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Definition
Adults!
Overweight BMI: 25.0-29.9!
Obese BMI: > 30!
Children (2-19 y/o)!
Using growth charts!
Overweight BMI: 85th -95th
percentile!
Obese BMI: > 95th percentile !
http://www.cdc.gov/growthcharts/
clinical_charts.htm
Rates by age: young adults < elderly < middle aged adults!
2/3 U.S. adults are overweight!
If trends continue!
By 2015: 75% adults will be overweight, 41% adults will be
obese!
By 2030: entire U.S. population will be overweight or obese
Rates by age: 2-5 y/o < 6-11 y/o < 12-19 y/o!
New generations may face a shorter life expectancy
than their parents in the near future
Disorders!
Cushing syndrome,
hypothyroidism!
Medications: antidepressants, steroids!
Behavior and lifestyle!
Dietary intake!
Physical activity!
Hormonal balance!
Psychosocial and
psychosomatic
Associated disorders!
Dyslipidemia!
Gallbladder and kidney
disease!
Impaired immunity!
Dermatologic disease!
Impotence and reduced libido!
Back pain and disorders!
Type II diabetes!
Depression
Assessing Obesity
Body Mass Index!
Class I obesity: 30.0-34.9!
Class II obesity: 35.0-39.9!
Class III obesity: 40.0-49.9!
Morbid obesity: > 50.0!
!
!
!
!
Assessing Obesity
Waist Circumference!
Use tape measure, wrap around
waist at topmost point of iliac
crest!
Men: < 40 inches!
Women: < 35 inches!
Used in patients with BMI =
25-34.9!
Height-weight charts
Primary Prevention
Early recognition and prevention
is key!
Critical periods: prenatal
period, infancy and
preadolescence, pregnancy!
Those with family history!
Implementing preventive
measures after individual is
already overweight or obese is
usually inefficient
Primary Prevention
Diet and physical activity!
Patients should concentrate on health status not dieting!
Lifestyle Changes!
Reducing time spent in front of the TV improves BMI numbers in pediatric
patients!
Recommend < 2 hour of non-work/non-homework related screen time!
Monitor yourself and your family!
Weight, BMI, waist circumference!
Community programs: WeCan! Ways to enhance childrens activity and
nutrition!
Provide parents of children with the WeCan brochure: http://
www.nhlbi.nih.gov/health/educational/wecan/downloads/physician2.pdf !
Breastfeeding reduces the risk of pediatric obesity
Secondary Prevention
Improve management of overweight or obese individuals!
Lifestyle modifications!
Dietary Intake!
Dieting alone is not conducive to weight loss or weight
maintenance!
According to U.N.: minimum caloric requirement is 1800 kcal/day!
Depends on age, size, height, gender, lifestyle, general health
status!
Create healthy nutritional plan!
Balance energy IN and energy OUT!
Portion size, chew food longer, eat a good breakfast!
Involve the family!
Decreasing dietary fat is associated with reduction in body weight
Ages 31-50
Sedentary: 2200-2400
Moderately active: 2400-2600
Active: 2800-3000
Ages 51+
Sedentary: 2000-2200
Moderately active: 2200-2400
Active: 2400-2800
Ages 31-50
Sedentary: 1800
Moderately active: 2000
Active: 2200
Ages 51+
Sedentary: 1600
Moderately active: 1800
Active: 2000 - 2200
References
!
http://www.pace-cme.org/d/149/priorities-in-the-management-of-type-2-diabetes !
http://www.cdc.gov/Obesity/ !
http://acsm.org/!
http://www.health.qld.gov.au/cho_report/2008/images/hw_graph_hr.gif !
Journal of the American Medical Association!
http://www.nhlbi.nih.gov/health/health-topics/topics/obe/prevention.html !
https://www.health.ny.gov/prevention/obesity/ !
www.medicalnewstoday.com/info/obesity/ !
http://www.medscape.org/viewarticle/730678_transcript
Dyslipidemia and
Atherosclerosis
What is Dyslipidemia?
