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Diabetes 2020 Session 2 Cardiovascular Risk Reduction Beverly Thomassian, RN, MPH, BC-ADM, CDE President, Diabetes Education Services Welcome Everyone Recorded version ready later on same day Questions? Bryanna@diabetesed.net or


  1. Diabetes 2020 – Session 2 Cardiovascular Risk Reduction Beverly Thomassian, RN, MPH, BC-ADM, CDE President, Diabetes Education Services

  2. Welcome Everyone • Recorded version ready later on same day • Questions? Bryanna@diabetesed.net or phone 530/893-8635

  3. Reading Material DiabetesEdUniversity.net

  4. Bev has no conflict of interest � She’s not on any speakers bureau � Does not invest � Gathers information from reading package inserts, research and standards � She does engage in “pill-ow” talk with her husband (who is a PharmD)

  5. Session 2 Topics � Session 2 – Cardiovascular Risk Reduction Strategies � ADA and AACE Guidelines for CV Risk Reduction � Implement Risk Reduction Strategies � Addressing Hypertension, Lipids

  6. Let’s elevate our role ���������������� �������������������� ��������������� �������� ��������������������� �������������������������� ������������������������ �������������������������� ������������������������ ���������������������������� ������������������ ���������������� �������������������������������������������������������� �������������� ���������������������������������� ����������������������

  7. 10. Cardiovascular Disease and Risk Management � Heart disease is the leading cause of mortality and morbidity in diabetes � Large benefits are seen when multiple risk factors are addressed globally

  8. Insulin Resistance is the Seed � Muscles are insulin resistant � Building muscle decreases insulin resistance � Fat cells become more insulin resistant � Leads to more Free Fatty Acids and Triglycerides � More vascular inflammation � Pancreas becomes fatty � Losing wt helps improve

  9. Insulin Resistance

  10. BMI – Visual Image

  11. Poll question 1 � Which of the following BEST describes insulin resistance? a. Lack of sufficient insulin receptors on fat and muscle cells. b. Visceral adipose tissue. c. A physiological condition where insulin becomes less effective at lowering blood glucose levels. d. Excessive triglyceride levels

  12. Factors Associated with Insulin Resistance � Abdominal obesity � Sedentary lifestyle � Genetics / Ethnicity � Gestational Diabetes � Polycystic ovary syndrome � Acanthosis Nigricans � Obstructive Sleep Apnea � Cancer !��������������������������������"�#$$%

  13. Acanthosis Nigricans

  14. Acanthosis Nigricans (AN) � Signals high insulin levels in bloodstream and is a marker of insulin resistance � Patches of darkened skin over parts of body that bend or rub against each other � Neck, underarm, waistline, groin, knuckles, elbows, toes � Skin tags on neck and darkened areas around eyes, nose and cheeks. � No cure, lesions regress with treatment of insulin resistance

  15. Risk of CVD Is Elevated prior to Diagnosis of Type 2 Diabetes 5.00 Relative Risk of MI* or Stroke 4.00 3.64 3.00 3.19 2.00 2.40 1.00 1.00 0.00 Non-diabetic 15 yrs or more 10-14.9 yrs <10 years throughout before before before study diagnosis diagnosis diagnosis *MI = myocardial infarction. Nurses Health Study Adapted from: Hu F, et al. Diabetes Care. 2002;25:1129-1134.

  16. Natural History of Diabetes (� &��' '������� ����������� ������ ������"�( ����������� �������� ���������� ( ������������ � ����������� ����!����� "���� ��� "�������(��� ����#��$��%� ��������� ����#��$��%� &������� &������� '�)���&������*��+&�������������,�&&�����)���+���������������

  17. 3. PreDiabetes is FREAKING ME OUT � 86 million people in US � 90% don’t know they have it � In 3-5 years, about 30% of predm will get diabetes � Associated with higher rates of heart attack, stroke, neuropathy and vessel disease � Why isn’t is called stage 1 diabetes?

