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Obesity and Overweight

JEKELS EPIDEMIOLOGY, BIOSTATISTICS, PREVENTIVE MEDICINE AND PUBLIC HEALTH, Chapter 19


PREVENTIVE HEALTHCARE, HSC 3211
JULIA MARIAN, MD

Android vs. Gynoid

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

The Statistics of Adult Obesity


> 1/3 U.S. adults are obese as of 2008 (> 78.6 million)!
Non-Hispanic blacks: 47.8%!
Hispanics: 42.5%!
Non-Hispanic whites: 32.6%!
Non-Hispanic Asians: 10.8%!

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

The Statistics of Adult Obesity


Annual medical cost!
$147 billion: $1429 per person higher than those of normal
weight!
Socioeconomic status!
Men* with higher incomes have increased risk of obesity!
Women with higher incomes have reduced risk of obesity!
Women with college degrees have reduced risk of obesity!
!

Obesity and overweight are the second leading cause of death


in the US after tobacco- soon to overtake tobacco

The Statistics of Childhood Obesity


17% U.S. pediatric population obese: 12.5 million!
Significant reduction in obesity in 2-5 y/o: from
13.9% in 2003 to 8.4% in 2012!
Hispanics: 22.4%!
Non-Hispanic black: 20.2%!
Non-Hispanic white: 14.1%!
Non-Hispanic Asian: 8.6%!

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

Non-modifiable Risk Factors


Genetic disorders!
Prader-Willi syndrome!
Socio-economic status!
Personal biology!
Resting energy expenditure!
Fat cell number!
Psychosocial and psychosomatic!
Smoking cessation

Modifiable Risk Factors


Environment!
Family and friend!
School and workplace
settings!
Safe and pedestrian
friendly environments!
Recreational
opportunities!
http://www.cdc.gov/
cdctv/ObesityEpidemic/!
Smoking cessation!
!
!
!

Disorders!
Cushing syndrome,
hypothyroidism!
Medications: antidepressants, steroids!
Behavior and lifestyle!
Dietary intake!
Physical activity!
Hormonal balance!
Psychosocial and
psychosomatic

Modifiable Risk Factors in Children


School campuses or child care centers!
Sugary drinks, less healthy food choices!

Advertising, television and media!


Restrict viewing!

Lack of daily, quality physical activity at home and at school!


No safe and appealing recreational area in community!

Limited access to healthy affordable foods with increased


access to high energy dense foods and sugary drinks!
Increased portion sizes!
Lack of breastfeeding support and pregnancy education

Health Effects of Obesity


Increased mortality!
Mortality rate doubles
compared to non-obese
individuals!
Reduces life expectancy by
10-20 years!
Mental health!
Shame!
Self-blame!
Low self-esteem!
Depression

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!
!
!
!
!

Body Adiposity Index!


Hydrostatic weighing
and Bod Pod (air
displacement
plethysmography): most
accurate!
Skinfold measurement!
Bioelectric impedance
analysis: fat is not a good
conductor!
Scans: CT, MRI, DEXA
etc.

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

Ideal Body Weight


Depends on !
BMI!
Waist-hip ratio- ideal ratio < 0.8 in women and < 0.9 in
men!
Waist-to-height ratio- ideal ratio < 1:2!
Total body fat: ideally <25% in women and <18% in
men

Benefits of Weight Loss


5-10% weight loss !
Reduces HbA1c!
Reduces blood pressure!
Reduces total cholesterol!
Increases HDL cholesterol!
Reduces triglycerides!

2 kg weight loss reduces chances of CHD by more


than 40%

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

Increase awareness and education


of healthcare professional and
patient!
Improve lifelong healthy eating and
physical activity!
Reduce sedentariness!
Increase policy and environmental
supports!
Increase and maintain effective
public health responses to the
obesity epidemic

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

Secondary Prevention: Dietary Intake

Calculate your BMR!


Male BMR= 66 + ( 6.23 x pounds body weight) + ( 12.7 x height in inches ) - ( 6.76 x age) !
Female BMR= 55 + (4.35 x pounds body weight) + (4.7 x height in inches) - (4.7 x age)!

