Showing papers by "Scott M. Grundy published in 2000"

Beneficial Effects of High Dietary Fiber Intake in Patients with Type 2 Diabetes Mellitus

Abstract: Background The effect of increasing the intake of dietary fiber on glycemic control in patients with type 2 diabetes mellitus is controversial. Methods In a randomized, crossover study, we assigned 13 patients with type 2 diabetes mellitus to follow two diets, each for six weeks: a diet containing moderate amounts of fiber (total, 24 g; 8 g of soluble fiber and 16 g of insoluble fiber), as recommended by the American Diabetes Association (ADA), and a highfiber diet (total, 50 g; 25 g of soluble fiber and 25 g of insoluble fiber) containing foods not fortified with fiber (unfortified foods). Both diets, prepared in a research kitchen, had the same macronutrient and energy content. We compared the effects of the two diets on glycemic control and plasma lipid concentrations. Results Compliance with the diets was excellent. During the sixth week of the high-fiber diet, as compared with the sixth week of the ADA diet, mean daily preprandial plasma glucose concentrations were 13 mg per deciliter (0.7 mmol per liter) lower (95 percent confidence interval, 1 to 24 mg per deciliter [0.1 to 1.3 mmol per liter]; P=0.04) and mean daily urinary glucose excretion was 1.3 g lower (median difference, 0.23 g; 95 percent confidence interval, 0.03 to 1.83; P=0.008). The high-fiber diet also lowered the area under the curve for 24-hour plasma glucose and insulin concentrations, which were measured every two hours, by 10 percent (P=0.02) and 12 percent (P=0.05), respectively. The high-fiber diet reduced plasma total cholesterol concentrations by 6.7 percent (P=0.02), triglyceride concentrations by 10.2 percent (P=0.02), and very-low-density lipoprotein cholesterol concentrations by 12.5 percent (P=0.01). Conclusions A high intake of dietary fiber, particularly of the soluble type, above the level recommended by the ADA, improves glycemic control, decreases hyperinsulinemia, and lowers plasma lipid concentrations in patients with type 2 diabetes. (N Engl J

Prevention Conference V: Beyond secondary prevention: Identifying the high-risk patient for primary prevention: Executive summary

Abstract: This conference, “Beyond Secondary Prevention: Identifying the High-Risk Patient for Primary Prevention,” which was the fifth in a series of prevention conferences sponsored by the American Heart Association (AHA), was held October 26–28, 1998, in San Francisco, Calif. The need for this conference was precipitated by the remarkable advances in medical therapies for the prevention of coronary heart disease (CHD). The AHA has already set forth guidelines for aggressive medical therapy in patients with established CHD (secondary prevention). The major issue under consideration at this conference was the development of strategies to identify high-risk patients without established CHD who are candidates for aggressive medical therapies for primary prevention. Therefore, a central theme for the conference was the emphasis on establishing a prognosis for high-risk patients without clinical evidence of CHD. Three writing groups were established to report on the following areas: (1) medical office assessment, (2) tests for silent and inducible ischemia, and (3) noninvasive tests of atherosclerotic burden. Each working group reviewed research on existing risk-assessment strategies relevant to the prediction of risk in patients without clinical evidence of CHD. The key findings of each working group are presented in this Executive Summary of the conference. The full conference report with references is available online at http://circ.ahajournals.org/ in the January 4, 2000, issue of Circulation . The recommended strategies will assist in expanding preventive therapies, including lipid lowering, blood pressure control, smoking cessation, diet, and exercise, to patients at high risk for developing CHD. The following briefly summarizes the major conclusions of the conference. In the development of the Prevention V report, Writing Group I outlined a strategy for initial risk assessment of the asymptomatic patient to obtain an estimate of absolute risk. On the basis of standard risk factors and related risk correlates, the concept was set forth …

