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It is important to simplify the NCEP guidelines.

The guidelines advise TLC first. That sets the patient up for failure. There is no diet that will consistently keep weight off for 10 years in the majority of people.

We don't know what we are talking about when it comes to dieting, yet we put the responsibility on the patient to lose weight.

Three items in the news demonstrate our ignorance in weight loss:

1- Jeffrey Gordon: A change in bacteria in the intestine makes it easier to gain weight and more difficult to lose weight

2- Interleukin Genetics Inc. under the name Inherent Health sells a test for $149 to determine if your patient should be on a low carb diet or a low carb and low fat diet.

3- Jerry Heindel is an expert in Endocrine Disrupting Chemicals (EDC's). These chemicals disrupt our weight thermostat. The fat epidemic is not explained totally by video games and corn syrup in fast food.

It reminds me of how we treated HIV with one drug. Later we realized we did the wrong thing as it allowed resistance to develop in those patients.

If NCEP is evidenced based, lets leave diet and exercise out of it for now.

TLC - Couldn`t agree more,.. by the way,.. find someone [maybe yourself] who is very compliant with niacin. After stabilizing the dose for at least a year, or more,.. try skipping every other day. It works. Especially if the baseline total-HDL was low,.. <35. You may experience a chronic low-grade flush,.. but watch that HDL,.. it really restores one`s faith,.. kind of impressive really. I have a Met-Syn ENDO who asked my advice & he tries this. His baseline t-HDL was mid-20's. It is > 40 now & creeping up. 2.5 years now & still moving.

It seems the up/down regulation of the catabolic HDL receptor is enhanced when there is a longer trough between doses. That would explain the poor efficacy of the SR formulations. Too 'brief' of a trough. Who cares anyhow why,.. it does seem to work. Not necessary in most patients though.

SDMc

William Peter Castelli MD A Conversation with the Editor Wm Clifford Roberts The American Journal of Cardiology Vol 94 Sept 1st 2004‏

"Every time a patient comes to my clinic, he/she has to see the nurse manager, the dietitian, and me. I make out a scorecard with the patient’s numbers. Next to the numbers is the goal we want them to achieve. I go over the numbers; I pick the first strategy. The first 3 months in my clinic, patients are sent home on diet, exercise, and 3 fish oils. We want to find out what kind of mileage we’re going to get out of diet and exercise. It’s not very good. Even if the patient succeeds in the first 3 months, they can’t keep it up. That’s been the disappointing part of this clinic. It is hard to convince patients. In primary care it is difficult taking someone who feels well and convincing them to go on a diet, to exercise, and to take medicines. It doesn’t get done. The guidelines advocate that diet and exercise should be used to treat these people. The guidelines obviously are written by physicians who have never worked in a clinic doing diet and exercise. If they did, they did say try it for 3 months, but if they aren’t getting any mileage in 3 months, you have to add drugs. Physicians know that the patients are going to have to use these drugs.

This is a very intriguing discussion on physical activity and NCEP "ATP IV" (by the way these next guidelines will essentially integrate hypertension, obesity and dyslipidemia recommendations). I think if these recommendations were only addressing weight loss and TLC then perhaps we could make better use of the space but my guess is that they will address both dyslipidemia and cardiometabolic risk. From the cardiometabolic risk standpoint TLC should be square-on a central therapeutic focus in my view (weight loss as well) even if the writers base this recommendation on just the diabetes prevention study where very modest weight loss (<10 lbs over 3+ years) in those who were in the 208-210 lb body weight range reduced T2D by ~60% and nearly 70% in older adults. Of course we could go on and on on the multiplicity of trials demonstrating even modest but systemtatic dietary changes (particularly Mediterranean type changes) and modest 1000-1200 kcal/week physical activity programs improved. insulin sensitivity, LDL-P, CRP, SBP, etc. but well short of much weight loss. I think we have to look beyond weight loss as the sole gauge of assessing the cardiometabolic benefits of TLC and I am fairly sure this will be the focus of our next NIH guidelines.

Beyond that - the exercise volume to consistently reduce body weight is indeed more than most of us are willing to accept. Predicting exercise-generated weight loss has always been much of a roulette toss oweing to the multitude of genotypic and metabolic factors that are involved in fatty acid oxidation and regulation. There are no less than a dozen genes that can at least in part explain why two individuals, same gender and BMI, will have varying responses to a standardized exercise program (e.g., the perilipin PLIN1 hapotype ). Finally - there is growing research (Jim Hill - Univ. CO) showing that even with high daily physical activity energy expenditures - 24 hour fat oxidation is not significantly altered unless there is a meaningful change in daily caloric balance (ie. reduced intake) - again this is a hard lesson to accept for most of our patients. But again I think regular engagement of TLC clearly stands on it's own two feet as a core therapeutic strategy for reducing diabetes and vascular disease risk.

