行为干预：饮食控制、锻炼、控制体重.ppt

1、,Lifestyle Interventions: Dietary Therapy, Physical Activity, Weight ControlNeil J. Stone, M.D.,2010,Now,Primary Prevention: Status and Goals in 2010,NCEP. Adult Treatment Panel III Report. 2001.,Moderate physical activity,Vegetable intake of 3 servings,Saturated fat 10% of calories,Primary Preventi

2、on: Status and Goals in 2010,Fruit 2 servings/d,Smoking cessation,Healthy weight,2010,Now,NCEP. Adult Treatment Panel III Report. 2001.,Primary Prevention: Crucial Opportunity to Reduce the Burden of CHD,Law MR et al. BMJ 1994;308:367-372.,Age 70,Reduction in risk in men with 10% reductionin total c

3、holesterol (10 cohort studies),Age 50,Age 40,Primary Prevention: Adverse Life Habit Changes,Atherogenic diet Sedentary lifestyle Obesity,Expert Panel. JAMA 2001;285:2486-2497.,Primary PreventionRx: Therapeutic Lifestyle Changes (TLC),Therapeutic diet to lower LDL-C Physically active on a daily basis

4、 Weight control,Expert Panel. JAMA 2001;285:2486-2497.,Primary PreventionRx: TLC Measures to Lower LDL-C,Saturated fats (7% total calories) and cholesterol (200 mg/d) Also therapeutic options: Plant stanols/sterols (2 g/d) Increased viscous fiber (1025 g/d),Expert Panel. JAMA 2001;285:2486-2497.,Tot

5、al Fat.Why a range?,Primary emphasis is to reduce saturated fats Total fat should range 2530% for most cases Those with metabolic syndrome Avoid very high fat intakes Avoid very low fat intake (low HDL-C, high TG) Total fat intake can range from 3035% if extra fat is unsaturated May reduce some lipi

6、d and nonlipid risk factors Clinical judgment required.,Therapeutic Lifestyle Changes:Nutrient Composition of TLC Diet,* Lower trans fatty acids * Emphasize complex sources,LDL-C Response to Step II Diet: beFIT,178 Women / 231 MenDietary fat 25%; saturated fat 7.5% LDL reduction High cholesterol onl

7、y: 7.6 to 8.8% LDL reduction Combined hyperlipidemia:8.1%,Walden CE et al. Arterioscler Thromb Vasc Biol 1997;17:375-382.,DELTA I Dietary Trial,Subjects: age 22 to 67 Different groups of subjects: White, black Women: younger and postmenopausal Men: younger, older,AAD,Low Sat,Results: Compared to ave

8、rage American diet, when saturated fat fell from 15% to 6.1%, LDL-C fell by 11%,Negative aspects: HDL-C fell from 52.2 to 46.2 Lp(a) rose from 15.5 to 18.2,Ginsberg HN et al. Arterioscler Thromb Vasc Biol 1998;18:441-449.,Total Fat,Sat Fats,LDL,New Options to Lower LDL-C,Avoid Trans fatty acids* Add

9、 Dietary fiber Plant sterol/stanol ester margarines,Expert Panel. JAMA 2001;285:2486-2497.,* Keep trans fatty acids low,Trans Fatty Acids (TFA),TFA more densely packed than cis forms Usual intake: only 23% of energy If consumed in high amounts: LDL-C; HDL-C Examples of TFAStick margarine, cookies, b

10、iscuits, white bread,Lichtenstein AH et al. N Engl J Med 1999;340:1933-1940,Conclusion: Consume products low in saturated and TFA,Plant Sterol/Stanol Esters,Sterols are essential components of cell membranes Cholesterol exclusively an animal sterol We ingest almost as much plant sterols as we do die

11、tary cholesterol Stanols absorbed even less well Plant sterols/stanols lower cholesterol Interfere with micellar absorption of cholesterol No malabsorption of fat,Law MR et al. BMJ 2000;320:861-864.,Plant Sterol/Stanol Esters,If 2 g of plant sterol or stanol is added to average daily portion of marg

12、arine, it has variable effect on LDL-C by age group: Age LDL-C reduced by: 5059 21 mg/dl or 0.54 mmol/l 4049 17 mg/dl or 0.43 mmol/l 3039 13 mg/dl or 0.33 mmol/l,Law MR et al. BMJ 2000;320:861-864.,Esterification of Stanols,Plant Stanol Crystalline powder Restricted fat solubility Melting range 1401

13、50oC,R C -,= O,3,5,6,O,3,5,6,HO,17,Esterification,Fat-SolublePlant Stanol,Treatment with Stanol Ester Margarine,-2,Cholesterol (mg/dl),Study Period (mo),2,4,8,10,Miettinen TA et al. N Engl J Med 1995;333:1308-1312. 1995 Massachusetts Medical Society. All rights reserved.,0,12,14,6,Sitostanol-ester m

14、argarine,Plant Sterols/Stanols: Efficacy in Lowering LDL-C,Dose: Maximum is 2 g/d Meta-analysis results: LDL-C lowering about 913% Lowering greater in elderly Additive to statin therapy Used in various population groups Well-tolerated May decrease LDL-C adjusted carotenoids,Law M et al. BMJ 2000;320

15、:861-864. Lichtenstein AH et al. Circulation 201;103:1177-1179,Dietary Adjuncts,TLC for patients with LDL-C = 160,Walden CE et al. Arterioscler Thromb Vasc Biol 1997;17:375-382. Jenkins DJ et al. Curr Opin Lipidol 2000;11:49-56. Cato N. Stanol meta-analysis. Personal communication, 2000.,The Spectru