Abnormal lipid profile!
Total cholesterol!
VLDL!
IDL!
LDL!
HDL!
Triglycerides!
Hyperlipoproteinemia!
Hypercholesterolemia!
71 million US adults: !
32.5% of men, 31%
of women!
1/3 of diagnosed
patients are
controlled!
Doubles risk of heart
disease
Assessing Dyslipidemia
Assessing Dyslipidemia
Risk ratio!
TC/HDL = risk ratio!
Risk ratio < 3.0 = half average risk!
Risk ratio 4.4 = average risk!
Risk ratio > 6.2 = double average risk!
Framingham Study
What is Atherosclerosis?
Family History!
Ethnicity!
Non-hispanic white < Non-hispanic black <
Mexican American!
Age!
Genetic disorders
Primary Prevention
Healthy diet!
Physical activity!
Lifestyle!
Stop smoking!
Moderate alcohol intake!
Weight management
Secondary Prevention
TLC Diet
Secondary Prevention
Increase physical activity!
30 min/day, 7 days/week!
Reduces total cholesterol and
LDL!
Reduces triglycerides!
Increases HDL!
Weight loss!
Lifestyle !
Stop smoking!
Moderate alcohol intake!
Control blood pressure!
!
Pharmacological!
Statins: simvastatin,
pravastatin, atorvastatin!
When needed, aggressive
lipid lowering has better
patient outcomes than less
aggressive lipid lowering
References
http://www.brown.edu/Courses/Digital_Path/systemic_path/cardio/atherosclerosis-ca.html !
http://exercisevascularcells.org/about.htm!
http://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis/!
http://www.nhs.uk/Conditions/atherosclerosis/Pages/prevention.aspx
Hypertension
Definition
> 50 million in the U.S.!
2/3 of individuals > 65 y/o have HT!
Only 70% are aware of their condition!
Systole!
Diastole!
Recent clinical guidelines!
SBP more important than DBP for CVD risk factors in individuals > 50 y/o!
90% chance of developing HT after 55 y/o!
Motivation improves when patients have positive experiences and trust
their clinician
Assessing Blood
Pressure
In office!
2 reading 5 minutes apart!
Both arms!
Auscultatory method!
Self measurement!
To evaluate white coat HT!
Improve adherence!
Monitor response to interventions
HT!
Smoking!
Obesity!
Physical inactivity!
Dyslipidemia!
Diabetes mellitus!
Age!
Family history of premature CVD
Renal!
Chronic kidney failure!
Renal artery stenosis!
Retinopathy
Endocrine!
Thyroid or parathyroid
disease!
Cushing syndrome!
Pheochromocytoma!
Sleep apnea!
Medications: corticosteroids,
cold medicines, OCPs, HRT
Pregnancy!
Aging!
Ethnicity!
African American >
Puerto Rican > Hispanic
American > Caucasian >
Cuban American!
!
Alcohol, smoking!
Sedentariness!
Chronic stress
Primary Prevention
Community programs!
Increase awareness and detection!
Increase recognition of importance of healthy and controlled blood pressure!
Reduce ethnic, socioeconomic and regional variation in blood pressure!
Improve accessibility to prevention and management programs!
Community education, health fairs
Primary Prevention
Healthy diet !
Maintain electrolyte balance!
Physical activity!
Lifestyle!
Stop smoking!
Moderate alcohol intake!
Limit recreational screen time to < 2 hours/day!
Develop coping strategies to combat stress
Secondary Prevention
Weight reduction!
BMI: 18.5-24.9!
5-20 mmHg/ 10 kg weight loss!
DASH diet!
Fruits, vegetables, low fat dairy!
Can lower blood pressure by 8-14 mmHg!
Limit dietary sodium!
< 2.4 g sodium/day!
Can lower blood pressure by 2-8 mmHg!
Limit alcohol consumption!
< 2 drinks/day in men!
< 1 drink/day in women and small individuals!
Can lower blood pressure by 2-4 mmHg
Secondary Prevention
Secondary Prevention
Physical Activity!
