Elevated Cardiometabolic Risk Research Articles

Snapshots of Diabetes Care in Canada

Snapshots of Diabetes Care in Canada

Workers' Knowledge and Beliefs About Cardiometabolic Health Risk

Investigate workers' knowledge and beliefs about cardiometabolic risk. A survey on the risks of diabetes, cardiovascular disease, and chronic kidney disease was disseminated among Dutch construction workers and employees from the general working population. We had 482 respondents (26.8%) among construction workers and 738 respondents (65.1%) among the general working population. Employees showed reasonable basic knowledge, especially about cardiovascular disease risk factors and risk reduction. Nevertheless, they also had knowledge gaps (eg, specific dietary intake) and showed misconceptions of what elevated risk entails. Employees having lower education, being male, and having lower health literacy demonstrated less adequate knowledge and beliefs. To improve the potential effect of health risk assessments in the occupational setting, physicians should explain what it means to be at elevated cardiometabolic risk and target their messages to employee subgroups.

Relation Between Self-Reported Physical Activity Level, Fitness, and Cardiometabolic Risk

Physical activity and cardiorespiratory fitness are associated with improved cardiovascular health and reduced all-cause mortality. The relation between self-reported physical activity, objective physical fitness, and the association of each with cardiometabolic risk has not been fully described. We studied 2,800 healthy Brazilian subjects referred for an employer-sponsored health screening. Physical activity level was determined as "low," "moderate," or "high" with the International Physical Activity Questionnaire: Short Form (IPAQ-SF). Fitness was measured as METs achieved on a maximal, symptom-limited, treadmill stress test. Using multivariate linear regression analysis, we calculated age, gender, and smoking-adjusted correlation coefficients among IPAQ-SF, fitness, and cardiometabolic risk factors. Mean age of study participants was 43 ± 9 years; 81% were men, and 43% were highly active. Mean METs achieved was 12 ± 2. IPAQ-SF category and fitness were moderately correlated (r = 0.377). Compared with IPAQ-SF category, fitness was better correlated with cardiometabolic risk factors including anthropomorphic measurements, blood pressure, fasting blood glucose, dyslipidemia, high-sensitivity C-reactive protein, and hepatic steatosis (all p <0.01). Among these, anthropomorphic measurements, blood pressure, high-sensitivity C-reactive protein, and hepatic steatosis had the largest discrepancies in correlation, whereas lipid factors had the least discrepant correlation. When IPAQ-SF and fitness were discordant, poor fitness drove associations with elevated cardiometabolic risk. In conclusion, self-reported physical activity level and directly measured fitness are moderately correlated, and the latter is more strongly associated with a protective cardiovascular risk profile.

Seven to Eight Hours of Sleep a Night Is Associated with a Lower Prevalence of the Metabolic Syndrome and Reduced Overall Cardiometabolic Risk in Adults

BackgroundPrevious studies looking at the relationship between sleep duration and the metabolic syndrome have only used a dichotomous approach (presence/absence) and failed to adjust for important confounding factors. The objective of the present study was to examine the association between self-reported sleep duration and features of the metabolic syndrome in adults.MethodsA cross-sectional analysis from the Quebec Family Study (Canada) was conducted on 810 participants aged 18 to 65 years. Participants were categorized as short (≤6 h), adequate (7–8 h) or long (≥9 h) sleepers. The metabolic syndrome was defined according to the American Heart Association/National Heart, Lung, and Blood Institute’s criteria.ResultsOverall, 24.6% of the sample had the metabolic syndrome. A U-shaped relationship between sleep duration and the prevalence of metabolic syndrome (33.3%, 22.0% and 28.8% in short, adequate and long sleepers, respectively) was observed (P<0.01). Only short sleepers had a significant increase in the odds of having the metabolic syndrome (OR = 1.76, 95% CI = 1.08–2.84) compared to adequate sleepers after adjustment for age, sex, smoking habits, highest education level, total annual family income, alcohol consumption, coffee intake, menopausal status, daily caloric intake, and moderate-to-vigorous physical activity. Likewise, the clustered cardiometabolic risk score (i.e. continuous risk score based on the metabolic syndrome components) was significantly higher in short sleepers compared to adequate sleepers after adjustment for covariates (P<0.05).ConclusionSleeping ≤6 h per night is associated with an elevated cardiometabolic risk score and an increase in the odds of having the metabolic syndrome after adjusting for possible confounders. These results strongly suggest that short sleep duration is a risk factor for the metabolic syndrome.

