Screen for Five Markers to Ward Off Heart Disease, Diabetes

Marlene Busko

July 31, 2019

By screening for five simple markers — waist size, blood pressure, HDL cholesterol, triglycerides, and glucose/HbA1C — during office visits, clinicians could identify high-risk adults who need to improve their lifestyle to prevent cardiovascular disease or type 2 diabetes.

This is the main message from a new clinical practice guideline — "Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk" — issued by the Endocrine Society and published online July 31 in the Journal of Clinical Endocrinology and Metabolism.

"Doctors haven't been doing enough to measure waist circumference, but it's essential to identifying patients at metabolic risk earlier and preventing more cases of heart disease and diabetes," writing committee chair James L. Rosenzweig, MD, Hebrew Rehabilitation Hospital, Boston, Massachusetts, said in a statement issued by the Endocrine Society.

"We emphasize the importance of lifestyle, dietary and behavioral changes as the first line treatment," Rosenzweig stressed. "However, treatment with medication is appropriate if goals are not met with lifestyle changes alone."

Up Physical Activity, Reduce Sedentary Time, Lose 5% of Weight

The new guideline, which is cosponsored by the American Diabetes Association and the European Society of Endocrinology, is aimed at primary care providers, endocrinologists, geriatricians, and cardiologists.

"In individuals aged 40 to 75 years in the office setting," the report states, "we suggest providers screen for all five components of metabolic risk at the clinical visit."

Finding "at least three components should specifically alert the clinician to a patient at metabolic risk (at higher risk for atherosclerotic cardiovascular disease and type 2 diabetes)," the report says.

Although the evidence suggests that patients in their 40s through mid-70s would benefit most, other patients, especially those who are younger, may also benefit from early identification of risk for heart disease and diabetes by changing their diet and exercise habits to mitigate their risk, the guideline writers add.

The five risk factors are the following:

  • Elevated blood pressure

    • ≥130 mm Hg systolic and/or ≥80 mm Hg diastolic

  • Increased waist circumference

    • Non-Asian: ≥102 cm (40 inches) for men and ≥88 cm (34.6 inches) for women

    • Asian: ≥90 cm (35.4 inches) for men and ≥80 cm (31.5 inches) for women

  • Elevated fasting triglycerides

    • ≥150 mg/dL (≥1.7 mmol/L)

  • Low HDL cholesterol

    • <40 mg/dL (<1.0 mmol/L) in men or

    • <50 mg/dL (<1.3 mmol/L) in women

  • Elevated glycemia

    • HbA1C ≥5.7% to 6.4%, or

    • Fasting glucose ≥100 mg/dL (≥5.6 mmol/L)

Patients with three or more risk factors should be screened regularly, and those with one or two risk factors should be screened every 3 years.

Clinicians should also screen for cholesterol, smoking, and family history of cardiovascular disease.

And they "should initiate discussions about the importance of adopting a healthy lifestyle with all individuals at metabolic risk," the authors state.

In addition to routinely measuring weight and height and calculating body mass index, clinicians should measure a patient's waist size.

They should check a patient's office blood pressure every year, and if it is high, they should repeat the measurement on another day or have the patient check it with a home blood pressure monitor.

"For individuals at metabolic risk, we recommend prescribing daily physical activity, such as brisk walking, and reduction in sedentary time," and overweight patients should be encouraged to lose 5% of their weight over the next year, the guideline states.

Statin therapy should be prescribed on a case-by-case basis, as needed.

Guidance Updates Older 2008 Advice

The previous version of the guidelines was issued in 2008; the current guidelines have been updated with new data.

For example, the new guideline

  • Focuses on measures to identify and reduce the risk for atherosclerotic cardiovascular disease and type 2 diabetes, rather than defines metabolic syndrome as a clinical entity

  • Is more focused on adults aged 40 to 75 years

  • Includes HbA1C as a measure of glycemia

  • Recommends yearly screening for diabetes for individuals with prediabetes

  • Includes the American Heart Association/American College of Cardiology Pooled Cohort Equation to calculate 10-year risk for atherosclerotic disease

  • Defines 10-year risk for atherosclerotic disease as moderate if it is 5% to 7.5% (as opposed to 10%) and high if it is >7.5%

  • Sets a target blood pressure of 130/80 mmHg (as opposed to 140/90 mmHg) on the basis of data from the Heart Outcomes Prevention Evaluation-3 (HOPE 3), the Diabetes Reduction Assessment With Ramipril and Rosiglitazone Medication (DREAM), and the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack (ALLHAT) trials

  • No longer recommends aspirin in this population, owing to a lack of evidence of benefit and a risk for bleeding

  • Updates the recommendations for diet and exercise on the basis of more recent data

"This revision takes a fresh look at metabolic risk and presents recommendations which reflect more recent trial data on blood pressure and lipids," the Endocrine Society emphasizes. It also "prioritizes lifestyle and behavioral interventions and discusses new medical treatment options."

J Clin Endocrinol Metab. Published online July 31, 2019. Full text

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