5 acc prevention lifestyle changes

The Evidence for Current Cardiovascular Disease

Prevention Guidelines:

Lifestyle Management Evidence and Guidelines

American College of Cardiology Best Practice Quality Initiative Subcommittee

and Prevention Committee

Classification of Classification of Recommendations and Levels Recommendations and Levels of Evidenceof Evidence

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.

I IIa IIb III

I IIa IIb III

I IIa IIb III

I IIa IIb III I IIa IIb III

I IIa IIb III

I IIa IIb III

I IIa IIb III

I IIa IIb III

I IIa IIb III

I IIa IIb III

I IIa IIb III

Icons Representing the Classification and Icons Representing the Classification and Evidence Levels for RecommendationsEvidence Levels for Recommendations

Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence and GuidelinesEvidence and Guidelines

Evidence for Current Cardiovascular Evidence for Current Cardiovascular Disease Disease

Prevention GuidelinesPrevention Guidelines

Smoking Prevalence in the United Smoking Prevalence in the United StatesStates

Source: CDC, Morbidity and Mortality Weekly Report 2007;56:1157-1161

National Health Interview SurveyEstimated percentage of current smokers in the United

States by sex

There has been a decrease in the prevalence of cigarette smoking in men and women over time

Causes # (%) in 1990 # (%) in 2000

Tobacco 400,000 (19) 435,000 (18)

Poor diet and physical activity (obesity)

300,000 (14) 400,000 (17)

Alcohol consumption 100,000 (5) 85,000 (4)

Microbial agents 90,000 (4) 75,000 (3)

Toxic agents 60,000 (3) 55,000 (2)

Motor vehicle accidents 25,000 (1) 43,000 (2)

Firearms 35,000 (2) 29,000 (1)

Sexual behavior 30,000 (1) 20,000 (<1)

Illicit drug use 20,000 (<1) 17,000 (<1)

Total 1,060,000 (50*) 1,159,000 (48%*)

Source: Mokdad AH et al. JAMA 2004;291:1238-1245

Tobacco Use: Tobacco Use: Most Preventable Cause of DeathMost Preventable Cause of Death

Most preventable causes of death in the U.S. in 1990 and 2000

*Reflects percent total of 9 most preventable causes of death

0.1 1.0 10Ceased smoking Continued smoking

RR (95% Cl)Study

Aberg, et al. 1983 0.67(0.53-0.84)

Herlitz, et al. 1995 0.99(0.42-2.33)

Johansson, et al. 1985 0.79 (0.46-1.37)

Perkins, et al. 1985 3.87(0.81-18.37)

Sato, et al. 1992 0.10(0.00-1.95)

Sparrow, et al. 1978 0.76(0.37-1.58)

Vlietstra, et al. 1986 0.63(0.51-0.78)

Voors, et al. 1996 0.54(0.29-1.01)

Source: Critchley JA et al. JAMA 2003;290:86-97

*Includes those with known coronary heart disease

Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Risk of Non-fatal Myocardial Risk of Non-fatal Myocardial Infarction*Infarction*

Abst

inence

rate

s (%

)

Self-help materials tailored for the needs of individual smokers are more effective than usual materials

Source: Sutton S et al. Addiction 2007;102:994-1000.

Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Tailored MaterialsTailored Materials

0

5

10

15

20

25

30

35

24 hour

Duration of abstinence

Usual careTailored care

15.4

20.9

12.7

18.9

11.3

16.4

9.012.2

7 day 1 month 3 month

p=0.015 p=0.004p=0.013

p=0.080

1058 current and recent ex-smokers randomized to a smoking cessation strategy of usual care* vs. computed-generated tailored

advice**

*Usual care consists of telephone counselling and a mailed information packet**Tailored care consists of usual care + a computer-generated individually tailored advice letter

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Effect of Counseling Intervention Effect of Counseling Intervention

Intensity 1: Contact in hospital of <15 minutes only

Intensity 2: Contact in hospital of >15 minutes only

Intensity 3: Any hospital contact plus postdischarge support of <1 month

Intensity 4: Any hospital contact plus postdischarge support of >1 month

Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960

Meta-analysis of 33 clinical trials assessing the benefit of smoking cessation counseling interventions with or without pharmacotherapy

Inpatient counseling with contact >1 month after discharge is associated with the greatest rate of smoking cessation

Percent Reporting >1 Indicators of Nicotine Dependence, by Age and Intensity of Smoking

Source: Substance Abuse and Mental Health Services Administration; United States, 2010 National Survey.

