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Lifestyle Interventions: Lifestyle Interventions:
Dietary Therapy, Physical Activity, Dietary Therapy, Physical Activity,
Weight ControlWeight Control
Neil J. Stone, M.D.Neil J. Stone, M.D.
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0% 20% 40% 60% 80%
20102010 NowNow
Primary Prevention: Primary Prevention: Status and Goals Status and Goals in 2010in 2010
NCEP. Adult Treatment Panel III Report. 2001.
Moderate Moderate physical activityphysical activity
Vegetable intake Vegetable intake of >3 servingsof >3 servings
Saturated fat Saturated fat <10% of calories<10% of calories
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0% 20% 40% 60% 80%
Primary Prevention: Primary Prevention: Status and Goals Status and Goals in 2010in 2010
Fruit >2 servings/dFruit >2 servings/d
Smoking cessationSmoking cessation
Healthy weightHealthy weight
20102010 NowNow
NCEP. Adult Treatment Panel III Report. 2001.
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-60%-40%-20%0%
Primary Prevention: Primary Prevention: Crucial Opportunity to Crucial Opportunity to Reduce the Burden of CHDReduce the Burden of CHD
Law MR et al. BMJ 1994;308:367-372.
Age 70Age 70
Reduction in risk in men with 10% reductionReduction in risk in men with 10% reductionin total cholesterol (10 cohort studies)in total cholesterol (10 cohort studies)
Age 50Age 50
Age 40Age 40
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Primary Prevention: Primary Prevention: Adverse Life Habit Adverse Life Habit ChangesChanges
Atherogenic diet
Sedentary lifestyle
Obesity
Expert Panel. JAMA 2001;285:2486-2497.
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Primary Prevention—Rx: Primary Prevention—Rx: Therapeutic Therapeutic Lifestyle Changes (TLC)Lifestyle Changes (TLC)
Therapeutic diet to lower LDL-C
Physically active on a daily basis
Weight control
Expert Panel. JAMA 2001;285:2486-2497.
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Primary Prevention—Rx: Primary Prevention—Rx: TLC Measures to TLC Measures to Lower LDL-CLower LDL-C
Saturated fats (<7% total calories) and cholesterol (<200 mg/d)
Also therapeutic options:
— Plant stanols/sterols (2 g/d)
— Increased viscous fiber (10–25 g/d)
Expert Panel. JAMA 2001;285:2486-2497.
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Total Fat...Why a range?Total Fat...Why a range?
Primary emphasis is to reduce saturated fats Total fat should range 25–30% for most cases
Those with metabolic syndrome Avoid very high fat intakes Avoid very low fat intake (low HDL-C, high TG) Total fat intake can range from 30–35% if extra fat is
unsaturated May reduce some lipid and nonlipid risk factors Clinical judgment required.
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Therapeutic Lifestyle Changes:Therapeutic Lifestyle Changes:Nutrient Composition of TLC DietNutrient Composition of TLC Diet
NutrientNutrient Recommended IntakeRecommended Intake
Saturated fat*Saturated fat* Less than 7% of total caloriesLess than 7% of total calories
Polyunsaturated fatPolyunsaturated fat Up to 10% of total caloriesUp to 10% of total calories
Monounsaturated fatMonounsaturated fat Up to 20% of total caloriesUp to 20% of total calories
Total fatTotal fat 25–35% of total calories25–35% of total calories
Carbohydrate**Carbohydrate** 50–60% of total calories50–60% of total calories
FiberFiber 20–30 grams per day20–30 grams per day
ProteinProtein Approximately 15% of total caloriesApproximately 15% of total calories
CholesterolCholesterol Less than 200 mg/dayLess than 200 mg/day
Total calories (energy)Total calories (energy) Balance energy intake and output to Balance energy intake and output to maintain expendituremaintain expenditure healthy body healthy body weight/prevent weight gainweight/prevent weight gain
* Lower * Lower transtrans fatty acids fatty acids** Emphasize complex sources** Emphasize complex sources
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LDL-C Response to Step II Diet: LDL-C Response to Step II Diet: beFITbeFIT
178 Women / 231 MenDietary fat 25%; saturated fat 7.5%
LDL reduction High cholesterol only: –7.6 to 8.8%
LDL reduction Combined hyperlipidemia:–8.1%
Walden CE et al. Arterioscler Thromb Vasc Biol 1997;17:375-382.
