Blog | 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.