1、-Insert HereSpeaker Titleand AffiliationA comprehensive approach to patient care;Multiple disease pathways and risk factors are considered to facilitate earlier interventionEarly assessment and targeted intervention are needed to treat and prevent all risk factors associated with CVD and diabetes Gi
2、ves a comprehensive picture of a patients health and potential risk for future disease and complicationsIs inclusive of all risks related to metabolic changes associated with CVDAccommodates emerging risk factors as useful predictive toolsFocuses clinical attention to the value of systematic evaluat
3、ion,education,disease prevention and treatmentSupports an integrated approach to careKahn,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.Abnormal
4、 Lipid MetabolismLDL ApoB HDL Trigly.Cardiometabolic RiskGlobal Diabetes/CVD RiskOverweight/ObesityInflammation HypercoagulationHypertensionSmokingPhysical InactivityUnhealthy EatingAge,Race,Gender,Family History Glucose BP LipidsAgeGeneticsInsulin Resistance?AgeRace/ethnicityGenderFamily historyOve
5、rweightAbnormal lipid metabolismInflammation,hypercoagulationHypertensionSmokingPhysical inactivityUnhealthy dietInsulin resistance 47-year-old African American man,hasnt 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,
6、total cholesterol=210 Weight=230 lbs;BMI=29 kg/m Family history of HTN and diabetesAge47Race/ethnicityAfrican AmericanGenderMaleFamily historyHTN and diabetesOverweight/obesityBMI=29Abnormal lipid metab TC=210HypertensionBP=146/86Smoking1 pack per dayPhysical InactivityYesUnhealthy dietFast food die
7、tNumberCenters 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,2005.800,000600,000400,000200,0000Age Group
8、20-3940-5960+Centers for Disease Control&Prevention,Division for Heart Disease andStroke Prevention,Addressing the Nations Leading Killers:At A Glance 2007 33.628.227.219.017.030.833.126.314.939.236.029.326.41.83.53.44.65.014.8DiagnosedDiabetesSmokingHigh BloodPressureHigh TotalCholesterol1960-19621
9、971-19751976-19801988-19941999-2000Centers 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/L
10、atino AmericansNon-Hispanic WhitesAmerican Indians/Alaska NativesNon-Hispanic Blacks06421281020141618 Overweight/fat distribution Age Genetic predisposition Activity level Medications Puberty Pregnancy Impaired Fasting Glucose(IFG):a condition in which the blood glucose level is between 100 mg/dL to
11、 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).Healthy BG FPG 85th percentile for age and sex,weight for height 85th percentile,or weight 120 percent
12、 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 GDMTesting should be considered in all overweight adults (BMI 25 kg/m2*)and have additional risk factors:Physi
13、cal 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)ContinuedHDL cholesterol level 250 mg/dl(2.82 mmol/l)Women with polycystic ovarian syndrome(PCOS)IGT or IFG on previous
14、testingOther clinical conditions associated with insulin resistance(e.g.,severe obesity and acanthosis nigricans)History of CVD2.In the absence of the above criteria,testing for pre-diabetes and diabetes should begin at age 45 years3.If results are normal,testing should be repeated at least at 3-yea
15、r intervals,with consideration of more frequent testing depending on initial results and risk status.*At-risk BMI may be lower in some ethnic groups.0123CHD mortality,per 1000Fontbonne AM,et al.Diabetes Care.1991;14:461-469.Quintiles(pmol)of fasting plasma insulinP.01Insulin Sensitive Insulin Resist
16、ant(n=943)29 30-50 51-72 73-114 115Insulin SensitivityInsulin SecretionAssociated Risk Factors Hypertension DyslipidemiaAtherogenesisMicrovascularComplications Type 2 DiabetesAge(years)Fasting Blood Glucose Cardiometabolic RiskDiabetes Impaired Fasting GlucoseEuglycemiaCardiometabolic Risk FactorsDe
17、sired Goals for Healthy PatientsOverweight/obesitySource:CDC,ADAPrevention of overweight/obesity as measured by BMI(normal=18.524.9).In those who are overweight/obese,the goal is to lose 57%of body weight.Abnormal lipid metabolismHigh LDL cholesterolLow HDL cholesterolHigh triglyceridesSource:NHLBI,
18、ATP III Guidelines,ADADesirable 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/dLHypertensionSource:NHLBI,JNC7140/90 mm/Hg or 130/80 mm/Hg for people with diabetes(Ideal is less than 120/80 mm/
19、Hg)Fasting blood glucoseSource:ADABelow 100 mg/dLPhysical inactivity Source:CDCAt least 30 minutes of moderate activity most daysSmoking Source:ADAQuit or never startChildren Source:ADAMaintain healthy weight for age,sex,and height.Measure BMI routinely at each regular check-up.Classifications:BMI 1
20、8.5-24.9=normalBMI 25-29.9=overweightBMI 30-39.9=obesityBMI 40=extreme obesityClinical 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)c
21、an identify some at increased risk over BMI aloneIf BMI and other cardiometabolic risk factors are assessed,currently there is insufficient evidence to:Substitute WC for BMI Measure WC in addition to BMIKlein,et al.Waist Circumference and Cardiometabolic Risk.Diabetes Care.2007 0:dc07-9921v1-0.Prima
22、ryMetabolicDisturbanceIntermediate Vascular Disease Risk Factor IntravascularPathologyClinicalEventAtherosclerosisHypercoagulability Coronary arteries Carotid arteries Cerebral arteries Aorta Peripheral arteriesHypertensionDyslipidemiaHyperinsulinemiaHyperglycemiaInflammationImpairedFibrinolysisEndo
23、thelial DysfunctionInsulin ResistanceCVDDespres JP,et al.Abdominal obesity and metabolic syndrome.Nature.2006;444:881-887.Overnutrition100 110-129 130+110 110-129 130+010015020025030050125200267105121128*Metropolitan Relative Weight percent(percentage of desirable weight)Hubert HB et al.Circulation.
