Clinical Economics: Cardiometabolic syndrome

When interrelated risk factors such as high blood pressure, elevated fasting blood sugar, dyslipidemia, abdominal obesity, and elevated triglycerides cluster together, the resulting cardiometabolic syndrome can lead to cardiovascular disease and type 2 diabetes. Approximately 47 million Americans currently live with cardiometabolic syndrome and the resulting elevated risk of serious disease and mortality. 

Minimizing risk factors and preventing disease development and progression represents a critical task for primary care physicians and other healthcare providers. In addition to treating risk factors, clinicians must  counsel patients on lifestyle changes, smoking cessation, and weight management. Finding effective, efficient ways to treat these difficult-to-manage risk factors can result in significant risk reduction for patients.

Patient management tips

Recognize all risk factors. A wide range of traditional and newly recognized risk factors contribute to cardiometabolic disease, and it is important to review all of them during a patient examination. 

·      Traditional cardiometabolic risk factors:

o   Age

o   Sex

o   Family history

o   Hypertension

o   Dysglycemia

o   Dyslipidemia

o   Smoking

·      Newer cardiometabolic risk factors:

o   Abdominal obesity (measured by waist circumference)

o   Insulin resistance

o   Inflammation (measured by high-sensitivity C-reactive protein levels)

o   Lack of consumption of fruits and vegetables

o   Sedentary lifestyle

o   Psychosocial stress

When clusters of these risk factors are identified, a management plan should be promptly put into place to delay or prevent future complications.

Communicate conscientiously. Because patients with cardiometabolic risk factors may be asymptomatic or have no existing conditions, they may not understand the serious risks associated with cardiometabolic syndrome. Primary care physicians must explain the importance of early risk factor control and stress that cardiac disease and diabetes are harder to treat once they are established. However, clinicians must also be cautious not to label patients in a way that makes them feel self-conscious or guilty for their health-related behaviors. Instead, reinforce the concept that lifestyle change, good nutrition, and increased physical activity can substantially reduce their cardiometabolic risk and improve their quality of life overall. 

Focus on lifestyle modification. Lifestyle modification is the primary management strategy for cardiometabolic syndrome. This can be challenging to implement in a primary care practice because it requires simultaneous counseling on physical activity, diet, and smoking cessation with regular follow-up over a long period of time. Clinical guidelines recommend that lifestyle modifications be continued for 3 to 6 months before considering pharmacotherapy unless patients are at high risk. The importance of continuous, lifelong behavior change should be communicated to patients, even if they receive pharmacotherapy. 

Address both weight and waist. Obesity-defined as body mass index (BMI) ≥30 kg/m²-is a regularly measured cardiometabolic risk factor, but body fat distribution is also an important consideration that should be addressed in a patient’s exam. Excess abdominal fat is associated with increased incidence of cardiometabolic disease, and waist circumference measurements of >40 inches in men and >35 inches in women place patients at higher risk. Adding waist circumference measurements to a patient’s chart can help assess body fat and subsequent risk in ways that BMI alone does not allow. It also provides a measureable goal for patients who are tracking their weight loss.    

Build a care team. Because successful patient lifestyle modification requires long-term support, work to build a care team that can commit to being available to the patient over time. In addition to in-office support staff such as nurses and patient educators, it may be appropriate to refer patients to exercise specialists, registered dieticians, counselors or social workers, commercial weight-loss programs, and online or in-person support groups. Individual case managers or coaches can conduct weekly or bimonthly follow-up with patients via phone or email to provide ongoing motivation and reduce the need for office visits. Alternatively, patients within a practice can be organized into small groups that meet with a case manager or coach at regular intervals to discuss their challenges, share their stories, and support each other. Patients at high risk of cardiac disease or diabetes may also require referral to a cardiologist or endocrinologist.

Facilitate self-monitoring. Successful lifestyle modification requires self-monitoring by patients. When patients accurately track their food intake, exercise, weight loss, and change in waist circumference, they can provide valuable information to be discussed during office visits. Reinforce the importance of regular self-monitoring through a written diary, web-based program, or phone app. Patients can read reviews of available apps and choose one that appeals to them at: http://www.healthline.com/health-slideshow/top-iphone-android-apps-weight-loss.