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Diabetes and Cardiovascular Risk A review Thomas Bodenheimer MD University of California, San Francisco Diabetes and Cardiovascular Risk A review Thomas Bodenheimer MD University of California, San Francisco Department of Family and Community Medicine

Agenda • Mild diabetes: Bertha Goode – – Pathophysiology Diagnosis Management Chronic care model Agenda • Mild diabetes: Bertha Goode – – Pathophysiology Diagnosis Management Chronic care model • Poorly controlled diabetes, hyperlipidemia and hypertension: Dolores Rojas – – Framingham risk score Management of lipids Management of blood pressure Chronic care model • Population management: your entire panel of people with diabetes • Metabolic syndrome: Julio

Bertha Goode • Bertha Goode Is a 35 y. o. African. American woman who Bertha Goode • Bertha Goode Is a 35 y. o. African. American woman who comes to the clinic with weight loss, frequent urination, and thirst • The nurse practitioner, Nancy Rush, suspects diabetes, does a random glucose finger stick and finds a blood sugar of 237

Bertha Goode • Ms. Goode wants to know what diabetes is • She says Bertha Goode • Ms. Goode wants to know what diabetes is • She says her father had diabetes and died of kidney failure • She says she’s determine to “beat that sugar thing” • Nancy Rush spends 45 minutes with her; now she is 1 1/2 hours behind in seeing her morning patients

Pathophysiology of type 2 diabetes • Nancy Rush explains that type 2 diabetes starts Pathophysiology of type 2 diabetes • Nancy Rush explains that type 2 diabetes starts with insulin resistance • Insulin is required for sugar in the blood to go into the cells (brain, muscle, heart) where sugar is needed for energy • Insulin resistance means that the insulin is less effective in moving sugar into the cells

Pathophysiology of type 2 diabetes • Insulin resistance: It takes more insulin to move Pathophysiology of type 2 diabetes • Insulin resistance: It takes more insulin to move sugar from the blood into the cells • The beta cells of the pancreas have to constantly secrete more insulin • If you measure insulin in the blood, people with insulin resistance have higher insulin levels • Bertha Goode wants to know if insulin resistance is the same as diabetes

Pathophysiology of type 2 diabetes • Nancy Rush explains that people with insulin resistance Pathophysiology of type 2 diabetes • Nancy Rush explains that people with insulin resistance get diabetes only if the beta-cells of the pancreas are unable to keep producing enough insulin • In people with insulin resistance, the beta-cells are working harder year after year to produce the additional insulin needed to move the sugar into the cells • In many people with insulin resistance, the beta-cells poop out, are unable to produce enough insulin, and the person develops diabetes • Insulin resistance + insulin deficiency = type 2 diabetes

Insulin Resistance and Insulin Deficiency Insulin Resistance Insulin Deficiency Hyperglycemia Insulin Resistance and Insulin Deficiency Insulin Resistance Insulin Deficiency Hyperglycemia

Natural History of Type 2 Diabetes Glucose (mg/d. L) 350 Post Meal Glucose 300 Natural History of Type 2 Diabetes Glucose (mg/d. L) 350 Post Meal Glucose 300 250 Fasting Glucose 200 150 100 Relative function 50 Insulin Resistance 250 200 150 Progressive reduction in beta cell mass 100 Insulin Response Diabetes diagnosis Pre Diabetes (IFG, IGT) Metabolic Syndrome 50 0 -15 -10 -5 0 5 Onset Diabetes Kendall DM, Bergenstal RM © 2004 International Diabetes Center, Minneapolis, MN All rights reserved. 10 Years 15 20 25 30

Type 2 Diabetes is a Progressive Disease Median Hb. A 1 c (%) 9 Type 2 Diabetes is a Progressive Disease Median Hb. A 1 c (%) 9 8 7 6 0 UKPDS 34, Lancet 1998. 2 Years 4 6 8 10

Type 2 Diabetes as a “Syndrome” Hyperglycemia IFG/IGT Type 2 diabetes Hypertension Dyslipidemia Microalbuminuria Type 2 Diabetes as a “Syndrome” Hyperglycemia IFG/IGT Type 2 diabetes Hypertension Dyslipidemia Microalbuminuria LDL Trigs HDL Insulin Resistance Central obesity Abnormal vascular behavior Thrombotic risk Vascular inflammation Kendall DM and Harmel AP. Am J Manag Care 2002; 8: S 635–S 653.

