Transcript Diabesity

Diabesity
Jay Shubrook DO FACOFP
Associate Professor of Family Medicine
Director, Diabetes Fellowship
Ohio University Heritage College of
Osteopathic Medicine
Obesity and Diabetes
• Review the married epidemics of obesity and
diabetes
• Review how diabetes can be prevented in obese
individuals
• Review how you can improve obesity and diabetes
simultaneously
• Discuss different treatments for different types of
diabetes
Human Evolution
US Obesity Epidemic
• 17% of all US deaths from obesity
approx. 300,000 deaths/year
o Obesity equals smoking as cause of preventable death
o Shortens life span 5 -22 years
• Extremely obese white male 20-30
o Lose 13 yrs of life
o Mortality 12x higher if BMI >40
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Years of Life Lost Due to Obesity, JAMA January 8, 2003:89;2;187-193
Obesity Among US Immigrants Subgroups by Duration of Residence JAMA Dec 15, 2004.
Obesity
• Greatest US health expenditure
• Social and ethnic differences in obesity
o Greater in women x 2
o Greater among Black Americans
• Women>> men
o Greater among non-HS grads
o Largest increase in ages 19-28
• 75% of those with extreme obesity have a comorbid disease
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1999
1990
2009
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Risk of Type 2 Diabetes as a
function of BMI
Adjusted relative
risk of diabetes
100
90
80
70
60
50
40
30
20
10
0
<22
2222.9
2323.9
2424.9
2526.9
BMI Range
2728.9
2930.9
3132.9
3334.9
>35
Colditz GA et al. Ann Int Med, 1995
Age-adjusted Percentage of U.S. Adults Who Were
Obese or Who Had Diagnosed Diabetes
Obesity (BMI ≥30 kg/m2)
1994
<14.0%
14.0-17.9%
2008
2000
18.0-21.9%
22.0-25.9%
>26.0%
Diabetes
1994
<4.5%
2008
2000
4.5-5.9%
6.0-7.4%
7.5-8.9%
>9.0%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
What about closer to home?
Childhood Obesity in
Ohio
• 1/3 of 3rd graders were overweight or obese
• Higher rates in
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Hispanic and Non-Hispanic Black children
Children in Appalachian counties
Low income children
Children who watched at least 3 hours TV/day
Highest in kids who drank >1 sweetened beverage per day
ODH 2009-2010 data
Childhood Obesity in
Ohio
ODH
2009-2010
Non
Hispanic
white
NonHispanic
Black
Hispanic
Appalachian
Counties
overweight
15.2%
20.5%
23.0%
17.1%
obese
17.2%
19.8%
30.7%
22.8%
ODH 2009-2010 data
Childhood Obesity in
Ohio
Rural
Urban
Suburban
Free and
reduced
meals
Non
enrolled in
free school
plan
overweight 16.5%
16.1%
16.4%
16.9%
15.9%
obese
18.4%
14.3%
23.4%
13.8%
19.1%
ODH 2009-2010 data
Risk Factors for Obesity
• Obese parents
o Before age 3 parental weight predicts obesity more than
child’s weight
o If 1 parent is obese child’s risk x3
o If both obese odds ratio 10
• 10% chance normal weight
Whitaker NEJM 1997
Risk Factors for Obesity
• Environmental Factors
o Portion size (market portions are 2-8 times larger than
recommended USDA and FDA recs)
o Sweetened beverages
• Increasing since 1970
o Socioeconomic status inversely related to obesity
o Energy density and food cost inversely related
o Increase in sedentary leisure time
• 26% watch more than 4 hours of TV time per day
• 67% watch more than 2 hours
Obesity Related Comorbidities
• Glucose tolerance tests in obese children
o ABnormal results in
• 29% non-Hispanic white children
• 41% of African American children
• 50% of Hispanic children
• 53% of Asian/Pacific Island children
• 66% of American Indian children
Weiss R Diabetes Care 2005
Childhood Obesity
Complications
• Overall Diabetes Risk (children born in 2000)
o 1 in 3 boys
o 2 in 5 girls
• 20% of children with DM have Type 2
• NAFLD/NASH
o Steatosis in 40% of obese children (Guzzaloni 2000)
o Elevated LFTs in 6% of overweight and 10% of obese kids
(Rashid 2000)
Physicians Do not
Address Obesity Enough:
• Addressing obesity in the office
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Only 17.4% of 2-5 yr old
32.6% of 6-11 yr/old
39.6% of 12 -15 yr/old
51.6% of 16-19 yr/old
Diabetes Prevention in
Those at Risk
Case 1
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28 year while male presents with knee pain
Bilateral knee pain, worse as day goes on
No previous workup
No regular PA, computer programmer
No med hx/ family hx of HTN, DM2, CAD
No meds
ROS: admits fatigue, admits weight gain 80 lbs since
college
Case 1 (cont’d)
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Exam 5’ 10” weight 260 lbs
Stretch marks on abdomen
No synovitis, no swelling, normal ROM,
X-rays are normal
• BP 138/88
• FSG 148 non fasting
• HgA1c in office 6.0%
Case Questions
• What do you include in your problem list for this
person?