Aerobic physical activity > 30 min/day for most days of the week!
Lower intensity exercise seems to be equally, if not more, effective in lowering BP as higher intensities!
Avoid high intensity exercise and heavy lifting in patient with excessively high BP that is not well
controlled!
Constant screening!
Self and family measurement at home
Tertiary Prevention
Constant screening and monitoring!
Regular check-ups/follow-ups: every 3-6 months if BP at goal and stable!
Self and family measurement at home!
Frequency increases with complications and comorbidities!
Pharmacological!
Loop diuretics!
Thiazide diuretics!
Potassium sparing diuretics!
Beta blockers, alpha blockers, calcium channel blockers!
Vasodilators!
ACE-I, ARBs!
Pregnancy- methyldopa, beta blockers, vasodilators
References
http://www.nhlbi.nih.gov/health/health-topics/topics/hbp/!
Joint National Committee on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure report from
www.nhlbi.nih.gov
Health Effects
Diabetes (x5 chance mortality)!
Cardiovascular disease!
Atherosclerosis and hypercoagulability!
Hypercholesterolemia!
Hypertension!
Peripheral arterial disease!
Coronary Artery Disease and Heart attack (x2 chance mortality) !
International Diabetes
Federation Definition: Central
Obesity (waist circumference or
BMI > 30) plus at least 2 of the
following criteria met!
1. High triglycerides (>150)!
2. Low HDL!
3. High blood pressure!
4. High FPG
Additional diagnostic
measurements!
OGTT!
Vascular dysregulation!
Endothelial dysfunction!
Microalbuminuria!
Proinflammatory!
CRP, TNF-alpha!
Prothrombotic!
Fibrinolytic factors and
clotting factors!
Hormonal!
HPA axis
Risk Factors
Modifiable!
Non-modifiable!
LIFESTYLE!
!
!
!
Primary Prevention
Preventing and treating the metabolic syndrome reduces the chances of
T2DM by more than 58%!
LIFESTYLE: main prevention!
DASH diet!
ACSM physical activity recommendations!
Stop smoking!
Secondary Prevention!
LIFESTYLE!
DASH diet!
ACSM physical activity recommendations!
Stop smoking!
Secondary Prevention!
Correct atherogenic dyslipidemia!
Reduce triglycerides!
Increase HDL!
Reduce small, dense LDL!
Pharmacological: fibrates (increase HDL), statins (reduce LDL and ApoB
lipoproteins)!
References
www.medscape.org !
http://www.nhlbi.nih.gov/health/health-topics/topics/ms/!
http://www.mayoclinic.org/diseases-conditions/metabolic-syndrome/basics/definition/con-20027243!
http://www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/MetabolicSyndrome_UCM_002080_SubHomePage.jsp!
http://www.idf.org/metabolic-syndrome
What is Prediabetes?
Non-modifiable risk
factors
Autoimmune (past
viral infection)
HLA-DR3 and HLADR4
Modifiable risk factors
Environmental
American, Hispanic/Latino
American, American Indian, Asian
American, Pacific Islanders
A reversible form of
diabetes mellitus that
develops during pregnancy
and resolves spontaneously
after delivery
Occurs in 2-10% of all
pregnancies
Onset: pregnancy
Gastroparesis
Mental Health
Coma:
Non-ketotic
hyperosmolar coma
(mostly T2DM)
Ketoacidotic coma
(mostly T1DM)
Hypoglycemic coma
Cardiovascular disease
Stroke
Infection
!
!
!
Weight loss
Get out of overweight or
obese range: not necessary
to reach ideal body weight
Regular assessment and
screening
Healthy individuals
Individuals at risk:
overweight, obesity,
metabolic syndrome,
prediabetes
Glycemic control
FPG: < 110 mg/dl
(daily)
2 hour postprandial
glucose: < 130 mg/dl
(daily)
HbA1c: < 6.5%
(checked 2-4 times/
year if at target)
References
http://www.cdc.gov/diabetes/
http://www.diabetes.org
http://www.cdc.gov/diabetes/prevention/index.htm
http://www.nlm.nih.gov/medlineplus/magazine/issues/fall12/
articles/fall12pg12.html
http://touchbroward.org/rates-and-risk-factors-of-broward-childrenwith-diabetes/
Angina pectoris
Myocardial infarction
Complications
Heart failure
Arrhythmia and cardiac arrest
!