Criteria for Diagnosis of Type 2 Diabetes Random blood sugar > 200 mg/dl OR Criteria for Diagnosis of Type 2 Diabetes Random blood sugar > 200 mg/dl OR Fasting blood sugar > 126 mg/dl OR 2 hr blood sugar after 75 gm oral glucose > 200 mg/dl Testing should be repeated on a separate day Fasting blood sugar is preferred test

Categories of Fasting Blood Sugar Category FBS (mg/dl) Normal < 100 Impaired (IFG) 100 Categories of Fasting Blood Sugar Category FBS (mg/dl) Normal < 100 Impaired (IFG) 100 - 125 Diabetes 126 Blood sugar = blood glucose = plasma glucose

Initial management • Patient education in the ADA 26 domains of diabetes knowledge and Initial management • Patient education in the ADA 26 domains of diabetes knowledge and skills • Set specific goals for starting achievable lifestyle changes for diet and exercise • Bertha Goode says she will start by drinking no more sodas and drinking water instead. She says at the next visit she will set an exercise goal

Initial management: ADA: 26 domains of skills/knowledge • • • 1. All About Pre-Diabetes Initial management: ADA: 26 domains of skills/knowledge • • • 1. All About Pre-Diabetes 2. Getting the Best Care for Your Diabetes 3. Taking Care of Type 2 Diabetes • • • 4. All About Your Blood Glucose 5. All About Insulin Resistance 6. Protect Your Heart: Wise Food Choices 7. Protect Your Heart: Choose Fats Wisely 8. Protect Your Heart: Heart Healthy Foods 9. Protect your Heart: Check Food Labels 10. All About Carbohydrate Counting 11. Protect Your Heart by Losing Weight 12. All About Physical Activity • 13. Getting Started with Physical Activity • • • • 14. Learning How to Change Habits 15. Recognizing and Handling Depression 16. Treating High Blood Pressure 17. Treating High Cholesterol 18. Taking Care of Your Heart 19. Know Warning Signs of a Heart Attack 20. Taking Aspirin to Protect Your Heart 21. All About Stroke 22. All About Peripheral Arterial Disease 23. Tests for Heart and Blood Vessel Disease 24. Managing Your Medicines 25. Food and Activity Tracker 26. Blood Glucose Log Use Ask-Tell-Ask

Medication management • Bertha Goode says she never wants to take pills. Nancy Rush Medication management • Bertha Goode says she never wants to take pills. Nancy Rush explains that if lifestyle changes don’t work, she will recommend medications. • Most people start with metformin unless elevated creatinine or other contraindications. Start low dose because of GI side effects • Add other medications as needed • Most people with type 2 diabetes, if they live long enough, will eventually have serious beta cell failure and will need insulin

Matching Pharmacology to Pathophysiology Block absorption of glucose from food Reduce glucose output from Matching Pharmacology to Pathophysiology Block absorption of glucose from food Reduce glucose output from liver -Glucosidase Inhibitors Acarbose (Precose) Sulfonylureas Glyburide, Glipizide Hyperglycemia Metformin Glitazones (Actos, Avandia) Metformin Reduce insulin resistance, thereby making it easier for glucose to move from blood into cells Increase insulin from pancreas

ADA Treatment Guidelines: 2004 goals • • • Fasting blood sugar: 90 -130 mg/dl ADA Treatment Guidelines: 2004 goals • • • Fasting blood sugar: 90 -130 mg/dl Hb. A 1 C: <7% 2 hr postprandial BG: <180 LDL cholesterol: <100 (high risk < 70) Blood Pressure: <130/80 Individualize care: maintain an A 1 C level as close to normal as is safely possible. As A 1 c goes down, risk of hypoglycemia goes up www. diabetes. org

Hemoglobin A 1 c • Ms. Goode wants to know what that “hemoglobin thing” Hemoglobin A 1 c • Ms. Goode wants to know what that “hemoglobin thing” is • Blood sugar binds to the hemoglobin molecule in the red blood cell • You can measure the amount of sugar bound to hemoglobin with the lab test Hb. A 1 c • Because the red blood cell lives an average of 3 -4 months, the Hb. A 1 c is an indication of the average blood sugar over the past 3 -4 months

