Transcript 12:15 PM: Modifying Risk Factors to Prevent Type 2 Diabetes

Modifying Risk Factors to
Prevent Type 2 Diabetes
Sumeet Goel, D.O.
Family Medicine
Stevens Point, WI
Class of 2010
Objectives
Review Diabetes
Review risk factors that lead to diabetes
Discuss how to Modify those risk factors
Discuss pharmacologic and lifestyle options that may maximize outcomes for
patients at risk for developing diabetes
Pre-test Question #1
Which of the following defines diabetes:
1) Fasting glucose of 126 or greater on 2 separate occasions
2) A1c 6.5 or above
3) Random (non-fasting) glucose above 200
4) Oral glucose tolerance test with 2 hour post-prandial above 200
5) All of the above
Pre-test Question #1 (Answer)
Which of the following defines diabetes:
1) Fasting glucose of 126 or greater on 2 separate occasions
2) A1c 6.5 or above
3) Random (non-fasting) glucose above 200
4) Oral glucose tolerance test with 2 hour post-prandial above 200
5) All of the above
Pre-test Question #2
Which of the following defines impaired fasting glucose (pre-diabetes)?
1) Fasting glucose of 100 or greater
2) A1c 6.0 or above
3) Oral glucose tolerance test with 2 hour post-prandial between 140 and 199
4) All of the above
Pre-test Question #2 (Answer)
Which of the following defines impaired fasting glucose (pre-diabetes)?
1) Fasting glucose of 100 or greater
2) A1c 6.0 or above
3) Oral glucose tolerance test with 2 hour post-prandial between 140 and 199
4) All of the above
Introduction
Type 2 Diabetes is Characterized by:
Hyperglycemia
Insulin Resistance
Impairment of Insulin Secretion
Limited ability to predict and prevent Type 2 Diabetes in General Population
Who is most at risk?
Impaired Fasting Glucose/Impaired Glucose Tolerance
Obesity
Family History of Type 2 Diabetes
Certain Ethnic Groups (Asian, Hispanic, African American)
How do we prevent this?
First Step in Management is:
Lifestyle Changes
Tell me more
Lifestyle changes means?
Tell me more
and this?
Tell me more
Stop this?!?!
Stop this?!
I can still do this right?
Stop this?!
But this is legal...
well almost legal…
and not addictive.
Stop this?!
Wait now that’s crossing the line!
Easy fix.
I’ll just take these.
Early Pharmacologic Therapy
Pharmacologic Therapy (primarily metformin)
Clinical Trials have shown some ability to delay onset of diabetes but
impact on CVD risk factors is less clear. (note: how does one define diabetes while
on medication?)
Long-term benefits of early pharmacologic treatment versus withholding
until diabetes develops are unproven.
Neither Lifestyle Changes nor pharmacologic therapy have been shown to
reduce morbidity or mortality in patients at high risk for developing diabetes. That
said, lifestyle changes are generally beneficial and do not have adverse effects.
Lifestyle Modification
Targeted population include those with A1c 5.7 - 6.4 (Impaired Fasting Glucose)
Emphasize benefit of weight loss & increased physical activity
Emphasize quitting smoking
Follow closely with at least annual laboratory evaluation with fasting
glucose and lipid panel (foundation for biometric screening)
Lifestyle Modification
Lifestyle modifications delay onset of diabetes
Changes in diet/exercise show benefit even after progression to diabetes
Importance of these factors is further evidenced when looking at societies that have
undergone westernization and the increase in diabetes prevalence that occurs
Can be marked by increased obesity in society
Diet (without weight loss)
Diet without weight loss does not show benefit for diabetes prevention.
Women’s Health Initiative Dietary Modification Trial (2008)
48,000 postmenopausal women (average age 62) randomly assigned to a
regular diet or a low fat diet (20 percent reduction in caloric intake)
After follow-up 8 years later diabetes prevalence was the same in both
groups and mean weight was about equal in both groups (difference of 2kg between
groups)
This concept is difficult to study and this study had many flaws
Diet (without weight loss)
Mediterranean Diet:
Study in 2011 with 7447 participants (non-randomized)
High risk group cardiovascular group was assigned a low fat control diet
Remainder was assigned mediterranean diet with nuts or with virgin olive
oil
Four year follow-up with lower incidence of diabetes in mediterranean diet
groups (80 and 92 cases versus 101 cases in low fat control group)
Weight and physical activity was equal between groups.