Daily caloric requirement based on individual BMR and lifestyle!


Sedentary (little to no exercise): calories needed = BMR x 1.2!
Slightly active (light 1-3x/week): calories needed = BMR x 1.375!
Moderately active (moderate 3-5x/week): calories needed = BMR x 1.55!
Active (intense/heavy 6-7x/week): calories needed = BMR x 1.725!
Very active (very intense/heavy 2x/day): calories needed = BMR x 1.9

Secondary Prevention: Dietary Intake


Males need to go below this daily caloric
intake to lose weight!
Ages 19-30
Sedentary: 2400-2600
Moderately active: 2600-2800
Active: 3000

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

Females need to go below this daily


caloric intake to lose weight!
Ages 19 to 30
Sedentary: 1800 - 2000
Moderately active: 2000 - 2200
Active: 2400

Ages 31-50
Sedentary: 1800
Moderately active: 2000
Active: 2200

Ages 51+
Sedentary: 1600
Moderately active: 1800
Active: 2000 - 2200

Secondary Prevention: Physical Activity


Physical activity plan!
Involve the family!
At least 200 minutes of moderate intensity exercise each week, spread
over at least 3 days in order to maintain weight loss !

Physical activity alone results in minimal weight loss!


Physical activity does help to preserve fat-free body
tissue during weight loss!
Considerable activity is required to maintain weight loss

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

JEKELS EPIDEMIOLOGY, BIOSTATISTICS, PREVENTIVE MEDICINE AND PUBLIC HEALTH


CHAPTER 19
PREVENTIVE HEALTHCARE, HSC 3211
JULIA MARIAN, MD

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?

Health Risks of Atherosclerosis


Thrombosis and embolism!
Coronary heart disease!
Carotid artery disease!
Peripheral arterial disease!
Stroke!
Chronic kidney disease

Modifiable Risk factors


Diet!
Lack of physical activity!
Smoking!
Alcohol!
Hypertension!
Low HDL!

Medications: steroids, beta


blockers, OCP!
Diabetes!
Liver disorders!
Endocrinological disorders

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

PREVENTIVE HEALTHCARE, HSC 3211!


JULIA MARIAN, MD

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!

Ambulatory blood pressure monitor!


To evaluate white coat HT!
HT and CVD risk confirmed when
there is no 10-20% drop in blood
pressure during sleep!

Self measurement!
To evaluate white coat HT!
Improve adherence!
Monitor response to interventions

Assessing Blood Pressure


Evaluate your patient!

Assess lifestyle and other CVD risk factors!


Identify other causes for high BP!
Identify presence or absence of target organ damage and CVD!

CVD risk factors!

HT!
Smoking!
Obesity!
Physical inactivity!
Dyslipidemia!
Diabetes mellitus!
Age!
Family history of premature CVD

Health Risks of Hypertension


Cardiovascular!
Risk doubles with each 20/10 mmHg increment after 115/75 mmHg!
Coronary heart disease!
Myocardial infarction!
Left ventricular hypertrophy!
Heart failure!
Aortic aneurysm!
Peripheral vascular disease!
Areteriosclerosis

Health Risks of Hypertension


Cerebrovascular!
Stroke !
Hypertensive encephalopathy!
Cerebral aneurysms and hemorrhage!
Dementia and cognitive impairment!

Renal!
Chronic kidney failure!
Renal artery stenosis!

Retinopathy

Etiologies and Modifiable Risk Factors


Idiopathic: essential HT!
Renal!
Chronic kidney disease!
Primary aldosteronism!
Renovascular disease!
Especially in children < 10
y/o!
!
!

Endocrine!
Thyroid or parathyroid
disease!
Cushing syndrome!
Pheochromocytoma!
Sleep apnea!
Medications: corticosteroids,
cold medicines, OCPs, HRT

Etiologies and Non-modifiable Risk Factors


Idiopathic: essential HT!

Overweight and obesity!

Pregnancy!

Diet: high sodium, low


potassium!

Aging!
Ethnicity!
African American >
Puerto Rican > Hispanic
American > Caucasian >
Cuban American!
!

