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1、Slide SourceLipidsOnlinewww.lipidsonline.orgLifestyle Interventions: Dietary Therapy, Physical Activity, Weight ControlNeil J. Stone, M.D.Slide SourceLipidsOnlinewww.lipidsonline.org20102010NowNowPrimary Prevention: Primary Prevention: Status and Goals Status and Goals in 2010in 2010NCEP.AdultTreatm
2、entPanelIIIReport.2001.ModerateModeratephysicalactivityphysicalactivityVegetableintakeVegetableintakeof3servingsof3servingsSaturatedfatSaturatedfat10%ofcalories2servings/dFruit2servings/dSmokingcessationSmokingcessationHealthyweightHealthyweight20102010NowNowNCEP.AdultTreatmentPanelIIIReport.2001.Sl
3、ide SourceLipidsOnlinewww.lipidsonline.orgPrimary Prevention: Primary Prevention: Crucial Opportunity to Crucial Opportunity to Reduce the Burden of CHDReduce the Burden of CHDLawMRetal.BMJ1994;308:367-372.Age 70Age 70Reductioninriskinmenwith10%reductionReductioninriskinmenwith10%reductionintotalcho
4、lesterol(10cohortstudies)intotalcholesterol(10cohortstudies)Age 50Age 50Age 40Age 40Slide SourceLipidsOnlinewww.lipidsonline.orgPrimary Prevention: Primary Prevention: Adverse Life Habit Adverse Life Habit ChangesChangesnAtherogenicdietnSedentarylifestylenObesityExpertPanel.JAMA2001;285:2486-2497.Sl
5、ide SourceLipidsOnlinewww.lipidsonline.orgPrimary PreventionRx: Primary PreventionRx: Therapeutic Therapeutic Lifestyle Changes (TLC)Lifestyle Changes (TLC)nTherapeuticdiettolowerLDL-CnPhysicallyactiveonadailybasisnWeightcontrolExpertPanel.JAMA2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonl
6、ine.orgPrimary PreventionRx: Primary PreventionRx: TLC Measures to TLC Measures to Lower LDL-CLower LDL-CnSaturatedfats(7%totalcalories)andcholesterol(200mg/d)nAlsotherapeuticoptions:Plantstanols/sterols(2g/d)Increasedviscousfiber(1025g/d)ExpertPanel.JAMA2001;285:2486-2497.Slide SourceLipidsOnlineww
7、w.lipidsonline.orgTotal Fat.Why a range?Total Fat.Why a range?nPrimaryemphasisistoreducesaturatedfatsnTotalfatshouldrange2530%formostcasesnThosewithmetabolicsyndromenAvoidveryhighfatintakesnAvoidverylowfatintake(lowHDL-C,highTG)nTotalfatintakecanrangefrom3035%ifextrafatisunsaturatednMayreducesomelip
8、idandnonlipidriskfactorsnClinicaljudgmentrequired.Slide SourceLipidsOnlinewww.lipidsonline.orgTherapeutic Lifestyle Changes:Therapeutic Lifestyle Changes:Nutrient Composition of TLC DietNutrient Composition of TLC DietNutrientNutrientRecommended IntakeRecommended IntakeSaturatedfat*Saturatedfat*Less
9、than7%oftotalcaloriesLessthan7%oftotalcaloriesPolyunsaturatedfatPolyunsaturatedfatUpto10%oftotalcaloriesUpto10%oftotalcaloriesMonounsaturatedfatMonounsaturatedfatUpto20%oftotalcaloriesUpto20%oftotalcaloriesTotalfatTotalfat2535%oftotalcalories2535%oftotalcaloriesCarbohydrate*Carbohydrate*5060%oftotal
10、calories5060%oftotalcaloriesFiberFiber2030gramsperday2030gramsperdayProteinProteinApproximately15%oftotalcaloriesApproximately15%oftotalcaloriesCholesterolCholesterolLessthan200mg/dayLessthan200mg/dayTotalcalories(energy)Totalcalories(energy)BalanceenergyintakeandoutputtoBalanceenergyintakeandoutput
