2003;22:331-9.

11 Regulation of Body Weight Genes confer the potential for obesity Environment determines whether the potential is realized, and to what extent

12 Thrifty Genes Contribute to Morbid Obesity Genetic factors account for 80% of a person s tendency to develop obesity Thrifty genes are designed to protect us from starvation by allowing us to store large amounts of energy in the form of fat when food is abundant This is the first time in human history that food has been so abundant The age-old advantage of thrifty genes has been influenced by our unique environment to cause disease Kaplan L. Body Weight Regulation and Obesity. J Gastrointestinal Surgery 2003;7(4): Hales and Barker et al, Diabetologia (4;35: and 3;36:62-67)

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14 The Toxic Environment High-Calorie Food is Highly palatable Near-ubiquitous Heavily advertised Supersized Inexpensive Brownell KD & Horgen KB. Food Fight. New York: McGraw-Hill; 2003.

15 Sedentary Lifestyles Examples Physical activity is To be avoided Nearly unnecessary Limited by infrastructure

16 Defining Interventional Criteria for Pre-Diabetes Impaired fasting plasma glucose (IFG) = mg/dl ( mmol/l) Impaired glucose tolerance (IGT) = mg/dl ( mmol/l) Metabolic Syndrome diagnosed by National Cholesterol Education Program (NCEP) criteria should be considered a pre-diabetes equivalent Predicts future diabetes better than IFG 3 of 5 criteria of the metabolic syndrome are sufficient for diagnosis Hemoglobin A1C = 5.5%-6.4% In the absence of unequivocal hyperglycemia, this result should be confirmed by repeat testing AACE. Endocrine Practice. 2011;17(2)1-53. American Diabetes Association. Diabetes Care Jan; 36(Suppl 1):S National Cholesterol Education Program. National Institute of Health. Sept AACE. Endocrine Practice. 2008;14(7):933.

17 ADA Recommendations for Diabetes Screening HbA1c 5.7%, impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) on previous testing Polycystic ovary syndrome (PCOS) Other conditions associated with insulin resistance such as severe obesity or acanthosis nigricans Overweight children >10 years old (or after puberty onset if earlier) with 2 of family history of type 2 diabetes Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or PCOS) Maternal history of diabetes or gestational diabetes Ethnic group at increased risk Repeat screening every 3 years if normal, or every year if at increased risk for future diabetes Test every 1-2 years if prediabetes is diagnosed and every 3 years if glucose tolerance is normal ADA. Diabetes Care. 2012;35:S11-S63.

18 Acanthosis Nigricans: A Sign of Insulin Resistance Velvety, lightbrown-to-black discoloration usually on the neck, back, axilla, groin, and dorsum of hands may point to PCOS in females Insulin sensitivity decreases by 30% at puberty with compensatory increase in insulin secretion Unger J. Diabetes Management in Primary Care, 2 nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2012.

19 What are the health risks associated with prediabetes? Progression to diabetes: on average, 11% of people with prediabetes develop type 2 diabetes each year (DPP) Other studies: majority with prediabetes develop type 2 diabetes in 10 years Presence of microvascular complications at onset of diabetes 50% higher risk of CVD,CAD and stroke DPP, Diabetes Prevention Program NDIC/NIDDK. Diabetes Prevention Program. Accessed May 1, 2013.

20 Interventions to Reduce the Risks Associated with Prediabetes Intensive lifestyle management is the cornerstone of all prevention efforts No pharmacologic agents are currently approved for the management of prediabetes Pharmacotherapy targeted at glucose may be considered in high risk patients after individual risk: benefit analysis

21 Diabetes Incidence per 100 Person-Years Intensive Lifestyle Intervention Prevents Progression From IGT to T2DM Diabetes Prevention Program (n=3234) 31% 58% Intensive lifestyle intervention* (n=1079) Metformin 850mg BID (n=1073) Placebo (n=1082) *Goal: 7% reduction in baseline body weight through low-calorie, low-fat meal plan and 150 min/week moderate intensity physical activity. IGT, impaired glucose tolerance; T2DM, type 2 diabetes mellitus.. DPP Research Group. N Engl J Med. 2002;346:

22 Components of Therapeutic Lifestyle Change Nutrition Reduced calorie diet Healthy eating Sufficient physical activity Avoidance of tobacco products Limited alcohol consumption Sufficient sleep Stress reduction (including behavioral therapy as necessary) Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

