1 C Master of Advanced Studies in Nutrition and Health HS 2009 Cardiovascular Diseases and Blood Lipids Universität Zürich Institut für Sozial- und Präventivmedizin David Faeh Aims • CVD, CHD, Stroke • Morbidity, Mortality, Lethality • Prevalence, Incidence • Blood lipids: What is it? How influenced? • How are blood lipids related with CVD? Universität Zürich Institut für Sozial- und Präventivmedizin David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009 How are blood lipids related with CVD? • Risk and protective factors • Lifestyle recommendations
54
Embed
Cardiovascular Diseases and Blood Lipids€¦ · David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009 Institut für Sozial- und Präventivmedizin Source: Bundesamt für
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
C
Master of Advanced Studies in Nutrition and Health HS 2009
Cardiovascular Diseases and Blood Lipids
Universität ZürichInstitut für Sozial- und Präventivmedizin
David Faeh
Aims
• CVD, CHD, Stroke
• Morbidity, Mortality, Lethality
• Prevalence, Incidence
• Blood lipids: What is it? How influenced?
• How are blood lipids related with CVD?
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
How are blood lipids related with CVD?
• Risk and protective factors
• Lifestyle recommendations
2
Proportion of causes of death: Age standardized death rates per 100,000, Switzerland
1%
20%
Groups of causes of death 2007, Men
30%
33%
7%
9%
20%
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Bundesamt für Statistik, 2007
Infectious disease Cancer Cardiovascular Respiratory Injury Others
Proportion of causes of death: Age standardized death rates per 100,000, Switzerland
1%
Groups of causes of death 2007, Women
29%
33%
5%
6%
26%
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Bundesamt für Statistik, 2007
Infectious disease Cancer Cardiovascular Respiratory Injury Others
3
Proportion of years of life lost (1-70y) by cause of death: Age standardized rates per 100,000, CH
2%
19%
YLL by group of cause of death 2007, Men
28%
17%
2%
32%
19%
17% = 20 540 YYL or
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Bundesamt für Statistik, 2007
Infectious disease Cancer Cardiovascular Respiratory Injury Others
Number of years of life lost (YLL) due to CVD: years that people loose because they die before 70
17% = 20,540 YYL or 558 YLL / 100,000 inhabitants
Proportion of years of life lost (1-70y) by cause of death: Age standardized rates per 100,000, CH
2%
21%
YLL by group of cause of death 2007, Women
44%
11%
20%
21%
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Bundesamt für Statistik, 2007
2%
Infectious disease Cancer Cardiovascular Respiratory Injury Others
Number of years of life lost (YLL) due to CVD: years that people loose because they die before 70
11% = 7,335 YLL or 202 YLL / 100,000 inhabitants
4
175
200
225
Cardiovascular disease (CVD): cave definitionem!
standardisierte Sterberaten, Schweiz 2005
Sterbefälle pro 100‘000
Personenjahre
Subsumed causes of death
50
75
100
125
150
175
andere Herzkrankheiten
zerebrovaskuläre Krankheiten
Hypertonie
übrige Herz-Kreislauf-Krankh.
z.B.: Aneurysma, Thrombose, Phlebitis, Varizzen
z.B.: Myo-& Pericarditis,
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
0
25
Männer Frauen
KHK
mb 2007Datenquelle: Todesursachenstatistik (BFS)
Klappen- und Herzinsuff.
