By Paul Poirier MD, PhD, FRCPC, FACC, FAHA
Associate Professor, Faculty of Pharmacy, Université Laval
Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec
Québec, QC, Canada
The European Healthy Lifestyle Alliance (EHLA) is pleased to present - in close cooperation with ICCR - the first-ever 'Global Sugar-Sweetened Beverage Sale Barometer'.
The European Healthy Lifestyle Alliance (EHLA) is pleased to present - in close cooperation with ICCR - the first-ever 'Global Sugar-Sweetened Beverage Sale Barometer'.
Comparative effectives of angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers added to standard medical therapy for treating patients with stable ischemic heart disease and preserved left ventricular systolic function.
Prof. DR. Dr. Rochmad Romdoni, SpJP(K), FINASIM, FIHA, FAsCC. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
A systematic analysis for the Global Burden of Disease Study 2010
Stephen Lim, on behalf of the GBD 2010 Comparative Risk Assessment Group
The Royal Society, 14 December 2012
Dr. Jonathan Quick and Janneke Quick discuss the growing epidemic of non-communicable diseases and the Biblical wisdom behind developing healthy habits.
CORONARY ARTERY DISEASE is a modern epidemic in india. due to changes in living conditions and habits its prevalence is increasing day by day . in this presentation i have explained the various risk factors and innovations in diagnosis of CAD. IT is very useful for primary health care physicians and community medicine specialist
Comparative effectives of angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers added to standard medical therapy for treating patients with stable ischemic heart disease and preserved left ventricular systolic function.
Prof. DR. Dr. Rochmad Romdoni, SpJP(K), FINASIM, FIHA, FAsCC. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
A systematic analysis for the Global Burden of Disease Study 2010
Stephen Lim, on behalf of the GBD 2010 Comparative Risk Assessment Group
The Royal Society, 14 December 2012
Dr. Jonathan Quick and Janneke Quick discuss the growing epidemic of non-communicable diseases and the Biblical wisdom behind developing healthy habits.
CORONARY ARTERY DISEASE is a modern epidemic in india. due to changes in living conditions and habits its prevalence is increasing day by day . in this presentation i have explained the various risk factors and innovations in diagnosis of CAD. IT is very useful for primary health care physicians and community medicine specialist
د فيصل الناصر - Faisal Alnasir is a Professor and Chairman at Dept Of Family & Community Medicine at Arabian Gulf University.
http://www.faisalalnasir.com
Takes the viewer through some major trends in the world and gives an example on how technology combined with sport can help activate people to live healthier lives
Ray Baxter from Kaiser Permanente's Community Benefit presented at the Bay Area Open Space Council's 2011 conference. More about the conference here: http://openspacecouncil.org/upload/page.php?pageid=53
A special feature on the ‘dirty chemicals’ in cosmetics
Toxic chemicals are all around us.
They're in the soaps we bathe our kids with, the creams we lather on our skin day and night, the detergent we wash our clothes with. It’s in the food that we eat!
Many have been linked to increasing risks for chronic and life-threatening diseases.
Targeting abdominal obesity in diabetology: What can we do about it?My Healthy Waist
By Luc Van Gaal, MD, PhD, Professor of Medicine, Antwerp University Hospital, Faculty of Medicine, Department of Diabetology, Metabolism & Clinical Nutrition, Antwerp, Belgium
Hypertrophic obesity is associated with type 2 diabetes and impaired adipogen...My Healthy Waist
By Ulf Smith, MD, PhD, Professor of Internal Medicine, The Lundberg Laboratory for Diabetes Research, Center of Excellence for Cardiovascular and Metabolic Research, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
Global dimensions of sugary beverages in programmatic and policy solutions.My Healthy Waist
Global dimensions of sugary beverages in programmatic and policy solutions.
By Barry Popkin, PhD, Department of Nutrition, School of Public Health and Medicine Department of Economics, The University of North Carolina at Chapel Hill, NC, USA
Physical Activity in the Management of Abdominal ObesityMy Healthy Waist
By Robert Ross, PhD, Professor, School of Kinesiology and Health Studies, Department of Medicine, Division of Endocrinology and Metabolism, Queen's University, Kingston, ON, Canada
Abdominal obesity, intra-abdominal adiposity and related cardiometabolic risk...My Healthy Waist
By Jean-Pierre Després, PhD, FAHA, Scientific Director, International Chair on Cardiometabolic Risk, Professor, Division of Kinesiology, Université Laval, Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada.