Alcohol, smoking!
Sedentariness!
Chronic stress

Benefits of Lowering Blood Pressure


Stroke incidence reduced by 35-40%!
Myocardial infarction incidence reduced by 20-25%!
Heart failure risk reduced by 50%!
Stage 1 HT!
Sustained 12 mmHg reduction in SBP over 10 years
can prevent 1 death for every 11 patients treated

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!

Pediatric patients: 1-2 hours/day!


Can lower blood pressure by 4-11 mmHg!

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

The Metabolic Syndrome

PREVENTIVE HEALTHCARE, HSC 3211!


JULIA MARIAN, MD

What is the Metabolic Syndrome?

What is the Metabolic Syndrome?

> 1 in 4 people around the world!


> 1 in 3 Americans are diagnosed with the metabolic
syndrome!
Metabolic syndrome ahead of HIV/AIDS in morbidity and
mortality

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) !

Stroke (x2 chance mortality)!


High uric acid retention and increased CRP levels

Assessing the Metabolic Syndrome?


Diagnosed when at least 3 of
the following criteria met:!
1. Abdominal Obesity!
Visceral fat!
Increased waist
circumference!
2. High TG!
3. Low HDL!
4. Hypertension!
5. Impaired fasting glucose

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

Assessing the Metabolic Syndrome


Additional diagnostic
measurements !
Abnormal body fat distribution!
General body fat (DEXA)!
Central fat (CT/MRI)!
Adipose tissue biomarkers:
leptin, adiponectin!
Liver fat (MRS)!
Atherogenic dyslipidemia!
ApoB lipoprotein increase!
Small LDL particle increase]!
Elevated uric acid

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!

Age: > 40 y/o!

Obesity: apple > pear, BMI > 25,


high waist circumference!

Gender: men > women!

Personal history of Type 2 diabetes


mellitus!
History of other disease:
cardiovascular disease,
nonalcoholic fatty liver disease,
polycystic ovarian syndrome!

!
!
!

Race: Central America, South Asia


> Caucasian > African American!
Family history: diabetes,
hypertension, CVD!
Personal history of gestational
diabetes mellitus

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!

Correct insulin resistance!


Reduce weight!
Increase physical activity!
ADA meal plan guidelines recommended

Secondary Prevention!
LIFESTYLE!
DASH diet!
ACSM physical activity recommendations!
Stop smoking!

Correct insulin resistance!


Reduce weight!
Increase physical activity!
ADA meal plan guidelines recommended

Secondary Prevention!
Correct atherogenic dyslipidemia!
Reduce triglycerides!
Increase HDL!
Reduce small, dense LDL!
Pharmacological: fibrates (increase HDL), statins (reduce LDL and ApoB
lipoproteins)!

Correct prehypertension and hypertension!


Primarily lifestyle!
ACE inhibitors, ARBs!

Reduce coagulation: daily aspirin

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

Diabetes Mellitus Type 2

JEKELS EPIDEMIOLOGY, BIOSTATISTICS, PREVENTIVE MEDICINE AND PUBLIC HEALTH, Chapter 19


PREVENTIVE HEALTHCARE, HSC 3211
JULIA MARIAN, MD

What is Diabetes Mellitus?

23.6 million Americans (7.8%) have diabetes


79 million adults over 20 y/o have pre diabetes

What is Prediabetes?

Also Impaired Glucose Tolerance or Impaired Fasting


Glucose
Reversible condition where the bodys control is
glucose is becoming abnormal ,while still maintaining
glucose levels below a diabetic level
Variable symptomatology

What is Diabetes Mellitus Type 1 (T1DM)?


Insulin deficiency caused
by irreversible destruction
of pancreatic beta cells
5% of all diagnosed DM
Idiopathic disorder
Onset
Mostly children and
young adults

Non-modifiable risk
factors
Autoimmune (past
viral infection)
HLA-DR3 and HLADR4
Modifiable risk factors
Environmental

What is Diabetes Mellitus Type 2 (T2DM)?


