Disclosures. Outline. Metabolic Syndrome and Diabetes: Evaluating CVD Risk and Strategies for CVD Risk Reduction

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1 Metabolic Syndrome and Diabetes: Evaluating CVD Risk and Strategies for CVD Risk Reduction Nathan D. Wong, PhD, FACC, FAHA Professor and Director Heart Disease Prevention Program Division of Cardiology University of California, Irvine Immediate Past President, American Society for Preventive Cardiology Disclosures Research support through the University of California, Irvine from Merck and Bristol Myers- Squibb. Consultant, AVIIR and Amarin Outline Review the epidemiological relation of metabolic syndrome, diabetes, and cardiovascular disease. Discuss strategies for CVD risk assessment in persons with metabolic syndrome and diabetes. Review the evidence and recommendations for risk factor management for prevention of CVD in persons with metabolic syndrome and diabetes. 1

2 Six of the top 1 causes of death globally are cardiometabolic / behavioral risk factors Diabetes and CVD Atherosclerotic complications responsible for 8% of mortality among patients with diabetes 75% of cases due to coronary artery disease (CAD) Results in >75% of all hospitalizations for diabetic complications 5% of patients with type 2 diabetes have preexisting CAD. (This number may be less now that more younger people are diagnosed with diabetes.) 1/3 of patients presenting with myocardial infarction have undiagnosed diabetes mellitus Lewis GF. Can J Cardiol. 1995;11(suppl C):24C-28C Norhammar A, et.al. Lancet 22;359;

3 Mechanisms by which Diabetes Mellitus Leads to Coronary Heart Disease Hyperglycemia Insulin Resistance Inflammation HTN AGE Endothelial Oxidative dysfunction stress IL-6 Infection CRP SAA Defense mechanisms Pathogen burden Subclinical Atherosclerosis Dyslipidemia LDL TG Thrombosis HDL PAI-1 TF tpa Disease Progression Atherosclerotic Clinical Events AGE=Advanced glycation end products, CRP=C-reactive protein, CHD=Coronary heart disease HDL=Highdensity lipoprotein, HTN=Hypertension, IL-6=Interleukin-6, LDL=Low-density lipoprotein, PAI-1=Plasminogen activator inhibitor-1, SAA=Serum amyloid A protein, TF=Tissue factor, TG=Triglycerides, tpa=tissue plasminogen activator Biondi-Zoccai GGL et al. JACC 23;41: Most Cardiovascular Patients Have Abnormal Glucose Metabolism GAMI n = 164 EHS n = 192 CHS n = % 31% 37% 18% 37% 27% 34% 45% 36% Normoglycemia Prediabetes Type 2 Diabetes GAMI = Glucose Tolerance in Patients with Acute Myocardial Infarction study; EHS = Euro Heart Survey; CHS = China Heart Survey Anselmino M, et al. Rev Cardiovasc Med. 28;9: Diagnostic Criteria for Metabolic Syndrome: Modified NCEP ATP III 3 Components Required for Diagnosis Components Increased waist circumference Men Women Elevated triglycerides Defining Level 4 in 35 in 15 mg/dl (or Medical Rx) Reduced HDL-C Men Women Elevated blood pressure Elevated fasting glucose AHA/NHLBI Scientific Statement; Circulation 25; 112:e285-e29. <4 mg/dl <5 mg/dl (or Medical Rx) 13 / 85 mm Hg (or Medical Rx) 1 mg/dl (or Medical Rx) 3

4 IDF Criteria: Abdominal Obesity and Waist Circumference Thresholds Men Women Europid 94 cm (37. in) 8 cm (31.5 in) South Asian 9 cm (35.4 in) 8 cm (31.5 in) Chinese 9 cm (35.4 in) 8 cm (31.5 in) Japanese 85 cm (33.5 in) 9 cm (35.4 in) AHA/NHLBI criteria: 12 cm (4 in) in men, 88 cm (35 in) in women Some US adults of non-asian origin with marginal increases should benefit from lifestyle changes. Lower cutpoints ( 9 cm in men and 8 cm in women) for Asian Americans >9cm (male) and >8cm (female) recommended for persons of Central and South American ancestry (including US Hispanics) Alberti KGMM et al. Lancet 25;366: Grundy SM et al. Circulation 25;112: Intra-abdominal (Visceral) Fat The dangerous inner fat! Front Visceral AT Subcutaneous AT Back Abdominal Adiposity Is Associated With Increased Risk of Diabetes Relative Risk of Diabetes P value for trend <.1 <28 > Waist Circumference (in) Carey VJ, et al. Am J Epidemiol. 1997;145:

5 Pericardial Fat Predicts CVD Risk MACE patient (CABG): 58-year-old woman with BMI 32.8 and CCS =, PFV = 187 cm 3 and TFV 315 cm 3 After adjustment for Framingham risk score (FRS), CCS, and body mass index, PFV and TFV were significantly associated with MACE (odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.3 to 2.95 for each doubling of PFV; OR: 1.78, 95% CI: 1.1 to 3.14 for TFV). Cheng et al. JACC Img 21;3:352-6 Metabolic Syndrome and Diabetes in Relation to CHD, CVD, and Total Mortality: U.S. Men and Women Ages 3-74 Relative Risk (Risk-factor Adjusted Cox Regression) NHANES II Follow-up (n=6255) *** *** *** None *** MetS *** *** *** Diabetes *** * ** CVD *** *** CVD+Diabetes CHD Mortality CVD Mortality Total Mortality Malik and Wong, et al., Circulation 24. * p<.5, ** p<.1, **** p<.1 compared to none Is DM really a CHD Risk Equivalent? Meta-Analysis of 38,578 subjects (Bulugahapitiya et al. Diabetic Med 28) 5

6 Global Risk Assessment in DM: 1-year Total CVD Risk (Wong ND et al., Diab Vas Dis Res 212) Annual CHD Event Rates (in %) by Calcium Score Events by CAC Categories in Subjects with DM, MetS, or Neither Disease (Malik and Wong et al., Diabetes Care 211) Coronary Heart Disease 4 Annual CHD Event Rate DM MetS Neither MetS/DM Coronary Artery Calcium Score ACCF/AHA 21 Guideline: CAC Scoring for CV risk assessment in asymptomatic adults aged 4 and over with diabetes (Class IIa-B) Mean Absolute Progression of CAC (Volume Score) in Persons with and without MetS and DM, CAC> at baseline, MESA Study Wong ND et al., JACC Cadiovasc Imaging 212 6

7 Progression of CAC and Incidence of CHD in Persons with and without MetS and DM, MESA Study, by Tertile of CAC Progression Wong ND et al, JACC Cardiovasc Imaging 212 Metabolic syndrome & Intimal Medial Thickness in Caucasian (CS) and African American (AA) men and women in ARIC Study Carotid 748 IMT (micro mm) CS Men AA Men CS Women AA Women MS(+) MS(-) McNeill AM, et al. AJC 24. Prevalence of reduced Ankle Brachial Index according to Increasing components of Metabolic Syndrome P<.1 for trend ABI<.9 (%) RF 1 RF 2 RF 3 RF 4 RF 5 RF Olijhoek JK, et al. Eur Heart J 24. 7

8 Summary of Intervention Studies Risk Reduction with Individual Treatments Persons with Diabetes Mellitus Macrovascular Event Reduction Blood pressure treatment 3-5% Lipid treatment 25-55% Glucose treatment 1-2% per 1% HbA 1c Poor Control of Multiple Cardiovascular Risk Factors Among U.S. Adults with Type 2 Diabetes NHANES Survey 23-26, n=889 (14.3 million) or 6.6% of adults aged >/=18 years had type 2 diabetes 58.2% at HbA1c goal <7% 44.2% at BP goal <13/8 mmhg 56.4% at recommended HDL-C >/=4 (M), >/=5 (F) 25.8% at recommended triglycerides <15 mg/dl 13.9% at BMI<25 kg/m 2 Overall, only 1.5% of men and 9.9% of women at goal for HbA1c, BP, and LDL-C simultaneously; only.3% at goal also including BMI. Wong K, Wong ND et al. J Diab Complic 212 Summary of Care: ABC's for Providers A B C A1c Target Aspirin Daily Blood Pressure Control Cholesterol Management Cigarette Smoking Cessation D E F Diabetes and Pre-Diabetes Management Exercise Food Choices 8