Relative Risk of Complications Benefits of Lowering Hemoglobin A 1 c 16 12 8 Relative Risk of Complications Benefits of Lowering Hemoglobin A 1 c 16 12 8 4 0 Hemoglobin A 1 c 6 7 8 9 10 11 12 Average Glucose 120 150 180 210 240 270 300 Adapted from: Skyler JS. J Clin Endo Metab 1996 UKPDS 33: Lancet 1998; 352, 837 -853. UKPDS 33: Lancet DCCT Study Group. N Engl J Med 329: 977, 1993 DCCT Study Group. Med 329: 977, 1993

Lowering Hb. A 1 c: risk and benefit 120 20 100 Relative Risk for Lowering Hb. A 1 c: risk and benefit 120 20 100 Relative Risk for Progression of Retinopathy 80 Rate of Severe Hypoglycemia 60 (per 100 patientyears) 40 20 0 0 5. 5 6. 0 6. 5 7. 0 7. 5 8. 0 8. 5 9. 0 9. 5 10 10. 5 Hb. A 1 c (%) DCCT. NEJM. 1993; 329: 977 -986

Routine care guidelines • • • BP, weight, foot exam every visit Hb. A Routine care guidelines • • • BP, weight, foot exam every visit Hb. A 1 c every 6 months if stable, every 3 months if not stable Lipid panel, urine microalbumin every year Dilated eye exam every year Dental exam/cleanining at least twice a year Assess knowledge of diabetes, diet issues, physical activity, and set achievable goals at least once a year Aspirin 81 mg/day or 325 mg every other if moderate/high risk Smoking cessation advice every visit if needed Flu shot every year and pneumococcal immunization at least once in lifetime with repeat for higher-risk patients www. diabetes. org

2004 Revisions to ADA Guidelines 2004 Revisions to ADA Guidelines "Standards of Medical Care in Diabetes” www. diabetes. org · Glycemic control: A normal Hb. A 1 C <6% can be considered in individual patients · Lipid management: In people with diabetes over the age of 40 with a total cholesterol >135 mg/dl, statin therapy to reduce LDL regardless of baseline LDL levels may be appropriate. · Retinopathy: Consider less frequent exams in low-risk patients on the advice of an eye care professional (Diabetes Care, January, 2004)

Chronic Care Model components needed • Patient self-management • Clinical information system: reminders for Chronic Care Model components needed • Patient self-management • Clinical information system: reminders for clinicians and for patients • Delivery system redesign to create a team • Decision support to make sure the caregivers know best practice guidelines • Use community resources • Health system organization

Self-management: Disease-specific information • • • 1. All About Pre-Diabetes 2. Getting the Best Self-management: Disease-specific information • • • 1. All About Pre-Diabetes 2. Getting the Best Care for Your Diabetes 3. Taking Care of Type 2 Diabetes • • • 4. All About Your Blood Glucose 5. All About Insulin Resistance 6. Protect Your Heart: Wise Food Choices 7. Protect Your Heart: Choose Fats Wisely 8. Protect Your Heart: Heart Healthy Foods 9. Protect your Heart: Check Food Labels 10. All About Carbohydrate Counting 11. Protect Your Heart by Losing Weight 12. All About Physical Activity • 13. Getting Started with Physical Activity • • • • 14. Learning How to Change Habits 15. Recognizing and Handling Depression 16. Treating High Blood Pressure 17. Treating High Cholesterol 18. Taking Care of Your Heart 19. Know Warning Signs of a Heart Attack 20. Taking Aspirin to Protect Your Heart 21. All About Stroke 22. All About Peripheral Arterial Disease 23. Tests for Heart and Blood Vessel Disease 24. Managing Your Medicines 25. Food and Activity Tracker 26. Blood Glucose Log

Self-management: collaborative decision-making • Informed patient by itself does not improve clinical outcomes; an Self-management: collaborative decision-making • Informed patient by itself does not improve clinical outcomes; an additional factor is needed • That additional factor appears to be collaborative decision making, which makes the patient an active participant in his/her management • Nancy Rush promised to make Ms. Goode a run chart of her Hb. A 1 c to increase her involvement in her own care Norris et al. Diab Care 2001; 24: 561. Hunt et al. J Fam Pract 1998; 46: 207. Piette et al. JIM 2003; 18: 624. Korsch et al. N Engl J Med 1969; 280: 535.