Metabolic complications of obesity

Abstract: The rising prevalence of obesity is accompanied by an increasing number of patients with the metabolic complications of obesity. The major complications come under the heading of the metabolic syndrome. This syndrome is characterized by plasma lipid disorders (atherogenic dyslipidemia), raised blood pressure, elevated plasma glucose, and a prothrombotic state. The clinical consequences of the metabolic syndrome are coronary heart disease and stroke, type 2 diabetes and its complications, fatty liver, cholesterol gallstones, and possibly some forms of cancer. At the heart of the metabolic syndrome is insulin resistance, which represents a generalized derangement in metabolic processes. Obesity is the predominant factor leading to insulin resistance, although other factors play a role. The mechanistic link between insulin resistance and the metabolic syndrome is complex. The relationship is modulated by yet other factors, such as physical activity, body fat distribution, hormones, and a person's genetic polymorphic architecture. A better understanding of the molecular basis of this relationship is needed to suggest new targets for prevention and treatment of the complications of obesity. In addition, understanding at the clinical level will lead to improved management of these complications.

Prevention Conference V Beyond Secondary Prevention: Identifying the High-Risk Patient for Primary Prevention Medical Office Assessment

Abstract: Writing Group I of Prevention Conference V reviewed the role of medical office assessment in the detection of risk factors and estimation of total cardiovascular risk. The primary focus was on identification of known risk factors for coronary heart disease (CHD). Population screening may identify risk factors that prompt people to seek clinical consultation. Risk factors may also be identified in patients who are seeking medical treatment for other conditions. Physicians have the responsibility to evaluate cardiovascular risk in all their patients. Medical office assessment permits the identification of many high-risk patients without the need for noninvasive testing for atherosclerotic burden or subclinical myocardial ischemia. Techniques for office assessment available to clinicians include history, physical examination, laboratory testing, and electrocardiography (ECG). Routine evaluation and testing provides most of the information needed to estimate risk and make treatment decisions. The essential information required for estimating risk for CHD lies in the known risk factors for coronary disease. These risk factors must first be identified and their severity determined. The relationship between risk factors and development of CHD is strong but variable. When a risk factor is causally and independently related to disease, the physician should make recommendations to the patient about risk factor modification. When risk factors are associated with increased risk for CHD but are not directly causative, the risk factor is considered to be a marker for increased risk. In the following discussion, the major risk factors and risk markers for CHD that can be detected in medical office assessment are reviewed. The different categories of risk are then considered. Finally, the special characteristics of each risk factor in relation to global risk assessment are reviewed. Special groups, including older patients and those with diabetes, are considered, and suggestions are made for modifying the existing guidelines for risk assessment.

Prevention Conference V Beyond Secondary Prevention : Identifying the High-Risk Patient for Primary Prevention : Medical Office Assessment : Writing Group I

Abstract: Writing Group I of Prevention Conference V reviewed the role of medical office assessment in the detection of risk factors and estimation of total cardiovascular risk The primary focus was on identification of known risk factors for coronary heart disease (CHD) Population screening may identify risk factors that prompt people to seek clinical consultation Risk factors may also be identified in patients who are seeking medical treatment for other conditions Physicians have the responsibility to evaluate cardiovascular risk in all their patients Medical office assessment permits the identification of many high-risk patients without the need for noninvasive testing for atherosclerotic burden or subclinical myocardial ischemia Techniques for office assessment available to clinicians include history, physical examination, laboratory testing, and electrocardiography (ECG) Routine evaluation and testing provides most of the information needed to estimate risk and make treatment decisions The essential information required for estimating risk for CHD lies in the known risk factors for coronary disease These risk factors must first be identified and their severity determined The relationship between risk factors and development of CHD is strong but variable When a risk factor is causally and independently related to disease, the physician should make recommendations to the patient about risk factor modification When risk factors are associated with increased risk for CHD but are not directly causative, the risk factor is considered to be a marker for increased risk In the following discussion, the major risk factors and risk markers for CHD that can be detected in medical office assessment are reviewed The different categories of risk are then considered Finally, the special characteristics of each risk factor in relation to global risk assessment are reviewed Special groups, including older patients and those with diabetes, are considered, and suggestions are made for modifying the existing guidelines for risk …

Clinical goals and performance measures for cholesterol management in secondary prevention of coronary heart disease.

