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Modifiable Risk Factors

There are a number of factors that contribute to a person’s overall likelihood of developing type 2 diabetes and heart disease. 


Modifiable risk factors include:

 


Overweight/Obesity

Two out of three Americans are now overweight or obese, which poses a threat to their cardiometabolic health. For many patients, weight loss can be a struggle because it means substantial changes in eating and exercising habits. These can be some of the hardest habits to change, and there is no "one size fits all" or quick fix.


Have a frank, open discussion with your patient about their risk for diabetes and CVD. Explain how even just a small weight loss could have a big impact on their health, quality of life, and on the length of their life. If they have other cardiometabolic risk factors, they should know that losing weight can help manage blood pressure and cholesterol, among others.


Clinical Intervention:


  • BMI 18.5-24.9 = normal
  • BMI 25-29.9 = overweight
  • BMI of 30 or greater = obesity
  • Recommend & counsel for lifestyle modification
  • Reduce calorie intake
  • Increase physical activity
  • Remind patients that even a small calorie deficit will lead to weight loss. A deficit of 100 calories per day leads to a 10 pound weight loss over a year.
  • Consider pharmacologic treatment


High Blood Glucose

High blood glucose is a substantial risk factors for diabetes and in the long run, heart disease and stroke. The American Diabetes Association recommends using one of three testing methods.

 


A1C
Fasting Plasma Glucose (FPG)
Oral Glucose Tolerance Test (OGTT)
Normal < 5.7%
< 100 mg/dl
<140 mg/dl
Prediabetes
5.7%-6.4%
100 mg/dl to 125 mg/dl
140 mg/dl to 199 mg/dl
Diabetes
6.5% or higher
126 mg/dl or higher
200 mg/dl or higher

Clinical Intervention:


  • Patients with prediabetes should be referred to an effective ongoing support program targeting weight loss of 7% of body weight and increasing physical activity to at least 150 min/week of moderate activity, such as walking.
  • Follow up counseling appears to be important for success.
  • Metformin therapy for prevention of type 2 diabetes may be considered in those with impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or an A1C 5.7-6.4%, especially for those with BMI > 35 kg/m2, aged <60 years, and women with prior gestational diabetes.

Hypertension

Hypertension leads to elevated risk for myocardial infarction, stroke, eye problems and kidney disease. Often a silent disease, many patients won't know they have high blood pressure until informed by their health care provider.

For patients without diabetes:

  • Blood Pressure should be measured at each regular visit or at least once every 2 years if it is less than 120/80 mmHg
  • Blood Pressure should be measured  while seated after 5 min rest in office

For patients with diabetes:

  • Blood Pressure should be measured at each regular visit
  • Blood Pressure should be measured while seated after 5 minutes rest in office
  • Patients with ;::1 30 or ;;:80 mmHg should have Blood Pressure confirmed on a separate day

Clinical Intervention:

DASH (Dietary Approaches to Stop Hypertension) diet

High in whole grains, fruits, vegetables, and low-fat dairy

Low in saturated and trans fat, cholesterol

Physical Activity

Weight loss, if applicable

If Blood Pressure ;::140/ ;;:90 mm Hg, drug therapy is indicated

  • Combination therapy often necessary
  • Treatment should include ACE or ARB
  • Thiazide diuretic may be added to reach goals
  • Monitor renal function and serum potassium

Related Research:

The DASH Diet

Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for The American Cancer Society, the American Diabetes Association, and the American Heart Association. - 2004

Blood Pressure Measurement in Diabetes Clinic- 2006  


Abnormal Lipid Metabolism

Inform patients of the health risks of both high LDL cholesterol and low HDL cholesterol, as well as triglycerides. Patients should also be aware that modest weight loss and increased physical activity can have a beneficial effect on lipid management.