Bertha Goode’s diabetes run chart: hemoglobin A 1 c Bertha Goode’s diabetes run chart: hemoglobin A 1 c

Self-management: Goal-setting • One aspect of collaborative decisionmaking is goal-setting, which means making an Self-management: Goal-setting • One aspect of collaborative decisionmaking is goal-setting, which means making an action plan that is easily achievable • Remember Bertha Goode’s first action plan: to stop drinking sodas and drink water instead. • She did not promise to lose 20 pounds in a month, which is not achievable

Reminder system for clinicians and for patients • Nancy Rush created a reminder prompt Reminder system for clinicians and for patients • Nancy Rush created a reminder prompt sheet (or pop-up on electronic medical record) so that at each visit, it is easy to see which tests/ procedures/check up on action plans are needed • Evidence is clear that reminder prompts improve diabetes care • Sending patients reminders (e. g. it is time to get your lab tests) also works

Clinical information system • Diabetes registry is by far the most effective way to Clinical information system • Diabetes registry is by far the most effective way to create reminder prompt

Delivery system redesign to create a team • Studies show that physicians often ignore Delivery system redesign to create a team • Studies show that physicians often ignore reminder prompts due to lack of time • Nancy Rush created a team with training and a clear division of labor. The team decided that the medical assistant would use the reminder prompt and order the tests indicated. This was done via standing orders from the medical director

Delivery system redesign to create a team • Physicians also do not have time Delivery system redesign to create a team • Physicians also do not have time to do patient education in the ADA 26 categories, nor to do goal-setting and problem-solving about the patient’s goals • Team needs health educator or diabetestrained nurse • Medical assistants can be trained to do goal-setting and problem-solving with patient

Decision support • To make sure physicians and others on the team know up-to-date Decision support • To make sure physicians and others on the team know up-to-date diabetes guidelines, it is best to have those guidelines embedded in the reminder prompts or in a diabetes and cardiovascular risk reduction progress note

Community resources • Nancy Rush’s practice does not have a health educator or diabetes Community resources • Nancy Rush’s practice does not have a health educator or diabetes nurse. She made arrangements for Bertha Goode to see the diabetes educator at a nearby hospital • She has been planning to make a resource guide of exercise programs in the community, but hasn’t had time. Bertha Goode said that she could do that for herself and other patients with diabetes • Sometimes patients are the most valuable community resource, but we seldom ask them to use their time and skills to help

Health system organization • In order to make all those care processes happen, to Health system organization • In order to make all those care processes happen, to improve diabetes care, the larger health system must – Help provide resources – Reward these processes by paying for them

Dolores Rojas • 47 year old Latina woman, smoker • Family history: father had Dolores Rojas • 47 year old Latina woman, smoker • Family history: father had diabetes and died of heart attack age 45 • Ms. Rojas had diabetes for 8 years, with Hb. A 1 c running between 9 and 13. Has not been to clinic for 2 years because went to Mexico to help her sick mother • Has FBS 350, BP 164/95, Cholesterol 260, LDL 155, HDL 30, BMI 28 (normal <25), urine microalbumin 80, creatinine 1. 2 • No history of cardiac symptoms, normal EKG

What should be her initial management? • • Patient education Goal setting for lifestyle What should be her initial management? • • Patient education Goal setting for lifestyle changes Metformin for blood sugar Ace inhibitor for blood pressure and for kidney protection Statin for cholesterol If blood pressure not controlled, add HCTZ or beta blocker Aspirin for cardioprotection All this has to be negotiated with Ms. Rojas, because she is unlikely to accept this entire regimen

Framingham Risk Score • Data from the Framingham Heart Study to estimate risk of Framingham Risk Score • Data from the Framingham Heart Study to estimate risk of having a heart attack or death from coronary heart disease within 10 years – – – – Age Gender Total Cholesterol HDL Cholesterol Current Smoker Systolic Blood Pressure Currently on any medication to treat high blood pressure Note: Some Framingham score sheets use total and HDL cholesterol, others use LDL and HDL cholesterol Circulation 1998; 97: 1837 -1847.

