The Evidence for Current Cardiovascular
Disease Prevention Guidelines:
Lifestyle Management
Evidence and Guidelines
American College of Cardiology
Best Practice Quality Initiative Subcommittee
and Prevention Committee
Classification of Recommendations
and Levels of Evidence
*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.
Icons Representing the Classification and Evidence
Levels for Recommendations
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
Evidence for Current Cardiovascular Disease
Prevention Guidelines
Cigarette Smoking Cessation
Evidence and Guidelines
Smoking Prevalence in the United States
National Health Interview Survey
Estimated percentage of current smokers in the United States by sex
There has been a decrease in the prevalence of cigarette smoking in
men and women over time
Source: CDC, Morbidity and Mortality Weekly Report 2007;56:1157-1161
Tobacco Use:
Most Preventable Cause of Death
Most preventable causes of death in the U.S. in 1990 and 2000
Causes
# (%) in 1990
# (%) in 2000
Tobacco
400,000 (19)
435,000 (18)
Poor diet and physical activity (obesity)
300,000 (14)
400,000 (17)
Alcohol consumption
100,000 (5)
85,000 (4)
Microbial agents
90,000 (4)
75,000 (3)
Toxic agents
60,000 (3)
55,000 (2)
Motor vehicle accidents
25,000 (1)
43,000 (2)
Firearms
35,000 (2)
29,000 (1)
Sexual behavior
30,000 (1)
20,000 (<1)
Illicit drug use
20,000 (<1)
17,000 (<1)
1,060,000 (50*)
1,159,000 (48%*)
Total
*Reflects percent total of 9 most preventable causes of death
Source: Mokdad AH et al. JAMA 2004;291:1238-1245
Cigarette Smoking Cessation Evidence:
Risk of Non-fatal Myocardial Infarction*
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)
0.1
Ceased smoking
1.0
Continued smoking
10
*Includes those with known coronary heart disease
Source: Critchley JA et al. JAMA 2003;290:86-97
Cigarette Smoking Cessation Evidence:
Tailored Materials
1058 current and recent ex-smokers randomized to a smoking cessation
strategy of usual care* vs. computed-generated tailored advice**
Abstinence rates (%)
35
30
25
20
Usual care
Tailored care
p=0.015
20.9
p=0.004
18.9
15.4
15
p=0.013
16.4
12.7
p=0.080
11.3
10
12.2
9.0
5
0
24 hour
7 day
1 month
3 month
Duration of abstinence
Self-help materials tailored for the needs of individual smokers are more
effective than usual materials
*Usual care consists of telephone counselling and a mailed information packet
**Tailored care consists of usual care + a computer-generated individually tailored advice letter
Source: Sutton S et al. Addiction 2007;102:994-1000.
Cigarette Smoking Cessation:
Effect of Counseling Intervention
Meta-analysis of 33 clinical trials assessing the benefit of smoking cessation
counseling interventions with or without pharmacotherapy
Intensity 1: Contact in
hospital of <15 minutes only
Intensity 2: Contact in
hospital of >15 minutes only
Intensity 3: Any hospital
contact plus postdischarge
support of <1 month
Intensity 4: Any hospital
contact plus postdischarge
support of >1 month
Inpatient counseling with contact >1 month after discharge is associated with
the greatest rate of smoking cessation
Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960
Cigarette Smoking Cessation:
Frequency of Nicotine Dependence
Percent Reporting >1 Indicators of Nicotine Dependence, by Age and
Intensity of Smoking
12-24 Years Old
Less than 6*
25+ Years Old
6-15*
16-25*
26+*
*Cigarettes per day
Source: Substance Abuse and Mental Health Services
Administration; United States, 2010 National Survey.
