cardiometabolic risk : evaluation & treatment in your patient population --insert here—...

Cardiometabolic Risk: Evaluation & Treatment in Your Patient Population

--Insert Here—Speaker Titleand Affiliation

--Insert Here—Speaker Titleand Affiliation

A comprehensive approach to patient care; Multiple disease pathways and risk factors are considered to facilitate earlier intervention

Early assessment and targeted intervention are needed to treat and prevent all risk factors associated with CVD and diabetes

A comprehensive approach to patient care; Multiple disease pathways and risk factors are considered to facilitate earlier intervention

Early assessment and targeted intervention are needed to treat and prevent all risk factors associated with CVD and diabetes

Cardiometabolic Risk

Gives a comprehensive picture of a patient’s health and potential risk for future disease and complications

Is inclusive of all risks related to metabolic changes associated with CVD

Accommodates emerging risk factors as useful predictive tools

Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment

Supports an integrated approach to care

Gives a comprehensive picture of a patient’s health and potential risk for future disease and complications

Is inclusive of all risks related to metabolic changes associated with CVD

Accommodates emerging risk factors as useful predictive tools

Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment

Supports an integrated approach to care

Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the AmericanDiabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the AmericanDiabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.

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

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

$296 billion $152 billion



*Note: these figures may not account for potential overlap.Sources: 2008 statistics from the American Diabetes Association and American Heart Association.

Cardiovascular

Disease

Diabetes

TOTAL

Estimated DirectMedical Costs

Estimated Indirect Costs

(disability, work loss,

premature mortality)

Abnormal Lipid Metabolism

LDL ApoB HDL Trigly.

Abnormal Lipid Metabolism

LDL ApoB HDL Trigly.

Cardiometabolic Risk

Global Diabetes / CVD Risk

Overweight / ObesityOverweight / Obesity

Inflammation Hypercoagulation

Inflammation Hypercoagulation

HypertensionHypertension

SmokingPhysical InactivityUnhealthy Eating

SmokingPhysical InactivityUnhealthy Eating

Age, Race, Gender,

Age, Race, Gender,

Family HistoryFamily History

GlucoseGlucoseBPBP Lipids Lipids

AgeAge GeneticsGenetics

Insulin ResistanceInsulin Resistance?? Insulin Resistance Insulin Resistance

SyndromeSyndrome Insulin Resistance Insulin Resistance

SyndromeSyndrome

Cardiometabolic Risk - Graphic

Non-modifiableNon-modifiable

Age

Race/ethnicity

Gender

Family history

Age

Race/ethnicity

Gender

Family history

Overweight

Abnormal lipid metabolism

Inflammation, hypercoagulation

Hypertension

Smoking

Physical inactivity

Unhealthy diet

Insulin resistance

Overweight

Abnormal lipid metabolism

Inflammation, hypercoagulation

Hypertension

Smoking

Physical inactivity

Unhealthy diet

Insulin resistance

ModifiableModifiable

Case - Mr. Martin

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

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

Age 47 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

Age 47 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

Non-ModifiableRisk Factors

Nu

mb

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um

ber

Centers for Disease Control and Prevention. National diabetes fact sheet: general information and nationalestimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, 2005.

800,000800,000

600,000600,000

400,000400,000

200,000200,000

00

Age GroupAge Group20-3920-39 40-5940-59 60+60+

0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

Cardiovascular Risk Factor Trends Among U.S. Adults Aged 20-74Cardiovascular Risk Factor Trends Among U.S. Adults Aged 20-74

Centers for Disease Control & Prevention, Division for Heart Disease andStroke Prevention, "Addressing the Nation's Leading Killers: At A Glance 2007

33.6

28.2

27.2

19.017.0

30.8

33.1

26.3

14.9

39.2

36.0

29.3

26.4

1.8

3.5

3.4

4.65.0

14.8

DiagnosedDiabetesDiagnosedDiabetes

SmokingSmokingHigh BloodPressureHigh BloodPressure

High TotalCholesterolHigh TotalCholesterol

1960-19621960-1962

1971-19751971-1975

1976-19801976-1980

1988-19941988-1994

1999-20001999-2000

Centers for Disease Control and Prevention. National diabetes fact sheet: general information and nationalestimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, 2005.