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Frequency of Nicotine DependenceFrequency of Nicotine Dependence

12-24 Years Old 25+ Years Old

Less than 6* 6-15* 16-25* 26+*

*Cigarettes per day

Minutes

CigaretteGum 4 mg

Gum 2 mg

Inhaler

Nasal sprayPatch

5 10 15 20 25 30

0

2

4

6

8

10

12

14

Source: Balfour DJ et al. Pharmacol Ther 1996;72:51-81

Incr

ease

in n

icoti

ne c

once

ntr

ati

on

(ng/m

l)Plasma nicotine concentrations

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Types of Nicotine ReplacementTypes of Nicotine Replacement

Limited Behavioral Support

Intervention Effect Size 95% CI

Nicotine gum 5% 4-6%

Nicotine transdermal patch

5% 4-7%

Intervention Effect Size 95% CI

Nicotine gum 8% 6-10%

Nicotine transdermal patch

6% 5-8%

Nicotine nasal spray 12% 7-17%

Nicotine inhaler 8% 4-12%

Nicotine sublingual tablet 8% 1-14%

Intensive Behavioral Support

Sources: West R et al. Thorax 2000;55:987-999

Silagy C et al. Cochrane Database Syst Rev 2002;CD000146

Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Effect of Combination TherapyEffect of Combination Therapy

CI=Confidence interval

Source: Jorenby DE et al. NEJM 1999;340:685-691

Placebo (n=160)

NRT (n=244)

Bupropion (n=244)

Nicotine patch and Bupropion (n=245)

Abstinence rate at 6 months

18.8% 21.3% 34.8%a,b 38.8%a,c,d

Abstinence rate at 12 months

15.6% 16.4% 30.3%a,c 35.5%a,c,e

ap<0.001 when compared to placebobp=0.001 when compared to NRTcp<0.001 when compared to NRT

dp=0.37 when compared to bupropionep=0.22 when compared to bupropion

NRT=Nicotine replacement therapy

Bupropion with or without NRT provides the greatest benefit

Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Primary PreventionPrimary Prevention893 smokers randomized to 9 weeks of bupropion (150 mg daily for 3 days and then 150 mg bid), NRT (21 mg patch weeks 2-7, 14 mg patch week 8, and 7 mg patch week 9), bupropion and NRT, or

placebo

Source: Jorenby DE et al. JAMA 2006;296:56-63

Varenicline vs. Bupropion P<0.001 (weeks 9-12), P=0.004 (weeks

9-52)

Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Primary PreventionPrimary Prevention1,027 smokers randomized to 12 weeks of varenicline (titrated to 1

mg bid), bupropion (titrated to 150 mg bid), or placebo

Varenicline provides greater rates of abstinence than bupropion

Agent Caution Side Effects

Dosage Duration Instructions

Bupropion SR

(Zyban®)**

Seizure disorderEating

disorderTaking MAO

inhibitorPregnancy

InsomniaDry mouth

Depression/Suicide

150 mg QAMthen

150 mg BID

3 days

8 weeks, but up to 6 months

Start 1-2 weeks before quit date.Take 2nd dose in early afternoon or decrease to 150 mg QAM for

insomnia.

Transdermal

NicotinePatch***

Within 2 weeks of a MI

Unstable angina

ArrhythmiasHeart failure

Skin reactionInsomnia

21 mg QAM14 mg QAM 7 mg QAM

or15 mg QAM

4 weeks2 weeks2 weeks

8 weeks

Apply to different hairless site daily.

Remove before bed for insomnia.Start at <15 mg for <10 cigs/day

Varenicline(Chantix®)*

*

Pregnancy NauseaSleep

disorderDepression

/SuicideCV risk

0.5 mg QD then

0.5 mg BIDthen

1 mg BID

3 days

4 days

12 weeks

Start 1 week before the quit

date

*Pharmacotherapy combined with behavioral support provides the best success rate

***Other nicotine replacement therapy options include: nicotine gum, lozenge, inhaler, nasal spray

**The FDA has placed a black box warning on varenicline and buproprion SR due to the risk of depression and/or suicidal thoughts

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Pharmacotherapy*Pharmacotherapy*

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Effect of Pharmacotherapy Effect of Pharmacotherapy

Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960

Meta-analysis of 33 clinical trials assessing the benefit of smoking cessation counseling interventions with or without

pharmacotherapy

Adding pharmacotherapy (nicotine replacement or bupropion) to counseling intervention does not improve rates of smoking

cessation NRT=Nicotine replacement therapy

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Benefit of Community Smoking BanBenefit of Community Smoking Ban

Source: Pell JP et al. NEJM 2008;359:482-491

ACS=Acute coronary syndrome

Prospective assessment of smoking status and exposure to second-hand smoke among patients admitted with an ACS to 9

Scottish hospitals before and after legislation prohibiting smoking in enclosed public places

Smoke-free legislation results in reduced ACS admissions

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Benefit of Community Smoking Ban Benefit of Community Smoking Ban

Source: Lightwood JM et al. Circulation 2009;120:1373-1379

MI=Myocardial infarction

Meta-analysis evaluating the ratio of community rates of acute MI before and after implementation of a smoking restriction law

Smoke-free legislation results in a rapid and substantial reduction in MI

Cigarette Smoking Cessation: Cigarette Smoking Cessation: Benefit of Financial Incentives Benefit of Financial Incentives

Source: Volpp KG et al. NEJM 2009;360:699-709

878 smokers working for a U.S. company randomized to receive information about smoking-cessation programs or information plus

financial incentives

Financial incentives for smokers increase the cessation rate

http://content.nejm.org/content/vol360/issue7/images/large/08t2.jpeg

Ask and document tobacco use status

Advise Provide a strong, personalized message

Assess Readiness to quit in next 30 days

Prevent Relapse• Congratulate successes• Encourage • Discuss benefits experienced by patient• Address weight gain, negative mood, and lack of support