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DELTA I Dietary TrialDELTA I Dietary Trial
Subjects:Subjects: age 22 to 67 Different groups of subjects:
White, black Women: younger and
postmenopausal Men: younger, older
-20%
-10%
0%
10%
20%
30%
40%
AADAAD Low SatLow SatResults:Results: Compared to average
American diet, when saturated fat fell from 15% to 6.1%, LDL-C fell by 11%
Negative aspects:Negative aspects: HDL-C fell from 52.2 to 46.2 Lp(a) rose from 15.5 to 18.2
Ginsberg HN et al. Arterioscler Thromb Vasc Biol 1998;18:441-449.
Total Fat Sat Fats LDL
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New Options to Lower LDL-CNew Options to Lower LDL-C
Avoid
Trans fatty acids*
Add
Dietary fiber
Plant sterol/stanol ester margarines
Expert Panel. JAMA 2001;285:2486-2497.
* Keep trans fatty acids low
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TransTrans Fatty Acids (TFA) Fatty Acids (TFA)
TFA more densely packed than cis forms
Usual intake: only 2–3% of energy
If consumed in high amounts: LDL-C; HDL-C
Examples of TFAStick margarine, cookies, biscuits, white bread
Lichtenstein AH et al. N Engl J Med 1999;340:1933-1940
Conclusion:Conclusion: Consume products low in Consume products low in saturated and TFAsaturated and TFA
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Plant Sterol/Stanol EstersPlant Sterol/Stanol Esters
Sterols are essential components of cell membranes
Cholesterol exclusively an animal sterol
We ingest almost as much plant sterols as we do dietary cholesterol
Stanols absorbed even less well
Plant sterols/stanols lower cholesterol
Interfere with micellar absorption of cholesterol
No malabsorption of fat
Law MR et al. BMJ 2000;320:861-864.
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Plant Sterol/Stanol EstersPlant Sterol/Stanol Esters
If 2 g of plant sterol or stanol is added to average daily portion of margarine, it has variable effect on LDL-C by age group:
Age LDL-C reduced by:
50–59 21 mg/dl or 0.54 mmol/l
40–49 17 mg/dl or 0.43 mmol/l
30–39 13 mg/dl or 0.33 mmol/l
Law MR et al. BMJ 2000;320:861-864.
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Esterification of StanolsEsterification of Stanols Plant Stanol Crystalline powder
Restricted fat solubility
Melting range 140–150oC
R C -
= O 33
5566
OO
33
5566
HOHO
1717
EsterificationEsterification
Fat-SolubleFat-SolublePlant StanolPlant Stanol
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200
210
220
230
240
250Treatment with Stanol Ester MargarineTreatment with Stanol Ester Margarine
-2-2
Chole
stero
l (m
g/d
l)
Study Period (mo)Study Period (mo)22 44 88 1010
Miettinen TA et al. N Engl J Med 1995;333:1308-1312.1995 Massachusetts Medical Society. All rights reserved.
00 1212 141466
Sitostanol-ester margarineSitostanol-ester margarine
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Plant Sterols/Stanols: Efficacy in Lowering Plant Sterols/Stanols: Efficacy in Lowering LDL-CLDL-C
Dose: Maximum is 2 g/d
Meta-analysis results: LDL-C lowering about 9–13%
Lowering greater in elderly Additive to statin therapy Used in various population groups
Well-tolerated
May decrease LDL-C adjusted carotenoids
Law M et al. BMJ 2000;320:861-864.Lichtenstein AH et al. Circulation 201;103:1177-1179
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Dietary AdjunctsDietary Adjuncts TLC for patients with LDL-C = 160
Walden CE et al. Arterioscler Thromb Vasc Biol 1997;17:375-382.Jenkins DJ et al. Curr Opin Lipidol 2000;11:49-56.Cato N. Stanol meta-analysis. Personal communication, 2000.
