evidence-based lifestyle recommendations for prevention of cardiovascular disease nathan d. wong,...

Evidence-Based Lifestyle Recommendations for Prevention

of Cardiovascular Disease

Nathan D. Wong, PhD, FACC, FAHAProfessor and Director, Heart Disease Prevention Program

Division of Cardiology, University of California, IrvinePresident, American Society for Preventive Cardiology

Global burden of Cardiovascular disease

• Up to 80% of heart disease, stroke and type 2 diabetes and over a third of the most common cancers could be prevented by eliminating obesity, unhealthy diets and physical inactivity

• Call for commitments at the global and national level to address these risk factors including:

– Control food supply, food information and marketing and promotion of energy-dense, nutrient-poor foods that are high in saturated, trans-fat, salt or refined sugars

Nutrition, physical activity and NCD prevention

Modifiable causative risk factors

Tobacco useUnhealthy

dietsPhysical inactivity

Harmful use of alcohol

Non

-com

mu

nic

ab

le D

iseases

Heart disease and stroke Diabetes Cancer Chronic lung disease

The NCD Alliance: United by 4 risk factors

Age-standardized prevalence estimates for poor, intermediate and ideal cardiovascular health for each of the seven metrics of cardiovascular health in the AHA 2020 goals, among US adults

>20 years of age, NHANES 2005-2006 (baseline available data as of January 1, 2010).

©2010 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2010

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.

Classification of Recommendations Classification of Recommendations and Levels of Evidenceand Levels of Evidence

Diet and Weight Management Evidence and Guidelines

Evidence for Current Cardiovascular Disease

Prevention Guidelines

Weight Management Recommendations Goals Recommendations

Calculate BMI* and measure waist circumference

Monitor response to treatmentBMI 18.5 to 24.9 kg/m2

Women: <35 inchesMen: <40 inches

Start weight management and physical activity as appropriate

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

10% weight reduction within the 1st yr of Rx

Smith SC Jr. et al. JACC 2006;47:2130-9

I IIa IIb III

Mhurchu N et al. Int J Epidemiol 2004;33:751-758

0.5

1.0

2.0

4.0

16 20 24 28 32 36

Body Mass Index (kg/m2)*

Haza

rd R

ati

o

0.5

1.0

2.0

4.0

16 20 24 28 32 36

0.5

1.0

2.0

4.0

16 20 24 28 32 36

HemorrhagicCVA

IschemicCVA

Ischemic HeartDisease

CV=Cardiovascular

*BMI is calculated as the weight in kg divided by the BSA in meters2

Body Mass Index: Risk of Cardiovascular Disease

0

5

10

15

20

25

<28 >28-29 30-31 32-33 34-35 36-37 ≥38

Rel

ativ

e R

isk

of

Dia

bet

es

Waist Circumference (in)

Abdominal Adiposity Is AssociatedAbdominal Adiposity Is Associated With Increased Risk of DiabetesWith Increased Risk of Diabetes

P value for trend <0.001

Carey VJ, et al. Am J Epidemiol. 1997;145:614-619

• 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

Diet Evidence: Types of Treatment Programs

• 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.

Diet Evidence: Types of Treatment Programs (Continued)

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

Dansinger, ML et al. JAMA 2005;293:43-53

20/40*

26/40*

26/40*

21/40*

0 3 6 9

Atkins

Zone

Weight Watchers

Ornish

Wt loss (lbs)

*Ratio of individuals completing the study to those enrolled

Diet Evidence: Primary Prevention

Lifestyle Heart Trial• 41 male and female CHD patients• Randomized to <10% fat diet, exercise and

meditation (Rx group) vs. Step 1 diet• At one year 37% LDL-C reduction, 22%

weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography)

• At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35)

Ornish et al. Lancet 1990; 336:129-133, and JAMA 1998; 280:2001-2007.