A simplified view of Victor Dzau´s cardiovascular continuumMy Healthy Waist
By Luis Miguel Ruilope, MD, Professor, Internal Medicine, Complutense University, Head of the Hypertension Unit, 12 de Octubre Hospital, Madrid, Spain.
Sugar-sweetened beverage consumption in relation to diabetes and cardiovascul...My Healthy Waist
By Frank B. Hu, MD, PhD Professor of Nutrition and Epidemiology Harvard School of Public HealthChanning Laboratory, Harvard Medical School and Brigham and Women’s Hospital
By Juliana C N Chan, MBChB, MD, FRCP Professor of Medicine & Therapeutics, Director, Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Clinical Management of CVD Risk in Abdominal Obesity and Type 2 DiabetesTargeting Blood Pressure
1. CLINICAL MANAGEMENT OF CVD
RISK IN ABDOMINAL OBESITY AND
TYPE 2 DIABETES
TARGETING BLOOD PRESSURE
Paul Poirier MD, PhD, FRCPC, FACC, FAHA
Associate Professor, Faculty of Pharmacy, Université Laval
Centre de recherche de l’Institut universitaire de cardiologie et de
pneumologie de Québec
Québec, QC, Canada
Source: www.myhealthywaist.org
7. Physician Attitudes Toward Managing Obesity (1 of 2)
Mail survey of 1,222 physicians.
Six specialties:
• Family practice
• Internal medicine
• Gynecology
• Endocrinology
• Cardiology
• Orthopedics
Beliefs, attitudes and practices regarding obesity.
High concern for the health risks of moderate and morbid obesity
(smoking ranked first).
Adapted from Kristeller JL et al. Prev Med 1997;26:542-9
Source: www.myhealthywaist.org
8. Physician Attitudes Toward Managing Obesity (2 of 2)
Family practitioners, internists, endocrinologists.
• Reported treating obesity themselves
• 50% of patients
Gynecologists, cardiologists, orthopedics.
• 5 to 29% of patients
• Greater interest in referral
Formal referral to weight-loss program.
• Unlikely: family practitioners, internists
• Referral to a nutritionist: endocrinologists
Providing counselling, giving written information, making a
specific plan, scheduling follow-up visits.
• Family practitioners
• Internists
• Endocrinologists
Adapted from Kristeller JL et al. Prev Med 1997;26:542-9
Source: www.myhealthywaist.org
9. Potential Pathophysiological Pathways of Insulin Leading to
Hypertension
Adapted from Poirier P et al. Therapy 2007;4:575-83
Source: www.myhealthywaist.org
10. Québec Health Survey
Representative sample of Québec
• Institut de la statistique de Québec
• 95 territories of 40 patients
18 to 74 years (6 groups)
• 18-34, 35-64, 65-74 years
• Men and women
Complete data for 1,844 patients
Adapted from Poirier P et al. Hypertension 2005;45:363-7
Source: www.myhealthywaist.org
11. Impact of Waist Circumference on Blood Pressure
Men
<88 cm
≥88 cm
82 135
Diastolic blood pressure
Systolic blood pressure
1,2,3
1,2,3 1,3 1,3
1,3
80 130
(mm Hg)
(mm Hg)
78 125
2
76 120
74 115
(1) (2) (3) (4) (5) (6) (1) (2) (3) (4) (5) (6)
72 110
<23.2 23.2-26.6 ≥26.6 <23.2 23.2-26.6 ≥26.6
Tertiles of BMI (kg/m2) Tertiles of BMI (kg/m2)
1,2,3: significantly different from the corresponding subgroup
Adapted from Poirier P et al. Hypertension 2005;45:363-7
Source: www.myhealthywaist.org
12. Impact of Waist Circumference on Blood Pressure
Women
<74 cm
≥74 cm
80 135
Diastolic blood pressure
Systolic blood pressure
1,3,4 1,2
78 130
1 3,4,5
76
(mm Hg)
1
(mm Hg)
125
74
1 120
72 1
115
70
68 110
(1) (2) (3) (4) (5) (6) (1) (2) (3) (4) (5) (6)
66 105
<21.4 21.4-24.8 ≥24.8 <21.4 21.4-24.8 ≥24.8
Tertiles of BMI (kg/m2) Tertiles of BMI (kg/m2)
1,2,3,4,5: significantly different from the corresponding subgroup
Adapted from Poirier P et al. Hypertension 2005;45:363-7
Source: www.myhealthywaist.org
13. Blood Pressure Lowering in Diabetes: Major Issue
Guidelines recommend reduction of systolic
blood pressure to 130-135 mm Hg or lower.