Clinical utility and reproducibility of visceral adipose tissue measurements derived from dual-energy X-ray absorptiometry in white and African American adults

Computed tomography and magnetic resonance imaging are currently used to measure abdominal visceral adipose tissue (VAT) in humans; however, more widely available and less costly dual-energy x-ray absorptiometry (DXA) also has the potential to measure VAT.ObjectiveThe purpose of this study was to determine reproducibility and clinical thresholds for DXA-derived VAT.Design and MethodsThe sample included 2317 white and African American adults 18–74 years of age. VAT areas (cm2) were measured using a Hologic DXA scanner equipped with APEX 4.0 software. Reproducibility was assessed using repeated measurements on 101 participants scanned 14 days apart. Receiver Operating Characteristic (ROC) curves were used to assess clinical utility and select thresholds that identified elevated cardiometabolic risk, defined as the presence of ≥2 risk factors.ResultsReproducibility of DXA-VAT was 8.1%. The areas under the ROC curves ranged from 0.754 in African American men to 0.807 in white women. The thresholds were higher in white men (154 cm2) and women (143 cm2) compared to African American men (101 cm2) and women (114 cm2).ConclusionThe results demonstrate that DXA VAT is a useful clinical marker of cardiometabolic risk; however, further research is required to determine associations with health outcomes using longitudinal studies.

A comparison of the assessment and management of cardiometabolic risk in patients with and without type 2 diabetes mellitus in Canadian primary care

To investigate the cardiometabolic risk (CMR) assessment and management patterns for individuals with and without type 2 diabetes mellitus (T2DM) in Canadian primary care practices. Between April 2011 and March 2012, physicians from 9 primary care teams and 88 traditional non-team practices completed a practice assessment on the management of 2461 patients >40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least one of the following risk factor-T2DM, dyslipidaemia or hypertension. There were 1304 individuals with T2DM and 1157 without. Pharmacotherapy to manage hyperglycaemia, dyslipidaemia and hypertension was widely prescribed. Fifty-eight percent of individuals with T2DM had a glycated haemoglobin (HbA1c) ≤7.0%. Amongst individuals with dyslipidaemia, median low-density lipoprotein cholesterol (LDL-C) was 1.8 mmol/l for those with T2DM and 2.8 mmol/l for those without. Amongst individuals with hypertension, 30% of those with T2DM achieved the <130/80 mmHg target, whereas 60% of those without met the <140/90 mmHg target. The composite glycaemic, LDL-C and blood pressure (BP) target outcome was achieved by 12% of individuals with T2DM. Only 17% of individuals with T2DM and 11% without were advised to increase their physical activity. Dietary modifications were recommended to 32 and 10% of those with and without T2DM, respectively. Patients at elevated CMR were suboptimally managed in the primary care practices surveyed. There was low attainment of recommended therapeutic glycaemic, lipid and BP targets. Advice on healthy lifestyle changes was infrequently dispensed, representing a missed opportunity to educate patients on the long-term benefits of lifestyle modification.

Two-year weight-loss maintenance in primary care-based Diabetes Prevention Program lifestyle interventions

Objective:To investigate whether the effects on weight loss and cardiometabolic risk factor reduction of two technology-mediated lifestyle interventions for 15 months in a primary care-based translation trial sustained at 24 months (that is, 9 months after the end of intervention).Design:This study analyzed data from an extended follow-up of participants in the original ‘E-LITE' (Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care)-randomized controlled trial, which demonstrated the effectiveness of two adapted Diabetes Prevention Program (DPP) lifestyle interventions compared with usual primary care.Subjects:E-LITE randomized 241 overweight or obese participants with pre-diabetes and/or metabolic syndrome to receive usual care alone (n=81) or usual care plus a coach-led (n=79) or self-directed intervention (n=81). The interventions provided coach-led group behavioral weight-loss treatment or a take-home, self-directed DVD using the same 12-week curriculum, followed by 12 additional months of technology-mediated coach contact and self-monitoring support. Participants received no further intervention after month 15. A blinded assessor conducted 24-month visits by following the measurement protocols of the original trial. Measurements include weight and cardiometabolic risk factors (waist circumference, fasting plasma glucose, resting blood pressure, triglycerides, high- and low-density lipoprotein cholesterol, total cholesterol and triglyceride to high-density lipoprotein cholesterol ratio).Results:At month 24, mean±s.e. changes in body mass index (trial primary outcome) and weight (kg) from baseline were –1.9±0.3 (P=0.001) and –5.4±0.9 (P<0.001) in the coach-led intervention, and –1.6±0.3 (P=0.03) and –4.5±0.9 (P=0.001) in the self-directed intervention, compared with –0.9±0.3 and 2.4±0.9 in the usual care group. In addition, both interventions led to a greater percentage of participants maintaining ⩾7% weight loss and sustained improvements in waist circumference and fasting plasma glucose levels than usual care.Conclusion:This study shows sustained benefits of the two primary care-based, technology-mediated DPP lifestyle interventions. The findings warrant replication in long-term studies involving diverse populations.

