managing cardiometabolic risk
Post on 31-Dec-2015
43 Views
Preview:
DESCRIPTION
TRANSCRIPT
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)
• 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.
BMI classifications
BMI (kg/m2)
Underweight <18.5
Normal weight 18.5-24.9
Overweight 25-29.9
Class 1 obesity 30-34.9
Class 2 obesity 35-39.9
Class 3 (extreme) obesity ≥40
NHLBI. www.nhlbi.nih.gov.
Measuring waist circumference
• 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
NHLBI. www.nhlbi.nih.gov.
Iliac crest
Hypertension
Dyslipidemia
BP ≥130/85 mm Hg
HDL-C <40 mg/dL (men)
HDL-C <50 mg/dL (women)
TG ≥150 mg/dL
Diagnostic criteria for metabolic syndrome
Grundy SM. J Am Coll Cardiol. 2006;47:1093-100.
Adiposity
Dysglycemia
WC (men)≥35 (Asian)≥40 (other ethnicities)
WC (women)≥31 (Asian)≥35 (other ethnicities)
FG ≥100 mg/dL
WC = waist circumference (inches)
Any 3 criteria
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.
Guide to adiposity management
BMI category (kg/m2)
Strategy 25.0-26.9 27.0-29.9 30.0-34.9 35.0-39.9 ≥40
DietPhysical activityBehavior therapy
With
comorbidities
With
comorbidities
Pharmacotherapy
With comorbidities
Surgery
With comorbidities
NHLBI. www.nhlbi.nih.gov.Lee M, Aronne LJ. Am J Cardiol. 2007;99(suppl):68B-79B.
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.
Some moderate-intensity physical activities
Daily life Sports
Washing car, 45–60 min Walking 3 mph, 35 min Less vigorous
Washing windows or floors, 45–60 min
Bicycling 10 mph, 30 min
Gardening, 30–45 min Dancing, 30 min
Raking leaves, 30 min Water aerobics, 30 min
Swimming, 20 min
Jogging 1 mile, 15 min
More vigorous
Moderate activity 150 calories of energy per day
NHLBI. www.nhlbi.nih.gov.
3-Week diet + exercise regimen yields favorable metabolic changes
*
*
†
*
*
0
50
100
150
200
250
Total-C LDL-C HDL-C TG Fastingglucose
mg/dL
*P < 0.01†P < 0.05 Roberts CK et al. J Appl Physiol. 2006;100:1657-65.
*
0
5
10
15
20
25
30
35
Insulin
μU/mL
N = 31 overweight/obese men; weight 8.4 lbs
Baseline Follow-up
Physical activity may reduce CV and all-cause mortality
Fang J et al. Am J Hypertens. 2005;18:751-8.
N = 9791; moderate physical activity vs little or no physical activity
0.75 (0.53–1.05)
0.76 (0.39–1.49)
0.79 (0.65–0.97)
All-cause death
CV death
All-cause death
Prehypertension
CV death
Hypertension
Hazard ratio
1.51.00.5
Normal BP
0 2.0
All-cause death
CV death
0.79 (0.58–1.09)
0.88 (0.80–0.98)
0.84 (0.73–0.97)
Adjusted HR (95% CI)Favorsexercise
Favorsno exercise
NHANES 1 Epidemiological Follow-up Survey (1971–1992)
Lifestyle modification associated with diabetes prevention
Yamaoka K, Tango T. Diabetes Care. 2005;28:2780-6.
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: FixedCombined: RandomCombined: Bayesian
Relative risk (95% CI)0.1 0.5 1.0 5.0 10.0
*vs placebo (unadjusted)†Achieve/maintain ≥7% reduction of initial body weight via diet + moderate-intensity physical activity ≥150 minutes/week
DPP: Benefit of diet + exercise or metformin on diabetes prevention in at-risk patients
DPP Research Group. N Engl J Med. 2002;346:393-403.
Year
N = 3234 with IFG and IGT without diabetes
0
0
10
20
30
40
1 2 3 4
Placebo
Metformin
Lifestyle†
Cumulativeincidence
of diabetes(%)
31%
58%
P*
<0.001
<0.001
Popular dietary programs: Effective yet difficult to maintain
-4.7
-7.3-6.7 -7.1-8
-4
0
Atkins OrnishWeight
Watchers The Zone
Weight loss after 1 year
(lbs)
50
3535
48
01020304050
Drop out rateat 1 year
(%)
N = 160 overweight or obese with ≥1 CV risk factor
Dansinger ML et al. JAMA. 2005;293:43-53.