Hispanic/Latino AmericansHispanic/Latino Americans

Non-Hispanic WhitesNon-Hispanic Whites

American Indians/Alaska NativesAmerican Indians/Alaska Natives

Non-Hispanic BlacksNon-Hispanic Blacks

00 664422 121288 1010 20201414 1616 1818

Insulin Resistance Insulin Resistance

Factors affectinginsulin resistance

• Overweight/ fat distribution• Age• Genetic predisposition• Activity level• Medications• Puberty• Pregnancy

• Overweight/ fat distribution• Age• Genetic predisposition• Activity level• Medications• Puberty• Pregnancy

IFG and IGT

• Impaired Fasting Glucose (IFG): a condition in which the blood glucose level is between 100 mg/dL to 125mg/dL after an 8- to 12-hour fast.

• Impaired Glucose Tolerance (IGT): a condition in which the blood glucose level is between 140 and 199 mg/dL at 2 hours during an oral glucose tolerance test (OGTT).

• Impaired Fasting Glucose (IFG): a condition in which the blood glucose level is between 100 mg/dL to 125mg/dL after an 8- to 12-hour fast.

• Impaired Glucose Tolerance (IGT): a condition in which the blood glucose level is between 140 and 199 mg/dL at 2 hours during an oral glucose tolerance test (OGTT).

Interpreting BloodGlucose Levels

Healthy BG FPG < 100 mg/dL

Pre-diabetes FPG 100–125 mg/dL

Diabetes FPG ≥126 mg/dL

Healthy BG FPG < 100 mg/dL

Pre-diabetes FPG 100–125 mg/dL

Diabetes FPG ≥126 mg/dL

Criteria for testing for type 2 diabetesin asymptomatic children50

Overweight (BMI > 85th percentile for age and sex, weight for height > 85th percentile, or weight

>120 percent of ideal for height) Plus any two of the following:

• Family history

• Race/ethnicity

• Signs of insulin resistance or conditions associated with insulin resistance

• Maternal history of diabetes or GDM

Overweight (BMI > 85th percentile for age and sex, weight for height > 85th percentile, or weight

>120 percent of ideal for height) Plus any two of the following:

• Family history

• Race/ethnicity

• Signs of insulin resistance or conditions associated with insulin resistance

• Maternal history of diabetes or GDM

Criteria for testing for diabetes in asymptomatic adult individuals50

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)

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)

ContinuedContinued


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

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 pre-diabetes 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.

2. In the absence of the above criteria, testing for pre-diabetes 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.

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Fontbonne AM, et al. Diabetes Care. 1991;14:461-469.

Quintiles (pmol) of fasting plasma insulinQuintiles (pmol) of fasting plasma insulin

P<.01P<.01

Insulin Sensitive Insulin ResistantInsulin Sensitive Insulin Resistant

(n=943)(n=943)

29 30-50 51-72 73-114 115 29 30-50 51-72 73-114 115

Insulin SensitivityInsulin Sensitivity

Insulin SecretionInsulin Secretion

Associated Risk FactorsAssociated Risk Factors• Hypertension• Hypertension• Dyslipidemia• Dyslipidemia

AtherogenesisAtherogenesis

MicrovascularMicrovascularComplicationsComplications

Type 2 Diabetes Type 2 DiabetesAge (years)Age (years)

Fasting Blood GlucoseFasting Blood Glucose

Cardiometabolic Risk Cardiometabolic Risk

Diabetes

Impaired Fasting GlucoseEuglycemia

Proposed Metabolic Observations in the Natural History of Type 2 DiabetesProposed Metabolic Observations in the Natural History of Type 2 Diabetes

Overweight/Obesity

Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management

Cardiometabolic Risk Factors

Desired Goals for Healthy Patients

Overweight/obesitySource: CDC , ADA

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.