Dietary ComponentDietary Component LDL-C LDL-C (mg/dL) (mg/dL)
Low saturated fat/dietary Low saturated fat/dietary cholesterolcholesterol ––1212
Viscous fiber (10–25 g/d)Viscous fiber (10–25 g/d) – –88
Plant stanols/sterols (2 g/d)Plant stanols/sterols (2 g/d) ––1616
TotalTotal – –36 mg/dl36 mg/dl
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The Spectrum of CHD RiskThe Spectrum of CHD Risk
Expert Panel. JAMA 2001;285:2486-2497.
““More higher risk patients brought into the algorithm”More higher risk patients brought into the algorithm”
MetabolicMetabolicSyndromeSyndrome
ElevatedElevatedLDL-CLDL-C
GlucoseGlucose 110–125110–125 AbdominalAbdominal Obesity Obesity HDL-CHDL-C BPBP TG TG 150150
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The Metabolic SyndromeThe Metabolic Syndrome Constellation of major risk
factors, life-habit risk factors and emerging risk factors
Over-represented among populations with CHD
Clue is distinctive body-type with increased abdominal circumference (although some leaner men and women with abdominal obesity without increased waist)
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Metabolic Syndrome as a Secondary Goal Metabolic Syndrome as a Secondary Goal after LDL-Cafter LDL-C
Expert Panel. JAMA 2001;285:2486-2497.
Risk Factor (Risk Factor (3)3) Defining LevelDefining Level
Abdominal obesityAbdominal obesity Waist circumferenceWaist circumference**
TriglyceridesTriglycerides 150 mg/dl150 mg/dl
HDL-CHDL-C<40 mg/dl in men; <40 mg/dl in men; <50 mg/dl in women<50 mg/dl in women
Blood pressureBlood pressure 130/130/85 mm Hg85 mm Hg
Fasting glucoseFasting glucose 110 mg/dl110 mg/dl
* Men: >40 in (102 cm); women >35 in (88 cm)* Men: >40 in (102 cm); women >35 in (88 cm)
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Metabolic Syndrome as a Secondary Goal Metabolic Syndrome as a Secondary Goal after LDL-Cafter LDL-C
Expert Panel. JAMA 2001;285:2486-2497.
Risk FactorRisk Factor Defining LevelDefining Level
Abdominal obesityAbdominal obesity> 40 waist circ. in men> 40 waist circ. in men> 35 waist circ. in women> 35 waist circ. in women
HDL-CHDL-C< 40 mg/dl in men< 40 mg/dl in men< 50 mg/dl in women< 50 mg/dl in women
Circ. = circumference measured at level of the Circ. = circumference measured at level of the iliac spine iliac spine
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Clustering of Risk Factors Incorporated Clustering of Risk Factors Incorporated into the Metabolic Syndromeinto the Metabolic Syndrome
Includes risk factors not routinely measured
Insulin resistance
Small dense LDL
Endothelial dysfunction
Abnormal sympathetic nervous activity
Prothrombotic markers—PAI-1, fibrinogen
Proinflammatory markers such as CRP
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Does Treating the Metabolic Syndrome Does Treating the Metabolic Syndrome Make a Difference? Make a Difference? Finnish Diabetes Finnish Diabetes Prevention StudyPrevention Study
Design522 middle-aged overweight (BMI 31)172 men and 350 womenMean duration 3.2 years
Intervention Group: Individualized counselingReducing weight, total intake of fat and
saturated fat Increasing uptake of fiber, physical activity
Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.
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Treating the Metabolic SyndromeTreating the Metabolic Syndrome
Goals Goals
InterventionIntervention ControlsControls
P valueP value% of subjects% of subjects
Wt reduction >5%Wt reduction >5% 4343 1313 0.0010.001
Fat intake < 30% Fat intake < 30% energyenergy
4747 2626 0.0010.001
Sat fat Sat fat <10% energy<10% energy
2626 1111 0.0010.001
Fiber Fiber >15 g/1000 kcal>15 g/1000 kcal
2525 1212 0.0010.001
Exercise > 4 hr/wkExercise > 4 hr/wk 8686 7171 0.0010.001
Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.
