therapeutic lifestyle changes for cardiovascular disease
TRANSCRIPT
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Therapeutic Lifestyle Changes for Cardiovascular
Disease
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Cardiovascular Disease (CVD)
• Accounts for 1 of every 2.8 deaths in the US
• The leading cause of death among both men and women
• Heart disease accounted for 16,438 deaths in Saudi Arabia in 2002 (WHO statistics)
• Improving diet and lifestyle is a critical component of cardiovascular disease risk reduction
Artinian et al. Circulation. 2010;122:406-441
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AHA 2006 Diet and Lifestyle Goals forCardiovascular Disease Risk Reduction
•Consume an overall healthy diet.•Aim for a healthy body weight.•Aim for recommended levels of LDL cholesterol, HDL
cholesterol, and triglycerides.•Aim for a normal blood pressure.•Aim for a normal blood glucose level.•Be physically active.•Avoid use of and exposure to tobacco products.
Lichtenstein et al. Circulation. 2006;114:82-96
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Consume An Overall Healthy Diet
•Healthy dietary patterns are associated with substantially reduced risk of CVD, CVD risk factors, and noncardiovascular diseases
•Rather than focusing on a single nutrient or food, aim to improve the whole diet
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Aim for a Healthy Body Weight
•Obesity is an independent risk factor for CVD
•Obesity also adversely affects other CVD risk factors:▫↑LDL cholesterol, triglycerides, BP, & blood glucose▫↓ HDL cholesterol
•A healthy body weight is currently defined as a body mass index (BMI) of 18.5 to 24.9 kg/m2
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Aim for a Healthy Body Weight
•Recommended weight loss goal: 10% of initial weight gradually over 6 months 1 to 2 lb (0.5–0.9 kg) per week
• Low calorie diet: 1,000 to 1,200 kcal/day for most women; 1,200 to 1,600 kcal/day for most men
•Very low calorie diets, providing less than 800 kcal/day are not recommended
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Aim for a Desirable Lipid Profile
• LDL- Cholesterol:▫↑ the risk of developing CVD
▫Goal recommendations depend on the 10-year risk of developing CVD & presence of CVD-related risk factors
▫Determinants of ↑ LDL cholesterol: Dietary saturated fatty acids Dietary trans fatty acids Dietary cholesterol Excess body weight
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Aim for a Desirable Lipid Profile
• HDL- Cholesterol:▫ Inversely associated with the risk of developing CVD
▫ Nongenetic determinants of low HDL cholesterol: Hyperglycemia Diabetes Hypertriglyceridemia Very low-fat diets (< 15% energy as fat), and Excess body weight
▫ Levels < 50 mg/dL in women and < 40 mg/dL in men considered one of the criteria for classification of metabolic syndrome
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Aim for a Desirable Lipid Profile
•Triglycerides:▫Levels > 150 mg/dL considered one of the criteria for
classification of metabolic syndrome
▫Moderate inverse relationship exists between triglycerides and HDL
▫Determinants of high triglycerides are the same as those of low HDL cholesterol
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Aim for a Normal Blood Pressure
•A normal BP is < 120/80 mm Hg
•Risk of CVD increases progressively throughout the range of BP, including the prehypertensive range
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Aim for a Normal Blood Pressure
•Dietary modifications that lower BP are: ▫reduced salt intake▫caloric deficit to induce weight loss ▫moderation of alcohol consumption ▫ increased potassium intake▫consumption of an overall healthy diet, based on the DASH
(Dietary Approaches to Stop Hypertension) diet
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Aim for a Normal Blood Pressure
Modification Average SBP Reduction Range
Weight Reduction 5-20 mmHg/10 kg
DASH Eating Plan 8-14 mmHg
Dietary Sodium Restriction 2-8 mmHg
Aerobic Physical Activity 4-9 mmHg
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Aim for a Normal Blood PressureDASH Diet
• Is a carbohydrate-rich diet that:▫emphasizes fruits, vegetables, and low-fat dairy products▫ includes whole grains, poultry, fish, and nuts▫reduced in fats, red meat, sweets, and sugar-containing
beverages
•Replacement of some carbohydrates with either protein from plant sources or with monounsaturated fat can further lower BP
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Aim for a Normal Blood Glucose Level
•A normal fasting glucose level is ≤ 100 mg/dL, whereas diabetes is defined by a fasting glucose level ≥ 126 mg/dL
•↓ caloric intake & ↑ physical activity to achieve even a modest weight loss can ↓ insulin resistance & improve glucose control
• In nondiabetics, weight loss & increased physical activity can delay onset of and possibly prevent diabetes
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Be Physically Active
•Regular physical activity:▫Improves cardiovascular risk factors (BP, lipid profiles, &
blood sugar)
▫Lowers risk of developing other chronic diseases including type 2 diabetes, osteoporosis, obesity, depression, breast & colon cancer
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Avoid Use and Exposure to Tobacco Products
•Eliminate the use of tobacco products and minimizeexposure to second-hand smoke
