Therapeutic Lifestyle Changes for Cardiovascular Disease

1. Therapeutic Lifestyle Changes for Cardiovascular Disease

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Aim for a Normal Blood Pressure

13. 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

14. 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

15. 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

16. Avoid Use and Exposure to Tobacco Products • Eliminate the use of tobacco products and minimize exposure to second-hand smoke • Concern about weight gain should not be a reason for continued use of tobacco products

17. 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

18. AHA 2006 Diet and Lifestyle RecommendationsPhysical Activity

19. 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)

20. 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

21. 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

22. 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

23. 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

24. AHA 2006 Diet and Lifestyle Recommendations • Minimize Intake of Beverages & Foods With Added Sugars • This will lower total calorie intake and promote nutrient adequacy

25. 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)

26. AHA 2006 Diet and Lifestyle Recommendations • When Eating Food That Is Prepared Outside of the Home, Follow the AHA 2006 Diet and Lifestyle Recommendations

27. 2 Examples of Dietary Patterns Consistent With AHA Dietary Goals

28. 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

29. Low Calorie Diet (LCD) for Weight Loss

30. 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

31. 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

32. 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

33. 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

34. 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

35. Interventions to Promote Therapeutic Lifestyle Changes Artinian et al. Circulation. 2010;122:406-441

36. Interventions to Promote Therapeutic Lifestyle Changes • Use a combination of ≥ 2 of the following strategies in an intervention

37. 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

38. 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, decreasing cost, & increasing availability

39. 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

40. Self-Efficacy Enhancement • Self-efficacy describes an individual’s perception regarding his/her abilities to carry out actions necessary to perform certain behaviors

41. 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

42. 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

43. 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

44. 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)

45. Motivational Interviewing • 7 key principles : • Motivation to change is elicited from individual • It is the person’s task, not counselor’s, to articulate & resolve ambivalence • Direct persuasion is not an effective method for resolving ambivalence • Counseling style is generally a quiet and eliciting one • Counselor is directive in helping person to examine & resolve ambivalence • Readiness to change is not a personal trait, but a fluctuating product of interpersonal interaction • Therapeutic relationship is more like a partnership than one in which there are expert/recipient roles

46. 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

47. 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