23 Nutrition Nutritional Components Topic Recommendation Carbohydrate Understand health effects of the 3 types of carbohydrates: sugars, starch, and fiber Target 7-10 servings per day of healthful carbohydrates (fresh fruits and vegetables, pulses, whole grains) Lower-glycemic index foods may facilitate glycemic control:* multigrain bread, pumpernickel bread, whole oats, legumes, apple, lentils, chickpeas, mango, yams, brown rice Eat healthful fats: low-mercury/low-contaminant-containing nuts, avocado, certain plant oils, fish Fat Limit saturated fats (butter, fatty red meats, tropical plant oils, fast foods) and trans fats Use no- or low-fat dairy products Consume protein from foods low in saturated fats (fish, egg whites, beans) Protein Avoid or limit processed meats Routine supplementation not necessary except for patients at risk of insufficiency or deficiency Micronutrients Chromium; vanadium; magnesium; vitamins A, C, and E; and CoQ10 not recommended for glycemic control *Insufficient evidence to support a formal recommendation to educate patients that sugars have both positive and negative health effects Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

24 Macronutrient Diet Composition Diets enriched in the following are associated with a decrease in insulin sensitivity Total fat Saturated fat Trans-fat Refined grains Diets enriched in the following are associated with an increase in insulin sensitivity Fiber Fruits/vegetables Polyunsaturated fats Monounsaturated fats Whole grain Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53. Garvey WY, Lara-Castro C. J Clin Endocrinol Metab. 2004;89:

25 Physical Activity Adults with T2DM should be advised to perform at least 150 min/week of moderate-intense aerobic activity (50%-70% of maximum HR) spread over 3 days with no more than 2 consecutive days without exercising In the absence of contraindications, resistance training should be performed at least twice weekly Providers should use clinical judgment when deciding whether to screen asymptomatic patients for silent CAD High risk patients should be encouraged to start with short periods of low intensity exercise and progress slowly ADA Clinical Practice Recommendations. Diabetes Care. 2013;36 (Suppl 1):S24. HR, heart rate

26 AACE Physical Activity Recommendations Patients 150 minutes per week of moderate-intensity (ie, conversational ) exercise Flexibility and strength training Aerobic exercise (e.g., brisk walking) Cross-train Heart rate to 70% maximum (max HR = 220 age) Start slowly and build up gradually Use exercise partners, organized activities, or professional trainer to help with motivation Healthcare Professionals Exude positive attitude Evaluate for contraindications and/or limitations to increased physical activity before patient begins or intensifies exercise program Develop exercise recommendations according to individual goals and limitations Set realistic goals and schedules Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

27 How Much Exercise Is Enough? Intensity Moderate, conversational exercise (: should be able to talk comfortably ) Heart rate at 70% of maximum (max HR = 220 age) Frequency 3-4 times per week Maintain regular schedule with realistic goals Motivation Cross-train (ie, walk, ride, swim) Use exercise partner or professional trainer or attend organized programs Reward self Health care professional team must exude positive attitude regarding importance of exercise

28 Diabetes Mellitus Reduction (%) Is it Possible to Delay the Onset of T2DM? % >5% loss 42% 58% 31% 25% 55% 41% 62% 72% Finnish-Diet+ Exercise Da Qing Diet + Exercise DPP-Lifestyle DPP-Metformin STOP-NIDDM Diabetes Prevention Clinical Trials TRIPOD XENDOS DREAM ActNOW FINNISH=Tuomilehto J, et al. N Engl J Med 2001; 344: DA QING=Pan XR, et al. Diabetes Care. 1997; 20: DPP=Diabetes Prevention Program. Nathan DM, et al. N Engl J Med 2002; 346: STOP-NIDDM=Study TO Prevent Non-Insulin-Dependent Diabetes Mellitus. Chiasson JL, et al. Lancet 2002; 359: TRIPOD=Troglitazone in the Prevention of Diabetes. Buchanan T, et al. Diabetes 2002; 51(9): XENDOS=XEnical in the Prevention of Diabetes in Obese Subjects. Torgerson JS, et al. Diabetes Care 2004; 27 (1): DREAM=Diabetes Reduction Assessment with Ramipril & Rosiglitazone Medication. Gerstein H, et al. Lancet 2006; 368:

29 Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis

30 Reduction in Mortality with Modest Weight Loss Effects of Weight Loss in Type 2 Diabetes Every kg of weight loss is associated with 3 to 4 months of improved survival In a prospective analysis of 5000 people with type 2 diabetes, 35% reported intentional weight loss; this subgroup experienced a 25% reduction in mortality over 12 years Alternately, a 5-kg weight gain increases coronary heart disease risk by 30% Lean ME, et al. Diabet Med. 1990;7: ; Williamson DF, et al. Diabetes Care. 2000;23: Anderson JW et al. J Am Coll Nutr. 2003;22:331-9.