•Concern about weight gain should not be a reason forcontinued use of tobacco products
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AHA 2006 Diet and Lifestyle Recommendations
•Balance Calorie Intake and Physical Activity to Achieve or Maintain a Healthy Body Weight▫Increase awareness of calorie content of foods & control
portion size
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AHA 2006 Diet and Lifestyle RecommendationsPhysical Activity
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AHA 2006 Diet and Lifestyle Recommendations
•Balance Calorie Intake and Physical Activity to Achieve or Maintain a Healthy Body Weight▫60-90 minutes of physical activity most days of the week
for adults who are attempting to lose weight or maintain weight loss
▫Exercises may include walking, jogging, swimming or biking
▫Stay between 50-85% of your maximum heart rate (Maximum HR is 220-age)
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AHA 2006 Diet and Lifestyle Recommendations
•Consume a Diet Rich in Vegetables and Fruits ▫Meet micronutrient, macronutrient, & fiber requirements
without adding substantially to energy consumption
▫Fruit juice is not equivalent to whole fruit in fiber content & perhaps satiety value
▫Preparation techniques that preserve nutrient and fiber content without adding unnecessary calories, saturated or trans fat, sugar, and salt are recommended
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AHA 2006 Diet and Lifestyle Recommendations
•Choose Whole-Grain, High-Fiber Foods▫Soluble or viscous fibers (notably β-glucan and pectin)
reduce LDL cholesterol
▫Insoluble fiber has been associated with decreased CVD risk and slower progression in high-risk individuals
▫Dietary fiber may promote satiety by slowing gastric emptying, leading to overall decrease in calorie intake
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AHA 2006 Diet and Lifestyle Recommendations
•Consume Fish, Especially Oily Fish, at Least Twice/Week ▫Facilitate displacement of foods higher in saturated & trans
fatty acids from diet e.g. fatty meats & full-fat dairy
▫Consumption of 2 servings (8 ounces) per week of fish high in EPA and DHA associated with reduced risk of both sudden death & death from CAD in adults
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AHA 2006 Diet and Lifestyle Recommendations
• Limit intake of saturated fat to <7% of energy, trans fat to <1% of energy, and cholesterol to <300 mg per day by:
▫choosing lean meats and vegetable alternatives
▫selecting fat-free (skim), 1%-fat, and low-fat dairy products
▫minimizing intake of partially hydrogenated fats
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AHA 2006 Diet and Lifestyle Recommendations
•Minimize Intake of Beverages & Foods With Added Sugars
▫This will lower total calorie intake and promote nutrient adequacy
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AHA 2006 Diet and Lifestyle Recommendations
•Choose and Prepare Foods With Little or No Salt▫A reduced sodium intake:
Can prevent hypertension in nonhypertensive individuals Can lower BP in the setting of antihypertensive drugs Associated with reduced risk of atherosclerotic cardiovascular
events and congestive heart failure
▫Recommendation: 1.5 g/d (65 mmol/d)▫Reasonable: 2.3 g/d (100 mmol/d)
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AHA 2006 Diet and Lifestyle Recommendations
•When Eating Food That Is Prepared Outside of the Home, Follow the AHA 2006 Diet and Lifestyle Recommendations
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2 Examples of Dietary Patterns Consistent With AHA Dietary Goals
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Mediterranean Diet
•Close to AHA recommendations, but don’t follow them exactly (high % of calories from fat)
▫High consumption of fruits, vegetables, bread &other cereals, potatoes, beans, nuts and seeds
▫Olive oil is an important monounsaturated fat source▫Dairy products, fish and poultry consumed in low to
moderate amounts,& little red meat is eaten▫Eggs are consumed zero to four times a week
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Low Calorie Diet (LCD) for Weight Loss
Nutrient Recommended Intake
Total fat 25 to 35% or less of total calories
Saturated fat <7% of total calories
Monounsaturated fat ≤ 20% of total calories
Polyunsaturated fat ≤ 10% of total calories
Cholesterol <200 mg/day
Protein ~ 15% of total calories
Carbohydrates 50 to 60% or more of total calories
Fiber 20 to 30 g
Calories Overall daily intake reduced by 500 to 1,000 kcal
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Dietary Factors With Unproven or Uncertain Effects on CVD Risk
•Antioxidant Supplements
▫Antioxidant vitamin supplements or other supplements e.g. selenium to prevent CVD are not recommended
▫Food sources of antioxidant nutrients, principally fruits, vegetables, whole grains, and vegetable oils are recommended
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Dietary Factors With Unproven or Uncertain Effects on CVD Risk
•Soy Protein
▫Evidence of a direct cardiovascular health benefit from consuming soy protein products instead of dairy or other proteins or of isoflavone supplements is minimal
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Dietary Factors With Unproven or Uncertain Effects on CVD Risk
•Folate and Other B Vitamins