Does this:
Produce additional vascular protection?
• Microvascular
• Macrovascular
Source: www.myhealthywaist.org
14. 2007 ESH-ESC Practice Guidelines for the Management of
Arterial Hypertension
Diabetic patients
• Where applicable, intense nonpharmacological
measures should be encouraged in all patients
with diabetes, with particular attention to weight
loss and reduction of salt intake in type 2
diabetes.
ESC: European Society of Cardiology
ESH: European Society of Hypertension
Adapted from 2007 ESH-ESC Guidelines for the management of arterial hypertension
J Hypertens 2007;25:1105-87
Source: www.myhealthywaist.org
15. Effects of a fixed combination of
perindopril and indapamide on
macrovascular and microvascular
outcomes in patients with type 2 diabetes
mellitus (the ADVANCE trial): a
randomised controlled trial.
Patel A; ADVANCE Collaborative Group, MacMahon S, Chalmers J, Neal B,
Woodward M, Billot L, Harrap S, Poulter N, Marre M, Cooper M, Glasziou P,
Grobbee DE, Hamet P, Heller S, Liu LS, Mancia G, Mogensen CE, Pan CY,
Rodgers A, Williams B.
Adapted from Patel A et al. Lancet 2007;370:829-40
and http://www.advance-trial.com
Source: www.myhealthywaist.org
16. The ADVANCE Trial
Blood pressure decrease
165 Mean blood
pressure during
155 follow-up
Blood pressure (mm Hg)
145 Systolic
140.3 mm Hg
135 134.7 mm Hg
125 Δ 5.6 mm Hg (95% CI: 5.2-6.0, p<0.0001)
115
105
95
85
Diastolic
75 77.0 mm Hg
Δ 2.2 mm Hg (95% CI: 2.0-2.4, p<0.0001) 74.8 mm Hg
65
R 6 12 18 24 30 36 42 48 54 60
N=11,140 patients Follow-up (months) Placebo
Mean follow-up duration 4.3 years
BMI: 28±5 kg/m2 in both groups
Perindopril-indapamide
Adapted from Patel A et al. Lancet 2007;370:829-40
and http://www.advance-trial.com
Source: www.myhealthywaist.org
18. Summary – Main Results
Blood Pressure Lowering Comparison
Routine treatment of type 2 diabetic
patients with drug therapy resulted in:
• 14% reduction in total mortality
• 18% reduction in cardiovascular death
• 9% reduction in major vascular events
• 14% reduction in total coronary events
• 21% reduction in total renal events
No mention of BMI at follow-up
Adapted from Patel A et al. Lancet 2007;370:829-40
and http://www.advance-trial.com
Source: www.myhealthywaist.org
19. Effects of Intensive Blood Pressure
Control on Cardiovascular Events in Type
2 Diabetes Mellitus: the Action to Control
Cardiovascular Risk in Diabetes
(ACCORD) Blood Pressure Trial
ACCORD Study Group, Cushman WC, Evans GW, Byington RP, Goff DC Jr,
Grimm RH Jr, Cutler JA, Simons-Morton DG, Basile JN, Corson MA, Probstfield
JL, Katz L, Peterson KA, Friedewald WT, Buse JB, Bigger JT, Gerstein HC, Ismail-
Beigi F.
Adapted from the ACCORD study group. N Engl J Med 2010;362:1575-85
Source: www.myhealthywaist.org
20. The ACCORD Trial – Study Design
Randomized multicentre clinical trial.
Conducted in 77 clinical sites in North America (U.S. and
Canada).
Designed to independently test three medical strategies
to reduce cardiovascular disease in diabetic patients.
