Nutrition and Physical Activity: The ‘Low-Hanging Fruit’ for Cardiologists Programmed to Prescribe Pills

INNSBRUCK, Austria—The complexity of maintaining cardiometabolic health through diet and exercise has now eclipsed part of the stage previously reserved for pharmacotherapy, according to European experts who convened last week at the European Atherosclerosis Society (EAS) 2016 Congress.

After a standing room-only session on the topic, presenter and co-moderator Jean Pierre Després, PhD (Laval University, Quebec City, Canada), told TCTMD the crowd was “really a sign of the times.” As recently as 15 years ago, the focus of the EAS was solely on cholesterol, he said, and now all involved have “a better understanding that there are other things . . . we need to pay attention to—very simple, basic issues: the way we eat and being physically active.”

Després said he has seen a trend toward greater recognition of cardiometabolic health overall in his 30-year career. This is partly due to the “explosion of sedentary behavior” and “people [who] are treating their mouths like a garbage can” around the world, he suggested. “As a consequence [of these behaviors], we have this epidemic of obesity and type 2 diabetes.”

Hence the significance of a session like this at an international meeting of atherosclerosis experts, Després said. While many of the world’s top researchers have earnestly devoted their careers to making practice-changing strides in pharmacotherapy, all of the presenters at EAS 2016 stressed the importance of physicians incorporating more basic approaches to caring for their patients—such as diet and exercise counseling.

In his presentation, Després stressed that while smoking is “of course” a bigger risk factor for heart disease than physical inactivity, “because there are more physically inactive people than smokers, inactivity is [now leading] to more deaths than smoking.”

He cited a 2013 Canadian study showing that less than one-third and one-fifth of physicians even raise the issues of nutrition and physical activity, respectively, with their patients regardless of diabetes status. US research has produced similar estimates. “This is not rocket science,” he stressed. “There is low-hanging fruit out there.”

Després also pointed out that enough evidence exists to support the notion that “fitness is a lot more important than weight.” For example, there is a “very linear” relationship between waist circumference and cardiometabolic health, he said, adding that, “If you don’t measure waist circumference, you are not a very good doctor.”

But the issue still remains that physicians don’t have the means to quantitatively measure improvements in cardiometabolic health, Després said. “It’s one thing to say nutrition is important, physical activity is important, but can we develop very, very simple tools that at the end of the day are going to be used in clinical practice?” he asked. “You can be as sophisticated as you want about nutrition, but if it’s not implemented in clinical practice, then what’s the point?”

Physicians should be petitioning cardiology societies for these tools, he concluded, adding that “it’s not that expensive,” especially as compared with the economic pressure healthcare is putting on governments worldwide.

Can One Be Healthy and Obese at the Same Time?

In another presentation, Luc Van Gaal, MD, PhD (Antwerp University Hospital, Belgium), sought to answer the question of whether the metabolically healthy obese phenotype exists and what that means for physicians trying to combat the larger issue of global cardiometabolic health.

Given that several studies have demonstrated an obesity paradox where better cardiac outcomes are seen in patients with higher BMIs, Van Gaal said it is likely that those most protected are those who fall in the “metabolically healthy obese” category. While these people are obviously obese (BMI ≥ 30 kg/m²), he explained, they also usually have a normal cardiovascular disease risk profile and normal insulin sensitivity. Their prevalence ranges from 2-28% of obese people in most European countries, Van Gaal estimated.

He highlighted the importance of paying attention to fat types because those labeled as metabolically healthy obese usually have low visceral fat mass. This phenotype is also associated with larger fat cells, Van Gaal said.

And while these patients might be considered metabolically healthy, whether they are actually healthy is the key unanswered question. Until more studies can be done on this population, all that is known now is that they benefit from “partial protection” from cardiovascular events, Van Gaal concluded. Until more is learned, physicians should pay close attention to these patients and treat them with caution. However, obesity is still obesity, and these patients should receive counselling on diet and exercise in order to prevent a multitude of complications down the line, he stressed.

Nutrition the Heart of the Issue

At the heart of the entire issue is nutrition, said Vasanti Malik, ScD (Harvard University, Cambridge, MA), in a separate presentation in the cardiometabolic risk session. Echoing the other presenters, she said that while blood pressure, BMI, glucose, and cholesterol are all important risk factors that need to be managed appropriately, diet is the only one that can be easily modified by the patient.

Malik explained that her research focus is on translating nutrition into clinical practice. “[Després] made the critical point that doctors need to be talking to their patients about diet,” she said. To give those conversations some heft, “nutritional epidemiologists need to generate the science.”

There is “ample evidence” that it is beneficial to consume whole grains over refined grains, Malik said, but the current focus has turned to sugar and saturated fat. She said she supports the initiatives many governments are taking to try and include added sugars on nutritional labels, especially since sugar-sweetened beverages have become the number one source of added sugar in the diets of many across the globe.

Malik also called out the media for perpetuating misinformation about nutrition. Like other presenters in this year’s EAS program, Malik ridiculed 2014 New York Times “Butter Is Back” headline.

Lastly, she urged researchers to do a better job of distinguishing between “healthy and unhealthy plant-based foods” so that people have a more reliable way of knowing whether foods they eat are good or bad for them.

According to Després, it will be “a long and winding road” to increase the overall cardiometabolic health of the world. But aggressive management of diet and exercise by physicians, new research on obesity and heart disease, and further investigation into optimal nutrition seem to be what’s needed to help move us closer.

Tending to lifestyle issues should be the “cornerstone” of patient management, Després stressed, but most physicians only treat the “classical risk factors,” such as cholesterol, blood pressure, and diabetes. While not denying the efficacy of traditional pharmacotherapeutic options for primary and secondary prevention, he called on physicians to increase the time and emphasis given to behavior modification with their patients.