Translating an Evidence-Based Lifestyle Intervention Program Into Primary Care

The E-LITE (Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care) trial evaluated the feasibility and potential effectiveness of translating an evidence-based lifestyle intervention for the management of obesity and related risk factors in a primary care setting. Delivered by allied health care providers, the intervention promoted at least 7% weight loss and at least 150 minutes per week of moderate-intensity physical activity through gradual, sustainable lifestyle changes. Activities included interactive group lessons, food tasting, guided physical activity, and technology-mediated self-monitoring and behavioral counseling. This article discusses insights and potential areas for improvement to strengthen program implementation for dissemination of the E-LITE program to other primary care settings. We focus on (a) the role of allied health professionals in program delivery, (b) strengthening program integration within a primary care clinic, and (c) the use of information technology to extend the reach and impact of the program. Our experience shows the feasibility of implementing an evidence-based lifestyle intervention program combining group-delivered nutrition and behavioral counseling, physical activity training, and technology-mediated follow-up in a primary care setting. Challenges remain, and we offer possible solutions to overcome them.

Identification and Management of Patients at Elevated Cardiometabolic Risk in Canadian Primary Care: How Well Are We Doing?

BackgroundWe evaluated the risk assessment and management patterns employed by primary care physicians in patients at elevated cardiometabolic risk. MethodsBetween April 2011 and March 2012, multiple physicians from 9 Primary Care Teams (PCTs) and 88 physicians from traditional nonteam (Solo) practices completed a practice assessment on the management of 2461 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. ResultsIndividuals with dyslipidemia, T2DM, or hypertension tended to have a body mass index ≥ 25 kg/m2. Waist circumference measurements, obtained for only 392/829 (47.0%) Solo patients, revealed that 88.9% of these individuals were abdominally obese and that at least 52.2% of Solo patients had metabolic syndrome. Cardiovascular risk, determined by the physicians for 83.5% of all patients without T2DM and typically performed using traditional risk engines, was often miscalculated (43.2% PCTs, 58.8% Solo; P = 0.0007). Healthy behavioural modifications were infrequently recommended (< 50%). Pharmacotherapy was widely used (> 70%) but treatment targets were infrequently met. The composite outcome of guideline-recommended low-density lipoprotein cholesterol, glycemic, and blood pressure targets was met by 9.0% and 8.1% of patients managed by PCT and Solo physicians respectively. ConclusionsObesity and cardiovascular risk were underassessed and the latter often underestimated. Patients were infrequently counselled on the benefits of healthy behavioural changes. A paradigm change in assessing and managing obesity and cardiovascular risk via aggressive lifestyle interventions is warranted in individuals at elevated cardiometabolic risk.

Clinical utility of visceral adipose tissue for the identification of cardiometabolic risk in white and African American adults

Visceral adipose tissue (VAT) has been identified as a harmful fat depot, and sex and race differences in VAT have been reported in white and African Americans. We determined the clinical utility of VAT in the identification of individuals at elevated cardiometabolic risk in white and African American adults and compared the clinical utility with measures obtained by using dual-energy X-ray absorptiometry (DXA) and anthropometric measures. The sample included 429 white women, 311 African American women, 406 white men, and 100 African American men who were 18-74 y of age. VAT was measured by using computed tomography, fat mass (FM) and percentage of body fat were measured by using DXA, and waist circumference (WC) and BMI were assessed. Receiver operating characteristic curves were used to compare the utility of measures in the identification of participants in the upper quintile of a continuous score derived from principal components analysis of fasting glucose, HDL cholesterol, triglycerides, and blood pressure. The clinical utility of measures varied across sex-by-race groups. In the overall sample, the areas under the curve were significantly higher for VAT and WC in comparison with the other indicators. Identified VAT thresholds were higher in white men (140 cm(2)) and women (141 cm(2)) than in African American men (82 cm(2)) and women (97 cm(2)). VAT and WC showed greater clinical utility than did other obesity measures. Because of the complexity of measuring VAT, the use of WC is recommended for the identification of adults with elevated cardiometabolic risk factors. The Pennington Center Longitudinal Study was registered at clinicaltrials.gov as NCT00959270.