Defective response of tissue
receptors to insulin resulting in
abnormal glucose uptakeinsulin resistance. Eventual,
irreversible pancreatic beta
cell damage does result,
leading to insulin deficiency
90-95% of all diagnosed DM
Onset
Variable age

Non-modifiable risk factors


Age (>30 y/o)
Race, ethnicity: African

American, Hispanic/Latino
American, American Indian, Asian
American, Pacific Islanders

Family history: diabetes


Personal history: gestational
diabetes
Modifiable risk factors
Personal history: prediabetes,
metabolic syndrome
Overweight, obesity
Low physical activity or
sedentariness
Hypertension, dyslipidemia
Smoking, alcohol

What is Gestational Diabetes Mellitus (GDM)?

A reversible form of
diabetes mellitus that
develops during pregnancy
and resolves spontaneously
after delivery
Occurs in 2-10% of all
pregnancies
Onset: pregnancy

Non-modifiable risk factors


Race and ethnicity:
African American,
Hispanic/Latino American,
American Indian
Family history: diabetes
Modifiable risk factors
Obesity

Complications and Sequelae


Hypoglycemia
Hyperglycemia
Dermatologic
Ophthalmologic
Neuropathy
Angiopathy
Podiatric
Nephropathy

Gastroparesis
Mental Health
Coma:
Non-ketotic
hyperosmolar coma
(mostly T2DM)
Ketoacidotic coma
(mostly T1DM)
Hypoglycemic coma
Cardiovascular disease
Stroke
Infection

Assessing Diabetes Mellitus


Clinical diagnosis
Signs and
symptoms
Fasting plasma
glucose (FPG)
Casual plasma
glucose
Oral glucose
tolerance test
(OGTT)
Glycated hemoglobin
(HbA1c)

Assessing Complications and Sequelae of T2DM

Regular and complete physical exams


Regular glucose monitoring
Urinalysis
Albuminuria
Glycosuria
Ketoaciduria
Annual eye checkups
Fundoscopic exams

Primary Prevention of T2DM


Increase education and awareness
T2DM risk test: http://www.diabetes.org/are-you-atrisk/diabetes-risk-test/
Set goals:
Keep time limit for reaching goals short
Keep it realistic
Be specific about your goals
Set 1-3 goals at a time and write them down
Maintain health through diet and physical activity

Secondary Prevention of T2DM


Lower risk of T2DM by 58%
with:
7% body weight loss: 15 lbs
of 200 lbs
Moderate exercise 30 min/
day for 5 days/week
Healthy eating
ADA meal plan
Lean meats: chicken, turkey,
lean cuts of beef or pork
Low fat or skim dairy products
Whole grain breads and
cereals
Abundant fruits and
vegetables

!
!
!

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

Secondary Prevention of T2DM


Physical Activity
20-30 minutes moderate intensity exercise/day
Increase insulin sensitivity and glucose tolerance
Improves prognosis post-MI and reduces CVD risk factors
Avoid weight training and high intensity exercise due to
peripheral neuropathy and retinopathy: prolonged
walking, jogging, treadmills, stairmaster
Avoid physical activity late during the day due to
hypoglycemia, or when it is too hot outside
Plenty of fluids

Secondary Prevention of T2DM

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)

Tertiary Prevention of T2DM


Regular glucose and HbA1c monitoring/assessment
Diet and physical activity
ADA meal plan
Low GI diet reduces risk of complications
Lifestyle changes
Urinalysis
Monitor and treat hypertension
ACE inhibitors
Caution with beta blockers: mask signs of
hypoglycemia
Monitor and treat dyslipidemia
Low dose, daily aspirin

Tertiary Prevention of T2DM


Annual eye check ups
Annual foot exams
Foot hygiene and care
Always wear shoes: leather, adequate width, molded
insoles
Inspect feet daily and visit provider if changes are
noticed
Regular foot check-ups
Avoid hot water and hot surfaces
Education on signs of hypoglycemia and hyperglycemia

Tertiary Prevention of T2DM


Pharmacotherapy
Insulin
Metformin
Incretins
ACE-inhibitors
Statins
Precautions: meals, exercise
Bariatric surgery

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/

Coronary Artery Disease

JEKELS EPIDEMIOLOGY, BIOSTATISTICS, PREVENTIVE MEDICINE AND PUBLIC HEALTH



CHAPTER 19

PREVENTIVE HEALTHCARE, HSC 3211

JULIA MARIAN, MD

What is Coronary Artery Disease?


