Beyond Retinopathy. Beyond Retinopathy: Course Goal. Key Factors in Diabetes Wellness. A Global Epidemic.

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Felix Jones
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participant with useful clinical information in the

their life 50% of the global diabetes population is

1 Beyond Retinopathy Joseph J. Pizzimenti, OD, FAAO Course Goal To provide the participant with useful clinical information in the management of patients living with diabetes mellitus. Beyond Retinopathy: Key Factors in Diabetes Wellness! The Eye is an extension of the brain! The anatomy of the eye is structured to serve the functions of the retina! Primary reason for dilation is to detect systemic disease A Global Epidemic. 1 in 3 children born today will develop diabetes in their life 50% of the global diabetes population is undiagnosed Up to 50% of diabetes is detected because of a clinical complication (e.g. retinopathy, nephropathy) 7 th leading cause of death in the US > 25 million people with diabetes, costing $132 billon 75 million have pre-diabetes leading cause of new blindness, lower limb amputation and renal failure Diabetes => a 2-4 fold increased risk of CV disease 1

!"#$%&'&(# )#*+,-.$/*&0#0$12$3#*'"$,-$4565 23.0 M 36.2 M 57.0% World 2003 = 194 M 2025 = 333 M 72% 14.2 M 26.2 M 85% 48.4 M 58.6 M 21% 7.1M 15.0 M 111% 19.2 M 39.4 M 105% 2003 2025 43.0 M 75.

Accidents (unintentional injuries): 120,859 6. Alzheimer's disease: 83,494 7. Diabetes: 69,071 8. Nephritis, nephrotic syndrome: 50,476 9. Influenza and Pneumonia: 50,097 10.

Hispanic population has highest overall prevalence rate of Diabetic Retinopathy! African Americans tend to have highest rates of sight- threatening Diabetic Retinopathy!

126 mg/dl! 2 hr PG during 75 g OGTT! 200 mg/dl! Random PG! 200 mg/dl PLUS symptoms (polyuria, polydipsia, unexplained weight loss)! A1C! 6.5% 3,*;#'#0$,0$*$+,0#*0#$12,?

2 !"#$%&'&(# )#*+,-.$/*&0#0$12$3#*'"$,-$ M 36.2 M 57.0% World 2003 = 194 M 2025 = 333 M 72% 14.2 M 26.2 M 85% 48.4 M 58.6 M 21% 7.1M 15.0 M 111% 19.2 M 39.4 M 105% M 75.8 M 79% 39.3 M 81.6 M 108% 1. Heart disease: 597, Cancer: 574, Chronic lower respiratory diseases: 138, Stroke (cerebrovascular diseases): 129, Accidents (unintentional injuries): 120, Alzheimer's disease: 83, Diabetes: 69, Nephritis, nephrotic syndrome: 50, Influenza and Pneumonia: 50, Intentional self-harm (suicide): 38,364 Diabetes Atlas Committee. Diabetes Atlas 2 nd Edition: IDF (#8*9#-:#$12$3,*;#',:$<#',-1=*'">! Hispanic population has highest overall prevalence rate of Diabetic Retinopathy! African Americans tend to have highest rates of sight- threatening Diabetic Retinopathy! No prominent difference between genders in prevalence of Diabetic Retinopathy! Higher prevalence of DR in older age groups Diagnosing diabetes blood tests! Fasting plasma glucose (PG)! 126 mg/dl! 2 hr PG during 75 g OGTT! 200 mg/dl! Random PG! 200 mg/dl PLUS symptoms (polyuria, polydipsia, unexplained weight loss)! A1C! 6.5% 3,*;#'#0$,0$*$+,0#*0#$12,?=*,(#+$,-0&9,-$*:',1-3,*;#'#0$,0$H-B9*??*',1- )#&@1:>'#0A$1-:#$,-0,+#$(#',-*9$',00&#A$0#:(#'#$*$8*(,#'>$12$ $$,-B9*??*'1(>$0&;0'*-:#0$0&:"$*0$!C%$*-+$DEF%G!"#0#$(#9#*0#+$?#+,*'1(0$,-:(#*0#$8*0:&9*($=#(?#*;,9,'> $*-+$0',?&9*'#$?1(#$?#+,*'1(0$'1$#-"*-:#$'"#$,-B9*??*'1(>$(#*:',1-G Decreased insulin production Resistance to insulin action 2

3 C1-I$7(19,2#(*',8# 3,*;#',:$<#',-1=*'"> 3,*;#',:$J*:&9*($E+#?* 3,*;#',:$7*=,991=*'"> $%&'()*+,'(-%./'01%(2!"# 3'/'/1%20-+4/5(''046/ 3

IRMA Capillary Non-perfusion Microaneurysms and IRMA QUESTIONS AND COMMENTS?

