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1、,Lifestyle Interventions:Dietary Therapy,Physical Activity,Weight ControlNeil J.Stone,M.D.,2010,Now,Primary Prevention:Status and Goals in 2010,NCEP.Adult Treatment Panel III Report.2001.,Moderate physical activity,Vegetable intake of 3 servings,Saturated fat 10%of calories,Primary Prevention:Status
2、 and Goals in 2010,Fruit 2 servings/d,Smoking cessation,Healthy weight,2010,Now,NCEP.Adult Treatment Panel III Report.2001.,Primary Prevention:Crucial Opportunity to Reduce the Burden of CHD,Law MR et al.BMJ 1994;308:367-372.,Age 70,Reduction in risk in men with 10%reductionin total cholesterol(10 c
3、ohort studies),Age 50,Age 40,Primary Prevention:Adverse Life Habit Changes,Atherogenic dietSedentary lifestyleObesity,Expert Panel.JAMA 2001;285:2486-2497.,Primary PreventionRx:Therapeutic Lifestyle Changes(TLC),Therapeutic diet to lower LDL-CPhysically active on a daily basisWeight control,Expert P
4、anel.JAMA 2001;285:2486-2497.,Primary PreventionRx:TLC Measures to Lower LDL-C,Saturated fats(7%total calories)and cholesterol(200 mg/d)Also therapeutic options:Plant stanols/sterols(2 g/d)Increased viscous fiber(1025 g/d),Expert Panel.JAMA 2001;285:2486-2497.,Total Fat.Why a range?,Primary emphasis
5、 is to reduce saturated fats Total fat should range 2530%for most casesThose with metabolic syndromeAvoid very high fat intakesAvoid very low fat intake(low HDL-C,high TG)Total fat intake can range from 3035%if extra fat is unsaturatedMay reduce some lipid and nonlipid risk factorsClinical judgment
6、required.,Therapeutic Lifestyle Changes:Nutrient Composition of TLC Diet,*Lower trans fatty acids*Emphasize complex sources,LDL-C Response to Step II Diet:beFIT,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
7、%,Walden CE et al.Arterioscler Thromb Vasc Biol 1997;17:375-382.,DELTA I Dietary Trial,Subjects:age 22 to 67Different groups of subjects:White,blackWomen:younger and postmenopausalMen:younger,older,AAD,Low Sat,Results:Compared to average American diet,when saturated fat fell from 15%to 6.1%,LDL-C fe
8、ll by 11%,Negative aspects:HDL-C fell from 52.2 to 46.2Lp(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,New Options to Lower LDL-C,AvoidTrans fatty acids*AddDietary fiberPlant sterol/stanol ester margarines,Expert Panel.JAMA 2001;285
9、:2486-2497.,*Keep trans fatty acids low,Trans Fatty Acids(TFA),TFA more densely packed than cis formsUsual intake:only 23%of energyIf consumed in high amounts:LDL-C;HDL-CExamples of TFAStick margarine,cookies,biscuits,white bread,Lichtenstein AH et al.N Engl J Med 1999;340:1933-1940,Conclusion:Consu
10、me products low in saturated and TFA,Plant Sterol/Stanol Esters,Sterols are essential components of cell membranesCholesterol exclusively an animal sterolWe ingest almost as much plant sterols as we do dietary cholesterolStanols absorbed even less wellPlant sterols/stanols lower cholesterolInterfere
11、 with micellar absorption of cholesterolNo malabsorption of fat,Law MR et al.BMJ 2000;320:861-864.,Plant 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:5059 21 mg/dl or 0.54 mmol/l
12、 4049 17 mg/dl or 0.43 mmol/l 3039 13 mg/dl or 0.33 mmol/l,Law MR et al.BMJ 2000;320:861-864.,Esterification of Stanols,Plant StanolCrystalline powderRestricted fat solubilityMelting range 140150oC,R C-,=O,3,5,6,O,3,5,6,HO,17,Esterification,Fat-SolublePlant Stanol,Treatment with Stanol Ester Margari
