Moving Towards Primordial Prevention: Effective Interventions in the Clinical Setting Engaging and Empowering Patients

Transcription

1 Moving Towards Primordial Prevention: Effective Interventions in the Clinical Setting Engaging and Empowering Patients Michael J. Bloch, M.D. Doina Kulick, M.D.

2 PREVALENCE OF CARDIOVASCULAR AND METABOLIC RISK FACTORS

3 Prevalence of CVD Risk Factors in Adults: US, Percent of Population Overweight Hypertension Smoking High cholesterol Year Reproduced with permission from National Institutes of Health, National Heart, Lung, and Blood Institute. Fact Book Fiscal Year :52.

4 Obesity Trends Among U.S. Adults, BRFSS (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

5 Prevalence of Childhood Obesity in U.S., BRFSS, 2008

6 The Evolution of Man (and Woman) The Economist, December 13 th -19 th 2003

7 Calories kcal Increase in Mean Caloric Intake in U.S. Cince 1970 s (Mostly carbohydrates) Men Total Carb Fat Women Year Year

8 Food Industry, 2010 New Yorker, August, 2010

9 Walking the Dog,

10 Age-Standardized Prevalence of Diagnosed Diabetes per 100 Adult Population <4% 4%-4.9% 5%-5.9% > 6% Behavioral Risk Factor Surveillance System.

11 Diagnosed Diabetes Just Tip of the Iceberg: 1 in 4 Adult Americans Have Metabolic Syndrome Prevalence, %, age 18 yrs Diagnosed diabetes White Black Hispanic Other Population at risk (millions) 6.2 Undiagnosed diabetes* 14.6 Diagnosed diabetes* Prevalence, %, age 20 yrs Metabolic syndrome White Black Hispanic Other Mokdad AH, et al. JAMA. 2003;289: Ford ES, et al. JAMA. 2002;287: Ford ES, et al. Diabetes Care. 2004;27: ~64 Metabolic syndrome *2005 US data, NIDDK, NIH. Based on revised NCEP/ATP III definition (NHANES 2000 data).

12 Cumulative Hazard (%) Presence of Metabolic Syndrome Increases Risk of CV Mortality: The Kuopio Ischemic Heart Disease Risk Study 20 Coronary Heart Diseas Mortality 20 Cardiovascular Disease Mortality 20 All Cause Mortality 15 RR (95% CI), 3.77 ( ) 15 RR (95% CI), 3.55 ( ) 15 RR (95% CI), 2.43 ( ) Follow-up, Y No. at Risk Metabolic Syndrome Follow-up, Y Follow-up, Y Yes No Metabolic Syndrome: Yes No Lakka H-M, et al. JAMA. 2002;288:

13 FROM PRIMARY TO PRIMORDIAL PREVENTION

14 Primordial Prevention in Overweight or Metabolicly Challenged Individuals Abdominally obese patient at increased cardiometabolic risk Risk factors Coronary heart disease Hypertension Dyslipidemia Type 2 diabetes Treat the cause Treat the complications? Manage coronary heart disease risk Adapted with permission from Després JP, et al. BMJ. 2001;322:

15 Steve Martin, Oscar Awards, 2003 I d do anything to look like all these beautiful people you see here tonight. except, of course, exercise and eat right.

16 Omnivore s Dilemma, Michael Pollen When you can eat anything what should you eat?

17 Approach to Lifestyle Modification 3 Separate Issues to Address Heart Healthy Food Choices DASH Diet, Mediterranean-style diet, etc Unlikely to result in significant weight loss alone Exercise for Life Give specific advice (exercise prescription) No recommendation for routine exercise treadmill testing in asymptomatic individuals Start slowly, as little as 5 min/day, but work-up to at least 30 minutes of moderate intensity exercise daily Work exercise into daily routinemultiple short bursts are appropriate for some patients Mix of cardio and resistance training appropriate for most Unlikely to result in significant weight loss alone, but crucial for weight maintenance Calorie Manipulation for weight loss or maintenance

18 Obese Patients Have Unrealistic Weight Loss Expectations Outcome Weight (lbs) % Reduction Initial Dream Happy Acceptable Disappointed Foster et al. J Consult Clin Psychol 1997;65:79.

19 % Reduction in Incidence of Diabetes Weight Change, kg Reduction in Risk of Metabolic Syndrome, % Diabetes Prevention Program: LS = 7% Reduction in Weight and 150 min Exercise per Week PB (n = 1082) -0.1 MET (n = 1073) -2.1* *P <.001 vs placebo MET -31 *P <.05 vs metformin LS (n = 1079) -5.6* LS -58* Risk of developing metabolic syndrome MET -17% n=1523 LS = lifestyle intervention; MET = metformin; PB = placebo. LS -41%* *P <.001; P =.03 Knowler WM, et al; Diabetes Prevention Program Research Group. N Engl J Med. 2002;346: Orchard TJ, et al; Diabetes Prevention Program Research Group. Ann Intern Med. 2005;142:

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21 A to Z Trial: Comparison of Four Popular Diets on Weight Loss Gardner CD, et al. JAMA. 2007;297(9):

22 Key to Weight Loss: Calories in and Calories Out: To Achieve a 300 kcal Negative Energy Balance: Reduce intake by: Eliminating 2 oz potato chips Or increase activity by: Running 3 miles in 30 min or Substituting 2 diet sodas for 2 regular sodas or Bicycling 8 miles in 30 min

23 Weight Loss Goal: Achieve a kcal Negative Energy Balance each day 12 oz café mocha 4 oz muffin 16 oz juice Original Breakfast + + = 1070 cal 330 Calories 500 calories 240 calories Coffee with 2 oz skim milk 2 slices of whole wheat bread 1 T light margarine small banana Breakfast Makeover 40 calories calories + + = 410 cal 50 calories 120 calories

24 Increase Satiety by Decreasing Energy Density Kcal = 120 Yogurt: 170 grams Raspberries: 60 grams Total = 230 grams Energy Density = ~0.5 Kcal/g Kcal = 130 Yogurt Mix: 170 grams Energy Density = ~0.75 Kcal/g Courtesy of Christopher Gardner, M.D.

25 Practical Approach to Maximize Satiety and Achieve Meaningful Weight Loss and Weight Management 1. Individualized balance of Carbs / Fats / Protein for sustained adherence Focus on FOOD Right Fats (mono- and poly- unsaturated, omega 3 s Right Carbs (high fiber, low glycemic index, complex Right Protein (plant, marine, and lean animal sources) 2. Limit or eliminate sugar, high fructose corn syrup, and refined starches and snack foods 3. Reduce or eliminate all calories from beverages 4. Smaller portions, low energy density, high nutrient density 5. Consider book-keeping of calories, points, etc 6. Drink (and eat) water 7. Exercise for life 8. Get adequate sleep

26 Assess Readiness for Change Each Visit Motivation: Stress level: Psychiatric issues: Time availability: Patient seeks weight reduction Free of major life crises Free of severe depression, substance abuse, bulimia nervosa, other eating disorders Patient can devote min/d to weight control for next 26 weeks YES Patient Ready? NO Initiate more aggressive weight loss therapy Prevent weight gain and explore barriers to weight reduction

27 Inferior doctors treat full-blown disease, Mediocre doctors treat disease before it is evident, Superior doctors prevent disease --Huang Dee, Nai-Chian Cohen JD. Arch Intern Med. 2002;162(4):