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Michael J. Bloch, M.D. Doina Kulick, M.D.

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  1. Moving Towards Primordial Prevention: Effective Interventions in the Clinical Setting – Engaging and Empowering Patients Michael J. Bloch, M.D. Doina Kulick, M.D.

  2. PREVALENCE OF CARDIOVASCULAR AND METABOLIC RISK FACTORS

  3. Prevalence of CVD Risk Factors in Adults:US, 1961-2001 70 60 50 40 Percent of Population 30 Overweight Hypertension Smoking High cholesterol 20 10 0 2000 2005 1960 1965 1970 1975 1980 1985 1995 1990 Year Reproduced with permission from National Institutes of Health, National Heart, Lung, and Blood Institute. Fact Book Fiscal Year 2005. 2005:52.

  4. Obesity Trends Among U.S. Adults, BRFSS (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1999 1990 2008 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  5. Prevalence of Childhood Obesity in U.S., BRFSS, 2008


  6. The Evolution of Man (and Woman) The Economist, December 13th-19th 2003

  7. 200-300 kcal Increase in Mean Caloric Intake in U.S. Cince 1970’s (Mostly carbohydrates) Total Carb Fat ‘80 ‘80 ‘95 ‘95 ‘85 ‘85 2000 2000 1970 1970 ‘75 ‘75 ‘90 ‘90 Women Men 3000 3000 2618 2450 2500 2500 2666 1877 1798 2439 2000 2000 1542 1522 1282 1285 Calories 1500 1500 1039 1039 969 910 700 700 1000 1000 904 898 904 859 500 500 616 601 557 548 0 0 Year Year http://www.cdc.gov.revproxy.brown.edu/nchs/data/hus/hus05.pdf#027

  8. Food Industry, 2010 New Yorker, August, 2010

  9. Walking the Dog, 2010 www.humor.com

  10. Age-Standardized Prevalence of Diagnosed Diabetes per 100 Adult Population <4% 4%-4.9% 5%-5.9% > 6% 1991 2003 Behavioral Risk Factor Surveillance System.

  11. Diagnosed Diabetes Just Tip of the Iceberg:1 in 4 Adult Americans Have Metabolic Syndrome Diagnosed diabetes Population at risk (millions) 12 6.2 10 Undiagnosed diabetes* Prevalence, %,age ≥18 yrs 8 6 4 Diagnosed diabetes* 14.6 2 0 White Black Hispanic Other Metabolic syndrome 35 30 Metabolic syndrome† ~64 25 Prevalence, %,age ≥20 yrs 20 15 10 5 0 White Black Hispanic Other *2005 US data, NIDDK, NIH.†Based on revised NCEP/ATP III definition (NHANES 2000 data). Mokdad AH, et al. JAMA. 2003;289:76-79. Ford ES, et al. JAMA. 2002;287:356-359. Ford ES, et al. Diabetes Care. 2004;27:2444-2449.

  12. Presence of Metabolic Syndrome Increases Risk of CV Mortality: The Kuopio Ischemic Heart Disease Risk Study 20 15 RR (95% CI), 3.55 (1.96-6.43) 10 5 0 8 10 12 2 6 0 4 Follow-up, Y 834 234 292 100 866 288 852 279 All Cause Mortality Cardiovascular Disease Mortality Coronary Heart Diseas Mortality 20 20 15 15 RR (95% CI), 2.43 (1.64-3.61) RR (95% CI), 3.77 (1.74-8.17) Cumulative Hazard (%) 10 10 5 5 0 0 8 10 12 2 6 0 4 8 10 12 2 6 0 4 Follow-up, Y Follow-up, Y No. at Risk Metabolic Syndrome 834 234 292 100 866 288 852 279 834 234 292 100 Yes No 866 288 852 279 Metabolic Syndrome: Yes No Lakka H-M, et al. JAMA. 2002;288:2709-2716.

  13. From primary to primordial prevention

  14. Primordial Prevention in Overweight or ‘Metabolicly Challenged’ Individuals Abdominally obesepatient at increasedcardiometabolic risk Coronary heart disease Risk factors Hypertension Dyslipidemia Type 2 diabetes Managecoronary heartdisease risk Treat the complications? Treat the cause Adapted with permission from Després JP, et al. BMJ. 2001;322:716-720.

  15. Steve Martin, Oscar Awards, 2003 “I’d do anything to look like all these beautiful people you see here tonight…. except, of course, exercise and eat right.”