13、ne,-2,Cholesterol(mg/dl),Study Period(mo),2,4,8,10,Miettinen TA et al.N Engl J Med 1995;333:1308-1312.1995 Massachusetts Medical Society.All rights reserved.,0,12,14,6,Sitostanol-ester margarine,Plant Sterols/Stanols:Efficacy in Lowering LDL-C,Dose:Maximum is 2 g/dMeta-analysis results:LDL-C lowerin
14、g about 913%Lowering greater in elderlyAdditive to statin therapyUsed in various population groupsWell-toleratedMay decrease LDL-C adjusted carotenoids,Law M et al.BMJ 2000;320:861-864.Lichtenstein AH et al.Circulation 201;103:1177-1179,Dietary Adjuncts,TLC for patients with LDL-C=160,Walden CE et a
15、l.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.,The Spectrum of CHD Risk,Expert Panel.JAMA 2001;285:2486-2497.,“More higher risk patients brought into the algorithm”,MetabolicSyndrome,ElevatedLD
16、L-C,Glucose 110125 Abdominal Obesity HDL-C BP TG 150,The Metabolic Syndrome,Constellation of major risk factors,life-habit risk factors and emerging risk factorsOver-represented among populations with CHDClue is distinctive body-type with increased abdominal circumference(although some leaner men an
17、d women with abdominal obesity without increased waist),Metabolic Syndrome as a Secondary Goal after LDL-C,Expert Panel.JAMA 2001;285:2486-2497.,*Men:40 in(102 cm);women 35 in(88 cm),Metabolic Syndrome as a Secondary Goal after LDL-C,Expert Panel.JAMA 2001;285:2486-2497.,Circ.=circumference measured
18、 at level of the iliac spine,Clustering of Risk Factors Incorporated into the Metabolic Syndrome,Includes risk factors not routinely measuredInsulin resistanceSmall dense LDLEndothelial dysfunctionAbnormal sympathetic nervous activityProthrombotic markersPAI-1,fibrinogenProinflammatory markers such
19、as CRP,Does Treating the Metabolic Syndrome Make a Difference?Finnish Diabetes Prevention Study,Design522 middle-aged overweight(BMI 31)172 men and 350 womenMean duration 3.2 yearsIntervention Group:Individualized counselingReducing weight,total intake of fat and saturated fatIncreasing uptake of fi
20、ber,physical activity,Tuomilehto J et al.N Engl J Med 2001;344:1343-1350.,Treating the Metabolic Syndrome,Tuomilehto J et al.N Engl J Med 2001;344:1343-1350.,Benefit of Treating the Metabolic Syndrome,Tuomilehto J et al.N Engl J Med 2001;344:1343-1350.,Intervention,Control,After 4 years risk of diab
21、etes reduced by 58%,11%,23%,(615 CI),(1729 CI),%with Diabetes,Goals of Weight Loss,1.Reduce body weight in the short term2.Maintain a lower body weight for the long term3.Prevent further weight gain minimum goal,Obesity Education Initiative.Clinical Guidelines on the Identification,Evaluation and Tr
22、eatment of Overweight and Obesity in Adults:the Evidence Report.Bethesda,Md.:NIH,1998,Further Goals of Weight Loss,1.Rate of weight loss10%reduction in body weight in 6 months of therapyRate is 12 lbs per week,Goals of Physical Activity,People of all ages,male and female benefit from physical activi
23、ty1.Include a moderate amount of physical activity on most,if not all days of the week2.Additional health benefits can be derived from greater amounts of activity3.Emphasis is on amount not intensity,U.S.Dept.of Health and Human Services.Physical Activity and Health:A Report of the Surgeon General.A
24、tlanta,Ga:Centers for Disease Control and Prevention,1996.,Suggestions on Activity,1.Scheduled physical activity a.Walking,treadmill,jogging,walking dog b.Swimming,biking,volleyball2.Lifestyle physical activity a.Walk more stairs at work,walking for errands,parking farther away in parking lots b.Hou
