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FM10 Family Medicine
Health Promotion and Counselling
Toronto Notes 2019
Clinical Definition of Metabolic Syndrome
• Central obesity
Men – waist circumference ≥94 cm Women – waist circumference ≥80 cm
• Plus any TWO of the following four factors
Management
• intensityandtypeoftreatmentisguidedby“riskcategory”assigned(seeFigure5) 1. Health behaviours (can decrease LDL-C by up to 10%)
■ smoking cessation: probably the most important for preventing CAD
■ dietary modification: reduce saturated fat, red meat, refined sugar, alcohol; consume nuts, fruits/
vegetables, poultry, fish
■ physical activity: at least 150 min of moderate to vigorous intensity aerobic exercise per wk, in bouts
of 10 min or more to reduce CVD risk (see Table 6)
■ employ consistent lifestyle modifications for at least 3 mo before considering drug therapy; high risk
patients should start treatment immediately with concurrent health behaviour interventions 2. Pharmacologic therapy (can decrease LDL-C by up to 40%)
■ for a comparison of dyslipidemia medications, see Endocrinology, E2
■ 1st line monotherapy: statins (HMG-CoA reductase inhibitors)
• risks:myopathyandhepatotoxicity
• ifseveresideeffects:ezetimibe(cholesterolabsorptioninhibitor)canbeusedfor19%reductionin
LDL-C
• post-acutecoronarysyndrome,cholesterolabsorptioninhibitors(e.g.ezetimibe)inadditionto
simvastatin reduced mortality, attained lipid targets <1.8, and improved outcomes in high risk
individuals
• lowerevidenceforotheragents:bileacidsequestrants,nicotinicacid,fibrates,psyllium
■ monitoring
◆ ALT, CK, creatinine at baseline then 6 wk later for signs of transaminitis or myositis; tolerate rise
in CK up to 10 times upper limit of normal vs. 2-3 times if symptomatic, or serum creatinine
rise of ≤25%
◆ no routine repeated measures of ALT and CK necessary in asymptomatic patients using statin
therapy
◆ if adequate response is achieved, evaluate fasting lipids q6-12mo
Isolated Hypertriglyceridemia
• doesnotincreasecardiovascularrisk
• normalHDL-CandTC,elevatedTG
• mild≥2.2mmol/L(≥200mg/dL);marked≥5.6mmol/L(≥500mg/dL) • principaltherapyislifestylemodification
■ weight loss, exercise, avoidance of smoking and alcohol, effective blood glucose control in diabetics, increased omega-3 fatty acid intake
■ severe hypertriglyceridemia (typically >10 mmol/L) is associated with an increased risk of acute pancreatitis
• drugtherapy(lowersriskforpancreatitis,notCAD) ■ nicotinic acid
■ fibrates
Exercise
Table 6. Canadian Physical Activity and Sedentary Behaviour Guidelines (2012 CSEP Guidelines)
Risk Factor
TG level HDL-C level:
Men
Women
Blood pressure Fasting glucose level
Defining Level
≥1.7 mmol/L (150 mg/dL) <1.0 mmol/L (40 mg/dL)
<1.3 mmol/L (50 mg/dL) ≥130/85 mmHg
≥5.6 mmol/L (100 mg/dL)
Statin-Related Adverse Events: A Meta-Analysis
Clin Ther 2006;28:26-35
Purpose: To synthesize adverse event (AE) data with statin use based on RCT data.
Methods: Meta-analysis of RCTs focused on adverse effects of statins. Eligible patients were those taking statin monotherapy for primary or secondary prevention of CVD, compared to placebo. AEs including elevated liver enzymes or myopathy (myalgias, elevated CK, rhabdomyolysis) were the main outcomes.
Results: Statin therapy increased the risk of any AE by 39% (OR 1.4; 95% CI 1.09-1.80; p=0.008) compared with placebo. Treating 1,000 patients with a statin would cause 5 AE. Serious events
(CK >10 times the upper limit of normal or rhabdomyolysis) are infrequent (NNH 3,400) and rhabdomyolysis, although serious, is rare (NNH 7,428).
Conclusion: Statin therapy was associated with greater odds of AEs compared with placebo but with substantial clinical benefit. Similar rates of serious AEs were observed between statin and placebo.
Age Category
Infant (<1)
Toddler (1-2) and
Preschool (2-4)
Children (5-11) and
Youth (12-17)
Adults (18-64)
Older Adults
(≥65)
Physical Activity Guidelines
Active several times daily
Accumulate 180 min of physical activity at any intensity spread throughout the day
Accumulate 60 min of moderate to vigorous intensity physical activity daily
Vigorous intensity activities at least 3 d/wk
Activities that strengthen muscle and bone at least 3 d/wk
Accumulate 150 min of moderate to vigorous intensity aerobic physical activity per wk, in bouts of 10 min or more. It is beneficial to add muscle and bone strengthening activities using major muscle groups, at least 2 d/wk
Same as Adults above
Example Activities
Interactive floor-based play including tummy time, reaching for toys, crawling
Moving around the home Climbing stairs
Exploring environment
Brisk walking, running, dancing
Moderate: bike riding, playground Vigorous: running, swimming
Moderate: brisk walking, bike riding Vigorous: jogging, cross country skiing
Same as Adults above
Those with poor mobility should perform physical activities to enhance balance and prevent falls
Sedentary Behaviour Guidelines
Minimize time spent sedentary, including sitting and being restrained (stroller, etc.)
Screen time not recommended for infants <1 yr, limit to <1 h/d ages 2-4
Minimize time spent sedentary, including sitting and being restrained (stroller, etc.)
Screen time limit to <1 h/d
Minimize time spent being sedentary Limited recreational screen time to 2 h/d Limit sedentary (motorized) transport, sitting, and time spent indoors
No specific guidelines
No specific guidelines