Diabesity A Public Health Crisis: AOA Evidence Based Translation to Care Series Joseph J. Pizzimenti, OD, FAAO Associate Professor Nova Southeastern University The Eye Care Institute pizzimen@nova.edu Abstract: At least one third of Americans have been unsuccessful at maintaining their weight within healthy ranges. Obesity is a major risk factor for type 2 diabetes. Because obesity and diabetes often go hand in hand, a new term has been coined to describe America's current healthcare crisis: "the diabesity epidemic." In managing such patients, a multidisciplinary, integrated team approach has the best chance of success. Optometrists are in an excellent position to participate in a chronic disease management program whose goal is to help individuals not only see better and maintain good ocular health, but to walk farther, feel better, maintain a healthy weight, and add life to years. Course Goal: This goal of this course is to provide a review of ocular and systemic manifestations of diabesity. Objectives: At the conclusion of this course, participants will: 1. State and describe the problem of diabesity in America. 2. Discuss the various categories of body mass index. 3. Recognize the growing rate of obesity and type 2 diabetes in children and adolescents. 4. Describe systemic complications of diabesity. 5. Describe ocular complications of diabesity. 6. Diagnose and properly manage/co-manage complications of diabesity within an integrated health care model of chronic disease management. 7. Recognize the importanceof enhancing productivity and reducing medical costs associated with diabesity. 8. Educate and encourage their patients using evidence-based recommendations.
Course Outline Introduction Statement of course goals and objectives The problem of diabesity in America. Diabetes and Diabetic Retinopathy Statement of the Problem o Diabetic retinopathy (DR) is the leading cause of blindness in the working population in the western world. As the number of people living with type 2 DM is on the rise, eye care providers are seeing more and more DR. o Diabetes mellitus (DM) i. Dx as: HbA1c > 6.5% or FBS > 125mg/dl ii. Patient with DM need to maintained their HbA1c near normal (6.5-7%) iii. Risk factors associated with increase risk towards DR include 1. Duration of DM 2. HTN 3. Hypercholesterolemia 4. Higher than normal or fluctuating Hb A1c measurements 5. Sleep apnea 6. Obesity o Diabetic retinopathy (DR) iv. Pathophysiology v. NPDR (non-proliferative DR NPDR ) classifications: 1. Minimal: micro-aneurysms (MA) 2. Mild a. MA b. Hemorrhages c. Exudates 3. Moderate: MA/hemorrhages + a. CWS (cotton wool spot) b. IRMA c. exudates 4. Severe (4:2:1 rule) a. Four quadrants of hemorrhages b. 2 quadrants of venous beading c. One quadrant of intraretinal microvascular abnormalities (IRMA) vi. PDR (proliferative DR PDR ) 1. Presence of neovascularation of the disc or elsewhere 2. Complications may include
a. Vitreous hemorrhages b. Tractional retinal detachment c. NVG/NVA/NVI 3. Without Tx, 50% of PDR cases go blind w/in 5 yrs (ETDRS) vii. Clinical significant diabetic macular edema (CSDME) 1. Pathophysiology 2. Clinical findings 3. Macular edema is the #1 cause of vision loss in patients with DM o Follow-up and Referral in DR/DME viii. NPDR follow-up is dictated based on staging ix. Follow up includes 1. DM w/o DR: annually 2. Mild-Moderate: 6-12M 3. Severe: 2-4months x. Referral should be considered if: 1. Severe NPDR 2. Neovascularization 3. CSME a. Definition o Ancillary testing: o Optical Coherence Tomography o Fluorescein Angiography Management of Retinopathy o Approaches to Treatment for NV, CSME o In the 1990s, both AMD and diabetic retinopathy were treated with ablative therapy (laser). o Focal/grid laser photocoagulation as performed in the Early Treatment Diabetic Retinopathy Study (ETDRS) for CSME. o In 2005, we had a major paradigm shift in AMD. We converted from ablative therapy to pharmacotherapy. o Anti-VEGF injections improve the visual acuity rapidly and sustain visual acuity gains. o This same paradigm shift is happening in diabetic retinopathy, but at a much slower pace. o Will there still be a role for laser in DR? Probably. In DM/DR, VEGF production is continuous, and if
pharmacotherapy is the only thing we have, this will mean sustained injections for the rest of the patient's life. o Diabetic Retinopathy Clinical Research Network is going to looking combination therapy. What is Obesity? Increased body weight caused by excessive accumulation of fat. BMI defined as patient s weight (kg) divided by height (m2). BMI categories of obesity o Obesity 30-34.9 o Moderate obesity 35-39.9 o Extreme obesity over 40 Epidemiology of Excess Weight Statistics on obesity The burden of disease Obesity in children and adolescents Increase in type 2 diabetes in children and adolescents Obesity is associated with o Diabetes o Hypertension o Dyslipidemia o Type 2 DM o CAD o Stroke o Gallbladder Disease o Osteoarthritis o OSA o Malignancies Systemic complications of diabesity Ocular complications of diabesity. An integrated health care model of chronic disease management Enhancing productivity and reducing medical costs associated with diabesity. Educate and encourage your patients using evidence-based recommendations Sleep Apnea Syndrome Systemic Complications Ocular Complications Pathophysiology of sleep apnea in vascular disease
Figure 1. Ocular Complications of Excess Weight External disease o Floppy Eyelid Syndrome Anterior segment o Cornea Optic Nerve o Glaucoma o NAAION o Papilledema in Pseudotumor Cerebri Retina o AMD o Diabetic Retinopathy o Hypertensive Retinopathy o Retinal Vascular Occlusion Case Studies in Obesity o Case 1 32 y/o WM PDR OSA o Case 2 35 y/o BF PTC DM/DR Clinical Practice Examples Summary of AOA Evidence Based Clinical Practice Guidelines for Diabetes
So, what does this all mean to us? The evidence suggests an association between obesity, type diabetes, and certain ocular diseases. Diabetic Retinopathy and other ocular complications can be modified by numerous systemic and lifestyle factors (smoking, HTN, dyslipidemia, sleep apnea). Figure 2. References www.mypyramid.gov Centers for Disease Control and Prevention Division of Diabetes Translation National Vision Program www.cdc.gov AOA's Eye Care of the Patient with Diabetes Mellitus clinical practice guideline. www.aoa.org www.diabetes.org