Look AHEAD: Study design
Usual medical care+ lifestyle intervention* for 4 years, with maintenance
counseling thereafter
*≥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)
Primary endpoint: CV death, nonfatal MI, nonfatal stroke
Look AHEAD Research Group. Control Clin Trials. 2003;24:610-28; Obesity. 2006;14:737-52.
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
Total follow-up 11.5 years
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.
Pharmacologic weight management options
Orlistat* Sibutramine
Mechanism of action Inhibits fat absorption
Inhibits NE and serotonin reuptake
Mean weight loss 1 yr† 6.4 lbs 9.9 lbs
Pooled data 22 trials 5 trials
Adverse events GI discomfort BPHeart rate
*Available Rx and OTC (1/2 dose)†Placebo-correctedNE = norepinephrine
Arterburn DE et al. Arch Intern Med. 2004;164:994-1003. Li Z et al. Ann Intern Med. 2005;142:532-46.
Efficacy of orlistat as adjunct to lifestyle modificationN = 3305, mean BMI 37 kg/m2
All subjects prescribed a reduced-calorie diet (~800 kcal/day deficit) and encouraged tophysical activity Torgerson JS et al. Diabetes Care. 2004;27:155-61.
P < 0.001Δ Body weight
(kg)
Weeks0 52 156 208
-12
-9
-6
-3
0
Placebo + lifestyle Orlistat + lifestyle
104
-3.0 kg
-5.8 kg
Efficacy of sibutramine as adjunct to lifestyle modification
Wadden TA et al. N Engl J Med. 2005;353:2111-20.
All subjects prescribed balanced 1200-1500 kcal/day diet and encouraged to walk 30 min/day
N = 224 with obesity, mean BMI 38 kg/m2
Weight loss (kg)
Sibutramine alone
Lifestyle modification aloneSibutramine + brief therapy
Combined therapy
Weeks
0 3 6 10 18 40 52
16
14
12
10
8
6
4
2
0
Effects of sibutramine and lifestyle modification on cardiometabolic risk factors
Sibutramine alone
Lifestylemodification alone Combined
Total-C (mg/dL) 3.4 2.7 7.9
LDL-C (mg/dL) 2.2 1.0 4.6
HDL-C (mg/dL) 0.9 0.8 2.7
TG (mg/dL) 12.0 31.6 33.9
Glucose (mg/dL) 0.6 4.2 3.0
Insulin (U/mL) 0.5 4.3 6.2
HOMA-IR 0.3 1.1 1.5
Wadden TA et al. N Engl J Med. 2005;353:2111-20.
Change from baseline at 1 year
SCOUT: Study design
6-week single-blind lead-inSibutramine 10 mg + lifestyle intervention*
Sibutramine 10–15 mg + lifestyle intervention*
*Hypocaloric diet (-600 kcal/day) + ≥150 min/week moderate physical activity
Primary endpoint: MI, stroke, resuscitated cardiac arrest, CV death
James WPT. Eur Heart J Suppl. 2005;7(suppl L):L44-8.
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)
Placebo + lifestyle intervention*
3-year randomized, double-blind phase
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.
SOS: Bariatric surgery-associated improvements in cardiometabolic risk
-25
-20
-15
-10
-5
0
5
10
15
20
25
Weight SBP DBP HDL-C FPG
Change from
baseline* (%)
Sjöström L et al. N Engl J Med. 2004;351:2683-93.
Conventional treatment (n = 1660)
Gastric surgery (n = 1845)
*At 2 years
Swedish Obese Subjects (SOS) Study, N = 4047, mean BMI 41 kg/m2
Improved Framingham risk score following bariatric surgery
Vogel JA et al. Am J Cardiol. 2007;99:222-6.
N = 109, mean BMI 49 kg/m2 (preoperative), 36 kg/m2 (13-month follow-up)
10-year CHD risk
(%)
2
4
6
8
10
12
Men Women
P < 0.0001
P = 0.002
Before surgery After surgery
top related