Increase Motivation• Relevance to personal situation• Risks: short and long-term, environmental• Rewards: potential benefits of quitting• Roadblocks: identify barriers and solutions• Repetition: repeat motivational intervention• Reassess readiness to quit

Assist: Negotiate plan • STAR**• Discuss pharmacotherapy• Social support• Provide educational materials

Arrange Follow-up to check plan or adjust meds• Call right before and after quit date• Weekly follow-up x 2 weeks, then monthly x 6 months• Ask about difficulties (withdrawal, depressed mood)• Build upon successes• Seek commitment to stay tobacco-free

**STARSet quit dateTell family, friends, and coworkersAnticipate challenges: withdrawal, breaksRemove tobacco from the house, car, etc.

Recent Quitter(<6 months) Current

User

Not Ready Ready

Tobacco Cessation AlgorithmTobacco Cessation Algorithm

Source: Fiore MC et al. Treating tobacco use and dependence: an

evidence based clinical practice guideline for tobacco cessation. U.S. Department of Health and Human Services, 2000

Source: Buse JB et al. Circulation 2007;115:114-126

AHA=American Heart Association, CV=Cardiovascular,DM=Diabetes mellitus, NRT=Nicotine replacement therapy

• All patients should be asked about tobacco use status at every visit.

• Every tobacco user should be advised to quit.

• The tobacco user’s willingness to quit should be assessed.

•The patient can be assisted by counseling and by developing a plan to quit.

• Follow-up, referral to special programs, or pharmacotherapy (e.g., NRT and buproprion) should be incorporated as needed.

AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMTobacco RecommendationsTobacco RecommendationsPrimary Prevention

• All patients should be advised not to smoke.

• Smoking cessation counseling and other forms of treatment should be included as a routine component of diabetes care.

Source: American Diabetes Association. Diabetes Care 2010;33:S11-61

ADA=American Diabetes Association

ADA Smoking Cessation RecommendationsADA Smoking Cessation Recommendationsfor Patients with Diabetes Mellitusfor Patients with Diabetes Mellitus

Primary Prevention

Tobacco Cessation Tobacco Cessation RecommendationsRecommendations

Source: Smith SC Jr. et al. JACC 2011;58:2432-2446

Complete tobacco cessation and no environmental tobacco smoke exposure

Patients should be asked about tobacco use status at every office visit

Every tobacco user should be advised at every visit to quit

The tobacco user’s willingness to quit should be assessed at every visit.

Goals:

I IIa IIb III

I IIa IIb III

I IIa IIb III

Secondary Prevention

Tobacco Cessation Recommendations Tobacco Cessation Recommendations (Continued)(Continued)


Patients should be assisted by counseling and by development of a plan for quitting that may include pharmacotherapy and/or referral to a smoking cessation program

Arrangement for follow up is recommended.

All patients should be advised at every office visit to avoid exposure to environmental tobacco smoke at work, home, and public places


I IIa IIb III

I IIa IIb III

I IIa IIb III

Diet and Weight Management Diet and Weight Management Evidence and GuidelinesEvidence and Guidelines



Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht2 (in)

Source: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH/NHLBI/NAASO. October, 2000. NIH publication No. 00-4084

*Measurement of waist circumference is most helpful in this category

Weight Category BMI (kg/m2)

Normal 18.5-24.9

Overweight* 25.0-29.9

Obesity (Class I) 30.0-34.9

Obesity (Class II) 35.0-39.9

Obesity (Class III) >40.0

Overweight and Obese States: Overweight and Obese States: Definition Using the Body Mass Definition Using the Body Mass Index (BMI)Index (BMI)

Prevalence of Obesity in U.S. Prevalence of Obesity in U.S. AdultsAdults

1991 1996

2006

No Data <10% 10–14% 15–19% 20–24% 25-29% >30%

Source: CDC Overweight and Obesity

Percentage of State Obese (BMI > 30)

2008

Change in Body Mass Index Change in Body Mass Index DistributionDistributionin the United States Over Timein the United States Over Time

Source: Ford ES et al. Circulation 2009;120:1181-1188

0%

10%

20%

60%

40%

50%

30%

70%

80%

90%

100%

Body m

ass

index (

kg/m

2)

age-a

dju

sted p

erc

enta

ge

>35

National Health and Nutrition Examination Survey (NHANES)

30-3525-30>25

Source: Whitaker RC et al. NEJM 1997;337:869-873

BMI=Body mass index

Ad

ult

ob

esi

ty

At

ag

e 2

1-2

9 y

ears

(%

)

Age of child (years)

Body Mass Index: Body Mass Index: Risk of Developing Obesity in Risk of Developing Obesity in AdulthoodAdulthood

Source: Despres JP et al. Arterioscler Thromb Vasc Biol 2008;48:1039-1049

Body Mass Index: Body Mass Index: Relationship with Waist Relationship with Waist CircumferenceCircumference