11、tomaintainexpendituremaintainexpenditure healthybodyhealthybodyweight/preventweightgainweight/preventweightgain* Lower * Lower transtrans fatty acids fatty acids* Emphasize complex sources* Emphasize complex sourcesSlide SourceLipidsOnlinewww.lipidsonline.orgLDL-C Response to Step II Diet: LDL-C Res
12、ponse to Step II Diet: beFITbeFITn178Women/231MenDietaryfat25%;saturatedfat7.5%nLDL reduction Highcholesterolonly:7.6to8.8%nLDL reductionCombinedhyperlipidemia:8.1%WaldenCEetal.Arterioscler Thromb Vasc Biol1997;17:375-382.Slide SourceLipidsOnlinewww.lipidsonline.orgDELTA I Dietary TrialDELTA I Dieta
13、ry TrialSubjects:Subjects:age22to67nDifferentgroupsofsubjects:nWhite,blacknWomen:youngerandpostmenopausalnMen:younger,olderAADAADLowSatLowSatResults:Results:nComparedtoaverageAmericandiet,whensaturatedfatfellfrom15%to6.1%,LDL-Cfellby11%Negative aspects:Negative aspects:nHDL-Cfellfrom52.2to46.2nLp(a)
14、rosefrom15.5to18.2GinsbergHNetal.Arterioscler Thromb Vasc Biol1998;18:441-449.TotalFatSatFatsLDLSlide SourceLipidsOnlinewww.lipidsonline.orgNew Options to Lower LDL-CNew Options to Lower LDL-CnAvoidnTransfattyacids*nAddnDietaryfibernPlantsterol/stanolestermargarinesExpertPanel.JAMA2001;285:2486-2497
15、.*KeeptransfattyacidslowSlide SourceLipidsOnlinewww.lipidsonline.orgTransTrans Fatty Acids (TFA) Fatty Acids (TFA)nTFAmoredenselypackedthancisformsnUsualintake:only23%ofenergynIfconsumedinhighamounts: LDL-C; HDL-CnExamplesofTFAStickmargarine,cookies,biscuits,whitebreadLichtensteinAHetal.N Engl J Med
16、1999;340:1933-1940Conclusion:ConsumeproductslowinsaturatedandTFASlide SourceLipidsOnlinewww.lipidsonline.orgPlant Sterol/Plant Sterol/Stanol Stanol EstersEstersnSterolsareessentialcomponentsofcellmembranesnCholesterolexclusivelyananimalsterolnWeingestalmostasmuchplantsterolsaswedodietarycholesteroln
17、StanolsabsorbedevenlesswellnPlantsterols/stanolslowercholesterolnInterferewithmicellarabsorptionofcholesterolnNomalabsorptionoffatLawMRetal.BMJ2000;320:861-864.Slide SourceLipidsOnlinewww.lipidsonline.orgPlant Sterol/Plant Sterol/Stanol Stanol EstersEstersnIf2gofplantsterolorstanolisaddedtoaverageda
18、ilyportionofmargarine,ithasvariableeffectonLDL-Cbyagegroup:nAgeLDL-Creducedby:505921mg/dlor0.54mmol/l404917mg/dlor0.43mmol/l303913mg/dlor0.33mmol/lLawMRetal.BMJ2000;320:861-864.Slide SourceLipidsOnlinewww.lipidsonline.orgEsterification Esterification of of StanolsStanolsPlant StanolnCrystallinepowde
19、rnRestrictedfatsolubilitynMeltingrange140150oCR C - = O3 35 56 6OO3 35 56 6HOHO1717EsterificationEsterificationFat-SolubleFat-SolublePlantPlantStanolStanolSlide SourceLipidsOnlinewww.lipidsonline.orgTreatment with Treatment with Stanol Stanol Ester MargarineEster Margarine-2-2Cholesterol(mg/dl)Study
20、Period(mo)StudyPeriod(mo)2 24 48 81010MiettinenTAetal.N Engl J Med1995;333:1308-1312.1995MassachusettsMedicalSociety.Allrightsreserved.0 0121214146 6SitostanolSitostanol-estermargarine-estermargarineSlide SourceLipidsOnlinewww.lipidsonline.orgPlant Sterols/Plant Sterols/StanolsStanols: Efficacy in L
21、owering : Efficacy in Lowering LDL-CLDL-CnDose:Maximumis2g/dnMeta-analysisresults:nLDL-Cloweringabout913%nLoweringgreaterinelderlynAdditivetostatintherapynUsedinvariouspopulationgroupsnWell-toleratednMaydecreaseLDL-CadjustedcarotenoidsLawMetal.BMJ2000;320:861-864.LichtensteinAHetal.Circulation201;10
