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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
Normal
18.5-24.9
Overweight
25-29.9
Obese
>30


  • 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
  • Patients with elevated blood pressure should have blood pressure confirmed on a separate day

Goal
Systolic  
<140 mmHg
Diastolic  
<80 mmHg


Clinical Intervention:


Patients with blood pressure >120/80 mmHg should be advised on lifestyle changes to reduce blood pressure.

  • DASH (Dietary Approaches to Stop Hypertension) diet
  • Diet high in whole grains, vegetables, fruits, and low-fat dairy
  • Lean meats and nuts
  • Diet low in saturated and trans fat, cholesterol
  • Increased physical activity
  • Weight loss, if applicable

If blood pressure is >140/90 mmHg, drug therapy should be used in addition to lifestyle modification

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

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.



Goal
LDL
<100 mg/dL
HDL
> 50 mg/dL
Triglycerides
< 150 mg/dL

Clinical Intervention:

Lifestyle modification:

  • Reduce saturated fat, trans fat, and cholesterol intake
  • Increase of fatty acids
  • Increase fiber intake
  • Lose weight (if indicated)
  • Increase physical activity
Pharmacological Therapy:
  • Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for patients with diabetes:
      • with overt CVD
      • without CVD who are over age 40 and have one or more other CVD risk factors
  • For lower-risk patients than the ones above, statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains above 100 mg/dL or in those with multiple CVD risk factors



Physical Inactivity


Staying active can:

  • Increase insulin sensitivity.
  • Improve lipid levels.
  • Lower blood pressure.
  • Aid weight management.
  • Improve blood glucose management in type 2 diabetes and 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 with no more than 2 consecutive days without exercise.  If they are just starting out, encourage them to start with just 10 minutes, three times per day and build from there.
  • Adults with type 2 diabetes should be encouraged to perform resistance training at lest twice a week in the absence of contraindications.
  • 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. 
 
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.