Abnormal lipid metabolismHigh LDL cholesterol

Low HDL cholesterol

High triglyceridesSource: NHLBI, ATP III Guidelines, ADA

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

HypertensionSource: 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 glucoseSource: ADA

Below 100 mg/dL

Physical inactivity Source: CDC At least 30 minutes of moderate activity most days

Smoking Source: ADA Quit or never start

Children Source: ADA Maintain healthy weight for age, sex, and height.

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

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.

Measuring Waist CircumferenceMeasuring Waist Circumference

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

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.

PrimaryMetabolic

Disturbance

PrimaryMetabolic

Disturbance

Intermediate Vascular Disease

Risk Factor

Intermediate Vascular Disease

Risk Factor Intravascular

PathologyIntravascular

PathologyClinicalEvent

ClinicalEvent

Atherosclerosis

Hypercoagulability

• Coronary arteries• Carotid arteries• Cerebral arteries• Aorta• Peripheral arteries

Hypertension

Dyslipidemia

Hyperinsulinemia

Hyperglycemia

Inflammation

ImpairedFibrinolysis

Endothelial Dysfunction

Insulin Resistance

CVD

Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887.

Overnutrition

<100 110-129 130+ <110 110-129 130+<100 110-129 130+ <110 110-129 130+00

100100

150150

200200

250250

300300

5050

125125

200200

267267

105105121121 128128

*Metropolitan Relative Weight percent (percentage of desirable weight)

*Metropolitan Relative Weight percent (percentage of desirable weight)

Hubert HB et al. Circulation. 1983;67:968-977

MenMen WomenWomen

Incidence of CVD

per 1,000

Incidence of CVD

per 1,000

n=56 n=75 n=30 n=191 n=199 n=78 n=56 n=75 n=30 n=191 n=199 n=78

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

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

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 conditionsClinical 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

Abnormal Lipid MetabolismAbnormal Lipid Metabolism

Total Cholesterol Goals34Total Cholesterol Goals34

• Desirable — Less than 200 mg/dL

• Borderline high risk — 200–239 mg/dL

• High risk — 240 mg/dL and over

• 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

Increased:

TriglyceridesVLDLLDL and small

dense LDLApoB

Increased:

TriglyceridesVLDLLDL and small

dense LDLApoB

Decreased:

HDLApo A-I

Decreased:

HDLApo A-I

American Diabetes Association. Diabetes Care. 2007;30:S4-41.

Major Risk FactorsAffecting Lipid Goals36

• 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)

• 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)

Statins (also called HMG-CoA reductase inhibitors) work by increasing hepatic LDL-C removal from the blood.

Resins (also called bile acid sequestrants) bind to bile acids in the intestines and prevent their reabsorption, leading to increased hepatic LDL-C removal from the blood.

Cholesterol absorption inhibitors help lower LDL-C by reducing the amount of cholesterol absorbed in the intestines; increases LDL receptor activity.

Statins (also called HMG-CoA reductase inhibitors) work by increasing hepatic LDL-C removal from the blood.

Resins (also called bile acid sequestrants) bind to bile acids in the intestines and prevent their reabsorption, leading to increased hepatic LDL-C removal from the blood.

Cholesterol absorption inhibitors help lower LDL-C by reducing the amount of cholesterol absorbed in the intestines; increases LDL receptor activity.

Fibrates (also called fibric acid derivatives) activate an enzyme that speeds the breakdown of triglyceriderich lipoproteins while also increasing HDL-C.

Niacin (also called nicotinic acid) reduces the liver’s ability to produce VLDL. When given at high doses, it can also increase HDL-C.