Mediterranean Diet
Eating primarily plant-based foods (fruits, vegetables, whole grains, legumes, nuts)
Replacing Butter with olive oil or other healthy fats
Using Herbs/Spices instead of salt to flavor foods
Limiting Red Meat to less than a few times a month
Eating fish/poultry at least twice weekly
Red wine in moderation (optional)
Diet also recognizes importance of physical activity and enjoying meals with
family/friends
Mediterranean Diet
Has role in heart health, chronic disease prevention, and long-term health benefits
Does not, however, have strong correlation with diabetes prevention
This statement is focused on a dietary change without associated weight loss.
Weight Loss
Weight reduction improves glycemic control and prevents onset of diabetes
Many different trials showing different interventions and their benefits:
Finnish Diabetes Prevention Study
Diabetes Prevention Program
China Da Qing Diabetes Prevention Study
Zensharen Study for Prevention of Lifestyle Disease
Finnish Diabetes Prevention Study
522 Middle-Aged patients (mean age 55 years) with impaired glucose tolerance
were assigned to a weight-reduction and exercise program versus a control group
After 2 years the intervention group lost 3.5kg
Diabetes incidence in intervention group - 11% (23% in control group)
Additional 3 year follow-up without additional intervention showed
reduced diabetes incidence (23% in intervention group versus 38% in control group)
China Da Qing Diabetes Prevention Study
577 adults with impaired glucose tolerance were randomly assigned to a control
group or one of three active intervention groups (diet, exercise, or both)
6 year followup
Intervention group diabetes incidence 72% vs 90%
CV Indicence 12% vs 20%
All cause mortality 28% vs 38%
Zensharen Study for Prevention of
Lifestyle Diseases
641 Overweight Japanese patients with impaired fasting glucose assigned to
diet/exercise program versus control group
After 3 years – incidence of type 2 diabetes showed greatest benefit in
those at greatest risk of diabetes (A1c >5.6%)
No benefit of lifestyle intervention in group with isolated impaired fasting
glucose
Diabetes Prevention Program
Much larger trial – 3,234 patients with impaired glucose tolerance and obesity:
Intensive Lifestyle group (aim reducing weight by 7% with behavioral
modification, low fat diet, exercise 150 minutes per week).
Metformin 850mg bid plus information on diet and exercise
Placebo plus diet and exercise
Diabetes Prevention Program
Intensive lifestyle group: Fewest developed diabetes (14%)
Metformin + diet/exercise: 22%
Placebo plus diet/exercise: 29%
*Lifestyle intervention was effective in men and women in all age and ethnic groups
Diabetes Prevention Program
Average weight loss in intensive intervention group was 15 lbs (7%)
Diabetes prevention was most strongly correlated with weight loss as opposed to
diet and exercise (16% risk reduction for every kilogram reduction in weight)
Smoking
Smoking increases systemic inflammation thereby reducing peripheral receptor
sensitivity
Diabetes risk reduction with smoking cessation varies depending on individual risk
factors
Smoking cessation can be associated with weight gain, however
In general smoking cessation is of paramount importance for diabetes prevention
and obviously to minimize other associated comorbidities
Vitamin D
Several studies show an inverse relationship between circulating 25hydroxyvitamin D levels and Type 2 diabetes risk
I.e. Low Vitamin D increases Type 2 Diabetes Risk
Intervention studies (testing/supplementation) show no effect on glycemic control
Intensive Lifestyle Modifications
Case #1
68 year old patient presents for routine physical exam. He is mildly overweight with
BMI of 27.5 and has a fasting glucose of 104 with a creatinine of 0.8. Family history
has 2nd degree relatives with type 2 diabetes. What would you recommend?
