Preventing Cardiometabolic Disease Achievable: Are You Doing Enough?

Given the effectiveness of available interventions, the Endocrine Society issues a practice guideline to prompt proactive efforts at screening for the metabolic components leading to cardiovascular disease and type 2 Diabetes.

with James L. Rosenzweig, MD, and J. Michael Gonzalez-Campoy, MD, PhD

Recognizing the substantial increase in incidence of individuals at risk for combined atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2D), the Endocrine Society developed a clinical practice guideline to aid clinicians in identifying at risk patients and facilitating the implementation of proactive management strategies.1

 “This new clinical practice recommendation is not an update to the 2008 guidelines, which focused on defining the metabolic syndrome (MetS) as a clinical entity. Rather, the 2019 guideline highlights evidence-based, measurable factors that clinicians should monitor and address in order to minimize progression of ASCVD and T2D in adults ages 40 to 75 years,” said James L. Rosenzweig, MD, an endocrinology consultant at Hebrew Rehabilitation Hospital in Boston, Massachusetts and chair of the Guidelines Task Force.

ENDO Society recommends lower blood pressure levels to treat.

Monitor 5 Components Necessary to Reduce Risk of Metabolic Syndrome

“In this guidance, we are targeting those ‘at risk’ versus those with established clinical disease,” Dr. Rosenzweig told EndocrineWeb. “We specifically selected this age range owing to the high quality of evidence for this specific patient cohort, and because there is substantial evidence that indicates that the available interventions have the greatest impact on patient outcomes and offer the greatest likelihood of long-term efficacy,”

“We defined metabolic risk in this guideline so as to include those people with the metabolic syndrome who do not yet have either CVD or T2D but are at increased risk for both conditions,” Dr. Rosenzweig said. Metabolic syndrome refers to a cluster of five specific risk factors.

As such, the task force advocated in favor of screening patients in this designated age group regularly for:1

  • Obesity
  • Hypertension
  • Fasting lipid profile—evaluating specifically for elevated triglycerides (TG), and low high density lipoprotein cholesterol (HDL-C)
  • Glycemic status—measured by either hemoglobin A1c [HbA1c], fasting glucose, or 2-hour glucose with a second test for confirmation using a new blood sample) (see Table 1).

For any patient who has a confirmed elevation in any three or more of these clinical components (or an HDL-C under 40 mg/dL) considered of metabolic risk, a 10-year global risk assessment for ASCVD or coronary heart disease should be completed to inform treatment targets aimed to reduce apolipoprotein B-containing lipoproteins

In individuals with at least one risk factor, the recommendation is to monitor all five components of metabolic risk every three years. In the guidance,1  the authors provide a comprehensive discussion of the assessment tactics and significance of each metabolic parameter.

Implementation of Metabolic Risk Factor Screening Techniques Highlighted

The guideline underscores a strong preference for the use of waist circumference over body mass index (BMI) in evaluating for obesity but go on to explain that this parameter is not intended to replace routine weigh-ins for measurement of body weight or calculations of BMI. Waist circumference provides a more targeted assessment regarding potential risk for ASCVD and type 2 diabetes. Specific ranges for waist circumference are provided in the guideline for each sex and for various ethnicities and racial groups.1

Blood pressure should be measured (after 5 minutes of rest) annually for all individuals at metabolic risk; if elevated, blood pressure should be measured at each subsequent visit and managed accordingly if the patient is found to have hypertension.
Most importantly, are you sure your patients blood pressure was taken properly? Don't be so sure. Read this to confirm.

Of note, this guideline introduces a lower blood pressure threshold before initiating intervention. The recommendation is for individuals whose blood pressure is > 130 mmHg systolic and/or > 80 mmHg diastolic without a documented history of hypertension to undergo repeat measurements within a few weeks of an elevated measure as a better method for identifying a need for intervention.1

Acknowledging that various national organizations define prediabetes differently, the clinical practice guidance does not endorse any specific definition but focuses instead on advocating for a minimum of annual testing for the onset of overt diabetes in all patients identified as having prediabetes based on high normal measures of weight and blood glucose.

