Established Risk Factors for Coronary Heart Disease (CHD)

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Getting Patients to Make Small Lifestyle Changes That Result in SIGNIFICANT Improvements in Health - Prevention of Diabetes and Obesity for Better Health Maureen E.

1 Getting Patients to Make Small Lifestyle Changes That Result in SIGNIFICANT Improvements in Health - Prevention of Diabetes and Obesity for Better Health Maureen E. Mays, MD, MS, FACC Director ~ Portland Preventive Cardiology Diplomate, American Board of Clinical Lipidology October Established Risk Factors for Coronary Heart Disease (CHD) Obesity Metabolic syndrome Diabetes Physical inactivity Dyslipidemia CHD Atherogenic diet Hypertension Male sex Age Family history Smoking Modifiable Nonmodifiable Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA.2001;285: Normal Atherosclerosis 2 1

2 Risk & Prevention Why do we care? 3 The Burden of Heart Disease Coronary Heart Disease remains the leading single cause of death in the U.S. 1 Prevalence = 16 million 1 Prevalence is expected to double in next 50 years 2 1 million Heart Attacks every year 1 47% of all heart attacks are fatal Currently, over 10% of adults, age have significant coronary heart disease American Heart Association Heart and Stroke Statistical Update. At: 2. Foot, DK, et al. JACC. 2000;35: The Burden for Women CHD is the leading killer of women More women die of CHD than of the next five causes combined! Women tend to ignore the symptoms of heart attack or think that they are another problem Women who have a heart event do poorly compared to men American Heart Association, AHA.org 5 2

3 Therefore, once your children reach adulthood, nearly half of them will die of cardiovascular disease or stroke 6 Risk Factors Hypertension (High Blood Pressure) Obesity Metabolic syndrome Physical Inactivity Atherogenic Diet Diabetes Mellitus Dyslipidemia 7 Hypertension and Risk The BP relationship to risk of CHD is continuous, consistent, and independent of other risk factors In adults, each increment of 20/10 mmhg doubles the risk of CHD across the entire BP range starting from 115/75 mmhg JNC 7, JAMA May 21,

4 Hypertension and Kids GOAL: Blood pressure < 95th percentile for age, sex, height Kavey, et al, Circulation. 2003; Lifestyle Modification Modification Weight reduction Dietary sodium Physical activity Blood Pressure reduction (range) 5 20 mmhg/5 lb. loss 2 8 mmhg 4 9 mmhg 10 Benefits of Lowering BP Incidence of: Average Percent Reduction Stroke 35 40% Heart Attack 20 25% Heart failure 50% JNC 7, JAMA May 21,

5 What you can do: Set realistic BP goals with the patient Follow closely when not at goal Ask patients to keep a home BP log for about 10 days prior to each BP visit Explain the impact of HTN on CHF and renal failure Consider nutrition therapy or handouts to reduce sodium intake 12 Risk Factors Hypertension Obesity Metabolic syndrome Physical Inactivity Atherogenic Diet Diabetes Mellitus Dyslipidemia 13 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% Source: Behavioral Risk Factor Surveillance System, CDC. 5

6 Obese adults often have obese children Pediatric Obesity Predicts Adult Obesity 17 6

7 Impact of Reducing Obesity Lowers blood pressure Improves diabetes control Improves lipid profile Decreases risk of diabetes Reduces ALL-CAUSE mortality 18 What you can do: Ask patients to lose lb in weeks Set goals with pt and follow up OFTEN Push exercise (or meds) Add other activities: Take the stairs Park in the last parking spot - every time Walk your dog Teach keeping energy in equal to or less than your energy out 19 Outback Steakhouse Aussie Cheese Fries a quiz! Calories g fat g carbohydrate g protein mg cholesterol mg sodium g fiber 20 7

8 Risk Factors Hypertension Obesity Metabolic syndrome - the NEW risk factor Physical Inactivity Atherogenic Diet Diabetes Mellitus Dyslipidemia 21 Android (Apple) vs. Gynoid (Pear) Obesity A Tribute to a Pioneer: Jean Vague (1947) Vague J. Presse Med 1947;30:

24 Diagnosis of the Metabolic Syndrome Presence of

circumference Men Women Triglycerides HDL-C Men

>35 inches 150 mg/dl <40 mg/dl <50 mg/dl 130/85

25 What you can do: Explain pre diabetes and it s

glucose, and lipid levels Follow A1C (use 790.