Intensive lifestyle intervention (at least 7% weight loss)
Lifestyle modification (low carb diet)
Metformin therapy with lifestyle modification
Other
Case #2
A 40 year old presents for routine biometric screening. BMI is 34& fasting glucose is
112 with an LDL of 134. He is currently a smoker & both his parents died from
diabetes complications in their 50s. What would you do?
Begin Bariatric Surgery program/Intensive Lifestyle Modifications
Low Glucose Diet
Chantix for Smoking Cessation
Begin Statin or Metformin
Other
Case #2 continued
The same 40 year old presents for routine biometric screening 3 years later. BMI is
greater than 40 & fasting glucose is now 120 with an LDL of 194. He is still a smoker
& both his parents died from diabetes complications in their 50s. What would you
do?
Begin Bariatric Surgery program/Intensive Lifestyle Modifications
Low Glucose Diet
Chantix for Smoking Cessation
Begin Statin or Metformin
Other
Case #3
A 28 year old comes in for an annual physical looking to establish a primary care
doctor. She has significant concern about her future health – notably diabetes. Her
best friend has been struggling with brittle type 1 diabetes and her neighbors are
uncontrolled type 2 diabetics. Her screening labs are unremarkable, BMI is less than
25, and blood pressure is at goal. What do you recommend?
Tell her not to worry about diabetes
Talk about mediterranean diet or other healthy diet choices
Emphasize preventive care, routine screenings, and discuss factors that
would increase her risk
Application to Population Health
Challenge for population health is risk stratification.
This is primary purpose of biometric screenings
Next challenge is an intervention that a patient can actually achieve
7% weight loss and 150 minutes of exercise is not feasible for everyone
How to identify who is mostly likely to succeed
Finding other methods to reduce risk more effectively
Pitfalls of Population Health
Doing what’s best for the patient, not the data
Early adoption of new medication classes:
DPP-4
GLP-1
SGLT-2
Population Health Concerns
There is significant variability in how to utilize data
There are people from numerous points of view using this data in different ways
Statistics can be made to say anything
Individual clinician patient populations are not comparable (n size is not high
enough)
Where population health is going; what the motivations are; and what we can do to
help steer the ship so it doesn’t sink
References
Nathan DM, Berkwits M. Trials that matter: rosiglitazone, ramipril, and the prevention of type 2 diabetes. Ann Intern Med 2007;
146:461.
Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological
study. BMJ 2013; 347:f5577.
Gillett M, Royle P, Snaith A, et al. Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose
regulation: a systematic review and economic evaluation. Health Technol Assess 2012; 16:1.
Selph S, Dana T, Blazina I, et al. Screening for type 2 diabetes mellitus: a systematic review for the U.S. Preventive Services Task
Force. Ann Intern Med 2015; 162:765.
Balk EM, Earley A, Raman G, et al. Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among
Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force. Ann Intern Med 2015.
Tinker LF, Bonds DE, Margolis KL, et al. Low-fat dietary pattern and risk of treated diabetes mellitus in postmenopausal women: the
Women's Health Initiative randomized controlled dietary modification trial. Arch Intern Med 2008; 168:1500.
Salas-Salvadó J, Bulló M, Babio N, et al. Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the
PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care 2011; 34:14.
References
Salas-Salvadó J, Bulló M, Estruch R, et al. Prevention of diabetes with Mediterranean diets: a subgroup analysis of a randomized trial. Ann
Intern Med 2014; 160:1.
Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;
368:1279.
Bennett PH. Epidemiology of diabetes mellitus. In: Ellenberg and Rifkin's Diabetes Mellitus, Rifkin H, Porte D Jr (Eds), Elsevier, New York
1990. p.363.
Collins VR, Dowse GK, Toelupe PM, et al. Increasing prevalence of NIDDM in the Pacific island population of Western Samoa over a 13year period. Diabetes Care 1994; 17:288.
Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N
Engl J Med 2002; 346:393.
Nield L, Summerbell CD, Hooper L, et al. Dietary advice for the prevention of type 2 diabetes mellitus in adults. Cochrane Database Syst
Rev 2008; :CD005102.
Mculloch et al., Prevention of Type 2 Diabetes Mellitus. UpToDate. July 2015.