M.S. Weintraub

The metabolic fitness program: lifestyle modification for the metabolic syndrome using the resources of cardiac rehabilitation.

PURPOSE: To describe and assess the effectiveness of a lifestyle intervention program (Met Fit) designed to treat the metabolic syndrome (MetSyn) in a cardiac rehabilitation setting. METHODS: Met Fit is a physician referred and patient pay (

Assessing the incremental benefit of an extended duration lifestyle intervention for the components of the metabolic syndrome

350) program consisting of 12 weekly sessions of 45 minutes of exercise and 45 minutes of education with target exercise recommendations of 150 to 200 minutes weekly and 5% loss in body weight using a Mediterranean-style diet. Primary outcomes are compliance with program recommendations and secondary outcomes effecting MetSyn components. RESULTS: Patients (N = 126) were enrolled between June 2005 and July 2009 averaging 9 per class. Mean (SD) age was 51(12) years, body mass index 38(6.9) kg/m2, high density lipoprotein-cholesterol for men 37(9.4) mg/dL and women 46(10) mg/dL, glucose 121(39) mg/dL, and homeostatic model assessment of insulin resistance 7.2(6.1). For the 93 (73.8%) patients for whom there was complete data, mean weight loss was 6.2(6.9) kg, 63.4% lost at least 4 kg, and 19.4% lost more than 5% of weight. Significant reductions were observed in the waist circumference and body fat, and systolic and diastolic blood pressure. Triglycerides decreased significantly in both diabetics and nondiabetics but glucose decreased significantly only in diabetics. At baseline, 51% had evidence of depression, which decreased to 24.7% at 12 weeks. At program completion, 18 patients (19.4%) no longer had the MetSyn and 39 (41.9%) lost at least 1 criterion (P < .0001). CONCLUSIONS: A 12-week patient-pay lifestyle interventional program conducted in a cardiac rehabilitation setting can result in a highly significant benefit to patients with the MetSyn.

The Lipid Management Nutrition Outcomes Project: Perspectives from a National Experience in Protocol Implementation and Nutrition Outcomes Tracking

Background Lifestyle interventions targeting the components of the metabolic syndrome (MetSyn) have been demonstrated to be a cost-effective and suitable treatment strategy for reducing one’s risk of developing coronary artery disease and diabetes. The optimal duration has not yet been defined. We sought to evaluate the incremental benefit of extending a lifestyle intervention from 3 months to 6 months. Methods We evaluated 114 participants with at least three criteria for the MetSyn in a physician-referred 6-month lifestyle intervention between August 2008 and December 2012. Baseline and follow-up physiological, biochemical, and anthropometric data were analyzed for mean change and incremental change at each time point. Results The mean age at enrollment was 53.0±10.2 years, and 42% of participants were males. The mean body mass index at enrollment was 38.2±0.86 kg/m2 for males and 38.6±0.93 kg/m2 for females. Anthropometric measures associated with weight management (body mass index, weight, and body fat percentage) improved significantly with the additional 3-month intervention (P<0.001). Systolic blood pressure (P=0.0001) and diastolic blood pressure (P=0.00006) and triglycerides, fasting blood glucose, and homeostatic model assessment of insulin resistance in diabetic participants (P=0.006, P=0.004, P=0.01, respectively) improved rapidly in the initial 3-month intervention without incremental benefit of the additional 3 months. Improvements in fasting insulin (P=0.01) and homeostatic model assessment of insulin resistance (P=0.02) for nondiabetic participants required the full 6-month intervention before significant reductions were achieved. Conclusion A 6-month lifestyle intervention yielded significantly better results for variables related to weight management. Standard physiological measures for the MetSyn respond rapidly in a 3-month lifestyle intervention. The long-term impact of an increased duration lifestyle intervention remains to be seen.

Medical nutrition therapy is the essential cornerstone for effective treatment of “refractory” severe hypertriglyceridemia regardless of pharmaceutical treatment: Evidence from a Lipid Management Program

The Lipid Management Nutrition Outcomes Project was a multicenter prospective noncontrolled observational study in which a network of 51 registered dietitians (RDs) from practice settings across the United States implemented the 1998 Medical Nutrition Therapy Hyperlipidemia Protocol and collected outcomes. Difficulty recruiting RDs and enrolling patients revealed a gap between practice guidelines and clinical practice. Many RDs did not have laboratory values or follow-up visits required by the protocol. RDs able to follow protocol recommendations had the expected positive results. Within a 6-month period, 377 new patients presenting for lipid management met inclusion/exclusion criteria. Some follow-up data were available on 280 (74.3%) patients. There were follow-up lipid data prior to lipid-lowering medication changes for 219 patients. Reported mean dietary fat intake was reduced to <30% (P<0.0001). The population lost weight and increased exercise frequency (P<0.001, P<0.001). In the 175 patients with initial triglycerides <400 mg/dL (4.52 mmol/L), 44.6% had either a 15% drop in low-density lipoprotein cholesterol or reached low-density lipoprotein cholesterol goal. Lipid response occurred in 34.7+/-16.5 weeks with 3.0+/-1.4 RD visits. The Lipid Management Nutrition Outcomes Project highlights frustrations and values of outcomes monitoring in actual practice and identifies areas for practice advancement.