Autofluorescence (CLA) The Importance of Macular Pigments MPOD--HFP with QuantifEye " Serum

4 IRMA Capillary Non-perfusion Microaneurysms and IRMA QUESTIONS AND COMMENTS? Novel Ocular Biomarkers for Diabetes Macular Pigment Optical Density (MPOD) Crystalline Lens Autofluorescence (CLA) The Importance of Macular Pigments MPOD--HFP with QuantifEye " Serum levels of lutein and zeaxanthin are inversely associated with type 2 DM and impaired glucose metabolism. " A recent study showed that type 2 patients with or without retinopathy had reduced MPOD compared to non-diabetic patients. In addition, researchers observed an inverse correlation between MPOD and HbA1c levels. Davies NP, Morland AB. Color matching in diabetes: optical density of the crystalline lens and macular pigments. Invest Ophthalmol Vis Sci Jan;43(1): Lima VC, Rosen RB, Maia M, et al. Macular pigment optical density measured by dual-wavelength autofluorescence imaging in diabetic and nondiabetic patients: a comparative study. Invest Ophthalmol Vis Sci Nov;51(11):

Crystalline Lens Autofluorescence (CLA) CLA with ClearPath DS-120 " CLA identifies elevated advanced glycosolated end-products (AGEs) a biomarker highly correlated to glycemic status prior to the

Yu NT, Krantz BS, Eppstein JA, et al. Development of a noninvasive diabetes screening device using the ratio of fluorescence to Rayleigh scattered light. J Biomed Opt. 1996 Jul;1(3):280-8.

5 Crystalline Lens Autofluorescence (CLA) CLA with ClearPath DS-120 " CLA identifies elevated advanced glycosolated end-products (AGEs) a biomarker highly correlated to glycemic status prior to the presentation of earlystage complications of DM. " Subjects with poor long-term glycemic control had significantly higher levels of lens AGEs compared to age-matched healthy controls. Yu NT, Krantz BS, Eppstein JA, et al. Development of a noninvasive diabetes screening device using the ratio of fluorescence to Rayleigh scattered light. J Biomed Opt Jul;1(3): Sparrow JM, Bron AJ, Brown NA, Neil HA. Autofluorescence of the crystalline lens in early and late onset diabetes. B J Ophthalmol Jan;76(1): A clinician plots the fluorescence ratio (.21) and age (45) on X/Y axis of data chart Important systemic effects of diabetes and associated conditions that modify Retinopathy and/or increase risk of other end organ damage. #1. Glycemic Control Hb A1C under 7% (ADA), (AACE <6.5%) Can be higher in patients with CVD, hypoglycemia, shorter life expectancy and children ( 7%- 8% ) ACCORD vs. ADVANCE studies #2. Hypertension Patients with diabetes need a BP of 125/80 or better #3. Dyslipidemia Target LDL cholesterol level for men and women with diabetes is <100mg/dL. For HDL, the target is >40mg/dL for men and >50mg/dL for women. Triglycerides < 150 mg/dl #4. Sleep Apnea needs to be ruled out/treated CPAP - reduces nocturnal hypertension, increases oxygen, decreases FBS Activity of Hormones #5. Anemia needs to be ruled out/treated Hemaglobin needs to be above 11 Procrit (E-poetin alfa) needs to be considered if Hb below 9 Starts early, has negative impact on CV morbidity, mortality #6. Kidney Disease Proteinuria (albuminuria) Starlings Law (hydrostatic vs. osmotic pressure) mg = microalbumninuria 300 mg or more = albuminuria ADA recommends yearly urinalysis followed by GFR Start ACE inhibitors = renoprotective #7. Obesity BMI (body mass index) less than better if less than 25 AACE recommends Bariatric surgery for type 2 patients with BMI > to 35 kg/m2. Stressed if other conditions are present (PTC, OSA, hypertension, heart disease). 5

<#K*(+$/#-'#($L$C&:9#&0$M::&?;#-0$L$31=*?,-# Visceral vs.

with the obesity epidemic. Fructose is not glucose.