Cigarette Smoking Cessation:
Types of Nicotine Replacement
Increase in nicotine concentration (ng/ml)
Plasma nicotine concentrations
14
12
10
8
Cigarette
Gum 4 mg
6
Gum 2 mg
4
Inhaler
2
Nasal spray
Patch
0
5
10
15
20
25
30
Minutes
Source: Balfour DJ et al. Pharmacol Ther 1996;72:51-81
Cigarette Smoking Cessation Evidence:
Effect of Combination Therapy
Limited Behavioral Support
Intervention
Effect Size
95% CI
Nicotine gum
5%
4-6%
Nicotine transdermal patch
5%
4-7%
Intensive Behavioral Support
Intervention
Effect Size
95% CI
Nicotine gum
8%
6-10%
Nicotine transdermal patch
6%
5-8%
12%
7-17%
Nicotine inhaler
8%
4-12%
Nicotine sublingual tablet
8%
1-14%
Nicotine nasal spray
CI=Confidence interval
Sources:
West R et al. Thorax 2000;55:987-999
Silagy C et al. Cochrane Database Syst Rev 2002;CD000146
Cigarette Smoking Cessation Evidence:
Primary Prevention
893 smokers randomized to 9 weeks of bupropion (150 mg daily for 3 days
and then 150 mg bid), NRT (21 mg patch weeks 2-7, 14 mg patch week 8,
and 7 mg patch week 9), bupropion and NRT, or placebo
Placebo
(n=160)
NRT
(n=244)
Bupropion
(n=244)
Nicotine patch and
Bupropion (n=245)
Abstinence rate
at 6 months
18.8%
21.3%
34.8%a,b
38.8%a,c,d
Abstinence rate
at 12 months
15.6%
16.4%
30.3%a,c
35.5%a,c,e
Bupropion with or without NRT provides the greatest benefit
ap<0.001
when compared to placebo
when compared to NRT
cp<0.001 when compared to NRT
dp=0.37 when compared to bupropion
ep=0.22 when compared to bupropion
bp=0.001
NRT=Nicotine replacement therapy
Source: Jorenby DE et al. NEJM 1999;340:685-691
Cigarette Smoking Cessation Evidence:
Primary Prevention
1,027 smokers randomized to 12 weeks of varenicline (titrated to 1 mg bid),
bupropion (titrated to 150 mg bid), or placebo
Varenicline vs. Bupropion
P<0.001 (weeks 9-12), P=0.004 (weeks 9-52)
Varenicline provides greater rates of abstinence than bupropion
Source: Jorenby DE et al. JAMA 2006;296:56-63
Cigarette Smoking Cessation:
Pharmacotherapy*
Agent
Caution
Side Effects
Dosage
Duration
Instructions
Bupropion SR
(Zyban®)**
Seizure disorder
Eating disorder
Taking MAO
inhibitor
Pregnancy
Insomnia
Dry mouth
150 mg QAM
then
150 mg BID
3 days
Start 1-2 weeks
before quit date.
Take 2nd dose in
early afternoon or
decrease to 150 mg
QAM for insomnia.
Transdermal
Nicotine
Patch***
Varenicline
(Chantix®)**
Depression/
Suicide
Within 2 weeks
of a MI
Unstable angina
Arrhythmias
Heart failure
Skin reaction
Insomnia
Pregnancy
Nausea
Sleep
disorder
Depression/
Suicide
CV risk
8 weeks, but up
to 6 months
21 mg QAM
14 mg QAM
7 mg QAM
or
15 mg QAM
4 weeks
2 weeks
2 weeks
0.5 mg QD
then
0.5 mg BID
then
1 mg BID
3 days
8 weeks
Apply to different
hairless site daily.
Remove before bed
for insomnia.
Start at <15 mg for
<10 cigs/day
Start 1 week before
the quit date
4 days
12 weeks
*Pharmacotherapy combined with behavioral support provides the best success rate
**The FDA has placed a black box warning on varenicline and buproprion SR
due to the risk of depression and/or suicidal thoughts
***Other nicotine replacement therapy options include: nicotine gum,
lozenge, inhaler, nasal spray
Cigarette Smoking Cessation:
Effect of Pharmacotherapy
Meta-analysis of 33 clinical trials assessing the benefit of smoking
cessation counseling interventions with or without pharmacotherapy
Adding pharmacotherapy (nicotine replacement or bupropion) to counseling
intervention does not improve rates of smoking cessation
NRT=Nicotine replacement therapy
Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960
Cigarette Smoking Cessation:
Benefit of Community Smoking Ban
Prospective assessment of smoking status and exposure to second-hand
smoke among patients admitted with an ACS to 9 Scottish hospitals before
and after legislation prohibiting smoking in enclosed public places
Smoke-free legislation results in reduced ACS admissions
ACS=Acute coronary syndrome
Source: Pell JP et al. NEJM 2008;359:482-491
Cigarette Smoking Cessation:
Benefit of Community Smoking Ban
Meta-analysis evaluating the ratio of community rates of acute MI before
and after implementation of a smoking restriction law
Smoke-free legislation results in a rapid and substantial reduction in MI
MI=Myocardial infarction
Source: Lightwood JM et al. Circulation 2009;120:1373-1379
Cigarette Smoking Cessation:
Benefit of Financial Incentives
878 smokers working for a U.S. company randomized to receive information
about smoking-cessation programs or information plus financial incentives
Financial incentives for smokers increase the cessation rate
Source: Volpp KG et al. NEJM 2009;360:699-709
Tobacco Cessation Algorithm
Ask and document tobacco use status
Current User
Recent Quitter
(<6 months)
Advise Provide a strong, personalized message
Assess Readiness to quit in next 30 days
Ready
Not Ready
Assist: Negotiate plan
• STAR**
• Discuss pharmacotherapy
• Social support
• Provide educational materials
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
**STAR
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
Set quit date
Tell family, friends, and coworkers
Anticipate challenges: withdrawal, breaks
Remove tobacco from the house, car, etc.