Framingham Risk Score point system • – – • • Age 30 -34 35 Framingham Risk Score point system • – – • • Age 30 -34 35 -39 40 -44 70 -74 Systolic blood pressure – – -1 0 1 7 < 130 -139 140 -159 > 160 0 1 2 3 HDL – – < 35 35 -44 45 -59 >60 2 1 0 -1 • Smoker – Yes – No 2 0 The more points, the greater risk

Dolores Rojas • Smoker, high cholesterol, hypertension, diabetes, age 47 • She has Framingham Dolores Rojas • Smoker, high cholesterol, hypertension, diabetes, age 47 • She has Framingham risk score of 18%. This puts her at intermediate risk (1020%) of a heart attack or coronary death within 10 years. She is very close to being at high risk (> 20%).

Tobacco Treating tobacco use and dependence. A clinical practice guideline U. S. Department of Tobacco Treating tobacco use and dependence. A clinical practice guideline U. S. Department of Health and Human Services, Public Health Services. Treating tobacco use and dependence. Rockville (MD): U. S. Department of Health and Human Services, Public Health Service; 2000 Jun. 197 p. [311 references] Available on www. guidelines. gov Key word to search for: Smoking cessation

Hyperlipidemia Hyperlipidemia

Major Risk Factors That Modify LDL Goals • Cigarette smoking • Hypertension (BP 140/90 Major Risk Factors That Modify LDL Goals • Cigarette smoking • Hypertension (BP 140/90 mm. Hg or on antihypertensive medication) • Low HDL cholesterol (<40 mg/d. L)† • Family history of premature CHD – CHD in male first degree relative <55 years – CHD in female first degree relative <65 years • Age (men 45 years; women 55 years) † HDL cholesterol 60 mg/d. L counts as a “negative” risk factor; its presence removes one risk factor from the total count.

Framingham and ATP III • Unfortunately, the risk categories are different between Framingham and Framingham and ATP III • Unfortunately, the risk categories are different between Framingham and ATP III • How about putting everything into one algorithm! • Framingham risk is for people who do not have diabetes or coronary heart disease • ATP III risk is for people with and without diabetes, with and without coronary heart disease

National Cholesterol Education Project Adult Treatment Panel III (ATP III) • ATP III came National Cholesterol Education Project Adult Treatment Panel III (ATP III) • ATP III came out in 2001. In 2004, LDL goal recommendations were lowered. Current goals [Circulation 2004; 110: 227 -239] • Very high-risk: Coronary heart disease plus other risk factors such as diabetes, continued smoking, or metabolic syndrome. Also history of hospitalization for heart attack. • Goal: LDL > 70

National Cholesterol Education Project ATP III -- 2004 update • High-risk: – a) coronary National Cholesterol Education Project ATP III -- 2004 update • High-risk: – a) coronary heart disease – b) carotid or lower extremity vascular disease, or – c) diabetes, or – d) Framingham risk score resulting > 20% chance of having a heart attack or coronary death within 10 years • Goal: LDL > 100

National Cholesterol Education Project ATP III -- 2004 update • Moderately high-risk: – Intermediate National Cholesterol Education Project ATP III -- 2004 update • Moderately high-risk: – Intermediate Framingham risk score of 1020% risk of heart attack or coronary death within 10 years • Goal: Option of choosing goal of < 100 or < 130

National Cholesterol Education Project ATP III -- 2004 update • Lower/Moderate Risk: – Low National Cholesterol Education Project ATP III -- 2004 update • Lower/Moderate Risk: – Low Framingham risk score giving under 10% risk of heart attack or coronary death in 10 years • Goal: LDL > 160

Drug Therapy HMG Co. A Reductase Inhibitors (Statins) • Reduce LDL-C 18– 55% • Drug Therapy HMG Co. A Reductase Inhibitors (Statins) • Reduce LDL-C 18– 55% • Major side effects – Myopathy – Increased liver enzymes • Contraindications – Absolute: liver disease – Relative: use with certain drugs

