Lifestyle Medicine. This presentation will:

Transcription

1 Lifestyle Medicine This presentation will: Identify barriers to lifestyle therapy and develop strategies to promote behavioral changes in patients with obesity and/or T2D. AACE = American Association of Clinical Endocrinologists

2 IDF Diabetes Atlas: Diabetes Prevalence 415 million people worldwide have diabetes By 2040, this number will rise to 642 million ( million) AFR = Africa; EUR = Europe; IDF = International Diabetes Federation; MENA = Middle East and North Africa; NAC = North America and Caribbean; SACA = South and Central America; SEA = South-East Asia; WP = Western Pacific. IDF Diabetes Atlas, 7 th Edition

3 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Obesity (BMI 30 kg/m 2 ) No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% 1994 Diabetes No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% BMI = body mass index; CDC = U.S. Center for Disease Control and Prevention. CDC s Division of Diabetes Translation. National Diabetes Surveillance System.

4 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 T2DM = type 2 diabetes mellitus. American Academy of Family Physicians. Accessed April 15, 2015.

5 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 CAD = coronary artery disease; CVD = cardiovascular disease; DPP = Diabetes Prevention Program. NDIC/NIDDK. Diabetes Prevention Program. Accessed May 1, 2013.

6 Diabetes Incidence per 100 Person-Years Intensive Lifestyle Intervention Prevents Progression from IGT to T2DM Diabetes Prevention Program (N=3234) % 31% Intensive lifestyle intervention*, (n=1079) IGT = impaired glucose tolerance; T2DM = type 2 diabetes mellitus. DPP Research Group. N Engl J Med. 2002;346: 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.

7 Diabetes Incidence per 100 Person-Years Intensive Lifestyle Intervention Effectively Prevents T2DM as Populations Age Diabetes Prevention Program (DPP) (N=3234) 48% 59% 71% DPP Research Group. N Engl J Med. 2002;346: Age (years) * Goal: 7% reduction in baseline body weight through low-calorie, low-fat meal plan and 150 min/week moderate intensity physical activity. DPP = Diabetes Prevention Program; T2DM = type 2 diabetes mellitus.

8 Diabetes Mellitus Reduction (%) Is It Possible to Delay the Onset of T2DM? 80 74% 72% >5% loss 42% 58% 55% 41% 62% Finnish-Diet+ Exercise Da Qing Diet + Exercise DPP-Lifestyle 30 31% 25% DPP-Metformin STOP-NIDDM 20 TRIPOD 10 0 Diabetes Prevention Clinical Trials XENDOS DREAM ActNOW DPP = Diabetes Prevention Program; DREAM = Diabetes Reduction Assessment with Ramipril & Rosiglitazone Medication; STOP-NIDDM = Study to Prevent Non-Insulin-Dependent Diabetes Mellitus; T2DM = type 2 diabetes mellitus; TRIPOD = Troglitazone in the Prevention of Diabetes; XENDOS = XEnical in the Prevention of Diabetes in Obese Subjects. Buchanan T, et al. Diabetes 2002; 51(9): ; Chiasson JL, et al. Lancet 2002; 359: ; Da Qing, et al. Diabetes Care. 1997; 20: ; Gerstein H, et al. Lancet 2006; 368: ; Nathan DM, et al. N Engl J Med 2002; 346: ; Torgerson JS, et al. Diabetes Care 2004; 27 (1): ; Tuomilehto J, et al. N Engl J Med 2001; 344:

9 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

10 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 ACC = American College of Cardiology; AHA = American Heart Association; BMI = body mass index; TOS = The Obesity Society. Jensen MD, et al. Circulation. 129(25 suppl 2):S102 S138, 2014.

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

12 Relationship Between BMI and Risk of T2DM BMI = body mass index; T2DM = type 2 diabetes mellitus. Chan JM, et al. Diabetes Care. 17(9): Colditz GA, et al. Ann Intern Med. 122(7):

13 The Role of the Physician >50% of visits no BMI measured If BMI data available >70% of obese patients were not diagnosed If obesity diagnosed >63% received no counseling (even with risk factors) BMI = body mass index. Ma J, et al. Adult obesity and office-based quality of care in the US. Obesity 17: , 2009.

14 Obesity Classification: Waist Circumference (WC) Patients with overweight/obesity = increased body fat (adiposity) Overweight and obesity classification: waist circumference (WC) Men abdominal obesity 40 in. ( 102 cm)* Women abdominal obesity 35 in. ( 88 cm)* ACTION ITEM: Measure WC at annual visits or more frequently in patients with overweight or obesity. WC = waist circumference. *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 Accessed April 6, 2015.

15 Treatment: Modest Weight Loss = Major Health Benefits 5% weight loss 10% weight loss 15% weight loss 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 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. BP = blood pressure; CVD = cardiovascular disease; HDL-C = high density lipoprotein-cholesterol; QOL = quality of life; T2DM = type 2 diabetes mellitus; TG = triglycerides. Blackburn G. Obes Res. 3(suppl 2):211s-216s Christou NV, et al. Surg Obes Relat Dis. 4(6): Foster GD, et al. Arch Intern Med. 169(17): Gregg EW, et al. JAMA. 308(23): Sjostrom L, et al. J Intern Med. 273(3):

16 Determinants of Body Weight Genes Protective and at risk alleles for weight gain Race (ancestral admixture) Gene-gene interactions Environment Food availability Food quality Built environment Socioeconomic status Education Biological factors In utero environment Birthweight Gender Age Concurrent diseases Behavior Dietary preferences Physical activity Psychological factors Cultural factors Diurnal life patterns

17 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.

18 Garvey et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22(Suppl 3). Garber et al.consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm Executive Summary. Endocr Pract. 2016;22(No. 1) Lifestyle Modification: Diet Guidelines and Recommendations Goal of 5% to 15% weight loss Caloric deficit of ~500 to 750 kcal/day (kcal = ~10x BW in lbs) Balanced, healthful diet with 50% to 55% carb, 30% fat, 15% protein BW = body weight.

19 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 WT, Lara-Castro C. J Clin Endocrinol Metab. 2004;89:

20 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 Garvey et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22(Suppl 3). Garber et al.consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm Executive Summary. Endocr Pract. 2016;22(No. 1). Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

21 Sedentary Lifestyles

22 Garvey et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22(Suppl 3). Garber et al.consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm Executive Summary. Endocr Pract. 2016;22(No. 1) Lifestyle Modification: Physical Activity Guidelines and Recommendations Talk about physical activity (not exercise ) Some is better than none 150 min/wk of moderate intensity activity Both aerobic (endurance) and strengthening (resistance) activity are beneficial

23 AACE Physical Activity Recommendations Patients 150 minutes per week of moderate-intensity exercise Strength training Aerobic exercise (e.g., walking, stair climbing) Increase as tolerated Use community engagement 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 AACE = American Association of Clinical Endocrinologists; HR = heart rate. Garvey et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22(Suppl 3). Garber et al.consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm Executive Summary. Endocr Pract. 2016;22(No. 1). Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

24 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.

25 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.

26 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.

27

28 Conditions for Success Engagement with other health team members Support at home (and at work) Patience Persistence Set realistic 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 BMI = body mass index.

29 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% ean ME, et al. Diabet Med. 1990;7: ; Williamson DF, et al. Diabetes Care. 2000;23: nderson JW et al. J Am Coll Nutr. 2003;22:331-9.