cardiometabolic risk--REIVEW unit 8-11

cardiometabolic risk--REIVEW unit 8-11 - Metabolic Syndrome...

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Unformatted text preview: Metabolic Syndrome: Preventing Disease through Risk Identification and Management Multiple disease pathways and risk factors are considered to facilitate earlier intervention Early assessment and targeted intervention are needed to prevent and, if necessary treat, all risk factors associated with CVD and diabetes 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 Estimated Direct Medical Costs Estimated Indirect Costs (disability, work loss, premature mortality) Cardiovascular Disease $296 billion $152 billion Diabetes $116 billion $58 billion $412 billion $210 billion TOTAL *Note: these figures may not account for potential overlap. Sources: 2008 statistics from the American Diabetes Association and American Heart Association. Overweight Overweight // Obesity Obesity Age Age Abnormal Abnormal Lipid Lipid Metabolism Metabolism Genetics Genetics Insulin Insulin Resistance Resistance LDL LDL HDL HDL Trigly. Trigly. Insulin Insulin Resistance Resistance ? Syndrome Syndrome Glucose Lipids BP Glucose Lipids BP Cardiometabolic Risk Global Diabetes / CVD Risk Smoking Smoking Physical Physical Inactivity Inactivity Unhealthy Unhealthy Eating Eating Age, Age, Race, Race, Gender, Gender, Family Family History History Inflammation Inflammation Hypercoagulation Hypercoagulation Hypertension Hypertension Non-modifiable Age Race/ethnicity Gender Family history Modifiable Overweight Abnormal lipid metabolism Inflammation, hypercoagulation Hypertension Smoking Physical inactivity Unhealthy diet Insulin resistance 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 Age47 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 Modifiable Risk Factors: Screening, Prevention and Intervention Number 800,000 600,000 400,000 200,000 0 20-39 40-59 Age Group 60+ Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005. 39.2 30.8 33.6 36.0 33.1 28.2 1960-1962 1971-1975 29.3 27.2 19.0 17.0 26.3 26.4 1976-1980 1988-1994 1999-2000 14.8 14.9 4.6 5.0 3.5 3.4 1.8 High Total Cholesterol High Blood Pressure Smoking Centers for Disease Control & Prevention, Division for Heart Disease and Stroke Prevention, "Addressing the Nation's Leading Killers: At A Glance 2007 Diagnosed Diabetes American Indians/ Alaska Natives Non-Hispanic Blacks Hispanic/Latino Americans Non-Hispanic Whites 0 2 4 6 8 10 12 14 16 18 20 Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005. • • • • • • • Overweight/ fat distribution Age Genetic predisposition Activity level Medications Puberty Pregnancy Healthy BG FPG < 100 mg/dL Pre-diabetes FPG 100–125 mg/dL Diabetes FPG ≥126 mg/dL 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.. Fasting Plasma Glucose Any abnormality must be repeated and confirmed on a separate day* Diabetes Mellitus 2-hour Plasma Glucose On OGTT Diabetes Mellitus 126 mg/dL 100 mg/dL Impaired Glucose Tolerance Impaired Fasting Glucose 200 mg/dL 140 mg/dL Normal Normal “Pre-Diabetes” * One can also make the diagnosis of diabetes based on unequivocal symptoms and a random glucose >200 mg/dL Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2004; Supplement 1 A1C*† <7.0% Preprandial glucose 90-130 mg/dL Postprandial plasma glucose <180 mg/dL * For non-pregnant individuals † As close to normal (<6%) as possible without significant hypoglycemia A1C test measures what percentage of your hemoglobin — a protein in red blood cells that carries oxygen — is coated with sugar (glycated). The higher your A1C level, the poorer your blood sugar control and the higher your risk of diabetes complications. American Diabetes Association. Diabetes Care. 2007:30:S4-41.. 