Diet, Cardiovascular Events, and Guidelines



Jenkins DJ et al. JAMA 2003;290:502-10

0

10

20

30

-50

-40

-30

-20

-10

0 2 4 0 2 4 0 2 4

LDL-C

Change f

rom

Base

line

(%)

LDL-C:HDL-C CRP

Weeks

Weeks

Weeks

Low fat dietStatin

Dietary portfolio*

*Enriched in plant sterols, soy protein, viscous fiber, and almonds

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

Appel LJ et al. NEJM 1997;336:1117-24

Dietary Approaches to Stop Hypertension (DASH) Group

Diet Evidence:Effect on Blood Pressure

A diversified diet improves blood pressure

459 hypertensive patients randomized to 1 of 3 diets for 8 weeks

Systolic blood pressure

(mm Hg)

Diastolic blood pressure

(mm Hg)

Diabetes Prevention Program (DPP)

Knowler WC et al. NEJM 2002;346:393-403.

0 1 2 3 4

0

10

20

30

40Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Plac)Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

Percent developing diabetes

All participants

All participants

Years from randomization

Cum

ulat

ive in

ciden

ce (

%)

*Includes 7% weight loss and at least 150 minutes of physical activity per week

PlaceboMetforminLifestyle modification

Inci

dence

of

DM

(%

)

0

20

30

10

40

00 1 42 3

Years

Pre-diabetic Conditions:Pre-diabetic Conditions:Benefit of Lifestyle ModificationBenefit of Lifestyle Modification

3,234 patients with elevated fasting and post-load glucose levels randomized to placebo, metformin (850 mg bid), or lifestyle modification*

for 3 years

Lifestyle modification reduces the risk of developing DM

Diabetes Prevention Program: Reduction in Diabetes Incidence

Joshipura KJ, et al. 2001 Ann Intern Med134:1106-14

Nurses’ Health Study and Health Professional’s Follow-up Study

*Includes nonfatal MI and fatal coronary heart disease

CV=Cardiovascular, MI=Myocardial infarction

Diet Evidence:Benefits of Fruits and Vegetables

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

Pereira MA et al. Arch Int Med 2004;164:370-76

RR=0.73, P<0.001

CV=Cardiovascular, CHD=Coronary heart disease

Diet Evidence:Benefits of Whole Grains 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

Trichopoulou A, et al. NEJM 2003;348:2595-6

Variable# of Deaths/

# of ParticipantsFully Adjusted Hazard

Ratio (95% CI)

Death from any cause

275/22,043 0.75 (0.64-0.87)

Death from CHD

54/22,043 0.67 (0.47-0.94)

Death from cancer

97/22,043 0.76 (0.59-0.98)

Diet Evidence:Primary Prevention22,043 adults evaluated for adherence to a Mediterranean diet, with

points given for high consumption of vegetables, legumes, fruits, nuts, cereal, and fish and points subtracted for high consumption of

meat, poultry, and dairy

High adherence to a Mediterranean diet is associated with a reduction in death

Lyon Diet Heart Study

De Lorgeril M et al. Circulation 1999;99:779-785

*High in polyunsaturated fat and fiber, **High in saturated fat and low in fiber

Diet Evidence:Secondary Prevention

605 patients following a MI randomized to a Mediterranean* or Western** diet for 4 years

A Mediterranean diet reduces cardiovascular events

Yokoyama M et al. Lancet. 2007;369:1090-8

Japan Eicosapentaenoic acid Lipid Intervention Study (JELIS)

*Composite of cardiac death, myocardial infarction, angina, PCI, or CABG

Years

-3 Fatty Acids Evidence:Primary and Secondary Prevention

18,645 patients with hypercholesterolemia randomized to EPA (1800 mg) with a statin or a statin alone for 5 years

-3 fatty acids provide CV benefit, particularly in secondary prevention CV=Cardiovascular, EPA=Eicosapentaenoic acid

11,324 patients with a history of a MI randomized to -3 polyunsaturated fatty acids [PUFA] (1 gram), vitamin E (300 mg), both or none for 3.5 years

GISSI Investigators. Lancet 1999;354:447-455

-3 Fatty Acids Evidence:Secondary Prevention

CV=Cardiovascular, MI=Myocardial infarction, NF=Non-fatal, PUFA=Polyunsaturated fatty acids

-3 fatty acids provide significant CV benefit after a MI

Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (GISSI-Prevenzione)

*Trans fatty acids also raise LDL-C and should be kept at a low intakeNote: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight.

