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Diabetes/CVD prevention guideline released.

A new clinical practice guideline from the Endocrine Society gives clinicians strategies to keep type 2 diabetes and cardiovascular disease at bay in adults with metabolic risk factors.

The metabolic risk factors that should raise red flags for primary care clinicians include enlarged waist circumference, hypertension, and high plasma glucose levels.

"This guideline focuses on the population of individuals with the components of the metabolic syndrome who do not yet have diagnosed cardiovascular disease or type 2 diabetes mellitus, and on the steps that can be taken to prevent these two diseases," the guideline authors said.

The guideline recommends making metabolic risk reduction part of regular practice by measuring waist circumference, blood pressure, fasting lipid profiles, and fasting glucose at every routine visit. (See table.) Patients who approach or fall into the at-risk category for any of the measures should receive counseling on risk reduction with a healthy diet, adequate exercise, and weight loss if needed (J. Clin. Endocrinol. Metab. 2008; 93:3671-89).

The guideline defines metabolic risk as a person's risk for CVD and type 2 diabetes based on several elements, including elevated triglycerides, reduced HDL cholesterol level, increased plasma glucose level, hypertension, enlarged waist circumference, a prothrombotic state, and a proinflammatory state.

The guideline also recommends a global risk assessment every 10 years for all patients who meet the criteria for metabolic risk, to check for signs of coronary heart disease and cardiovascular disease. The LDL cholesterol measure should be used to target lipoprotein-lowering therapy if lifestyle modification has been insufficient.

Patients who meet criteria for prediabetes at a routine clinical visit should be screened for diabetes at 1-to 2-year intervals using either a fasting plasma glucose test or a 2-hour oral glucose tolerance test.

The members of the Endocrine Society task force who developed the guideline did not offer a specific definition of the metabolic syndrome. The society suggests that physicians screen for metabolic risk factors using the American Heart Association/National Heart, Lung, and Blood Institute definition at each clinical visit because it is easy to use in the office setting.

"The finding of three or more components especially should alert the clinician to a patient at metabolic risk (a higher risk for CVD and type 2 diabetes mellitus)." the guideline states.

The task force members said the guide-line should not be cosidered inclusive or exclusive of other approaches to patient care, and it does not establish a standard of care or guarantee a specific outcome. The guideline corresponds to a similar statement from the American College of Endocrinology after a consensus conference in July 2008, available at

Dr. James L. Rosenzweig of Boston University, chair of the guideline task, stated that he had no financial conflicts to disclose. Other members of the task force had no financial interests to disclose, but they have served on speakers bureaus for multiple pharmaceutical companies including Novartis, Pfizer Inc., Merck. & Co., and GlaxoSmithKline.
The Endocrine Society's Recommended Criteria for Metabolic Risk

Clinical measure Any three of these five elements

Waist circumference [greater than or equal to] 102 cm for men or
 [greater then or equal to] 88 cm for women
 (non-Asian); [greater than or equal to] 90 cm
 for East Asian and South Asian men or [greater
 than or equal to] 80 cm for East Asian or South
 Asian women

Fasting 150 mg/dL or higher, or patients taking
triglyceridas medication for high triglycerides

HDL cholesterol HDL < 40 mg/dL in men or < 50 mg/dL in women,
 or patients taking medication for low HDL

Blood pressure 130 mm Hg systolic or higher; or 85 mm Hg
 diastolic or higher, or patients taking
 medication for hypertension

Fasting glucose 100 mg/dL or higher, or patients taking
 medication for elevated glucose

Note: The Endocrine Society recommends the American Heart Association
/National Heart, Lung, and Blood Institute's criteria for metabolic
syndrome as a screening tool to reduce risk for cardiovascular
disease and type 2 diabetes.

Sources: The Endocrine Society, AHA/NHLBI


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Title Annotation:Endocrinology
Author:Splete, Heidi
Publication:Internal Medicine News
Date:Dec 15, 2008
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