Lifestyle Medicine and Cardiovascular Health: The Future is Now! May 11, 2011

1. Lifestyle Medicine and Cardiovascular Health: The Future is Now!May 11, 2011 Presenter: James M. Rippe, MD – Leading cardiologist, Founder and Director, Rippe Lifestyle Institute Moderator: Barbara J. Ivens, MS, RD, FADA – Senior Nutrition Director, ConAgra Foods Approved for 1 CPE (Level 2) by the American Dietetic Association Commission on Dietetic Registration • Recording of the May 11, 2011 webinar and PDF download of complete PowerPoint available at: www.ConAgraFoodsScienceInstitute.com

2. Lifestyle Medicine and Cardiovascular Health: The Future is Now! Nutri-Bitessm Summary This webinar covered: • Major risk factors for heart disease relate directly to four lifestyle behaviors: sedentary lifestyle; overweight and obesity; energy-dense diet; smoking. • Numerous authoritative national guidelines recommend lifestyle behaviors for prevention and treatment of chronic diseases (i.e. Dietary Guidelines 2010; Physical Activity Guidelines for Americans 2008; AHA 2020 Strategic Impact Goals; Am Diabetes Assoc Diabetes Mgt; AAP; etc) • Encourage primary and secondary prevention through lifestyle principles. • Strategies should focus on building awareness and tracking changes. Weigh regularly; moderate portion sizes; increase activity; self-monitor; model healthful behaviors; offer counseling.

3. Lifestyle Risk Factors for CVD Evidence shows many major risk factors for heart disease relate directly to four lifestyle behaviors. • Sedentary lifestyle • Overweight and obesity • Energy-dense diet (high in calories; high in saturated fats, added sugars and refined grains; and low in fiber, whole grains, healthy fats, and certain micronutrients) • Smoking

4. Authoritative Guidelines Many current authoritative guidelines recommend lifestyle behaviors for prevention and treatment of chronic disease and place emphasis on implementation • Dietary Guidelines for Americans 2010 (released 1/31/2011) • Physical Activity Guidelines for Americans 2008 • National Cholesterol Education Program • JNC VII Guidelines for Prevention and Management of Hypertension • Institute of Medicine Guidelines for Management of Obesity • AHA Guidelines for the Prevention and Management of Coronary Artery Disease • AHA Nutrition Implementation Guidelines • AHA 2020 Strategic Impact Goals

5. Authoritative Guidelines • Guidelines from the American Diabetes Association for the Management of Diabetes • American Academy of Pediatrics Guidelines for Prevention and Treatment of Childhood Obesity • American Academy of Pediatrics for Heart Disease Risk Factor Reduction in Children • AHA and AAP Guidelines for Prevention and Treatment of Metabolic Syndrome • AHA and American Cancer Society Joint Statement on prevention of heart disease and cancer. • Endocrine Society guidelines for prevention of CVD and type 2 diabetes in patients at metabolic risk • American Dietetic Association position paper on Total Diet Approach to Communicating Food and Nutrition Information

6. Cornerstone Principles Lifestyle Medicine principles serve as a cornerstone in all these guidelines. • Put primary prevention through lifestyle first • Manage weight—get regular physical activity, match calories consumed to calories burned • Get nutrients needed from foods; select a variety of nutrient-dense foods; eat fewer energy-dense foods • Get regular physical activity. Goals– 30 min/d or 150 min/wk of moderate intensity or equivalent high intensity; strength train 2 d/wk • Quit smoking or don’t start smoking • Manage stress and get adequate rest

7. It’s Never Too Late to Change • Newly adopting a healthful lifestyle in middle age lowers overall mortality and decreases incidence of cardiovascular events for years.1 • 15, 708 Adults, 45 – 65 y, Atherosclerosis in Communities Study • Choices: eat 5 or more F/V daily; regularly PA; BMI <30; not current smoker • Longitudinal lifestyle interventions in individuals at high risk of type 2 diabetes found a lower incidence of diabetes in participants vs. controls. 2, 3 • Lifestyle practices in very old lowered risk of CVD mortality • 13,296 adults, Leisure World Cohort Study • Not smoking, moderate alcohol intake, physical activity and normal weight for >70 y to 80+ years associated with decreased mortality4 Sources: 1) King 2007 2) Li 2008 3)Lindstrom 2006, 4) Paganini 2011

