lifestyle management evidence and guidelines

1

Lifestyle Management Evidence and Lifestyle Management Evidence and Guidelines Guidelines

Andrew P. DeFilippis, Ty J. Gluckman, Catherine Campbell, Suzanne Hughes, Gregg Fonarow, & Roger S. Blumenthal

2

Cigarette Smoking Cessation Evidence Cigarette Smoking Cessation Evidence and Guidelinesand Guidelines

3

Smoking Prevalence in the United StatesSmoking Prevalence in the United States

0

10

20

30

40

50

60

1965 1974 1979 1983 1985 1987 1990 1991 1992 1993 1994 1995 1997

MalesFemales

MMWR 1999;48:998National Center for Health Statistics-1998

%

4

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%)

Common preventable causes of death in U.S. in 1990 & 2000

Cigarette Smoking Cessation: EvidenceCigarette Smoking Cessation: Evidence

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

5

0.1 1.0 10Ceased smoking Continued smoking

RR (95% Cl)StudyAberg, 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)

Cigarette Smoking Cessation: Risk of Non-fatal MI*Cigarette Smoking Cessation: Risk of Non-fatal MI*

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

*Includes those with known coronary heart disease

CI=Confidence interval, RR=Relative risk

6

7.1 7.7

30.7

9

0

5

10

15

20

25

30

35

Light / moderate (<20 cig/day) Heavy (>20 cig/day)

Cigarettes smoked per day

Generic materialsTailored materials

% A

bstin

ent a

t 4 m

onth

s

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

Strecher VJ. Patient Educ Couns 1999;36:107-117Strecher VJ et al. Journal of Family Practice 1994;39:262–270.

Cigarette Smoking Cessation: Self-help MaterialsCigarette Smoking Cessation: Self-help Materials

7

62

84 87 88

47

82 8678

0

20

40

60

80

100

Cigarettes/Day

Per

cent

12-24 Years Old 25+ Years Old

Less than 6 6-15 16-25 26+

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

Substance Abuse and Mental Health Services Administration; United States, National Household Survey on Drug Abuse, 1991/1992.

Cigarette Smoking Cessation: Nicotine DependenceCigarette Smoking Cessation: Nicotine Dependence

8

Minutes

CigaretteGum 4 mg

Gum 2 mg

Inhaler

Nasal sprayPatch

5 10 15 20 25 30

0

2

4

6

8

10

12

14

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

Incr

ease

in n

icot

ine

conc

entra

tion

(ng/

ml)

Cigarette Smoking Cessation: Nicotine ReplacementCigarette Smoking Cessation: Nicotine Replacement

Plasma nicotine concentrations

9

Limited Behavioral Support

Greatest Benefit with Combination TherapyGreatest Benefit with Combination Therapy

Intervention Effect Size 95% CI

Nicotine gum 5% 4-6%Nicotine transdermal patch 5% 4-7%

Intervention Effect Size 95% CINicotine 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

West R et al. Thorax 2000;55:987-999Silagy C et al. Cochrane Database Syst Rev 2002;CD000146

CI=Confidence interval

10Jorenby DE et al. NEJM 1999;340:685-91

Cigarette Smoking Cessation: Primary PreventionCigarette Smoking Cessation: Primary Prevention

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

NRT=Nicotine replacement therapy

893 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

Bupropion with or without NRT provides the greatest benefit

11Jorenby DE et al. JAMA 2006;296:56-63

Cigarette Smoking Cessation: Primary PreventionCigarette Smoking Cessation: Primary Prevention1,027 smokers randomized to 12 weeks of varenicline (titrated to 1 mg bid), bupropion

(titrated to 150 mg bid), or placebo

Varenicline appears more effective than bupropion

Varenicline vs. Bupropion P<0.001 (weeks 9-12), P=0.004 (weeks 9-52)

12

Smoking Cessation Pharmacotherapy*Smoking Cessation Pharmacotherapy*Agent Caution Side Effects Dosage Duration Instructions

Bupropion SR(Zyban®)

Seizure disorderEating disorder

Taking MAO inhibitor

Pregnancy

InsomniaDry mouth

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.

