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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. Smoking Prevalence in the United States. %. MMWR 1999;48:998

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Lifestyle Management Evidence and Guidelines

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  1. Lifestyle Management Evidence and Guidelines Andrew P. DeFilippis, Ty J. Gluckman, Catherine Campbell, Suzanne Hughes, Gregg Fonarow, & Roger S. Blumenthal

  2. Cigarette Smoking Cessation Evidence and Guidelines

  3. Smoking Prevalence in the United States % MMWR 1999;48:998 National Center for Health Statistics-1998

  4. Cigarette Smoking Cessation: Evidence Common preventable causes of death in U.S. in 1990 & 2000 Mokdad AH et al. JAMA 2004;291:1238-1245

  5. 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

  6. 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.

  7. 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.

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. Diet and Weight Management Evidence and Guidelines

  16. 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.

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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. 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

  26. 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

  27. Diet, Cardiovascular Events, and Guidelines

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. USDA vs. Mediterranean Dietary Recommendations USDA=United States Department of Agriculture

  35. Mediterranean Diet and Survival Trichopoulou A et al. NEJM 2003;348:2595-6

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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.

  43. Physical Activity Evidence and Guidelines

  44. Exercise Evidence: Role of Physical Inactivity Physical Inactivity Inflammation Dyslipidemia Age Hypertension Diabetes Mellitus Smoking Obesity Hypercoagulability Atherosclerosis Genetics Novel Risk Factors

  45. Prevalence of Physical Inactivity National Population Health Survey Statistics Canada, National Population Health Survey, 1996/1997

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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

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