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    Cardiometabolic Disorders & Weight: Action for Outcomes

    The National Heart, Lung, and Blood Institute (NHLBI) estimates that almost 25% of US adults have a constellation of abnormalities constituting what was once called "syndrome X" and, later, "metabolic syndrome" or "insulin resistance syndrome."1 The component disorders include central adiposity defined by waist circumference or hip-waist ratio, elevated triglycerides, low levels of high-density lipoprotein, hypertension, and elevated blood glucose levels. Most people with one cardiometabolic abnormality have others as well, and the cumulative effect is a predisposition to atherosclerotic plaque development, inflammation, and thrombosis, ultimately resulting in cardiovascular disease that is often premature. In fact, the Third Report of the National Cholesterol Education Program–Adult Treatment Panel (ATP III) states that having 3 or more of these abnormalities confers the same cardiovascular risk as does existing coronary artery disease.2 Diabetes alone also carries increased risk similar to that seen among confirmed heart disease patients.2

    The public health impact of cardiometabolic abnormalities becomes clearer when one considers that 38.9% of US adults report a prescription drug expense for a cardiovascular agent and 28.9% report a prescription drug expense for a metabolic agent. Furthermore, metabolic agents are the No. 1 type of medication prescribed in the United States, accounting for an expenditure of $38.1 billion annually, and cardiovascular agents rank No. 2 at $33.1 billion annually.3

    tableEfforts to develop effective management strategies for patients with a cluster of cardiometabolic abnormalities have been confounded by the differing definitions of and treatment guidelines for "metabolic syndrome" issued by various government entities and organizations. The NHLBI and the American Heart Association collaborate to update the ATP metabolic syndrome criteria and treatment guidelines.4 The World Health Organization and the International Diabetes Federation also recognize metabolic syndrome, but their criteria differ from each other and also from ATP III; the European Group for the Study of Insulin Resistance has yet another set of criteria (see Table).5–7

    A further complication for healthcare professionals seeking to identify the most appropriate treatment strategies from current guidelines is that the American Diabetes Association (ADA) and the European Association for the Study of Diabetes do not recognize "metabolic syndrome" per se. Instead, they recommend that any patient with one cardiometabolic disorder be screened for the others and that each component disorder be treated to its individual target.8 In addition, current guidelines from the NHLBI-sponsored Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) recommend a lower blood pressure goal for patients with diabetes than does ATP III,9 and current ADA treatment guidelines recommend earlier drug treatment—at the prediabetes level—especially for patients with other risk factors for developing type 2 diabetes, including hypertension, low HDL, elevated triglycerides, and obesity.10

    Not only do the various treatment parameters conflict, they are updated often. For example, the NHLBI has convened experts to update both ATP and JNC guidelines, and the proposed new versions are expected to be available for public comment in December 2009. The ADA released its updated clinical practice guidelines earlier this year.10

    An estimated 47 million Americans have double the average risk of heart disease because they are affected by a complex constellation of interrelated conditions, including obesity, impaired glucose metabolism, hypertension, and lipid disorders. Read our overview article, “A complex constellation of interrelated conditions,” which describes these components of cardiometabolic disorders in more detail. For a complete list of articles in the series, please see “Series Content” below the References.

    References

    1. National, Heart, Lung, and Blood Institute Diseases and Conditions Index. Metabolic syndrome. www.nhlbi.nih.gov/health/dci/Diseases/ms/ms_whoisatrisk.html. Accessed July 29, 2009.

    2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143–3421.

    3. Soni A. Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. Statistical Brief #232. The top five therapeutic classes of outpatient prescription drugs ranked by total expense for adults age 18 and older in the US civilian noninstitutionalized population, 2006. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st232/stat232.pdf. Accessed July 29, 2009.

    4. Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110(2):227–239.

    5. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15(7):539–553.

    6. Alberti KG, Zimmet P. Shaw J; IDF Epidemiology Task Force Consensus Group. The metabolic syndrome—a new worldwide definition. Lancet. 2005;366(9491):1059–1062.

    7. Balkau B, Charles MA. Comment on the provisional report from the WHO consultation. European Group for the Study of Insulin Resistance (EGIR). Diabet Med. 1999;16(5):442–443.

    8. Kahn R, Buse J, Ferrannini E, Stern M; American Diabetes Association; European Association for the Study of Diabetes. The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005;28(9):2289–2304.

