Lifestyle Management Evidence and Guidelines
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Lifestyle Management Evidence and Guidelines Andrew P. DeFilippis, Ty J. Gluckman, Catherine Campbell, Suzanne Hughes, Gregg Fonarow, & Roger S. Blumenthal. Cigarette Smoking Cessation Evidence and Guidelines. Smoking Prevalence in the United States. %. MMWR 1999;48:998

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Lifestyle management evidence and guidelines

Lifestyle Management Evidence and Guidelines

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


Cigarette smoking cessation evidence and guidelines

Cigarette Smoking Cessation Evidence and Guidelines


Lifestyle management evidence and guidelines

Smoking Prevalence in the United States

%

MMWR 1999;48:998

National Center for Health Statistics-1998


Lifestyle management evidence and guidelines

Cigarette Smoking Cessation: Evidence

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

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


Lifestyle management evidence and guidelines

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)

Cigarette Smoking Cessation: Risk of Non-fatal MI*

Study

RR (95% Cl)

10

0.1

1.0

Ceased smoking

Continued smoking

  • *Includes those with known coronary heart disease

  • CI=Confidence interval, RR=Relative risk

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


Lifestyle management evidence and guidelines

Cigarette Smoking Cessation: Self-help Materials

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

% Abstinent at 4 months

Strecher VJ. Patient Educ Couns 1999;36:107-117

Strecher VJ et al. Journal of Family Practice

1994;39:262–270.


Lifestyle management evidence and guidelines

12-24 Years Old

25+ Years Old

Cigarette Smoking Cessation: Nicotine Dependence

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

Less than 6

6-15

16-25

26+

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


Lifestyle management evidence and guidelines

14

12

10

8

Cigarette

Gum 4 mg

Gum 2 mg

Inhaler

Nasal spray

Patch

6

4

2

0

5 10 15 20 25 30

Minutes

Cigarette Smoking Cessation: Nicotine Replacement

Plasma nicotine concentrations

Increase in nicotine concentration (ng/ml)

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


Lifestyle management evidence and guidelines

Greatest Benefit with Combination Therapy

Limited Behavioral Support

Intensive Behavioral Support

  • CI=Confidence interval

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

Silagy C et al. Cochrane Database Syst Rev

2002;CD000146


Lifestyle management evidence and guidelines

Cigarette Smoking Cessation: Primary Prevention

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

NRT=Nicotine replacement therapy

ap<0.001 when compared to placebo

bp=0.001 when compared to NRT

cp<0.001 when compared to NRT

dp=0.37 when compared to bupropion

ep=0.22 when compared to bupropion

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


Lifestyle management evidence and guidelines

Cigarette Smoking Cessation: Primary Prevention

1,027 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)

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


Lifestyle management evidence and guidelines

Smoking Cessation Pharmacotherapy*

*Pharmacotherapy combined with behavioral support provides the best success rate

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


Lifestyle management evidence and guidelines

Smoking Cessation Algorithm

Ask and document

tobacco use status

  • Prevent Relapse

  • Congratulate successes

  • Encourage

  • Discuss benefits experienced by patient

  • Address weight gain, negative mood, and lack of support

Recent Quitter

(<6 months)

Current User

Advise: Provide a strong, personalized

message

  • 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

Assess* readiness to quit in next 30 days

Not Ready

Ready

  • Assist

  • Negotiate plan

  • STAR**

  • Discuss pharmacotherapy

  • Social support

  • Provide educational materials

**STAR

Set quit date

Tell family, friends, and coworkers

Anticipate challenges: withdrawal, breaks

Remove tobacco from the house, car etc.

  • 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


Lifestyle management evidence and guidelines

Goals Recommendations

Cigarette Smoking Cessation Guidelines

Complete cessation

No environmental tobacco smoke exposure

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


Diet and weight management evidence and guidelines

Diet and Weight Management Evidence and Guidelines


Lifestyle management evidence and guidelines

Overweight and Obese States—Body Mass Index

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

*Measurement of waist circumference is most helpful in this category

BMI=Body mass index

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.

NIH/NHLBI/NAASO. October, 2000. NIH publication No. 00-4084.