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32 Diabetes Prevention Program Conclusions Lifestyle modification was most effective for individuals 60 years of age and for those with lower baseline BMI Metformin reduced the risk of developing type 2 diabetes most effectively in patients <60 years of age, and in those with a baseline BMI >35 kg/m 2 Early intervention resulted in the greatest rate of diabetes prevention/delay in all groups The Diabetes Prevention Program Research Group. New Engl J Med. 2002;346:

33 5 Keys To Successful Diabetes Self- Management Know your metabolic targets (A1C, blood pressure, lipids) Know how to attain your metabolic targets by practicing lifestyle intervention (healthy nutritional choices and daily exercise) Take your medications (be adherent to the prescribed treatment program) Do not smoke Make certain your health care provider is knowledgeable about intensive diabetes management Unger, J. Diabetes Management in Primary Care. 2 nd Ed. Lippincott. 2012

34 Two-track Approach To Reduce Risk of Diabetes Development (1) Lower glucose to prevent microvascular complications and progression to diabetes Lifestyle intervention Pharmacotherapy in highrisk patients (2) Address cardiovascular (CV) disease risk factors Lifestyle intervention Blood pressure goals: <130/80 mm Hg Calculate CV risk

35 Feasibility of Preventing Type 2 Diabetes There is a long period of glucose intolerance that precedes the development of diabetes Screening tests can identify persons at high risk There are safe, potentially effective interventions that can address modifiable risk factors: Obesity Body fat distribution Physical inactivity High blood glucose American Diabetes Association. Diabetes Care Jan; 36(Suppl 1):S11-66.

36 Advice for Exercise Drink fluids (18 ounces) 1-2 hours before exercise Stretch Include warm-up and cool-down periods of 5-10 min each Wear silica gel or air midsoles and polyester seamless socks Check for blisters before and after activity Wear ID bracelet Aerobic or resistance training beneficial Light weights and high repetitions

37 But Doc, I Can t Walk Too Far All patients Foot disease, peripheral vascular disease, arthritis Orthostatic conditions Elderly Recommend low-impact exercise: stationary bicycle, swimming, elliptical machine, stairstepper, treadmill, low-impact aerobics, weight-lifting machine Swimming, water aerobics, upper body resistance training Semi-recumbent chair and weight lifting, semi-recumbent cycling, water exercise Stretching while sitting, movement exercise (eg, tai chi, hatha yoga) Anything is better than nothing

38 Set Realistic Goals With Your Patient Goal: decrease risk of complications and improve long-term outlook Ask patient: What are your goals? Patients often want to lose ~30% of body weight (a loss of only 7% to 10% or less may be equated with failure) Advise patients to accept steady, incremental progress and emphasize that improved health not necessarily reduced weight is the goal Short-term weight loss goal (for most patients): 7% to 10% loss at 6 months Increase in muscle mass may be more important than decrease in fat mass Interim goal: maintenance Long-term goal (if desired): additional energy deficit recalculated for next weight loss goal Remind patients that reducing caloric intake and increasing physical activity are key to achieving and maintaining weight loss

39 Summary Lifestyle intervention effectively prevents diabetes and adverse cardiovascular outcomes Lifestyle alone is less effective in more obese populations Weight loss with lifestyle change is difficult to maintain long-term Ongoing behavioral support from healthcare team and/or structured support group can help patients maintain weight loss Benefits of initial weight loss are sustained even with weight regain Medical interventions are more effective when combined with lifestyle change Healthcare professionals should work with patients to set realistic goals and encourage adherence to weight loss/maintenance behaviors

40 Conditions for Success Engagement with other health team members Support at home (and at work) Patience Persistence Realism set goals The weight treatment goal is to lose 5 to 10% of current body weight over the next 6 to 12 months. Perpetual goal until BMI is 18.5 to 24.9 kg/m 2

41 Strategies for Maintaining Weight Loss From the Academy of Nutrition and Dietetics Evidence Analysis Library: Reduced calorie diet Distribute calories throughout day Portion control Avoid large meals, especially later in day Meal replacements can be helpful Other Strategies: Increasing fruits, vegetables, and low-fat dairy effective in the Weight Loss Maintenance Clinical Trial National Weight Control Registry promotes eating breakfast, physical activity (1.5 hr/day) and self-monitoring

42 Motivational Interviewing Encourage collaboration Let s put our heads together and review the options. Support autonomy and problem-solving; remember, 99% of outcomes are the patient s Develop motivation by eliciting change talk Ask open-ended, motivational questions What do you want to accomplish in this visit today? What is the most important concern to you about your diabetes right now? Miller R, Rollnick S, eds. Motivational Interviewing. New York, NY: The Guilford Press; 2002.

43 Motivational Interviewing Ask permission before giving advice Ask: May I propose a plan? or What about? Avoid: You should eat less and walk more. Approach with curiosity or invitation Say: I wonder or One option could be Invite: How about week or so trial of? or Some people with diabetes have found Miller R, Rollnick S, eds. Motivational Interviewing. New York, NY: The Guilford Press; 2002.

44 Motivational Empowerment Focus on: Optimism: I think you re onto something. Strengths: What are your strongest areas in managing your diabetes? What are you most comfortable with? Legitimizing experiences: I know what you mean about shopping when hungry. If I stop at the store on my way home from work, I always buy too much. Miller R, Rollnick S, eds. Motivational Interviewing. New York, NY: The Guilford Press; 2002.