Body Mass Index: Body Mass Index: Risk of HypertensionRisk of Hypertension

Study to Help Improve Early Evaluation and Management of Risk Factors Leading to Diabetes (SHIELD) and National

Health and Nutrition Examination Survey (NHANES)

Source: Bays HE et al. Int J Clin Pract 2007;61:737-747

Source: Bays HE et al. Int J Clin Pract 2007;61:737-747

Body Mass Index: Body Mass Index: Risk of Diabetes MellitusRisk of Diabetes Mellitus

Study to Help Improve Early Evaluation and Management of Risk Factors Leading to Diabetes (SHIELD) and National

Health and Nutrition Examination Survey (NHANES)

Source: Mhurchu N et al. Int J Epidemiol 2004;33:751-758

0.5

1.0

2.0

4.0

16 20 24 28 32 36

Body Mass Index (kg/m2)*

Haza

rd R

ati

o

0.5

1.0

2.0

4.0

16 20 24 28 32 36

0.5

1.0

2.0

4.0

16 20 24 28 32 36

HemorrhagicCVA

IschemicCVA

Ischemic HeartDisease

CVA=Cerebrovascular accident

*BMI is calculated as the weight in kg divided by the BSA in meters2

Body Mass Index: Body Mass Index: Risk of Cardiovascular DiseaseRisk of Cardiovascular Disease

Very low fat– Ornish (Reversal diet and Prevention diet)

• Vegetarian with 10% calories from fat. No cooking oils, avocados, nuts, and seeds. High fiber. No caloric restriction.

– Pritikin

• Very low-fat (primarily vegetarian) diet based on whole grains, fruits, and vegetables

Intermediate– Sugar Busters

• 30% protein, 40% fat, 30% carbohydrates (low glycemic index)

– Zone

• 30% protein, 30% fat, 40% carbohydrates

Diet Evidence: Diet Evidence: Types of Treatment ProgramsTypes of Treatment Programs

Very low carbohydrate– Atkins (Induction and Maintenance)

• 1st 2 weeks (<20 grams of carbohydrates/day with no high glycemic foods).

• Then can add 5 grams of carbohydrates/day each week to maximum of 90 grams of carbohydrates/day long term.

– South Beach (3 Phases)• 1st phase (2 weeks) significantly restricts carbohydrates• 2nd phase reintroduces low glycemic carbohydrates• 3rd phase attempts to maintain weight

Caloric restriction– Weight watchers

• Assigns foods a point value and restricts the number of points that can be consumed/day

Diet Evidence: Diet Evidence: Types of Treatment Programs Types of Treatment Programs (Continued)(Continued)

160 overweight and obese patients randomized to the Atkins, Zone, Weight Watchers, or Ornish diets for 1 year

Weight loss is similar among diet programs, but hard to sustain because of poor long-term compliance

Source: Dansinger, ML et al. JAMA 2005;293:43-53

20/40*

26/40*

26/40*

21/40*

0 3 6 9

Atkins

Zone

Weight Watchers

Ornish

Wt loss (lbs)

*Ratio of individuals completing the study to those enrolled

Diet Evidence: Diet Evidence: Primary PreventionPrimary Prevention


• Structured programs that emphasize lifestyle changes such as reduced fat (<30% of daily energy) and total energy intake and increased regular physical activity, alone with regular participant contact, can produce long-term weight loss on the order of 5-7% of starting weight, with improvement in blood pressure.

• For individuals with elevated plasma triglycerides and reduced HDL-C, improved glycemic control, moderate weight loss (5-7% of starting weight), increased physical activity, dietary saturated fat restriction, and modest replacement of dietary carbohydrates (5-7%) by either monounsaturated or polyunsaturated fats may be beneficial.

AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMWeight Management RecommendationsWeight Management RecommendationsPrimary Prevention

AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, HDL-C=High density lipoprotein cholesterol


BMI 18.5-24.9 kg/m2, Waist circumference for women: <35 inches, men: <40 inches*

Body mass index and/or waist circumference should be assessed at every visit, and the clinician should consistently encourage weight maintenance/reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2


I IIa IIb III

Weight ManagementWeight ManagementRecommendationsRecommendations

Goals:


If waist circumference (measured horizontally at the iliac crest) is >35 inches (>89 cm) in women and >40 inches (>102 cm) in men, therapeutic lifestyle interventions should be intensified and focused on weight management

The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. With success, further weight loss can be attempted if indicated.


