The Great Debate: Which Nutritional Plan is Best for Your Patient?
The 3rd Annual CMHC West: Advancing Cardiometabolic Health from East to West was held in Phoenix, AZ, May 3-5, 2019 and focused on the multi-disciplinary prevention and management of cardiometabolic diseases, and chaired by top experts: Christie M. Ballantyne, MD; Ken Fujioka, MD; George L. Bakris, MD; and Jay S. Skyler, MD. Here are some highlights from the meeting:
The Great Debate: Which Nutritional Plan is Best for Your Patient?
Nutrition is a critical aspect of cardiometabolic health, however, due to the lack of formal and continuing education training that clinicians receive on nutrition, most clinicians do not adequately address this topic with their patients. Furthermore, there are many controversies as to what optimal nutritional plans consist of, leaving clinicians more puzzled about how to approach nutrition counseling in clinical practice.
In this two-part session, expert faculty Alice H. Lichtenstein, D.Sc, Andrew M. Freeman, MD, and Kim A. Williams, Sr., MD took on this challenging and important topic, which generated a lot of questions from the audience. Dr. Lichtenstein advocated for the promotion of common elements that promote cardiometabolic health without focusing on a specific dietary approach. These included eating a diet rich in fruits, vegetables, plant-based proteins, fish, lean meats and to limit sugar beverages and dietary cholesterol intake. Dr. Freeman reviewed the negative impacts of animal protein on heart disease and atherosclerosis, and advocated for plant-based diets to improve cardiometabolic health in his talk titled “Diet, Lifestyle, and CVD: It’s Time to Make Changes.” Dr. Williams, in his talk “Nutrition and Heart Disease: Taking the DIE out of Your DIET”, took this concept further and mentioned that “there are no generally safe animal products for those with cardiac risk factors”. Furthermore, “plant-based and vegetarian diets are associated with less hypertension, diabetes, dyslipidemia, heart failure, stroke and death”, Dr. Williams said.
Keynote: The Special Diabetes Program for Indians: A current and Future Legacy
The venue location—on the Gila River Indian Community, home to the Pima and Maricopa tribes-- and the important role that Native Americans have played in the overall study of diabetes etiology, provided an ideal prelude to the keynote address, delivered by Spero M. Manson, Ph.D., a Distinguished Professor of Public Health & Psychiatry at the Colorado School of Public Health. A renowned researcher of native communities, Dr. Manson presented on the challenges in managing type 2 diabetes in native populations and shared the lessons learned through more than 20 years of experience from the Special Diabetes Program for Indians, including the importance of building upon local, social, and cultural dynamics to enhance recruitment and retention, as well as optimize outcomes.
Updated Lipid Guidelines: What Do They Mean for Clinical Practice?
Salim S. Virani, MD, PhD, FACC, FAHA, Associate Professor of Cardiology at Baylor College of Medicine in Houston, TX and co-author of the 2018 ACC/AHA cholesterol guidelines reviewed the basic principles of lipid management as outlined in the updated document. Dr. Virani extracted key messages for both primary and secondary cardiovascular prevention. He emphasized a practical approach for primary prevention—“we need to calculate ASCVD risk, personalize our approach by overviewing common risk enhancers and having a discussion with the patient prior to treatment initiation, and when a risk decision is uncertain, reclassify a patient’s risk by using coronary artery calcium score to identify the most likely individuals to benefit from lipid-lowering therapy.” Emphasizing a heart-healthy lifestyle and treating patients with LDL-C ≥190 mg/dL and those with diabetes early and aggressively were some other key messages for primary prevention. For secondary prevention, Dr. Virani overviewed the “very high-risk ASCVD group” among secondary prevention patients who are most likely to benefit from the use of non-statin therapies, such as PCSK9 inhibitors. He further mentioned that, in this group, “statin use and emphasis on statin adherence remains the first step before step-wise addition of ezetimibe or a PCSK9 inhibitor.”
The Story Continues: Heart Failure and Type 2 Diabetes
There is a strong association between heart failure (HF) and type 2 diabetes (T2D); they often coexist,
and patients with T2D and HF are at a greater risk for HF-related hospitalizations, as well as all-cause
and cardiovascular-related mortality. The link between HF and T2D has also been emphasized in the
latest cardiovascular outcome trials (CVOTs) of newer diabetes drugs. Specifically, sodium-glucose co-transporter-2 (SGLT-2) inhibitors have demonstrated they can reduce HF hospitalizations in patients with T2D and established cardiovascular disease. During his talk, Matthew R. Weir, MD, Professor and Chief of Nephrology at the University of Maryland School of Medicine, emphasized the connection between these conditions and the emerging role of SGLT-2 inhibitors in HF prevention for this high-risk population. In overviewing the effects of newer diabetes drugs on HF outcomes from recent CVOT studies, including DPP-4 inhibitors and GLP-1 RAs, Dr. Weir focused on the strong effects on HF outcomes observed with SGLT-2 inhibitors empagliflozin, canagliflozin, and dapagliflozin. “The consistency of HF benefits with SGLT-2 inhibitors begs more importance from the cardiovascular community”, Dr. Weir mentioned, but clinicians should also pay attention to optimizing current guideline-directed medical therapy since “most RAAS inhibitors are under-utilized or under-dosed in patients with heart failure and chronic kidney disease”. While postulating on the potential mechanisms of action for the observed HF benefits with this agent class, Dr. Weir said that “we must now move beyond serendipity to expand precision-based approached in order to target heart failure, which is an expanding and ominous disease process with multiple pathophysiologic processes.”
Women’s Health Summit: Navigating Female Cardiometabolic Care
The increasing prevalence of metabolic syndrome and associated comorbidities, such as cardiovascular disease, obesity, and type 2 diabetes means that these conditions are becoming more common in women of reproductive age and beyond. In addition to traditional cardiometabolic risk factors, women have additional risk factors, such as adverse pregnancy outcomes and polycystic ovarian syndrome (PCOS). The Women’s Health Summit, chaired by Pamela B. Morris, MD, expert on female cardiovascular risk and co-director of the Women’s Heart Care Program at the Medical University of South Carolina, explored the unique challenges faced by women in cardiometabolic health. Conversations on specific cardiometabolic risk enhancers in women—PCOS, adverse pregnancy outcomes, and postmenopausal hormone therapy were covered by expert faculty Andrea Dunaif, MD, Pam R. Taub, MD, FACC, and Cynthia Stuenkel, MD, respectively. Comprehensive CVD risk assessment in women was presented by Salim S. Virani, MD, Phd, who candidly reminded the audience that “statin therapy works in women as well as it does in men.” Ralph LaForge, MSc, FNLA, CLS, focused on addressing cardiometabolic risk in American Indian and Alaska native women, a population that “is disproportionally affected by gestational diabetes mellitus”, he noted. The intersection between breast cancer and cardiovascular disease was covered by Bonnie Ky, MD, MSCE, who overviewed the adverse CV events from common cancer therapies and how to address this increased risk in patients undergoing cancer treatment or in cancer survivors. Deepak L. Bhatt, MD, MPH, overviewed the role of aspirin therapy for CVD prevention in women in light of recent clinical trials. The summit was concluded with a power presentation by Anne L. Peters, MD, on how diabetes affects women’s quality of life.
