Istanbul, Turkey - Waist circumference, not unlike previous fights against high cholesterol levels, is the new battle of the 21st century, declared Dr Jean-Pierre Després (Université Laval, Quebec City, QC), lead investigator of an ongoing lifestyle-modification study, and clinicians must go beyond body weight to truly improve the risk-factor profile of their high-risk, abdominally obese patients.

Speaking here at the 77th European Atherosclerosis Society Congress, Després presented the interim results of the SYNERGIE trial, "a simple study" designed to assess the clinical benefits of getting obese men with features of the metabolic syndrome to regularly consult with a dietician and kinesiologist to modify their diet and exercise habits with the intention of reducing their cardiometabolic risk [1].

"I think we have made remarkable improvements, at least in many countries around the world, in the battle against smoking, high cholesterol levels, and other risk factors," said Després, also noting that clinicians have a nearly full pharmacological armamentarium for the battle against hypertension and atherosclerosis. "But unfortunately, we still have big waistlines with abdominal obesity and type 2 diabetes. This will cause [problems] for us to keep the risk of cardiovascular disease low."

Speaking with the media during a press conference announcing the one-year SYNERGIE findings, Després said there is a need for greater concern about how patients are putting on weight. Among subjects who are equally overweight, those with more abdominal cavity fat, or visceral adipose tissue, compared with those with excessive subcutaneous adipose tissue, are at greater risk for cardiovascular disease. Waist-circumference measures, a crude, but simple measure of abdominal fat, could measure this risk factor, yet only about 25% of clinicians actually take the measurement, instead preferring to rely on the deceptive body-mass index.

The purpose of SYNERGIE, explained Després, was to determine whether monthly visits to a dietician and kinesiologist could reduce visceral fat, as well as other components of the metabolic syndrome. Dieticians worked with participants to modify diet around healthy patient preferences, rather than dictate foods they were unlikely to eat, and kinesiologists tried to get them physically active in a way suited to their lifestyle. "Our goal was not to turn them into marathon runners," said Després.

Investigators included patients with waist circumferences >90 cm, triglycerides >150 mg/dL, and HDL cholesterol levels <40 mg/dL, and, after screening with an oral glucose-tolerance test, excluded patients with diabetes mellitus. In total, 144 patients were randomized to the lifestyle-intervention program and 26 patients to usual clinical care. About 40% of those screened had impaired glucose tolerance and were included in randomization.

The SYNERGIE investigators showed that the lifestyle-modification program resulted in significant improvements in many components of the metabolic syndrome. Compared with baseline, plasma triglyceride levels were down significantly and HDL-cholesterol levels were increased. Apolipoprotein B and important cholesterol ratios also improved among those randomized to the lifestyle program, as did the size of LDL-cholesterol particles and markers of inflammation. In terms of their physical health, more patients in the lifestyle arm were exercising, with noted improvements in physical working capacity measured on the treadmill and various heart-rate measures.

Importantly, waist circumferences decreased approximately 9 cm with lifestyle modification, even though body weight remained unchanged in some patients. However, computed tomography analyses showed that the distribution of fat was significantly altered in patients randomized to see a dietician and kinesiologist. Visceral fat was cut by more than half at one year, reported Després.

Speaking with the media, Després said that most patients are willing, at least in the doctor's office, to change their eating and exercise habits but find it very difficult once they return to the "toxic jungle" of the real world, a world where, in Canada at least, French fries are the most consumed food and the average individual watches five to six hours of television daily. "Prevention could work, but we have to do more than say to our patients, you should exercise and you should diet, because if those poor patients aren't getting any support or any help, it will not work," he said.

The cost of seeing a dietician and kinesiologist once per month is approximately $1000 per year, a number that is affordable considering the tremendous cardiometabolic benefit. Interestingly, Després noted that patients in the usual-care treatment arm reported reducing caloric intakes over the course of the year, telling investigators they cut more than 500 kcal daily from their diet. The patients, Després told heartwire, had no real concept of what or how much they were eating, as such reductions would have translated in significant reductions in body weight, which did not occur. "If they tell you they are eating healthy, they're lying," he said. Most diabetes' clinics, he noted, require patients to come in only twice per year, a level of monitoring that is insufficient.

Source

1) Després JP on behalf of the SYNERGIE investigators. Lifestyle management of abdominal obesity and related cardiometabolic risk: the SYNERGIE trial. 77th European Atherosclerosis Society Congress; April 27, 2008; Istanbul, Turkey.