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.. Additional risk factors: • Race/ethnicity (e.g., African-Americans, HispanicAmericans, 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.. Age Race/ethnicity Gender Family history Overweight/obesity Abnormal lipid metab Hypertension Smoking Physical Inactivity Unhealthy diet 47 African American Male HTN and diabetes BMI = 29 TC = 210 BP = 146/86 1 pack per day Sedentary Fast food diet 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) Continued 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 2. In the absence of the above criteria, testing for prediabetes 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. (n=943) CHD mortality, per 1000 3 P<.01 2 1 0 29 30-50 51-72 73-114 115 Quintiles (pmol) of fasting plasma insulin Insulin Sensitive Fontbonne AM, et al. Diabetes Care. 1991;14:461-469. Insulin Resistant Cardiometabolic Risk Factors Overweight/obesity Source: CDC , ADA Abnormal lipid metabolism High LDL cholesterol Low HDL cholesterol High triglycerides Desired Goals for Healthy Patients 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. 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 Source: NHLBI, ATP III Guidelines, ADA Hypertension Source: 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 glucose Below 100 mg/dL Source: ADA Physical inactivity Source: CDC At least 30 minutes of moderate activity most days Smoking Source: ADA Quit or never start Children Maintain healthy weight for age, sex, and height. Source: ADA 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. 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. Primary Metabolic Disturbance Intermediate Vascular Disease Risk Factor Intravascular Pathology Clinical Event Insulin Resistance Hypertension Dyslipidemia Hyperglycemia Overnutrition Hyperinsulinemia Inflammation Atherosclerosis • • • • • Coronary arteries Carotid arteries Cerebral arteries Aorta Peripheral arteries Hypercoagulability Impaired Fibrinolysis Endothelial Dysfunction Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887. CVD Men 300 267 267 Women 250 200 200 200 Incidence of CVD per 1,000 150 125 125 100 105 105 121 121 128 128 50 0 <100 110-129 130+ <110 110-129 130+ n=56 n=75 n=30 n=191 n=199 n=78 *Metropolitan Relative Weight percent (percentage of desirable weight) Hubert HB et al. Circulation. 1983;67:968-977 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 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 • 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 • 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) 3 2.5 Relative Risk Women Men n=5,127 2 1.5 1 0.5 0 50 100 150 200 250 300 350 400 Triglyceride Level, mg/dL Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiology. 1992;70:3H-9H. Mean Steady State Plasma Glucose (mmol/L) at Identical Plasma Insulin 12 (n=19) (n=19) 10 8 (n=29) (n=29) (n=52) (n=52) 6 4 2 0 A A Larger LDL particle pattern Intermediate pattern B Small LDL particle pattern LDL-Size Phenotype Reaven GM, et al. J Clin Invest. 1993;92:141-146. Risk of CHD -C L HD L) d g/ (m LDL-C (mg/dL) 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. Total <200 mg/dL LDL <70 mg/dL HDL >40 men mg/dL >50 women mg/dL Triglycerides < 150 mg/dL 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 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 American Diabetes Association. Diabetes Care. 2007;30:S4-41. 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 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 The Dash Diet. . American Diabetes Association. Diabetes Care. 2007;30:S4-41. 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. . American Diabetes Association. Diabetes Care. 2007;30:S4-41. 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 American Diabetes Association. Diabetes Care. 2007;30:S4-41.. 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. 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. 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. 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. Hazards Ratio (95% CI) Never Smoked Ex-Smoker Current Smoker 1 1.08 (0.75 - 1.54) 1.58 (1.11 - 2.25) 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. 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. High-sensitivity CRP tests may be used to further evaluate underlying risk Relative risk categories <1 mg/L • Low risk 1-3 mg/L • Average risk >3 mg/L • High risk 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. 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 American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005;28 (9)2289-2304. ...
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  • Spring '14
  • SharonM.Knight
  • Diabetes, Atherosclerosis, Diabetes Care.

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