▫Available evidence is inadequate to recommend folate and other B vitamin supplements as a means to reduce CVD risk at this time
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Other Dietary Factors That Affect CVD Risk
•Fish Oil Supplements▫AHA recommends that patients without documented CHD
eat fish, preferably oily fish, at least twice a week
▫Patients with documented CHD : consume 1 g of EPA+DHA /day, preferably from oily fish, although EPA+DHA supplements could be considered
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Other Dietary Factors That Affect CVD Risk
•Plant Stanols/Sterols▫Lower LDL cholesterol levels by up to 15%
▫Maximum effects are observed at plant stanol/sterol intakes of 2 g per day
▫To sustain LDL cholesterol reductions from these products, individuals need to consume them daily
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Interventions to Promote Therapeutic Lifestyle Changes
Artinian et al. Circulation. 2010;122:406-441
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Interventions to Promote Therapeutic Lifestyle Changes
•Use a combination of ≥ 2 of the following strategies in an intervention
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Goal Setting
•More successful when goals are specific, proximal in terms of attainment, realistic & appropriately ambitious
•Goals that focus on behavior (e.g. increasing whole grain intake) rather than a physiological target (e.g. improving glucose levels) are preferable
•Provide feedback on progress toward goals
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Self-Monitoring
•Aims to increase one’s awareness of physical cues and/or behaviors & identify the barriers to changing a behavior
•Can be simple, such as pencil-and paper logs of dietary intake or charting of weight lost, or distance walked
•Electronic systems advantage: mobility, decreasingcost, & increasing availability
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Frequent & Prolonged Contact
•Establish a plan for frequency & duration of follow-up
•Various modes: face-to-face, telephone, email, internet
•Can be combined with group-based interventions
•Expert opinion suggests follow-up at 6 wks, then at 3,6,9,12 months then every 6 months thereafter
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Self-Efficacy Enhancement
•Self-efficacy describes an individual’s perception regarding his/her abilities to carry out actions necessary to perform certain behaviors
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Self-Efficacy Enhancement
•To enhance individual’s self-efficacy:▫Have him/her successfully achieve a reasonable, proximal
goal▫Have him/her witness someone who is similar in capability
successfully perform desired task▫Persuade person that you believe in person’s capability to
perform task▫Interpret to the individual the meaning of different
symptoms associated with behavior change
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Modeling
•Having the person observe another individual perform behaviors that are related to his/her goal
•Examples:▫In-person or video cooking demonstrations and personal
physical activity training
▫Have a person speak with someone who has been successful in making behavior changes
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Relapse Prevention
•An approach that makes a person aware that it is normal to deviate episodically from the goal behavior
• Individuals are taught to recognize past situations that have placed them at risk for lapses from their program (e.g. vacations or holidays) & how to handle them
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Motivational Interviewing
•A directive, individual-centered counseling style for eliciting behavior change with a purpose of helping individuals to explore and resolve their ambivalence (i.e. lack of readiness toward changing their behavior)
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Motivational Interviewing
•7 key principles :1) Motivation to change is elicited from individual2) It is the person’s task, not counselor’s, to articulate & resolve
ambivalence 3) Direct persuasion is not an effective method for resolving ambivalence4) Counseling style is generally a quiet and eliciting one 5) Counselor is directive in helping person to examine & resolve
ambivalence 6) Readiness to change is not a personal trait, but a fluctuating product
of interpersonal interaction7) Therapeutic relationship is more like a partnership than one in which
there are expert/recipient roles
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Intervention Processes/Delivery Strategies
• Use individual-oriented sessions to:▫assess where the individual is in relation to behavior change▫ jointly identify goals for risk reduction or improved
cardiovascular health▫develop a personalized plan to achieve it
• Use group sessions to:▫ teach skills to modify diet & develop a physical activity
program▫provide role modeling and positive observational learning▫maximize benefits of peer support and group problem solving
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Intervention Processes/Delivery Strategies
•For appropriate target populations, use Internet- & computer-based programs to target dietary & physical activity change
•Use individualized rather than nonindividualized print- or media-only delivery strategies