HMG Co. A Reductase Inhibitors (Statins) (continued) Demonstrated Therapeutic Benefits • • • Reduce HMG Co. A Reductase Inhibitors (Statins) (continued) Demonstrated Therapeutic Benefits • • • Reduce major coronary events Reduce coronary heart disease mortality Reduce coronary procedures (PTCA/CABG) Reduce stroke Reduce total mortality

New Treatment Goal for lipid management in type 2 diabetes People with known coronary New Treatment Goal for lipid management in type 2 diabetes People with known coronary heart disease and people with diabetes > 40 years of age should receive statin therapy regardless of cholesterol level. This is a recommendation, not a firm guideline yet. Lipid Control in the Management of Type 2 Diabetes Mellitus: A Clinical Practice Guideline from the American College of Physicians Ann Intern Med. 2004; 140: 644 -649

Hypertension Hypertension

Risk of Complications Relative Risk of Complications Hypertension and Diabetes 16 12 8 4 Risk of Complications Relative Risk of Complications Hypertension and Diabetes 16 12 8 4 0 60 70 80 90 Diastolic BP SHEP Study. JAMA 276: 1886, 1996 HOT Trial. Lancet 351: 1757, 1998 UKPDS 38: BMJ 317, 703 -713, 1998 100 110 120

Compelling Indications for Individual Drug Classes Compelling Indication Diabetes Initial Therapy Options THIAZ, BB, Compelling Indications for Individual Drug Classes Compelling Indication Diabetes Initial Therapy Options THIAZ, BB, ACE, ARB, CCB Chronic ACEI, ARB kidney disease Clinical Trial Basis NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK

Compelling Indications for Individual Drug Classes Compelling Indication Heart failure Initial Therapy Options THIAZ, Compelling Indications for Individual Drug Classes Compelling Indication Heart failure Initial Therapy Options THIAZ, BB, ACEI, ARB, ALDO ANT Clinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, Val. HEFT, RALES Post-myocardial infarction BB, ACEI, ALDO ANT ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP 2, High CHD risk THIAZ, BB, ACE, CCB LIFE, CONVINCE

ALLHAT To determine whether the newer, more costly antihypertensive drugs - CCBs, ACE inhibitors ALLHAT To determine whether the newer, more costly antihypertensive drugs - CCBs, ACE inhibitors and alpha-blockers - are superior to the older, less expensive diuretics in preventing CV complications of hypertension. The diuretics were superior.

Aspirin: who takes? • People at intermediate and high-risk by Framingham score • Also Aspirin: who takes? • People at intermediate and high-risk by Framingham score • Also people with diabetes and people with existing coronary heart disease • Unless contraindications 2004 ADA guidelines, www. diabetes. org

Dolores Rojas • By virtue of having diabetes, she is in the same risk Dolores Rojas • By virtue of having diabetes, she is in the same risk category of someone who already has coronary heart disease • Her ATP III risk is high (LDL goal < 100) • She is close to being at very high-risk, which would place her LDL goal at < 70 • Her blood pressure goal is 130/80 • Her Hb. A 1 c goal is 7 • She has a long way to go

Chronic care model • For Ms. Rojas, the chronic care model component of planned Chronic care model • For Ms. Rojas, the chronic care model component of planned visits is crucially important; perhaps she needs intensive case management • To help her manage critically needed lifestyle changes plus complicated lab monitoring and medications cannot be done in the acute primary care visit

Population management Population management

Prevalence of Diabetes Among Adults 1993 -1994 < 4% 4 -6% >6% Prevalence of Diabetes Among Adults 1993 -1994 < 4% 4 -6% >6%

Prevalence of Diabetes Among Adults 1999 < 4% 4 -6% >6% Prevalence of Diabetes Among Adults 1999 < 4% 4 -6% >6%

Prevalence of Diabetes Among Adults 2000 < 4% 4 -6% >6% Prevalence of Diabetes Among Adults 2000 < 4% 4 -6% >6%

Population management • It’s hard enough to manage each of your patients with diabetes Population management • It’s hard enough to manage each of your patients with diabetes (often with hyperlipidemia and HBP as well) • But even more is needed: to manage the population of patients with diabetes/CV risk in your patient panel