9 Diabetes Mellitus: Effect of Aspirin 25 2 p<.2 p=ns No ASA ASA Endpoint (%) 15 p<.5 p=.4 p < p=ns p=ns PHS ETDRS APT BIP PPP POPADAD JPAD n= Endpoint 5 yr MI 7 yr MI 1 yr MCE 5 yr CV Death 4 yr MCE 7yr MCE 4 yr MCE # Events 26 vs vs vs vs vs vs vs 68 NS=Not Significant 1. Steering Committee of the Physicians' Health Study Research Group. NEJM 1989;321: ETDRS Investigators. JAMA 1992;268: Antiplatelet Trialists' Collaboration. BMJ 1994; 38:81 4. Harpaz D et al. Am J Med 1998;15: Sacco M et al. Diabetes Care 23;26: Belch J et al. BMJ 28; 337:a Ogawa H et al. JAMA 28; 3: 2134 Recommendations: Antiplatelet Agents (1) Consider aspirin therapy ( mg/day) (C) As a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (1-year risk >1%) Includes most men >5 years of age or women >6 years of age who have at least one additional major risk factor Family history of CVD Hypertension Smoking Dyslipidemia Albuminuria ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S32-S33. Recommendations: Antiplatelet Agents (2) Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk, since potential adverse effects from bleeding likely offset potential benefits (C) 1-year CVD risk <5%: men <5 and women <6 years of age with no major additional CVD risk factors In patients in these age groups with multiple other risk factors (1-year risk 5 1%), clinical judgment is required (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S33. 9

10 Recommendations: Antiplatelet Agents (3) Use aspirin therapy ( mg/day) Secondary prevention strategy in those with diabetes with a history of CVD (A) For patients with CVD and documented aspirin allergy Clopidogrel (75 mg/day) should be used (B) Combination therapy with aspirin ( mg/day) and clopidogrel (75 mg/day) Reasonable for up to a year after an acute coronary syndrome (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S33-S34. Diabetes Mellitus (Type II): Effect of Intensive Glycemic Control United Kingdom Prospective Diabetes Study (UKPDS) 3,867 patients with DM randomized to intensive therapy with a sulphonylurea or insulin (mean HbA 1C 7.%) or conventional therapy (mean HbA 1C 7.9%) P<.1-21 P=.2-16 P=.5-12 P=.3 P<.1-4 Microalbuminuria at 12 years Microvascular complications Retinopathy Myocardial infarction Any DM endpoint -5 Intensive glycemic control in DM reduces the risk of microvascular complications DM=Diabetes mellitus, HbA 1C=Glycosylated hemoglobin UKPDS Group. Lancet 1998;352: Glycemic Legacy? N Engl J Med 28;359:

11 Recent Trials Show No Reduction in CV Events with More Intensive Glycemic Control Patients with events (%) ACCORD: Primary Outcome 25 2 Intensive therapy Standard therapy Years Cumulative incidence (%) ADVANCE: Primary Outcome Intensive therapy Standard therapy Months of follow-up Number at Risk Intensive Standard Number at Risk Intensive Standard ACCORD Study Group. N Engl J Med. 28;358: ADVANCE Collaborative Group. N Engl J Med. 28;358: Was Intensive Glycemic Control Harmful? A closer look at ACCORD AND ADVANCE ACCORD was discontinued early due to increased total and CVD mortality in the intensive arm. VA Diabetes Trial showed severe hypoglycemia to be a powerful predictor of CVD events. A recent analysis of ACCORD (Diabetes Care, May 21) showed deaths related to unsuccessful intensive therapy where A1c remained high. But in both ACCORD AND ADVANCE, those without macrovascular disease at baseline had an actual benefit in the primary endpoint. Metabolic Memory and Glycemic Legacy UKPDS vs. VADT Start of intensive therapy in UKPDS Ideal course = early and sustained glycemic control A1C (%) Bad Glycemic Legacy Time Since Diagnosis (years) Start of intensive therapy in VADT Drives risk of Complications Risk of complications continues despite glycemic control Del Prato S. Diabetalogia. 29;52:

12 American Diabetes Association 212 Standards of Medical Care: HbA1c Goals A reasonable A1C goal for many nonpregnant adults is <7% due to efficacy in reducing microvascular complications. Consider more stringent A1C goals (such as <6.5%) for selected patients, if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, and extensive comorbid conditions and for those with longstanding diabetes in whom the general goal is difficult to attain. UKPDS: Effects of Tight vs. Less-Tight Blood Pressure Control UK Prospective Diabetes Study Group. BMJ. 1998; 317: Diabetes Mellitus: Effect of Blood Pressure Control Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial 4,733 diabetic patients randomized to intensive BP control (target SBP <12 mm Hg) or standard BP control (target SBP <14 mm Hg) for 4.7 years Nonfatal MI, nonfatal stroke, or CV death Patients with Events (%) HR=.88 95% CI ( ) Years Post-Randomization Total Stroke Patients with Events (%) HR=.59 95% CI ( ) Years Post-Randomization Intensive BP control in DM does not reduce a composite of adverse CV events, but does reduce the rate of stroke BP=Blood pressure, DM=Diabetes mellitus, HR=Hazard ratio, SBP=Systolic blood pressure ACCORD study group. NEJM 21 12

13 Recommendations: Hypertension/Blood Pressure Control Goals People with diabetes and hypertension should be treated to a systolic blood pressure goal of <14 mmhg (B) Lower systolic targets, such as <13 mmhg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden (C) Patients with diabetes should be treated to a diastolic blood pressure <8 mmhg (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S29. Masked hypertension with target organ damage presenting as pre-htn in DM2 patients Presence of masked HTN (MH) in DM2 patients = 3% Office MH: BP = 128 /76 mm Hg Office NTN: BP = 123/77 mm Hg Office MH vs. NTN: macroalbuminuria+ (p=.1) Office MH vs. NTN: LVH+ (p=.15) ~ 1/3 of DM2 patients misclassified as normotensive! Leitao, CB., Diabetic Care 27;3: Recommendations: Hypertension/Blood Pressure Control Treatment (1) Patients with a blood pressure (BP) >12/8 mmhg should be advised on lifestyle changes to reduce BP (B) Patients with confirmed BP 14/8 mmhg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve BP goals (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S29. 13

14 Recommendations: Hypertension/Blood Pressure Control Treatment (2) Lifestyle therapy for elevated BP (B) Weight loss if overweight DASH-style dietary pattern including reducing sodium, increasing potassium intake Moderation of alcohol intake Increased physical activity ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S29. Recommendations: Hypertension/Blood Pressure Control Treatment (3) Pharmacological therapy for patients with diabetes and hypertension (C) A regimen that includes either an ACE inhibitor or angiotensin II receptor blocker; if one class is not tolerated, substitute the other Multiple drug therapy (two or more agents at maximal doses) generally required to achieve BP targets (B) Administer one or more antihypertensive medications at bedtime (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S29. Recommendations: Hypertension/Blood Pressure Control Treatment (4) If ACE inhibitors, ARBs, or diuretics are used, kidney function, serum potassium levels should be monitored (E) In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of /65 79 mmhg are suggested in interest of long-term maternal health and minimizing impaired fetal growth; ACE inhibitors, ARBs, contraindicated during pregnancy (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S29. 14