22、3:1177-1179Slide SourceLipidsOnlinewww.lipidsonline.orgDietary AdjunctsDietary AdjunctsnTLCforpatientswithLDL-C=160WaldenCEetal.ArteriosclerThrombVascBiol1997;17:375-382.JenkinsDJetal.CurrOpinLipidol2000;11:49-56.CatoN.Stanolmeta-analysis.Personalcommunication,2000.DietaryComponentLDL-C (mg/dL)Lowsa
23、turatedfat/dietaryLowsaturatedfat/dietarycholesterolcholesterol1212Viscousfiber(1025g/d)Viscousfiber(1025g/d)88PlantPlantstanolsstanols/sterols(2g/d)/sterols(2g/d)1616TotalTotal36mg/dl36mg/dlSlide SourceLipidsOnlinewww.lipidsonline.orgThe Spectrum of CHD RiskThe Spectrum of CHD RiskExpertPanel.JAMA2
24、001;285:2486-2497.“Morehigherriskpatientsbroughtintothealgorithm”“Morehigherriskpatientsbroughtintothealgorithm”MetabolicSyndromeElevatedLDL-CGlucoseGlucose 110125110125AbdominalAbdominalObesityObesity HDL-CHDL-C BPBPTGTG 150150Slide SourceLipidsOnlinewww.lipidsonline.orgThe Metabolic SyndromeThe Me
25、tabolic SyndromenConstellationofmajorriskfactors,life-habitriskfactorsandemergingriskfactorsnOver-representedamongpopulationswithCHDnClueisdistinctivebody-typewithincreasedabdominalcircumference(althoughsomeleanermenandwomenwithabdominalobesitywithoutincreasedwaist)Slide SourceLipidsOnlinewww.lipids
26、online.orgMetabolic Syndrome as a Secondary Goal Metabolic Syndrome as a Secondary Goal after LDL-Cafter LDL-CExpertPanel.JAMA2001;285:2486-2497.RiskFactor(RiskFactor( 3)3)DefiningLevelDefiningLevelAbdominalobesityAbdominalobesityWaistcircumferenceWaistcircumference* *TriglyceridesTriglycerides 150m
27、g/dl150mg/dlHDL-CHDL-C40mg/dlinmen;40mg/dlinmen;50mg/dlinwomen40in(102cm);women35in(88cm)*Men:40in(102cm);women35in(88cm)Slide SourceLipidsOnlinewww.lipidsonline.orgMetabolic Syndrome as a Secondary Goal Metabolic Syndrome as a Secondary Goal after LDL-Cafter LDL-CExpertPanel.JAMA2001;285:2486-2497.
28、RiskFactorRiskFactorDefiningLevelDefiningLevelAbdominalobesityAbdominalobesity40waistcirc.inmen40waistcirc.inmen35waistcirc.inwomen35waistcirc.inwomenHDL-CHDL-C40mg/dlinmen40mg/dlinmen50mg/dlinwomen5%Wtreduction5%434313130.0010.001Fatintake30%Fatintake30%energyenergy474726260.0010.001SatfatSatfat10%
29、energy15g/1000kcal15g/1000kcal252512120.0010.001Exercise4hr/wkExercise4hr/wk868671710.0010.001TuomilehtoJetal.N Engl J Med2001;344:1343-1350.Slide SourceLipidsOnlinewww.lipidsonline.orgBenefit of Treating the Metabolic SyndromeBenefit of Treating the Metabolic SyndromeTuomilehtoJetal.N Engl J Med200
30、1;344:1343-1350.InterventionInterventionControlControlAfter4yearsriskofdiabetesreducedby58%11%11%23%23%(615 (615 CI)CI)(1729 (1729 CI)CI)%withDiabetes%withDiabetesSlide SourceLipidsOnlinewww.lipidsonline.orgGoals of Weight LossGoals of Weight Loss1.Reducebodyweightintheshortterm2.Maintainalowerbodyw
31、eightforthelongterm3.PreventfurtherweightgainminimumgoalObesityEducationInitiative.Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report.Bethesda,Md.:NIH,1998Slide SourceLipidsOnlinewww.lipidsonline.orgFurther Goals of Weight Los
32、sFurther Goals of Weight Loss1.Rateofweightlossn10%reductioninbodyweightin6monthsoftherapynRateis12lbsperweekSlide SourceLipidsOnlinewww.lipidsonline.orgGoals of Physical ActivityGoals of Physical ActivityPeopleofallages,maleandfemalebenefitfromphysicalactivity1.Includeamoderateamountofphysicalactiv