<200 mg/dCholesterol

~15% of total caloriesProtein

20–30 g/dFiber50%–60% of total caloriesCarbohydrate (esp. complex

carbs)

25%–35% of total caloriesTotal fat

Up to 20% of total caloriesMonounsaturated fat

Up to 10% of total caloriesPolyunsaturated fat

<7% of total caloriesSaturated fat*

Recommended IntakeNutrient

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-97

Adult Treatment Panel (ATP) IIIDietary Recommendations

American Heart Association (AHA) Nutrition Committee Dietary Recommendations

• 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 (AHA 2011 rec. <1500mg/d)• If alcohol is consumed, do so in moderation

Recommendations for Cardiovascular Disease Risk Reduction

AHA Nutrition Committee. Circulation 2006;114:82-96

N-3 Fatty Acid Recommendation American Dietetic Association 2007

For those without heart disease

• Two 3.5 oz svgs/wk of fatty fish are assoc with 30-40% reduced risk of death from cardiac

events.

Grade II Fair

N-3 Fatty Acids American Dietetic Association 2007

For those with heart disease

• Approx 1g/d of DHA & EPA from fatty fish OR supplement decreases the risk of death from

cardiac events.

Grade II Fair

N-3 Fatty Acid RecommendationAmerican Dietetic Association 2007

• Consume both marine & plant sources .

Fatty fish: two 3.5 oz serving/wk (salmon, herring, sardines)

or

1.5 g ALA/day eg 1 TBS canola, 1/2 TBS ground flax seeds.

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

Mosca L et al. Circulation 2007;115:1481-501

Dietary Guidelines

I IIa IIb III

Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg per day).

Encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 gram per day) for risk reduction may be reasonable for patients with known CAD.


Dietary Guidelines (Continued)

Secondary PreventionI IIa IIb III

I IIa IIb III

Modification Recommendation Approximate SBP Reduction Range

Weight reduction Maintain normal body weight (BMI=18.5-24.9)

5-20 mmHg/10 kg weight lost

Adopt DASH eating plan

Diet rich in fruits, vegetables, low fat dairy and reduced in fat

8-14 mmHg

Restrict sodium intake

<2.4 grams of sodium per day 2-8 mmHg

Physical activity Regular aerobic exercise for at least 30 minutes on most days of the week

4-9 mmHg

Moderate alcohol consumption

<2 drinks/day for men and <1 drink/day for women

2-4 mmHg

JNC VII Lifestyle Modifications for BP Control

Chobanian AV et al. JAMA. 2003;289:2560-2572

BMI=Body mass index, SBP=Systolic blood pressure

You Can Now Receive Medicare Reimbursement for Nutrition Counseling

• The Centers for Medicare and Medicaid Services (CMS) has issued a decision memorandum that will allow you to be reimbursed for providing Medicare beneficiaries with intensive behavioral therapy for obesity, defined as a body mass index (BMI) ≥30.

• The agency suggests that more than 30% of the Medicare population will likely qualify for the new benefit.

Intensive behavioral therapy for obesity consists of the following:

• Screening for obesity in adults using BMI measurement calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/m2)

• Dietary (nutritional) assessment• Intensive behavioral counseling and behavioral therapy

to promote sustained weight loss through high intensity interventions on diet and exercise

To be eligible for reimbursement, the counseling should follow the “Five-A’s” format:

• Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

• Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

• Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

• Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

• Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

• Providing that a Medicare beneficiary is obese, competent, and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician, or other primary care practitioner, and in a primary care setting, CMS covers:

• One face-to-face visit every week for the first month• One face-to-face visit every other week for months 2-6• One face-to-face visit every month for months 7-12, if the beneficiary

meets the 3 kg weight loss requirement as discussed below• At the six-month visit, you must reassess the patient’s obesity and

document the amount of weight lost. To be eligible for additional face-to-face visits occurring once a month for an additional six months, patients must have lost at least 3 kg (6.6 lbs) over the course of the first six months of intensive therapy and should be documented in the record. For patients who do not achieve this minimum weight loss during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six-month period.

