Lifestyle and CV Prevention: Emphasis on Obesity

Robert Eckel, MD
Edwin Bierman Lectureship
American Diabetes Association Council on Complications

Reported by Joelle Escoffery, PhD

Global projections indicate that there will be a 40% increase in diabetes prevalence by 2010, at which time it is anticipated that 241 million people will have the disease. People with diabetes are at risk for various macrovascular diseases, which are associated with considerable mortality and morbidity. Numerous organizations, including the American Diabetes Association, American Heart Association, and the American Cancer Society have all established guidelines for strategies to reduce mortality and morbidity. These guidelines include the following:

• Eat a well-balanced diet, including fruits, vegetables, and whole grains. Also low fat dairy, legumes, poultry, lean meat, and fish
• Maintain a healthy body weight by matching caloric intake with physical activity
• Maintain desirable lipoprotein profile
• Maintain normal blood pressure

The Breast Cancer Detection Project demonstrated that recommended food score (RFS), an index of healthy eating, was associated with a reduction in all causes of mortality and CHD. The Women’s Health Study also showed the RFS was linearly associated with a decreased risk of coronary disease.

Physical activity is also associated with a variety of beneficial effects, including antiatherosclerotic effects, antithrombotic effects, anti-ischemic effects, and antiarrhythmic effects. Physical activity is associated with reductions in mortality and morbidity. A meta-analysis on the effect of physical activity in women demonstrated a decrease in stroke, coronary heart disease, and overall mortality.

Modest weight reductions (5-10%) are associated with numerous benefits, including improvements in hypertension, glucose tolerance, lipid parameters, left ventricular function, and obstructive sleep apnea symptoms. Although there is currently no evidence that weight reduction can reduce risk of cardiovascular disease (CVD), it has been clearly shown to reduce diabetes progression in the Finnish Diabetes Prevention Study and the Diabetes Prevention Program (DPP). Despite the clear benefits of weight reduction, obesity is a survival advantage when there is not enough food, even in the 20th century. Not surprisingly, data from the National Weight Loss Registry show that only 6% of people lose weight and keep it off for 15 years. The ongoing Look AHEAD Study will assess the effect of weight loss on obese subjects with type 2 diabetes, and the primary endpoint will be time until first cardiovascular event.

Because of the difficulty of weight loss, prevention of obesity and additional weight gain should be a primary objective. Additionally, addressing CVD risk in obese patients with more aggressive treatment of risk factors should also be a goal to improve public health.