• Which do you address first?
• What is your treatment plan?
How would you address
his weight
Nothing –he is here for knee pain
Recommend that he start a new diet
Refer him to medical nutrition therapy
Not address it today but get more labs and bring
him back
• Start him on a medication
• Refer him for weight loss surgery
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Medications
• Which medication would you start?
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o
o
o
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Phentermine/topiramate (QnexaR )
Phentermine (AdipexR)
Topiramate (TopamaxR)
Orlistat (ALLIR)
Metformin
Amylin (SymlinR)
Exenatide (ByettaR)
Weight Loss Surgery
• What surgery would you recommend?
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o
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Lipoplasty
Lap-band
Roux-en-Y (gastric by pass)
Gastric sleeve
Biliarypancreatic diversion
Diabetes Prevention
Lifestyle
Recommendations
• Reduce total caloric intake
• Increase physical activity
• Stop sweetened beverages
• What are the specifics and how do you decide
which he does?
• What is the motivation to make all of these
changes?
Setting Goals for Weight
Loss
• Set reasonable goals
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10% weight loss for first 6 months
500-1000 calories less/day
Decrease 1-2 lb/week
Most patients set goals 2-3 x higher
• Physical activity is important
o More effective in maintaining weight than weight loss
• Resetting goals and diet/exercise is necessary at 6
months and plateaus in weight loss
• Preventing weight gain is an important long-term
goal
NHLBI Obesity Education Initiative: A Practical Guide to Identification, Evaluation,
and Treatment of Overweight and Obesity in Adults, 2000.
Is there any evidence that
lifestyle changes makes a
difference to prevent
diabetes?
Diabetes Prevention
• Diabetes Prevention program
• Finnish Diabetes Trail
• Da Qing trial
Diabetes Prevention: Lifestyle
Trial
Intervention Population Results
Da Qing
IGT study
Diet, PA or
both
Finnish DM
Prevention
Study
Diabetes
Prevention
Trial
Diet
counseling
+ PA
Chinese
Each arm
m/w 45y/o decreased
IGT
DM 3146%
w/m 55y/o D + PA
IGT
decreased
DM 58%
Wt loss +
PA
w/m 51y/o decreased
IGT
DM 58%
The Finnish Diabetes Prevention Study: Lifestyle
Modifications
Incidence of diabetes
(cases/1000 person-years)
Control (n=250)
Diet intervention (n=256)
80
60
40
20
0
Tuomilehto et al. N Engl J Med. 2001;344:1343.
 58%
The Finnish Diabetes Prevention Study:
Lifestyle Modifications
• 522 overweight individuals with IGT randomized to
o Control: diet instruction at the onset of study
o Individualized advice given 7 times in the first year
and every 3 months thereafter with goals of
• Weight loss 5%
• Reducing fat intake to <30% of energy
consumption
• Increasing fiber intake to 15 g/1000 kcal
• Exercising at a moderate level for 30 min/d
• Primary end point: Prevention of diabetes, as assessed
by annual OGTT
Tuomilehto et al. N Engl J Med. 2001;344:1343.
The Finnish Diabetes Prevention Study: Lifestyle
Modifications (cont’d)
Control (n=250)
Weight (kg)
Diet intervention (n=256)
Waist (cm)
SBP (mm Hg) DBP (mm Hg)
Change from baseline
0
-1
-2
-3
-4
-5
-6
P<0.001
Tuomilehto et al. N Engl J Med. 2001;344:1343.
P<0.001
P=0.007
P=0.02
The Diabetes Prevention Program
A Randomized Clinical Trial
to Prevent Type 2 Diabetes
in Persons at High Risk
Sponsored by the NIDDK, NIA, NICHD, NIH, IHS, CDC,
ADA, and other agencies and corporations
Diabetes Prevention Program:
Primary Objectives
• Compare safety and efficacy of 4 interventions for
preventing or delaying development of diabetes
o Standard lifestyle recommendations + masked
metformin titrated to 850 mg bid or troglitazone
400 mg/d
o Standard lifestyle recommendations + masked
placebo
o Intensive lifestyle intervention by case managers
with goals of
– 7% weight reduction through healthy eating and
physical activity
– 150 min/wk moderate intensity physical activity
The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623.