  16. Omnivore’s Dilemma, Michael Pollen “When you can eat anything what should you eat?”

  17. Approach to Lifestyle Modification—3 Separate Issues to Address • Heart Healthy Food Choices • DASH Diet, Mediterranean-style diet, etc • Unlikely to result in significant weight loss alone • Exercise for Life • Give specific advice (exercise prescription) • No recommendation for routine exercise treadmill testing in asymptomatic individuals • Start slowly, as little as 5 min/day, but work-up to at least 30 minutes of moderate intensity exercise daily • Work exercise into daily routineMultiple short bursts are appropriate for some patients • Mix of cardio and resistance training appropriate for most • Unlikely to result in significant weight loss alone, but crucial for weight maintenance • Calorie Manipulation for weight loss or maintenance

  18. Obese Patients Have Unrealistic Weight Loss Expectations Foster et al. J Consult Clin Psychol 1997;65:79.

  19. Diabetes Prevention Program: LS = 7% Reduction in Weight and 150 min Exercise per Week Risk of developing metabolic syndrome PB (n = 1082) MET (n = 1073) LS (n = 1079) MET LS 0 0 -0.1 -2.1* -2 Weight Change, kg -10 -4 -5.6* *P <.001 vs placebo -20 -17%† -6 Reduction in Risk of Metabolic Syndrome, % -30 -8 MET LS -40 n=1523 -41%* -20 -50 -31 % Reduction in Incidence of Diabetes -40 *P <.001; †P = .03 -58* *P <.05 vs metformin -60 LS = lifestyle intervention; MET = metformin; PB = placebo. Orchard TJ, et al; Diabetes Prevention Program Research Group. Ann Intern Med. 2005;142:611-619. Knowler WM, et al; Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393-403.

  20. A to Z Trial: Comparison of Four Popular Diets on Weight Loss Gardner CD, et al. JAMA. 2007;297(9):969-977.

  21. Reduce intake by: Key to Weight Loss: Calories in and Calories Out: To Achieve a 300 kcal Negative Energy Balance: Or increase activity by: Eliminating 2 oz potato chips Running 3 miles in 30 min or or Substituting 2 diet sodas for 2 regular sodas Bicycling 8 miles in 30 min

  22. 4 oz muffin Weight Loss Goal: Achieve a 300 - 800 kcal Negative Energy Balance each day 12 oz café mocha 16 oz juice Original Breakfast = 1070 cal + + 500 calories 330 Calories 240 calories Coffee with 2 oz skim milk 1 T light margarine 2 slices of whole wheat bread small banana 410 cal = Breakfast Makeover + + + 120 calories 200 calories 40 calories 50calories

  23. Increase Satiety by Decreasing Energy Density Kcal = 120 Yogurt: 170 grams Raspberries: 60 grams Total = 230 grams Energy Density = ~0.5 Kcal/g Kcal = 130 Yogurt Mix: 170 grams Energy Density = ~0.75 Kcal/g Courtesy of Christopher Gardner, M.D.

  24. Practical Approach to Maximize Satiety and Achieve Meaningful Weight Loss and Weight Management • Individualized balance of Carbs / Fats / Protein for sustained adherence—Focus on FOOD • Right Fats (mono- and poly- unsaturated, omega 3’s • Right Carbs (high fiber, low glycemic index, complex • Right Protein (plant, marine, and lean animal sources) • Limit or eliminate sugar, high fructose corn syrup, and refined starches and snack foods • Reduce or eliminate all calories from beverages • Smaller portions, low energy density, high nutrient density • Consider book-keeping of calories, points, etc • Drink (and eat) water • Exercise for life • Get adequate sleep

  25. Motivation: Stress level: Psychiatric issues: Time availability: Assess Readiness for Change Each Visit Patient seeks weight reduction Free of major life crises Free of severe depression, substance abuse, bulimia nervosa, other eating disorders Patient can devote 15-30 min/d to weight control for next 26 weeks YES NO Patient Ready? Initiate more aggressive weight loss therapy Prevent weight gain and explore barriers to weight reduction

  26. “Inferior doctors treat full-blown disease, Mediocre doctors treat diseasebefore it is evident, Superior doctors prevent disease” --Huang Dee, Nai-Chian Cohen JD. Arch InternMed. 2002;162(4):387-388.