LIFESTYLE MANAGEMENT UPDATE IN

CARDIOVASCULAR
CHOLID TRI TJAHJONO, MD
DISCLOSURE STATEMENT OF FINANCIAL INTEREST
I, (CHOLID TRI TJAHJONO) DO NOT HAVE A FINANCIAL
INTEREST/ARRANGEMENT OR AFFILIATION WITH ONE OR
MORE ORGANIZATIONS THAT COULD BE PERCEIVED AS A
REAL OR APPARENT CONFLICT OF INTEREST IN THE
CONTEXT OF THE SUBJECT OF THIS PRESENTATION.
INTRODUCTION
 Cardiovascular disease (CVD) is the leading cause of mortality
worldwide
 It is estimated that elderly people will increase globally
 Increasing longevity prolongs the time exposure to risk factors,
resulting in greater probability of CVD
 Lifestyle changes ( rich diet and sedentary habits) contributes to
the incremental trend of CVD
Lifestyle Risk Factors for CVD
Evidence shows many major risk factors for heart disease relate directly to
four lifestyle behaviors:
 Sedentary lifestyle
 Overweight and obesity
 Energy-dense diet (high in calories; high in saturated fats, added sugars
and refined grains; and low in fiber, whole grains, healthy fats, and
certain micronutrients)
 Smoking
Other risk factors and co-morbidities of heart disease
 Dyslipidemias
 Hypertension
 Glucose intolerance and Diabetes
 Metabolic syndrome
A Perfect (Health) Storm
 An estimated 36.9% of U.S. adults has some type of CVD. One of every
2.8 U.S. adults dies of heart disease.
 An estimated 1 in 3 U.S. adults (33.6%) has hypertension.
 46.8% of U.S. adults have total cholesterol ≥200 mg/dL; 16.2% ≥240
mg/dL. 32.6% have LDL cholesterol ≥130 mg/dL.
 Diagnosed diabetes among adults aged 18 years and over increased
from 5.1% in 1997 to 9.0% in 2009 and a statistically similar 8.8% in
2010.
Sources: American Heart Association, Heart Disease & Stroke Statistics: 2010 Update; CDC, 2010 National Health Information Survey; NIDDK Diabetes Statistics 2007
Contibuting Behaviours
The underlying lifestyle behaviors contributing to the Perfect Health Storm
 In 2009 and 2010, approximately two thirds of American adults are obese or
overweight
 In 2010, only 34.4% of U.S. adults age 18 and older engaged in self-reported
regular leisure-time physical activity
 In numerous studies, only 25-30% of U.S. adults consume the recommended
daily servings of fruits and vegetables
 In 2010, 19.9% of U.S. adults age 18 and older smoked

Sources: American Heart Association, Heart Disease & Stroke Statistics: 2010 Update; CDC, 2010 National Health Information Survey;Rippe 2011
Lifestyle Medicine

Helping individuals adopt healthful lifestyle behaviors –implement the

guidelines in practical ways for primary and secondary prevention –is
the overarching objective of Lifestyle Medicine
Healthy Lifestyle
 Healthy diet
 energy balanced and nutrient dense
 fruits and vegetables
 high-fiber whole grains, low-fat milk, seafood
 reduced added sugars, solid fats, refined grains and sodium
 Physical activity (PA)
 150 min/wk of moderate physical activity (MPA)
 75 min vigorous physical activity (VPA), or combination of two
Leading Health Indicators Healthy People 2020
Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and Violence
Environmental quality
Immunization
Access to health care
Physical Activity
Goal: 30 minutes 7 days/week, minimum 5 days/week
 Assess risk with a physical activity history and/or an exercise test, to
guide prescription (I B)

 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 ( I B)

 Advise medically supervised programs for high-risk patients (e.g.

recent acute coronary syndrome or revascularization, HF) (I B)
Adverse Effects of Physical Inactivity

