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People with any CKM disease should have at least annual assessments to determine whether there has been any progression, complications or development of other CKM disease
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Manifestations of CKM include:
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Clinical obesity
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Elevated blood pressure and hypertension
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Type 2 diabetes
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Dyslipidaemia
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CVD including ischaemic heart disease, cerebrovascular disease, peripheral arterial disease, atrial fibrillation and heart failure
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Chronic kidney disease (eGFR < 60mL/min and/or UACR > 3 mg/mmol)
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Metabolic dysfunction-associated steatotic liver disease (MASLD; previously termed fatty liver disease)
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Gout
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Obstructive sleep apnoea
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These clinical assessments should include at least:
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Smoking status and alcohol intake
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Waist circumference and BMI
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Seated blood pressure (BP) +/- standing BP
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Measure sitting/standing or ideally lying/standing if any concerns over postural hypotension e.g. postural symptoms, frail, elderly, multiple BP lowering agents etc.
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HbA1c +/- fasting glucose
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Combining fasting glucose with HbA1c prevents the need for another confirmatory test to diagnose diabetes if the HbA1c is > 48 mmol/mol. Fasting glucose is also the preferred diagnostic test if measurement of HbA1c may be unreliable such as:
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Any haemoglobinopathy e,g, thalassaemia, sickle cell anaemia etc.
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Altered red cell turnover e.g. bleeding, haemolysis, severe iron deficiency
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Second and third trimesters of pregnancy
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Post blood transfusion
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HbA1c screening may be reduced to every 3 years if < 42 mmol/mol
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eGFR and urinary ACR
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Non fasting lipid studies
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Serum urate if history of gout (may need to ask at assessment)
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Foot examination and check of retinal photoscreening if known diabetes
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Epworth sleep score if history suggestive of obstructive sleep apnoea
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Screen for depression e.g. PHQ-2 score
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Screen for diabetes distress if known diabetes e.g. DDS2 score
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Calculation of 5 year CV risk on PREDICT CV risk calculator at diagnosis of CKM and then:
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Low CV risk (5 year CV risk < 5%) → 5 yearly
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Moderate CV risk (5 year CV risk 5 – <10%) → yearly
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May be relaxed to 2 yearly if gout or MASLD alone
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High CV risk (5 year CV risk ≥ 10%) → no need to repeat as need to optimise treatment
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It is critical that management commences as soon as reasonably practical if any positive findings:
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If BP ≥ 130/80 mmHg start management of elevated blood pressure and hypertension
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If HbA1c ≥ 48 mmol/mol and start management of type 2 diabetes if diagnosis confirmed
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The diagnosis of diabetes requires a confirmatory test either with a repeat elevated HbA1c, fasting glucose ≥ 7 mmol/L, a random glucose > 11 mmol/L if symptomatic, or a 2 hour glucose > 11 mmol/L on a 75 g glucose tolerance test. The 2nd test should be done without delay and may be 2 of the same test e.g. 2 x HbA1c measurements.