Blood pressure question: Does a therapeutic strategy
targeting systolic blood pressure <120 mm Hg reduce
cardiovascular disease events vs. a strategy targeting
systolic blood pressure <140 mm Hg in patients with type
2 diabetes at high risk for cardiovascular disease events.
N=4,733 patients
Mean follow-up duration 4.7 years for the primary outcome
Adapted from the ACCORD study group. N Engl J Med 2010;362:1575-85
Source: www.myhealthywaist.org
21. The ACCORD Trial – Systolic Pressures
Systolic pressures (mean±95% CI) Standard
140 Intensive
Systolic blood pressure (mm Hg)
130
Average=133.5 Standard vs. 119.3 Intensive, Δ=14.2 mm Hg
120
N=4,382 N=4,050 N=2,391 N=359
110
0 1 2 3 4 5 6 7 8
Years post-randomization Baseline BMI:
32.2±5.7 vs. 32.1±5.4 kg/m2
Mean number of medications prescribed:
Intensive 3.2 3.4 3.5 3.4
Standard 1.9 2.1 2.2 2.3
Adapted from the ACCORD study group. N Engl J Med 2010;362:1575-85
Source: www.myhealthywaist.org
22. The ACCORD Trial – Primary and Secondary Outcomes
Intensive Standard
Hazard ratio (HR)
Events Events p
(95% CI)
(%/year) (%/year)
Primary 208 (1.87) 237 (2.09) 0.88 (0.73-1.06) 0.20
Total mortality 150 (1.28) 144 (1.19) 1.07 (0.85-1.35) 0.55
Cardiovascular
60 (0.52) 58 (0.49) 1.06 (0.74-1.52) 0.74
deaths
Nonfatal myocardial
126 (1.13) 146 (1.28) 0.87 (0.68-1.10) 0.25
infarction
Nonfatal stroke 34 (0.30) 55 (0.47) 0.63 (0.41-0.96) 0.03
Total stroke 36 (0.32) 62 (0.53) 0.59 (0.39-0.89) 0.01
Also examined fatal/nonfatal heart failure (HR=0.94, p=0.67), a composite of fatal coronary events, nonfatal
myocardial infarction and unstable angina (HR=0.94, p=0.50) and a composite of the primary outcome,
revascularization and unstable angina (HR=0.95, p=0.40).
Adapted from the ACCORD study group. N Engl J Med 2010;362:1575-85
Source: www.myhealthywaist.org
23. The ACCORD Trial – Primary Outcome (Nonfatal Myocardial
Infarction, Nonfatal Stroke or Cadiovascular Disease Death)
Baseline weight:
20
20
92.1±19.4 vs. 91.8±17.7 kg
HR=0.88
Follow-up weight:
95% CI (0.73-1.06)
93.3±21.2 vs. 92.5±20.2 kg
Patients with Events (%)
15
15
10
10
55
00 Standard
0
0 1
1 2
2 3
3 4
4 55 66 77 88 Intensive
Years Post-Randomization
Years post-randomization
Adapted from the ACCORD study group. N Engl J Med 2010;362:1575-85
Source: www.myhealthywaist.org
24. The ACCORD Trial – Nonfatal Stroke
Baseline weight:
20
20 92.1±19.4 vs. 91.8±17.7 kg
HR=0.63 Follow-up weight:
95% CI (0.41-0.96) 93.3±21.2 vs. 92.5±20.2 kg
Patients with Events (%)
15
15
10
10
55
00
0 1 2 3 4 5 6 7 8 Standard
0 1 2 3 4 5 6 7 8
Years Post-Randomization Intensive
Years post-randomization
Adapted from the ACCORD study group. N Engl J Med 2010;362:1575-85
Source: www.myhealthywaist.org
25. The ACCORD Trial – Total Stroke
Baseline weight:
20
20 92.1±19.4 vs. 91.8±17.7 kg
HR=0.59 Follow-up weight:
95% CI (0.39-0.89) 93.3±21.2 vs. 92.5±20.2 kg
Patients with Events (%)
15
15
10
10
5
5
0
0
0
0 1
1 2
2 3
3 4
4 5
5 6
6 77 88 Standard
Years Post-Randomization Intensive
Years post-randomization
Adapted from the ACCORD study group. N Engl J Med 2010;362:1575-85
Source: www.myhealthywaist.org
26. Long-Term Effects of Weight-Reducing
Interventions in Hypertensive Patients
Systematic Review and Meta-Analysis
Horvath K, Jeitler K, Siering U, Stich AK, Skipka G, Gratzer TW, Siebenhofer A.