Thanks for a great response. Perhaps you can weigh in on some other material I reviewed in the book, Ultimate Fitness by Gina Kolata.

p230: Claude Bouchard is quoted as stating that "weight lifting has virtually no effect on resting metabolism. The reason is that any added muscle is miniscule compared with the total amount of skeletal muscle in the body. And the muscle has very low metabolic rate while at rest, which is most of the time. Skeletal muscle burns about 13 calories per kg of body weight over 24 hours when a person is at rest. A typical man who weighs 70 kg has about 28 kg of skeletal muscle, Bouchard says. His muscles when he is at rest burn about 22 % of the calories the body uses. The brain would use about the same number of calories as would the liver. If the man lifts weights and gains 2 kg of muscle his metabolic rate would increase by 24 calories a day. According to Jack Wilmore the average amount of muscle gained after a serious weight-lifting program that lasted 12 weeks was 2 kg. Women of course will gain much less."

The good news is on p.232:

"Weight lifting makes for more efficient muscles with more mitochondria and it is better at using fat for fuel. The cells are also more permeable to glucose , which, in turn, reduces the need for excess insulin in the blood. The result is a reduced susceptibility to diabetes."

Will the new guidelines include weight lifting?

Thanks much. No, I have not read Gina's book although I have shared several NYT fitness articles with her over the years. I don't think Sidney, Neil, or Alice (principles on the next guidelines) will isolate resistance exercise except to include it within the confines of overall physical activity. Resistance training comes in many forms - some helpful with regard to metabolic fitness and some not so helpful but certainly inducing increases in strength. As a rule - higher rep lower resistance exercise (eg. 10-15 reps) over 5-10 exercises would be preferable to high resistance and low reps, e.g., where you have failure within 2-3 reps although the hi res/low rep protocols certainly can build muscle mass. Anyway - likely a mix of both styles for optimum overall fitness. The high rep program is safer for those at CV and metabolic risk and has the added advantage of building more muscular endlurance which I think is more important as we age. We (I) I speak briefly to this concept in the new NLA Cardiometabolic Risk Reduction Program - Phase III offered at all of 2010 regional NLA conferences.

I agree that TLC should not put pharmacotherapy on the back burner. However, I try to work with my patient--be he from Connecticut or Mexico--on a diet/lifestyle that works for him. My favorite is a variation of the Mediteranean diet with whatever ethnic modification is palatable. After all, fail or not, a person wants to be acitvely involved in her health. Controlling our fate--even a small bit--promotes a sense of well-being and accomlishment, which a drug like Crestor cannot make up for.

"Of course we could go on and on on the multiplicity of trials demonstrating even modest but systemtatic dietary changes (particularly Mediterranean type changes) and modest 1000-1200 kcal/week physical activity programs improved. insulin sensitivity, LDL-P, CRP, SBP, etc. but well short of much weight loss. I think we have to look beyond weight loss as the sole gauge of assessing the cardiometabolic benefits of TLC and I am fairly sure this will be the focus of our next NIH guidelines."

Concerning the Mediterranean diet, I would like to refer to the Journal of Clinical Lipidology Oct 2009, volume 3, number 5 on p303-314.

I would like to quote Dr Brown in the Round Table Discussion: "(Mediterranean diet) is viewed as healthful and as you pointed out the Lyon Diet Heart study really found that the one fat that correlated best with reduction in events was not monounsaturated oleic acid, the major fat of olive oil, it was linoleic acid. And so I'm afraid that this has become a great hoax applied to the American diet."

I have gone easy on the intensity of exercise and have not had an injury for the last five years.

Quick reanalysis of the DPP regarding exercise. The goal was 150 min/week (~1500-1600 kcal) which was not achieved. They actually achieved and average of ~1000 kcal per week by study's end (less than 75% achieved 150 minutes per week). Know that they could not control exercise allocation that well with all the sites. Even though the initial paper looking at weight loss being the biggest predictor of T2D risk reduction it was interesting to note that they did very little to objectively measure the changes in physical activity itself except for self-reported minutes per week (that is a problem I think and this issue is shared with many such trials). It is also noteworthy that among the participants who did not meet the weight loss goal in DPP but who met the activity goal (150 min/week) had a 44% reduction in diabetes incidence.

You might me interested in reading the latest post (by me) on the Exercise and Physical Activity Group link here (re: haplotype, exercise and weight loss).