Download Soji Swaraj

Sedentary Death syndrome : stop sitting
and dying early
Soji Swaraj
Dept of Endocrinology
Concord Hospital
Background: Diabesity epidemic
• 7-10 % of population
• 50% undiagnosed
• 275 people newly diagnosed diabetic in
Australia daily
• ? 100 per day in NSW
• ? > 50 % don’t achieve HbA1c targets
• ? Enough clinicians to cope
The Economic explanation of the Obesity
epidemic ?
•Humans ( mammals) are economic valuedriven:
•mars bar with 30% extra for free
•TV remote controls
• automatic windscreen wipers
Australians spend on average 39
hours a week sedentary
People in office jobs average 22
hours a week in their chairs,
Australian Health Survey 2011
Saving energy is instinctive
Great innovations help us save energy
? Avoidable vicious cycle
Weight gain diabetes
 diabetes treatment 
 weight gain ?  cancer ?
Doctors can help you !
•
Diagnose you as “obese”
•
Excellent Advice:
 “see a dietician”
 “do more exercise”
•
Frequent home glucose testing ( ? qid)
•
Steadily increase drug/insulin doses
•
‘ Next patient please’
Pharmacomania: Just give them a drug to
fix it
Mr RA
47 yrs
T2D 2 yrs
HbA1c 8.1 %
Waist 99 cm
BP 148/91
Diabex XR 1g daily
Zanidip 10mg
Mr RA
• Diamicron 60 mg bd
• And Coversyl 10 mg added
• 6 months later:
• HbA1c improved to 6.9 %
Mr RA
• Diamicron 60 mg bd
• And Coversyl 10 mg added
• 6 months later:
• HbA1c improved to 6.9 %
• BP 150/90
• Waist 99 109cm
The link between diabetes and cancer
• Long recognised increased incidence in several
cancers in people with diabetes
• Is diabetes a pre-cancerous state: Colon, breast,
ovarian
• ? Insulin: hyperinsulinaemia
• Hybrid receptors bind both Insulin and IGF-1
promote growth in already oncogenic cells
The link between diabetes and cancer
• Colon Cancer:
• Skin tags
• Polyps ?
• ? Screening colonoscopy for all t2D over 40?
Jessica , 51 yrs
• One of cohort of 54 women
• Breast cancer
• Metabolic syndrome
• Referred for fat loss to decrease cancer
recurrence risk
17
18
Adipose tissue is an endocrine organ
Sedentary death syndrome
• millions of premature deaths each year
• physically inactive people
• Twice the risk for coronary heart disease
• Similar risk as blood cholesterol, high blood pressure or
cigarette smoking (American Heart Association)
• 2 hours sitting or TV per day : 20 % increased risk of T2D
Lees SJ, Booth FW. Can J Appl Physiol. 2004 Aug;29(4):447-60;
Background
• 1953 study published in the Lancet :
•
Bus conductors had a risk of heart attack half that of bus drivers
UK Meta-analysis : 18 studies (800,000 people in 2012):
• those who are least active in their normal daily lives:
•
twice as likely to develop diabetes
• twice as likely to die from AMI
•
independent of the amount of vigorous, gym-style
Wilmot et al 2012
Sitting isn’ t just lack of activity
Actively sinister physiology of inactivity in long
periods sitting:
• Less lipoprotein lipase produced during leg
muscle contraction
• Around 100 diferent genes expression altered
including ? GLUT4
Why we should measure our dose of sitting
 women who sat >6 hours a day : 37% more likely to die
prematurely than women who sat < 3 hours,
 Sitting > 11 hours a day had a 40% higher risk of dying in
the next three years than people who sat less than four
hours a day (222,497 Australians)
 Regardless of physical activity and general health
status
 clear dose-response effect: the more sitting, the higher
risk of death
2010 American Cancer Society Report.
2011 Review. Sax Institute. Medicine & Science in Sports & Exercise
Sedentary death syndrome: ? Genetic cause
• ? Genes which have functioned to support physical
activity for survival through most of humankind's
existence
• require daily exercise to maintain long-term health
and vitality
• Type 2 diabetes : GLUT4 expression is higher in
active controls than in sedentary and T2D groups.
Lees. Can J appl Physiol 2004 Aug;29(4):447-60;
? Leading cause of chronic back pain
“ Its ok to smoke” ?
We also ‘ Force’ sedentarism and do as
we’re told
Reducing toxic sitting dose is hard
• Start counting ‘seated’ or screen hours
 Standing on public transport, in meetings
 Taking any stairs
 Getting up to move every hour
 Standing to watching children's sporting activities
 Meet for a walk rather than lunch
Standing desks
Prevention: forced sedentarism
• Start counting ‘still’ or screen time
• Spend 23 hours of still time a day if you must
Screen Time
Tablets
Laptops
Facebook
TV
Xbox
DVDs
What about Food ?
Grandma’s advice was right for the post
depression years
‘You’re not getting up till you’ve finished
what’s on your plate”
“We don’t waste good food in this house
“Think of the poor kids in Africa”
Stop Forcefeeding
• 2 Czech studies 2012
• Randomised , cross-over clinical trials
comparing :
• Standard 6 meals per day advice with
• Breakfast and lunch only ( 7 am and 124pm)
Belinova L et al Data presented EASD 2012
Kahleova H et al. Data presented EASD 2012
Stop Forcefeeding
• In the two meals per day group:
• Improved weight, BMI, waist, FBG, cpeptide
• 19% of patients required decreased OHGA
due to hypos
Belinova L et al Data presented EASD 2012
Kahleova H et al. Data presented EASD 2012
What about toxic
Food intake ?