15 Diabetes Mellitus: Effect of an HMG-CoA Reductase Inhibitor Meta-analysis of 18,686 patients with DM randomized to treatment with a HMG-CoA Reductase Inhibitor Statins reduce CV events 21% in diabetics (similar to non-diabetics) Cholesterol Treatment Trialists (CTT) Collaborators. Lancet 28;37: ACCORD Lipid Study Results (NEJM 21; 362: ) 5518 patients with type 2 DM treated with open label simvastatin randomly assigned to fenofibrate or placebo and followed for 4.7 years. Annual rate of primary outcome of nonfatal MI, stroke or CVD death 2.2% in fenofibrate group vs. 1.6% in placebo group (HR=.91, p=.33). Pre-specified subgroup analyses showed possible benefit in men vs. women and those with high triglycerides and low HDL-C. Results support statin therapy alone to reduce CVD risk in high risk type 2 DM patients. 15

16 Recommendations: Dyslipidemia/Lipid Management (1) Screening In most adult patients, measure fasting lipid profile at least annually (B) In adults with low-risk lipid values (LDL cholesterol <1 mg/dl, HDL cholesterol >5 mg/dl, and triglycerides <15 mg/dl), lipid assessments may be repeated every 2 years (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S31. Recommendations: Dyslipidemia/Lipid Management (2) Treatment recommendations and goals (1) To improve lipid profile in patients with diabetes, recommend lifestyle modification (A), focusing on Reduction of saturated fat, trans fat, cholesterol intake Increased n-3 fatty acids, viscous fiber, plant stanols/sterols Weight loss (if indicated) Increased physical activity ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S31. 16

17 Recommendations: Dyslipidemia/Lipid Management (3) Treatment recommendations and goals (2) Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels with overt CVD (A) without CVD >4 years of age who have one or more other CVD risk factors (A) For patients at lower risk (e.g., without overt CVD, <4 years of age) (C) Consider statin therapy in addition to lifestyle therapy if LDL cholesterol remains >1 mg/dl In those with multiple CVD risk factors ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S31. Recommendations: Dyslipidemia/Lipid Management (4) Treatment recommendations and goals (3) In individuals without overt CVD Primary goal is an LDL cholesterol <1 mg/dl (2.6 mmol/l) (B) In individuals with overt CVD Lower LDL cholesterol goal of <7 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S31. Recommendations: Dyslipidemia/Lipid Management (5) Treatment recommendations and goals (4) If targets not reached on maximal tolerated statin therapy Alternative therapeutic goal: reduce LDL cholesterol ~3 4% from baseline (B) Triglyceride levels <15 mg/dl (1.7 mmol/l), HDL cholesterol >4 mg/dl (1. mmol/l) in men and >5 mg/dl (1.3 mmol/l) in women, are desirable (C) However, LDL cholesterol targeted statin therapy remains the preferred strategy (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S31. 17

18 Recommendations: Dyslipidemia/Lipid Management (6) Treatment recommendations and goals (5) Combination therapy has been shown not to provide additional cardiovascular benefit above statin therapy alone and is not generally recommended (A) Statin therapy is contraindicated in pregnancy (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S31. Weight Management Recommendations Goals Recommendations Calculate BMI* and measure waist circumference BMI 18.5 to 24.9 kg/m 2 Women: <35 inches Men: <4 inches 1% weight reduction within the 1 st yr of Rx I IIa IIb III *BMI is calculated as the weight in kilograms divided by the body surface area in meters 2 Monitor response to treatment Start weight management and physical activity as appropriate If BMI and/or waist circumference is above goal, initiate caloric restriction and increase caloric expenditure BMI=Body mass index, Rx=Treatment Source: Smith SC Jr. et al. JACC 26;47:

19 Diabetes Prevention Program: Reduction in Diabetes Incidence Look AHEAD (Action for Health in Diabetes): Trial Halted Early Intensive lifestyle intervention resulted in 1 Average 8.6% weight loss Significant reduction of A1C Reduction in several CVD risk factors Benefits sustained at 4 years 2 However, trial halted after 11 years of follow-up because there was no significant difference in primary cardiovascular outcome between weight loss, standard care group 1, 2. Look AHEAD Research Group. Diabetes Care. 27;3: and Arch Intern Med. 21;17: ; Recommendations: Medical Nutrition Therapy (MNT) Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT (A) Because MNT can result in cost-savings and improved outcomes (B), MNT should be adequately covered by insurance and other payers (E) ADA. V. Diabetes Care. Diabetes Care 213;36(suppl 1):S22. 19