I IIa IIb III

Weight ManagementWeight ManagementRecommendations (Continued)Recommendations (Continued)

I IIa IIb III

Diet Evidence, Diet Evidence, Cardiovascular Events, and Cardiovascular Events, and

GuidelinesGuidelines



Source: Hu FB et al. JAMA. 2002;288:2569-2578

Diet Intermediary Biological Mechanisms*

Risk of Coronary

Heart Disease

*Includes lipid levels [LDL-C, HDL-C, triglycerides, Lp(a), blood pressure, thrombotic tendency, cardiac rhythm, endothelial function, systemic

inflammation, insulin sensitivity, oxidative stress, homocysteine level

Relationship Between Diet and CV Relationship Between Diet and CV DiseaseDisease

CV=Cardiovascular

Source: Jenkins DJ et al. JAMA 2003;290:502-510

0

10

20

30

-50

-40

-30

-20

-10

0 2 4 0 2 4 0 2 4

LDL-C

Change f

rom

Base

line

(%)

LDL-C:HDL-C CRP

Weeks

Weeks

Weeks

Low fat dietStatin

Dietary portfolio*

*Enriched in plant sterols, soy protein, viscous fiber, and almonds

Diet Evidence:Diet Evidence:Effect on Lipid Parameters and CRPEffect on Lipid Parameters and CRP

46 dyslipidemic patients randomized to a low fat diet, a low fat diet and lovastatin (20 mg), or a dietary portfolio* for 4 weeks

A diversified diet improves lipid parameters and CRP levels

CRP=C-reactive protein, HDl-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol

Source: Appel LJ et al. NEJM 1997;336:1117-1124

Dietary Approaches to Stop Hypertension (DASH) Group

Diet low in fruits, vegetables, and dairy products

Diet enriched in fruits, vegetables, and fiber

Diet enriched in fruits and vegetables and low in fat and cholesterol

132

130

128

126

124

86

84

82

80

78 1 2 0 3 4 5 6

Systolic blood pressure

(mm Hg)

Diastolic blood pressure

(mm Hg)

Weeks

7/8

Diet Evidence:Diet Evidence:Effect on Blood PressureEffect on Blood Pressure

459 hypertensive patients randomized to 1 of 3 diets for 8 weeks

A diversified diet improves blood pressure

Joshipura KJ et al. Ann Intern Med 2001;134:1106-1114

Nurses’ Health Study and Health Professional’s Follow-up Study

*Includes nonfatal MI and fatal coronary heart disease

CV=Cardiovascular

Diet Evidence:Diet Evidence:Benefits of Fruits and VegetablesBenefits of Fruits and Vegetables

126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes*

Increased fruit and vegetable intake reduces CV risk

Source: Pereira MA et al. Arch Int Med 2004;164:370-376

RR=0.73, P<0.001

CV=Cardiovascular, CHD=Coronary heart disease

Diet Evidence:Diet Evidence:Benefits of Whole Grains and FiberBenefits of Whole Grains and Fiber

336,244 persons followed for 6-10 years to assess the relationship between dietary fiber intake and adverse CV

outcomes

Increased dietary fiber intake reduces CV risk

Diet Evidence:Diet Evidence:Making Smart Food ChoicesMaking Smart Food Choices

• Helps consumers make better food choices• Reminds individuals to eat healthfully• Illustrates the 5 food groups using a mealtime visual• Selected messages include:

• Balancing calories• Foods to increase• Foods to reduce

Source: United States Department of Agriculture, http://www.choosemyplate.gov/index.html

Source: Trichopoulou A et al. NEJM 2003;348:2599-2608

Variable# of Deaths/

# of ParticipantsFully Adjusted Hazard

Ratio (95% CI)

Death from any cause

275/22,043 0.75 (0.64-0.87)

Death from CHD

54/22,043 0.67 (0.47-0.94)

Death from cancer

97/22,043 0.76 (0.59-0.98)

Diet Evidence:Diet Evidence:Primary PreventionPrimary Prevention

CHD=Coronary heart disease

22,043 adults evaluated for adherence to a Mediterranean diet, with points given for high consumption of vegetables, legumes, fruits,

nuts, cereal, and fish and points subtracted for high consumption of meat, poultry, and dairy

High adherence to a Mediterranean diet is associated with a reduction in death

Lyon Diet Heart Study

Source: De Lorgeril M et al. Circulation 1999;99:779-785

*High in polyunsaturated fat and fiber, **High in saturated fat and low in fiber

605 patients following a myocardial infarction randomized to a Mediterranean* or Western** diet for 4 years

A Mediterranean diet reduces cardiovascular events

Diet Evidence:Diet Evidence:Secondary PreventionSecondary Prevention

1 2 3 4 570

80

90

100

Year

P=0.0001

Mediterranean dietWestern diet

Freedom

fro

m c

ard

iac

death

or

myoca

rdia

l in

farc

tion (

%)

<200 mg/dCholesterol

~15% of total caloriesProtein

20–30 g/dFiber50%–60% of total caloriesCarbohydrate (esp. complex

carbs)

25%–35% of total caloriesTotal fat

Up to 20% of total caloriesMonounsaturated fat

Up to 10% of total caloriesPolyunsaturated fat

<7% of total caloriesSaturated fat*

Recommended IntakeNutrient

Source: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497

Adult Treatment Panel (ATP) IIIAdult Treatment Panel (ATP) IIIDietary RecommendationsDietary Recommendations

*Trans fatty acids also raise LDL-C and should be kept at a low intakeNote: Regarding total calories, balance energy intake and expenditure to

maintain desirable body weight

LDL-C=Low density lipoprotein cholesterol

American Heart Association Nutrition American Heart Association Nutrition Committee Dietary RecommendationsCommittee Dietary Recommendations

