A 32-year-old man has gained 35 pounds since he graduated from college and started working as computer programmer. He has never smoked. He has treated hypertension. He has tried several popular diets to lose weight and lost about 20 pounds each time, but he always regains the weight lost within one year. He bowls once a week. He weighs 220 lbs and his BMI is 32.5, and the highest it has ever been. His BP is 138/92. His labs show total cholesterol 218 mg/dL, triglycerides 188 mg/dL, HDL–C 40 mg/dL, LDL–C 138 mg/dL, and non HDL–C 178 mg/dL. His fasting glucose is 101 mg/dL. His father died of an MI at age 73.
Which of the following should be incorporated into your advice for ASCVD risk reduction for him?
The correct answer is: a. Refer to a program providing a series of group counseling comprehensive lifestyle change sessions.
This patient is not in 1 of the 4 statin benefit groups. While he currently has an increased ASCVD lifetime risk due to multiple risk factors, there is much he can do now since his 10-year ASCVD risk is low. He does not qualify for statin therapy but his lipids along with other risk factors need to be assessed at regular intervals. A major focus on his weight gain since college is appropriate and should help with risk factor control.
The Obesity Guidelines recommend delivery of high intensity comprehensive lifestyle intervention as the most effective approach to weight loss. This includes delivery of 14 or more group or individual sessions in the first 6 months by a trained interventionist. Therapy for at least a year is recommended. Of course, not all patients have access to the programmatic lifestyle counseling that produces successful weight loss skill building as demonstrated in the Diabetes Prevention Program study. Referral to other sources when this is not available is also endorsed. This may be telephonic counseling, electronic delivery or even referral for commercial programs where an evidence base supports efficacy. The Obesity Guidelines indicate that the choice of diet should be determined by the patient's preferences and health consideration. In the case of this patient, a reduced calorie diet with sodium restriction would be the obvious choice.
The Guidelines also recommend that physicians refer to registered dietitians when diets are prescribed for a specific health target, such as hypertension or diabetes.
This patient has shown by his history that he needs help in building the skills to sustain long term weight loss. This patient needs more than encouragement, he needs counseling and this is a central feature of the Obesity Guidelines.
The essential component of a weight loss effort is creating a negative energy balance. Dieting is not enough if weight loss is to be sustained. The Guidelines endorse incorporating physical activity into the weight loss effort and emphasize the role of physical activity in weight loss maintenance. The patient must also find ways to increase physical activity to >200 minutes a week, as recommended in the Guidelines.
Finally, at his current weight he does not qualify for bariatric surgery.
Eckel RH, Jakicic JM, Ard, JD, Hubbard VS, de Jesus JM, Lee IM, Lichtenstein AH, Loria CM, Millen BE, Houston Miller N, Nonas CA, Sacks FM, Smith SC Jr, Svetkey LP, Wadden TW, Yanovski SZ. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology American/Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013. (In press)
Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, Hu FB, Hubbard VS, Jakicic JM, Kushner RF, Loria C, Millen BE, Nonas CA, Pi-Sunyer FX, Stevens J, Stevens VJ, Wadden TA, Wolfe BM, Yanovski SZ. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and The Obesity Society. J Am Coll Cardiol 2013. (In press)
Sacks, F. M., Bray, G. A., Carey, V. J., Smith, S. R., Ryan, D. H., Anton, S. D., et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. New England Journal of Medicine, 209: 360(9), 859873.
Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med. 2010; 170:15661575.
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA,Nathan DM; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002; 346(6):393-403.