9Cumulative Incidence of Diabetes (%) Modest Weight Loss Reduces the Incidence of New-Onset Diabetes In An At-Risk PopulationWt Loss RRPlaceboMetforminLifestyle0.1 kg2.1 kg 31%5.6 kg 58%Cumulative Incidence of Diabetes (%)RR = Risk ReductionYearsP < .001 for each comparisonThe Diabetes Prevention Program Research Group conducted a large randomized study of lifestyle intervention or metformin compared with placebo in preventing new-onset diabetes in high-risk patients.Patients with BMI ≥24 kg/m2 with elevated fasting plasma glucose or elevated post-challenge plasma glucose were enrolled. A total of 3234 participants were enrolled in the study. The average follow-up time was 2.8 years.The reduction in new-onset diabetes in the lifestyle group was 58% lower compared with the placebo group and was 31% lower compared with the metformin group.Note that the group that had the greatest decrease in body weight had the lowest incidence of new-onset diabetes.Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:
10FPG 99 mg/dl TG 250 mg/dl BMI 32 FPG 86 mg/dl TG 150 mg/dl BMI 26 Amir Tirosh N Engl J Med 2006;354(22):2401.
11Modest Weight Loss Dramatically Improves Cardiometabolic Risk Even modest weight loss, defined as weight loss of between 5% and 10%, translates into dramatic improvement in cardiometabolic risk. HDL-C is improved with modest weight loss. Additionally insulin sensitivity is improved with modest weight loss. There is a decreased susceptibility to thrombosis and a decrease in inflammatory markers with modest weight loss. Finally endothelial function is improved with modest weight loss.Reference:Despres JP, Lemieux I, Prud'homme D. Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001;322(7288):Modified from Després JP, et al. BMJ. 2001;322:
26Incidence of Microvascular Complications in IGT Diabetic Retinopathy (%)IGT (HbA1c=5.9%) IGT………..…7.9%IGT (HbA1c=6.1%) T2DM………12.6%The Diabetes Prevention Program (DPP) recruited overweight and obese patients with elevated fasting glucose and impaired glucose tolerance (IGT) for weight loss intervention with the aim of diabetes prevention.A DPP substudy examined the frequency of retinopathy among a representative sample of participants who had not received a diabetes diagnosis by study end.1At the start of the study, participants who developed diabetes had a mean baseline HbA1c level of 6.1%, while the mean baseline HbA1c of participants who did not develop diabetes was 5.9%.1Of participants diagnosed with diabetes during the DPP, 12.6% developed diabetic retinopathy, compared with 7.9% of patients with IGT.1Subjects with and without diabetes who participated in the Monitoring Trends and Determinants on Cardiovascular Diseases/Cooperative Research in the Region of Augsburg Surveys (MONICA/KORA) were assessed for neuropathy. The prevalence of neuropathy in subjects with IGT was 13%.2These data suggest that traditional cut points for diabetes diagnosis may be inappropriate, considering that DPP patients presented with diabetic complications, such as retinopathy, without a diabetes diagnosis. Diabetes Prevention Program Research Group (DPP Group). The prevalence of retinopathy in impaired glucose tolerance and recent-onset diabetes in the Diabetes Prevention Program. Diabet Med. 2007;24: Ziegler D, Rathman W, Dickhaus T, Meisinger C, Mielck A, for the KORA Study Group. Prevalence of polyneuropathy in pre-diabetes and diabetes is associated with abdominal obesity and microangiopathy. Diabetes Care. 2008;31:Neuropathy (%)IGT………..…13%**Prevalence.Diabetes Prevention Program Research Group. Diabet Med. 2007;24: ; Singleton JR, et al. Diabetes Care. 2001;24: ; Ziegler D, et al. Diabetes Care. 2008;31:2626
27Number 0f Subject institute number N = 9,419 Chulalongkorn 1110 RAMA 843Siriraj621Vajira997Phra Mongkutklao956Theptarin964Rajavidhi1412Chiangmai675Khonkaen250Songkhla525Nakorn Rajsima1066N = 9,419(expected sample size= 8360 cases)
28อุบัติการณ์การเกิดภาวะแทรกซ้อนจากโรคเบาหวาน TDR:J Med Assoc Thai 2006;89(suppl1):S1-9
30Retinopathy N= 7,119 No 69.3% NA 2,300/9,419 (24.4%) 31.4%PDR 9.4 %NoNPDRPDRN= 7,119NDPR 21.3 %No 69.3%NA 2,300/9,419(24.4%)Blindness from DM 118/8,128 (1.5 %)
31CODE-2: effect of complications on costs Total costs (€)Costs due to hospitalization (%)Increase in costs vs. no complications6,000 247%5,0005,2264,000Cost (€) 109% 70%60%3,0003,1482,5632,00056%1,5051,00046%38%NocomplicationsMicro- vascularMacro- vascularBoth microand macroWilliams R, et al. Diabetologia 2002; 45:S13–S17.Complication costs driven by hospitalization3131