De novo lipid production, TG increase and FFA increase!

CNS leptin (protein hormone) resistance promoting continuous

3,*;#'#0 7$O>=#(9,=,+#?,* 7$/,.*(#''#$P?1@,-.

Behavioral 7$O>=#('#-0,1-7$M9:1"19$:1-0&?

6 <#K*(+$/#-'#($L$C&:9#&0$M::&?;#-0$L$31=*?,-# Visceral vs. Subcutaneous fat BMI Type 1 BMI Type II BMI > 40 Extreme Obesity Fructose (sucrose vs. HFCS) consumption has increased in the last 30 years, coinciding with the obesity epidemic. Fructose is not glucose. Hepatic fructose metabolism leads to all the manifestations of the metabolic syndrome:! Hypertension uric acid pathway (stopping nitric oxide)! De novo lipid production, TG increase and FFA increase! Inflammation! Obesity! CNS leptin (protein hormone) resistance promoting continuous consumption Fructose is a hepatotoxin $$M'"#(10:9#(10,0$N$J10'$:1??1-$:*&0#$12$'"(1?;10,0 The Pathology of Obesity P@,- R#*0'$H-2#:',1-0A$F1&'A$3S3 3,*;#'#0 7$O>=#(9,=,+#?,* 7$/,.*(#''#$P?1@,-. 7$Q;#0,'> Genetics, Environmental (super-size), Psychological, Behavioral 7$O>=#('#-0,1-7$M9:1"19$:1-0&?=',1- E-+1:(,-# 719>:>0',:$Q8*(,*-$P>-+(1?#A$91K$'#0'10'#(1-#A$",."$#0'(1.#- O#*(' O#*('$M''*:@A$P'(1@#A$/O% )&-. P9##=$M=-#* FH F*990'1-#0A$FE<3 T(,-*(> H-:1-',-#-:# F>-1 M;-1(?*9$?#-0#0A$H-2#(',9,'> C#&(1 3#=(#00,1-A$?#?1(>$=(1;9#?0 /*-:#( U(#*0'$:*-:#(A$:191-A$=(10'*'#A$;9*++#($*-+$#01="*.&0 710'IQ= 7&9?1-*(>$#?;19,0? 6

20 oz bottle a day / year = 25 lb of fat per year Fructose is a carbohydrate Fructose is

Fructose/Sucrose doubles as fat Beer belly = Soda belly Fructose is a toxin #8.

Vasculitis Rule out gum disease, gastritis, UTIs, legulcers, etc.

for patients under the age of 30 CRP of 3.

5 mg / L or less rarely experience heart attacks #10.

VITAMIN D EPIDEMIC Sunlight in a bottle 4000 IU Needed 90% Vitamin D from Sun Exposure

Winter Influenza Diet provides only 10% of RDA of Vitamin D Winter Depression (Seasonal

Lupus) Organ Transplant Rejection Copyright 2005 Knowledge of Health Inc.

Obesity Carbohydrate Craving Loss of estrogen lowers vitamin D Osteoporosis 11.

sleep quality = obesity, diabetes Short sleepers (< 7 hours) is increasing in Blacks and

activity Increased cortisol release and insulin sensitivity Melatonin s role in diabetes?

