|By Bonnie Darves
NEW ORLEANS, LA -- April 27, 2004 -- The emerging twin epidemics of obesity and diabetes in the United States are a call to action for physicians treating patients who have modifiable risk factors for heart and cardiovascular disease, and time is running out to reverse the disturbing trend, according to Robert Bonow, MD, chief of cardiology, Northwestern University, Chicago, Illinois.
In his cardiology update here on April 23rd at the American College of Physicians - American Society of Internal Medicine Annual Session, Dr. Bonow urged internists to take a more active role in counseling patients who either have heart disease or who may soon develop it based on their lifestyle.
The key issue now is that the epidemic of cardiovascular disease related to obesity and diabetes is only beginning to emerge. "We've made great strides in public education and prevention of heart disease, which have contributed to longer lifespan, but those statistics are misleading because our population has gotten bigger and older," he said. He noted that data from 1950 to 2000 show no real reductions in mortality form cardiovascular disease and stroke, and that more than 2,600 Americans die from this disease each day.
"It is important to remember that more than 150 of those [deaths] occur in people under age 65 and a quarter million deaths [annually] occur before hospitalization," he said.
What is occurring, he explained, is a balancing act of sorts that is not likely to work out well with regard to heart disease. Since 1997, the good news is that coronary artery disease (CAD) mortality decreased by 4.5% and cholesterol decreased by 14%; but hypertension incidence increased by 18% and obesity by 8%―a clear indication of trouble ahead, Dr. Bonow noted.
Although confusion and a certain amount of controversy exist over the true rate of obesity in the UnitedStates, Dr. Bonow said the key point to remember is that the increase is occurring rapidly. A 2003 survey-based study in published in the Journal of the American Medical Association involving 195,000 found an obesity rate of 20.9% (289(1):76-79), but the fact that the data was self-reported likely means the numbers may be much higher, Dr. Bonow said. Other recent studies have found rates as high as 35%, he said.
"No matter which figure we want to argue, we have a real problem that more [physicians] will address," he said. "If we plot [body mass index] … it's clear that within a year or 2 obesity will become the leading preventable risk factor that leads to cardiovascular death and other forms of mortality. It's going to overtake tobacco."
The upshot, he said, is that more cardiologists and internists need to focus on this distressing trend as they approach patients who have lifestyle issues. Studies of congestive heart failure indicate that 25% of patients with CHF have diabetes, he noted. "So if the national presence [of diabetes] is 8.4%, clearly diabetes is contributing to the heart failure epidemic we're facing as well," he said. He urged physicians to talk to patients about increasing exercise and physical activity and improving diet, and indicated that many patients are likely to be receptive to such discussions.
The confounding issue, however, is that there is little data on diet to provide a supporting framework for such discussions. "No question is asked more often of physicians, especially cardiologists, than 'what should I be eating to prevent heart disease?' The issue is that physicians don't have good data with which to make recommendations," Dr. Bonow said, adding that no controlled studies have focused on the low-carbohydrate diets that have been so heavily touted in the lay press. The only good data available show the benefits of a low-fat diet, he said, suggesting that physicians should focus diet-related discussions on reduction of calorie intake.
[Presentation Title: Update in Cardiology.]