Clinical Intervention:

  • In adults (> 19 years) without diabetes, test at least every 5 years, including adults with low-risk values. Low-risk values are:
    • LDL <100 mgdL
    • HDL >40 mgdL for men and
    • >50 mgdL for women
    • Triglycerides <150 mgdL)

Related Research:

Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for The American Cancer Society, the American Diabetes Association, and the American Heart Association

Atorvastatin Helps Lower LDL Cholesterol and Prevent Heart Attack and Stroke - 2006

Lowering Cholesterol in Patients With Diabetes and Dyslipidemia - 2005 


Inflammation & Hypercoagulation

Proinflammatory/prothrombotic factors are known to underlie cardiometabolic risk. Inflammation is a major component of atherogenesis and other cardiometabolic problems. Creactive protein (CRP), an emerging marker of inflammation, may provide useful information to assess CVD risk, but trials documenting its clinical utility have not been completed. This may give a more complete picture of risk.

High-sensitivity CRP (hs-CRP) tests may be used to further evaluate patients' underlying risk, especially for patients otherwise at indeterminate risk.

Relative risk categories for hs-CRP levels:

  • Low risk <1 mg/L
  • Average risk 1-3 mg/L
  • High risk> 3 mg/L

Patients with hs-CRP levels in the high end of the normal range have 1.5 to 4 times the risk of having MI than those with CRP values at the low end of the normal range. Weight loss, aspirin and statins have been shown to reduce CRP levels, however, at this point, no controlled prospective trials have shown the benefit of CRP lowering.

More research is needed to establish hypercoagulation as a solid indicator of risk, to determine the positive predictive value of the test, and to standardize assays.

Related Research:

Inflammation and metabolic disorders.Hotamisligil, Gokhan S. Nature 444, 860-867 (December 2006)

Atherosclerosis: an inflammatory disease. Ross R..N Engl J Med 1999;340:115-126.

Markers of inflammation and their clinical significance. Ballantyne CH, Nambi V. Atherosclerosis supp12005; 6: 21-9.

Differentiation between obesity and insulin resistance in the association with C-reactive protein. McLaughlin T et all. Circulation.2002;106:2908-2912.

Metabolic Syndrome: Is It a Syndrome? Does it Matter?Kahn, R. Circulation 2007;115;1806-1811. 


Physical Inactivity

35% of coronary heart disease deaths in the United States can be attributed to an inactive lifestyle, and consistent exercise can reduce CVD risk.

Staying active can:

  • Increase insulin sensitivity
  • Improve lipid levels
  • Lower blood pressure
  • Aid weight management
  • Improve blood glucose management in type 2 diabetes \ Lower risk of CVD

Clinical Intervention:

  • Encourage your patients to find ways to fit activity into their daily routine. Examples include taking the stairs, parking further away, taking the stairs instead of elevator, or walking to another bus stop.
  • Encourage patients to aim for at least 150 minutes/week of moderate aerobic exercise. This can be broken down into multiple spurts of activity each day. If they are just starting out, encourage them to start with just 5 or 10 minutes, 3x per day and build from there.
  • Many patients are motivated by wearing a pedometer and tracking their steps. Encourage them to join a walking group and challenge each other to more and more steps. A good online group exists at diabetes.org/ClubPed

Related Research:

Physical Activity in U.S. Adults With Diabetes and At Risk for Developing Diabetes, 2003 - (February 2007)

Adiposity Compared With Physical Inactivity and Risk of Type 2 Diabetes in Women- (January 2007)

Physical Activity/Exercise and Diabetes (Position Statement)- (January 2004)


Smoking

Most patients know smoking is bad for their health, but quitting is often easier said than done. If you have patients who smoke, be sure to emphasize not only the grave dangers of continuing smoking, but also the tremendous benefits of quitting.

Clinical Intervention:

  • Obtain documentation of history of tobacco use
  • Ask whether smoker is willing to quit
  • If no, initiate brief, motivational discussion regarding:
    • The need to stop using tobacco
    • Risks of continued use
    • Encouragement to quit, as well as support when ready
  • If yes, assess preference for and initiate either minimal, brief, or intensive cessation counseling.

Download an online guide to quitting smoking.

Related Research:

Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study(UKPDS: 23). BMJ. 1998;316:823-828.
Smoking and Diabetes(Position Statement) - 2004
Cigarette Smoking Affects Glycemic Control in Diabetes- 2002