Diabetes Prevention Program:
Achievement of Study Goals
Average follow-up of 2.8 years
Goal
Lifestyle modifications
Weight loss
Physical activity
(min/wk)
7%
150
Pharmacologic intervention
Compliance
80%
Full dose
2 tablets/d
% Achieving Goal
Week 24
50%
74%
Last visit
38%
58%
Placebo
77%
97%
Metformin
72%
84%
The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.
Diabetes Prevention Program:
Effects on Weight and Dietary Intake
Wt change (kg)
Placebo Met
-0.1
-2.
Change in fat intake*
(% of total calories)-0.8
-0.8
Change in energy intake
(kcal/d) at 1 year -249-296
Lifestyle
Inter.
-5.6
P Value
<0.001
-6.6
<0.001
-450
<0.001
*Baseline fat intake was 34.1% of total calories.
The goal of intensive lifestyle modification was <25% of total calories.
The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.
Diabetes Prevention Program:
Progression to Type 2 Diabetes
Cases/100 person-years
Average follow-up of 2.8 years
12
10
 31%*
8
 58%*
6
4
2
0
Placebo
Metformin
Intensive
lifestyle
*All pairwise comparisons significantly different by group; sequential log-rank test.
The Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393.
Diabetes Treatment in
Obese Adults
Look AHEAD Trial
• Randomized trial 5,145 obese adults diagnosed with
type 2 DM
o Randomized to intensive lifestyle intervention
• Goal >7% initial weight loss
• 175 minutes per week physical activity
o Outcomes
• Fatal MI, CVA, non fatal MI
• 11.5 years of follow up
LOOK AHEAD Results
• One year results
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Weight loss 8.6% vs 0.7% (p<0.001)
Fitness improved 20.9% vs 5.8% (p<0.001)
A1c improved 0.7% vs 0.1% (p<0.001)
Lipids, bp, urine albumin/creatinine ratio all improved
(p<0.01)
Look AHEAD: Diabetes Care 2007. 30(6):1374-1383
Medications to Prevent
Diabetes
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Diabetes Prevention Program
Tripod trial/Pipod trial
Stop NIDDM
Xenidos Study
Diabetes Prevention: Medications
Diabetes
Prevention
Program
TRIPOD
STOPNIDDM
XENIDOS
study
Heymsfield et
al
Met vs
Placebo
Trog. vs.
Placebo*
Acarbose
vs plac.
Orlistat vs
placebo*
Orlistat
vs
Placebo
*
W/M 51y/o
IFG or IGT
Hispanic W w/m 56y/o
35y/o
IGT
Hx GDM
BMI >30
w/m 43y/o
IGT/ norm
w/m 44
y/o
BMI 3043
Met decr. DM
31%
Trog.decr.
55%*
Orlistat decr. Orlistat
37%
decr.
60%
Acarbose
decr. 24%
What works better to treat
diabetes and obesitymedications or surgery?
Surgery vs Meds in obese
adults with T2DM
• 150 obese adults with type 2 DM
o Intensive medical therapy
o Roux-en-Y
o Sleeve gastrectomy
• Primary outcome
o % patients with HgA1c < 6%
• Secondary outcomes
o Weight loss
o Lab values
Schauer et al NEJM March 2012
Surgery vs Meds Results
• Primary outcome achieved at 1 year
o 12% of medication group (p=0.008 vs surgeries)
o 37% of sleeve gastectomy
o 42% of Roux-en-Y
• Secondary outcomes
o Weight loss surgery groups better (p<0.01)
• 24.7-27.5% vs 5.2% (p <0.001)
o Reduced medications
• Surgery better (p<0.01)
Schauer et al NEJM March 2012
Surgical Therapies for Obesity
• Restrictive Procedures
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Laparoscopic Adjustable Gastric Banding
Vertical Banded Gastroplasty
Silastic Ring Gastroplasty
Roux-en-Y Gastric Bypass*
• Malabsorptive Procedures
o Biliopancreatic Diversion
o Duodenal Switch
o Roux-en-Y Gastric Bypass*
*Considered both restrictive and malabsorptive
Primary Care Perspective on Bariatric Surgery
Mayo Clinic Proceedings, 2004.
Weight Loss Surgeries
Treatment of Combined
Obesity and Diabetes
Metabolic Effects of
Agents
Med
SU/
glinide
Wt gain
xx
MET
DPP- AGI
4
Colesev Bromoc
elam
riptine
x
x
xxx
Neutral
Wt loss
TZD
x
x
x
Metabolic Effects of
Medications
Weight loss
GLP-1 RA
Amylin
xx
x
Insulin
Neutral
Weight loss
xx
Summary
• Obesity and type 2 diabetes are intimately related
• Treating obesity can prevent diabetes
• Diabetes treatments should be selected with effects
on weight in mind
• Aggressive management of weight is important
even once diagnosed with type 2 diabetes
• Insulin while necessary in type 1 DM can contribute
to insulin resistance