25、sework,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.,Metabolic Benefits of Weight Loss,Reverse changes of insulin resistance and metabolic syndromeRaise HDL-C(can see increase o
26、f 1.6 mg/dl from a 10-lb weight loss),Dattilo AM et al.Am J Clin Nutr 1992;56:320-328.,Metabolic Response to 10-lb Weight Loss:Framingham Data,Higgins M et al.Acta Med Scand Suppl 1988;723:23-36.,Cholesterol,Small changes can add up to significant changes in long-term risk,Syst BP,Glucose,mg/dl,mm H
27、g,mg/dl,Men,Women,Dietary Options Benefit Independent of LDL-C Lowering,AvoidMegavitamins(adverse effects shown for supplements of beta-carotene,no convincing clinical trial benefit for vitamin E supplementation)AddFishPlant sources of omega-3 fatty acidsFruits and vegetables,Clinical Trial Data Sho
28、wing Lack of Benefit of Megavitamins,Beta CaroteneNo proof of benefit in 3 trialsOne stopped prematurely(CARET)Vitamin ENo proof of benefit in 2 large trialsHOPE Trial Natural vitamin EGISSI Prevention Synthetic vitamin E,Alpha-Tocopherol,Beta-Carotene Cancer Prevention Study Group.N Engl J Med 1994
29、;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.,Clinical Trial Data Showing Significant Effect of Diet,Omega-3 Fatty AcidsDA
30、RT:29%reduction in deathGISSI: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 19
31、99;354:447-455.de Longeril M et al.Circulation 1999;99:779-785.,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:Significant Effect on Deaths,DART,GISSI,3,482 patients,11,324 patients,Expt Deaths,Control Deaths,Lyo
32、n Diet Heart Study:Cumulative Survival without Cardiac Death and Nonfatal MI,de Lorgeril M et al.Circulation 1999;99:779-785.1999 Lippincott Williams&Wilkins.,1,%Without Event,Canola oil based margarine,fiber,low cholesterol,low saturated fat,fruits,vegetables,Experimental,Control,P=0.0001,Year,2,3,
33、4,5,Comparison of the Diets,de Lorgeril M et al.Circulation 1999;99:779-785.,*Significantly different,How to Implement Primary Prevention with TLC,Stepwise approachResourcesClinical Guidelines on the Identification,Evaluation,and Treatment of Overweight and Obesity in Adults(download from web for pa
34、lm-based material)Surgeon Generals Report on Physical Activity,Implementing Primary Prevention with TLC?,Emphasize reduction in saturated fat and cholesterolReduce animal/high fat dairyGet lower fat food if eats outRegular physical activity,Visit 1,Expert Panel.JAMA 2001;285:2486-2497.,Implementing
35、Primary Prevention with TLC?,Evaluate LDL-C responseIntensify LDL-C lowering with dietary adjunctsPlant stanols/sterolsIncreased fiber intake,Visit 2,Expert Panel.JAMA 2001;285:2486-2497.,Implementing Primary Prevention with TLC,At all stages of dietary therapy,physicians are encouraged to refer pat
36、ients for:Medical nutrition therapyRegistered dietitians/other qualified nutritionists,Expert Panel.JAMA 2001;285:2486-2497.,Implementing Primary Prevention with TLC?,Evaluate LDL-C responseInitiate therapy for metabolic syndromeIntensify weight managementPhysical activityConsider drug Rx if LDL-C g
37、oal not achieved,Visit 3,Expert Panel.JAMA 2001;285:2486-2497.,Primary Prevention with TLC,Therapeutic Lifestyle Changes can lower LDL-C so medication not required or increase not neededCan treat metabolic syndromeLowers TGRaises HDL-CReduces risk of diabetesProvides overall healthful lifestyle,Expert Panel.JAMA 2001;285:2486-2497.,
