Preventing Progression to ASCVD and T2D: An Endocrine Society Guideline

To guide clinicians in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (T2D) in high-risk patients, the Endocrine Society published new clinical practice guidelines in The Journal of Clinical Endocrinology & Metabolism, cosponsored by the American Diabetes Association and the European Society of Endocrinology.

The update follows the Society’s 2008 ASCVD prevention guidelines and, based on newer published literature, includes major changes to definitions of metabolic risk and recommendations for diabetes screening, lipid lowering goals, and diet and exercise.

Screening for Metabolic Risk

To initiate early intervention and combat the increasing prevalence of ASCVD and T2D, it is important that clinicians be able to identify patients at high metabolic risk.

Healthcare providers should screen for metabolic risk at clinical visits. For a population aged 40 to 75 years, the guidelines define metabolic risk as the presence of ≥3 of the following risk factors:

• Increased waist circumference (≥102 cm in men and ≥88 cm in women; for East Asian or South Asian patients, ≥90 cm in men and ≥80 cm in women)
• Elevated fasting triglyceride level (≥150 mg/dL or receipt of triglyceride therapy)
• Low high-density lipoprotein cholesterol (HDL-C) level (<40 mg/dL for men, <50 mg/dL for women, or receipt of HDL-C therapy)
• Hypertension (systolic blood pressure ≥130 mm Hg, diastolic blood pressure ≥80 mm Hg, or receipt of antihypertensive therapy)
• Hyperglycemia (defined as one of the following: fasting glucose level between ≥100 mg/dL and <126 mg/dL; 2-hour oral glucose tolerance test result between ≥140 mg/dL and <200 mg/dL; hemoglobin A1c level ≥5.7%-6.4%; or receipt of glucose-lowering therapy without a diabetes diagnosis)

Patients at high metabolic risk should undergo regular screening, while patients with 1 or 2 risk factors should undergo screening every 3 years for all 5 components defined above. For patients with prediabetes, screening for T2D should occur at least annually.

The guidelines focus on individuals aged 40 to 75 years given a higher quality of evidence from published literature, but the recommendations can apply to other age groups, particularly younger patients.

According to the guidelines, waist circumference should be measured as part of clinical examination to establish metabolic risk in the general population. Placement for measuring tape to measure waist circumference is demonstrated by a figure from the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report.

Lifestyle and Behavioral Therapy

Clinicians should use lifestyle intervention as first-line therapy in patients with high metabolic risk, encouraging a healthy lifestyle with moderate but sustained weight loss. For patients with excess weight, the Society recommends the adoption of a weight loss goal of ≥5% of initial body weight within the first year.

Prescription of daily physical activity and reduction of sedentary time is recommended for patients at metabolic risk. Structured activity programs led by exercise specialists may be appropriate for some individuals.

The Society also recommends that clinicians prescribe a cardiovascular-healthy diet. This translates to a diet rich in vegetables, fruits, whole grains, nuts, legumes, unsaturated oils, low-fat dairy, poultry, and fish; moderate in alcohol; and low in red and processed meat, high-fat dairy, sodium, and sugar-sweetened foods and beverages.

Based on research investigating dietary changes and lipid profiles, additional recommendations include a diet low in saturated fats (meat, dairy) and trans fats (margarines, snack foods), and rich in monounsaturated and polyunsaturated fatty acids and fiber-rich whole grain carbohydrates.

The guideline authors noted that evidence supporting dietary changes can be difficult to translate into clinical practice in terms that patients understand. Support from nutrition specialists and/or primary care providers can aid in the implementation of diet plans.

Other lifestyle areas to assess and potentially modify are tobacco use, sleep disorders, and stress. Psychological support, such as the 5 As approach to smoking cessation, can be highly beneficial to patients who smoke and may be available remotely to individuals who lack access to in-person programs. Clinicians should screen for sleep apnea when suspected, as it is a common comorbidity in those with metabolic disorders. Stress management interventions may also be useful for secondary prevention of ASCVD.