Cardiovascular disease (CVD)
Mortality Morbidity
Death: Disease:
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Death:Can be assessed only once „Tip of the iceberg“
Disease:Is always higher than mortality. Can occur numerous times in one individual
5
Mortality Morbidity
„Film“:Number of…
„Photo“:Number of
„Incidence“ PrevalenceIncidence
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Number of… •…death cases (mortality) or •…new diseases (morbidity) per number of persons under risk (100‘000) and during a certain time span (1 year)
persons that have a disease at a specific point of time (in %)
Myocardial infarction (GB, 60 Mio inhabitants in 2003)
Morbidity of CVD: UK, CDN
•260´000 new cases per year (incidence)
•1.4 Mio live with the consequences (prevalence)
Cerebrovascular disease (Canada, 32 Mio, 2003)
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
• 50´000 new cases per year (incidence)
•300´000 live with the consequences (prevalence)
Sources: British Heart Foundation & Heart and Stroke Foundation of Canada
6
•60´000 cases of myocardial infarction,
Morbidity of CVD, Switzerland
stroke and cardiac arrest per year
•30-40% without specific warning signs
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Switzerlanderische Herzstiftung
•2005: Globally 17.5 Mio death cases / year
Mortality of CVD, globally
– 30% of all death cases
– 7.6 Mio † coronary heart disease (CHD)
– 5.7 Mio † cerebrovascular disease
C f
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
•2010: CVD = Main cause of death in developing countries
Source: World Health Organization WHO, 2005, http://www.who.int
7
• 2005: 23´000 death cases per yearAb t 38% f ll i t d d th
Mortality of CVD, Switzerland
– About 38% of all registered death cases
– 9´400 † coronary heart disease (CHD)
– 4´100 † cerebrovascular disease
• German CH > Ticino & French CH, Men > Women
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
• Social gradient (inequality)
• 86.5% (M) und 97% (W) of death cases occur after
age 65 (2005)Source: Bundesamt für Statistik, 2005
Sterbefälle pro 100‘000 Einwohner und Jahr (WHO-Standard- bevölkerung „Europa“)
160
180
200
KHK: Rohraten , Schweiz 1969-2003
Männer
CHD: Crude ratesDeath cases per 100‘000 inhabitantsper year
Men
60
80
100
120
140
Frauen
RohratenCrude rates
Women
Men
Universität ZürichInstitut für Sozial- und Präventivmedizin
Incidence of Coronary Events According to HDL- & LDL Cholesterol and Glycemic State
Incidence per 1.000in 10 years
Incidence per 1.000in 10 years
1
33
72
144
26 3783
50
100
150
200
in 10 years in 10 years
1
111
147175
5059
154
40
125
50
100
150
200
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
1 2 3
3
226 26 60
0
50
Tertiles ofHDL cholesterol Tertiles of
LDL cholesterol
Tertiles ofHDL cholesterol Tertiles of
LDL cholesterol
1 2 3
3
22340
0
50
Source: PROCAM (Münster Heart Study)
Lifestyle and blood lipids
• Risk factors– Carbohydrates (fructose, glucose)
– Saturated and trans-fat
– Obesity
• Protective factorsUnsaturated fat
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
– Unsaturated fat
– Fibres
– Physical activity
28
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
1 2
1.4
1.6
/l)
†
Effect of dietary fructose on fasting triglycerides
0.2
0.4
0.6
0.8
1
1.2
Tri
gly
ceri
des
(m
mo
l/
* *
‡
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
white bar: controlgreen bar: fish oilred bar: high-fructosestriped red and green bar: fish oil & high-fructose
0
Source: Faeh et al, Diabetes. 2005 Jul;54(7):1907-13.
29
Increase in triglycerides byfructose-induced DNL
NEFANEFA
5Adipose Adipose tissuetissue
TGTG
FAFA
GlucoseGlucose
2
1
34
GlycogenGlycogen
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
FructoseFructose
VLDLVLDLTGTG
GlucoseGlucose
Source: Faeh et al, Diabetes. 2005 Jul;54(7):1907-13.
DNL: De Novo Lipogenesis
Metaanalysis: Dose-dependenthypotriglyceridemic effect of omega-3 fatty acids.