  18. 3. Prevention or Delay of Type 2 � Prediabetes is associated with heightened cardiovascular risk; therefore, screening for and treatment of modifiable risk factors for cardiovascular disease are suggested. Standards of Medical Care in Diabetes - 2020 . Diabetes Care 2020;43(Suppl. 1)

  19. What is Type 2 Diabetes? � Complex metabolic disorder …. (Insulin resistance and deficiency) with social, behavioral and environmental risk factors unmasking the effects of genetic susceptibility. (������������)� �����*$$�+ �,!-�.�/���� ��������01�������/�������2��3 ����������������

  20. Cardio Metabolic Risk - 5 Hypers - � Hyperinsulinemia (resistance) � Hyperglycemia � Hyperlipidemia � Hypertension � Hyper”waistline”emia (35” women, 40” men) Manifestations of Insulin Resistance

  21. Poll question 2 � Which of the following Cardiovascular Conditions are associated with diabetes? A . Congestive Heart Failure B. Hypervasodilation C. Acanthosis Nigricans D. CardioNephritis

  22. Heart Disease & DM = 3-5xs Risk � CHF � 7.9 % w/ diabetes vs. � 1.1 % no diabetes � Heart attack � 9.8 % w/ diabetes vs. � 1.8 % no diabetes � Coronary heart disease � 9.1 % w/ diabetes vs. � 2.1 % no diabetes � Stroke � 6.6 % w/ diabetes vs. � 1.8 % no diabetes � 2007 AACE

  23. Cardiovascular Disease and Risk Management � Cardiovascular disease is the leading cause of mortality and morbidity in diabetes � Largest contributor to direct and indirect costs � Controlling cardiovascular risk improves outcomes � Large benefits are seen when multiple risk factors are addressed globally

  24. Poll question 3 � What is the relationship between diabetes and cardiovascular disease? A. Diabetes is associated with a lower rate of congestive heart failure. B. Diabetes is associated with decreased incidence of heart attack and stroke C. People with diabetes are destined to get CV complications. D. People with diabetes can decrease their risk of a CV event

  25. Diabetes & Heart Disease Motivational Stats � Every 18 mg/dl increase in fasting glucose increases risk of CV events/death by 17% � Every 1% increase in A1c increased: � CVD events by 18% � MI events by 19% � All cause mortality by 12-14% � Microvascular disease by 35% ADA Standards of Care

  26. ABCs of Diabetes � A 1c less than 7% (avg 3 month BG) � Pre-meal BG 80-130 � Post meal BG <180 � B lood Pressure < 140/90 � BP target <130/80 � If 10 year CVD Risk > 15% � C holesterol � Statin therapy indicated?

  27. Vascular Risk Factors � Modifiable � Glucose � Blood Pressure � Lipids � Smoking � Weight � Dietary Habits � Other factors – lack of exercise, Type A personality

  28. Poll Question 4 � Which of the following is the best recommendation to protect cardiovascular health? A. Avoid all fast foods B. Stop smoking C. Keep B/P as low as possible D. Eliminate sugar from diet

  29. /��������������������� Smoking and Diabetes Smoking increases risk of diabetes 30% • Ask at every visit • Assess • Advise • Assist with stop smoking • Arrange for referrals • Organize your clinic

  30. DASH Diet – Dietary Approaches to Stop Hypertension � The DASH diet emphasizes vegetables, fruits and low-fat dairy foods — and moderate amounts of whole grains, fish, poultry, nuts. � Pt recommendations � Eat lots of whole grains, fruits, vegetables and low-fat dairy products. � Also includes some fish, poultry and legumes, and encourages a small amount of nuts and seeds a few times a week. � Red meat, sweets and fats in small amounts. � Focus on low saturated fat, cholesterol, total fat.

  31. Mediterranean Diet Pyramid

  32. Benefits of Exercise and Diabetes � Increase muscle glucose uptake 5-fold � Glucose uptake remains elevated for 24 - 48 hours (depending on exercise duration) � Increases insulin sensitivity in muscle, fat, liver. � Reduce CV Risk factors (BP, cholesterol, A1c) � Maintain wt loss � Contribute to well being � Muscle strength � Better physical mobility

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