• Source: Decision memo for intensive behavioral therapy for obesity (CAG-00423N). Centers for Medicare & Medicaid Services Website. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=253 [1]. Published November 29, 2011. Accessed November 30, 2011.

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=253

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=253

Physical Activity Evidence and Guidelines



Physical Activity Recommendations

Assess risk with a physical activity history and/or an exercise test, to guide prescription

Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities

Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, HF)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Goal: 30 minutes 7 days/week, minimum 5 days/week



RCT Trial Assessment of Pedometer RCT Trial Assessment of Pedometer InterventionsInterventions

Bravata, DM et al. JAMA 2007; 298:2296-2304

N=277; 8 TrialsPedometer increased steps by 2500/day

Adverse Effects of Physical Inactivity

Age

Diabetes Mellitus

Obesity

Genetics Atherosclerosis

Hypercoagulability

Smoking

Hypertension

Novel Risk Factors

Inflammation Dyslipidemia

Physical Inactivity

Note: Minutes per week spent in moderate-intensity sports activity (low-active, 135min/wk; intermediately active, 136-195 min/wk; and highly active, >195 min/wk)

Total Body Fat Intra-abdominal Fat

Irwin ML et al. JAMA 2003;289:323-330

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

Exercise Evidence:Effect on Body Composition

NS

5% 20%†

15% 34%*

8% 20%*

Change from Baseline

202171

199174

197190

200188

TGMenWomen

3956

4155

4050

3747

HDL-CMenWomen

118102

131120

134135

138155

LDL-CMenWomen

Year and Lipid Level (mg/dL)

196193

210209

213223

214239

TCMenWomen

531BaselineLipids

Warner JG et al. Circulation 1995;92:773-777

*P=0.0001 for change in women vs men†P=0.03 for change in women vs men

HDL-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol, TG=Triglyceride

Exercise Evidence:Effect on Lipid Parameters

ILI DSE P value

LDL (mg/dL) -5.2 ± 0.6 -5.7 ± 0.6 0.49

HDL (mg/dL) 3.4 ± 0.2 1.4 ± 0.1 <0.001

Triglycerides (mg/dL) -30.3 ± 2.0 -14.6 ± 1.8 <0.001

% Metabolic Syndrome -14.7 ± 0.8 -7.1 ± 0.7 <0.001

5,145 patients aged 45-74 years with type 2 DM and BMI 25 kg/m2 (27 kg/m2 if taking insulin) randomized to an intensive lifestyle

intervention (ILI) involving group and individual meetings to achieve and maintain weight loss through decreased caloric intake

and increased physical activity versus diabetes support and education (DSE)

Look AHEAD investigators. Diabetes Care 2007;30:1374-83

Exercise Evidence:Effect on Lipid Parameters

Look AHEAD Trial

Intensive lifestyle intervention results in greater improvements in lipid parameters

BMI=Body mass index, DM=Diabetes mellitus

Hu FB et al. JAMA 2003;289:1785-91

Nurse’s Health Study

Exercise reduces the incidence of obesity and DM

Exercise Evidence:Effect on Obesity and Diabetes Mellitus (DM)

Manson JE et al. NEJM 2002;347:716-25

Quintiles of activity (MET-hour/week**)