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Benefit of Treating the Metabolic SyndromeBenefit of Treating the Metabolic Syndrome
Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.
0%
5%
10%
15%
20%
25%
InterventionIntervention ControlControl
After 4 After 4
years — years —
risk of risk of
diabetes diabetes
reduced reduced
by by 58%58%
11%11%
23%23%
(6–15 (6–15 CI)CI)
(17–29 (17–29 CI)CI)
% with Diabetes% with Diabetes
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Goals of Weight LossGoals of Weight Loss1. Reduce body weight in the short term
2. Maintain a lower body weight for the long term
3. Prevent further weight gain — minimum goal
Obesity Education Initiative. Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report. Bethesda, Md.: NIH, 1998
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Further Goals of Weight LossFurther Goals of Weight Loss1. Rate of weight loss
10% reduction in body weight in 6 months of therapy
Rate is 1–2 lbs per week
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Goals of Physical ActivityGoals of Physical ActivityPeople of all ages, male and female benefit People of all ages, male and female benefit
from physical activityfrom physical activity
1. Include a moderate amount of physical activity on most, if not all days of the week
2. Additional health benefits can be derived from greater amounts of activity
3. Emphasis is on amount not intensity
U.S. Dept. of Health and Human Services. Physical Activity and Health:A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, 1996.
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Suggestions on ActivitySuggestions on Activity1. Scheduled physical activity
a. Walking, treadmill, jogging, walking dog
b. Swimming, biking, volleyball
2. Lifestyle physical activity
a. Walk more stairs at work, walking for errands, parking farther away in parking lots
b. Housework, gardening
U.S. Dept. of Health and Human Services. Physical Activity and Health:A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, 1996.
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Metabolic Benefits of Weight LossMetabolic Benefits of Weight Loss Reverse changes of insulin resistance and
metabolic syndrome
Raise HDL-C (can see increase of 1.6 mg/dl from a 10-lb weight loss)
Dattilo AM et al. Am J Clin Nutr 1992;56:320-328.
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-8
-7
-6
-5
-4
-3
-2
-1
0
Metabolic Response to 10-lb Weight Loss: Metabolic Response to 10-lb Weight Loss: Framingham DataFramingham Data
Higgins M et al. Acta Med Scand Suppl 1988;723:23-36.
CholesterolCholesterol
Small Small
changes changes
can add up can add up
to to
significant significant
changes in changes in
long-term long-term
riskrisk Syst BPSyst BP GlucoseGlucose
mg/dlmg/dl mm Hgmm Hg mg/dlmg/dl
MenMen
WomenWomen
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Dietary Options — Benefit Independent of Dietary Options — Benefit Independent of LDL-C LoweringLDL-C Lowering
AvoidAvoid Megavitamins (adverse effects shown for
supplements of beta-carotene, no convincing clinical trial benefit for vitamin E supplementation)
AddAdd Fish
Plant sources of omega-3 fatty acids
Fruits and vegetables
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Clinical Trial Data Showing Lack of Benefit Clinical Trial Data Showing Lack of Benefit of Megavitaminsof Megavitamins
Beta Carotene No proof of benefit in 3 trials One stopped prematurely (CARET)
Vitamin E No proof of benefit in 2 large trials
HOPE Trial – Natural vitamin EGISSI Prevention – Synthetic vitamin E
Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study Group. N Engl J Med 1994;330:1029-1035. Hennekens CH et al. N Engl J Med1996;334:1145-1149. Omenn GS et al. N Engl J Med 1996;334:1150-1155. HOPE Study Investigators. N Engl J Med 2000;342:154-160. GISSI-Prevenzione Investigators. Lancet 1999;354:447-455.
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Clinical Trial Data Showing Significant Clinical Trial Data Showing Significant Effect of DietEffect of Diet
Omega-3 Fatty Acids
DART: 29% reduction in death
GISSI: Significant reduction of one of two combined endpoints
“Mediterranean Diet”
Lyon Trial: Multiple differences in diet; diet was low in animal, dairy fat, high in plant-based omega-3 fatty acids, fiber
Burr ML et al. Lancet 1989;2:757-761. GISSI-Prevenzione Investigators.Lancet 1999;354:447-455. de Longeril M et al. Circulation 1999;99:779-785.