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Proc Nutr Soc 1999;58(2):397–401
30
Low-carbohydrate vs. high-carbohydrate diets
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Nutr Metab (Lond) 2005;2:31
Predicted Changes in Serum Lipids and LipoproteinsUse of dietary fats:
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Hu et al, JAMA 2002;288:2569-2578
31
Changes by Diet Group during the Maximum Weight-Loss Phase (1 to 6 Months) and the Weight-Loss Maintenance Phase (7 to 24 Months) of the 2-Year Intervention
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Shai et al, N Engl J Med. 2008 Jul 17;359(3):229-41
Risk of mortality from CVD associated with two point increase in adherence score for Mediterranean diet
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Sofi et al. BMJ 2008;337:a1344
Squares represent effect size; extended lines show 95% confidence intervals; diamond represents total effect size
32
0.02
TotalCholesterol
LDL-C TG HDL-C(weightstable)
HDL-C(activelylosing)
Plasma Lipids Improve with Weight Loss Meta-analysis of 70 Clinical Trials
ss 0 5
-0 04
-0.02
0.00
) g)
ol/L
kg
of W
eigh
t Lo
s m
g/dL per kg of W**
**
0.5
0.0
-0.5
-1.0
1 5
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
-0.06
0.04
m
mo
LDL-C=low density lipoprotein cholesterol; HDL-C=high-density lipoprotein cholesterol; TG=triglyceridesSource: Dattilo et al. Am J Clin Nutr 1992;56:320.
*P<0.05.
Weight Loss
*-1.5
-2.0
-2.5
8
16
24
Effects of Exercise Level and Intensity on LDL and HDL Particles in Overweight/Obese Men
l LD
Ll (
mg/
dL)
34567
oles
tero
l dL
)
P=0.015
-16
-8
0
S
mal
lC
hole
ster
o
0.0
0.4
-2-10123
H
DL
Cho
(mg/
d
L D
iam
eter
(n
m)
2
4
6
8
arge
HD
L te
rol (
mg/
dL)
P=0.03P=0.015 P=0.002
P=0.05
P=0.016
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Kraus et al. N Engl J Med. 2002;347:1483-1492.
Control HighAmountModerateIntensity
-0.4Low
AmountHigh
Intensity
LowAmountModerateIntensity
LD
L
Control High AmountModerateIntensity
-2
0
2
LowAmount
HighIntensity
LowAmount
HighIntensity
La
Cho
lest
33
Indication for drug therapy
Women Pre-Men, Women Post- Lipid Criteria
Primary prevention
MenopausalPost-Menopausal
Lipid Criteria
Other Riskfactors*
Other Riskfactors*
TCmmol/l (mg/dl)
TC / HDL-C
LDL-Cmmol/l (mg/dl)
0 or 1 0 >8.0 (309) >6.5 >5.0 (194)
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
( ) ( )
2 1 >6.5 (252) >5.0 >4.0 (155)
* Risk factors: 1. Family history of CHD; 2. Age (Men > 50y / women > 60 y); 3. Smoking; 4. Hypertension; 5. (Central) Obesity ( BMI >30 kg/m2), central; Hypertriglyceridemia >2,0mmol / l (175mg/dl ); Physical inactivity
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
34
Recommendations
• DASH: Dietary Approaches to Stop HypertensionHypertension
• TLC: Therapeutic Lifestyle Changes
• VLCD: Very Low Carbohydrate Diet
Universität ZürichInstitut für Sozial- und Präventivmedizin
VLCD: Very Low Carbohydrate Diet
• Mediterranean diet
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Nutrient Composition of TLC Diet
Nutrient Recommended Intake
• Saturated fat Less than 7% of total caloriesSaturated fat Less than 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 50–60% of total calories
• Fiber 20–30 grams per day
• Protein Approximately 15% of total calories
Universität ZürichInstitut für Sozial- und Präventivmedizin
• Cholesterol Less than 200 mg/day
• Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain
Source: ATP III Guidelines, Therapeutic Lifestyle Changes (TLC)
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
35
Eating Pattern DASH TLC
Grains 6–8 sv/d 7 sv/d
Examples of daily dietary patterns consistent withAHA-recommended dietary goals at 2000 calories
Vegetables 4–5 sv/d 5 sv/d
Fruits 4–5 sv/d 4 sv/d
Fat-free or low-fat dairy products
2–3 sv/d 2–3 sv/d
Lean meats, poultry and fish <6oz./d ≤5 oz./d
Nuts seeds legumes 4–5 sv/wkCounted in
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Endocrinol Metab Clin North Am. 2009 Mar;38(1):45-78
Nuts, seeds, legumes 4–5 sv/wkvegetable servings
Fats and oils 2–3 sv/dAmount depends on calorie level
Sweets and added sugars 5 or less sv/wk No recommendation
AHA, American Heart Association; DASH, dietary approaches to stop hypertension; TLC, Therapeutic Lifestyle Changes; sv, serving.