Source:
Fiore MC et al. Treating tobacco use and dependence: an
evidence based clinical practice guideline for tobacco cessation.
U.S. Department of Health and Human Services, 2000
AHA Primary Prevention of CV Disease in DM
Tobacco Recommendations
Primary Prevention
• All patients should be asked about tobacco use status at every visit.
• Every tobacco user should be advised to quit.
• The tobacco user’s willingness to quit should be assessed.
•The patient can be assisted by counseling and by developing a plan to
quit.
• Follow-up, referral to special programs, or pharmacotherapy (e.g.,
NRT and buproprion) should be incorporated as needed.
AHA=American Heart Association, CV=Cardiovascular,
DM=Diabetes mellitus, NRT=Nicotine replacement therapy
Source: Buse JB et al. Circulation 2007;115:114-126
ADA Smoking Cessation Recommendations
for Patients with Diabetes Mellitus
Primary Prevention
• All patients should be advised not to smoke.
• Smoking cessation counseling and other forms of treatment
should be included as a routine component of diabetes care.
ADA=American Diabetes Association
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
Tobacco Cessation Recommendations
Secondary Prevention
Goals:
Complete tobacco cessation and no environmental tobacco
smoke exposure
I IIa IIb III
Patients should be asked about tobacco use status at every
office visit
I IIa IIb III
Every tobacco user should be advised at every visit to quit
I IIa IIb III
The tobacco user’s willingness to quit should be assessed at
every visit.
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Tobacco Cessation Recommendations (Continued)
Secondary Prevention
I IIa IIb III
Patients should be assisted by counseling and by
development of a plan for quitting that may include
pharmacotherapy and/or referral to a smoking cessation
program
I IIa IIb III
Arrangement for follow up is recommended.
I IIa IIb III
All patients should be advised at every office visit to avoid
exposure to environmental tobacco smoke at
work, home, and public places
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Evidence for Current Cardiovascular Disease
Prevention Guidelines
Diet and Weight Management
Evidence and Guidelines
Overweight and Obese States:
Definition Using the Body Mass Index (BMI)
Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht2 (in)
Weight Category
BMI (kg/m2)
Normal
18.5-24.9
Overweight*
25.0-29.9
Obesity (Class I)
30.0-34.9
Obesity (Class II)
35.0-39.9
Obesity (Class III)
>40.0
*Measurement of waist circumference is most helpful in this category
Source: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and
Obesity in Adults. NIH/NHLBI/NAASO. October, 2000. NIH publication No. 00-4084
Prevalence of Obesity in U.S. Adults
1991
1996
2006
2008
Percentage of State Obese (BMI > 30)
No Data
<10%
10–14%
15–19%
20–24%
25-29%
>30%
Source: CDC Overweight and Obesity
Change in Body Mass Index Distribution
in the United States Over Time
National Health and Nutrition Examination Survey (NHANES)
100%
Body mass index (kg/m2)
age-adjusted percentage
90%
80%
70%
60%
50%
40%
30%
>35
30-35
25-30
>25
20%
10%
0%
Source: Ford ES et al. Circulation 2009;120:1181-1188
Adult obesity
At age 21-29 years (%)
Body Mass Index:
Risk of Developing Obesity in Adulthood
Age of child (years)
BMI=Body mass index
Source: Whitaker RC et al. NEJM 1997;337:869-873
Body Mass Index:
Relationship with Waist Circumference
Source: Despres JP et al. Arterioscler Thromb Vasc Biol 2008;48:1039-1049