Adapted from Horvath K et al. Arch Intern Med 2008;168:571-80
Source: www.myhealthywaist.org
27. Diet vs. Usual Care: Changes in Body Weight
Diet group Control group
Participants Standard Participants Standard WMD (random) WMD
Source Mean Mean Weight (%)
no. deviation no. deviation (95% CI) (95% CI)
Croft et al.† 66 -6.50 (10.65) 64 -0.20 (10.65) 4.75 -6.30 (-9.96 to -2.64)
Jalkanen* 24 -4.00 (6.96) 25 0.00 (6.96) 4.24 -4.00 (-7.90 to -0.10)
DISH 67 -4.00 (5.00) 77 -0.50 (3.60) 20.08 -3.50 (-4.94 to -2.06)
TAIM IG + P vs. 90 -4.40 (6.64) 90 -0.70 (3.79) 17.96 -3.70 (-5.28 to -2.12)
CG + P
TAIM IG + A vs. 88 -3.00 (3.75) 87 0.50 (2.80) 29.50 -3.50 (-4.48 to -2.52)
CG + A
TAIM IG + C vs. 87 -6.90 (4.66) 87 -1.50 (3.73) 23.47 -5.40 (-6.65 to -4.15)
CG + C
Total 422 430 100.00 -4.14 (-4.98 to -3.30)
Heterogeneity: Q=7.86 (p=0.16), I2=36.4%
Overall effect: Z score=-9.66 (p=0.000), τ2=0.372 -10.00 -5.00 0.00 5.00 10.00
A: atenolol Favours diet Favours control
C: chlorthalidone
CG: control group
DISH: Dietary Intervention Study of Hypertension − The size of the squares represents the weight of studies in meta-analysis (a numerical
I2: Higgins I2 representation is given in the “Weight (%)” column).
IG: intervention group − The width of the diamond shapes represents the 95% CI (see also WMD (95% CI)
P: placebo column).
TAIM: Trial of Antihypertensive Interventions and Management − * The standard deviations are calculated on the basis of p=0.05.
WMD: weighted mean difference − † The standard deviations are calculated on the basis of p=0.001.
Adapted from Horvath K et al. Arch Intern Med 2008;168:571-80
Source: www.myhealthywaist.org
28. Diet vs. Usual Care: Changes in Systolic Blood Pressure
Diet group Control group
Participants Standard Participants Standard WMD (random) WMD
Source Mean Mean Weight (%)
no. deviation no. deviation (95% CI) (95% CI)
Croft et al.* 66 -11.00 (15.26) 64 -4.00 (15.26) 46.01 -7.00 (-12.25 to -1.75)
ODES IG vs. CG 16 -8.40 (13.20) 12 2.90 (15.24) 10.90 -11.30 (-22.08 to -0.52)
ODES IG + Pa 24 -8.30 (10.29) 20 -4.10 (8.05) 43.09 -4.20 (-9.62 to 1.22)
vs. CG + Pa
Total 106 96 100.00 -6.26 (-9.82 to -2.70)
-30.00 -15.00 0.00 15.00 30.00
Favours diet Favours control
Heterogeneity: Q=1.47 (p=0.48), I2=0%
Overall effect: Z score=-3.45 (p=0.001), τ2=0.000
CG: control group − The size of the squares represents the weight of studies in meta-analysis (a numerical
I2: Higgins I2 representation is given in the “Weight (%)” column).
IG: intervention group − The width of the diamond shapes represents the 95% CI (see also WMD (95% CI)
ODES: Oslo Diet and Exercise Study column).
Pa: physical activity − * The standard deviations are calculated on the basis of p=0.05.
