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How Well Is Cardiometabolic Risk Being Managed in Primary Care?



sharma-obesity-cardiometabolic-risk1“Cardiometabolic” is a term that is often used (often synonymous with “metabolic syndrome”) to describe the constellation of cardiovascular risk factors (many of which happen to be metabolic).

A study by Teoh and colleagues from across Canada, published in the Canadian Journal of Cardiology, examined risk assessment and management patterns by primary care physicians, working both in primary care teams (PCT) and in solo practice.

Based on an analysis of almost 2,500 patients (40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least 1 of the following: dyslipidemia, type 2 diabetes mellitus (T2DM), or hypertension.), most (~90%) were abdominally obese and at least 52.2% had metabolic syndrome.

Cardiovascular risk, was often miscalculated and behavioural modification was recommended in fewer than 50% of patients (compared to pharmacotherapy in >70%).

Overall, guideline-recommended control of cardiometabolic risk factors was achieved in only about 10% of patients.

Not surprisingly, the authors are not happy about how obesity and cardiovascular risk is currently being assessed in primary care and call for a paradigm change in assessing and managing obesity and cardiovascular risk with more aggressive lifestyle interventions.

While this is certainly a laudable goal, there is ample evidence that simply telling people to “eat-less-move-more” is not the answer. In fact, even simply putting more allied health into these teams may also not be the answer.

As the authors note,

“We found that evidence for exercise and nutrition counselling aimed at encouraging sustained negative energy balance was disappointingly infrequent. This was surprising because 5 PCTs had a diabetes educator and 7 had a dietitian on staff or as part of the extended care program.”

In fact, it was particularly surprising to note that,

“Management of CMR factors appeared to be no more effective in PCTs compared with the more traditional Solo practices.”

Thus, the paradigm shift is probably not so much in recognising the importance of “lifestyle” interventions but rather in their delivery – so far I have yet to see a successful sustainable delivery model outside of the rather artificial constraints of clinical intervention trials that demonstrate “successful” lifestyle management.

This is not to say that “lifestyle” interventions cannot significantly improve cardiometabolic risk factors. However, the effort to achieve and maintain these changes in clinical practice in enough patients to make a significant impact on outcomes is generally underestimated.

Not to say that such a model may not not exist in some corner of the earth – it is just that most health systems have yet to figure out how to do this.

AMS
Edmonton, AB

ResearchBlogging.orgTeoh H, Despr├ęs JP, Dufour R, Fitchett DH, Goldin L, Goodman SG, Harris SB, Langer A, Lau DC, Lonn EM, John Mancini GB, McFarlane PA, Poirier P, Rabasa-Lhoret R, Tan MK, & Leiter LA (2013). Identification and Management of Patients at Elevated Cardiometabolic Risk in Canadian Primary Care: How Well Are We Doing? The Canadian journal of cardiology PMID: 23465284

2 Comments

  1. I suspect that the reason that lifestyle intervention is not often very successful is that the paradigm used is based on information— about what to eat, what to do for activity etc, rather than how to navigate an obesogenic environment. In order to be successful a person needs a divergent constellation of knowledge, skills, attitudes and most importantly, resources, to be successful. Knowledge about food, shopping, how to deal with stress appropriately, the need to choose activity that is fun, not punitive; skills in food preparation, organzing and juggling time pressures; an attitude that food and activity is important and the resource of time and enough money. Our standard treatment protocols often just focus on information.

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  2. I am a Registered Dietitian working with a Family Health Team in Ontario. Several FHT’s in Ontario were funded for two years by the Ministry of Health and Long term Care in 2011 to teach a pilot 12 week group Diabetes Prevention Program modelled after the University of Pittsburgh’s DPP program. The 2 main goals of the program are for participants to lose 5-7% of their starting body weight and to be physically active for minimum of 150mins per week. This program has been so successful, we have been funded for an additional year. Participants learn not only how to eat healthy and reduce fat, but also how to handle stress, social events and other people that make it hard to change. Also, how to stop negative thoughts. After the 12 weeks, participants are seen bi-weekly for 4-5 months for support and to help them maintain their behaviour changes. Average weight loss is 4-5% after 12 weeks, up to 7% after the additional 5 months. Delivery is important! It needs to be kept fun and interactive using visual tools, to minimize dropouts.
    Feel free to contact me for more information.
    I have included the University of Pittsburgh DPP website with all the materials.

    http://www.diabetesprevention.pitt.edu/glbmaterials.aspx

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