BMI-Specific Waist Circumference Thresholds to Discriminate Elevated Cardiometabolic Risk in White and African American Adults

Objective: Waist circumference (WC) is a useful anthropometric tool to estimate cardiometabolic risk. However, BMI influences the relationship between WC and health. This study determined BMI-, sex- and race-specific WC thresholds. Methods: The study sample included 6,452 whites and African Americans (AA) aged 18-64 years. WC, BMI, and cardiovascular risk factors were assessed in the clinic. An elevated cardiometabolic risk was defined as the presence of ≥2 cardiometabolic risk factors. Receiver Operating Characteristic (ROC) curves were used to determine BMI-, sex-, and race-specific WC thresholds. Results: Based on logistic regression, elevated WC within each BMI category was associated with higher cardiometabolic risk. The respective optimal BMI-specific WC thresholds for white women, AA women, white men, and AA men were as follows: 72, 76, 82, and 78 cm for normal-weight (18.5-24.9 kg/m²); 87, 85, 95, and 92 cm for overweight (25-29.9 kg/m²); 97, 97, 107, and 104 cm for obese I (30-34.9 kg/m²); and 111, 110, 120, and 119 cm for obese II+ (≥35 kg/m²) participants. Sensitivities ranged from 52.7 to 73.3%, and specificities ranged from 57.1 to 73.5%. Conclusion: The proposed optimal BMI-, sex-, and race-specific WC thresholds are warranted for use in the clinical setting until representative standards become available based on results from longitudinal studies.

Appropriate anthropometric indices to identify cardiometabolic risk in South Asians.

South Asians show an elevated cardiometabolic risk compared to Caucasians. They are clinically metabolically obese but are considered normal weight based on current international cut-off levels of several anthropometric indices. This study has two main objectives: (i) to predict the most sensitive anthropometric measures for commonly studied cardiometabolic risk factors, and (ii) to determine optimal cut-off levels of each of the anthropometric indices in relation to these cardiometabolic risk factors in South Asians. The study was conducted on a random sample of 1178 adults of 20-80 years of age from an urban population of eastern India. Obesity, as evaluated by standard anthropometric indices of BMI (body mass index), WC (waist circumference), WHpR (waist-to-hip ratio) and WHtR (waist-to-height ratio), was individually correlated with cardiometabolic risk factors. Receiver operating characteristic (ROC) curve analyses were performed which includes: (i) the area under the receiver operating characteristic curve (AUROC) analysis to assess the predictive validity of each cardiometabolic risk factor; and (ii) Youden index to determine optimal cut-off levels of each of the anthropometric indices. Overall, AUROC values for WHtR were the highest, but showed variations within the sexes for each of the cardiometabolic risk factors studied. Further, WHpR cut-offs were higher for men (0.93-0.95) than women (0.85-0.88). WC cut-offs were 84.5-89.5 cm in men and 77.5-82.0 cm in women. For both sexes the optimal WHtR cut-off value was 0.51-0.55. The optimal BMI cut-offs were 23.4-24.2 kg/m2 in men and 23.6-25.3 kg/m2 in women. WHtR may be a better anthropometric marker of cardiometabolic risks in South Asian adults than BMI, WC or WHpR.