WMD: weighted mean difference
Adapted from Horvath K et al. Arch Intern Med 2008;168:571-80
Source: www.myhealthywaist.org
29. Diet vs. Usual Care: Changes in Diastolic Blood Pressure
Diet group Control group
Participants Standard Participants Standard WMD (random) WMD
Source Mean Mean Weight (%)
no. deviation no. deviation (95% CI) (95% CI)
Croft et al.† 66 -7.00 (10.15) 64 -1.00 (10.15) 24.18 -6.00 (-9.49 to -2.51)
ODES IG vs. CG 16 -7.10 (7.20) 12 -0.40 (12.47) 6.64 -6.70 (-14.59 to 1.19)
ODES IG + Pa 24 -7.10 (6.37) 20 -5.50 (7.60) 18.81 -1.60 (-5.79 to 2.59)
vs. CG + Pa
TAIM IG vs. CG 265 -12.80 (10.00) 264 -10.40 (7.80) 50.37 -2.40 (-3.93 to -0.87)
Total 371 360 100.00 -3.41 (-5.55 to -1.27)
-20.00 -10.00 0.00 10.00 20.00
Heterogeneity: Q=4.7 (p=0.20), I2=36.1%
Overall effect: Z score=-3.12 (p=0.002), τ2=1.759 Favours diet Favours control
CG: control group − The size of the squares represents the weight of studies in meta-analysis (a numerical
I2: Higgins I2 representation is given in the “Weight (%)” column).
IG: intervention group − The width of the diamond shapes represents the 95% CI (see also WMD (95% CI)
ODES: Oslo Diet and Exercise Study column).
Pa: physical activity − † The standards deviations are calculated on the basis of p=0.001.
TAIM: Trial of Antihypertensive Interventions and Management
WMD: weighted mean difference
Adapted from Horvath K et al. Arch Intern Med 2008;168:571-80
Source: www.myhealthywaist.org
30. VICTORY Trial – Body Weight
Placebo
Rosiglitazone
100
90
80
70
p=0.36 p=0.10 p=0.02
60
Baseline 2 4 6 8 10 12
p<0.0001 interaction
Months
Adapted from Bertrand OF et al. Atherosclerosis 2010;211:565-73
Source: www.myhealthywaist.org
31. VICTORY Trial – Body Composition
Placebo
Rosiglitazone
Body fat (DEXA) Total body water (BIA)
50
35
30 45
25
40
20
p=0.39 p=0.06 p=0.001 p=0.81 p=0.15 p=0.11
15 35
Baseline Follow-up Follow-up Baseline 2 4 6 12
(6 months) (12 months)
Months
p<0.0001 interaction p=0.0007 interaction
DEXA: dual energy X-ray absorptiometry
BIA: bioelectrical impedance analysis
Adapted from Bertrand OF et al. Atherosclerosis 2010;211:565-73
Source: www.myhealthywaist.org
34. Long-Term Effects of a Lifestyle Intervention
on Weight and Cardiovascular Risk Factors
in Individuals With Type 2 Diabetes Mellitus
Four-Year Results of the Look AHEAD Trial
The Look AHEAD Research Group
Adapted from the Look AHEAD Research Group. Arch Intern Med 2010;170:1566-75
Source: www.myhealthywaist.org
35. Mean Changes in Weight, Fitness and Cardiovascular Disease Risk Factors in
Intensive Lifestyle Intervention (ILI) and Diabetes Support and Education (DES)
Groups and the Difference Between Groups Averaged Across 4 Years
Look AHEAD
Groups, Mean change (95% CI) Between-group
Measure mean difference p value of
DES ILI (95% CI) difference†
Weight (% initial weight) -0.88 (-1.12 to -0.64) -6.15 (-6.39 to -5.91) -5.27 (-5.61 to -4.93) <0.001
Fitness (% METS) 1.96 (1.07 to 2.85) 12.74 (11.87 to 13.62) 10.78 (9.53 to 12.03) <0.001
Hemoglobin A1c (%)* -0.09 (-0.13 to -0.06) -0.36 (-0.40 to -0.33) -0.27 (-0.32 to -0.22) <0.001
Systolic blood pressure (mm Hg)* -2.97 (-3.44 to -2.49) -5.33 (-5.80 to -4.86) -2.36 (-3.03 to -1.70) <0.001
Diastolic blood pressure (mm Hg)* -2.48 (-2.73 to -2.24) -2.92 (-3.16 to -2.68) -0.43 (-0.77 to -0.10) 0.01
HDL cholesterol (mmol/l)* 0.05 (0.04 to 0.06) 0.10 (0.09 to 0.10) 0.04 (0.03 to 0.05) <0.001
Triglycerides (mmol/l)* -0.22 (-0.25 to -0.20) -0.29 (-0.32 to -0.26) -0.07 (-0.10 to -0.03) <0.001
LDL cholesterol (mmol/l)
-0.33 (-0.35 to -0.31) -0.29 (-0.31 to -0.27) 0.04 (0.01 to 0.07) 0.009
Without adjustment for medication use
-0.24 (-0.26 to -0.22) -0.23 (-0.25 to -0.21) 0.01 (-0.02 to 0.04) 0.42
Adjusted for medication use
† Adjusting for baseline use of medications or changes over time did not influence the average effect for the p value.