    9. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC7 report. JAMA. 2003;289(19):2560–2572.

    10. American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care.2009;32(suppl 1):S13–S61.

    SERIES CONTENT

    Applied Clinical Trials

    Obesity, Lipids, and Diabetes
    Success and challenges for clinical trials that address these interrelated conditions.

    Clinical Pharmacy

    P&T considerations in fashioning a knowledge base, action plan for cardiometabolic disorders and weight
    The P&T committee is uniquely positioned to provide knowledge and strategies to improve the treatment of patients with cardiometabolic disorders.

    Community Pharmacy

    Cardiometabolic disorders: The pharmacist's role
    With an estimated 47 million Americans facing increased risk of heart disease because of atherosclerotic cardiovascular disease and type 2 diabetes conditions, management of patients' cardiometabolic disorders is a priority for pharmacists.

    Metabolic syndrome throughout the life cycle
    Prevalence of metabolic syndrome in adults, as well as the increasing prevalence of pediatric obesity, has spurred research into how the condition may affect children and adolescents. Pharmacists should be able to define insulin resistance and metabolic syndrome in children and adults according to national guidelines, list the risk factors associated with metabolic syndrome in children that may increase their risk as adults, describe the role of lifestyle modification in children and adults with metabolic syndrome, and identify the role of medical and surgical treatment for metabolic syndrome and/or obesity.

    Retail pharmacy and the diabetes epidemic
    For drugstores, the medical nature of their retail business often makes them the outlet of choice for shoppers purchasing diabetes products. The average consumer spends $300 in annual retail pharmacy purchases, but a consumer with diabetes spends eight times that amount, averaging $2,500 per year on medication, insulin, blood-glucose monitoring products, and other OTC supplies.

    Cosmetic Surgery

    Liposuction may hold key in treating metabolic syndrome
    If a positive connection between abdominal liposuction and metabolic syndrome can be confirmed, a paradigm shift with insurance coverage of liposuction could emerge.

    Understanding research on subcutaneous fat
    Many studies have found a connection between subcutaneous fat and insulin sensitivity, and more still have substantiated the ties between insulin sensitivity and metabolic syndrome. An example of an interesting and relevant study is one that was carried out by Japanese scientists at Chiba University. It suggests that the balance between accumulation of subcutaneous fat and visceral fat may be important with respect to the occurrence of systemic insulin resistance in metabolic syndrome.

    When paired with behavior modification, can liposuction have a positive impact on obesity and on metabolic syndrome?
    In this installment in Cosmetic Surgery Times's three-part series, the implications and current research findings on the potential linkage of abdominal fat and metabolic syndrome — and what role liposuction might play in its treatment — are discussed.

    Dermatology

    All systems go: Association between psoriasis, metabolic syndrome is strong
    The evidence linking psoriasis to metabolic syndrome and cardiovascular disease is overwhelming, classifying psoriasis as a systemic disease and not simply a disease of the skin.

    Cutaneous clues: Specific dermatologic conditions can aid in diagnosis of metabolic syndrome
    It is well known that the skin often reflects internal pathology. Following this notion, there are several cutaneous manifestations that a psoriasis patient can present with (other than the classic psoriasis symptoms) that can clue a dermatologist in on components of metabolic syndrome.

    Reducing risks: Anti-inflammatory therapy is panacea for psoriasis, comorbidities
    Psoriatics are at an increased risk for developing several comorbidities, including diabetes, obesity, dyslipidemia and hypertension—all of which are components of metabolic syndrome.

    Geriatrics

    Cardiovascular medication adherence among the elderly
    A review of the current evidence describing the etiology, diagnosis, and treatment of poor adherence to cardiovascular medications among the elderly.

    Opinion: Baby Boomers court metabolic syndrome
    Many bulging Baby Boomers already have the “metabolic syndrome,” and if clinicians don’t do anything about it, their patients are 3 to 5 times more likely to develop type 2 diabetes and twice as likely to develop cardiovascular heart disease.

    Practical strategies for management of hypertension in the elderly
    Key strategies for hypertension treatment in elderly include lifestyle changes and hypertension treatment until target BP goal is reached with mono or combination therapy.