Also known as Coronary Heart Disease** and
Ischemic Heart Disease

Leading cause of death in the U.S. (men and
women)
1 in 3 deaths in the U.S. is due to CAD
1 death due to CAD every 34 seconds

Eliminating CAD would add 7 years to the life
span

What is Coronary Artery Disease?


Mechanism
Unstable atherosclerotic plaques result in
narrowing of coronary arteries or thrombus
formation >> Decreased coronary blood flow
to heart muscle >> Cardiac muscle ischemia
Evidence suggests that plaque build-up starts in
childhood, and becomes permanent by
adolescence

What is Coronary Artery Disease?

National Heart, Lung and Blood Institute (2014)

What is Coronary Artery Disease

Angina pectoris

Myocardial infarction

Complications
Heart failure

Arrhythmia and cardiac arrest

Major Risk Factors of CAD


Modifiable risk factors

Dyslipidemia (total cholesterol > 181)

Hypertension (systolic blood pressure
>120)

Metabolic syndrome and Diabetes
mellitus

Smoking

Physical inactivity and sedentariness

Diet and Nutrition

Overweight and obesity

!
!
!
!
!

Non-modifiable risk factors



Age

> 45 in men, postmenopausal in
women (>55 y/o)

82% deaths due to CAD occur in
those > 65 y/o

Elderly women have a higher
mortality due to CAD than elderly
men

Gender

Family history of premature heart
disease

Before 55 y/o in men, before 65 y/o in
women

!

Other Risk Factors of CAD


Modifiable risk factors!
Chronic stress

Alcohol

Chronic inflammatory disorders (high CRP):
periodontal disease

Sleep apnea

Pre-eclampsia

Non-modifiable risk factors

Race

Socioeconomic status

CAD Risk Factor Assessment


Framingham Heart Study general cardiovascular
disease

Provides tailored overall risk status of
individual

Provides overall risk age
Find the interactive risk calculator at: https://
www.framinghamheartstudy.org/risk-functions/
cardiovascular-disease/30-year-risk.php#

Assessing Coronary Artery Disease


Clinical diagnosis

CBC and lipid panel

Electrocardiogram
At rest

Holter monitor

Stress test


!
!

Cardiac markers

Elevated during MI
Echocardiogram
(cardiac ultrasound)
Nuclear myocardial
perfusion imaging
Angiogram

Primary Prevention
Heart healthy diet

Increase physical activity

Minimum 30 minutes of
moderate intensity
activity 5-7 days/week

DASH diet

Total fats < 30% total


diet

Increase fiber intake

Lifestyle

Moderate alcohol intake

Reduced sodium and


increased potassium
intake

!
!

Stop smoking

Reduce stress, improve


coping strategies

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

JEKELS EPIDEMIOLOGY, BIOSTATISTICS, PREVENTIVE MEDICINE AND PUBLIC HEALTH


CHAPTER 19
PREVENTIVE HEALTHCARE, HSC 3211
JULIA MARIAN, MD

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)

2 million neurons/minute die during a


stroke (need to act fast)

Signs and symptoms depend upon


which portion of the brain was affected

What is Stroke?- Ischemic Stroke


Accounts for 80% of all strokes
Types

Thrombotic stroke
Complete arterial occlusion
Most commonly due to atherosclerosis

Embolic stroke
Complete arterial occlusion
Most commonly due to atrial fibrillation

Transient ischemic attack


Partial arterial occlusion
Permanent damage does not always occur
!

What is Stroke?- Ischemic Stroke

What is Stroke?- Hemorrhagic Stroke


Accounts for 20% of all strokes
Types

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

What is Stroke?- Hemorrhagic Stroke

Modifiable Risk Factors


Cardiac

Hypertension

Coronary artery disease

Smoking

Cardiomyopathy

Diabetes
Atherosclerosis

Heart failure

Carotid artery disease


!

