Managing Cardiometabolic Risk in Abdominally Obese Patients

Despite evidence that visceral obesity is the most dangerous form of obesity, no study has shown that reducing visceral adipose tissue reduces the risk of cardiovascular outcomes and type 2 diabetes. However, the data available suggests that, regardless of the therapy used (diet, exercise), visceral fat generally decreases when patients with large amounts of this fat lose weight. Although randomized trials with hard endpoints are required to test this hypothesis, a selective reduction of visceral fat has been shown to improve metabolic markers predictive of type 2 diabetes and CHD risk.

Studies have shown that making dietary changes and limiting calorie intake can induce weight loss. The challenge now is to use this knowledge in clinical practice. Most physicians have limited access to additional nutritional expertise to help them reshape the nutritional habits of their patients. The same applies to reshaping exercise habits and prescribing physical activities. Although many studies have shown that regular exercise has a beneficial effect on numerous type 2 diabetes and cardiovascular disease risk factors, few studies have addressed how primary care physicians can implement a lifestyle modification program in the context of a busy clinical practice. However, trials such as the Finnish Diabetes Prevention Study and the American Diabetes Prevention Program have both demonstrated the relevance and value of a lifestyle modification program intended to turn sedentary, abdominally obese, and glucose-intolerant subjects (who are at high risk of type 2 diabetes) into physically active individuals with better nutritional habits. But to successfully lower the risk of diabetes, physicians must be able to refer patients to a multidisciplinary team of dietitians, exercise physiologists, and behaviourists. The move from theory to practice must be made to support patients in their attempts to improve their lifestyle. Providing a supportive, professional environment will enhance the effect of weight loss pharmacotherapy and optimize improvements to cardiometabolic risk factors/markers.

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Key Points
Tips on how to eat/live healthy:

• Eat more vegetables. They are rich in nutrients and low in calories.
  Make wholegrain breads and cereals that contain soluble fibre—such as those made with oats—part of every meal.
• Eat more high-fibre foods (wholegrain cereals, lentils, dried beans and peas, brown rice, vegetables, and fruits).
• Enjoy soy products (soy milk, burgers, and hot dogs), nuts (almonds and walnuts), and pulses (dried beans, peas, lentils, and peanuts) as snacks or alternatives to high-fat meats.
• Include fish, lean meats, low-fat cheeses, eggs, or vegetarian protein choices in your meals.
• Have a glass of low-fat milk and piece of fruit to complete your meal.
• Limit your intake of high-fat food such as fried foods, chips, and pastries.
• Limit sugars and sweets such as sugar, regular soft drinks, desserts, candies, jam, and honey.
• Limit your intake of sweetened drinks (soft drinks, juice, etc.), which are sources of excess calories.
• Drink more water if you are thirsty.
• Make physical activity part of your lifestyle.

Read more on Nutrition.

—THIS EBOOK IS UNDER REVISION—
Key Points

• Physical inactivity is the most common cardiometabolic risk factor and the easiest one to eliminate.
• Up to 60 minutes of moderate-intensity endurance exercise on most days of the week can significantly reduce abdominal fat, visceral fat in particular (~30%).
• Both an acute bout of exercise and chronic endurance exercise can significantly improve insulin sensitivity. The effect is equal to or greater than that achieved with pharmacotherapy (~20% improvement with acute and 30-85% improvement with chronic exercise).
• Regular endurance exercise can lead to modest but significant improvements in HDL cholesterol (~5%) and triglyceride (~15%) levels. It has less of an effect on LDL cholesterol levels. The lack of change in LDL cholesterol may be misleading, as physical activity can produce a beneficial increase in LDL particle size from small to large.
• While regular, moderate-intensity endurance exercise can reduce the risk of cardiovascular events by improving an individual’s hemostatic and fibrinolytic profile, intense acute exercise may trigger myocardial infarction, especially in at-risk individuals, by inducing a hypercoaguable state.
• Endurance exercise has consistently been shown to modestly reduce both systolic and diastolic blood pressure by ~4 mmHg in lean, overweight, hypertensive, and normotensive patients.
• Although acute exercise can cause elevated systemic inflammation, regular endurance exercise of fairly vigorous intensity appears to reduce levels of inflammatory markers by ~30%.
• Although the metabolic improvements achieved through regular endurance exercise are generally greater when body weight is reduced, increasing physical activity can dramatically improve visceral fat, insulin resistance, lipid levels, and blood pressure, even when body weight does not change.

Read more on Physical Activity and Exercise.