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TLC takes on a new meaning |
 All our patients deserve a little TLC or ‘tender loving care’ but an increasing number are also badly in need of another TLC, namely ‘therapeutic lifestyle change’. This is a new acronym that has crept in to US guidelines to manage cardiovascular risk (1). It is particularly targeted at those individuals with the metabolic syndrome or syndrome X.
The importance of the metabolic syndrome
At the recent International Congress on Obesity (ICO) in Brazil in August, much was talked about the metabolic syndrome, which is the combination of obesity, dyslipidaemia, insulin resistance and hypertension. The official definition is in the following table and highlights a relatively new combination of cardiovascular disease risk factors over and above smoking and high cholesterol that is being seen more and more as populations gain weight.
Metabolic syndrome definition (ATP 111)
3 out of these 5
(1) WC >102 cm men
>88 cm women
(2) TG >/= 1.7 mmol/L
(3) HDL men < 1.0 mmol/L
women < 1.3 mmol/L
(4) BP >/= 130/85 mm Hg
(5) FBG >/= 6.1
(NB - high total and LDL cholesterol are not part of the MS)
Using this quite stringent definition it has been estimated that about 22% of US adults have the metabolic syndrome as defined by the Adult Treatment Protocol 111 (ATM 111) of the US National Cholesterol Education Program (2) and of great concern is the increasing prevalence of the metabolic syndrome amongst younger people. In the future this problem is going to absorb the time and expertise of health professionals in a very significant way. Health economists are alarmed at the potential costs of this epidemic.
The ticking clock hypothesis
Also highlighted at the ICO was the so called ‘ticking clock hypothesis’ (3) for both the microvascular and macrovascular complications of diabetes, where diabetes is considered a coronary heart disease risk equivalent. For microvascular complications the clock starts ticking at the onset of hyperglycaemia with potential complications involving the eye, kidney and nervous system. But for macrovascular complications the clock starts ticking before the diagnosis of hyerpglycaemia. This results in abnormal risk factors possibly associated with insulin resistance and the metabolic syndrome that increase the risk from macrovascular complications before the blood sugars become abnormal.
Finding and diagnosing those individuals with the metabolic syndrome is an important cardiovascular preventative measure. Obese people with insulin resistance and hyperinsulinaemia need to be identified with appropriate blood tests including fasting lipids and blood glucose. Fasting insulin levels are difficult to interpret and the best test is a GTT to uncover insulin resistance in appropriately selected cases, particularly targeting those with fasting plasma glucose of 5.6-6.9mmol/L. High triglycerides, low HDL levels and raised blood pressure are so often also found to varying degrees in these patients.
An extension of the ticking clock hypothesis is that some of these abnormalities actually contribute to diabetes and that early intervention may delay the onset of overt diabetes. Patients with impaired fasting glucose or impaired glucose tolerance usually convert to type 2 diabetes at a rate of 5-10% per year. The way is open with TLC and sometimes medications to prevent the onset of diabetes and cardiovascular risk. Evidence to support the health benefit in this sort of intervention was described in GPSpeak (Aug ’02). Early intervention is the key before too much atheromatous change takes place.
Managing cardiovascular risk
Smoking and high cholesterol are of course priorities in managing cardiovascular risk, but closely following is the need to address the metabolic syndrome and TLC is the mainstay of treatment although medications may be needed for recalcitrant cases. GPs are ideally placed to opportunistically intervene with TLC coaching and encouragement. For an overweight or obese patient a sensitive history taking of lifestyle habits or what is known as motivational interviewing is the first step. The next is measurement of weight, waist, BMI, blood pressure and then the ordering of fasting lipids and BSL. This blood test provides an ideal opportunity to have the patient return to discuss the results and can often open the way to further the lifestyle discussion. GPs will often find the need to refer their patients to other health professionals but should not underestimate their own influence in bringing about change, just as many studies show how they can influence people in giving up smoking.
Local TLC providers
So what is available for GPs to offer their patients in initiating TLC? Firstly the patient needs to be ready to change and this readiness needs to be sought out by the GP. Then there are options from referral to educational/motivational programs like Professor Trim’s or Weight Watchers, to referring to dietitians or exercise physiologists.
Special clinics for people wanting to bring about TLC are being proposed for the future in partnership with the Southern Cross University Exercise Science Department. Gymnasiums are threatening for some and there is a need for more user friendly weight loss gyms catering for all ages, sizes and shapes, males and females, and run by well trained weight loss coaches. Such facilities need to be safe and provide relevant physical activity and nutritional advice that can result in sustainable lifestyle change. The emphasis needs to be on long term weight loss without regain as discussed in GPSpeak (Oct ’02).
GPs as TLC coaches
In addition to this highly resourced one-on-one intervention there needs to be an environmental approach to the obesity pandemic that addresses the obesogenic nature of our lives. This is a large and important topic that will be addressed in the February edition of GPSpeak. In the meantime an environmental strategy that GPs collectively can participate in now is never to miss an opportunity to bring up lifestyle change issues with their metabolic syndrome patients. 20,000 GPs in Australia doing just that could make a difference - 20,000 GPs acting as lifestyle coaches. It may result in more job satisfaction and fun than writing millions of scripts and certainly has the potential to contain health costs.
(1) Executive Summary of the Third Report of the National Cholesterol Education Program Expert Panel (NCEP) Expert Panel on Detection, Evaluation, and Treatment Of High Blood Cholesterol in Adults (Adult Treatment Panel 111) JAMA May 16, 2001 Vol 285, No.19
(2) Earl S et al Prevalence of the Metabolic Syndrome Among US Adults JAMA Jan 2002, 287:356-359
(3) Haffner SM et al JAMA 1990 283:2893-2898
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