Summary of nutrition guidelines for dyslipidemiatreatment derived from a metanalysis
1. Mediterranean and portfolio diets are recommended.
2. Reduce saturated fats to about 10% of total fat intake.
3. Eliminate trans fats.
4. Increase monounsaturated fats to 40% of total fat intake.
5. Increase polyunsaturated fats (ω-3 fats) to 40%-50% of total fat intake.
6. Increase viscous fiber to 50 g/d.
7. Increase vegetables to 6 servings per day.
8. Increase fruits to 4 servings per day.
9. Add plant sterols and nuts to diet.
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
10.Reduce refined carbohydrates and use low glycemic foods. Use more complex carbohydrates.
11.Consume high quality protein with cold water fish and organic lean meat and poultry.
12.Maintain ideal body weight and body composition.
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Diabetes Care 2004;27(12):2954–9
37
Dietary Component Dietary Change LDL-C Reduction
Major
Approximate and cumulative LDL-C reductionachievable by dietary modification
j
Saturated fat <7% of calories 8%–10%
Dietary cholesterol <200 mg/d 3%–5%
Weight reduction Lose 10 lbs (4.5 kg) 5%–8%
Other LDL-lowering options
Viscous fiber 5–10 g/d 3%–5%
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Endocrinol Metab Clin North Am. 2009 Mar;38(1):45-78
Viscous fiber 5 10 g/d 3% 5%
Plant sterol/stanol esters 2 g/d 6%–15%
Cumulative estimate 20%–30%
1. γ-/δ-Tocotrienols: 200 mg per night with food.2. Pantethine: 300 mg 3 times per day (or 450 mg 2 times a day).
Recommondations for nutritional supplements for improvement of blood lipids
g p y ( g y)3. ω-3 Fatty Acids: at 3 to 5 g/d at a ratio of 3 parts EPA, 2 parts DHA, and
gamma Linoleic acid (GLA) at 75% to 90% of the total DHA and EPA. Vitamin E at 100 IU/d with mostly γ-/δ-tocopherol (80%) should be added to reduce oxidative stress.
4. Niacin (nicotinic acid): various forms at 500 to 3000 mg/d.5. Red yeast rice (high quality and standardized): 2400 mg per night. Doses
of 4800 mg may be safe and even more effective.6. Probiotics: standardized to provide the optimal bacterial count.
C i 00 /d
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
7. Curcumin: 500 mg/d.8. Green tea extract: standardized to 250 to 500 mg of EGCG twice per day.9. Plant Sterols: 1.6 to 3.0 g/d in divided doses with food.