9 24 Diagnosis of the Metabolic Syndrome Presence of three or more of the following: Waist circumference Men Women Triglycerides HDL-C Men Women Blood pressure Fasting glucose >40 inches >35 inches 150 mg/dl <40 mg/dl <50 mg/dl 130/ mg/dl NCEP. JAMA. 2001;285: What you can do: Explain pre diabetes and it s risk Teach the NUMBERS: blood pressure, waist, glucose, and lipid levels Follow A1C (use ) Remind them that a healthy weight, exercise, etc., can prevent diabetes (or meds) 26 9

Risk Factors Hypertension Obesity Metabolic syndrome Physical Inactivity Atherogenic Diet Diabetes Mellitus Dyslipidemia 27 Physical Activity: Exercise For CV benefit: 150 minutes per week divided by

10 Risk Factors Hypertension Obesity Metabolic syndrome Physical Inactivity Atherogenic Diet Diabetes Mellitus Dyslipidemia 27 Physical Activity: Exercise For CV benefit: 150 minutes per week divided by a minimum of 5 days, so: 22 min/day, 7 days per week, or 25 min/day, 6 days per week, or 30 min/day, 5 days per week Medically supervised programs for moderate to high-risk patients demonstrate benefits JAMA 2013;288: Physical Activity and Kids GOAL: Physical activity 60 min or more EVERY DAY Work with your children: Limiting screen time to < 2 hours daily Make activity fun Include the family Kavey, et al, Circulation. 2003;

11 Impact of Exercise Lowers blood pressure Improves insulin sensitivity, reducing risk of metabolic syndrome diabetes Improves lipid profile Natural antidepressant Decreases risk of future CHD, regardless of weight/bmi 30 What Exercise is best? 31 What Exercise is best for kids? 32 11

12 What you can do: ENCOURAGE exercise Suggest help starting an exercise program Warn: Increase gradually, don t over-do Be a role model Suggest alternative exercises (swimming for those with back pain, etc.) Silver Sneakers 33 Risk Factors Hypertension Obesity Metabolic syndrome Physical Inactivity Atherogenic Diet Diabetes Mellitus Dyslipidemia 34 The Atherogenic Diet The American Way Directly related to overweight/obesity Increases risk of Diabetes Increases risk of heart disease Consists of: large portions high in fat and sugar low in fiber calorie-rich 35 12

transfats, salt and sugar AVOID juice at all ages (none) Kavey, et al, Circulation. 2003;107.

13 It All Adds Up 10 calories / day excess = 1 LB / year 100 calories / day excess = 10 LB / year 36 Food and Kids GOAL: Healthy eating pattern Advocate healthy choices No fat restrictions < age 2 years > 2 years, reduction of saturated and transfats, salt and sugar AVOID juice at all ages (none) Kavey, et al, Circulation. 2003; Risk Factors Hypertension Obesity Metabolic syndrome Physical Inactivity Atherogenic Diet Diabetes Mellitus - no longer a risk factor Dyslipidemia 38 13

14 Diabetes and Prior Myocardial Infarction (MI) Carry Same Mortality Risk 50% 40% Equivalent MI Risk Levels 45.0% Fatal or Nonfatal MI 30% 20% 18.8% 20.2% 10% 0% 3.5% Nondiabetic Subjects (N = 1,373) Type 2 Diabetic Subjects (N = 1,059) Haffner SM, et al. N Engl J Med. 1998;339(4): No Prior Myocardial Infarction Prior Myocardial Infarction 39 Diabetes and Kids Diabetes in kids: up 10-fold in 10 years GOAL: - Fasting blood glucose < 100 mg/dl Kavey, et al, Circulation. 2003; What you can do: See your patients every 3-4 months Follow A1C Ask patients to help themselves by maintaining a healthy weight, exercising regularly, etc. Set goals for weight A1C, etc

15 Risk Factors Hypertension Obesity Metabolic syndrome Physical Inactivity Atherogenic Diet Diabetes Mellitus Dyslipidemia 42 The Old Way Total Cholesterol < Now we use: LDL-cholesterol (bad cholesterol) HDL-cholesterol (good cholesterol) Triglycerides (little fats bad) It s three numbers, instead of one, but it s three with meaning

