行为干预：饮食控制、锻炼、控制体重.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Slide Source,LipidsOnline,www.,lipidsonline,.org,Lifestyle Interventions:Dietary Therapy,Physical Activity,Weight Control,Neil 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 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 cholesterol(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,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.,Total 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 lipid and,nonlipid,risk factors,Clinical judgment required.,Therapeutic Lifestyle Changes:,Nutrient Composition of TLC Diet,Nutrient,Recommended Intake,Saturated 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,2535%of total calories,Carbohydrate*,5060%of total calories,Fiber,2030 grams per day,Protein,Approximately 15%of total calories,Cholesterol,Less than 200 mg/day,Total calories(energy),Balance energy intake and output to maintain expenditure,healthy body weight/prevent weight gain,*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 only: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 average 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,Dietary fiber,Plant sterol/,stanol,ester margarines,Expert Panel.,JAMA,2001285:2486-2497.,*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,biscuits,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 dietary 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 margarine,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 140150,o,C,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 margarine,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;320:861-864.,Lichtenstein,AH et al.,Circulation,201;103:1177-1179,Dietary AdjunctsTLC 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.,Dietary Component,LDL-C,(mg/,dL,),Low saturated fat/dietary cholesterol,12,Viscous fiber(1025 g/d),8,Plant,stanols,/sterols(2 g/d),16,Total,36 mg/dl,The Spectrum 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,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.,Risk Factor(,3),Defining Level,Abdominal obesity,Waist circumference,*,Triglycerides,150 mg/dl,HDL-C,40 mg/dl in men;40 in(102 cm);women 35 in(88 cm),Metabolic Syndrome as a Secondary Goal after LDL-C,Expert Panel.,JAMA,2001;285:2486-2497.,Risk Factor,Defining Level,Abdominal obesity,40 waist circ.in men 35 waist circ.in women,HDL-C,40 mg/dl in men5%,43,13,0.001,Fat intake 30%energy,47,26,0.001,Sat fat 15 g/1000 kcal,25,12,0.001,Exercise 4 hr/wk,86,71,0.001,Tuomilehto,J et al.,N,Engl,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.Maintain 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,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 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 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 Health:,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,1992;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 Lowering,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 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 Med,1996;334:1145-1149.,Omenn,GS et al.,N,Engl,J Med,1996;334:1150-1155.HOPE Study Investigators.,N,Engl,J Med2000;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:Significant reduction of one of two combined endpoints,“Mediterranean Diet”,Lyon Trial:Multiple differences in dietdiet 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 et 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:,Cumulative Survival without Cardiac Death and Nonfatal MI,de,Lorgeril,M et al.Circulation 1999;99:779-785.,1999,Lippincott,Williams&Wilkins,.www.,lww,.com,1,%Without Event,Canola oil based margarine,fiber,low cholesterol,low saturated fat,fruits,vegetables,Experimental,Control,P=0.0001,Year,2,3,4,5,Comparison of the Diets,Item,Experimental,Control,Total calories,1947,2088*,Total fat,30.4%,33.6%*,Saturated fat,8%,11.7%,Dietary cholesterol,203 mg/dl,312 mg/dl*,Alcohol,Same,Same,Olive oil,None,None,MUFA n-9,Increased*,PUFA,Increased*,n-3/n-6 fatty acids,Increased*,Fiber,18.6,de,Lorgeril,M et al.Circulation 1999;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 saturated fat and cholesterol,Reduce animal/high fat dairy,Get lower fat food if eats out,Regular physical activity,Visit 1,Expert Panel.,JAMA,2001;285:2486-2497.,Implementing Primary Prevention with TLC?,Evaluate LDL-C response,Intensify LDL-C lowering with dietary adjuncts,Plant,stanols,/sterols,Increased fiber intake,Visit 2,Expert Panel.,JAMA,2001;285:2486-2497.,Implementing Primary Prevention with TLC,At all stages of dietary therapy,physicians are encouraged to refer patients for:,Medical nutrition therapy,Registered dietitians/other qualified nutritionists,Expert Panel.,JAMA,2001;285:2486-2497.,Implementing Primary Prevention with TLC?,Evaluate LDL-C response,Initiate therapy for metabolic syndrome,Intensify weight management,Physical activity,Consider drug Rx if LDL-C goal not achieved,Visit 3,Expert Panel.,JAMA,2001;285:2486-2497.,Primary Prevention with TLC,Therapeutic Lifestyle Changes can lower LDL-C so medication not required or increase not needed,Can treat metabolic syndrome,Lowers TG,Raises HDL-C,Reduces risk of diabetes,Provides overall healthful lifestyle,Expert Panel.,JAMA,2001;285:2486-2497.,