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
27 282930313233
48495051525354
6970717273
1.41.51.71.92.12.22.42.6
9.110.110.912.012.813.414.316.7
45.048.051.054.057.060
Source: PROCAM (Münster Heart Study)
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Riesen et al, Switzerlanderische Aerztezeitung 2005;86:Nr 22
44
CVD Risk Score: Framingham PROCAM SCOREPopulation General population* Male labour force General populationsAge range at recruitment 30-74 35-65 24-80Sample size 10,156 (+1,176)* 5,389 205,178Region USA Germany EuropeTime of recruitment 1948-1979 (Gen I&II) 1979-1985 1967-1988Time of follow-up Ongoing Ongoing Partially ongoing
CVD endpoint Morbidity and Mortality Morbidity and Mortality Mortality
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
p y y y y yRisk period 10 years 10 years 10 years
Number of eventsCHD 623§ 325& 5,652Total CVD 432 7,934$
*without and with history of CVD§Myocardial infarction, coronary insufficiency, angina pectoris, and sudden and nonsudden coronary death (mostly hospitalized events)&Sudden cardiac death or fatal or nonfatal myocardial infarction (based on ECG, enzyme changes)$Fatal events according to ICD-9 (401-141; 426-443, except for 426.7, 429.0, 430.0, 432.1, 437.3, 437.4, 437.5; 798.1, 798.2)
MetabolicSyndrome:
WHO NCEP ATP III EGIR IDF
Impaired glucose regulation, diabetes or insulin resistance and ≥ any two of the other four criteria
Three or more of the following:
Insulin resistance (upper quartile of fasting insulin values) and any two of the following
Central obesity and ≥ any two of the other four criteria
Central obesity WHR > 90 cm (M) > 85 cm (F) or BMI >30 kg/m2
Waist circumference > 102 cm (M) or > 88 cm (F)
Waist circumference ≥ 94cm (M), ≥ 80cm (F)
Waist circumference ≥ 94 cm (M) or ≥ 80 cm (F)
Triglycerides ≥ 1.7 mmol/l (150 mg/dl) ≥ 1.7 mmol/l (150 mg/dl) ≥ 2.0 mmol/l or … ≥ 1.7 mmol/l (150 mg/dl)g y ( g )and/or HDL < 0.9 mmol/l (35 mg/dl) M /< 1.0 mmol/l (39 mg/dl) F
Insulin Insulin resistance (upper quartile of HOMA-index)
Insulin resistance (upper quartile of HOMA-index)
Microalbuminuria Microalbuminuria ≥ 20 µg/min or albumin : creatinine ratio (ACR) ≥ 30 mg/g
In bold: index factor; M: male; F: female; WHR: Waist-to-Hip-Ratio
45
„Non-traditional“ blood lipids
• Apolipoprotein AI (from HDL-C) & B (from LDL-C)
• Lipoprotein (a) (modifyed LDL-C)
• LDL-C density / size
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
LDL C density / size
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
46
Incidence of Major Coronary EventsAccording to Lp(a)
7280
Observed events per 1,000 in 8 years
19
33
5158
0
20
40
60
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
0
0.02 <0.10 <0.20 <0.30 0.30
prevalence: 18% 53% 11% 8% 10%
Lipoprotein (a) g/L 33 coronary events in 2,861 men, aged 40-65 years,
Source: PROCAM (Münster Heart Study)
LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)
and Drug Therapy in Different Risk Categories
LDL Level at Which
Risk CategoryLDL Goal(mg/dL)
LDL Level at Which to Initiate
Therapeutic Lifestyle Changes
(TLC) (mg/dL)
LDL Level at Which to Consider
Drug Therapy (mg/dL)
CHD or CHD Risk Equivalents
(10-year risk >20%)<100 100
130 (100–129: drug
optional)
2+ Risk Factors
10-year risk 10–20%: 130
Universität ZürichInstitut für Sozial- und Präventivmedizin
2+ Risk Factors (10-year risk 20%)
<130 13010-year risk <10%:
160
0–1 Risk Factor <160 160
190 (160–189: LDL-lowering drug
optional)
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
47
ATP III G id liATP III Guidelines
Therapeutic LifestyleChanges (TLC)
Universität ZürichInstitut für Sozial- und Präventivmedizin
Changes (TLC)
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Visit 2 Visit 3E l t LDL
A Model of Steps in Therapeutic Lifestyle Changes (TLC)
• Reinforce reductionin saturated fat andcholesterol • Initiate Tx for
6 wks 6 wks Q 4-6 mo
• Emphasizereduction insaturated fat &cholesterol
E
Visit I
Begin LifestyleTherapies
Evaluate LDLresponse
