diabesity
DESCRIPTION
From the first Annual Health Disparities Conference at Teacher's College, Columbia University,NYC--2002by Raymond Zakhari, NPMetro Medical DirectTRANSCRIPT
![Page 1: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/1.jpg)
Diabesity:
The goal of achieving optimum glycemic control through the use of
stages of change (SOC), motivational interviewing (MI), and relapse
Prevention (RP).
Raymond Zakhari, NPMetro Medical Direct
![Page 2: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/2.jpg)
Obesity Diabetes Connection
• Type 2 Diabeteso Insulin resistanceo Relative beta-cell failureo Central adiposityo Elevated Triglycerides
**Reduction of central adiposity (Weight Loss) is better than medications in controlling T2DM
![Page 3: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/3.jpg)
Significance
1) Heart Disease: 696,9473) Stroke: 162,6726) Diabetes: 73,249
CDC: 2002 http://www.cdc.gov/nchs/fastats/lcod.htm
![Page 4: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/4.jpg)
The only people who truly welcome change are wet
babies!!
If you want to understand something, try to change it!
(Kurt Lewin 1951)
![Page 5: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/5.jpg)
Persuasion Exercise
• 53 yo. M. venture capitalist, starting your own firm. T2DM, HTN, Obesity, (Metabolic Syndrome). You don’t ever exercise because you think it’s too much for your heart to take. You want to be made just to feel better.
![Page 6: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/6.jpg)
Persuasion Exercise
• You’re a New PCP, who just started in a new group practice, you want to help ALL your patients improve.
The patient has been passed around from provider to provider with no improvement and if he doesn’t loose weight and exercise he may have some serious complications.
![Page 7: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/7.jpg)
Your Mission
• Get the patient to do something about his weight and inactivity and his disease management. This is a serious problem.
• You have 5 minutes!!. . . . On your mark!! Get set!!!!GO!!!!!
![Page 8: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/8.jpg)
Type 2 Diabetes ? ?
What comes to mind?
![Page 9: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/9.jpg)
Behaviors
• Pre- Diagnosiso InactivityoPoor Eating Habits
• Post-Diagnosiso Inactivityo Poor Eating Habitso Medication Managemento SMBG (self-monitoring
blood glucose)o Health appointments
![Page 10: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/10.jpg)
You Want Me to . . .
• Stop eating my favorite foods
• Start exercising everyday
• Stick my finger at least 3 times per day
• See my PCP, Eye Doctor, Dentist, Podiatrist, Nutritionist, Diabetic Educator
• Take the following Medications Every Day:o 1) ASAo 2) ARB / ACE-Io 3) TZD / Biguanadineo 4) Statin
• Blood work every 3 months at least
![Page 11: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/11.jpg)
Adherence Complications
• ACE-I : irritating cough• TZD: legs may swell, fluid in lungs—SOB• Biguanadine- diarrhea and stomach cramps• ASA- nausea• Statin- generalized muscle aches and pains• ARB- dizziness
![Page 12: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/12.jpg)
Non-adherence Complications
• Renal Failure• Cardiovascular disease• Stroke• Amputation of limbs• Sexual dysfunction• Peripheral Neuropathy• Gastroparesis
![Page 13: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/13.jpg)
Stages Of ChangePrecontemplator
“I feel fine. Your test must be wrong.”“Your not even a doctor”“Those medicines all have side effects worse than this disease that you claim I have”“There is no way I can make all those changes”“What difference does it make? We all have to go sometime, and if I go, I want to go happy.”“I’ve tried before and I can’t do it.”
![Page 14: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/14.jpg)
Contemplators
• “Uncontrolled diabetes is bad”• “My relative had this and they lost their . . .”• “How many times do I really have to check
my sugar?”• “Do I really have to give up all my favorite
foods?”• “I know I need to loose weight”• “I don’t want to become a burden to . . .”
![Page 15: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/15.jpg)
Preparatory Stage
• “I’m going to join a gym closer to my house this time”
• “I’m going to pack my lunch and an afternoon snack so I don’t raid the vending machine”
• “I’m going to get a daily pill box and put it next to my tooth brush”
• “I can put my glucometer on my night stand”• “I can schedule something fun to do after my
appointments”
![Page 16: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/16.jpg)
Action
• “I booked or have gone to my appointments”• “I got the prescription filled”• “I calibrated my glucometer”• “I pre-poured my med’s for the week”• “I’m walking 20 minutes every day”• “I look at my feet every night”• “I didn’t super-size my fast-food lunch”
![Page 17: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/17.jpg)
Maintenance
• “I feel so much better and I never want to go back to the way I used to be”
• “Did you know that they serve grilled chicken at fast-food places and I can get mustard instead of mayo?”