Discordant risk: Overweight and cardiometabolic risk in Chinese adults

Recent US work identified "metabolically healthy overweight" and "metabolically at risk normal weight" individuals. Less is known for modernizing countries with recent increased obesity. Fasting blood samples, anthropometry and blood pressure from 8,233 adults aged 18-98 in the 2009 nationwide China Health and Nutrition Survey, were used to determine prevalence of overweight (Asian cut point, BMI ≥ 23 kg/m(2) ) and five risk factors (prediabetes/diabetes (hemoglobin A1c ≥ 5.7%) inflammation (high-sensitivity C-reactive protein (hsCRP) ≥ 3 mg/l), prehypertension/hypertension (Systolic blood pressure/diastolic blood pressure ≥ 130/85 mm Hg), high triglycerides (≥ 150 mg/dl), low high-density lipoprotein cholesterol (<40 (men)/ <50 mg/dl (women)). Sex-stratified, logistic, and multinomial logistic regression models estimated concurrent obesity and cardiometabolic risk, with and without abdominal obesity, adjusting for age, smoking, alcohol consumption, physical activity, urbanicity, and income. Irrespective of urbanicity, 78.3% of the sample had ≥ 1 elevated cardiometabolic risk factor (normal weight: 33.2% had ≥ 1 elevated risk factor; overweight: 5.7% had none). At the age of 18-30 years, 47.4% had no elevated risk factors, which dropped to 6% by the age 70, largely due to age-related increase in hypertension risk (18-30 years: 11%; >70 years: 73%). Abdominal obesity was highly predictive of metabolic risk, irrespective of overweight (e.g., "metabolically at risk overweight" relative to "metabolically healthy normal weight" (men: relative risk ratio (RRR) = 39.06; 95% confidence interval (CI): 23.47, 65.00; women: RRR = 22.26; 95% CI: 17.49, 28.33)). A large proportion of Chinese adults have metabolic abnormalities. High hypertension risk with age, underlies the low prevalence of metabolically healthy overweight. Screening for cardiometabolic-related outcomes dependent upon overweight will likely miss a large portion of the Chinese at risk population.

Television, Adiposity, and Cardiometabolic Risk in Children and Adolescents

It is largely unknown how TV use relates to depot-specific adiposity or cardiometabolic risk in children. To examine relationships between having a TV in the bedroom and TV viewing time with total fat mass, abdominal subcutaneous and visceral adiposity, and cardiometabolic risk in children and adolescents. A cross-sectional study of 369 children and adolescents aged 5-18 years was conducted (2010-2011; analysis 2011-2012). Waist circumference; resting blood pressure; fasting triglycerides, high-density lipoprotein cholesterol [HDL-C] and glucose; fat mass by dual-energy x-ray absorptiometry; and abdominal subcutaneous and visceral adiposity by MRI were assessed. Cardiometabolic risk was defined as three or more risk factors including adverse levels of waist circumference, blood pressure, triglycerides, HDL-C, and glucose. Logistic regression analysis was used to compute ORs of high fat mass; subcutaneous and visceral adipose tissue mass (top age-adjusted quartile); and cardiometabolic risk, based on self-reported TV present in the bedroom and TV viewing time, controlling for age, gender, ethnicity, moderate-to-vigorous physical activity level, and unhealthy diet. In multivariable models, presence of a TV in the bedroom and TV viewing time were associated with (p<0.05) higher odds of high waist circumference (OR=1.9-2.1); fat mass (OR=2.0-2.5); and subcutaneous adiposity (OR=2.1-2.9), whereas viewing TV ≥5 hours/day was associated with high visceral adiposity (OR=2.0). Having a TV in the bedroom was associated with elevated cardiometabolic risk (OR=2.9) and high triglycerides (OR=2.0). Having a bedroom TV and TV viewing time were related to high waist circumference, fat mass, and abdominal subcutaneous adiposity. TV viewing time was related to visceral adiposity, and bedroom TV was related to cardiometabolic risk in children, controlling for moderate-to-vigorous physical activity and an unhealthy diet. This study is registered at Clinicaltrials.govNCT01595100.

BMI percentiles for the identification of abdominal obesity and metabolic risk in children and adolescents: evidence in support of the CDC 95th percentile