Physical Inactivity

Inflammation Dyslipidemia

Age Hypertension

Diabetes Mellitus Smoking

Obesity Hypercoagulability

Genetics Atherosclerosis Novel Risk Factors

 Exercise Evidence:
Effect on Obesity and Diabetes Mellitus (DM)
Nurse’s Health Study

Exercise reduces the incidence

of obesity and DM
Hu FB et al. JAMA
2003;289:1785-91
 Physical Activity: Secondary Prevention
Observational study of self-reported physical activity in 772 men with CHD

Moderate exercise is
associated with reduced
Wannamethee SG et al.
mortality Circulation 2000;102:1358-
1363
AHA 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 (AHA 2011 rec. <1500mg/d)
• If alcohol is consumed, do so in moderation AHA Nutrition Committee. Circulation
2006;114:82-96
JNC VII Lifestyle Modifications for BP Control
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 Diet rich in fruits, vegetables, low fat dairy and 8-14 mmHg
plan reduced in fat
Restrict sodium intake <2.4 grams of sodium per day 2-8 mmHg

Physical activity Regular aerobic exercise for at least 30 4-9 mmHg

minutes on most days of the week
Moderate alcohol <2 drinks/day for men and <1 drink/day for 2-4 mmHg
consumption women

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

WEIGHT MANAGEMENT
GOALS:
 BMI 18.5 to 24.9 kg/m 2

 Women: <35 inches

 Men: <40 inches
 10% weight reduction within the 1 year of Treatment
st
 WEIGHT MANAGEMENT
GOALS:
 Calculate BMI* and measure waist circumference
 Monitor response to treatment
 Start weight management and physical activity as appropriate
 If BMI and/or waist circumference is above goal, initiate caloric
restriction and increase caloric expenditure

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

*BMI is calculated as the weight in kilograms divided by the body surface area in meters2

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

Body Mass Index:
Risk of Cardiovascular Disease
Hemorrhagic Ischemic Ischemic Heart
CVA CVA Disease
4.0 4.0 4.0

Hazard Ratio
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 16 20 24 28 32 36

Body Mass Index (kg/m2)*

CV=Cardiovascular

*BMI is calculated as the weight in kg divided by the BSA in meters 2

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

Dietary Intakes in Comparison to Recommended Intake Levels/Limits

2010 Dietary Guidelines Advisory Committee Report

NCDs, tobacco control
• 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
acceleratee

Grube E. et al, Am Journal Cardiol 2006; “in press”

Tobacco Cessation Algorithm
Ask and document tobacco use status
Recent Quitter
Current User
Advise Provide a strong, personalized message
Assess Readiness to quit in next 30 days
Ready
Assist: Negotiate plan
• STAR**
• Discuss pharmacotherapy
• Social support
• Provide educational materials
Prevent Relapse
• Congratulate successes
(<6 months)
• Encourage
• Discuss benefits experienced by patient
• Address weight gain, negative mood, and
lack of support
Not Ready 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
Set quit date
Arrange Follow-up to check plan or adjust meds
Tell family, friends, and coworkers
• Call right before and after quit date
Anticipate challenges: withdrawal, breaks
• Weekly follow-up x 2 weeks, then monthly x 6 months
Remove tobacco from the house, car etc.
• Ask about difficulties (withdrawal, depressed mood)
• Build upon successes
• Seek commitment to stay tobacco-free
Decline in Treatment Adherence Over Time

PREFER Trial
Acharya, Elci, Sereika et al., 2009
Summary
 The increasing epidemic of obesity, diabetes, and inadequate
attainment of CVD prevention goals necessitates improved efforts
at therapeutic lifestyle management.
 Therapeutic lifestyle changes are a crucial and necessary part of
any cardiovascular risk reduction effort
Summary
 Healthcare providers and facilities need to provide patients with
adequate access to lifestyle experts, including registered
dietitians, cardiologist, exercise specialists, to address lifestyle-
associated CVD risk in patients
TERIMA KASIH