32Diabetes: the cost to society Estimated US costsDirect costs breakdown4Hospital inpatient careNursing home carePhysician office visitsInsulin and suppliesNon-diabetic outpatient medication44%15%11%8%5%6%$132140Cost of diabetes care in ThailandIPD: 41,950 – 42,921 b/case 11,827.2 mBaht/year2548: ,828 b/case 3,259.3 mBaht/year (MOPH)OPD2546: 9,033 baht/case 11,200,9 mBaht/year120Indirect costs$98100$9280Cost per year (US$ billion)60Direct costs40$2020In 2002, the total annual cost of diabetes in the US was estimated at $132 billion. This graph illustrates how the cost of diabetes has risen over 16 years. The figures are original estimates taken from four different analyses.1–4The full burden of diabetes is hard to measure. From the data for 2002 we can see how the total cost burden includes both direct costs for medical care and indirect costs from lost productivity due to morbidity and mortality.The indirect costs refer to the resources lost as a result of illness. Its components include the values of reduced and lost productivity due to morbidity, disability, and premature mortality.The direct cost components include expenditures associated with medical treatments, such as hospital and nursing home care, physician services, prescription drugs, laboratory tests, medical supplies, and other medical professional services.The breakdown of direct costs in the United States is illustrated in the pie chart. We can see that oral anti-diabetic agents account for only 5% of the total direct cost burden of diabetes.This slide shows data from the United States. While these data are likely to be similar worldwide, please refer to specific data in your own region if available.1. Huse DM, et al. JAMA 1989; 262:2708–2713.2. Ray NF, et al. Direct and indirect costs of diabetes in the United States in ADA, 1993.3. American Diabetes Association. Diabetes Care 1998; 21:296–309.4. American Diabetes Association. Diabetes Care 2003; 26:917–932.Oral anti-diabetic agents19861199221997320024Year1Huse DM, et al. JAMA 1989; 262:2708– Ray NF, et al. ADA, ADA. Diabetes Care 1998; 21:296–309. 4ADA. Diabetes Care 2003; 26:917–932.3232
33Indirect costIncome lossNeed other person to helpPhysical suffer: Blindness, Stroke, DyspniaPsychologicalMortality
51เหตุผลที่ควบคุมโรคเบาหวานไม่ถึงเกณฑ์จากผู้ป่วยและแพทย์ Reasons for failureเหตุผลที่ควบคุมโรคเบาหวานไม่ถึงเกณฑ์จากผู้ป่วยและแพทย์แพทย์:*ไม่สามารถบอกถึงผลดีของการรักษาได้เกณฑ์การรักษาที่แตกต่างกันไม่มีเวลาไม่มีอุปกรณ์การสอนไม่กล้าที่จะใช้อินซูลินผู้ป่วย:**ไม่มีความรู้เกี่ยวกับโรคกลัวน้ำตาลต่ำไม่กล้าตรวจเลือดที่บ้านกลัวฉีดยาปัญหาเศรษฐานะไม่สามารถปรับเปลี่ยนพฤติกรรมทาง อาหาร, การออกกำลังกายมีความเชื่อที่แตกต่างกันPhysicians and patients cite many reasons for failing to reach recommended glycemic targets with their diabetes medications.1,2Therapy-related barriers include reduced long-term efficacy with oral agents, fear of hypoglycemia and a variety of issues related to flexibility and convenience that encourage poor compliance with therapy.From the patient’s perspective, issues relating to lifestyle, education, psychology and the environment can prevent optimum diabetes self-management. Poor access to and/or use of specialist healthcare resources also has a negative effect on treatment outcomes.ReferencesGerich JE. The importance of tight glycemic control. Am J Med 2005;118(Suppl 9A):7S–11S.Barnett AH. Treating to goal: challenges of current management. Eur J Endocrinol 2004;151(Suppl 2):T3–7.* Gerich JE. Am J Med 2005;118(Suppl 9A):7S–11S** Barnett AH. Eur J Endocrinol 2004;151(Suppl 2):T3–751