• Balance calorie intake and physical activity to achieve or maintain a healthy body weight• Consume a diet rich in fruits and vegetables• Consume whole-grain, high-fiber foods• Consume fish, especially oily fish, at least twice a week• Limit intake of saturated fat to <7%, trans fat to <1% of energy, and cholesterol <300 mg/day by:

– Choosing lean mean and vegetable alternatives– Choosing fat free (skim), 1% fat, and low-fat dairy products,– Minimizing intake of partially hydrogenated fats

• Minimize intake of beverages and foods with added sugar• Choose and prepare foods with little or no salt• If alcohol is consumed, do so in moderation

Recommendations for Cardiovascular Disease Risk Reduction

Source: AHA Nutrition Committee. Circulation 2006;114:82-96

AHA=American Heart Association

Primary Prevention

Women should consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods; consume fish, especially oily fish,* at least twice a week; limit intake of saturated fat to <10% of energy, and if possible to <7%, cholesterol to <300 mg/d, alcohol intake to no more than 1 drink per day, and sodium intake to <2.3 g/d (approximately 1 tsp salt). Consumption of trans-fatty acids should be as low as possible (eg, <1% of energy)

*Pregnant and lactating women should avoid eating fish potentially high in methylmercury

Source: Mosca L et al. Circulation 2007;115:1481-1501

Dietary RecommendationsDietary Recommendations

I IIa IIb III


• To achieve reductions in LDL-C levels:

o Saturated fats should be <7% of energy intake.

o Dietary cholesterol intake should be <200 mg/day.

o Intake of trans-unsaturated fatty acids should be <1% of energy intake.

• Total energy intake should be adjusted to achieve body-weight goals.

• Total dietary fat intake should be moderated (25-35% of total calories) and should consist mainly of monounsaturated or polyunsaturated fat.

AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMDietary RecommendationsDietary RecommendationsPrimary Prevention

AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, LDL-C=Low density lipoprotein cholesterol


AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus

• Ample intake of dietary fiber (>14 grams/1000 calories consumed) may be of benefit.

• If individuals choose to drink alcohol, daily intake should be limited to 1 drink* for adult women and 2 drinks* for adult men. Alcohol ingestion increase caloric intake and should be minimized when weight loss is the goal. Individuals with elevated plasma triglyceride levels should limit alcohol intake, because intake may exacerbate hypertriglyceridemia.

• In both normotensive and hypertensive individuals, a reduction in sodium intake may lower blood pressure. The goal should be to reduce sodium intake to 1200-2300 mg/day.**

* Defined as a 12 ounce beer, a 4 ounce glass of wine, or a 1.5 ounce glass of distilled spirits

** Equivalent to 3000-6000 mg/day of sodium chloride

AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMDietary RecommendationsDietary RecommendationsPrimary Prevention

• Weight loss is recommended for all overweight or obese individuals who are at risk for DM.

• For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short-term (up to 1 year).

• Among individuals at high risk for developing type II DM, structured programs emphasizing lifestyle changes that include moderate weight loss (7% body weight) and regular physical activity (150 minutes/week) with dietary strategies include reduced intake of dietary fat and can reduce the risk of developing DM and are therefore recommended.


ADA=American Diabetes Association, DM=Diabetes mellitus

ADA Medical Nutrition Therapy ADA Medical Nutrition Therapy RecommendationsRecommendationsfor Patients with Diabetes Mellitusfor Patients with Diabetes MellitusPrimary Prevention

• Individuals at high risk for type II DM should be encouraged to achieve USDA recommendation for dietary fiber (14 grams fiber/1000 kcal) and foods containing whole grains (one-half of gram intake).

• Saturated fat intake should be <7% of total calories.

• Reducing intake of trans-fat lowers LDL-C and increase HDL-C. Therefore, intake of trans-fat should be minimized.

• Monitoring carbohydrate intake, whether by carbohydrate counting, exchanges, or experience-based estimation remains a key strategy in achieving glycemic control.


ADA=American Diabetes Association, DM=Diabetes mellitus, HDL-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol

ADA Medical Nutrition Therapy ADA Medical Nutrition Therapy RecommendationsRecommendationsfor Patients with Diabetes Mellitus for Patients with Diabetes Mellitus (Continued)(Continued)

Primary Prevention

• For individuals with DM, use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone.

• Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the FDA.

• If adults with DM choose to use alcohol, daily intake should be limited to a moderate amount (<1 drink per day for adult women and <2 drinks per day for adult men).



Primary Prevention

AHA=American Heart Association, DM=Diabetes mellitus, FDA=Food and Drug Administration

• Routine supplementation with antioxidants, such as Vitamin E and C, and carotene, is not advised because of lack of evidence of efficacy and concerns related to long-term safety.

• Benefit from chromium supplementation in patients with DM or obesity has not been conclusively demonstrated and therefore cannot be recommended.

• Individualized meal planning should include optimization of food choices to meet recommended dietary allowances (RDAs)/dietary reference intakes (DRIs) for all micronutrients.