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Although > 90% of new diagnoses are type 2 diabetes beware of red flags for other types of diabetes such as:
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Onset of diabetes at a young age
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Symptoms of insulin deficiency at or shortly following diagnosis
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Normal or low BMI at diagnosis
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Family history of non-type 2 diabetes
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Pancreatic exocrine deficiency
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Positive anti-GAD, anti-IA2 and/or anti-ZnT8 antibodies
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Low C-peptide (fasting < 250 pmol/L; random < 600 pmol/L) with glucose > 8 mmol/L
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If eGFR < 60mL/min and/or UACR > 3 mg/mmol on ≥ 2 collections over ≥ 3 months → start management of chronic kidney disease
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Confirmation of albuminuria requires 2 x UACR > 3 mg/mmol over ≥ 3 months to exclude falsely raised ratios due to:
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Urinary tract infection
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Intercurrent illness
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Vigorous physical activity
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Haematuria
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Significant hyperglycaemia
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Orthostatic (postural) proteinuria – particulalry in youth and young adults
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Idiopathic proteinuria – transient proteinuria of unknown cause
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False positives are reduced by performing the UACR in the early morning but do not let this be a barrier to any test
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If excess adiposity then start interventions for weight loss
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Excess adiposity is defined as:
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BMI > 40 kg/m2 OR
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BMI > ethnicity-specific threshold AND one increased anthropometric criteria OR
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> 35 kg/m2 in Pacific peoples
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> 32 kg/m2 in Māori
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> 30 kg/m2 in Europeans
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> 25 kg/m2 in Asian Indians
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Two increased anthropometric criteria regardless of BMI
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Anthropometric criteria include:
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Waist:height ratio > 0.5
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Increased waist circumference:
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> 88 cm in females and > 102 cm in males of non-Asian Indians
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> 80 cm in females and > 90 cm in males of Asian Indians
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Waist:hip ratio > 0.86 in women and > 1 in men
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Body fat percentage by DEXA or bioimpedance > 30% for men and > 42% for women
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If LDL cholesterol > 1.4 mmol/L and/or triglycerides > 1.7 mmol/L determine whether starting management of dyslipidaemia is appropriate
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If gout and serum urate > 0.36 mmol/L (or > 0.3 mmol/L if tophi) then optimise management of gout
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If smoking or vaping then discuss cessation
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If ≥ 3 on PHQ-2 then complete PHQ-9 and consider treatment for depression as appropriate
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If ≥ 3 on DDS2 then evaluate diabetes distress and consider support as appropriate
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NB: People with CKM with elevated blood pressure, lipids, urate (if gout) or glucose levels should be reviewed at least every 1-3 months with escalation of treatment until targets are reached.
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BP and urate (if gout) levels should ideally be reviewed every month until at target
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Lipids may also be reviewed monthly as 90% of effects of statin doses are evident within 2 weeks
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Although it takes 3 months for the full treatment effects on HbA1c, if glucose levels are significantly elevated 1 month after an intervention, then escalation of treatment is almost certainly required
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People with preclinical obesity should be assessed at least every 5 years from 15 years of age to determine whether they have developed clinical obesity i.e. CKM disease or non-CKM sequelae
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Preclinical obesity is defined as excess adiposity without any other features of CKM disease. Excess adiposity is defined as:
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BMI > 40 kg/m2 OR
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BMI > ethnicity-specific threshold AND one increased anthropometric criteria OR
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> 35 kg/m2 in Pacific peoples
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> 32 kg/m2 in Māori
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> 30 kg/m2 in Europeans
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> 25 kg/m2 in Asian Indians
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Two increased anthropometric criteria regardless of BMI
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Anthropometric criteria include:
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Waist:height ratio > 0.5
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Increased waist circumference:
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> 88 cm in females and > 102 cm in males of non-Asian Indian ethnicity
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> 80 cm in females and > 90 cm in males of Asian Indian ethnicity
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Waist:hip ratio > 0.86 in women and > 1 in men
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Body fat percentage by DEXA or bioimpedance > 30% for men and > 42% for women
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Non-CKM manifestations of clinical obesity include:
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Joint pain and osteoarthritis
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Reduced age-adjusted mobility
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Lymphoedema
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Raised intracranial hypertension
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Obstructive sleep apnoea
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Assessments should be increased to at least 3 yearly if at least one other risk factor for CKM disease is present:
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Māori, Pacific, Asian Indian and other non-European ethnicities
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Socioeconomic deprivation
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Direct family history of CKM at < 40 years of age
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Smoker
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Post transplant
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History of preeclampsia or gestational diabetes
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Long term glucocorticoid and/or antipsychotic use
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Chronic dental and/or peridontal disease
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Clinical features of insulin resistance e.g. acanthosis nigricans, PCOS etc.
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NB: In clinical obesity interventions for weight loss are first line treatment to reverse (if able), prevent, delay and slow progression of complications