The Endocrine Society’s latest clinical practice guideline calls for regular monitoring of key metabolic measures at routine appointments. These initial steps can alert clinicians and patients alike to any potential metabolic threats that might be lurking.
Better screening to detect the metabolic risk factors for cardiovascular disease and type 2 diabetes can lead to earlier intervention using lifestyle modifications — changes that could prevent patients from progressing to these conditions, according to a new Endocrine Society clinical practice guideline.
The five key components of metabolic risk that should be monitored regularly are elevated blood pressure, increased waist circumference, elevated fasting triglycerides, low high-density lipoprotein cholesterol, and elevated glycemia.
The finding of three or more of these components should identify the patient as being at metabolic risk for developing atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM).
“Doctors haven’t been doing enough to measure waist circumference, but it is an important aid to identifying patients at metabolic risk earlier and preventing more cases of heart disease and diabetes. We would like to encourage the primary care doctor or internist to put waist circumference in as one of the measures when they first see a patient.” – James L. Rosenzweig, MD, Hebrew Rehabilitation Hospital, Boston; chair, guideline writing committee
“Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk: An Endocrine Society Clinical Practice Guideline” is an update of a guideline published in 2008. “The guideline needed to be updated because of new data in the past 10 years,” says James L. Rosenzweig, MD, of Hebrew Rehabilitation Hospital in Boston, who chaired the writing committees for both documents.
“The term ‘metabolic syndrome’ has been used to describe a set of clustered risk factors,” Rosenzweig says. The concept and definition of metabolic syndrome has been dogged by controversy, but there is no doubt that it increases the risks of developing cardiovascular disease and diabetes — hence the guideline refers to “metabolic risk” in individuals who do not yet have either condition and highlights the importance of overall risk assessment. The guideline also points users to risk engines for specific conditions such as heart disease to guide treatment targets.
- A new practice guideline urges healthcare providers to incorporate screening of key indicators to identify patients at metabolic risk of developing atherosclerotic cardiovascular disease and type 2 diabetes.
- The five key factors for assessing metabolic risk are abdominal body fat, HDL cholesterol, triglycerides, blood pressure, and glycemic control.
- For patients identified as being at metabolic risk, first-line therapy is prevention through lifestyle and behavioral interventions such as healthier diet, increased exercise, and weight loss.
One approach that hasn’t changed since the first edition of the guideline is that the first-line therapy for those found to be at metabolic risk is lifestyle modification, including a healthier diet, more physical activity, and weight loss. The guideline says that providers “should encourage individuals to join comprehensive programs led by trained health professionals that support the adoption of healthy lifestyles.”
Specific components of the healthy lifestyle should include daily physical activity such as brisk walking and reduction in sedentary time; weight loss of at least 5% in the first year that is sustained over time; and a cardiovascular-healthy diet. “There are lots of changes in the dietary and exercise recommendations that are updated in the current guideline,” Rosenzweig says. “We didn’t talk much about Mediterranean diets and various other aspects of healthy diets the last time, but in this one we did much more.”
Another piece of advice that hasn’t changed is the recommendation that clinicians measure waist circumference as a routine part of the clinical examination. The guideline emphasizes waist circumference over simple reliance on BMI because abdominal fat is a more sensitive indicator of the risk of developing cardiovascular disease and diabetes.
“Doctors haven’t been doing enough to measure waist circumference, but it is an important aid to identifying patients at metabolic risk earlier and preventing more cases of heart disease and diabetes,” Rosenzweig says. “We would like to encourage the primary care doctor or internist to put waist circumference in as one of the measures when they first see a patient.”
Beyond Lifestyle Changes
“We emphasize the importance of lifestyle, dietary, and behavioral changes as the first line treatment,” Rosenzweig says. “However, treatment with medication is appropriate if goals are not met with lifestyle changes alone. We didn’t have much in the way of recommendations for the prevention of type 2 diabetes last time around, but now there are several drugs that show promise. The one that we most specifically recommend is metformin. Although not for all patients, it can clearly aid in the reduction of the risk of diabetes.”
Making Prevention Routine
To head off the need for medications, the guideline writers would like to see prevention by monitoring for potential problems and providing support for lifestyle changes woven into routine care.
“We didn’t have much in the way of recommendations for the prevention of type 2 diabetes last time around, but now there are several drugs that show promise. The one that we most specifically recommend is metformin. Although not for all patients, it can clearly aid in the reduction of the risk of diabetes.” – James L. Rosenzweig, MD, Hebrew Rehabilitation Hospital, Boston; chair, guideline writing committee
“Physicians can screen for the key risk factors for ASCVD and T2DM at routine clinical visits when they obtain a patient’s history and perform physical examinations,” the guideline says. “Behavior changes should be supported by a comprehensive program led by trained interventionists and reinforced by primary-care providers. Structured activity programs may be added with the help of an exercise specialist for appropriate individuals.”
Seaborg is a freelance writer based in Charlottesville, Va. He wrote about the Endocrine Society’s clinical practice guideline on treating older patients with diabetes in the July issue.
Co-sponsored by the American Diabetes Association and the European Society for Endocrinology, the guideline appeared in the September print issue of The Journal of Clinical Endocrinology & Metabolism and is available online: www.endocrine.org/2019MetabolicRisk.
There are many areas where the approach and recommendations have changed, including:
* The new guideline focuses on adults between the ages of 40 and 75 because the evidence is the best — and because intervention is the most critical — for this age group. Many of the recommendations can be used to guide decision-making in patients of other ages, however.
* The guideline incorporates the use of hemoglobin A1c as a measure of glycemic control.
* For individuals with prediabetes, the guideline has increased the frequency of screening for diabetes to at least yearly. It recommends that these individuals should be “referred to intensive diet and physical activity behavioral counseling programs.”
* Since the last guideline, the American Heart Association/College of American Cardiology equation for estimating cardiovascular risk was published, so the guideline recommends using it to calculate 10-year atherosclerotic cardiovascular disease risk.
* The new guideline tightens the risk levels that call for drug intervention. The previous guideline defined moderate risk as a 10-year ASCVD risk of less than 10%. The new guideline considers any level greater than 7.5% to be high, and moderate risk to be 5% to 7.5%.
* In the same vein, the recommendations call for more intensive use of lipid-lowering agents. For example, individuals with low-density lipoprotein (LDL) cholesterol concentrations of 190 mg/dL or greater should receive high-intensity statin therapy to reduce their levels by 50% or more. In individuals at metabolic risk who are taking statins and the therapy is controlling their LDL cholesterol but their triglyceride levels are high and their high-density lipoprotein levels are low, the guideline suggests adding fenofibrate as adjunct therapy.
* In keeping with newer data and recommendations from other organizations, the new edition calls for more intensive blood pressure treatment, with the target lowered from 140/90 mm Hg to 130/80 mm Hg.
* The guideline drops the recommendation for the use of low-dose aspirin as a preventive because of a lack of evidence of a benefit in the face of risks of bleeding and other complications.