Abstract: Guidelines from the National Cholesterol Education Program (NCEP) recommend reduction of low-density lipoprotein cholesterol (LDL-C) to 100 mg/dL (2.59 mmol/L) or less in patients with established coronary heart disease (CHD). However, the National Committee for Quality Assurance (NCQA) is implementing a new performance measure as part of the Health Plan Employer and Data Information Set (HEDIS) that appears to endorse a different target. The new HEDIS measure will require managed care organizations seeking NCQA accreditation to measure and report the percentage of patients who have had major CHD events who achieve LDL-C levels less than 130 mg/dL (3.36 mmol/L) between 60 and 365 days after discharge. These different LDL-C thresholds emphasize the difference between a clinical goal for the management of individual patients (≤100 mg/dL) and a performance measure used to evaluate the care of a population of patients (<130 mg/dL). This article discusses the rationale for each threshold and explains the use of 2 different thresholds for these 2 purposes. Both the NCQA and NCEP expect that the new HEDIS measure will encourage managed care organizations to develop systems that improve secondary prevention of CHD.

Cholesterol management in the era of managed care

Abstract: Several large controlled clinical trials have documented that cholesterol lowering causes a marked reduction in major coronary events in patients with established coronary heart disease. Cholesterol lowering thus joins other proven therapies for risk reduction in secondary prevention. The need to include cholesterol-lowering therapy in secondary prevention has been endorsed as a new practice measure in the Health Plan Employer Data Information Set. This endorsement ensures that managed care will get behind the effort to better control cholesterol in patients with coronary heart disease. The next issue is whether managed care will support cholesterol-lowering therapy in primary-prevention patients. The patients at highest risk for developing coronary heart disease are those with noncoronary forms of atherosclerotic disease, type 2 diabetes, multiple risk factors, and risk factors plus evidence of advanced subclinical atherosclerosis. Such patients can be said to have coronary heart disease risk equivalents. These patients should be good candidates for aggressive cholesterol management. A strong case can be made for managed-care support for this approach. Support for treatment of patients at lower risk may be open to some question, but the current guidelines of the National Cholesterol Education Program provide a strong rationale for cholesterol management for primary prevention in the medical setting.

Early detection of high cholesterol levels in young adults.

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Cholesterol-Lowering Therapy: Evaluation Of Clinical Trial Evidence

Abstract: Cholesterol-Lowering Clinical Trials: A Historical Perspective Scott M. Grundy Scandinavian Simvastatin Survival Study (4S) Terje R. Pedersen The Cholesterol and Recurrent Events Trial (CARE): The Effect of Pravastatin on Coronary Events After Myocardial Infarction in Patients with Average Cholesterol Levels Frank M. Sacks, Marc A. Pfeffer, Lemuel A. Moye, C. Morton Hawkins, Barry R. Davis, Jean L. Rouleau, Thomas G. Cole, and Eugene Braunwald Lessons from the West of Scotland Coronary Prevention Study (WOSCOPS) James Shepherd and Allan Gaw Program on the Surgical Control of the Hyperlipidemias (POSCH) Trial: A Pivotal 25-Year Study Henry Buchwald The Air Force/Texas Atherosclerosis Prevention Study (AFCAPS/TexCAPS): Primary Prevention of Acute Major Coronary Events in Women and Men with Average Cholesterol Stephen Weis, Michael Clearfield, Lt. Col. John R. Downs, and Antonio M. Gotto, Jr. Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) Study: Clinical Implications for Cardiovascular Practice Andrew M. Tonkin and David Hunt Angiographic Results of Lipid-Lowering Trials: A Systematic Review and Meta-Analysis Cheryl L. Holmes, Michael Schulzer, and G. B. John Mancini Biochemical Correlates of Plaque Progression and Coronary Events Melissa Ferraro-Borgida and David Waters Lipid Therapy to Stabilize the Vulnerable Atherosclerotic Plaque: New Insights into the Prevention of Cardiovascular Events B. Greg Brown and Xue-Qiao Zhao Cholesterol-Lowering Trials with Carotid Ultrasonographic Outcomes Robert P. Byington Cholesterol Lowering Reduces Mortality: The Statins David J. Gordon

Pravastatin treatment of very low density, intermediate density and low density lipoproteins in hypercholesterolemia and combined hyperlipidemia secondary to the nephrotic syndrome.

Abstract: Background/Aims: In the current study pravastatin was used in nephrotic syndrome patients with hypercholesterolemia and combined hyperlipidemia to test whether the drug decreases pr