Body Mass Index:
Risk of Hypertension
Study to Help Improve Early Evaluation and Management of Risk
Factors Leading to Diabetes (SHIELD) and National Health and
Nutrition Examination Survey (NHANES)
Source: Bays HE et al. Int J Clin Pract 2007;61:737-747
Body Mass Index:
Risk of Diabetes Mellitus
Study to Help Improve Early Evaluation and Management of Risk
Factors Leading to Diabetes (SHIELD) and National Health and
Nutrition Examination Survey (NHANES)
Source: Bays HE et al. Int J Clin Pract 2007;61:737-747
Body Mass Index:
Risk of Cardiovascular Disease
Hazard Ratio
4.0
Hemorrhagic
CVA
4.0
Ischemic
CVA
4.0
2.0
2.0
2.0
1.0
1.0
1.0
0.5
0.5
0.5
16 20 24 28 32 36
16 20 24 28 32 36
Ischemic Heart
Disease
16 20 24 28 32 36
Body Mass Index (kg/m2)*
*BMI is calculated as the weight in kg divided by the BSA in meters2
CVA=Cerebrovascular accident
Source: Mhurchu N et al. Int J Epidemiol 2004;33:751-758
Diet Evidence:
Types of Treatment Programs
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 (Continued)
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:
Primary Prevention
160 overweight and obese patients randomized to the Atkins, Zone, Weight
Watchers, or Ornish diets for 1 year
Ornish
20/40*
Weight Watchers
26/40*
Zone
26/40*
Atkins
21/40*
0
3
Wt loss (lbs)
6
9
Weight loss is similar among diet programs, but hard to sustain because of
poor long-term compliance
*Ratio of individuals completing the study to those enrolled
Source: Dansinger, ML et al. JAMA 2005;293:43-53
AHA Primary Prevention of CV Disease in DM
Weight Management Recommendations
Primary Prevention
• Structured programs that emphasize lifestyle changes such as
reduced fat (<30% of daily energy) and total energy intake and
increased regular physical activity, alone with regular participant
contact, can produce long-term weight loss on the order of 5-7% of
starting weight, with improvement in blood pressure.
• For individuals with elevated plasma triglycerides and reduced HDLC, improved glycemic control, moderate weight loss (5-7% of starting
weight), increased physical activity, dietary saturated fat restriction,
and modest replacement of dietary carbohydrates (5-7%) by either
monounsaturated or polyunsaturated fats may be beneficial.
AHA=American Heart Association,
CV=Cardiovascular, DM=Diabetes mellitus,
HDL-C=High density lipoprotein cholesterol
Source: Buse JB et al. Circulation 2007;115:114-126
Weight Management
Recommendations
Secondary Prevention
Goals:
I IIa IIb III
BMI 18.5-24.9 kg/m2, Waist circumference for women: <35
inches, men: <40 inches*
Body mass index and/or waist circumference should be
assessed at every visit, and the clinician should consistently
encourage weight maintenance/reduction through an
appropriate balance of lifestyle physical activity, structured
exercise, caloric intake, and formal behavioral programs
when indicated to maintain/achieve a body mass index
between 18.5 and 24.9 kg/m2
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Weight Management
Recommendations (Continued)
Secondary Prevention
I IIa IIb III
If waist circumference (measured horizontally at the iliac
crest) is >35 inches (>89 cm) in women and >40 inches
(>102 cm) in men, therapeutic lifestyle interventions should
be intensified and focused on weight management
I IIa IIb III
The initial goal of weight loss therapy should be to reduce
body weight by approximately 5% to 10% from baseline.
With success, further weight loss can be attempted if
indicated.