24、1983;67:968-977MenWomenIncidence of CVDper 1,000n=56 n=75 n=30 n=191 n=199 n=78 Lifestyle modificationReduce caloric intake by 500-1000 kcal/day(depending on starting weight)Target 1-2 pound/week weight lossIncrease physical activityHealthy dietDiabetes Prevention ProgramDASH dietClinical Guidelines
25、 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 25:21652171,2002.The Seventh Report of the Joint National Committee on Prevention
26、,Detection,Evaluation,and Treatment of High Blood Pressure,NIH Publication No.04-5230,August 2004Consider pharmacologic treatmentBMI 30 with no related risk factors or diseases,orBMI 27 with related risk factors or diseasesAs part of a comprehensive weight loss program incl.diet&physical activity Co
27、nsider 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 25:216
28、52171,2002 Desirable Less than 200 mg/dL Borderline high risk 200239 mg/dL High risk 240 mg/dL and overAmerican Diabetes Association.Understanding Cardiometabolic Risk:Broadening Risk Assessment and Management,Dyslipidemia Richard M Bergenstal,MD International Diabetes CenterIncreased:Triglycerides
29、VLDL LDL and small dense LDL ApoBDecreased:HDL Apo A-IAmerican Diabetes Association.Diabetes Care.2007;30:S4-41.Cigarette smoking Hypertension(140/90 mm Hg or on antihypertensive medication)Low HDL-C(20 years of age,cholesterol should be checked every 5 years Ordering a fasting lipid panel is prefer
30、red to gauge the patients total cholesterol,LDL-C,HDL-C and triglycerides Treatment prioritiesCategory of riskLDL-C Goal0-1 risk factor*160 mg/dL or lowerMultiple(2+)risk factors*130 mg/dL or lowerPeople with coronary heart disease or risk equivalent(e.g.,diabetes)100 mg/dL or lowerKnown CAD and DM
31、70 mg/dL or lower may be idealLDL-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 chol
32、esterol(no more than 200 mg daily)diet Pharmacologic treatment frequently necessary Risk factors include hypertension;HDL 45 years old;female 55 years old;smoking.MenWomenn=5,127Triglyceride Level,mg/dL50100150200250300350400Relative Risk00.511.522.53Castelli WP.Epidemiology of triglycerides:a view
33、from Framingham American Journal of Cardiology.1992;70:3H-9H.Reaven GM,et al.J Clin Invest.1993;92:141-146.Mean Steady StatePlasma Glucose(mmol/L)at Identical Plasma InsulinLarger LDL particlepatternIntermediatepatternBSmall LDL particlepattern026101284LDL-Size Phenotype(n=52)(n=19)(n=29)LDL-C(mg/dL
34、)HDL-C(mg/dL)Risk of CHDGordon 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.Preventing Cancer,Cardiovascular Disease,and Diabetes:A Common Agenda for The
35、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/S4Third Report of the National Chol
36、esterol 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 2001Total200 mg
37、/dLLDL40 men mg/dL50 women mg/dLTriglycerides 150 mg/dLLifestyle modificationIncreased physical activityDiet:reduced saturated fat,trans fat,and cholesterolWeight loss,if indicatedAmerican Diabetes Association.Diabetes Care.2007;30:S4-41.Pharmacologic treatment:primary goal is LDL loweringWithout ov
38、ert CVD:If over 40,statin therapy recommended to achieve 30-40%LDL reductionWith overt CVD:All patients should receive statin therapy to achieve 30-40%LDL reductionLowering triglycerides and raising HDL with a fibrate is associated with fewer cardiovascular events in patients with clinical CVD,low H
39、DL,and near-normal LDLAmerican Diabetes Association.Diabetes Care.2007;30:S4-41.Persons without DiabetesBP should be measured at each regular visit or at least once every 2 years if BP 120/80 mmHgBP measured seated after 5 min rest in office Persons with DiabetesBP should be measured at each regular
40、 visit BP measured seated after 5 min rest in officePatients with 130 or 80 mmHg should have BP confirmed on a separate dayPreventing Cancer,Cardiovascular Disease,and Diabetes A Common Agenda for the American Cancer Society,the American Diabetes Association,and the American Heart Association.Circul
41、ation.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 applicableThe Da
42、sh Diet.http:/dashdiet.org.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 potassiu
43、m The Dash Diet.http:/dashdiet.org.American Diabetes Association.Diabetes Care.2007;30:S4-41.MicrovascularRenal diseaseAutonomic neuropathyEye disease(glaucoma,retinopathy with potential blindness)MacrovascularCardiac diseaseCerebrovascular diseaseReduced survival and recovery rates from strokePerip
44、heral vascular diseaseAmerican 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 typ
45、e 2 diabetes*American Diabetes Association.Diabetes Care.2007;30:S4-41.Diabetes Prevention Program Diabetes Care 25:21652171,2002.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)
46、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 CV
47、D Prevent/delay onset of type 2 diabetesAmerican 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 exerc
48、ise 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.R C Turner,H Millns,H A W Neil,I M Stratton,S E Manley,D R Matthews,and R R Hol
49、man.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 Smoked1Ex-Smoker1.08(0.75-1.54)Current Smoker1.58(1.11-2.25)Obtain documentation of history of tobacco useAsk whet
50、her 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 Dia