8. Moderate Changes = Big Difference • DASH and Mediterranean dietary patterns have been associated with lower blood pressure, lipid profile, risk of CVD1 • Smoking cessation reduces risk of CVD to half in 1 year; risk of stroke to never-smoker in 5-10 yr and lung cancer in 5 yr2 • Recommended PA helps reduce blood pressure, increase HDL cholesterol, reduce triglycerides, support weight loss, may decrease insulin resistance3 • Losing 5 – 10% of body weight (as little as 10 lbs) can improve blood pressure, blood cholesterol and blood sugar.4 Sources: 1) DGAC 2010 report 2)CDC “Benefits of Quitting” 3)Am Heart Assn “Physical Activity” Position Statement 4)CDC Healthy Weight: It’s not a diet, it’s a lifestyle http://www.cdc.gov/healthyweight/losing_weight/index.html

9. Strategies – From What to How • DGA 2010 emphasizes patterns of eating and importance of physical activity in addition to healthful nutrition • Prevention and treatment guidelines for chronic diseases typically recommend a cluster of inter-related behaviors including diet, activity, weight management, smoking cessation, stress management Evidence suggests that addressing patterns of behavior(s)not just one element or behavioris key Source: DGA 2010 Chap 5, Building Healthy Eating Patterns

10. Strategy:Be Aware. Be Intentional. • Weigh regularly. Know your healthful weight range. • Know your appropriate energy intake levels. • Learn and observe portion sizes that meet your energy needs. Dietary Guidelines for Americans 2010 strategies Source: DGA 2010, www.dietaryguidelines.gov

11. Strategy:Track efforts to measure progress • Using personal tracking or self-monitoring programs has been shown effective for reaching diet and activity goals • Tracking encourages adherence • Tip: MyPyramid.gov offers a free, individualized online tracking program for diet and PA Sources: Greaves et al. BMC Public Health. 2011; Chambliss et al. Patient Educ Couns 2011 Feb epub; Hartwell et al. Primary Care Diabetes 2011 Jan epub; Conroy et al, Med Sci Sports Exerc 2010 epub; Yon et al; J BehavMed 2007; Cushing et al; J Ped Psych 2010 epub; Masoudi et al. J Biomed Inform 2010

12. Strategy:Model Healthful Behaviors • Health care professionals who adopt healthful lifestyles are more likely to counsel and encourage patients • Parents are effective models for children of nutrition and activity behaviors • Workplace, school and community environments may encourage or discourage behaviors Sources: Howe et al. Prev Cardiol 2010; Abramson et al. Clin J Sport Med 2000; Frank et al. J Am Women’s Med Assn 2003; Frank et al. AJCN 2002; Pearson, Pub Health Nutr 2009; Johannsen et al. Obesity 2006; Gidding et al. Circulation 2009; Story et al. JADA 2002

13. Strategy:Provide Counseling • Motivational, behavioral counseling is typically more effective than just providing information. • Clients and patients trust health care professionals as source. • Why not begin with this strategy? Counseling without the other strategies may not be as effective. Sources: Berben et al, Eur J Cardio Nurs 2010; Clune et al. Prev Med 2010; Greaves et al. BMC Pub Health 2011; Jackson et al. Clin Cardiol 2010; Jansink et al. BMC Health Serv Res 2009; McIvor et al. Can Respir J 2009; Patrick et al. J Phys Act Health 2009; Persson et al. BMC Res Notes 2010; Prokhorov et al. Arch Intern Med 2010l; Whittemore et al. J Am Acad Nurse Pract 2010

14. Realizing strategies through specific action goals • Encourage eating more fruits and vegetables • Select sensible portions • Encourage regular physical activity • Facilitate weight loss and weight management • Encourage smoking cessation

15. Cardiovascular Health and Lifestyle Medicine—the Future is Now • Discussion of how to improve our health care system in ability to delivery better outcomes at better cost has centered on two strategies: the “patient centered medical home” (PCMH) and the “accountable care organization” (ACO) • PCMH model focuses on a strong primary care foundation for health care. • ACO model focus on provider-led integrated delivery across the whole continuum of care with accountability for quality of care and cost. • Lifestyle Medicine with its emphasis on the integrated and inter-dependent nature of the importance of lifestyle behaviors to health or risk of disease is the optimum foundation for delivery of such health care.