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Evidence for Current Cardiovascular Disease
Prevention Guidelines
Diet Evidence,
Cardiovascular Events, and
Guidelines
Relationship Between Diet and CV Disease
Diet
Intermediary Biological Mechanisms*
Risk of
Coronary Heart
Disease
*Includes lipid levels [LDL-C, HDL-C, triglycerides, Lp(a), blood pressure,
thrombotic tendency, cardiac rhythm, endothelial function, systemic
inflammation, insulin sensitivity, oxidative stress, homocysteine level
CV=Cardiovascular
Source: Hu FB et al. JAMA. 2002;288:2569-2578
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
Change from Baseline (%)
30
LDL-C
20
LDL-C:HDL-C
CRP
10
Low fat diet
0
Statin
-10
Dietary
portfolio*
-20
-30
-40
-50
0
2
Weeks
4
0
2
Weeks
4
0
2
4
Weeks
A diversified diet improves lipid parameters and CRP levels
*Enriched in plant sterols, soy protein, viscous fiber, and almonds
CRP=C-reactive protein, HDl-C=High density lipoprotein
cholesterol, LDL-C=Low density lipoprotein cholesterol
Source: Jenkins DJ et al. JAMA 2003;290:502-510
Diet Evidence:
Effect on Blood Pressure
Dietary Approaches to Stop Hypertension (DASH) Group
459 hypertensive patients randomized to 1 of 3 diets for 8 weeks
132
Systolic blood
pressure
130
(mm Hg)
126
128
Diet low in fruits, vegetables, and
dairy products
124
Diet enriched in fruits, vegetables,
and fiber
86
Diastolic blood
pressure
84
(mm Hg)
80
Diet enriched in fruits and vegetables
and low in fat and cholesterol
82
78
0 1 2 3 4 5 6 7/8
Weeks
A diversified diet improves blood pressure
Source: Appel LJ et al. NEJM 1997;336:1117-1124
Diet Evidence:
Benefits of Fruits and Vegetables
Nurses’ Health Study and Health Professional’s Follow-up Study
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
*Includes nonfatal MI and fatal coronary heart disease
CV=Cardiovascular
Joshipura KJ et al. Ann Intern Med 2001;134:1106-1114
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
RR=0.73, P<0.001
Increased dietary fiber intake reduces CV risk
CV=Cardiovascular, CHD=Coronary heart disease
Source: Pereira MA et al. Arch Int Med 2004;164:370-376
Diet Evidence:
Making Smart Food Choices
• Helps consumers make
better food choices
• Reminds individuals to eat
healthfully
• Illustrates the 5 food groups
using a mealtime visual
• Selected messages include:
• Balancing calories
• Foods to increase
• Foods to reduce
Source: United States Department of Agriculture,
http://www.choosemyplate.gov/index.html
Diet Evidence:
Primary Prevention
22,043 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
Variable
# of Deaths/
# of Participants
Fully Adjusted Hazard Ratio
(95% CI)
Death from any
cause
275/22,043
0.75 (0.64-0.87)
54/22,043
0.67 (0.47-0.94)
97/22,043
0.76 (0.59-0.98)
Death from
CHD
Death from
cancer
High adherence to a Mediterranean diet is associated with a reduction in death
CHD=Coronary heart disease
Source: Trichopoulou A et al. NEJM 2003;348:2599-2608
Diet Evidence:
Secondary Prevention
Lyon Diet Heart Study
605 patients following a myocardial infarction randomized to a
Mediterranean* or Western** diet for 4 years
Freedom from cardiac death
or myocardial infarction (%)
100
90
Mediterranean diet
Western diet
80
70
P=0.0001
1
2
3
Year
4
5
A Mediterranean diet reduces cardiovascular events
*High in polyunsaturated fat and fiber,
**High in saturated fat and low in fiber
Source: De Lorgeril M et al. Circulation 1999;99:779-785
Adult Treatment Panel (ATP) III
Dietary Recommendations
Nutrient
Saturated fat*
Recommended Intake
<7% of total calories
Polyunsaturated fat
Up to 10% of total calories
Monounsaturated fat
Up to 20% of total calories
Total fat
25%–35% of total calories
Carbohydrate (esp. complex carbs)
Fiber
50%–60% of total calories
20–30 g/d
Protein
Cholesterol
~15% of total calories
<200 mg/d
*Trans fatty acids also raise LDL-C and should be kept at a low intake
Note: Regarding total calories, balance energy intake and expenditure to
maintain desirable body weight
LDL-C=Low density lipoprotein cholesterol
Source: Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497
American Heart Association Nutrition Committee
Dietary Recommendations
Recommendations for Cardiovascular Disease Risk Reduction
• 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
• If alcohol is consumed, do so in moderation
AHA=American Heart Association
Source: AHA Nutrition Committee. Circulation 2006;114:82-96
Dietary Recommendations
Primary Prevention
I IIa IIb III
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
Source: Mosca L et al. Circulation 2007;115:1481-1501
AHA Primary Prevention of CV Disease in DM
Dietary Recommendations
Primary Prevention
• To achieve reductions in LDL-C levels:
o
Saturated fats should be <7% of energy intake.
o
Dietary cholesterol intake should be <200 mg/day.
o
Intake of trans-unsaturated fatty acids should be <1% of energy
intake.
