NEW ORLEANS—Patients with the metabolic syndrome require multiple interventions to protect them from cardiovascular (CV) events, and some approaches work better than others, presenters explained at the American College of Cardiology annual meeting.
Roger S. Blumenthal, MD, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease in Baltimore, simplified the syndrome and its management, and offered a checklist of the 6 associated risk conditions and the appropriate interventions:
Intensive lifestyle changes in patients with insulin resistance/impaired glucose tolerance (IGT) can reduce the progression to frank diabetes by nearly 60%, said Dr Blumenthal, largely through the effects of robust dietary changes and 30 minutes of moderate activity each day (“10,000 steps”). “These actions are just as important as giving an aspirin or a cholesterol-lowering pill every day,” he remarked.
Gail Underbakke, RD, of the University of Wisconsin Preventive Cardiology Program, Madison, echoed this emphasis on dietary modification for the effects on weight, as well as for the impact on endothelial function.
Fruits, vegetables, folic acid, and omega-3 fatty acids improve endothelial function, whereas high-fat diets worsen function postprandially; saturated and trans fats have the greatest negative effects. Studies with antioxidant vitamins have produced mixed results, she noted.
The optimal diet should emphasize the type of calories that are appropriate for weight management:
• Carbohydrates (high fiber, limited concentrated sugars) should comprise <60% of calories
• Fat—up to 25% to 35% of calories, with a stress on monounsaturated fat, omega-3 from fish and plants, and 1 oz of nuts daily
• Protein—up to 15% to 20% of calories, and derived from low-saturated-fat sources and plant proteins
• Vegetables and fruits should be consumed in abundance, while processed foods should be avoided.
Target Insulin Resistance
Steven M. Haffner, MD, professor of medicine, University of Texas Health Science Center, San Antonio, focused on the insulin resistance/IGT component of the metabolic syndrome. Sounding a more sober note, he acknowledged that, while interventions are noble, they do not always improve outcomes, at least in clinical trials.
Since risk for coronary heart disease risk is only “modestly” increased in patients with impaired fasting glucose (IFG), intensified risk factor management for this component alone is not formally recommended. Treatment for IFG or IGT is recommended only for very-high-risk patients whose likelihood of developing diabetes is >10% annually. Finally, Dr Haffner noted that there is little evidence showing that preventing diabetes will also prevent CV disease.
Focus on Immediate Benefits
Lynda Powell, PhD, of Rush University Medical Center, Chicago, acknowledged that it is difficult to motivate patients to make even those changes that will clearly prevent CV disease. “For every 100 patients treated, we achieve success in terms of blood pressure control in only 33, in lipid lowering in only 17, and in weight loss in only 10 patients,” she observed.
Physicians can improve on these numbers by focusing on 1 change at a time and by keeping the message simple—using catchy phrases—and repeating the message often. Dr Powell’s office adopted the slogan “Waste Energy” as a way to motivate patients to eat less and be more active. They post it on signs, and they printed the mantra on stickers that they put on their invoices. “We use the sophistication of the marketing world to our advantage,” she said.
Physicians should also emphasize the immediate benefits of change rather than the long-term goals. The immediate benefits of walking, for example, are the opportunity to breathe fresh air in an undisturbed environment, which allows them to reflect on life and thus reduce stress. Long-term changes are weight loss, blood pressure control, and a longer life.
Instantaneous reinforcement is key, she said. “You hope for the ripple effect, that they will become engaged in change, and it will multiply.” She also advocates a “coping peer” program, using fellow patients as a support system for lifestyle modification. “We make use of the social capital of the older patients with disease who have time on their hands.”
• Dietary changes and 30 minutes of daily exercise are as important as drug therapy for patients with the metabolic syndrome.
• Fruits, vegetables, folic acid, and omega-3 fatty acids improve endothelial function.
• Saturated and trans fats have the greatest negative effects on the progression to frank diabetes.
• Focus on the immediate benefits of change (rather than long-term goals), such as breathing fresh air while walking and reducing stress.