    Resistant disease or resistant patient: Problems with adherence to cardiovascular medications in the elderly
    When faced with difficult to control cardiovascular risk factors, clinicians need to address the potential role of adherence. This includes diagnosing an adherence problem, understanding why there is an adherence problem, and then employing simple tools and clear communication to overcome the relevant barriers.

    Locum Tenens

    Locum tenens providers inspire cardiometabolic patients
    Locum tenens providers can inspire cardiometabolic patients to make a difference in their own lives. Read on for the first installment of three-part series on cardiometabolic disorders.

    Managed Care

    Cardiometabolic care links
    Address the risks

    Nursing

    Diabetes: The tipping point to a metabolic meltdown
    Follow the treatment and education of a newly diagnosed type 2 diabetes patient: taking a case history, making a diagnosis, and teaching the patient how to monitor and control blood sugar.

    Hypertension: Nursing guide to this cardiac pressure cooker
    Patients may be overwhelmed with the multiple lifestyle changes that control of hypertension requires. RN's care guide will help them understand why each step toward normal blood pressure is so important for long-term health.

    Lipids: A nursing action plan for improving patients' lipoprotein levels
    Use our sample patient with high blood lipids as a guide for diagnosing hyperlipidemia, interpreting blood tests, and educating your own patients.

    #Motivating the diabetic patient
    To help you manage your patients' cardiometabolic disorders more effectively, listen to Rebecca Abernathy, an RN in San Diego, as she discusses how her practice is handling these increasingly prevalent disorders.

    Obstetrics/Gynecology & Women’s Health

    Cardiometabolic disorders and weight: A special report on metabolic syndrome
    The first in a series of articles on the disorder outlines the major editorial initiative being launched by Advanstar Communications' journals and ModermMedicine.com.

    High testosterone levels raise heart disease risk in older women
    Women older than age 65 years who are overweight and have elevated levels of testosterone are at increased risk for developing coronary heart disease, insulin resistance, and other manifestations of metabolic syndrome.

    Ob/gyn implications of metabolic syndrome
    Conceiving and sustaining a pregnancy can be challenging for women with metabolic syndrome. Moreover, implications of MS can be far more insidious and far-reaching, as emerging research traces several diseases of adulthood back to an in utero exposure to maternal metabolic risks.

    Time is of essence when screening for abnormal lipid levels
    About 64% of women who die of cardiovascular disease have no prior symptoms. Don't wait for cardiac symptoms—especially in diabetic patients—to assess for and treat lipid abnormalities.

    Ophthalmology

    Diabetic macular edema responds to ranibizumab in study
    Diabetic macular edema (DME) responds to ranibizumab (Lucentis, Genentech), according to the results of a phase II trial: 12-month analysis of ranibizumab in DME on behalf of the RESOLVE study group, said Pascale Massin, MD, PhD.

    Emerging technology aids diabetic retinopathy screening
    Ophthalmologists should take a proactive approach toward the screening, management, and early treatment of diabetic retinopathy.

    Pediatrics

    A Simple Blood Pressure Table
    I recently had an interesting conversation with Dr David Kaelber, a practicing internist and pediatrician and the Chief Medical Informatics Officer of the MetroHealth System, Cleveland, Ohio, and Assistant Program Director of the Case Western Reserve University (MetroHealth) Internal Medicine and Pediatrics (Med-Peds) Program. Dr. Kaelber is a prolific researcher and in 2007 co- authored a study where he discovered that pediatricians significantly underdiagnose hypertension and prehypertension in children.

    CP Links: Pediatric obesity resources
    A collection of web resources about pediatric obesity.

    Easier pediatric blood pressure screening
    An interview with Dr. David Kaelber on the implications of his vastly simplified screening tool for pediatric hypertension.

    New tools for children with Type 1 diabetes
    Normalization of blood glucose levels is the ultimate goal of diabetes treatment, but this goal must be balanced against the risk of hypoglycemia. In recent years, new technologies have helped us improve glycemic control while simultaneously decreasing the risk of hypoglycemia.

    #Simplified Pediatric Blood Pressure
    Dr. Andrew Schuman, contributing editor with Contemporary Pediatrics, recently sat down with Dr. David Kaelber to discuss the significance of blood pressure screening in pediatric patients.

    Viewpoint: When is a crisis also an opportunity?
    In a study published in 1996, Dr. Pinhas-Hamiel and co-investigators warned of an increased incidence of type 2 diabetes (then referred to as non-insulin dependent diabetes mellitus, or NIDDM) among adolescents in Cincinnati. They postulated that their finding was related to an increase in obesity, which was in turn related to increased availability of calorically dense foods and more sedentary lifestyle.