• Total energy intake should be adjusted to achieve body-weight goals.
• Total dietary fat intake should be moderated (25-35% of total calories)
and should consist mainly of monounsaturated or polyunsaturated fat.
AHA=American Heart Association,
CV=Cardiovascular, DM=Diabetes mellitus,
LDL-C=Low density lipoprotein cholesterol
Source: Buse JB et al. Circulation 2007;115:114-126
AHA Primary Prevention of CV Disease in DM
Dietary Recommendations
Primary Prevention
• Ample intake of dietary fiber (>14 grams/1000 calories consumed)
may be of benefit.
• If individuals choose to drink alcohol, daily intake should be limited
to 1 drink* for adult women and 2 drinks* for adult men. Alcohol
ingestion increase caloric intake and should be minimized when
weight loss is the goal. Individuals with elevated plasma triglyceride
levels should limit alcohol intake, because intake may exacerbate
hypertriglyceridemia.
• In both normotensive and hypertensive individuals, a reduction in
sodium intake may lower blood pressure. The goal should be to
reduce sodium intake to 1200-2300 mg/day.**
* Defined as a 12 ounce beer, a 4 ounce glass of
wine, or a 1.5 ounce glass of distilled spirits
** Equivalent to 3000-6000 mg/day of sodium chloride
AHA=American Heart Association,
CV=Cardiovascular, DM=Diabetes mellitus
Source: Buse JB et al. Circulation 2007;115:114-126
ADA Medical Nutrition Therapy Recommendations
for Patients with Diabetes Mellitus
Primary Prevention
• Weight loss is recommended for all overweight or obese individuals
who are at risk for DM.
• For weight loss, either low-carbohydrate or low-fat calorie-restricted
diets may be effective in the short-term (up to 1 year).
• Among individuals at high risk for developing type II DM, structured
programs emphasizing lifestyle changes that include moderate weight
loss (7% body weight) and regular physical activity (150
minutes/week) with dietary strategies include reduced intake of dietary
fat and can reduce the risk of developing DM and are therefore
recommended.
ADA=American Diabetes Association, DM=Diabetes mellitus
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA Medical Nutrition Therapy Recommendations
for Patients with Diabetes Mellitus (Continued)
Primary Prevention
• Individuals at high risk for type II DM should be encouraged to
achieve USDA recommendation for dietary fiber (14 grams fiber/1000
kcal) and foods containing whole grains (one-half of gram intake).
• Saturated fat intake should be <7% of total calories.
• Reducing intake of trans-fat lowers LDL-C and increase HDL-C.
Therefore, intake of trans-fat should be minimized.
• Monitoring carbohydrate intake, whether by carbohydrate counting,
exchanges, or experience-based estimation remains a key strategy in
achieving glycemic control.
ADA=American Diabetes Association, DM=Diabetes mellitus, HDL-C=High
density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA Medical Nutrition Therapy Recommendations
for Patients with Diabetes Mellitus (Continued)
Primary Prevention
• For individuals with DM, use of the glycemic index and glycemic load
may provide a modest additional benefit for glycemic control over that
observed when total carbohydrate is considered alone.
• Sugar alcohols and nonnutritive sweeteners are safe when consumed
within the acceptable daily intake levels established by the FDA.
• If adults with DM choose to use alcohol, daily intake should be limited
to a moderate amount (<1 drink per day for adult women and <2 drinks
per day for adult men).
AHA=American Heart Association, DM=Diabetes
mellitus, FDA=Food and Drug Administration
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA Medical Nutrition Therapy Recommendations
for Patients with Diabetes Mellitus (Continued)
Primary Prevention
• Routine supplementation with antioxidants, such as Vitamin E and C,
and carotene, is not advised because of lack of evidence of efficacy
and concerns related to long-term safety.
• Benefit from chromium supplementation in patients with DM or
obesity has not been conclusively demonstrated and therefore cannot
be recommended.
• Individualized meal planning should include optimization of food
choices to meet recommended dietary allowances (RDAs)/dietary
reference intakes (DRIs) for all micronutrients.