TransdermalNicotinePatch**

Within 2 weeks of a MI

Unstable anginaArrhythmiasHeart 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

disorder

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

13

Ask and document tobacco use status

Advise: Provide a strong, personalizedmessage

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

Smoking Cessation AlgorithmSmoking Cessation Algorithm

14

Complete cessation

No environmental tobacco smoke exposure

Cigarette Smoking Cessation GuidelinesCigarette Smoking Cessation Guidelines

Goals Recommendations

Ask about tobacco use at every visit

In a clear, strong, and personalized manner, advise the patient to stop smoking

Urge avoidance of exposure to second-hand smoke at work and home

Assess patient’s willingness to quit smoking

Develop a plan for smoking cessation and arrange follow-up

Provide counseling, pharmacologic therapy, and referral to a formal cessation program

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

15

Diet and Weight Management Evidence Diet and Weight Management Evidence and Guidelinesand Guidelines

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

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

Overweight and Obese States—Body Mass IndexOverweight and Obese States—Body Mass Index

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

BMI=Body mass index

17

Relationship between BMI and Visceral AdiposityRelationship between BMI and Visceral Adiposity

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160

Zumoff B et al. J Clin Endocrinol Metab 1990;70:929-931

BMI=Body mass index

Bod

y M

ass

Inde

x

Adipose Tissue (kg)

18

Prevalence of Obesity in U.S. AdultsPrevalence of Obesity in U.S. Adults1991 1996

2006

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

CDC Overweight and Obesity

Percentage of State Obese (BMI > 30)

19

Risk of Hypertension Increases with BMIRisk of Hypertension Increases with BMI

0

10

20

30

40

<21 21-22 23-24 25-26 27-28 29-30 31+

Men Women

Sys

tol ic

BP

>1

4 0 m

m H

g (%

)

Body Mass Index

Canadian Guidelines for Healthy Weights. Cat No. H39-134/1989E; 1988:69

BP=Blood pressure

20

BMI in Youth Predicts Adult ObesityBMI in Youth Predicts Adult Obesity

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

BMI=Body mass index

Adu

lt O

besi

ty

at A

ge 2

1-29

Yea

rs (%

)

Age of Child (Yrs)

21

Risk of DM Increases with Body Mass IndexRisk of DM Increases with Body Mass Index

0

20

40

60

80

100

<20 20-25 25-30 30-35 35-40 >40Body Mass Index

Inci

denc

e of

DM

(Per

1, 0

00 P

e rso

n-Y

ears

)

Knowler WC et al. Am J Epidemiol 1981;113:144-156

DM=Diabetes mellitus

22Mhurchu 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)*

Haz

ard

Rat

io

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

CV Risk Increases with BMICV Risk Increases with BMI

CV=Cardiovascular

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

23

• 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: Treatment ProgramsDiet Evidence: Treatment Programs

24

Diet Evidence: Treatment Programs (Continued)Diet Evidence: Treatment Programs (Continued)• 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.

25

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

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

Diet Evidence: Primary PreventionDiet Evidence: Primary Prevention

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

26


Calculate BMI* and measure waist circumference

Monitor response to treatmentBMI 18.5 to 24.9 kg/m2

Women: <35 inchesMen: <40 inches

Weight Management GuidelinesWeight Management Guidelines

Start weight management and physical activity as appropriate

If BMI and/or waist circumference is above goal, initiate caloric restriction and increase caloric expenditure

BMI=Body mass index, Rx=Treatment

*BMI is calculated as the weight in kilograms divided by the body surface area in meters2

Overweight state is defined by BMI=25-30 kg/m2 Obesity is defined by a BMI >30 kg/m2

10% weight reduction within the 1st yr of Rx



27

Diet, Cardiovascular Events, and Guidelines

28Jenkins DJ et al. JAMA 2003;290:502-10

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

0

10

20

30

-50

-40

-30

-20

-10

0 2 4 0 2 4 0 2 4

LDL-C

Cha

nge

from

Bas

elin

e (%

) LDL-C:HDL-C CRP

Weeks Weeks Weeks

Low fat diet

Statin

Dietary portfolio*

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

29Hu FB et al. JAMA. 2002;288:2569-2578

Relationship Between Diet and CV DiseaseRelationship Between Diet and CV Disease

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

30

Appel LJ et al. NEJM 1997;336:1117-24

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

Diet Evidence: Effect on Blood PressureDiet Evidence: Effect on Blood Pressure

132130128

126124

86

84

82

8078

1 2

Dietary Approaches to Stop Hypertension (DASH) Group

0 3 4 5 6

Systolic blood pressure

(mm Hg)

