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 G

2、ives 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 evalua

3、tion, 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

4、. 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 bloo

5、d pressure$296 billion$152 billion$116 billion$58 billion$412 billion$210 billion*Note: these figures may not account for potential overlap.Sources: 2008 statistics from the American Diabetes Association and American Heart Association.CardiovascularDiseaseDiabetesTOTALEstimated DirectMedical CostsEs

6、timated Indirect Costs(disability, work loss, premature mortality)Abnormal Lipid MetabolismLDL ApoB HDL Trigly. Cardiometabolic RiskGlobal Diabetes / CVD RiskOverweight / ObesityInflammation HypercoagulationHypertensionSmokingPhysical InactivityUnhealthy EatingAge, Race, Gender, Family History Gluco

7、se BP LipidsAgeGeneticsInsulin Resistance?AgeRace/ethnicityGenderFamily historyOverweightAbnormal lipid metabolismInflammation, hypercoagulationHypertensionSmokingPhysical inactivityUnhealthy dietInsulin resistance 47-year-old African American man, hasnt seen doctor in years Works as a truck driver,

8、 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/m Family history of HTN and diabetesAge47Race/ethnicityAfrican AmericanGenderMaleFamily historyHTN and diabetesOverweight/obesityBMI = 29Abnormal lipid metab T

9、C = 210HypertensionBP = 146/86Smoking1 pack per dayPhysical InactivityYesUnhealthy dietFast food dietNumberCenters 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 Healt

10、h and Human Services,Centers for Disease Control and Prevention, 2005.800,000600,000400,000200,0000Age Group20-3940-5960+Centers for Disease Control & Prevention, Division for Heart Disease andStroke Prevention, Addressing the Nations Leading Killers: At A Glance 2007 DiagnosedDiabetesSmokingHigh Bl

11、oodPressureHigh TotalCholesterol1960-19621971-19751976-19801988-19941999-2000Centers 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 f

12、or Disease Control and Prevention, 2005.Hispanic/Latino 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

13、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).Healthy BG FPG 85th percentile for age and s

14、ex, 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 GDMTesting should be considered in all overweigh

15、t 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)ContinuedHDL cholesterol level 250 mg/dl (2.82 mmol/l)W

16、omen with polycystic ovarian syndrome (PCOS)IGT or IFG on previous 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 ye

17、ars3. 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.0123CHD mortality, per 1000Fontbonne AM, et al. Diabetes Care. 1991;14:461-4

18、69.Quintiles (pmol) of fasting plasma insulinP.01Insulin Sensitive Insulin Resistant(n=943) 29 30-50 51-72 73-114 115Insulin SensitivityInsulin SecretionAssociated Risk Factors Hypertension DyslipidemiaAtherogenesisMicrovascularComplications Type 2 DiabetesAge (years)Fasting Blood Glucose Cardiometa

19、bolic RiskDiabetes Impaired Fasting GlucoseEuglycemiaCardiometabolic Risk FactorsDesired 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.Abnor

20、mal lipid metabolismHigh LDL cholesterolLow HDL cholesterolHigh triglyceridesSource: NHLBI, 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:

21、 NHLBI, JNC7140/90 mm/Hg or 130/80 mm/Hg for people with diabetes(Ideal is less than 120/80 mm/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

22、 weight for age, sex, and height.Measure BMI routinely at each regular check-up. Classifications:BMI 18.5-24.9 = 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 Ev

23、idence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health. Large waist circumference (WC) can 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 Mea

24、sure WC in addition to BMIKlein, et al. Waist Circumference and Cardiometabolic Risk. Diabetes Care. 2007 0: dc07-9921v1-0.PrimaryMetabolicDisturbanceIntermediate Vascular Disease Risk Factor IntravascularPathologyClinicalEventAtherosclerosisHypercoagulability Coronary arteries Carotid arteries Cere

25、bral arteries Aorta Peripheral arteriesHypertensionDyslipidemiaHyperinsulinemiaHyperglycemiaInflammationImpairedFibrinolysisEndothelial DysfunctionInsulin ResistanceCVDDespres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887. Overnutrition100 110-129 130+ 110 110-129 130