Primary Prevention

Dietary therapy for all patients should include reduced intake of saturated fats (to <7% of total calories), trans fatty acids (to <1% of total calories), and cholesterol (to <200 mg/d)

For all patients, it may be reasonable to recommend omega-3 fatty acids from fish or fish oil capsules (1 gram/day) for cardiovascular disease risk reduction


Dietary RecommendationsDietary Recommendations

Secondary PreventionI IIa IIb III

I IIa IIb III

Physical Activity Evidence Physical Activity Evidence and Guidelinesand Guidelines



Adverse Effects of Physical Adverse Effects of Physical InactivityInactivity

Age

Diabetes Mellitus

Obesity

Genetics Atherosclerosis

Hypercoagulability

Smoking

Hypertension

Novel Risk Factors

Inflammation Dyslipidemia

Physical Inactivity

Prevalence of Physical ActivityPrevalence of Physical Activity

Source: Lloyd-Jones D et al. Circulation 2010;121:46-215

Prevalence of physical activity among individuals >18 years of age

Over half the U.S. adult population is physically inactiveNH=Non-Hispanic

Note: Minutes per week spent in moderate-intensity sports activity (low-active, 135min/wk; intermediately active, 136-195 min/wk; and highly active, >195 min/wk)

Total Body Fat Intra-abdominal Fat

Source: Irwin ML et al. JAMA 2003;289:323-330

173 sedentary, overweight (body mass index >24 kg/m2) post-menopausal women randomized to moderate intensity exercise

vs. stretching for 1 year

Moderate exercise reduces total and intra-abdominal fat

Exercise Evidence:Exercise Evidence:Effect on Body CompositionEffect on Body Composition

NS

5% 20%†

15% 34%*

8% 20%*

Change from Baseline

202171

199174

197190

200188

TGMenWomen

3956

4155

4050

3747

HDL-CMenWomen

118102

131120

134135

138155

LDL-CMenWomen

Year and Lipid Level (mg/dL)

196193

210209

213223

214239

TCMenWomen

531BaselineLipids

Source: Warner JG et al. Circulation 1995;92:773-777

*P=0.0001 for change in women vs men†P=0.03 for change in women vs men

HDL-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol, TG=Triglyceride

Exercise Evidence:Exercise Evidence:Effect on Lipid ParametersEffect on Lipid Parameters

Assessment of lipid profiles in 719 patients undergoing cardiac rehab

ILI DSE P value

LDL (mg/dL) -5.2 ± 0.6 -5.7 ± 0.6 0.49

HDL (mg/dL) 3.4 ± 0.2 1.4 ± 0.1 <0.001

Triglycerides (mg/dL) -30.3 ± 2.0 -14.6 ± 1.8 <0.001

% Metabolic Syndrome -14.7 ± 0.8 -7.1 ± 0.7 <0.001

5,145 patients aged 45-74 years with type 2 DM and BMI of 25 kg/m2 (27 kg/m2 if taking insulin) randomized to an intensive lifestyle intervention (ILI) involving group and individual meetings

to achieve and maintain weight loss through decreased caloric intake and increased physical activity versus diabetes support and

education (DSE)

Source: Look AHEAD investigators. Diabetes Care 2007;30:1374-1383

Exercise Evidence:Exercise Evidence:Effect on Lipid ParametersEffect on Lipid Parameters

Look AHEAD Trial

Intensive lifestyle intervention results in greater improvement in lipid parameters

BMI=Body mass index, DM=Diabetes mellitus, DSE=Diabetes support and education, ILI=Intensive lifestyle intervention

Source: Hu FB et al. JAMA 2003;289:1785-1791

Reduction:

Each hour a day spent walking

briskly

Increase:

Each two hours a day spent watching

TV

Increase:

Each two hours a day spent sitting at

work

Nurse’s Health Study

Exercise reduces the incidence of obesity and DM

Risk of obesityRisk of DM

0%

5%

10%

15%

20%

25%

30%

35%

Exercise Evidence:Exercise Evidence:Effect on Obesity and Diabetes Mellitus Effect on Obesity and Diabetes Mellitus (DM)(DM)

Source: Manson JE et al. NEJM 2002;347:716-725

Quintiles of activity (MET-hour/week**)

Walking

Rela

tive R

isk

of

CH

D

Vigorous exercise*

Rela

tive R

isk

of

CH

D

P=0.004

P=0.008

1 2 3 4 5

Women’s Health Initiative Observational Study

1 2 3 4 5

*Includes aerobics, aerobic dancing, jogging, tennis, and swimming laps**Average active hours per week energy expenditure per activity

CHD=Coronary heart disease

Exercise Evidence:Exercise Evidence:Effect on Coronary Heart Disease Effect on Coronary Heart Disease RiskRisk

0

10

20

30

40

50

60

70

1 2 3 4 5

Death

Rate

(p

er

10

,00

0)

Fitness Level (Low to High)

Source: Blair SN et al. JAMA 1998;262:2395-2401

MenWomen

Physical Activity:Physical Activity:Effect on MortalityEffect on Mortality

13,344 healthy men and women followed for 8 years

Low physical fitness is associated with increased mortality

Fitness Level (Low to High)