33、ityonmost,ifnotalldaysoftheweek2.Additionalhealthbenefitscanbederivedfromgreateramountsofactivity3.EmphasisisonamountnotintensityU.S.Dept.ofHealthandHumanServices.Physical Activity and Health:A Report of the Surgeon General.Atlanta,Ga:CentersforDiseaseControlandPrevention,1996.Slide SourceLipidsOnli
34、newww.lipidsonline.orgSuggestions on ActivitySuggestions on Activity1. Scheduled physical activitya.Walking,treadmill,jogging,walkingdogb.Swimming,biking,volleyball2. Lifestyle physical activitya.Walkmorestairsatwork,walkingforerrands,parkingfartherawayinparkinglotsb.Housework,gardeningU.S.Dept.ofHe
35、althandHumanServices.Physical Activity and Health:A Report of the Surgeon General.Atlanta,Ga:CentersforDiseaseControlandPrevention,1996.Slide SourceLipidsOnlinewww.lipidsonline.orgMetabolic Benefits of Weight LossMetabolic Benefits of Weight LossnReversechangesofinsulinresistanceandmetabolicsyndrome
36、nRaiseHDL-C(canseeincreaseof1.6mg/dlfroma10-lbweightloss)DattiloAMetal.Am J Clin Nutr1992;56:320-328.Slide SourceLipidsOnlinewww.lipidsonline.orgMetabolic Response to 10-lb Weight Loss: Metabolic Response to 10-lb Weight Loss: Framingham DataFramingham DataHigginsMetal.ActaMedScandSuppl1988;723:23-3
37、6.CholesterolCholesterolSmallSmallchangeschangescanaddupcanadduptotosignificantsignificantchangesinchangesinlong-termlong-termriskriskSystSystBPBPGlucoseGlucosemg/dlmg/dlmmHgmmHgmg/dlmg/dlMenMenWomenWomenSlide SourceLipidsOnlinewww.lipidsonline.orgDietary Options Benefit Independent of Dietary Optio
38、ns Benefit Independent of LDL-C LoweringLDL-C Loweringn nAvoidnMegavitamins(adverseeffectsshownforsupplementsofbeta-carotene,noconvincingclinicaltrialbenefitforvitaminEsupplementation)n nAddnFishnPlantsourcesofomega-3fattyacidsnFruitsandvegetablesSlide SourceLipidsOnlinewww.lipidsonline.orgClinical
39、Trial Data Showing Lack of Benefit Clinical Trial Data Showing Lack of Benefit of Megavitaminsof MegavitaminsnBeta CarotenenNoproofofbenefitin3trialsnOnestoppedprematurely(CARET)nVitamin EnNoproofofbenefitin2largetrialsnHOPETrialNaturalvitaminEnGISSIPreventionSyntheticvitaminEAlpha-Tocopherol,Beta-C
40、aroteneCancerPreventionStudyGroup.N Engl J Med1994;330:1029-1035.HennekensCHetal.N Engl J Med1996;334:1145-1149.OmennGSetal.N Engl J Med1996;334:1150-1155.HOPEStudyInvestigators.N Engl J Med2000;342:154-160.GISSI-PrevenzioneInvestigators.Lancet 1999;354:447-455.Slide SourceLipidsOnlinewww.lipidsonli
41、ne.orgClinical Trial Data Showing Significant Clinical Trial Data Showing Significant Effect of DietEffect of DietnOmega-3 Fatty AcidsnDART:29%reductionindeathnGISSI:Significantreductionofoneoftwocombinedendpointsn“Mediterranean Diet”nLyonTrial:Multipledifferencesindiet;dietwaslowinanimal,dairyfat,h
42、ighinplant-basedomega-3fattyacids,fiberBurrMLetal.Lancet1989;2:757-761.GISSI-PrevenzioneInvestigators.Lancet1999;354:447-455.deLongerilMetal.Circulation1999;99:779-785.Slide SourceLipidsOnlinewww.lipidsonline.orgBurrMLetal.Lancet1989;2:757-761.GISSI-PrevenzioneInvestigators.Lancet1999;354:447-455.Tr