16、m of CHD Risk,Expert Panel. JAMA 2001;285:2486-2497.,“More higher risk patients brought into the algorithm”,Metabolic Syndrome,Elevated LDL-C,Glucose 110125 Abdominal Obesity HDL-C BP TG 150,The Metabolic Syndrome,Constellation of major risk factors, life-habit risk factors and emerging risk factors

17、 Over-represented among populations with CHD Clue is distinctive body-type with increased abdominal circumference (although some leaner men and women with abdominal obesity without increased waist),Metabolic Syndrome as a Secondary Goal after LDL-C,Expert Panel. JAMA 2001;285:2486-2497.,* Men: 40 in

18、 (102 cm); women 35 in (88 cm),Metabolic Syndrome as a Secondary Goal after LDL-C,Expert Panel. JAMA 2001;285:2486-2497.,Circ. = circumference measured at level of the iliac spine,Clustering of Risk Factors Incorporated into the Metabolic Syndrome,Includes risk factors not routinely measured Insulin

19、 resistance Small dense LDL Endothelial dysfunction Abnormal sympathetic nervous activity Prothrombotic markersPAI-1, fibrinogen Proinflammatory markers such as CRP,Does Treating the Metabolic Syndrome Make a Difference? Finnish Diabetes Prevention Study,Design 522 middle-aged overweight (BMI 31) 17

20、2 men and 350 women Mean duration 3.2 years Intervention Group: Individualized counseling Reducing weight, total intake of fat and saturated fat Increasing uptake of fiber, physical activity,Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.,Treating the Metabolic Syndrome,Tuomilehto J et al. N En

21、gl J Med 2001;344:1343-1350.,Benefit of Treating the Metabolic Syndrome,Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.,Intervention,Control,After 4 years risk of diabetes reduced by 58%,11%,23%,(615 CI),(1729 CI),% with Diabetes,Goals of Weight Loss,1. Reduce body weight in the short term 2. M

22、aintain a lower body weight for the long term 3. Prevent further weight gain minimum goal,Obesity Education Initiative. Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report. Bethesda, Md.: NIH, 1998,Further Goals of Weight Loss,

23、1. Rate of weight loss 10% reduction in body weight in 6 months of therapy Rate is 12 lbs per week,Goals of Physical Activity,People of all ages, male and female benefit from physical activity 1. Include a moderate amount of physical activity on most, if not all days of the week 2. Additional health

24、 benefits can be derived from greater amounts of activity 3. Emphasis is on amount not intensity,U.S. Dept. of Health and Human Services. Physical Activity and Health:A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, 1996.,Suggestions on Activity,1. Scheduled

25、physical activity a. Walking, treadmill, jogging, walking dog b. Swimming, biking, volleyball 2. Lifestyle physical activity a. Walk more stairs at work, walking for errands, parking farther away in parking lots b. Housework, gardening,U.S. Dept. of Health and Human Services. Physical Activity and H

26、ealth:A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, 1996.,Metabolic Benefits of Weight Loss,Reverse changes of insulin resistance and metabolic syndrome Raise HDL-C (can see increase of 1.6 mg/dl from a 10-lb weight loss),Dattilo AM et al. Am J Clin Nutr 1

27、992;56:320-328.,Metabolic Response to 10-lb Weight Loss: Framingham Data,Higgins M et al. Acta Med Scand Suppl 1988;723:23-36.,Cholesterol,Small changes can add up to significant changes in long-term risk,Syst BP,Glucose,mg/dl,mm Hg,mg/dl,Men,Women,Dietary Options Benefit Independent of LDL-C Loweri

28、ng,Avoid Megavitamins (adverse effects shown for supplements of beta-carotene, no convincing clinical trial benefit for vitamin E supplementation) Add Fish Plant sources of omega-3 fatty acids Fruits and vegetables,Clinical Trial Data Showing Lack of Benefit of Megavitamins,Beta Carotene No proof of

29、 benefit in 3 trials One stopped prematurely (CARET) Vitamin E No proof of benefit in 2 large trials HOPE Trial Natural vitamin E GISSI Prevention Synthetic vitamin E,Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study Group. N Engl J Med 1994;330:1029-1035. Hennekens CH et al. N Engl J Med1996;

30、334:1145-1149. Omenn GS et al. N Engl J Med 1996;334:1150-1155. HOPE Study Investigators. N Engl J Med 2000;342:154-160. GISSI-Prevenzione Investigators. Lancet 1999;354:447-455.,Clinical Trial Data Showing Significant Effect of Diet,Omega-3 Fatty Acids DART: 29% reduction in death GISSI: Significan

31、t reduction of one of two combined endpoints “Mediterranean Diet” Lyon Trial: Multiple differences in diet; diet was low in animal, dairy fat, high in plant-based omega-3 fatty acids, fiber,Burr ML et al. Lancet 1989;2:757-761. GISSI-Prevenzione Investigators.Lancet 1999;354:447-455. de Longeril M e

32、t al. Circulation 1999;99:779-785.,Burr ML et al. Lancet 1989;2:757-761. GISSI-Prevenzione Investigators.Lancet 1999;354:447-455.,Trials of n-3 Fatty Acids in MI Survivors: Significant Effect on Deaths,DART,GISSI,3,482 patients,11,324 patients,Expt Deaths,Control Deaths,Lyon Diet Heart Study: Cumula

33、tive Survival without Cardiac Death and Nonfatal MI,de Lorgeril M et al. Circulation 1999;99:779-785. 1999 Lippincott Williams 99:779-785.,*Significantly different,How to Implement Primary Prevention with TLC,Stepwise approach Resources Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (download from web for palm-based material) Surgeon Generals Report on Physical Activity,Implementing Primary Prevention with TLC?,Emphasize reduction in saturat