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Burr ML et al. Lancet 1989;2:757-761. GISSI-Prevenzione Investigators.Lancet 1999;354:447-455.
Trials of n-3 Fatty Acids in MI Survivors: Trials of n-3 Fatty Acids in MI Survivors: Significant Effect on DeathsSignificant Effect on Deaths
0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%
DARTDART GISSIGISSI3,482 patients3,482 patients 11,324 patients11,324 patients
Expt DeathsExpt Deaths
Control DeathsControl Deaths
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70
80
90
100
Lyon Diet Heart Study: Lyon Diet Heart Study: Cumulative Survival Cumulative Survival without Cardiac Death and Nonfatal MIwithout Cardiac Death and Nonfatal MI
de Lorgeril M et al. Circulation 1999;99:779-785.1999 Lippincott Williams & Wilkins. www.lww.com
11
% W
ithout
Event
Canola oil– Canola oil– based based margarine, margarine, fiber, low fiber, low cholesterol, cholesterol, low saturated low saturated fat, fruits, fat, fruits, vegetablesvegetables
ExperimentalExperimental
ControlControl
P = 0.0001P = 0.0001
YearYear22 33 44 55
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Comparison of the DietsComparison of the DietsItemItem ExperimentalExperimental ControlControl
Total caloriesTotal calories 19471947 2088*2088*
Total fatTotal fat 30.4%30.4% 33.6%*33.6%*
Saturated fatSaturated fat 8%8% 11.7%11.7%
Dietary cholesterolDietary cholesterol 203 mg/dl203 mg/dl 312 mg/dl*312 mg/dl*
AlcoholAlcohol SameSame SameSame
Olive oilOlive oil NoneNone NoneNone
MUFA n-9MUFA n-9 Increased*Increased*
PUFAPUFA Increased*Increased*
n-3/n-6 fatty acidsn-3/n-6 fatty acids Increased*Increased*
FiberFiber 18.618.6
de Lorgeril M et al. Circulation 1999;99:779-785.*Significantly different*Significantly different
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How to Implement Primary Prevention with How to Implement Primary Prevention with TLCTLC
Stepwise approach
Resources
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (download from web for palm-based material)
Surgeon General’s Report on Physical Activity
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Implementing Primary Prevention Implementing Primary Prevention with TLC?with TLC?
Emphasize reduction in saturated fat and cholesterol
Reduce animal/high fat dairy
Get lower fat food if eats out
Regular physical activity
Visit 1Visit 1
Expert Panel. JAMA 2001;285:2486-2497.
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Implementing Primary Prevention Implementing Primary Prevention with TLC?with TLC?
Evaluate LDL-C response
Intensify LDL-C lowering with dietary adjuncts
Plant stanols/sterols
Increased fiber intake
Visit 2Visit 2
Expert Panel. JAMA 2001;285:2486-2497.
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Implementing Primary Prevention Implementing Primary Prevention with TLCwith TLC
At all stages of dietary therapy, physicians are encouraged to refer patients for:
Medical nutrition therapy
Registered dietitians/other qualified nutritionists
Expert Panel. JAMA 2001;285:2486-2497.
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Implementing Primary Prevention Implementing Primary Prevention with TLC?with TLC?
Evaluate LDL-C response
Initiate therapy for metabolic syndrome
Intensify weight management
Physical activity
Consider drug Rx if LDL-C goal not achieved
Visit 3Visit 3
Expert Panel. JAMA 2001;285:2486-2497.
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Primary Prevention with TLCPrimary Prevention with TLC Therapeutic Lifestyle Changes can lower LDL-C so
medication not required or increase not needed
Can treat metabolic syndrome
Lowers TG
Raises HDL-C
Reduces risk of diabetes
Provides overall healthful lifestyle
Expert Panel. JAMA 2001;285:2486-2497.
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