Further, the writing group did not find sufficient evidence to support initiation of medication to treat individuals diagnosed as having prediabetes, emphasizing instead the need to recommend for lifestyle interventions, including referral for assistance.

Guidance is Sound but Requires More Aggressive Management

“Honestly, there really isn’t much new in these recommendations outside of lowering BP thresholds; they echo the recommendations that have been issued and reissued by government agencies and by multiple medical societies, including the American Association of Clinical Endocrinologists (AACE),2” said J. Michael Gonzalez-Campoy, MD, PhD, FACE, medical director and chief executive officer of the Minnesota Center for Obesity, Metabolism, and Endocrinology, in Eagan, Minnesota,

In addition, by focusing on an extended range of middle-aged adults, the task force is not addressing the needs of the group at highest risk, which are children, adolescents, and young adults,” Dr. Gonzalez-Campoy told EndocrineWeb. “Despite this, they are reinforcing the importance of early intervention to prevent metabolic complications of overweight, obesity, and adiposopathy (‘sick fat’).”

“However, it should be noted that these guidelines (as well as many from other organizations) continue to disregard the pathophysiology of metabolic syndrome (MetS). People with a genetic predisposition have an inherited propensity that promotes the accrual of adipose tissue when the environment allows it,” he said. 

It is important to emphasize that fat mass alone is not a predictor of metabolic derangements. Rather, in some individuals develop adiposopathy, which includes changes in adipose tissue distribution (ie, intra-abdominal or visceral fat), structure (ie, adipocyte hypertrophy; growth beyond its vascular supply leading to inflammation), and function (ie, insulin resistance, high leptin, low adiponectin).   

The measurements of visceral fat (waist circumference) and triglycerides do address the underlying pathophysiology, Dr. Gonzalez-Campoy said; however, when adiposopathy develops, then the normal signaling and regulation of metabolism with other organs, like the pancreas and the liver, becomes abnormal, leading to elevated blood sugars, increased blood pressure, and an acceleration of vascular disease (which can eventually compromise key organs including the brain, the heart and the kidneys). 

The development of adiposopathy explains why some people with overweight or obesity by BMI thresholds progress to metabolic disease, and not others.” By the age of 40 to 75 years, “the focus should no longer be on ‘screening’ but on aggressive case-finding and intervention,” he said.

Reiterating the Obvious—Emphasize Lifestyle Interventions Effectively and with Follow-Up

Lifestyle modifications are recommended as first-line therapy for all individuals at metabolic risk. In particular, the guideline task force recommends that clinicians discuss factors associated with a healthy lifestyle, or referring patients to specialists in weight management, suggesting support groups and/or other comprehensive weight management programs to meet individual needs that aid in these goals.

The fundamental endpoint of any lifestyle intervention should be to encourage patients to adopt a heart healthy diet with the aim to achieve a weight loss of > 5% during the first year; and daily physical activity–reducing sedentary time and aiming for brisk walking, Dr. Rosenzweig said.

In addition, he suggested that “clinicians find ways to support their patients–whether by advising them to keep a food diary and exercise log, joining a gym, or finding a diet support group.” He said, patient should be cautioned that physical activity alone is not sufficient to lose weight; it is a better intervention in the weight maintenance phase.

Dr. Gonzalez-Campoy agreed that advising patients to focus on “diet and exercise does not work.” Rather, he recommends utilizing the Healthy Eating Clinical Practice Guideline issued by the American Academy of Clinical Endocrinologist (AACE) and the Obesity Society,2 of which Dr. Gonzalez-Campoy was the writing committee co-chair—this guidance focuses away from “what not to eat” emphasizing instead what patients “ought to eat to be healthier.” 

