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Managing Cardiometabolic Risk

Managing Cardiometabolic Risk. Lifestyle modification and weight reduction strategies. NHLBI guidelines: Adiposity assessment. Use BMI to assess body fat Body weight alone can be used to track weight loss, and to determine efficacy of therapy (Evidence Category C)

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Managing Cardiometabolic Risk

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  1. Managing Cardiometabolic Risk Lifestyle modification and weight reduction strategies

  2. NHLBI guidelines: Adiposity assessment • Use BMI to assess body fat • Body weight alone can be used to track weight loss, and to determine efficacy of therapy(Evidence Category C) • Use BMI to classify overweight/obesity • Estimate relative risk of disease compared to normal weight (Evidence Category C) • Use waist circumference to assess abdominal fat content (Evidence Category C) NHLBI. www.nhlbi.nih.gov.

  3. BMI classifications NHLBI. www.nhlbi.nih.gov.

  4. Locate upper hip bone and top of right iliac crest Place measuring tape horizontally around abdomen at level of iliac crest Tape should be snug without causing compression Measuring waist circumference Iliac crest NHLBI. www.nhlbi.nih.gov.

  5. Diagnostic criteria for metabolic syndrome Any 3 criteria Adiposity Dyslipidemia HDL-C <40 mg/dL (men) HDL-C <50 mg/dL (women) TG ≥150 mg/dL WC (men)≥35 (Asian)≥40 (other ethnicities) WC (women)≥31 (Asian)≥35 (other ethnicities) Dysglycemia Hypertension BP ≥130/85 mm Hg FG ≥100 mg/dL WC = waist circumference (inches) Grundy SM. J Am Coll Cardiol. 2006;47:1093-100.

  6. NHLBI guidelines: Weight loss goals • Goal is ~10% reduction from baseline weight (Evidence Category A) • If successful, assess continued weight loss (Evidence Category A) • Aim for weight loss ~1–2 lb/week for 6 months • Base subsequent strategies on the amount of weight lost (Evidence Category B) NHLBI. www.nhlbi.nih.gov.

  7. Guide to adiposity management NHLBI. www.nhlbi.nih.gov.Lee M, Aronne LJ. Am J Cardiol. 2007;99(suppl):68B-79B.

  8. NHLBI guidelines: Lifestyle modification • Combined intervention of a calorie-deficit diet, physical activity, and behavioral treatment is most successful for weight loss and maintenance(Evidence Category A) • 500-1000 kcal/day deficit • Moderate physical activity 30-45 min, 3-5 days/week, with eventual goal of ≥30 min on most (and preferably all) days of the week • Maintain for ≥6 months before considering pharmacotherapy NHLBI. www.nhlbi.nih.gov.

  9. Some moderate-intensity physical activities Moderate activity  150 calories of energy per day NHLBI. www.nhlbi.nih.gov.

  10. 3-Week diet + exercise regimen yields favorable metabolic changes N = 31 overweight/obese men; weight 8.4 lbs μU/mL Baseline Follow-up *P < 0.01 †P < 0.05 Roberts CK et al. J Appl Physiol. 2006;100:1657-65.

  11. Physical activity may reduce CV and all-cause mortality N = 9791; moderate physical activity vs little or no physical activity Adjusted HR (95% CI) Favorsexercise Favorsno exercise Normal BP All-cause death 0.75 (0.53–1.05) CV death 0.76 (0.39–1.49) Prehypertension All-cause death 0.79 (0.65–0.97) CV death 0.79 (0.58–1.09) Hypertension All-cause death 0.88 (0.80–0.98) CV death 0.84 (0.73–0.97) 0.5 1.0 1.5 0 2.0 Hazard ratio NHANES 1 Epidemiological Follow-up Survey (1971–1992) Fang J et al. Am J Hypertens. 2005;18:751-8.

  12. Lifestyle modification associated with diabetes prevention Meta-analysis of 5 randomized, controlled trials Pan et al, 1997 Wein et al, 1999 Tuomilehto et al, 2001 DPPRG, 2002 Watanabe et al, 2003 Combined: Fixed Combined: Random Combined: Bayesian 0.1 0.5 1.0 5.0 10.0 Relative risk (95% CI) Yamaoka K, Tango T. Diabetes Care. 2005;28:2780-6.

  13. DPP: Benefit of diet + exercise or metformin on diabetes prevention in at-risk patients N = 3234 with IFG and IGT without diabetes 40 Placebo P* 30 Metformin <0.001 31% Cumulative incidence of diabetes (%) 20 Lifestyle† <0.001 58% 10 0 0 1 2 3 4 Year *vs placebo (unadjusted) †Achieve/maintain ≥7% reduction of initial body weight via diet + moderate-intensity physical activity ≥150 minutes/week DPP Research Group. N Engl J Med. 2002;346:393-403.