60ATP III: The Metabolic Syndrome ATP III: The Metabolic Syndrome* *Diagnosis is established when >3 of these risk factors are presentRisk FactorDefining LevelAbdominal obesity† (Waist circumference‡)Men>102 cm (>40 in)Women>88 cm (>35 in)TG>150 mg/dLHDL-C<40 mg/dL<50 mg/dLBlood Pressure>130/>85 mm HgFasting glucose>110 (>100)**mg/dLATP III: the metabolic syndromeThe NCEP ATP III guidelines define 5 components of the metabolic syndrome; at least 3 of the 5 criteria are required for the diagnosis of the metabolic syndrome. Note that the NCEP metabolic syndrome has different criteria for triglycerides and HDL-C, unlike the WHO definition, which lists high triglycerides and/or low HDL-C as a single factor. Almost all individuals in North America who have the metabolic syndrome have a high waist circumference as one of the criteria. Note also that the NCEP definition of the metabolic syndrome is more liberal than the NCEP major risk factors for blood pressure (140/90 mm Hg) and HDL-C (<40 mg/dl in both men and women).In 2003, the American Diabetes Association recommended lowering the limit for impaired fasting glucose from 110 mg/dL to 100 mg/dlL. It seems likely that the NCEP criteria will eventually accept this new criteria for fasting glucose levels. In 2004 a report from the series of workshops sponsored by the NIH, ADA and AHA reported the new ADA IFG criteria in a footnote to a table on the NCEP metabolic syndrome.References:Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third 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). JAMA 2001;285:The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26: ,2003Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant D, for the Conference Participants. Definition of metabolic syndrome: report of the National, Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition.Circulation. 2004;109:** 2003 New ADA IFG criteria (Expert Panel…,Diabetes Care 26: , 2003)* The Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:**The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26: ,
61The Metabolic Syndrome: Current Perspective Body Size BMI Central AdiposityInsulin Resistance+HyperinsulinemiaGlucose MetabolismUric Acid MetabolismDyslipidemiaHemodynamicNovel Risk Factors Uric acid Urinary uric acid clearance TG PP lipemia HDL-C PHLASmall, dense LDL± Glucose intolerance SNS activity Na retentionHypertension CRP PAI-1 FibrinogenThe metabolic syndrome: current perspectiveSince the 1998 Banting lecture, a number of new candidates have been recognized for the metabolic syndrome/insulin resistance syndrome/syndrome “X”. These additional candidates have included small dense LDL and a group of novel risk factors including elevated CRP levels, PAI-1 and fibrinogen. Other investigators have noted that insulin resistance occurs in women with polycystic ovarian syndrome and some authors are now making an association of insulin resistance with non-alcoholic fatty liver disease. Note that in this more recent review, Professor Reaven acknowledges the importance of visceral adiposity.References:1. Reaven G. Syndrome X: 10 years after. Drugs. 1999;58(suppl 1):19-20.CORONARY HEART DISEASEAdapted from Reaven G. Drugs. 1999;58 (suppl):19-20
62Waist Circumference is Correlated with Abdominal Adipose Tissue While BMI has received a lot of attention in the past few years as the way to define obesity, and hence, the associated risk factor, a number of sources suggest that this might not be the best parameter. For instance, a football lineman who is 6’4” tall and weighs 300 pounds (medium size by NFL standards) has a BMI of more than 35, which supposedly means he is markedly, nearly morbidly, obese. This same lineman may have a total body fat of less than 5%, hardly obese. This does not mean that he won’t have heart disease or is not at risk of developing it (especially if he is taking anabolic steroids).This graphic suggests that waist circumference might be a better surrogate measure than BMI. It shows the correlation between waist circumference and abdominal fat as measured by CT of the abdomen. Obviously, a CT scan is not a very efficient screening method, and waist circumference might serve as a surrogate marker for obesity.Reference:Despres JP, Lemieux I, Prud'homme D. Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001;322(7288):Note the high correlation coefficient (r = 0.80)Despres JP, et al. BMJ. 2001;322:
63Interrelationships Between Insulin Resistance and Atherosclerosis ObesityCardiovascular disease is largely preventableInflam-mationSmall dense LDL-CLow HDL-CHBP InsulinDiabetes TG CoagThis multi-daggered chart points out quite dramatically that the insulin resistance-obesity–atherosclerosis-endothelial dysfunction relationship is rather complicated, and reminds us that much needs to be learned.Reference:Courtesy of Ginsberg HN, with permission.Endothelial DysfunctionAtherosclerosisHBP = high blood pressure; TG = triglycerides; Coag = coagulation.Used with permission of Ginsberg HN.
