1. Section overview: Cardiometabolic risk reduction

2. Healthful dietary and lifestyle factors positively impact survival in the elderly
HALE (Healthy Ageing: a Longitudinal Study in Europe) studied apparently healthy men (n = 1507) and women (n = 832), aged 70 to 90 years, in 11 European countries between 1988 and 2000.
Adherence to a Mediterranean diet and a healthful lifestyle (determined by physical activity levels, smoking status, and alcohol intake) was associated with a more than 50% lower rate of all-causes and cause-specific mortality in this elderly population.

3. Assessment and management of metabolic risk
The Endocrine Society developed clinical practice guidelines for the primary prevention of CV disease and T2DM in patients at metabolic risk, ie, individuals with components of the metabolic syndrome.
Since hypertension, lipid abnormalities, hyperglycemia, and abdominal adiposity tend to cluster together, TES guidelines recommend that physicians screen for these key risk factors at routine clinical visits.

4. Lifestyle therapy to reduce plasma glucose and lower risk for T2DM
TES guidelines recommend that lifestyle management be considered first-line therapy for patients at increased metabolic risk.
Lifestyle therapies (weight reduction, increased physical activity, and an anti-atherogenic diet) have been shown to reduce all of the components of the metabolic syndrome simultaneously.

5. Guide to adiposity management
BMI classification and the presence or absence of comorbid conditions may be used as a guide to selecting the type of adiposity management.
Comorbid conditions that confer high absolute risk include:
Established coronary heart disease or other atherosclerotic disease
Type 2 diabetes
Sleep apnea
Hypertension
Smoking
Dyslipidemia
Dysglycemia
Family history of early CV disease
≥45 years of age (if male) or ≥55 years (if female)

6. NHLBI guidelines: Weight loss goals
The initial goal of weight loss therapy is a reduction of approximately 10% from baseline. Further weight loss can be attempted if necessary. These recommendations are given an evidence level of A, which are based on randomized, controlled trials.
A weight loss of 1-2 lbs per week is the target for the first 6 months. This recommendation is given an evidence level of B, indicating that it is based on evidence from a limited number of randomized clinical trials, or from post hoc or subgroup analyses.

7. NHLBI guidelines: Lifestyle modification
Lifestyle modification includes the following components:
Hypocaloric diet: A kcal per day deficit is recommended, which can translate to a weight loss goal of 1-2 lbs per week in most patients. Very low caloric diets are not recommended for weight loss since they require special monitoring and supplementation.
Physical activity: Increasing energy expenditure through physical activity is recommended. Initially, minutes of moderately-intense physical activity should be carried out 3-5 times per week. The long-term goal is ≥30 minutes on most, and preferably all, days of the week.
Behavior therapy: This consists of interventions to reinforce changes in diet and physical activity. Suggested strategies are provided in The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, available at:
Lifestyle modification should be maintained for at least 6 months before weight-loss pharmacotherapy is considered.

8. Popular dietary programs: Effective yet difficult to maintain
Dansinger conducted a single-center, randomized trial of 4 well-known diets: Atkins, The Zone, Weight Watchers, and Ornish.
These diets varied widely in their approaches, yet each resulted in comparable weight loss after 1 year. However, each was also associated with high recidivism.

9. ADA: Dietary recommendations
The American Diabetes Association (ADA) recommends that individuals with diabetes or prediabetes receive individualized dietary therapy, preferably by a registered dietitian.
The goals of the recommendations summarized on the slide are to help individuals achieve weight loss and glycemic control.

10. Popular diets vary widely in macronutrient composition, confusing patients
Given the wide variation in diets, Wadden et al have suggested that choice of a diet may be left, in part, to patient preference.

11. Helping patients with portion size
The NHLBI has posted a serving-size guide that can be downloaded for distribution to patients.
It provides examples of how standard servings of various foods appear.

12. Regular follow-up and support for lifestyle modification blunts weight regain
Long-term weight control is very difficult to achieve and many patients regain the weight they originally lost.
The slide summarizes the combined results of 3 studies. Regular follow-up with patients can blunt but not completely abolish this weight regain.

13. Lifestyle modification and pharmacotherapy: Potentially additive effects
Weight-loss medications should always be combined with a comprehensive program of lifestyle modification, since the 2 approaches have complementary mechanisms of action.

14. Drugs associated with weight gain
A number of commonly prescribed medications are associated with weight gain.
However, second-generation insulins and beta-blockers appear to avoid the weight problems associated with the first members of these drug classes.

15. Physical activity may reduce CV and all-cause mortality
The National Health and Nutrition Examination Survey (NHANES) I was conducted from 1971 to The NHANES I Epidemiological Follow-up Survey consisted of 4 additional surveys, the most recent of which was conducted in 1992.
These data show that even moderate exercise is associated with a reduction in all-cause and CV mortality.
The association was most robust in hypertensive subjects, although a trend to benefit was also seen at lower BP levels. This finding is consistent with other studies suggesting that the health benefits of increased physical activity extend beyond their effect on CV risk factors.(1)
Hazard ratios (HR) were adjusted for age, gender, race, BMI, education, diabetes, smoking, alcohol, diet, BP, and lipids.
Abbreviation:
CI = confidence interval
1. Blair SN, LaMonte MJ. Arch Intern Med. 2005;165:

16. Women’s Health Study: Joint effect of weight and physical activity on CV disease risk
Being physically active attenuates the CV disease risk associated with excess adiposity, but it does not completely abolish it, emphasizing the importance of being both lean and physically active.
In this study, physically active was defined as expending 1000 kcal or more weekly.
Changes in CV parameters associated with weight loss include reduced blood volume, stroke volume, cardiac output, pulmonary capillary wedge pressure, left ventricular mass, resting heart rate, and QTc interval; improvement of left ventricular systolic and diastolic dysfunction; and increased heart rate variability.(1)
1. Poirier P et al. Circulation. 2006;113:

17. STRRIDE: Vigorous physical activity may be required for significant weight loss
The Studies of Targeted Risk Reduction Interventions through Defined Exercise (STRRIDE) randomized 182 sedentary overweight men and women to either a control group or to 1 of 3 exercise groups:
High amount/vigorous intensity (equivalent to jogging approximately 20 miles per week at 65%-80% peak oxygen consumption).
Low amount/vigorous intensity (equivalent to jogging approximately 12 miles per week at 65%-80% peak oxygen consumption).
Low amount/moderate intensity (equivalent to walking approximately 12 miles per week at 40%-55% peak oxygen consumption).
Actual exercise modes included stationary bicycles, treadmills, and elliptical trainers.
All study subjects were counseled not to change their diet and encouraged to maintain their body weight.
The study was 8 months long and 120 subjects completed it.
The control group gained weight while the exercise groups lost weight in a dose-dependent manner.

18. Lifestyle modification and weight loss: Summary
Despite wide variations in macronutrient composition, weight-loss diets can be an effective means of weight control.
The specific dietary regimen, including use of meal replacements, in part, can be left to the patient’s own preferences.
However, regular follow-up and support to encourage adherence to the diet selected and to physical activity recommendations are essential.