ObjectivesBMI percentiles have been routinely and historically used to identify elevated adiposity. This paper aimed to investigate the optimal Centers for Disease Control and Prevention (CDC) body mass index (BMI) percentile that predicts elevated visceral adipose tissue (VAT), fat mass and cardiometabolic risk in a biracial sample of children and adolescents.Participants and MethodsThis cross-sectional analysis included 369 white and African American children (5–18 y). BMI was calculated using height and weight and converted to BMI percentiles based on CDC growth charts. Receiver operating characteristic curve analysis identified the optimal (balance of sensitivity and specificity) BMI percentile to predict the upper quartile of age-adjusted VAT (measured by magnetic resonance imaging), age-adjusted fat mass (measured by dual energy x-ray absorptiometry) and elevated cardiometabolic risk (≥ 2 of high glucose, triglycerides and blood pressure and low high density lipoprotein cholesterol) for each race-by-sex group.ResultsThe optimal CDC BMI percentile to predict those in the top quartile of age-adjusted VAT, age-adjusted fat mass and elevated cardiometabolic risk were the 96th, the 96th and the 94th percentiles, respectively, for the sample as a whole. Sensitivity and specificity was satisfactory (> 0.70) for VAT and fat mass. Compared to age-adjusted VAT and age-adjusted fat mass, there was a lower overall accuracy of the optimal percentile in identifying those with elevated cardiometabolic risk.ConclusionsThe present findings support the utility of the 95th CDC BMI percentile as a useful threshold for the prediction of elevated levels of VAT, fat mass and cardiometabolic risk in children and adolescents.The study is registered at clinicaltrials.gov as NCT01595100.

Life Goals Collaborative Care for Patients With Bipolar Disorder and Cardiovascular Disease Risk

This pilot study compared Life Goals Collaborative Care (LGCC) with enhanced treatment as usual in reducing cardiometabolic risk factors and improving outcomes for persons with bipolar disorder. Participants were randomly assigned to LGCC (N=34) or enhanced treatment as usual (N=34). LGCC included four weekly self-management sessions and monthly telephone contacts for six months thereafter. Enhanced treatment as usual included wellness mailings. Outcomes were blood pressure, body mass index (BMI), quality of life, functioning, and symptoms. Compared with enhanced treatment as usual, LGCC was not associated with reductions in cardiometabolic risk factors in 12-month repeated-measures analyses. Among patients with a BMI of ≥30 or systolic blood pressure of ≥140, LGCC was associated with improvements in functioning (beta=-2.2 and beta=-3.8, respectively, p=.04) and reduced depressive symptoms (beta=-2.0 and -3.5, respectively, p=.04). Further research is needed to determine whether LGCC improves outcomes for patients with elevated cardiometabolic risk.

Baseline reach and adoption characteristics in a randomized controlled trial of two weight loss interventions translated into primary care: A structured report of real-world applicability

BackgroundAlthough the Diabetes Prevention Program (DPP) lifestyle intervention reduced type 2 diabetes incidence by 58% among high-risk adults at academic centers, it requires translation into typical primary care settings. Using baseline data from the Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care (E-LITE) randomized controlled trial, we evaluated the potential of its two DPP-based interventions to reach their target populations and be adopted into routine use. MethodsOverweight/obese adults with increased cardiometabolic risk enrolled from one primary care clinic. Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model, we assessed reach with data on patient identification, participation, and representativeness, and adoption with data on intervention feasibility and potential for organizational diffusion. ResultsThe target population was identified by searching electronic health records. Contact was attempted for 2391 patients who completed initial screening by phone (56% uptake) or online (44%). Most (88%) of those screened ineligible were not within the target population; 12% were excluded because of research requirements. Conservatively estimated participation rate was 44%. Participants (n=241) included 54% men and had a mean (SD) age of 52.9years (10.6) and body mass index of 32kg/m2 (5.4). Regarding adoption, all clinic physicians agreed to participate. The feasibility of intervention implementation and dissemination was enhanced by leveraging existing intervention, training, and primary care resources. ConclusionsE-LITE's lifestyle interventions had fair-to-good potential for primary care reach and adoption. Our trial evidence and structured reporting may inform real-world implementation of translational trials by health networks, physicians, and payers.

750 Are Lifestyle Modifications Being Appropriately Recommended in the Canadian Primary Care Practice to Manage Elevated Cardiometabolic Risk?

750 Are Lifestyle Modifications Being Appropriately Recommended in the Canadian Primary Care Practice to Manage Elevated Cardiometabolic Risk?

247 How Do Canadian Primary Care Physicians in Family Health Teams Compare With Those in Solo-Physician Practices in Their Assessment and Management of Patients With Elevated Cardiometabolic Risk?