1 0 LDL-Cholesterol Low Density Lipoprotein Cholesterol The bad one - you want it to be low Think L for lethal 45 Risk Rises More Steeply With Increasing LDL-C Concentrations Relative risk of

16 1 0 LDL-Cholesterol Low Density Lipoprotein Cholesterol The bad one - you want it to be low Think L for lethal 45 Risk Rises More Steeply With Increasing LDL-C Concentrations Relative risk of coronary heart disease LDL-C Concentration adapted from: Huang JC, Hoogwerf BJ. Cleve Clin J Med. 2005;72: Less is More 3.7 Relative Risk for CHD Grundy, SM et al. Circulation 2004;110: LDL-C (mg/dl) 47 16

17 HDL-Cholesterol High Density Lipoprotein Cholesterol The good one - you want it to be high Think H for healthy 48 ATP III Classification of HDL-C <40 mg/dl Low >60 mg/dl High (good) NCEP. JAMA. 2001;285: Causes of Low HDL Cholesterol <40 mg/dl Elevated triglycerides Overweight and obesity Physical inactivity Type 2 diabetes Cigarette smoking 50 17

18 Low HDL-C is an Independent Predictor of CHD Risk Even When LDL-C is Low 3.0 RR for CHD Event LDL-C (mg/dl) Gordon T et al. Am J Med 1977;62: HDL-C (mg/dl) 51 Triglycerides Really Normal < 100 mg/dl Normal < 150 mg/dl High Very high 500 NCEP. JAMA. 2001;285: Risk of CHD by Triglyceride Level The Framingham Heart Study, n = 5, Men Women Relative Risk Triglyceride Level (mg/dl) Castelli W Am J Cardiol 1992;70:3H-9H 53 18

19 Causes of Elevated Triglycerides > 150 mg/dl Obesity and overweight Physical inactivity Cigarette smoking Excess alcohol intake Genetics High sugar diets > 60% of energy intake 54 Call to Action Twenty-five percent of patients or 1.4 million individuals who are newly diagnosed with a lipid disorder are not at goal* for all three lipid parameters Source: 2004 Verispan Physician Drug and Diagnosis Audit 55 Lifestyle-Related Risk Factors Treat lifestyle-related risk factors, regardless of LDL-C level: Obesity Physical inactivity Elevated triglyceride Low HDL-C Metabolic syndrome Grundy, SM et al. Circulation 2004;110:

20 Lifestyle-Related Risk Factors Treat lifestyle-related risk factors, regardless of LDL-C level: Obesity Physical inactivity Elevated triglyceride Low HDL-C Metabolic syndrome Grundy, SM et al. Circulation 2004;110: Traditional Treatment Approach Dyslipidemia Hypertension Type 2 DM Monitor Lipid panels Lipoprotein subsets BP Ambulatory BP Blood sugar Glycosylated hemoglobin Diet Total fat Cholesterol Fiber Sodium K ++ Sugar Distribute CHO, Pro, Fat Meds Statins Fibrates Niacin Resins ACEI ARB Diuretic Ca-channel blockers Insulin Sulfonylureas TZDs Weight Monitoring? Diet/Exercise? Medications? Slide courtesy of Dr. Caroline M. Apovian. 58 New Treatment Approach Adipose Tissue Reduce BMI and waist circumference Calories, glycemia Daily activity/exercise Behavior therapy Medication-Current, CB1 Antagonists, others in development, combinations Dyslipidemia Diet Omega-3s MUFA Sat fat Trans fat Glycemia + ETOH ATP III guidelines: TLC diet Hypertension DASH Na ETOH IGT Fiber Glycemic diet Meds Statins Fibrate Omega-3 Oil Slide from Dr. Caroline M. Apovian. ACEI ARB Metformin TZD Exenatide 59 20

21 Summary Teach patients to Know the numbers! Ask questions what are your goals? Offer choices: meds or exercise, etc. Don t give up keep throwing spaghetti at the wall until it sticks. Teach everyone something at every visit 60 21

Screening Results. Juniata College. Juniata College. Screening Results. October 11, October 12, 2016

Screening Results. Juniata College. Juniata College. Screening Results. October 11, October 12, 2016 Juniata College Screening Results Juniata College Screening Results October 11, 2016 & October 12, 2016 JUNIATA COLLEGE The J.C. Blair Hospital CARES team screened 55 Juniata College employees on October