43、ials of n-3 Fatty Acids in MI Survivors: Trials of n-3 Fatty Acids in MI Survivors: Significant Effect on DeathsSignificant Effect on DeathsDARTDARTGISSIGISSI3,482patients3,482patients11,324patients11,324patientsExptExptDeathsDeathsControlDeathsControlDeathsSlide SourceLipidsOnlinewww.lipidsonline.o
44、rgLyon Diet Heart Study: Lyon Diet Heart Study: Cumulative Survival Cumulative Survival without Cardiac Death and Nonfatal MIwithout Cardiac Death and Nonfatal MIdeLorgerilMetal.Circulation1999;99:779-785.1999LippincottWilliams&W1 1%WithoutEventCanolaoilCanolaoilbasedbasedmargarine,margarine,fiber,l
45、owfiber,lowcholesterol,cholesterol,lowsaturatedlowsaturatedfat,fruits,fat,fruits,vegetablesvegetablesExperimentalExperimentalControlControlP=0.0001P=0.0001YearYear2 23 34 45 5Slide SourceLipidsOnlinewww.lipidsonline.orgComparison of the DietsComparison of the DietsItemItemExperimentalExperimentalCon
46、trolControlTotalcaloriesTotalcalories194719472088*2088*TotalfatTotalfat30.4%30.4%33.6%*33.6%*SaturatedfatSaturatedfat8%8%11.7%11.7%DietarycholesterolDietarycholesterol203mg/dl203mg/dl312mg/dl*312mg/dl*AlcoholAlcoholSameSameSameSameOliveoilOliveoilNoneNoneNoneNoneMUFAn-9MUFAn-9Increased*Increased*PUF
47、APUFAIncreased*Increased*n-3/n-6fattyacidsn-3/n-6fattyacidsIncreased*Increased*FiberFiber18.618.6deLorgerilMetal.Circulation1999;99:779-785.*Significantlydifferent*SignificantlydifferentSlide SourceLipidsOnlinewww.lipidsonline.orgHow to Implement Primary Prevention How to Implement Primary Preventio
48、n with TLCwith TLCnStepwiseapproachnResourcesnClinicalGuidelinesontheIdentification,Evaluation,andTreatmentofOverweightandObesityinAdults(downloadfromwebforpalm-basedmaterial)nSurgeonGeneralsReportonPhysicalActivitySlide SourceLipidsOnlinewww.lipidsonline.orgImplementing Primary Prevention Implement
49、ing Primary Prevention with TLC?with TLC?nEmphasizereductioninsaturatedfatandcholesterolnReduceanimal/highfatdairynGetlowerfatfoodifeatsoutnRegularphysicalactivityVisit 1ExpertPanel.JAMA2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgImplementing Primary Prevention Implementing Primar
50、y Prevention with TLC?with TLC?nEvaluateLDL-CresponsenIntensifyLDL-CloweringwithdietaryadjunctsnPlantstanols/sterolsnIncreasedfiberintakeVisit 2ExpertPanel.JAMA2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgImplementing Primary Prevention Implementing Primary Prevention with TLCwith
51、TLCnAtallstagesofdietarytherapy,physiciansareencouragedtoreferpatientsfor:nMedicalnutritiontherapynRegistereddietitians/otherqualifiednutritionistsExpertPanel.JAMA2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgImplementing Primary Prevention Implementing Primary Prevention with TLC?w
52、ith TLC?nEvaluateLDL-CresponsenInitiatetherapyformetabolicsyndromenIntensifyweightmanagementnPhysicalactivitynConsiderdrugRxifLDL-CgoalnotachievedVisit 3ExpertPanel.JAMA2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgPrimary Prevention with TLCPrimary Prevention with TLCnTherapeuticLifestyleChangescanlowerLDL-CsomedicationnotrequiredorincreasenotneedednCantreatmetabolicsyndromenLowersTGnRaisesHDL-CnReducesriskofdiabetesnProvidesoverallhealthfullifestyleExpertPanel.JAMA2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.org