Is it safe to eat horse and cow food?: Wheat
toxins ( Gluten, Gliadin)
Abrupt evolutionary stressors: Post
10,000BC
 Agriculture
 Domestication of livestock ( how much red meat
is ok?)
 Industrial revolution
 Refrigeration
 Electronic entertainment
Confusion between T1D and T2D? “Must
have carbs with each meal”
41
So what can I eat when I reduce bread,
cereals and pasta ?
So what can I eat if I can’t have bread, rice
and pasta ?
42
The Dietician accomplice : Force feeding
“diabetic diets”
Mr XY
• 52 yrs
• Academic/ Truck Driver
• T2D 8 years
• HbA1c 8.7%
• Lantus 60 units
• Diamicron
• Diabex
• Waist 130 cm
• BP 149/90
• ED
• TATT
Prevention- ‘Paleo’ living
• Stop forcing 3 meals per day
• Listen to your body: respond to hunger if and
when it occurs
• ? Cut down the foods that we were not evolved
to eat : Cereals, processed grains
Prevention- ‘ Energy budget’
• Put a price on your calories ( ? 2km for a slice
of bread) and
• ‘Pay’ for them
• ? Make 60 min daily activity obligatory :
• ? Schools, work places
An Easily reproducible waist landmark: 40
cm caudal to sternal notch
40 cm
Myocytokines: Muscle has endocrine
Effects on other organs
Other Myokines:
IL8,
IL10,
IL15,
Musclin,
Myostatin
Copyright ©2005 American Physiological Society
Petersen, A. M. W. et al.
J Appl Physiol 98: 1154-1162, 2005
Exercise induces Autophagy
• lysosomal degradation pathway in intracellular recycling
system
• in organelle and protein quality control
• During stress, increased levels of autophagy permit cells
to adapt to changing nutritional and energy demands
through protein catabolism
• protects against diseases such as cancer,
neurodegenerative disorders, infections, inflammatory
diseases, ageing and insulin resistance in mice
• acute exercise induces autophagy in skeletal and
cardiac muscle of fed mice
Levine et al Nature 481, 511–515 (26 January 2012)
Compulsory Daily exercise prescription
1 Hour walking daily
tds
before
meals
20-30 bicep curls before
each meal :
•‘Pay for your food’
•No pay no eat, no
insulin, no tablets
Target weekly waist
circumference decrease:
•1 cm/fortnight
•10 cm over 20 weeks
‘community responsibility’ to lose weight,
‘Obesity is one of the worst choices a person can make
and one of the most dangerous habits ..
“you could call me fat. And yes, even obese, on a
doctor’s chart. But ..: Do you think I don’t know
that? That your cruel words are pointing out
something that I don't see?’
Diabetogenic/Carcinogenic
attitudes ?
Its ok to be a little bit chubby ?
MS
• 38 yrs
• Failed IVF
• Can’t lose weight: Waist 98
cm, BMI 30
• Hair loss
• Mild acne
• Excess facial hair
• Irregular periods since
menarche at age 9 yrs
Prevention: Diabetes, cancer and infertility
? Pre- cancer patients:
 PCOS
 GDM
 IGT
 IFG
 HT
 Dyslipidaemia
Exercise Protective against primary breast cancer
California Teachers study
110,599 women ( 20- 79)
if long term strenuous physical activity> 5 hour
per week reduced risk of :
cancer
RR 0.80
95 % CI 0.69-0.94
p= 0.02
A brave cohort
• 34 women
• Breast cancer
• Metabolic syndrome
• Referred for fat loss to decrease cancer
recurrence risk
Metformin and cancer risk
• Observational study ( Not an RCT)
• 85000 new users, currently cancer free
• Metformin appears protective
Ruiters at al Diabetes Care 2012. 35. 119-124
Mechanism of tumour inhibition of metformin via
insulin dependent and independent pathways –
including activation of adenosine monophosphate kinase ( AMPK)
through liver kinase B1 and ataxia telangectasia mutated gene kinase
Metformin use in postmenopausal women with
diabetes was associated with lower incidence
of invasive breast cancer compared to
women without diabetes as well as with
diabetes treated with other diabetes
Diabetic patients with breast cancer receiving
metformin and neoadjuvant chemotherapy have
higher complete response to treatment than do
diabetics not receiving metformin
24 % in metformin group
8 % in non metformin group
16 % in non diabetic group
Intervention
• Motivation
• Metformin 500 mg bd
• Vit D 1000 units daily
• Food strategy
• Resistance and aerobic dose prescribed
• Goal: 10 cm waist reduction (? 15Kg) over 10 weeks
? Outcomes
? Costs Vs Benefits
? Easier to motivate : fight of their lives
Call to action
• Don’t sit
• Determined approach to prevention and treatment of
Diabetes and Cancer:
• Fat loss
• Stop force feeding
• Exercise dose
• Look out for warning signs : Skin tags ? colonoscopy
• Breast conversation with every chubby or T2D woman
Sedentary Death syndrome : stop sitting
and dying early
Soji Swaraj
Dept of Endocrinology
Concord Hospital
Thank you