26、+010015020025030050125200267105121128*Metropolitan Relative Weight percent (percentage of desirable weight)Hubert HB et al. Circulation. 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 star

27、ting weight)Target 1-2 pound/week weight lossIncrease physical activityHealthy dietDiabetes Prevention ProgramDASH dietClinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National In

28、stitutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:21652171, 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 2004Consider pharmacologic treatmentBMI 30 with no

29、 related risk factors or diseases, orBMI 27 with related risk factors or diseasesAs 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

30、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 Desirable Less than 200 mg/dL Borderline high risk 200239 mg/dL High risk 240 mg/dL and overAmerican Diabetes Associ

31、ation. Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes CenterIncreased: Triglycerides VLDL LDL and small dense LDL ApoBDecreased: HDL Apo A-IAmerican Diabetes Association. Diabetes Care. 2007;30:S4-41. Cigare

32、tte 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 preferred to gauge the patients total cholesterol, LDL-C, HDL-C and triglycerides Treatment prioritiesCategory of riskLD

33、L-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 70 mg/dL or lower may be idealLDL-C-lowering Improve glucose control if diabetes is present Weight loss i

34、f 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 in

35、clude hypertension; HDL 45 years old; female 55 years old; smoking.MenWomenn=5,127Triglyceride Level, mg/dL50100150200250300350400Relative Risk0123Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiology. 1992;70:3H-9H. Reaven GM, et al. J Clin Invest. 1993;9

36、2:141-146.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)HDL-C (mg/dL)Risk of CHDGordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High densit

37、y 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 American Cancer Society, the American Diabetes Association, and the American Heart

38、 Association. CirculationThird 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

39、 Institutes of Health. NIH Publication No. 01-3670, May 2001Total200 mg/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.

40、 2007;30:S4-41.Pharmacologic treatment: primary goal is LDL loweringWithout overt 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

41、 is associated with fewer cardiovascular events in patients with clinical CVD, low HDL, 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 seat

42、ed after 5 min rest in office Persons with DiabetesBP should be measured at each regular 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

43、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-f

44、at dairy Low in saturated and trans fat, cholesterol Physical Activity Weight loss, if applicableThe 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

45、 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.MicrovascularRenal diseaseAutonomic neuropathyEye disease (glaucoma, retinopathy with potential blindness)MacrovascularCardiac

46、diseaseCerebrovascular diseaseReduced survival and recovery rates from strokePeripheral 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*Exerci

47、se, 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 25:21652171, 2002.Guidelines Fit into daily routine Aim for at least 150 minutes/week of moderat

48、e 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

49、lipid levels Lower blood pressure Weight control Improved blood glucose control Reduced risk of CVD 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

50、 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. D

51、iabetes 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 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

52、)Never Smoked1Ex-Smoker1.08 (0.75 - 1.54)Current Smoker1.58 (1.11 - 2.25)Obtain documentation of history of tobacco useAsk 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

53、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 behavior

54、al intervention Online guide to quitting: American Diabetes Association. Diabetes Care. 2004;27:S27:S74-S75.Proinflammatory/prothrombotic factors underlie cardiometabolic riskInflammation is a major component of atherogenesis and other cardiometabolic problemsObesity is associated with inflammationR

55、oss 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-

56、reactive protein. Circulation. 2002;106:2908-2912.High-sensitivity CRP tests may be used to further evaluate underlying risk Relative risk categoriesLow risk3 mg/LAspirin and statins reduce CRP levelsUnclear whether CRP should be a treatment target Reduce weightRoss R. Atherosclerosis: an inflammato

57、ry disease. N Engl J Med.1999;340:115- 126. Ballantyne CH.Pre-DiabetesPre-diabetes is an important risk factor for future diabetes and cardiovascular diseaseRecent studies have shown that lifestyle modification can reduce the rate of progression from pre-diabetes to diabetesAmerican 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 1Fasting Plas