7 20 oz bottle a day / year = 25 lb of fat per year Fructose is a carbohydrate Fructose is metabolized as fat 30% ends up as fat A low fat diet is not really low fat Fructose/Sucrose doubles as fat Beer belly = Soda belly Fructose is a toxin #8. Smoking Increases proteinuria, BV wall damage, vasoconstriction #9. Vasculitis Rule out gum disease, gastritis, UTIs, legulcers, etc. Daily aspirin decreases CVD in types 1 and 2 ADA mg /day Not studied extensively for patients under the age of 30 CRP of 3.0 mg / L or higher can triple risk of heart disease CRP of 0.5 mg / L or less rarely experience heart attacks #10. Vitamin D deficiency African Americans that live in the north have low levels THE VITAMIN D EPIDEMIC Sunlight in a bottle 4000 IU Needed 90% Vitamin D from Sun Exposure Blacks need 10 times more sun Loss of muscle tone: heart failure, incontinence, falls Winter Influenza Diet provides only 10% of RDA of Vitamin D Winter Depression (Seasonal Affective Disorder) Low vitamin D Hypertension Autoimmune Disease (Rheumatoid arthritis, Lupus) Organ Transplant Rejection Copyright 2005 Knowledge of Health Inc. Cancer Belt: Northern Latitudes Breast, Prostate, Uterine, Colon Rickets (Children) Obesity Carbohydrate Craving Loss of estrogen lowers vitamin D Osteoporosis 11. Insufficient Sleep Increase in blood insulin and inflammation Sleep loss / decreased sleep quality = obesity, diabetes Short sleepers (< 7 hours) is increasing in Blacks and Hispanics Sleep deprivation = Decreased leptin and increased ghrelin Decreased physical activity Increased cortisol release and insulin sensitivity Melatonin s role in diabetes? 12. Chronic Stress Leads to change in gene expression, cellular aging Increase in cortisol, insulin, inflammation Cortisol increases cytokines, oxidative stress Telomere shortening insulin resistance Prefrontal cortex overcome by limbic lobe and NA Stress and junk food = increase in visceral fat 7

$!#91?#(#$0"1('#-,-.$N$,-0&9,-$(#0,0'*-:# P'(#00$V$/1(',019 #13.

the risk factors, symptoms (numbness, tingling), signs (reduced

Medical Nutrition Therapy ADA Guidelines = dietary caloric

hyperglycemia Low fat (30%) (eliminate trans fat, reduce

=DCCT decreases DR progression 10-30 gram / day, US = 12 gram

Decreases insulin resistance! Decrease depression!

8 $!#91?#(#$0"1('#-,-.$N$,-0&9,-$(#0,0'*-:# P'(#00$V$/1(',019 #13. Neuropathy Microvascular complication (like DR, DNeph) Recognize the risk factors, symptoms (numbness, tingling), signs (reduced reflexes, poor nerve conduction) QUESTIONS AND COMMENTS? Medical Nutrition Therapy ADA Guidelines = dietary caloric intake: Low carbohydrate (50%) reduces post-prandial hyperglycemia Low fat (30%) (eliminate trans fat, reduce saturated fat intake) Low protein (20%) Increase dietary fiber =DCCT decreases DR progression gram / day, US = 12 gram MNT lowers Hb A1C ~ 1% Omega-3s (EPA and DHA)! Decreases insulin resistance! Decrease depression! Prevent cardiac arrhythmias! Increase Telomere length! 1000 mg to 4000 mg / daily Pseudotumor cerebri and diabetic retinopathy 8

BP 150/90 Smoker Gum Disease Vitamin D deficiency Coronary

Limb Amputations Cerebral vascular disease " Strokes Renal

Conclusions and Take Home Diabetic Retinopathy is exacerbated

Control of the systemic aspects of the disease improves

9 Hb A1C= 9.8% Sleep Apnea = No CPAP use Anemia = 8 Hb Albuminuria = >300 BP 150/90 Smoker Gum Disease Vitamin D deficiency Coronary artery disease " Heart attacks Peripheral vascular disease " Limb Amputations Cerebral vascular disease " Strokes Renal vascular disease " Renal failure and dialysis Conclusions Conclusions and Take Home Diabetic Retinopathy is exacerbated by many concomitant conditions. Control of the systemic aspects of the disease improves systemic and ocular health. Protect the Eye = Protect the Heart Understand how Diabetic Retinopathy relates to the overall systemic health. Thank you! Joe pizzimen@nova.edu 9

NOTES. Developed by Fabio Comana, MA., MS., All rights Reserved Page 1

NOTES. Developed by Fabio Comana, MA., MS., All rights Reserved Page 1 Session 455: Core Essentials in Science Fabio Comana, MA, MS, NASM CPT, CES & PES; ACE CPT & LWMC; ACSM HFS, NSCA CSCS; CISSN National Academy of Sports Medicine fabio.comana@nasm.org NOTES Developed by