    Pharmaceutical Industry

    Obesity: The last remaining categories with mega-blockbuster potential
    This article looks at what’s next in the pipeline and whether it will be enough to improve obesity rates.

    Primary Care

    A complex constellation of interrelated conditions
    An estimated 47 million Americans have double the average risk of heart disease because they are affected by a complex constellation of interrelated conditions, including obesity, impaired glucose metabolism, hypertension, and lipid disorders.

    Cardiometabolic Disorders & Weight: Action for Outcomes
    For the first time, 17 of Advanstar Communications’ Life Sciences publications and its web portal, ModernMedicine.com, are collaborating in a coordinated, interdisciplinary initiative to address a major public health issue: cardiometabolic disorders and weight.

    CCE: Cardiometabolic disorders management strategies
    Each patient with a cardiometabolic disorder is likely to have an additional related disorder.

    Clinical Centers of Excellence: Cardiometabolic Disorders & Weight
    More than two-thirds of US adults and one-third of children and adolescents are overweight or obese, according to the National Center for Health Statistics.

    Getting paid for managing cardiometabolic disorders
    As you are aware, the prevalence of cardiometabolic disorders and associated risk factors has increased significantly during the past 10 years. There are a number of disease processes that must be managed, and doing so offers opportunities for reimbursement that you might not have been aware of.

    #Helping Patients Manage Cardiometabolic Disorders & Weight
    Listen to Drs. Mike Hagaman and David Spees as they discuss how they are helping their patients tackle cardiometabolic disorders and weight problems head-on.

    How an integrated care group turns the tide against cardiometabolic disorders
    This series showcases practices across America that have implemented creative solutions to practice management challenges.

    Improve your management of cardiometabolic disorders
    The art of medicine can be as pivotal as the science of medicine when it comes to managing the treatment regimens of patients with cardiometabolic disorders.

    Mediterranean Diet: Benefits in Early Type 2 Diabetes
    It is rare that a study on prevention translates into a message that I can easily apply to my practice. Most behavior changes are difficult, even in the face of very convincing evidence. Not only is it difficult to change any well-established behavior, but in many cases we are asking our patients to substitute a behavior that is less rewarding.

    Researchers develop computer model to help doctors with statin therapy
    A new tool to help treat cardiometabolic conditions with greater certainty is ready to be tested in a practice environment.

    Sidebar: When to refer a nonadherent patient to a mental health specialist
    Consider a referral to a mental health provider for patients who remain nonadherent to therapy or lifestyle changes even after extensive patient education efforts.

    Sidebar: Getting reimbursed for patient education
    Insurers are also signing on to support new chronic care patient education delivery systems that incorporate web-based and electronic technologies.

    Study: Intervention raises costs for diabetes
    Medical interventions for patients with type 2 diabetes won't reduce health costs over the long term, according to a recently published study, but that doesn't mean they don't offer benefits.

    Viewpoint: Help your patients make a difference in their own lives
    Beginning this issue and continuing through November, Medical Economics will deliver "Cardiometabolic Disorders & eight: Action for Outcomes," a series of in-depth coverage designed to help you manage your patients’ disorders more effectively.

    Urology

    #Cardiometabolic Disorders on Urologists' Front Porch
    Cardiometabolic disorders and urologic disease represent a "perfect storm" of ailments, according to Dr. Kevin McVary, Associate Professor of Urology, Northwestern University's Feinberg School of Medicine.

    #Cardiometabolic disorders and ED
    Dr. Daniel H. Williams IV and Dr. Ajay Nangia discuss cardiometabolic disorders and urologic disease in aging men with Urology Times’ Ben Saylor

    Cardiometabolic Disorders: Do They Matter?

    Diabetes found to protect against prostate cancer
    Metabolic disorders confer lesser, albeit similar, protection, study data show

    New research links LUTS, cardiometabolic disorders
    Data indicate that even patients with mild urinary tract symptoms are at increased risk.

    Research links cardiometabolic disorders, urologic disease
    As research reveals more associations between cardiometabolic disorders and urologic disease, experts are emphasizing the importance of the urologist in detecting cardiometabolic risk factors in patients.