Atrial fibrillation

Cerebrovascular
Aneurysm

Arteriovenous
malformations

Modifiable Risk Factors


Oral contraceptives
Alcohol
Illicit drug use
Physical inactivity
Unhealthy diet
Dyslipidemia
!

Overweight and
obesity

Stress and depression

Other disorders:
sickle cell anemia,
vasculitis, bleeding
disorders,
autoimmune disorders
!

Non-modifiable Risk Factors


Aging
Gender

Incidence: Men > Women

Mortality: Women > Men

Race and ethnicity


African American, native Alaskan, Native American >
Caucasian, Hispanic, Asian American

Family history CVA


Personal history CVA

Complications and Sequelae


1 in 4 patients will die within 1 year of having
a stroke
Long-term immobility

Hypercoagulation: deep vein thrombosis


(DVT), pulmonary embolism (PE)

Muscle weakness and atrophy


Swallowing problems
Aspiration pneumonia

Complications and Sequelae


Paralysis
Walking impairment
Speech impairment

Bladder and/or bowel incontinence


Urinary retention and/or constipation

UTI
Memory loss
Behavioral changes

Assessing Stroke
Evaluation of clinical signs and risk factors
Brain imaging

CT: detect bleeds and brain tissue damage MRI: detect


brain tissue changes and damage

CTA and MRA (arteriogram): detects changes in blood flow


and obstructions in blood flow

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

Even 60 minutes/week of moderate intensity


aerobic activity provides some benefit

Secondary Prevention
Early detection and
management of risk factors
Screening for risk
factors

Screening for carotid


stenosis (?)
Weight reduction: goal
BMI < 25

Reduce blood pressure


Control blood glucose

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/

Chronic Pulmonary Disease

JEKELS EPIDEMIOLOGY, BIOSTATISTICS, PREVENTIVE MEDICINE AND PUBLIC HEALTH


CHAPTER 19
PREVENTIVE HEALTHCARE, HSC 3211
JULIA MARIAN, MD

What is Chronic Lung Disease?- COPD


Chronic Obstructive Pulmonary Disease
Third leading cause of death in U.S.
Includes Chronic Bronchitis and Emphysema
Abnormal ventilation and gas exchange due
to: progressive loss of elasticity and
destruction of pulmonary tissue, progressive
inflammation and thickening of respiratory
airways and increased production of mucus
and mucus plugs

What is Chronic Lung Disease?


Asthma
Affects more than 25 million people in the U.S.

Chronic inflammation of the airways that flares up, resulting in


acute and reversible narrowing of the airways, and consequently
hypoxemic episodes

Pneumoconioses

Chronic inflammation, as a result of inhaling occupational dusts


or chemicals, results in lung tissue stiffening and scarring

Cystic Fibrosis
Genetically transmitted disorder
Accumulation of mucus in body tracts, including respiratory tracts

Assessing Chronic Lung Disease


Pulmonary Function Tests
(PFTs)

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

Lung diffusion: measures


efficiency of gas exchange

Assessing Chronic Lung Disease


Exercise stress test
Pulse oximetry
Arterial blood gas
Genetic testing
Allergy testing
Imaging

Modifiable Risk Factors


Firsthand smoke and secondhand smoke
Pipe, cigar, cigarette smoke

Occupational and environmental


Air pollution

Dust, asbestos, silica dust, chemical fumes


(pneumoconiosis and occupational asthma)
Allergies (allergic asthma)
Personal history of asthma
Low educational level

Non-modifiable Risk Factors


Family history

Ethnicity: caucasian
Gender: women

Low socioeconomic
status

!
!

Genetic

Alpha 1 antitrypsin
deficiency
(emphysema)

CFTR gene mutations
(cystic fibrosis)

Age

Younger age: asthma

Older age: COPD

Complications and Sequelae


Acute hypoxemic episodes
Respiratory infection
Bronchiectasis
Lung Cancer

Pulmonary hypertension and resultant heart


failure
Mental health: anxiety and depression
Death

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

Quit smoking and avoid secondhand smoke


Avoid triggers and reduce risk factors
Pharmacological

Anti-inflammatory drugs: corticosteroids


Bronchodilators

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

Tertiary Prevention: Pulmonary Rehabilitation


Used as an adjuvant to
medical therapy

Team: physicians, nurses,


respiratory therapists,
physical and occupational
therapists, dietitians and
nutritionists, psychologists
and social workers
!
!
!