Fibrates (also called fibric acid derivatives) activate an enzyme that speeds the breakdown of triglyceriderich lipoproteins while also increasing HDL-C.

Niacin (also called nicotinic acid) reduces the liver’s ability to produce VLDL. When given at high doses, it can also increase HDL-C.

American Diabetes Association. Understanding Cardiometabolic risk: Broadening risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center

Cholesterol Management

For patients >20 years of age, cholesterol should be checked every 5 years

Ordering a fasting lipid panel is preferred to gauge the patient’s total cholesterol, LDL-C, HDL-C and triglycerides

Treatment priorities

For patients >20 years of age, cholesterol should be checked every 5 years

Ordering a fasting lipid panel is preferred to gauge the patient’s total cholesterol, LDL-C, HDL-C and triglycerides

Treatment priorities


Category of risk LDL-C Goal

0-1 risk factor* < 160 mg/dL or lower

Multiple (2+) risk factors* < 130 mg/dL or lower

People with coronary heart disease or risk equivalent (e.g., diabetes)

< 100 mg/dL or lower

Known CAD and DM < 70 mg/dL or lower may be ideal

LDL-C-loweringLDL-C-lowering


Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking cessation Dietary modifications including low saturated fat (fat

intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet

Pharmacologic treatment frequently necessary Risk factors include hypertension; HDL < 40; family

history of MI before age 55; male > 45 years old; female > 55 years old; smoking.

Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking cessation Dietary modifications including low saturated fat (fat

intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet

Pharmacologic treatment frequently necessary Risk factors include hypertension; HDL < 40; family

history of MI before age 55; male > 45 years old; female > 55 years old; smoking.

Risk of CHD by Triglyceride Level:Risk of CHD by Triglyceride Level:The Framingham Heart StudyThe Framingham Heart Study

MenMen WomenWomen

n=5,127n=5,127

Triglyceride Level, mg/dLTriglyceride Level, mg/dL

5050 100100 150150 200200 250250 300300 350350 400400

Rel

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isk

Rel

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isk

00

0.50.5

11

1.51.5

22

2.52.5

33

Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiology. 1992;70:3H-9H.

Reaven GM, et al. J Clin Invest. 1993;92:141-146.

Association Between Small, Association Between Small, Dense LDL and Insulin ResistanceDense LDL and Insulin Resistance

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AALarger LDL particle

pattern

AALarger LDL particle

patternIntermediate

patternIntermediate

pattern

BSmall LDL particle

pattern

BSmall LDL particle

pattern

0

2

6

10

12

8

4

LDL-Size PhenotypeLDL-Size Phenotype

(n=52)(n=52)

(n=19)(n=19)

(n=29)(n=29)

Low HDL-C: Independent Predictor of CHD Risk, Even When LDL-C is LowLow HDL-C: Independent Predictor of CHD Risk, Even When LDL-C is Low

0.0

1.0

2.0

3.0

100 160 220 8565

4525

LDL-C (mg/dL)LDL-C (mg/dL)

HDL-C (m

g/dL)

HDL-C (m

g/dL)

Ris

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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.

Screening for DyslipidemiaScreening for Dyslipidemia

Persons without DiabetesPersons without Diabetes

Test at least every 5 years, starting at age Test at least every 5 years, starting at age 20, including adults with low-risk values 20, including adults with low-risk values

Persons with DiabetesPersons with Diabetes

In adults, test at least annuallyIn adults, test at least annually

Lipoproteins: measure at after initial blood Lipoproteins: measure at after initial blood glucose control is achieved as hyperglycemia glucose control is achieved as hyperglycemia may alter resultsmay alter results

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. Standards of Medical Care in Diabetes 2007. Available at: http://care.diabetesjournals.org/cgi/reprint/30/suppl_1/S4

Healthy Lipid GoalsHealthy Lipid GoalsTargets for Patients Without DM or CVDTargets for Patients Without DM or CVD