  14. Popular dietary programs: Effective yet difficult to maintain N = 160 overweight or obese with ≥1 CV risk factor Dansinger ML et al. JAMA. 2005;293:43-53.

  15. Look AHEAD: Study design Look Action for Health in Diabetes N = 5145 45-74 years with T2DM, BMI ≥25 kg/m2 (≥27 kg/m2 if taking insulin) Usual medical care + diabetes support and education for 4 years Usual medical care+ lifestyle intervention* for 4 years, with maintenance counseling thereafter Total follow-up 11.5 years Primary endpoint: CV death, nonfatal MI, nonfatal stroke *≥7% mean weight loss with hypocaloric diet ± pharmacologic therapy+≥175 min/week moderate physical activity Diet = 1200-1500 kcal/day (<250 lbs) or1500-1800 kcal/day (≥250 lbs) Look AHEAD Research Group. Control Clin Trials. 2003;24:610-28; Obesity. 2006;14:737-52.

  16. NHLBI guidelines: Pharmacologic therapy • FDA-approved drugs may be used as part of a comprehensive weight-loss program, including dietary therapy and physical activity (Evidence Category B) in these individuals: • BMI ≥30 kg/m2 with no concomitant risk factors or diseases • BMI ≥27 kg/m2 with concomitant risk factors or diseases (hypertension, dyslipidemia, CHD, T2DM, sleep apnea) • Herbal preparations are not recommended. These preparations have unpredictable amounts of active ingredients and unpredictable, and potentially harmful, effects. NHLBI. www.nhlbi.nih.gov.

  17. Pharmacologic weight management options *Available Rx and OTC (1/2 dose) †Placebo-corrected NE = norepinephrine Arterburn DE et al. Arch Intern Med. 2004;164:994-1003. Li Z et al. Ann Intern Med. 2005;142:532-46.

  18. Efficacy of orlistat as adjunct to lifestyle modification N = 3305, mean BMI 37 kg/m2 0 -3.0 kg -3 P < 0.001 Δ Body weight(kg) -5.8 kg -6 -9 -12 0 52 104 156 208 Weeks Placebo + lifestyle Orlistat + lifestyle All subjects prescribed a reduced-calorie diet (~800 kcal/day deficit) and encouraged tophysical activity Torgerson JS et al. Diabetes Care. 2004;27:155-61.

  19. Efficacy of sibutramine as adjunct to lifestyle modification 0 2 4 Sibutramine alone 6 Lifestyle modification alone Weight loss (kg) Sibutramine + brief therapy 8 10 Combined therapy 12 14 16 0 3 6 10 18 40 52 Weeks N = 224 with obesity, mean BMI 38 kg/m2 All subjects prescribed balanced 1200-1500 kcal/day diet and encouraged to walk 30 min/day Wadden TA et al. N Engl J Med. 2005;353:2111-20.

  20. Effects of sibutramine and lifestyle modification on cardiometabolic risk factors Change from baseline at 1 year Wadden TA et al. N Engl J Med. 2005;353:2111-20.

  21. SCOUT: Study design Sibutramine Cardiovascular OUtcome Trial N  9000 ≥55 years with BMI 27–45 kg/m2 (or 25 to <27 kg/m2 + waist ≥40" men, ≥35" women) + History of CV event (or T2DM + 1 other CV risk factor) 6-week single-blind lead-in Sibutramine 10 mg + lifestyle intervention* Placebo + lifestyle intervention* Sibutramine 10–15 mg + lifestyle intervention* 3-year randomized, double-blind phase Primary endpoint: MI, stroke, resuscitated cardiac arrest, CV death *Hypocaloric diet (-600 kcal/day) + ≥150 min/week moderate physical activity James WPT. Eur Heart J Suppl. 2005;7(suppl L):L44-8.

  22. NHLBI guidelines: Weight loss surgery • An option for carefully selected patients when less-invasive methods have failed and the patient is at high risk for obesity-associated morbidity or mortality (Evidence Category B) • BMI ≥40 kg/m2 • BMI ≥35 kg/m2 with comorbid conditions NHLBI. www.nhlbi.nih.gov.

  23. SOS: Bariatric surgery-associated improvements in cardiometabolic risk Conventional treatment (n = 1660) Gastric surgery (n = 1845) Swedish Obese Subjects (SOS) Study, N = 4047, mean BMI 41 kg/m2 *At 2 years Sjöström L et al. N Engl J Med. 2004;351:2683-93.

  24. Improved Framingham risk score following bariatric surgery N = 109, mean BMI 49 kg/m2 (preoperative), 36 kg/m2 (13-month follow-up) 12 10 8 10-year CHD risk(%) P = 0.002 P < 0.0001 6 4 2 Men Women Before surgery After surgery Vogel JA et al. Am J Cardiol. 2007;99:222-6.

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