Population management • You cannot manage your population without knowing who they are, and Population management • You cannot manage your population without knowing who they are, and how they are doing – Number of your patients with diabetes – % of total diabetics with Hb. A 1 c > 8 (and who they are) – % of total diabetics with LDL > 100 (and who they are) – % of total diabetics with BP > 130/80 (and who they are)

Population management • You also need to know which patients in your panel have Population management • You also need to know which patients in your panel have not been coming to the clinic, which patients have not had Hb. A 1 c, LDL, and BP measured in the past year, because those are the most likely to be in poor control

Population management • To adequately manage your entire panel, you need a registry. If Population management • To adequately manage your entire panel, you need a registry. If it is kept up to date and if someone in the clinic looks at the registry at least once a month, it can answer all those questions: – what % are in poor control and who they are – what % haven’t been coming and who they are • With a registry you can risk-stratify patients to determine who can be cared for in primary care (Harriet Goode) and who needs more intensive planned visits (Dolores Rojas) • To keep a registry up to date and to use the registry requires system redesign; someone on the team needs to be responsible for the registry

Julio • Julio is a 13 year old Latino boy who considers himself perfectly Julio • Julio is a 13 year old Latino boy who considers himself perfectly healthy. He sees his pediatrician for a school physical and his mother is told that Julio has a BMI in the 90% percentile for his age • Julio is thus at risk for overweight • Julio likes to play video games, dislikes sports, and eats at Mc. Donald’s frequently

BMI • BMI (body mass index) = – weight in Kg/(height in meters)2 • BMI • BMI (body mass index) = – weight in Kg/(height in meters)2 • Adults: – Overweight: BMI 25 -29. 9 – Obese: BMI 30 and above • Children: use percentile (compared with BMI of other children of same age/gender) – 85 -95 th percentile: at risk for overweight – >95 th percentile: overweight www. cdc. gov/growthcharts

Prevalence of Obesity Among Adults 1989 < 10% 10 -15% > 15% Prevalence of Obesity Among Adults 1989 < 10% 10 -15% > 15%

Prevalence of Obesity Among Adults 1994 < 10% 10 -15% > 15% Prevalence of Obesity Among Adults 1994 < 10% 10 -15% > 15%

Prevalence of Obesity Among Adults 1998 < 10% 10 -15% > 15% Prevalence of Obesity Among Adults 1998 < 10% 10 -15% > 15%

Overweight Prevalence Among US Children and Adolescents, 1971 -2000 Prevalence (%) 20 NHANES I, Overweight Prevalence Among US Children and Adolescents, 1971 -2000 Prevalence (%) 20 NHANES I, 1971 -1974 NHANES III, 1988 -1994 NHANES 1999 -2000 15 10 5 0 2 -5 Years 6 -11 Years 12 -19 Years Ogden CL et al. JAMA. 2002; 288: 1728 -1732.

Metabolic Syndrome Metabolic Syndrome

The Metabolic Syndrome The Metabolic Syndrome

Metabolic Syndrome • Key features to measure – Abdominal Obesity (waist circumference > 35” Metabolic Syndrome • Key features to measure – Abdominal Obesity (waist circumference > 35” females, > 40” males) – Dyslipidemia • HDL <40 in males, <50 in females • Triglycerides (fasting) >150 – Blood pressure >130/85 – Insulin resistance: Impaired Fasting Glucose (FBS between 100 and 126) • Other features (not measured routinely) – Proinflammatory state (elevated C-reactive protein) – Prothrombotic state (abnormal coagulation factors)

Metabolic Syndrome • Prevalence increases with age • One-third of overweight/obese persons in the Metabolic Syndrome • Prevalence increases with age • One-third of overweight/obese persons in the US have the syndrome • Almost everyone with metabolic syndrome is overweight and physically inactive • Latinos and people from South Asia are more susceptible • People with metabolic syndrome have greatly increased risk of diabetes and coronary heart disease