!
Cardiac markers
Elevated during MI
Echocardiogram
(cardiac ultrasound)
Nuclear myocardial
perfusion imaging
Angiogram
Primary Prevention
Heart healthy diet
Minimum 30 minutes of
moderate intensity
activity 5-7 days/week
DASH diet
Lifestyle
Stop smoking
Secondary Prevention
Screening for risk factors and early detection
Manage risk factors
Lose weight
Improve lipid profile of patient
Reduce blood pressure
Maintain glycemic control
Pharmacological
Daily aspirin
Beta blocker
Statins
Tertiary Prevention
Manage heart disease to prevent complications
Manage dyslipidemia, weight, blood pressure and
glycemic control
Revascularization
PTCA: percutaneous transluminal angioplasty
(minimally invasive)
CABG: coronary artery bypass grafting (open heart
surgery)
Pharmacological
References
http://www.heart.org/
http://www.nhlbi.nih.gov/health/health-topics/topics/cad/
www.cdc.gov
Stroke
What is Stroke?
Also known as cerebrovascular accident (CVA)
1 person suffers from a stroke every 40
seconds
1 person dies from a stroke every 4 minutes
Third (or fourth) leading cause of death in the
U.S.
Rising stroke incidence in 5-14 y/o: likely
attributable to childhood obesity
What is Stroke
Portion of the brain becomes ischemic
due to lack of blood perfusion (cerebral
infarct)
Thrombotic stroke
Complete arterial occlusion
Most commonly due to atherosclerosis
Embolic stroke
Complete arterial occlusion
Most commonly due to atrial fibrillation
Subarachnoid hemorrhage
Due to Arterial leak or rupture in the subarachnoid
space
Most commonly caused by an aneurysm
Intracerebral hemorrhage
Due to arterial leak or rupture into the brain tissue
Most commonly caused by hypertension
Hypertension
Smoking
Cardiomyopathy
Diabetes
Atherosclerosis
Heart failure
Atrial fibrillation
Cerebrovascular
Aneurysm
Arteriovenous
malformations
Overweight and
obesity
Other disorders:
sickle cell anemia,
vasculitis, bleeding
disorders,
autoimmune disorders
!
UTI
Memory loss
Behavioral changes
Assessing Stroke
Evaluation of clinical signs and risk factors
Brain imaging
Carotid imaging
Ultrasound
Detect plaque formation, detect changes in blood flow
speed and direction
Angiography
Assessing Stroke
Cardiac testing
ECG/EKG
Echocardiography
Blood tests
CBC and metabolic panel, including glucose
Lipid profile
Inflammatory mediators: ESR, CRP
Antiphospholipid antibodies
Coagulation function tests: platelet count, PT, PTT
Toxicology
Primary Prevention
Lifestyle
Stop smoking
Moderate alcohol intake: < 2/day for men, < 1/day
for women
DASH diet
Increase physical activity
ACSM recommendations
Secondary Prevention
Early detection and
management of risk factors
Screening for risk
factors
Ischemic stroke
Daily aspirin
Anticoagulant and
thrombolytic therapies
in at risk patients
Appropriate
management of TIA
Revascularisation:
carotid endarterectomy
(plaque removal)
Tertiary Prevention
Early recognition and
treatment of stroke
Ischemic stroke
Daily aspirin
Anticoagulant and
thrombolytic
therapies
Revascularisation
after ischemic stroke
!