Lifestyle management evidence and guidelines

Relationship between BMI and Visceral Adiposity

Body Mass Index

Adipose Tissue (kg)

BMI=Body mass index

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


Lifestyle management evidence and guidelines

1991

Prevalence of Obesity in U.S. Adults

1996

2006

Percentage of State Obese (BMI > 30)

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

CDC Overweight and Obesity


Lifestyle management evidence and guidelines

Risk of Hypertension Increases with BMI

Systolic BP

>140 mm Hg (%)

Body Mass Index

BP=Blood pressure

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


Lifestyle management evidence and guidelines

BMI in Youth Predicts Adult Obesity

Adult Obesity

at Age 21-29 Years (%)

Age of Child (Yrs)

BMI=Body mass index

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


Lifestyle management evidence and guidelines

Risk of DM Increases with Body Mass Index

Incidence of DM

(Per 1,000 Person-Years)

Body Mass Index

DM=Diabetes mellitus

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


Lifestyle management evidence and guidelines

HemorrhagicCVA

IschemicCVA

Ischemic HeartDisease

4.0

4.0

4.0

2.0

2.0

2.0

Hazard Ratio

1.0

1.0

1.0

0.5

0.5

0.5

16

16

20

20

24

24

28

28

32

32

36

36

16

20

24

28

32

36

Body Mass Index (kg/m2)*

CV Risk Increases with BMI

CV=Cardiovascular

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

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


Lifestyle management evidence and guidelines

Diet Evidence: Treatment Programs

  • 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


Lifestyle management evidence and guidelines

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.


Lifestyle management evidence and guidelines

Diet Evidence: Primary Prevention

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

Ornish

20/40*

Weight Watchers

26/40*

Zone

26/40*

Atkins

21/40*

0

3

6

9

Wt loss (lbs)

*Ratio of individuals completing the study to those enrolled

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


Lifestyle management evidence and guidelines

Goals Recommendations

Weight Management Guidelines

Calculate BMI* and measure waist circumference

Monitor response to treatment

BMI 18.5 to 24.9 kg/m2

Women: <35 inches

Men: <40 inches

Start weight management and physical activity as appropriate

10% weight reduction within the 1st yr of Rx

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


Diet cardiovascular events and guidelines

Diet, Cardiovascular Events, and Guidelines


Lifestyle management evidence and guidelines

Diet Evidence: Effect 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

30

LDL-C

LDL-C:HDL-C

CRP

20

10

Low fat diet

0

Statin

Change from Baseline (%)

-10

Dietary portfolio*

-20

-30

-40

-50

0

2

4

0

2

4

0

2

4

Weeks

Weeks

Weeks

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

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


Lifestyle management evidence and guidelines

Relationship Between Diet and CV Disease

Risk of Coronary Heart Disease

Diet

Intermediary Biological Mechanisms*

*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

Hu FB et al. JAMA. 2002;288:2569-2578


Lifestyle management evidence and guidelines

Diet Evidence: Effect on Blood Pressure

Dietary Approaches to Stop Hypertension (DASH) Group

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

A diversified diet improves blood pressure

132

Systolic blood pressure

(mm Hg)

130

128

Diet low in fruits, vegetables, and dairy products

126

124

Diet enriched in fruits, vegetables, and fiber

86

84

Diastolic blood pressure

(mm Hg)

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

82

80

78

0

1

2

3

4

5

6

7/8

Weeks

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


Lifestyle management evidence and guidelines

Diet Evidence: Benefits of Fruits and Vegetables

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

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

*Includes nonfatal MI and fatal coronary heart disease

CV=Cardiovascular, MI=Myocardial infarction

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


Lifestyle management evidence and guidelines

Diet Evidence: Benefits of Whole Grain 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

RR=0.73, P<0.001

CV=Cardiovascular, CHD=Coronary heart disease

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


Lifestyle management evidence and guidelines

w-3 Fatty Acids: Secondary Prevention

Diet and Reinfarction Trial (DART)

Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (GISSI)

N-3 Fatty Acids

Placebo

All cause mortality (%)

DART* (n=3,482)

GISSI* (n=11,324)

w-3 fatty acids reduce mortality post MI

*Post myocardial infarction

Burr ML et al. Lancet 1989;2:757-761

GISSI Investigators. Lancet 1999;354:447-455


Lifestyle management evidence and guidelines

USDA vs. Mediterranean Dietary Recommendations

USDA=United States Department of Agriculture


Lifestyle management evidence and guidelines

Mediterranean Diet and Survival

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


Lifestyle management evidence and guidelines

Diet Evidence: Secondary Prevention

Lyon Diet Heart Study

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

A “Mediterranean” diet reduces CVD event rates

100

90

Cardiac death or myocardial infarction

Mediterranean diet

Western diet

80

P=0.0001

70

1

2

3

4

5

Year

*High in polyunsaturated fat and fiber

**High in saturated fat and low in fiber

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


Lifestyle management evidence and guidelines

w-3 Fatty Acids: Secondary Prevention

Diet and Reinfarction Trial (DART)

Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (GISSI)

N-3 Fatty Acids

Placebo

All cause mortality (%)

DART* (n=3,482)

GISSI* (n=11,324)

w-3 fatty acids reduce mortality post MI

*Post myocardial infarction

Burr ML et al. Lancet 1989;2:757-761

GISSI Investigators. Lancet 1999;354:447-455


Lifestyle management evidence and guidelines

ATP III Dietary Recommendations

Nutrient

Recommended Intake

Saturated fat*

<7% of total calories

Polyunsaturated fat

Up to 10% of total calories

Monounsaturated fat

Up to 20% of total calories

Total fat

25%–35% of total calories

Carbohydrate (esp. complex carbs)

50%–60% of total calories

Fiber

20–30 g/d

Protein

~15% of total calories

Cholesterol

<200 mg/d

*Trans fatty acids also raise LDL-C and should be kept at a low intake

Note: Regarding total calories, balance energy intake and expenditure to maintain

desirable body weight.

ATP=Adult Treatment Panel

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


Lifestyle management evidence and guidelines

w-3 Fatty Acids: Primary and Secondary Prevention

JELIS 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

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


Lifestyle management evidence and guidelines

AHA Nutrition Committee Dietary Recommendations

Recommendations for Cardiovascular Disease Risk Reduction

  • 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

AHA=American Heart Association

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


Lifestyle management evidence and guidelines

Dietary Guidelines

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


Lifestyle management evidence and guidelines

Dietary Guidelines

Secondary Prevention

Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and

cholesterol (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.


Physical activity evidence and guidelines

Physical Activity Evidence and Guidelines


Lifestyle management evidence and guidelines

Exercise Evidence: Role of Physical Inactivity

Physical Inactivity

Inflammation

Dyslipidemia

Age

Hypertension

Diabetes Mellitus

Smoking

Obesity

Hypercoagulability

Atherosclerosis

Genetics

Novel Risk Factors


Lifestyle management evidence and guidelines

Prevalence of Physical Inactivity

National Population Health Survey

Statistics Canada, National Population Health Survey, 1996/1997


Lifestyle management evidence and guidelines

Exercise Evidence: Effect on Body Composition

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

Total Body Fat

Intra-abdominal Fat

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)

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


Lifestyle management evidence and guidelines

Year and Lipid Level (mg/dL)

Change from Baseline

Lipids

Baseline

1

3

5

TC

Men

Women

214

239

213

223

210

209

196

193

 8%

 20%*

LDL-C

Men

Women

138

155

134

135

131

120

118

102

 15%

 34%*

HDL-C

Men

Women

37

47

40

50

41

55

39

56

 5%

 20%†

TG

Men

Women

200

188

197

190

199

174

202

171

NS

Exercise Evidence: Effect on Lipid Parameters

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

*P=0.0001 for change in women vs men

†P=0.03 for change in women vs men

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


Lifestyle management evidence and guidelines

Exercise Evidence: Effect on Obesity and Diabetes

Nurse’s Health Study

35%

Risk of obesity

30%

Risk of DM

25%

20%

15%

10%

5%

0%

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

Exercise reduces the incidence of obesity and DM

DM=Diabetes mellitus

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


Lifestyle management evidence and guidelines

Exercise Evidence: Effect on CHD Risk

Women’s Health Initiative Observational Study

Vigorous exercise*

Walking

P=0.008

P=0.004

Relative Risk of CHD

Relative Risk of CHD

1

2

3

4

5

1

2

3

4

5

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

CHD=Coronary heart disease

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

**Average active hours per week  energy expenditure per activity

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


Lifestyle management evidence and guidelines

Exercise Evidence: Effect on Mortality

13,344 healthy men and women followed for 8 years

Low physical fitness is associated with increased mortality

Men

Women

Death Rate (per 10,000)

Fitness Level (Low to High)

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


Lifestyle management evidence and guidelines

Exercise Evidence: Secondary Prevention

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

Moderate exercise is associated with reduced mortality

CHD=Coronary heart disease, CVD=Cardiovascular disease

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


Lifestyle management evidence and guidelines

Exercise Evidence: Secondary Prevention

Effect of cardiac rehabilitation in randomized controlled trials following a MI

*

*

CV=Cardiovascular, MI=Myocardial infarction,

*p<0.0125

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


Lifestyle management evidence and guidelines

Goals Recommendations

Physical Activity Guidelines

Minimum: 30-60 minutes,

5 days per week

Optimal: 30-60 minutes,

7 days per week

  • 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)


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