American College of Physicians: Internal Medicine — Doctors for Adults ®

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Wednesday, November 13, 2013

QD: News Every Day--4 guidelines make PCPs the point people for prevention

Health care providers can and should take a bigger role in obesity and lifestyle counseling, according to a slew of 4 cardiovascular guidelines released Tuesday.

The 4 guidelines make recommendations about lifestyle management, overweight/obesity management, blood cholesterol and risk assessment. A collaboration of the American Heart Association and the American College of Cardiology, and developed in conjunction with the National Heart, Lung, and Blood Institute, the guidelines appear in Circulation and the Journal of the American College of Cardiology.

Generally, the guidelines on lifestyle and obesity make several key recommendations:
• Health care providers to actively help their patients achieve and maintain a healthier body weight;
• Health care that includes developing individualized plans and focusing on behavior change is key to curbing obesity;
• To lower the risk of developing cardiovascular diseases, a heart-healthy dietary pattern that reduces saturated fat, trans fat and sodium intakes is strongly recommended; and
• Physical activity should average 40 minutes of moderate to vigorous-intensity aerobic exercise, three to four times a week.

“Weight loss isn’t about will power. It’s about behaviors around food and physical activity, and getting the help you need to change those behaviors,” said Donna H. Ryan, MD, FACP, co-chair of the writing committee on the obesity guidelines and professor emeritus at Louisiana State University’s Pennington Biomedical Research Center in Baton Rouge, La.

More specifically for primary care providers, the report recommends that health care providers calculate body-mass index (BMI) at annual visits or more frequently, and use the BMI cut points to identify adults who may be at a higher risk of heart disease and stroke.

The new guideline recommends health care providers develop individualized weight loss plans that include three key components: a moderately reduced calorie diet, increased physical activity, and behavioral strategies to help patients achieve and maintain a healthy body weight.

Other key recommendations include:
• tailoring dietary patterns to a patient’s food preferences and health risks. For example, a patient with high blood cholesterol would benefit most from a low-calorie, lower-saturated fat diet including foods that they find appealing.
• focusing on achieving sustained weight loss of 5% to 10% within the first six months. This can reduce high blood pressure, improve cholesterol and lessen the need for medications to control blood pressure and diabetes. Even as little as 3% sustained weight loss can reduce the risk for the development of type 2 diabetes as well as result in clinically meaningful reductions in triglycerides, blood glucose and other risk factors for cardiovascular disease.
• advising adults with a BMI of 40 or higher and patients with a BMI of 35 or higher who have two other cardiovascular risk factors such as diabetes or high blood pressure, that bariatric surgery may provide significant health benefits. The guideline does not recommend weight loss surgery for people with a BMI under 35 and does not recommend one surgical procedure over another.

The best way to achieve these goals is to work with a trained health care professional, such as a registered dietitian, behavioral psychologist or other trained weight loss counselor, in a primary care setting, according to the recommendations.

Weight loss counseling should focus on people who need to lose weight because of obesity or overweight with conditions that put them at higher risk for cardiovascular diseases, such as diabetes, high blood pressure, high blood cholesterol, or a waist circumference of more than 35 inches for women and more than 40 inches for men.

The most effective behavior change programs include 2 to 3 in-person meetings a month for at least 6 months. Web or phone-based weight loss programs are also an option for the weight loss phase, although research shows they are not as effective as face-to-face programs, according to the statement authors.

Currently, comprehensive lifestyle programs that assist participants in adhering to a lower calorie diet and in increasing physical activity through the use of behavioral strategies are not widely available, Dr. Ryan said.

To lower blood pressure, the guideline emphasizes sodium restriction down from the current excessive average in US adults of about 3,600 mg/day to no more than 2,400 mg/ day. And, no more than 1,500 mg/day is desirable since it is associated with greater reductions in blood pressure. Reducing sodium intake by at least 1,000 mg a day from the US average will lower blood pressure, even if the desired sodium intake is not yet achieved, the guidelines read.

To lower the blood cholesterol, and particularly LDL cholesterol, the guidelines strongly recommend limiting saturated fat and trans fat. The guideline recommends a diet that emphasizes fruits, vegetables, and whole grains, while including low-fat dairy products, poultry, fish and nuts, and limiting red meat, sweets and sugar-sweetened beverages. Following this pattern should help people limit their saturated fat, trans fat and sodium to the recommended levels even if they do not count grams.

Based on a 2,000 calorie per day diet, a heart-healthy eating pattern should include:
• fruits: 4-5 servings a day
• vegetables: 4-5 servings a day
• whole grains, preferably high fiber: 6-8 servings a day
• fat-free or low-fat milk and milk products: 2-3 servings a day
• lean meats, poultry and fish: 6 or fewer ounces a day
• nuts, legumes and seeds: 4-5 servings a week
• fats and oils: 2-3 servings of healthy oils per day, limit trans and saturated fat
• limit sweets and added sugars

Primary care physicians should adapt the heart-healthy dietary plan to an individual’s caloric requirements, personal and cultural food preferences and nutrition therapy for other medical conditions such as diabetes, the guideline states.

The guideline advises moderate- to vigorous-intensity aerobic exercise, such as brisk walking, for an average of 40 minutes 3 to 4 times a week.

While some patients will still need medications to manage blood pressure and cholesterol, doctors should always prescribe the lifestyle management strategies advised in the new guideline at the same time.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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