Patients at elevated cardiometabolic risk (CMR) may benefit from being managed by integrated multidisciplinary healthcare teams. We compared cardiovascular (CV) risk assessment and treatment patterns at the primary care level in Family Health Teams (FHTs) and in solo-physician practices. Between April 2011 and March 2012, multiple physicians from 6 FHTs in Ontario and Québec and 88 individual physicians from British Columbia, Ontario and Québec completed a practice assessment on the current health profile and management of patients >40 years with no clinical evidence of cardiovascular (CV) disease and diagnosed with at least one of the following - dyslipidemia, type 2 diabetes mellitus (T2DM) or hypertension as per the current Canadian Practice Guidelines (CPGs). Key physician and patient characteristics are provided in the Tables and Figures. The Framingham Risk Score (FRS) was the preferred CV risk algorithm (100% FHT; 95.3% solo). Underestimation of CV risk was prevalent in patients without T2DM (45.5% FHT; 44.2% solo; P=0.722). In solo-physician practices, the largest discrepancy in CV risk estimation occurred in the high-risk patient category (16.9% as estimated by the physicians; 49.6% according to the actual FRS). Recommendations to increase physical activity (4.0% FHT; 17.1% solo), improve diet (14.2% FHT; 34.1% solo) and cease smoking (15.2% FHT; 19.8% solo) were suboptimal. Although most of the patients diagnosed with dyslipidemia were prescribed lipid-lowering therapy (85.7% FHT; 86.9% solo), only about half attained the LDL-C goal (53.1% FHT; 47.7% solo). Despite the high use of antihyperglycemic agents in patients with T2DM (70.0% FHT; 83.9% solo), target A1C was achieved by less than a third of the patients (31.3% FHT; 29.3% solo). Even though antihypertensives were widely prescribed to patients with hypertension (86.0% FHT; 97.7% solo), recommended blood pressure goals were only realized by 39.1% and 51.0% of the patients managed by FHTs and solo-physician practices respectively. The composite outcome of LDL-C, glycemic and blood pressure targets was met in even fewer patients (11.9% FHT; 12.1% solo). Assessment and management of CV risk remains suboptimal in the primary care setting. Patients managed in the FHT setting were no more likely to meet recommended therapeutic targets than those patients managed by physicians in solo-physician practices. Tabled 1

248 Underestimation of Cardiovascular Risk in Patients With Elevated Cardiometabolic Risk in the Canadian Primary Care Setting

Primary care offers a unique opportunity for early identification and preventive management of patients at elevated cardiometabolic risk (CMR). We evaluated the risk assessment patterns employed by primary care physicians in patients at elevated CMR. Between April 2011 and March 2012, data from 88 individual physicians from British Columbia, Ontario and Québec, and from multiple physicians from 6 Family Health Teams (FHTs) in Ontario and Québec were collected on the current health profile and management of patients >40 years old with no clinical evidence of cardiovascular (CV) disease and diagnosed with at least one of the following - dyslipidemia, type 2 diabetes mellitus (T2DM) or hypertension as per the current Canadian Clinical Practice Guidelines (CPGs). Key patient characteristics from the 1864 patient charts are shown in the Table. Incidences of dyslipidemia, T2DM and hypertension were higher in individuals with a BMI ≥25 kg/m2 (84.7%) relative to those with a BMI <25 kg/m2. Waist circumference (WC) data, available from solo-physician practice assessments only, revealed that patients with WCs greater than their ethnic-specific cut-offs (41.8%) relative to patients with WCs below the thresholds also demonstrated higher occurrences of dyslipidemia, T2DM and hypertension. Approximately half (54.5%) of the patients managed by physicians in solo-physician practices had the metabolic syndrome based on the Harmonized Definition for the metabolic syndrome. CV risk was estimated in clinic in 52.2% of the 781 patients without T2DM with 98.8% of the physicians indicating that they used the Framingham Risk Score (FRS) and 0.5% the Reynolds Risk Score. Our own FRS analysis based on the complete data sets from 690 patients without T2DM implied that 57.0%, 30.7% and 12.3% of these individuals were actually at high, moderate and low CV risk respectively before invoking the 1.5- to 2-fold multiplier to determine absolute CMR. Notably, this suggests that 44.8% of the patients without T2DM who had their CV risk estimated in clinic were misclassified by their physicians into a lower risk category.Tabled 1 Current Canadian CPGs emphasize the importance of early identification of CMR in order to facilitate preventative measures against CMR factors. In this practice assessment program, CV risk using traditional CV risk algorithms was often underestimated. While the underlying reasons are unknown, this misclassification may have led to an inappropriate selection of therapeutic strategies contributing to a care gap.