He also emphasized the need to resist telling patients to do more “exercise” as the answer to reversing metabolic disease; this recommendation is often interpreted as a need to go to a gym, hire a trainer, or put in contiguous minutes of “work out” time—an approach could be detrimental to people with obesity (eg, increased risk of orthopedic injuries). 

Dr. Gonzalez believes “most people will be able to increase their movement with proper guidance that introduces physical activity that is realistic, achievable, and sustainable when coached to be added incrementally and over time, as this is what is best to change from sedentary.” 

While “exercising” is viewed as a barrier for people with adiposopathy, overweight, and obesity, a change in a person’s physical activity will prove very agreeable and feasible once initiated. A good way to begin with someone who has been very sedentary is to recommend one of the following suggestions and then build on it:

  • Always use a bathroom on another floor
  • Take the stairs rather than the elevator or escalator.
  • Get into the habit of picking a parking space at the end of the parking lot.
  • Set a timer to remind you to get up every hour or 2 and walk around for a minute.
  • Whenever you go to the grocery store, walk a lap or two around the perimeter before you put anything into your shopping cart.
  • Get an app to measure your steps and try to add 5 steps a week.

Lifestyle Changes Are Likely to be Insufficient: Recommend Medication 

Not all individuals will respond sufficiently to lifestyle interventions. In the case of hyperlipidemia, a comprehensive risk assessment and evaluation is indicated prior to making a diagnosis of primary hyperlipidemia and to rule out possible secondary causes of hyperlipidemia.

In appropriate instances, the evidence is there to support prescribing: metformin, a-glucosidase inhibitors, pioglitazone, and angiotensin II receptor blockers, all of which may significantly reduce the incidence of CVD in diabetes.3-6

High-intensity statin therapy is recommended to reduce LDL-C in those with LDL-C > 190 mg/dL. In patients with elevated LDL-C between 70 to 189 mg/dL, individualized management is recommended to help to reduce their LDL-C taking into account their current LCL-C level, comorbid diabetes, and presence or absence of other metabolic risk factors (eg, elevated TG). Blood pressure medications are recommended for patients unable to reduce hypertension with lifestyle interventions alone.  

Of note, in contrast to prior guidelines, this Clinical Practice Guideline has eliminated the recommendation to treat with low-dose aspirin owing to insufficient evidence of its efficacy.1 Moreover, the task force members consider that the potential risks of bleeding and other complications are outweighed by the potentially modest relative risk reduction in nonfatal myocardial infarction, noting an insignificant reduction in risks of cardiovascular or all-cause mortality.

5 Factors to be monitored to identify metabolic syndrome.

Seek Constructive Interventional Strategies that Meet Individual Circumstances

“Metabolic syndrome is a growing public health problem that should recognized by medical providers since the risk factors for CVD and T2D tend to cluster together in many patients in this age group. Fortunately, common clinical management approaches will reduce the risk for both conditions, leading to greater longevity and improved quality of life,” Dr. Rosenzweig said.

The Endocrine Society guidance, as with other clinical practice recommendations, emphasize the need for measuring waist circumference and calculating body mass index in medical practices, and then informing patients of their increased health risks should these measurements exceed established “normal” thresholds.1,2

“Aggressive case-finding creates opportunities for intervention,” Dr. Gonzalez-Campoy told EndocrineWeb. “Patients should be explicitly told that having adiposopathy, overweight, or obesity is not their fault. Further, they should be told that willpower is seldom the answer to overcoming biology and genetic predispositions, so allowing for medical interventions are often the necessary to achieve health and wellness, and more effective when initiated in a timely manner.”

Dr. Gonzalez-Campoy that while the guideline aims at early detection of individuals at risk, “it falls short in terms of recommendations for therapeutic interventions,” noting the absence of any discussion about factors that might interfere with sound sleep. However, he concluded that although “the Endocrine Society is a late comer in offering recommendations, the task force did a nice job summarizing what has been said, and updating recommendations, especially with the blood pressure thresholds.”

Continue Reading:
Hypertension in Diabetes: How Low to Go in Patients with Diabetes?
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