If LDL goal notachieved, intensifyLDL-Lowering Tx
Evaluate LDLresponse
If LDL goal notachieved, consideradding drug Tx
MonitorAdherenceto TLC
Visit N
Universität ZürichInstitut für Sozial- und Präventivmedizin
• Consider addingplant stanols/sterols
• Increase fiber intake
• Consider referral toa dietitian
MetabolicSyndrome
• Intensify weightmanagement &physical activity
• Consider referral to a dietitian
• Encouragemoderate physicalactivity
• Consider referral toa dietitian
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
48
Steps in Therapeutic Lifestyle Changes (TLC)
First Visit
• Begin Therapeutic Lifestyle Changes
• Emphasize reduction in saturated fats and cholesterol
• Initiate moderate physical activity
• Consider referral to a dietitian (medical nutrition therapy)
• Return visit in about 6 weeks
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Steps in Therapeutic Lifestyle Changes (TLC)
Second Visit
• Evaluate LDL response
• Intensify LDL-lowering therapy (if goal not achieved)
– Reinforce reduction in saturated fat and cholesterol
– Consider plant stanols/sterols
– Increase viscous (soluble) fiber
– Consider referral for medical nutrition therapy
• Return visit in about 6 weeks
Universität ZürichInstitut für Sozial- und Präventivmedizin
• Return visit in about 6 weeks
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
49
Steps in Therapeutic Lifestyle Changes (TLC)
Third Visit
• Evaluate LDL response
• Continue lifestyle therapy (if LDL goal is achieved)
• Consider LDL-lowering drug (if LDL goal not achieved)
• Initiate management of metabolic syndrome (if necessary)
– Intensify weight management and physical activity
• Consider referral to a dietitian
Universität ZürichInstitut für Sozial- und Präventivmedizin
Consider referral to a dietitian
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Therapeutic Lifestyle Changes in LDL-Lowering Therapy
Major Features
• TLC Diet– Reduced intake of cholesterol-raising nutrients (same as
previous Step II Diet)• Saturated fats <7% of total calories• Dietary cholesterol <200 mg per day
– LDL-lowering therapeutic options• Plant stanols/sterols (2 g per day)
Universität ZürichInstitut für Sozial- und Präventivmedizin
( g p y)• Viscous (soluble) fiber (10–25 g per day)
• Weight reduction • Increased physical activity
David Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
50
AHA 2006 Diet and Lifestyle Goals for Cardiovascular Disease Risk Reduction
• Consume an overall healthy diet.
• Aim for a healthy body weight.
• Aim for recommended levels of LDL, HDL, and TG.
• Aim for a normal blood pressure.
• Aim for a normal blood glucose level.
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Circulation. 2006;114:82-96
• Be physically active.
• Avoid use of and exposure to tobacco products.
AHA 2006 Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction
• Balance calorie intake and physical activity to achieve or maintain a healthy body weightor maintain a healthy body weight.
• Consume a diet rich in vegetables and fruits.
• Choose whole-grain, high-fiber foods.
• Consume fish, especially oily fish, at least twice a week.
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
Source: Circulation. 2006;114:82-96
51
AHA 2006 Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction
• Limit your intake of saturated fat to <7% of energy, trans fat to <1% of energy and cholesterol to <300 mg per day byfat 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; and
— minimizing intake of partially hydrogenated fats.
• Minimize your intake of beverages & foods with sugar.
Universität ZürichInstitut für Sozial- und PräventivmedizinDavid Faeh: Cardiovascular Diseases and Blood Lipids, 21.10.2009
• Choose and prepare foods with little or no salt.
• If you consume alcohol, do so in moderation.
Source: Circulation. 2006;114:82-96
Einfluss auf Herz-Kreislauf-Risiko*
Evidenz vermindert RisikoKeinen
Einflusserhöht Risiko
Über-zeugend
Körperliche AktivitätFisch und Fischöle (EPA, DHA**)Früchte und GemüseKalium