Dietary Intake and Psychological Assessment of Patients Entering Phase II Cardiac Rehabilitation

BACKGROUND Patients with refractory severe hypertriglyceridemia are at risk of pancreatitis and cardiovascular disease. The role of individualized nutrition therapy in these patients independent of pharmaceutical treatment has not been documented. OBJECTIVE To document the effect of nutrition intervention on severe hypertriglyceridemia regardless of medication status or prior nutrition counseling. METHODS Outcomes of new patients with triglycerides ≥ 500 mg/dL presenting to a Lipid Management Program over a 6-year period were tracked. Patients received comprehensive laboratory assessment, nutrition assessment, and initiation of an individualized diet intervention before seeing the lipidologist. Clinical and behavioral outcomes were recorded. RESULTS In all, 168 patients (117 men; mean age, 49.03 ± 11.22 years; body mass index, 32.61 ± 5.85 kg/m(2); 110 (65.5%) on lipid-lowering medications) returned for assessment of nutrition intervention. Triglycerides were reduced from median (interquartile range) 961.5 (611.5-1785.3) to 493.0 (337-736.3) mg/dL (P < .0001 for log transformation of triglycerides). There was no difference in median percentage reduction in triglycerides after nutrition intervention between those not on lipid-lowering medication, on a fibric acid derivative, on other lipid-lowering medication, or on a combination of lipid-lowering medications (P = .376) in a median (interquartile range) of 5 (3-7) weeks. Effect was independent of prior nutrition counseling (P = .260). Reported percentage fat in the diet at second visit correlated with log-transformed triglycerides achieved, independent of initial triglycerides level (r = 0.290; P = .001). CONCLUSIONS Individualized nutrition therapy results in changes in eating behavior and reductions in triglyceride levels in patients with refractory severe hypertriglyceridemia independent of lipid-lowering medication(s) and prior nutrition counseling.

Effectiveness of medical nutrition therapy for hyperlipidemia in a state-wide study

Abstract LEARNING OUTCOME: To describe dietary intake and psychological status of patients entering Phase II cardiac rehabilitation. Assessment of nutritional intake and psychological status at entry to a Phase II Cardiac Rehabilitation program can aid in individualization of the program. In addition to physical assessment, baseline dietary and psychological assessments were performed on 22 consecutive patients entering cardiac rehabilitation over a seven week period. Dietary intake was assessed using the Diet Habit Survey (S. L. Connor et. al.) to evaluate eating behavior during the previous month and using three-day food records to evaluate recent intake. Food records were reviewed and analyzed using Food Processor 6.11 (ESHA Research). Psychological status was assessed using the SCL-90-R (L.R. Derogatis). The participants included 14 males and 8 females with mean age of 62±10 and 65±9 years, respectively. Seventy-one percent of the males and 50 percent of females had BMIs greater than 27. Fifty-nine percent of patients reported modifying their dietary intake after their coronary event and prior to entering the program. The Diet Habit Survey indicated that 13.6% of the participants consumed 37% or more kilocalories as fat; 36.4% consumed 30% kilocalories as fat; 36.4% consumed 25% kilocalories as fat; and 13.6% consumed 20% kilocalories as fat. Mean daily intake from food records was 1700±480 kilocalories, 60.6±8.2% kilocalories as carbohydrate, 17.6±3.3% kilocalories as protein, and 20.9±2.9% kilocalories as fat. Food records revealed specific dietary deficiencies and excesses. Thirty-six percent of individuals were considered at risk for depression with a T-score of 63 or above on the Global Severity Index score of the SCL-90-R. These results suggest that a large percentage of patients have modified their diets prior to entry into cardiac rehabilitation. Therefore, nutrition intervention must not only reinforce low-fat food choices but aim at facilitating life-long balanced, low-fat eating and healthy weight maintenance. Psychological assessments indicate need for individualized referrals for mental health intervention. Individualizing treatment interventions based on entry assessments may optimize long-term outcomes of cardiac rehabilitation.