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

Total <200 mg/dL

LDL <70 mg/dL

HDL >40 men mg/dL

>50 women mg/dL

Triglycerides < 150 mg/dL

Risk ManagementRisk ManagementAbnormal LipidsAbnormal Lipids

Lifestyle modification• Increased physical activity

• Diet: reduced saturated fat, trans fat, and cholesterol

• Weight loss, if indicated

Lifestyle modification• Increased physical activity

• Diet: reduced saturated fat, trans fat, and cholesterol

• Weight loss, if indicated


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

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


Risk ManagementRisk ManagementAbnormal LipidsAbnormal Lipids

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 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

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

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. http://dashdiet.org. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

Management of HypertensionManagement of Hypertension

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

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. http://dashdiet.org. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

Microvascular Renal disease Autonomic

neuropathy Eye disease

(glaucoma, retinopathy with potential blindness)

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

Macrovascular Cardiac disease Cerebrovascular

disease Reduced survival and

recovery rates from stroke

Peripheral vascular disease

American Diabetes Association. Diabetes Care. 2007;30:S4-41..

Physical InactivityPhysical Inactivity

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

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.

Physical ActivityPhysical Activity

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.

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.


Physical ActivityPhysical Activity

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

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


Exercise Precautions Related to Complications of DiabetesExercise Precautions Related to Complications of Diabetes

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

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


SmokingSmoking

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.

Hazards Ratio (95% CI)

Never Smoked 1

Ex-Smoker 1.08 (0.75 - 1.54)

Current Smoker 1.58 (1.11 - 2.25)

Hazards Ratio (95% CI)

Never Smoked 1

Ex-Smoker 1.08 (0.75 - 1.54)

Current Smoker 1.58 (1.11 - 2.25)

Obtain documentation of history of tobacco use Ask whether smoker is willing to quit

– If no, initiate brief, motivational discussion regarding:

• the need to stop using tobacco• risks of continued use• encouragement to quit, as well as support

when ready– If yes, assess preference for and initiate either

minimal, brief, or intensive cessation counseling.

Obtain documentation of history of tobacco use Ask whether smoker is willing to quit

– If no, initiate brief, motivational discussion regarding:

• the need to stop using tobacco• risks of continued use• encouragement to quit, as well as support

when ready– If yes, assess preference for and initiate either

minimal, brief, or intensive cessation counseling.

American Diabetes Association. Diabetes Care. 2004;27:S27:S74-S75.

Set a Plan Offer counseling and referrals Offer medication assistance Offer combined pharmacologic and

behavioral intervention Online guide to quitting: SmokeFree.gov

Set a Plan Offer counseling and referrals Offer medication assistance Offer combined pharmacologic and

behavioral intervention Online guide to quitting: SmokeFree.gov

American Diabetes Association. Diabetes Care. 2004;27:S27:S74-S75.

InflammationInflammation

Inflammation / HypercoagulationInflammation / Hypercoagulation

Proinflammatory/prothrombotic factors underlie cardiometabolic risk

Inflammation is a major component of atherogenesis and other cardiometabolic problems

Obesity is associated with inflammation

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. 2002;106:2908-2912.

High-sensitivity CRP tests may be used to further evaluate underlying risk Relative risk categories

• Low risk <1 mg/L• Average risk 1-3 mg/L• High risk >3 mg/L

Aspirin and statins reduce CRP levels

Unclear whether CRP should be a treatment target

Reduce weight

High-sensitivity CRP tests may be used to further evaluate underlying risk Relative risk categories

• Low risk <1 mg/L• Average risk 1-3 mg/L• High risk >3 mg/L

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.

Pre-Diabetes and Pre-Diabetes and Diabetes PreventionDiabetes Prevention

Pre-DiabetesPre-Diabetes

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

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..

Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2004; Supplement 1

Fasting PlasmaGlucose

Fasting PlasmaGlucose

126 mg/dL126 mg/dL

Normal

2-hour Plasma Glucose On OGTT

2-hour Plasma Glucose On OGTT

200 mg/dL 200 mg/dL

140 mg/dL 140 mg/dL

Diabetes Mellitus

Impaired GlucoseTolerance

Normal

Diabetes Mellitus

Any abnormality must be repeated and confirmed on a separate day*

Any abnormality must be repeated and confirmed on a separate day*

* One can also make the diagnosis of diabetes based on unequivocal symptoms and a random glucose >200 mg/dL* One can also make the diagnosis of diabetes based on unequivocal symptoms and a random glucose >200 mg/dL

“Pre-Diabetes”

100 mg/dL100 mg/dL

Impaired FastingGlucose

ADA Consensus Conference ADA Consensus Conference on IFG and IGT: on IFG and IGT:

Implications for Diabetes Care Implications for Diabetes Care October 16-18, 2006October 16-18, 2006

Results: Treat IFG and IGT with aggressive

lifestyle modification For certain patients with both IFG and

IGT consider metformin

Results: Treat IFG and IGT with aggressive

lifestyle modification For certain patients with both IFG and

IGT consider metformin

Nathan D, et al. Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for Care. Diabetes Care. 2007 30: 753-759.

Cu

mu

lati

ve I

nci

den

ceo

f D

iab

etes

(%

)C

um

ula

tive

In

cid

ence

of

Dia

bet

es (

%)

YearsYears

4040

3030

2020

1010

0000 0.50.5 1.01.0 1.51.5 2.02.0 2.52.5 3.03.0 3.53.5 4.04.0

PlaceboPlacebo

MetforminMetformin

LifestyleLifestyle

Knowler WC, et al. NEJM. 2002;346:393-403.

Beh

avio

r M

edic

atio

n

Results of Recent Randomized TrialsResults of Recent Randomized Trials

58%

58%

58%

58%

31%

25%

55%

45%

61%/NS

31%

25%

55%

45%

61%/NS

Metformin

Acarbose

Troglitazone

OrlistatRosiglitazone/Ramipril

Metformin

Acarbose

Troglitazone

OrlistatRosiglitazone/Ramipril

IGT

IGT

Prior GDM

IGT

IGT

IGT

IGT

Prior GDM

IGT

IGT

US DPP

STOP-NIDDM

TRIPOD

XENDOS

DREAM

US DPP

STOP-NIDDM

TRIPOD

XENDOS

DREAM

Lifestyle

Lifestyle

Lifestyle

Lifestyle

IGT

IGT

IGT

IGT

Finnish DPS

US DPP

Finnish DPS

US DPP

Relative RiskReduction

Relative RiskReductionInterventionInterventionSubjectsSubjectsStudy Study

<180 mg/dL<180 mg/dLPostprandial plasma glucosePostprandial plasma glucose

90-130 mg/dL90-130 mg/dLPreprandial glucose Preprandial glucose

<7.0%<7.0%A1C*†A1C*†

* For non-pregnant individuals† As close to normal (<6%) as possible without significant hypoglycemia

American Diabetes Association. Diabetes Care. 2007:30:S4-41..

Goals for Glycemic Control

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)

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)


Screening For DiabetesScreening For Diabetes

Additional risk factors:

• Race/ethnicity (e.g., African-Americans, Hispanic-Americans, 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)

Additional risk factors:

• Race/ethnicity (e.g., African-Americans, Hispanic-Americans, 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)


Screening For DiabetesScreening For Diabetes

Age 47 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 Sedentary Unhealthy diet Fast food diet

Age 47 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 Sedentary Unhealthy diet Fast food diet

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

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 AmericanDiabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005;28 (9)2289-2304.

What Should We Do?What Should We Do?

cardiometabolic risk : evaluation & treatment in your patient population --insert here—...

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