• “If I don’t eat everything on my plate at dinner I can have lunch the next day.”
• “I can now fit into my old clothes”
![Page 18: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/18.jpg)
Lapse/ Relapse
• “I had a pasta dinner, wine and the whole Tiramisu”Two Pathways
“Next time I could eat half the pasta, and share the Tiramisu with everyone, or save it for tomorrow”
“I loved not feeling restricted in what I eat, if I want pasta, wine and dessert I’ll do it. This diabetes thing really isn’t that bad.”
![Page 19: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/19.jpg)
High Risk Eating
• Situational DeterminantsDarpkin et al. (1995):1) Family celebration w/ favorite foods.2) Argument ends with escape to kitchen full of favorite foods.3) Visit the kitchen during a TV commercial.4) Work break from pressure situation snacks by coworker.What would you do to Avoid over eating?
![Page 20: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/20.jpg)
• Rate your temptation:
• Rate your self efficacy regarding not overeating
• Those that came up with coping strategies had lasting effects of long-term weight loss (>6 months).
![Page 21: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/21.jpg)
Providing Alternatives for Maladaptive Eating
• How to counter High Risk Situations Boredom/ lack of activities Emotionally charged situations
• Development of healthy addictions: Exercise, Meditation
![Page 22: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/22.jpg)
RP
• Build Self Efficacy• How should one interpret lapse and relapse?• Abstinence Violation Effect (AVE)
o Cognitive attribution for the lapseo Affective reaction to the attribution
o The higher the AVE the more maladaptive eating ensues as a means of restoring feelings of well- being
![Page 23: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/23.jpg)
The individual’s state of health and well-being are multivariable in nature– While anyone can write the right prescription to fix the numbers, the prudent clinician must not focus merely on what those numbers represent, but who those numbers represent.
![Page 24: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/24.jpg)
Case Study
• 52 yo. W M. Opera Composer & pianist, single
Risk Factors:• Family History• Central adiposity• Hypertriglycericdemia• Sedentary
![Page 25: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/25.jpg)
Case study continued
• SHx:o Many social engagementso Much alone timeo Difficulty getting commissiono NO SMBG
• Labs:o A1C- 10, Creat. 1.2, Random Urine Micro Albumin
100, AST—15, ALT--20
![Page 26: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/26.jpg)
Case Study Continued
• Meds./ Treatmento glipizide 10mg, BIDo Exercise, watch carbs., try too loose weight.o Plan to start Insulin
![Page 27: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/27.jpg)
Perceived Resistance/ Non-compliant
Major Concerns Loss of sensitivity to fingers related to finger sticks What to eat at parties Occasional hypoglycemic events Needle phobia
![Page 28: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/28.jpg)
Assessment and Plan
• Type 2 Diabetes, Uncontrolledo 1) Weekly visits X 4 o 2) Stop glipizide, start metformin 500 b.i.d.
Warn of GI adverse effectso 3) Instruct in SMBGo 4) Refer to internet sites for Diabetic dieto 5) Review foot examso 6) Journal concernso 7) Repeat Random Chemistry in week 4
![Page 29: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/29.jpg)
A/P continued
• Increase metformen to 1500 mgs. q.h.s.• Add rosiglitazone 4mgs q hs, add Asprin.• Creative solution to finger-sticks• RV in 4 weeks with journal of ideas for
desired outcomes and check LFTs, phone f/u PRN.
• AII-RB started• Referral to RD
![Page 30: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/30.jpg)
9 Month Follow-up Visit
• A1C- 6.8, microalbumin—30mg/dl.• SMBG done 3 times per week with food
journaling• Exercising 4 times per week X 45 minutes
(home aerobic machine)• Reported Weight Loss of 6 inches (48 to 42)• Meds adjusted to 1 combination pill of
rosiglitazone/ metformin 4/2000 daily.
![Page 31: Diabesity](https://reader033.vdocument.in/reader033/viewer/2022061202/547b36feb4af9f38538b489c/html5/thumbnails/31.jpg)
References
Collins, R.L. (2005) Relapse Prevention for Eating Disorders and Obesity. In Marlatt, G.A. & Donovan, D.M., Relapse Prevention: Maintenance strategies in the Treatment of Addictive Beahviors (248- 269). New York: The Guilford Press.