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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

September 10, 2019 Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 e610

CLINICAL STATEMENTS AND GUIDELINES circumference, waist–hip ratio, bioimpedance, and dual-energy X-ray absorptiometry (DXA).S4.1-18 BMI, waist circumference, and waist–hip ratio are easily measured and therefore are the most widely used in clinical practice. A USPSTF document found good evidence supporting the use of BMI to identify adults at increased risk of future morbidity and mortality.S4.1-18 Because obesity/overweight defined by BMI is the most studied and standardized approach, we recommend its measurement for primary screening of individuals needing weight loss. BMI should be interpreted with caution in persons of Asian ancestry, older adults, and muscular adults.S4.1-19,S4.1-20

4 Increased waist circumference has been associ-

ated with increased cardiometabolic and ASCVD risk.S4.1-3–S4.1-6 Central adiposity, captured by using waist circumference, has been associated with ASCVD risk and may be missed when BMI is used as the only measure of obesity.S4.1-21,S4.1-22 Waist circumference measurement is recommended in all patients with BMI <35 kg/m2.S4.1-9,S4.1-19,S4.1-23 Ethnic differences in waist circumference thresholds associated with cardiometabolic risk have been reported. Waist circumference may be more useful than BMI in persons with abdominal obesity (central adiposity).S4.1-24 Definitions of elevated waist circumference as ≥40 inches (≥102 cm) in men and ≥35 inches (≥88 cm) in women were recommended by the 1998 National Heart, Lung, and Blood Institute Obesity Initiative Expert PanelS4.1-25 and were adopted by the 2013 AHA/ACC/TOS writing committee.S4.1-1 Furthermore, waist circumference assessment is needed for the diagnosis of metabolic syndrome. Thus, combining waist circumference and BMI may be the best approach for assessing obesity-related risk. Counseling and comprehensive lifestyle interventions, including calorie restriction and adjunctive therapies (eg, FDA–approved drugs, bariatric surgery), have all been associated with significant reductions in waist circumference and improvement in cardiometabolic risk profiles.S4.1-1

4.2 Adults With Type 2 Diabetes Mellitus

See Figure 2 for an algorithm for treatment of T2DM for primary prevention of cardiovascular disease.

Recommendations for Adults With Type 2 Diabetes Mellitus Referenced studies that support recommendations are summarized in Online Data Supplement 10.

COR LOE Recommendations

I A 1.  For all adults with T2DM, a tailored nutrition plan focusing on a heart-healthy dietary pattern is recommended to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors.S4.2-1,S4.2-2 I A 2.  Adults with T2DM should perform at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorousintensity physical activity to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors.S4.2-3,S4.2-4

IIa B-R 3.  For adults with T2DM, it is reasonable to initiate metformin as first-line therapy along with lifestyle therapies at the time of diagnosis to improve glycemic control and reduce ASCVD risk.S4.2-5–S4.2-8

IIb B-R 4.  For adults with T2DM and additional ASCVD risk factors who require glucose-lowering therapy despite initial lifestyle modifications and metformin, it may be reasonable to initiate a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like peptide-1 receptor (GLP-1R) agonist to improve glycemic control and reduce CVD risk.S4.2-9–S4.2-14

Synopsis

T2DM, defined as a hemoglobin A1c (HbA1c) >6.5%, is a metabolic disorder characterized by insulin resistance leading to hyperglycemia. Unlike type 1 diabetes mellitus (an autoimmune condition largely unrelated to lifestyle factors), the development and progression of T2DM are heavily influenced by dietary pattern, physical activity, and body weight. Approximately 12% of US adults have diabetes, 90% to 95% of whom have T2DM, with significant heterogeneity according to age, sex, race/ethnicity, and socioeconomic status.S4.2-15 Alarmingly, more than one-third of US adults (≈80 million adults) have prediabetes and are at risk of developing T2DM.S4.2-15* Although contemporary data have shown a significant decrease in ASCVD rates in individuals with T2DM,S4.2-15 T2DM remains a highly prevalent disease and a major ASCVD risk factor. An aggressive, comprehensive approach to ASCVD risk factor treatment in adults with T2DM reduces ASCVD events.S4.2-16 Management of cholesterol and hypertension in adults with T2DM is discussed in the relevant sections of the present guideline (see Sections 4.3. and 4.4.).

Recommendation-Specific Supportive Text

1 A heart-healthy dietary pattern is a key intervention

in the treatment of T2DM. The Mediterranean, DASH, and vegetarian/vegan diets have all been shown to help in the achievement of weight loss and improve glycemic control in T2DM.S4.2-1,S4.2-2 Prospective cohorts have demonstrated a significantly

Recommendations for Adults With Type 2 Diabetes Mellitus (Continued)

COR LOE Recommendations

*An HbA1c is the optimal screening method, with a level ≥6.5% indicating T2DM.

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