20 American Heart Association (AHA) Nutrition Committee Dietary Recommendations Balance calorie intake and physical activity to achieve or maintain a healthy body weight Consume a diet rich in fruits and vegetables Consume whole-grain, high-fiber foods Consume fish, especially oily fish, at least twice a week Limit intake of saturated fat to <7%, trans fat to <1% of energy, and cholesterol <3 mg/day by: Choosing lean mean and vegetable alternatives Choosing fat free (skim), 1% fat, and low-fat dairy products, Minimizing intake of partially hydrogenated fats Minimize intake of beverages and foods with added sugar Choose and prepare foods with little or no salt <15mg/d If alcohol is consumed, do so in moderation Source: AHA Nutrition Committee. Circulation 26;114:82-96 Recommendations: Smoking Cessation Advise all patients not to smoke or use tobacco products (A) Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 213;36(suppl 1):S34. 2

21 Recommendations: Physical Activity Advise people with diabetes to perform at least 15 min/week of moderate-intensity aerobic physical activity (5 7% of maximum heart rate), spread over at least 3 days per week with no more than 2 consecutive days without exercise (A) In absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week (A) ADA. V. Diabetes Care. Diabetes Care 213;36(suppl 1):S24. RCT Trial Assessment of Pedometer Interventions N=277; 8 Trials Pedometer increased steps by 25/day Bravata, DM et al. JAMA 27; 298: Benefit of Comprehensive, Intensive Management: STENO 2 Study Treatment Goals: Intensive TLC HgbA1c <6.5% Cholesterol <175 Triglycerides < BP <13/8 Primary End Point=CV events (%) Conventional Therapy Intensive Therapy n =8 n = Months of Follow Up Gaede, P. et al, NEJM 23;348:

22 Percent of CHD Events Over 1 Years Prevented in US Adults with T2DM, According to Individual and Composite Risk Factor Control (Wong ND, et al., AHA 212) Goal(ADA Guidelines) Nominal Aggressive HbA1C* 7% 1% AR 2% AR Systolic Blood Pressure 13mmHg 1% RR 2% RR Total Cholesterol 17mg/dl (4.4mmol/L) 25% RR 5% RR HDL-Cholesterol 4mg/dl(M), 5 mg/dl(f) 1% relative increase 2% relative increase RR-Relative Reduction; AR- Absolute Reduction; HbA1C levels were not allowed to be reduced further than 6.5% The Global CVD Taskforce calls on the CVD community to endorse and support the following top 4 targets to address NCDs and help ensure achievement of the 225 goal of reducing NCD mortality by 25%: 1) Physical inactivity: 1% relative reduction in prevalence of insufficient physical activity 2) Raised blood pressure: 25% relative reduction in prevalence of raised blood pressure 3) Salt/Sodium Intake: 3% relative reduction in mean population intake of salt, with aim of achieving recommended level of <5 g/d (2 mg of sodium) (note various organizations such as the AHA call for a limit of 15 mg/day) 4) Tobacco: 3% relative reduction in prevalence of current tobacco smoking Smith SC et al., 212 Nutrition, physical activity and NCD prevention Up to 8% of heart disease, stroke and type 2 diabetes and over a third of the most common cancers could be prevented by eliminating obesity, unhealthy diets and physical inactivity Call for commitments at the global and national level to address these risk factors including: Control food supply, food information and marketing and promotion of energy-dense, nutrient-poor foods that are high in saturated, trans-fat, salt or refined sugars 22

23 SUMMARY MetS and DM confer increased risks for CVD complications The wide spectrum in CVD risks, however, warrants careful CVD risk assessment in such individuals Lifestyle modification remains the cornerstone of efforts to prevent and reduce progression of MetS and DM globally Glycemic, blood pressure, lipid, and antiplatelet therapy are key to reduce CVD risks associated with MetS and DM Thank You! American Society for Preventive Cardiology 23