Education

Teach importance of
vaccinations

Teach importance of
avoidance of triggers
and risk factors

Infection risk and


prevention of infection

How to properly use


oxygen and medications

Tertiary Prevention: Pulmonary Rehabilitation


!
!

Exercise training

Nutritional counseling

At least 3x/week

Start slow and short,


progress to faster
and longer exercise

Move arms and legs:


treadmill, stationery
bike, weights

Build muscle mass

Return you to
normal BMI range,
whether overweight
or underweight

May require caloric


and protein
supplements

Tertiary Prevention: Pulmonary Rehabilitation


Energy-conserving techniques

Learn to perform daily activities in easier


ways
Avoid reaching, lifting and bending which
make it harder to breathe
Psychological counseling and/or group support
Reduce risk of and manage depression, anxiety
and other emotional problems

Tertiary Prevention: Pulmonary Rehabilitation


Breathing strategies
Learn to take longer, deeper and less frequent
breaths

Pursed lip breathing: reduces respiratory rate and


keeps airways open for longer, increases ability to
be physically active

Positioning body so lungs can expand most when


inhaling

Learn to use abdominal muscles for effective


exhalation

Tertiary Prevention: Pulmonary Rehabilitation


Chest Physical Therapy (Physiotherapy)

Percussion (chest clapping): loosen and unclog


mucus so it can be coughed up

Postural draining: gravity forces mucus out of lungs


Electrical chest clapper or mechanical percussor

Inflatable therapy vest: high frequency waves

Handheld device that patient exhales into, causing


vibrations that will dislodge mucus

Mask that creates vibrations

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

Excessive bone resorption or deficient bone formation


> 40 million Americans have or are at risk for
osteoporosis

47% of women over 50 y/o have osteopenia or


osteoporosis

1/3 of women and 1/6 of men have had at least 1


osteoporotic fracture by 90 y/o

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

Non-modifiable Risk Factors


Gender
Women: less bone tissue and faster bone loss due
to menopause
Age: thinner and weaker bones with age
Body frame: small frame
Ethnicity: caucasian and Asian
Family history
Personal history of fractures

Modifiable Risk Factors


Optimal peak bone mass not reached during bone
formation years
Up to 30 y/o
Hormones
Amenorrhea: athletes, anorexia nervosa

Low estrogen/testosterone: menopause/andropause

Cushing syndrome: high cortisol


High parathyroid hormone

Modifiable Risk Factors


Kidney disease!
Diabetes!
Nutritional!
Calcium, vitamin D!
Medications!
Corticosteroids, anticonvulsants!
Lifestyle!
Inactivity, sedentariness!
Cigarette smoking, alcohol use!
Immobility

Complications and Sequelae


Posture!
States of increased fall risk!
Pathological fractures!
Hip!
Compression fractures!
Colles fractures!

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

Sources: low-fat dairy, dark green and leafy


vegetable (broccoli, spinach), sardines and salmons
with bones, tofu, almonds, calcium fortified foods

Need increased quantities in childhood and


puberty, pregnancy, breastfeeding, postmenopause/
andropause, elderly, patients with chronic medical
conditions

Primary Prevention
Vitamin D

1000-2000 IU/day (if not vitamin D deficient)

Sources: egg yolks, saltwater fish, liver, fortified foods

Need good store of cholesterol, 15-30 minutes of


sunlight per day

Lifestyle
Stop smoking

Moderate alcohol consumption: 2-3 ounces/day alcohol


has been shown to damage bone in men and women

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

Regular eye check-ups


Be aware of medications causing drowsiness or
dizziness
Surgical

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

Fall prevention techniques: cane/walker, avoid slippery


surfaces, tripping hazards (mats, rugs, clutter), grab bars
(bathroom, stairs), well lit areas, cordless phone

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

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