Reports

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

PRIORITY PRESS - 61st Annual Refresher Course for Family Physicians

McGill University, Montreal, Quebec / November 28-December 1, 2010

Which Lifestyle Changes Are Effective?

Lifestyle measures can promote overall health, help effect disease prevention and modestly extend life and may be more effective than increasing doses of antihypertensive and/or lipid-lowering therapy, noted Dr. Steven Grover, Professor of Medicine and Director, McGill Cardiovascular Health Improvement Program. “If you really want to maximize risk factor management for your patients, look at what they’re doing in their lifestyle, as opposed to which medications and at what doses you are treating them with,” he commented.

Patients’ motivation to start and persist with lifestyle modification is generally poor, he acknowledged. Clinical studies indicate many lifestyle measures do not work well or rapidly, which leads to discouragement; and some are not based on good science, Dr. Grover remarked. The physician’s recommendations can be difficult to follow and the patient may be further confused by the barrage of health and nutrition information in the media.

For example, to ensure a healthy diet, a typical patient may be exhorted to restrict fat, salt, sugar and high-glycemic-index foods, and increase consumption of fruits and vegetables and foods containing anti-oxidants and vitamins. “I would argue that if you want to come up with a healthy eating recommendation for your patients, then probably encouraging more fruits and vegetables and staying away from processed foods is the [ideal step]...it’s a simple thing to do,” he maintained.

In contrast, “a little bit of exercise and a little bit of weight loss really do make a difference,” Dr. Grover stated. The Diabetes Prevention Program showed that among patients with a family history of diabetes or prediabetic blood glucose levels, intensive lifestyle intervention leading to an average weight loss of 5-10 lbs led to a 60% reduction in diabetes development compared with placebo. Ten-year follow-up of the trial participants showed that the people who initially benefited maintained their health advantage over the placebo group. “If you did nothing else but reduce the incidence of diabetes in your practice, you would make a huge difference... There’s nothing that brings up the cardiovascular risk as much as the presence of diabetes, and the complications of diabetes are of major concern,” Dr. Grover noted. In previously sedentary individuals, moderate daily exercise can decrease blood pressure (BP) by about 5-6 mm Hg and LDL-C by about 5%. Some patients experience impressive increases in HDL-C with exercise, especially with a program sustained over at least 18 months. In a recent study evaluating aerobic exercise and resistance training for patients with diabetes, many patients experienced a substantial drop in fasting glucose and hemoglobin A_1c levels and were able to reduce antidiabetic therapy.

Measures to improve exercise initiation and adherence include Web-based motivation tools, such as activity challenges that patients can take part in individually or in groups. It is realistic that 30% to 50% of patients will drop out of any exercise program, but “that’s still better than smoking cessation rates,” Dr. Grover observed. “When the patient stops, we have got to get them back on the wagon again when they’re ready.”

Highlights from Hypertension Guidelines

Sodium has acute and chronic effects on the kidneys (fluid retention, lower sodium excretion) and vasculature (increased endothelial dysfunction and reduced vasodilation). Especially in patients with hypertension, sodium restriction is an important lifestyle measure, asserted Dr. Luc Trudeau, Assistant Professor, Division of Internal Medicine, and cofounder of the Cardiovascular Prevention Centre, Jewish General Hospital. However, even in normotensive individuals, reducing sodium intake can be beneficial by reducing average BP. Epidemiological studies show that with sodium consumption of more than 6 g/day, cardiovascular disease and overall mortality are increased. On the other hand, restricting sodium intake to new recommended levels will likely have a significant positive effect on BP and cardiovascular events. “If people ate 1800 mg/day less, there would be one million fewer hypertensive individuals in Canada,” Dr. Trudeau stated.

Most patients with hypertension require several medications to achieve their BP goal. The latest Canadian Hypertension Education Program (CHEP) guidelines indicate that low-dose combination regimens are often more effective and better tolerated than stepped care (maximizing doses before adding another medication). In the recent STITCH trial, the initial combination regimen (ACE inhibitor or ARB plus diuretic in a fixed-dose pill) allowed 85% of patients to achieve their target of <140/90 mm Hg. The average initial BP reduction was more than 20 mmHg, “which was massive,” commented Dr. Trudeau. Another combination therapy trial, ACCOMPLISH, showed that patients at high cardiovascular risk experienced 20% fewer events with an ACE inhibitor/dihydropyridine calcium channel blocker regimen combination than with ACE inhibitor plus diuretic (Slide 18). “Diabetics or coronary patients with hypertension should ideally receive this combination,” he indicated.

Efficient Management of Low Back Pain

While hypertension is one of the most common reasons for primary care visits, back pain is not much farther down the list. At a special symposium, speakers from the McGill Scoliosis and Spine Group suggested that their algorithm (www.mcgill.ca/spineprogram/algorithms/) can aid the efficient assessment of any patient with low back pain. The algorithm starts in the waiting room, where patients should be asked to complete an Oswestry score questionnaire and the STartT Back screening tool, which help qualify pain and disability. (These are also available on the website and should be completed at every follow-up visit).

The history and physical examination will reveal symptoms or signs that suggest serious illness requiring emergency care or a specific diagnosis such as myelopathy or spinal stenosis. For most patients with nonspecific pain, education (for example, about the benefits of continued activity versus bed rest) and a short course of analgesic medication with or without muscle relaxants will be sufficient, observed surgeon Dr. Jean Ouellet, Chief, Scoliosis and Spine Service, Montreal General Hospital. The patient should be re-evaluated after four to six weeks if the pain has not subsided. At this point, the physician may consider imaging or investigations.

In addition, they should consider whether “yellow flags”—psychological or social issues—are contributing to chronic pain or disability, noted Dr. Mohan Radhakrishna, head of physical medicine and rehabilitation at McGill. Patients who remain symptomatic for weeks to months after an initial visit for back pain may require referral to a multidisciplinary spine or pain program.

Physiotherapy is another treatment option for low back pain, although there is sparse evidence about the benefits of specific interventions for particular patients or pain syndromes, acknowledged Richard Preuss, Assistant Professor, McGill University School of Physical and Occupational Therapy. However, programs involving muscle extension, core stabilization and/or spinal manipulation appear to achieve the best results. Patients who experience pain centralization (the receding of pain toward the midline) with extension or range of motion exercise appear to have a good prognosis with this treatment modality. If the patient’s condition has not improved after six to 10 sessions, physiotherapy probably should be discontinued.

Summary

Cardiovascular issues (especially hypertension) and back pain are among the most common reasons for patient visits to the primary care physician. Efficient evaluation and management, using available guidelines and protocols, as well as simple communication of goals, can save time and help ensure the patient’s needs are satisfied.