ADA=American Diabetes Association, DM=Diabetes mellitus
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
Dietary Recommendations
Secondary Prevention
I IIa IIb III
I IIa IIb III
Dietary therapy for all patients should include reduced intake
of saturated fats (to <7% of total calories), trans fatty acids
(to <1% of total calories), and cholesterol (to <200 mg/d)
For all patients, it may be reasonable to recommend omega3 fatty acids from fish or fish oil capsules
(1 gram/day) for cardiovascular disease risk reduction
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Evidence for Current Cardiovascular Disease
Prevention Guidelines
Physical Activity Evidence
and Guidelines
Adverse Effects of Physical Inactivity
Physical Inactivity
Inflammation
Dyslipidemia
Age
Hypertension
Diabetes Mellitus
Smoking
Obesity
Hypercoagulability
Genetics
Atherosclerosis
Novel Risk Factors
Prevalence of Physical Activity
Prevalence of physical activity among individuals >18 years of age
Over half the U.S. adult population is physically inactive
NH=Non-Hispanic
Source: Lloyd-Jones D et al. Circulation 2010;121:46-215
Exercise Evidence:
Effect on Body Composition
173 sedentary, overweight (body mass index >24 kg/m2) post-menopausal
women randomized to moderate intensity exercise vs. stretching for 1 year
Total Body Fat
Intra-abdominal Fat
Moderate exercise reduces total and intra-abdominal fat
Note: Minutes per week spent in moderate-intensity sports activity (low-active, 135
min/wk; intermediately active, 136-195 min/wk; and highly active, >195 min/wk)
Source: Irwin ML et al. JAMA 2003;289:323-330
Exercise Evidence:
Effect on Lipid Parameters
Assessment of lipid profiles in 719 patients undergoing cardiac rehab
Year and Lipid Level (mg/dL)
Baseline
1
3
5
Change from
Baseline
Men
Women
214
239
213
223
210
209
196
193
 8%
 20%*
LDL-C
Men
Women
138
155
134
135
131
120
118
102
 15%
 34%*
HDL-C
Men
Women
37
47
40
50
41
55
39
56
 5%
 20%†
TG
Men
Women
200
188
197
190
199
174
202
171
NS
Lipids
TC
*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
Source: Warner JG et al. Circulation 1995;92:773-777
Exercise Evidence:
Effect on Lipid Parameters
Look AHEAD Trial
5,145 patients aged 45-74 years with type 2 DM and BMI of 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)
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
Intensive lifestyle intervention results in greater
improvement in lipid parameters
BMI=Body mass index, DM=Diabetes mellitus, DSE=Diabetes
support and education, ILI=Intensive lifestyle intervention
Source: Look AHEAD investigators. Diabetes Care 2007;30:1374-1383
Exercise Evidence:
Effect on Obesity and Diabetes Mellitus (DM)
Nurse’s Health Study
35%
30%
Risk of obesity
Risk of DM
25%
20%
15%
10%
5%
0%
Reduction:
Each hour a day spent
walking briskly
Increase:
Each two hours a day
spent watching TV
Increase:
Each two hours a day
spent sitting at work
Exercise reduces the incidence of obesity and DM
Source: Hu FB et al. JAMA 2003;289:1785-1791
Exercise Evidence:
Effect on Coronary Heart Disease Risk
Women’s Health Initiative Observational Study
P=0.008
P=0.004
Relative Risk of CHD
Walking
Relative Risk of CHD
Vigorous exercise*
1
2
3
4
5
1
2
3
4
5
Quintiles of activity (MET-hour/week**)
*Includes aerobics, aerobic dancing, jogging, tennis, and swimming laps
**Average active hours per week  energy expenditure per activity
CHD=Coronary heart disease
Source: Manson JE et al. NEJM 2002;347:716-725
Physical Activity:
Effect on Mortality
13,344 healthy men and women followed for 8 years
Death Rate (per 10,000)
70
60
Men
Women
50
40
30
20
10
0
1
2
3
4
5
Fitness
to High)
Fitness
LevelLevel
(Low(Low
to High)
Low physical fitness is associated with increased mortality
Source: Blair SN et al. JAMA 1998;262:2395-2401
Physical Activity:
Secondary Prevention
Age-adjusted mortality
rate/1000 person-years
Observational study of self-reported physical activity in 772 men with CHD
Physical activity
Moderate exercise is associated with reduced mortality
CHD=Coronary heart disease, CVD=Cardiovascular disease
Source: Wannamethee SG et al. Circulation 2000;102:1358-1363
Cardiac Rehabilitation:
Benefits Following a Myocardial Infarction
Effect of cardiac rehabilitation in randomized controlled trials following a MI
*
*
Cardiac rehabilitation reduces CV events after a MI
*p<0.0125
CV=Cardiovascular, MI=Myocardial infarction
Source: Oldridge NB et al. JAMA 1988;260:945-950
Cardiac Rehabilitation:
Prevalence of Incomplete Attendance
Sessions attended (%)
Observational study of 30,161 Medicare patients attending at least 1
phase II cardiac rehabilitation session