Rehabilitation
Physical therapy
Occupational
therapy
Speech therapy
Psychotherapy
References
http://www.nhlbi.nih.gov/health/health-topics/ topics/stroke/
www.womenshealth.gov
www.dhhs.ne.gov
http://www.cdc.gov/stroke/
Pneumoconioses
Cystic Fibrosis
Genetically transmitted disorder
Accumulation of mucus in body tracts, including respiratory tracts
Spirometry: measures
amount of air inhaled and
exhaled, measures velocity
of exhalation
Body plethysmography:
measures amount of air in
lungs during deep
inhalation and amount of
air remaining in lungs after
complete exhalation
Genetic
Alpha 1 antitrypsin
deficiency
(emphysema)
CFTR gene mutations
(cystic fibrosis)
Age
Primary Prevention
Quit smoking
Avoid smoking and secondhand
smoking
Influenza and pneumococcal vaccines
Respiratory hygiene
Secondary Prevention
Focused on early detection and management
No current recommendations for screening
Tertiary Prevention
Manage symptoms and
slow down progression
Home oxygen
Pharmacological
Regular assessment
of symptoms and
progression
Anti-inflammatory
drugs:
corticosteroids
Influenza and
pneumococcal vaccines
Bronchodilators
Avoid complications
of chronic lung
disease
Singulair (allergic
asthma)
Surgical
Education
Teach importance of
vaccinations
Teach importance of
avoidance of triggers
and risk factors
Exercise training
Nutritional counseling
At least 3x/week
Return you to
normal BMI range,
whether overweight
or underweight
References
http://www.nhlbi.nih.gov/
http://www.cdc.gov/copd/
Osteoporosis
!
PREVENTIVE HEALTHCARE, HSC 3211
JULIA MARIAN, MD
What is Osteoporosis?
An irreversible, chronic bone disorder characterized by
bone fragility due to low bone mass density and
structural deterioration
Assessing Osteoporosis
DEXA scan!
Dual energy x-ray absorptiometry to measure density of
bone!
T-score is provided to provide a value for the bone mineral
density (BMD)!
Normal bone density: T score between -1.0 and +1.0!
Osteopenia (low bone density): T score between -2.5 and -1.0!
Osteoporosis: T score between -2.5 and -4.0
Assessing Osteoporosis
Assessing Osteoporosis
Quantitative CT!
More expensive, similar accuracy!
Used mostly for vertebral body density to predict
fracture risk!
Quantitative Ultrasound!
Cannot measure density!
Used at the bones of the heel to predict fracture risk
Assessing Osteoporosis
Complications of fracture:!
Immobility: muscle
atrophy, deep vein
thrombosis, pulmonary
embolism!
Infection!
25% mortality rate
within first year of
fracture
Primary Prevention
Calcium
1000-1300 mg/day
Primary Prevention
Vitamin D
Lifestyle
Stop smoking
Primary Prevention
Be aware of medications that reduce
bone mineral density
Glucocorticoids (corticosteroids),
GnRH drugs, excess thyroid hormones
Anticonvulsants and some sedatives
Aluminum based antacids
Some cancer treatments
Primary Prevention
Exercise
Based on Wolffs law: bone grows or
remodels in response to forces or
demands placed upon it
Weight bearing
Walking, hiking, jogging, climbing
stairs, weight training, tennis, dancing
Secondary Prevention
Early detection and screening for osteopenia and
osteoporosis
Nutrition, calcium and vitamin D
Exercise
Pharmacological
Biphosphonates: alendronate
Selective estrogen receptor modulators (SERMs):
raloxifene
Calcitonin
Parathyroid hormone
Testosterone therapy in males
Tertiary Prevention
Nutrition, calcium, vitamin D
Exercise
Pharmacological
Joint replacement
Tertiary Prevention
Physical therapy
Posture exercises
Hip and back strengthening exercises
Weight bearing exercises
Balance exercises
Functional exercises: for everyday activities
Occupational therapy
References
http://www.niams.nih.gov/Health_Info/Bone/default.asp
http://www.ncbi.nlm.nih.gov/pubmed/22274617
www.hopkinsmedicine.org
www.biij.org
www.webmd.com
http://nof.org/articles/543