* Data presented are average effects unadjusted for medication use.
Adapted from the Look AHEAD Research Group. Arch Intern Med 2010;170:1566-75
Source: www.myhealthywaist.org
36. Changes in Fitness in the Intensive Lifestyle Intervention (ILI) and Diabetes
Support and Education (DSE) Groups
Look AHEAD
Fitness
Average effect across visits: 10.78 (p<0.001)
30
Change in fitness (% METS)
DSE
ILI
20
10
0
-10
0 1 2 3 4
Years
Adapted from the Look AHEAD Research Group. Arch Intern Med 2010;170:1566-75
Source: www.myhealthywaist.org
37. Changes in Weight for Participants in the Intensive Lifestyle Intervention (ILI)
and Diabetes Support and Education (DSE) Groups
Look AHEAD
Weight
Average effect across visits: -5.27 (p<0.001)
0
-1
Change in weight (%)
-2
-3
-4
-5
-6
-7 DSE
ILI
-8
-9
0 1 2 3 4
Years
Adapted from the Look AHEAD Research Group. Arch Intern Med 2010;170:1566-75
Source: www.myhealthywaist.org
38. Changes in Systolic Blood Pressure (SBP) for Participants in the Intensive
Lifestyle Intervention (ILI) and Diabetes Support and Education (DSE) Groups
Look AHEAD
Systolic blood pressure
Average effect across visits: -2.36 (p<0.001)
0
-1
Change in systolic blood
-2
pressure (mm Hg)
-3
-4
-5
-6
-7 DSE
-8 ILI
-9
0 1 2 3 4
Years
Adapted from the Look AHEAD Research Group. Arch Intern Med 2010;170:1566-75
Source: www.myhealthywaist.org
39. Changes in Diastolic Blood Pressure for Participants in the Intensive Lifestyle
Intervention (ILI) and Diabetes Support and Education (DSE) Groups of the
Look AHEAD (Action for Health in Diabetes) Trial
Look AHEAD
Diastolic blood pressure
Average effect across visits: -0.43 (p=0.01)
0
DSE
Change in diastolic blood
ILI
-1
pressure (mm Hg)
-2
-3
-4
0 1 2 3 4
Years
Adapted from the Look AHEAD Research Group. Arch Intern Med 2010;170:1566-75
Source: www.myhealthywaist.org
40. - Identifying potential barriers
to long-term weight loss.
- The right approach for the
right patient.
- Interdisciplinary approach.
Talk to your patient
about weight/waist
management!
Source: www.myhealthywaist.org
41. Adiposity and Cardiovascular Disease: Are we Using the Right
Definition of Obesity?
Refinement of some cardiovascular risk factors
Lipid profile Blood pressure “At risk” obesity
Past Total cholesterol Resting blood pressure Weight
24-hour blood
Present LDL, HDL, TG
pressure monitoring
BMI
Early morning Waist circumference + TG
Future (?) Apo AI, Apo B
blood pressure Waist-to-hip ratio
Apo: apolipoprotein
BMI: body mass index
TG: triglycerides
Adapted from Poirier P Eur Heart J 2007;28:2047-8
Source: www.myhealthywaist.org
42. Conclusion
Management of blood pressure in diabetes
• Guidelines
• ACE-inhibitors, angiotensin receptor blockers
Multidrug regimen
• ACCORD
• 139 to 133 mm Hg - 2.3 drugs
• 139 to 119 mm Hg - 3.4 drugs
Aggressive nonpharmacological approach
• Look AHEAD
• ~5 mm Hg as an add-on therapy
Source: www.myhealthywaist.org