Source: Wannamethee SG et al. Circulation 2000;102:1358-1363

CHD=Coronary heart disease, CVD=Cardiovascular disease

Moderate exercise is associated with reduced mortality

Observational study of self-reported physical activity in 772 men with CHD

Physical Activity:Physical Activity:Secondary PreventionSecondary Prevention

Age-a

dju

sted m

ort

alit

y

rate

/100

0 p

ers

on-y

ears

Physical activity

* *

Effect of cardiac rehabilitation in randomized controlled trials following a MI

Source: Oldridge NB et al. JAMA 1988;260:945-950

*p<0.0125

Cardiac Rehabilitation:Cardiac Rehabilitation:Benefits Following a Myocardial Benefits Following a Myocardial InfarctionInfarction

Cardiac rehabilitation reduces CV events after a MI

CV=Cardiovascular, MI=Myocardial infarction

Source: Hammill BG et al. Circulation 2010;121:63-70

Observational study of 30,161 Medicare patients attending at least 1 phase II cardiac rehabilitation session

A large number of patients fail to complete 36 sessions of cardiac rehabilitation

Cardiac Rehabilitation:Cardiac Rehabilitation:Prevalence of Incomplete Prevalence of Incomplete AttendanceAttendance

Sess

ions

att

ended (

%)

Number of Sessions Attended

Source: Hammill BG et al. Circulation 2010;121:63-70

Cardiac Rehabilitation:Cardiac Rehabilitation:Greater Benefit with Greater Greater Benefit with Greater AttendanceAttendanceObservational study of 30,161 Medicare patients attending at

least 1 phase II cardiac rehabilitation session

There is a strong dose-response relationship between the number of cardiac rehabilitation sessions attended and long-term CV

outcomes

Death

(%

)

Myoca

rdia

l in

farc

tion

(%)

Years after Index Date Years after Index Date

CV=Cardiovascular

Source: Clark AM et al. Ann of Intern Med 2005;143:659-72

Meta-analysis of 63 randomized clinical trials evaluating cardiac secondary prevention programs with or without

exercise programs

Cardiac Rehabilitation:Cardiac Rehabilitation:Benefit of Secondary Prevention Benefit of Secondary Prevention ProgramsPrograms

All cause mortality Recurrent myocardial infarctionSecondary prevention programs provide CV benefit

CV=Cardiovascular


• To improve glycemic control, assist with weight loss or maintenance, and reduce the risk of CVD, at least 150 minutes of moderate-intensity aerobic physical activity or at least 90 minutes of vigorous aerobic exercise per week is recommended. The physical activity should be distributed over at least 3 days per week, with no more than 2 consecutive days without physical activity.

• For long-term maintenance of major weight loss, a larger amount of exercise (7 hours of moderate or vigorous aerobic physical activity per week) may be helpful.

AHA=American Heart Association, CV=Cardiovascular, CVD=Cardiovascular disease, DM=Diabetes mellitus

AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMPhysical Activity RecommendationsPhysical Activity RecommendationsPrimary Prevention

• People with DM should be advised to perform at least 150 minutes/week of moderate-intensity aerobic physical activity (50-70% of maximum heart rate).

• In the absence of contraindications, people with type II DM should be encouraged to perform resistance training three times per week.



ADA Physical Activity RecommendationsADA Physical Activity Recommendationsfor Patients with Diabetes Mellitusfor Patients with Diabetes Mellitus

Primary Prevention


At least 30 minutes, 7 days per week (minimum 5 days per week) of physical activity

For all patients, the clinician should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work) to improve cardiorespiratory fitness and move patients out of the least fit, least active high-risk cohort


I IIa IIb III

Physical ActivityPhysical ActivityRecommendationsRecommendations

Goal:


For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription

The clinician should counsel patients to report and be evaluated for symptoms related to exercise.

It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week


Physical ActivityPhysical ActivityRecommendations (Continued)Recommendations (Continued)

I IIa IIb III

I IIa IIb III

I IIa IIb III


All eligible patients with ACS or whose status is immediately post coronary artery bypass surgery or post-PCI should be referred to a comprehensive outpatient cardiovascular rehabilitation program either prior to hospital discharge or during the first follow-up office visit

All eligible outpatients with the diagnosis of ACS, coronary artery bypass surgery or PCI (Level of Evidence: A), chronic angina (Level of Evidence: B), and/or peripheral artery disease (Level of Evidence: A) within the past year should be referred to a comprehensive outpatient cardiovascular rehabilitation program.


Cardiac RehabilitationCardiac RehabilitationRecommendationsRecommendations

I IIa IIb III

I IIa IIb III

I IIa IIb III


A home-based cardiac rehabilitation program can be substituted for a supervised, center-based program for low-risk patients

A comprehensive exercise-based outpatient cardiac rehabilitation program can be safe and beneficial for clinically stable outpatients with a history of heart failure


Cardiac RehabilitationCardiac RehabilitationRecommendations (Continued)Recommendations (Continued)

I IIa IIb III

I IIa IIb III

5 acc prevention lifestyle changes

Health & Medicine

practice guidelines

levels of evidence

evidence levels

clinical trials

level of evidence b

sets of recommendations

guideline recommendations

smoking prevalence