0.0

0.2

0.4

0.6

0.8

1.0

Walking

Rela

tive R

isk o

f C

HD

0.0

0.2

0.4

0.6

0.8

1.0

Vigorous exercise*

Rela

tive R

isk o

f C

HD

P=0.004

P=0.008

1 2 3 4 5

Women’s Health Initiative Observational Study

1 2 3 4 5

**Average active hours per week energy expenditure per activity

*Includes aerobics, aerobic dancing, jogging, tennis, and swimming laps

CHD=Coronary heart disease

Exercise Evidence:Effect on Coronary Heart Disease Risk

Wannamethee SG et al. Circulation 2000;102:1358-1363

CHD=Coronary heart disease, CVD=Cardiovascular disease

Moderate exercise is associated with reduced mortality

Observational study of self-reported physical activity in 772 men with CHD

Physical Activity:Secondary Prevention

0.76 0.75

1.15

0

0.5

1

1.5

All Cause Death CV Mortality Nonfatal Recurrence

Po

ole

d O

dd

s R

atio

* *

Effect of cardiac rehabilitation in randomized controlled trials following a MI

Oldridge NB et al. JAMA 1988;260:945-950

*p<0.0125

Cardiac Rehabilitation:Benefits Following a Myocardial Infarction (MI)

Cardiac rehabilitation reduces CV events after a MI

CV=Cardiovascular

Clark AM et al. Ann of Intern Med 2005;143:659-72

Meta-analysis of 63 randomized clinical trials evaluating cardiac secondary prevention programs with or without

exercise programs

Cardiac Rehabilitation:Benefit of Secondary Prevention Programs

All cause mortality Recurrent myocardial infarction

Secondary prevention programs provide CV benefitCV=Cardiovascular

Cigarette Smoking Cessation Evidence and Guidelines



• Tobacco causes 1 in 6 of all NCD deaths

• By 2015 the WHO estimates tobacco will cause 6.4 million deaths a year

• Tobacco use impedes economic and social development

• the WHO Framework Convention on Tobacco Control (FCTC) is a set of internationally negotiated, legally binding, evidence-based tobacco control measures – implementation of the FCTC must be accelerate

NCDs, tobacco control and the FCTC

Tobacco Cessation Recommendations

Complete cessation

No environmental tobacco smoke

exposure

Goals Recommendations

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


I IIa IIb III

0.1 1.0 10Ceased smoking Continued smoking

RR (95% Cl)Study

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)

Critchley JA et al. JAMA 2003;290:86-97

*Includes those with known coronary heart disease

Cigarette Smoking Cessation Evidence: Risk of Non-fatal Myocardial Infarction*

Ask and document tobacco use status

Advise Provide a strong, personalized message

Assess Readiness to quit in next 30 days

Prevent Relapse• Congratulate successes• Encourage • Discuss benefits experienced by patient• Address weight gain, negative mood, and lack of support

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

Assist: Negotiate plan • STAR**• Discuss pharmacotherapy• Social support• Provide educational materials

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

**STARSet quit dateTell family, friends, and coworkersAnticipate challenges: withdrawal, breaksRemove tobacco from the house, car etc.

Recent Quitter

(<6 months) Current User

Not Ready

Ready

Tobacco Cessation Algorithm

The term “Psychosocial”

broadly categorizes factors which are:

• Psychologic – e.g, anxiety, depression• Psychosocial – e.g., work stress,

discrimination, emotional support• Social-structural – e.g., socioeconomic

status, social integration, neighborhood effects

Screening for Psychosocial Risk: AHA Science Advisory on Depression

(Lichtman J et al. Circulation 2008)• The recommendations, which are endorsed by

the American Psychiatric Association, include:– early and repeated screening for depression

in heart patients– the use of two questions to screen patients –

if depression is suspected the remaining questions are asked (9 questions total)

– coordinated follow-up for both heart disease and depressive symptoms in patients who have both.

From: Lichtman J et al., Circulation 2008

My Life Check Assessment

CONCLUSIONS

1)The increasing epidemic of obesity, diabetes, and inadequate attainment of CVD prevention goals necessitates improved efforts at therapeutic lifestyle management.2)Therapeutic lifestyle changes are a crucial and necessary part of any cardiovascular risk reduction effort3)Healthcare providers and facilities need to provide patients with adequate access to lifestyle experts, including registered dietitians, exercise specialists, and stress management personnel to address lifestyle-associated CVD risk in patients4)Recent legislation allowing for wider reimbursement for lifestyle management, medical nutrition therapy in particular, should be a motivation for healthcare providers to ensure that these resources are available.

evidence-based lifestyle recommendations for prevention of cardiovascular disease nathan d. wong,...

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