73Transteoretical model ProblemsidentifiedMotivationalForce for changeAction plandevelopedNew behaviorreinforced
74A social-ecological model of influences on pediatric obesity and its treatment. (Courtesy of Denise E. Wilfley, PhD, St. Louis, MO.)
75Calories Count Energy Expenditure Energy Intake To lose weight, energy intake must be reducedOne pound (0.5 kg) of body fat = 3500 kcalTo lose 0.5 kg / weekDecrease caloric intake by 500 kcal / dayTo lose 1 kg / weekDecrease caloric intake by 1000 kcal / day
77Iced Caffè Mocha venti iced 24oz whipped cream whole milk Nutrition Facts Per Serving (24 fl oz)Calories 430Calories from Fat 200% Daily Value*Total Fat 22g34%Saturated Fat 12g60%Trans Fat 0.5gCholesterol 65mg22%Sodium 115mg5%Total Carbohydrate 55g19%Dietary Fiber 3g12%Sugars 39gProtein 13gVitamin A 15% Vitamin C 0% Calcium 30% Iron 25%Caffeine 265mg*Percent Daily Values are based on a 2,000 calorie diet.
78Iced Caffè Americano venti iced 20 oz Nutrition Facts Per Serving (24 fl oz)Calories 25Calories from Fat 0% Daily Value*Total Fat 0g0%Saturated Fat 0gTrans Fat 0gCholesterol 0mgSodium 10mgTotal Carbohydrate 4g1%Dietary Fiber 0gSugars 0gProtein <1gVitamin A 0% Vitamin C 0% Calcium 2% Iron 0%Caffeine 300mg*Percent Daily Values are based on a 2,000 calorie diet.
79เครื่องดื่มรังนกสำเร็จรูปสูตรน้ำตาลกรวด ส่วนประกอบโดยประมาณ น้ำตาลกรวด 12.2% รังนกแท้ (น้ำหนักแห้งก่อนต้ม) 1.1% เครื่องดื่มรังนกสำเร็จรูปสูตรไม่มีน้ำตาลส่วนประกอบโดยประมาณซอร์บิทอล (ได้จากธรรมชาติ) 12.2%รังนกแท้ (น้ำหนักแห้งก่อนต้ม) 1.1%2.6 kilocalories per gram versus the average 4 kilocalories
97Suggest for altering pattern and behavior Common findingTherapeutic strategiesNight time eatingNot skip mealsTry to substitute with other behaviorBinge eatingNot skip mealAvoid situation and place that trigger binge behavior
98Common findingTherapeutic strategiesTrigger foodKeep trigger food out of sight and plan to eat them only the safe conditionPortion to largeChange portion sizePre portion food and placeDo not opt for 2nd serving
99Common findingTherapeutic strategiesTry to substitute with other activitiesEmotional eatingToo many snacksPre plan healthy snackshigh fiber cereal, low fat cheese,fruitMeal skippingRegular meal timeMeal replacement drink and bars
100Common findingTherapeutic strategiesToo many liquid caloriesChoose more calorie freeActivities while eatingTry not to watch TV,read, or drive while eatingPre plan orderingHealthy request like salad,soupDining out often
101Current Surgical Procedures Gold StandardRoux-en-YGastric BypassVertical BandedGastroplastyAdjustableGastric Banding48-74% ofinitial weight(weight loss at 5 years)50-60% ofinitial weight(weight loss at 5 years)36% ofexcess weight(weight loss at 3 years)1Maximum weight loss occurs months post-op
103This Cathy cartoon nicely sums up the issues related to pharmacotherapy. No diet drug is a magic pill; if used, diet drugs need to be considered as part of a comprehensive program for weight loss in carefully selected patients.
104You…. Need to think Start with myself ! Start right here ! Start right now !Stop living the sedentary life style !
105It’s time to prevent obesity Thank you for your attentionIt’s time to prevent obesity