Diastolic blood pressure

(mm Hg)

Weeks 7/8

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

A diversified diet improves blood pressure

31Joshipura KJ et al. Ann Intern Med 2001;134:1106-14

Diet Evidence: Benefits of Fruits and VegetablesDiet Evidence: Benefits of Fruits and VegetablesNurses’ Health Study and Health Professional’s Follow-up Study

*Includes nonfatal MI and fatal coronary heart disease

CV=Cardiovascular, MI=Myocardial infarction

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

32Pereira MA et al. Arch Int Med 2004;164:370-76

Diet Evidence: Benefits of Whole Grain and FiberDiet Evidence: Benefits of Whole Grain and Fiber

RR=0.73, P<0.001

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

CV=Cardiovascular, CHD=Coronary heart disease

33

*Post myocardial infarction

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

DART* (n=3,482) GISSI* (n=11,324)

N-3 Fatty Acids

Placebo

-3 Fatty Acids: Secondary Prevention-3 Fatty Acids: Secondary Prevention

Burr ML et al. Lancet 1989;2:757-761GISSI Investigators. Lancet 1999;354:447-455

Diet and Reinfarction Trial (DART)Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto

miocardico (GISSI)

All

caus

e m

orta

lity

(%)

-3 fatty acids reduce mortality post MI

34

USDA vs. Mediterranean Dietary RecommendationsUSDA vs. Mediterranean Dietary Recommendations

USDA=United States Department of Agriculture

35Trichopoulou A et al. NEJM 2003;348:2595-6

Variable No. of Deaths/No of Participants

Fully Adjusted Hazard Ratio (95%

CI)Death from any

cause275/22,043 0.75 (0.64-0.87)

Death form coronary heart

disease

54/22,043 0.67 (0.47-0.94)

Death from cancer 97/22,043 0.76 (0.59-0.98)

Mediterranean Diet and SurvivalMediterranean Diet and Survival

36

1 2 3 4 570

80

90

100

Year

P=0.0001

Mediterranean dietWestern diet

Lyon Diet Heart Study

Diet Evidence: Secondary PreventionDiet Evidence: Secondary Prevention

Car

diac

dea

th o

r m

yoca

rdia

l inf

arct

ion

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 MI randomized to a Mediterranean* or Western** diet for 4 years

A “Mediterranean” diet reduces CVD event rates

37

*Post myocardial infarction

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

DART* (n=3,482) GISSI* (n=11,324)

N-3 Fatty Acids

Placebo

-3 Fatty Acids: Secondary Prevention-3 Fatty Acids: Secondary Prevention

Burr ML et al. Lancet 1989;2:757-761GISSI Investigators. Lancet 1999;354:447-455

Diet and Reinfarction Trial (DART)Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto

miocardico (GISSI)

All

caus

e m

orta

lity

(%)

-3 fatty acids reduce mortality post MI

38

*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.

<200 mg/dCholesterol~15% of total caloriesProtein

20–30 g/dFiber50%–60% of total caloriesCarbohydrate (esp. complex carbs)25%–35% of total caloriesTotal fatUp to 20% of total caloriesMonounsaturated fatUp to 10% of total caloriesPolyunsaturated fat

<7% of total caloriesSaturated fat*Recommended IntakeNutrient

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-97

ATP III Dietary RecommendationsATP III Dietary Recommendations

ATP=Adult Treatment Panel

39Yokoyama M et al. Lancet. 2007;369:1090-8

-3 Fatty Acids: Primary and Secondary Prevention-3 Fatty Acids: Primary and Secondary PreventionJELIS Trial

18,645 patients with hypercholesterolemia randomized to EPA (1800 mg) with a statin or a statin alone for 5 years

EPA provides additional cardiovascular benefit to those on statin therapy, particularly in secondary prevention

Composite of cardiac death, myocardial infarction, angina, PCI, or CABG

40

AHA Nutrition Committee Dietary RecommendationsAHA Nutrition Committee 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

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

AHA=American Heart Association

41

Primary Prevention

Dietary Guidelines Dietary Guidelines

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


42

Secondary Prevention

Dietary GuidelinesDietary Guidelines

Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, andcholesterol (to <200 mg/d).

Encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per d) for risk reduction may be reasonable for patients with known CAD.



43

Physical Activity Evidence and Physical Activity Evidence and GuidelinesGuidelines

44

Age

Diabetes Mellitus

Obesity

Genetics

Exercise Evidence: Role of Physical InactivityExercise Evidence: Role of Physical Inactivity

Atherosclerosis

Hypercoagulability

Smoking

Hypertension

Novel Risk Factors

Inflammation Dyslipidemia

Physical Inactivity

45

49

59 61 63 6064

80

59

37

5561 62

58 56

65

54

0

20

40

60

80

100

15-24 25-34 35-44 45-54 55-64 65-74 75+ All

Age Group

Per

cent Women

Men

Prevalence of Physical InactivityPrevalence of Physical Inactivity

Statistics Canada, National Population Health Survey, 1996/1997

National Population Health Survey

46

Exercise Evidence: Effect on Body CompositionExercise Evidence: Effect on Body Composition

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

Total Body Fat Intra-abdominal Fat

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

173 sedentary, overweight (BMI >24 kg/m2) post-menopausal women randomized to moderate intensity exercise vs. stretching for 1 year

Moderate exercise reduces total and intra-abdominal fat

47

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

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

Exercise Evidence: Effect on Lipid ParametersExercise Evidence: Effect on Lipid Parameters

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

48Hu FB et al. JAMA 2003;289:1785-91

Exercise Evidence: Effect on Obesity and DiabetesExercise Evidence: Effect on Obesity and Diabetes

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 or driving

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%

DM=Diabetes mellitus

49Manson JE et al. NEJM 2002;347:716-25

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

0.0

0.2

0.4

0.6

0.8

1.0

Walking

Rel

ativ

e R

isk

of C

HD

0.0

0.2

0.4

0.6

0.8

1.0

Vigorous exercise*

Rel

ativ

e R

isk

of C

HD

P=0.004P=0.008

1 2 3 4 5

Exercise Evidence: Effect on CHD RiskExercise Evidence: Effect on CHD RiskWomen’s Health Initiative Observational Study

1 2 3 4 5

**Average active hours per week energy expenditure per activity

*Includes aerobics, aerobic dancing, jogging, tennis, and swimming laps

CHD=Coronary heart disease

50

Exercise Evidence: Effect on MortalityExercise Evidence: Effect on Mortality

0

10

20

30

40

50

60

70

1 2 3 4 5

Dea

th R

ate

(per

10,

000)

Fitness Level (Low to High)

Blain SN et al. JAMA 1989; 262:2395-401

MenWomen

13,344 healthy men and women followed for 8 years

Low physical fitness is associated with increased mortality

51Wannamethee SG et al. Circulation 2000;102:1358-1363

Exercise Evidence: Secondary PreventionExercise Evidence: Secondary Prevention

CHD=Coronary heart disease, CVD=Cardiovascular disease

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

Moderate exercise is associated with reduced mortality

52

0.76 0.75

1.15

0

0.5

1

1.5

All Cause Death CV Mortality Nonfatal Recurrence

Poo

led

Odd

s R

atio

* *

Exercise Evidence: Secondary PreventionExercise Evidence: Secondary Prevention Effect of cardiac rehabilitation in randomized controlled trials following a MI

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

*p<0.0125

CV=Cardiovascular, MI=Myocardial infarction,

53

Assess risk, preferably with an exercise test, to guide prescription (Class I, Level B)

Encourage aerobic activity (e.g., walking, jogging, cycling) supplemented by an increase in daily activities (e.g., walking breaks at work, gardening, household work) (Class I, Level B)

Encourage resistance training (e.g., weight machines, free weights) 2 days a week (Class IIb, Level C)

Encourage cardiac rehabilitation for patients with stable angina, recent MI, LV systolic dysfunction, or recent CABG (Class I, Level B)

Minimum: 30-60 minutes,5 days per week

Optimal: 30-60 minutes,7 days per week


Physical Activity GuidelinesPhysical Activity Guidelines


lifestyle management evidence and guidelines

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