Number of Sessions Attended
A large number of patients fail to complete 36 sessions of
cardiac rehabilitation
Source: Hammill BG et al. Circulation 2010;121:63-70
Cardiac Rehabilitation:
Greater Benefit with Greater Attendance
Death (%)
Myocardial infarction (%)
Observational study of 30,161 Medicare patients attending at least 1
phase II cardiac rehabilitation session
Years after Index Date
Years after Index Date
There is a strong dose-response relationship between the number of cardiac
rehabilitation sessions attended and long-term CV outcomes
CV=Cardiovascular
Source: Hammill BG et al. Circulation 2010;121:63-70
Cardiac Rehabilitation:
Benefit of Secondary Prevention Programs
Meta-analysis of 63 randomized clinical trials evaluating cardiac
secondary prevention programs with or without exercise programs
All cause mortality
Recurrent myocardial infarction
Secondary prevention programs provide CV benefit
CV=Cardiovascular
Source: Clark AM et al. Ann of Intern Med 2005;143:659-72
AHA Primary Prevention of CV Disease in DM
Physical Activity Recommendations
Primary Prevention
• To improve glycemic control, assist with weight loss or maintenance,
and reduce the risk of CVD, at least 150 minutes of moderateintensity aerobic physical activity or at least 90 minutes of vigorous
aerobic exercise per week is recommended. The physical activity
should be distributed over at least 3 days per week, with no more
than 2 consecutive days without physical activity.
• For long-term maintenance of major weight loss, a larger amount of
exercise (7 hours of moderate or vigorous aerobic physical activity
per week) may be helpful.
AHA=American Heart Association, CV=Cardiovascular,
CVD=Cardiovascular disease, DM=Diabetes mellitus
Source: Buse JB et al. Circulation 2007;115:114-126
ADA Physical Activity Recommendations
for Patients with Diabetes Mellitus
Primary Prevention
• People with DM should be advised to perform at least 150
minutes/week of moderate-intensity aerobic physical activity (50-70%
of maximum heart rate).
• In the absence of contraindications, people with type II DM should
be encouraged to perform resistance training three times per week.
ADA=American Diabetes Association, DM=Diabetes mellitus
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
Physical Activity
Recommendations
Secondary Prevention
Goal:
I IIa IIb III
At least 30 minutes, 7 days per week (minimum 5 days per
week) of physical activity
For all patients, the clinician should encourage 30 to 60
minutes of moderate-intensity aerobic activity, such as brisk
walking, at least 5 days and preferably 7 days per week,
supplemented by an increase in daily lifestyle activities (e.g.,
walking breaks at work, gardening, household work) to
improve cardiorespiratory fitness and move patients out of
the least fit, least active high-risk cohort
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Physical Activity
Recommendations (Continued)
Secondary Prevention
I IIa IIb III
For all patients, risk assessment with a physical activity
history and/or an exercise test is recommended to guide
prognosis and prescription
I IIa IIb III
The clinician should counsel patients to report and be
evaluated for symptoms related to exercise.
I IIa IIb III
It is reasonable for the clinician to recommend
complementary resistance training at least 2 days per week
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Cardiac Rehabilitation
Recommendations
Secondary Prevention
I IIa IIb III
All eligible patients with ACS or whose status is
immediately post coronary artery bypass surgery or postPCI should be referred to a comprehensive outpatient
cardiovascular rehabilitation program either prior to hospital
discharge or during the first follow-up office visit
I IIa IIb III
I IIa IIb III
All eligible outpatients with the diagnosis of ACS, coronary
artery bypass surgery or PCI (Level of Evidence: A),
chronic angina (Level of Evidence: B), and/or peripheral
artery disease (Level of Evidence: A) within the past year
should be referred to a comprehensive outpatient
cardiovascular rehabilitation program.
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Cardiac Rehabilitation
Recommendations (Continued)
Secondary Prevention
I IIa IIb III
I IIa IIb III
A home-based cardiac rehabilitation program can be
substituted for a supervised, center-based program for lowrisk patients
A comprehensive exercise-based outpatient cardiac
rehabilitation program can be safe and beneficial for
clinically stable outpatients with a history of heart failure
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446