Metabolic Syndrome • Cause: not proven. Hypothesis: abdominal fat is the primary etiologic agent Metabolic Syndrome • Cause: not proven. Hypothesis: abdominal fat is the primary etiologic agent • Visceral fat cells may produce fatty acids and cytokines that cause insulin resistance, inflammatory and pro-thrombotic states • Lack of physical activity also causes loss of muscle mass which increases insulin resistance • Regardless of the cause, the underlying risk factors are – Overweight/obesity – Physical inactivity – Diet of high saturated fat, simple sugars, high calories (atherogenic diet)

Metabolic Syndrome • Does Julio have metabolic syndrome? • Probably not yet – – Metabolic Syndrome • Does Julio have metabolic syndrome? • Probably not yet – – Prevalence increases with age 2/3 of overweight people in the US do not have the syndrome. 1/3 do – It would be worth checking his fasting glucose to see if it is over 100 (impaired fasting glucose) • With his BMI, diet and physical inactivity, he is at high risk of developing metabolic syndrome • He is also at risk for diabetes

Metabolic Syndrome • Management – Weight loss – Increased physical activity – Diet with Metabolic Syndrome • Management – Weight loss – Increased physical activity – Diet with fewer saturated fats, simple sugars, and calories; more fruits and vegetables – Medication management is far less important than lifestyle changes, but may be necessary for blood pressure and cholesterol. Aspirin if intermediate or high Framingham risk

Metabolic syndrome and diabetes prevention • Diabetes can be prevented in people with impaired Metabolic syndrome and diabetes prevention • Diabetes can be prevented in people with impaired fasting glucose (between 100 and 126) -some of whom have the entire metabolic syndrome • Diabetes Prevention Program – > 7% loss of body weight and maintenance of weight loss, <25% of calories from fat, total calories 1200 -1800/day – > 150 minutes per week of physical activity • 58% reduced incidence of diabetes after 4 years compared with controls NEJM 346: 393 -403, 2002

Julio • Julio (age 13) and his family need to be informed of his Julio • Julio (age 13) and his family need to be informed of his risk • If it is possible for him and his family to set some lifestyle change goals, that could be enormously important • Even if his weight stays the same, his BMI will go down as his height increases. This could be accomplished by reducing caloric intake by a small amount and increasing exercise by a small amount • The changes required are achievable if Julio and his family understand the importance and if Julio feels confidence in his ability to make the changes

Complications in Type 2 Diabetes and the Metabolic Syndrome Hyperglycemia Hypertension Risk Relative To Complications in Type 2 Diabetes and the Metabolic Syndrome Hyperglycemia Hypertension Risk Relative To General Population Dyslipidemia Insulin Resistance 6 Macrovascular Disease 5 4 Microalbumin Neuropathy 3 2 Diabetic Retinopathy 1 0 -20 -15 -10 -5 0 5 Years of Diabetes Adapted from: Kendall DM. Am J Manag Care 7 S 327 -S 343, 2001. Care 7 S 327 -S 343, 10 15 20

Julio and the chronic care model • Kids should stay away from the health Julio and the chronic care model • Kids should stay away from the health care system as much as possible. System redesign is needed to make sure some caregiver is available to spend quite a bit of time with Julio and family in person or by phone or email • Julio will reduce his BMI through empathetic engagement in collaborative goal-setting -- his action plans must involve participation in community resources, especially exercise programs that he enjoys. • Like everyone else, if Julio doesn’t want to do something, he won’t do it.

Putting evidence-based medicine into practice Evidencebased medicine (EBM) Clinicians actually practice EBM Chronic care Putting evidence-based medicine into practice Evidencebased medicine (EBM) Clinicians actually practice EBM Chronic care model components: decision support, registries, reminders, practice redesign Informed, activated patients make choices consistent with EBM to improve their outcomes and lives Self-management support to inform and activate patients through collaborative decisionmaking

Clinical Guidelines Websites American Diabetes Association: http: //www. diabetes. org/for-health-professionals-and scientists/cpr. jsp American College Clinical Guidelines Websites American Diabetes Association: http: //www. diabetes. org/for-health-professionals-and scientists/cpr. jsp American College of Cardiology: http: //www. acc. org/clinical/statements. htm American Heart Association: http: //www. americanheart. org/presenter. jhtml? identifier=554 National Cholesterol Education Program: http: //www. nhlbi. nih. gov/guidelines/cholesterol/index. htm