Evidence-Based Lifestyle Recommendations for Prevention of Cardiovascular Disease Nathan D. Wong, PhD, FACC, FAHA Professor and Director, Heart Disease Prevention Program Division of Cardiology, University of California, Irvine President, American Society for Preventive Cardiology Global burden of Cardiovascular disease Nutrition, physical activity and NCD prevention • Up to 80% of heart disease, stroke and type 2 diabetes and over a third of the most common cancers could be prevented by eliminating obesity, unhealthy diets and physical inactivity • Call for commitments at the global and national level to address these risk factors including: – Control food supply, food information and marketing and promotion of energy-dense, nutrient-poor foods that are high in saturated, trans-fat, salt or refined sugars The NCD Alliance: United by 4 risk factors Modifiable causative risk factors Non-communicable Diseases Tobacco use Unhealthy diets Physical inactivity Harmful use of alcohol Heart disease and stroke Diabetes Cancer Chronic lung disease Age-standardized prevalence estimates for poor, intermediate and ideal cardiovascular health for each of the seven metrics of cardiovascular health in the AHA 2020 goals, among US adults >20 years of age, NHANES 2005-2006 (baseline available data as of January 1, 2010). ©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010 Classification of Recommendations and Levels of Evidence *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. †In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level. Evidence for Current Cardiovascular Disease Prevention Guidelines Diet and Weight Management Evidence and Guidelines Weight Management Recommendations Goals Recommendations Calculate BMI* and measure waist circumference BMI 18.5 to 24.9 kg/m2 Women: <35 inches Men: <40 inches Monitor response to treatment I IIa IIb III Start weight management and physical activity as appropriate 10% weight reduction within the 1st yr of Rx *BMI is calculated as the weight in kilograms divided by the body surface area in meters2 If BMI and/or waist circumference is above goal, initiate caloric restriction and increase caloric expenditure BMI=Body mass index, Rx=Treatment Smith SC Jr. et al. JACC 2006;47:2130-9 Body Mass Index: Risk of Cardiovascular Disease Hazard Ratio Hemorrhagic CVA Ischemic CVA Ischemic Heart Disease 4.0 4.0 4.0 2.0 2.0 2.0 1.0 1.0 1.0 0.5 0.5 0.5 16 20 24 28 32 36 16 20 24 28 32 36 16 20 24 28 32 36 Body Mass Index (kg/m2)* CV=Cardiovascular *BMI is calculated as the weight in kg divided by the BSA in meters2 Mhurchu N et al. Int J Epidemiol 2004;33:751-758 Abdominal Adiposity Is Associated With Increased Risk of Diabetes Relative Risk of Diabetes 25 P value for trend <0.001 20 15 10 5 0 <28 >28-29 30-31 32-33 34-35 36-37 Waist Circumference (in) Carey VJ, et al. Am J Epidemiol. 1997;145:614-619 ≥38 Diet Evidence: Types of Treatment Programs • Very low fat – Ornish (Reversal diet and Prevention diet) • Vegetarian with 10% calories from fat. No cooking oils, avocados, nuts, and seeds. High fiber. No caloric restriction. – Pritikin • Very low-fat (primarily vegetarian) diet based on whole grains, fruits, and vegetables • Intermediate – Sugar Busters • 30% protein, 40% fat, 30% carbohydrates (low glycemic index) – Zone • 30% protein, 30% fat, 40% carbohydrates Diet Evidence: Types of Treatment Programs (Continued) • Very low carbohydrate – Atkins (Induction and Maintenance) • 1st 2 weeks (<20 grams of carbohydrates/day with no high glycemic foods). • Then can add 5 grams of carbohydrates/day each week to maximum of 90 grams of carbohydrates/day long term. – South Beach (3 Phases) • 1st phase (2 weeks) significantly restricts carbohydrates • 2nd phase reintroduces low glycemic carbohydrates • 3rd phase attempts to maintain weight • Caloric restriction – Weight watchers • Assigns foods a point value and restricts the number of points that can be consumed/day. Diet Evidence: Primary Prevention 160 overweight and obese patients randomized to the Atkins, Zone, Weight Watchers, or Ornish diets for 1 year Ornish 20/40* Weight Watchers 26/40* Zone 26/40* Atkins 21/40* 0 3 Wt loss (lbs) 6 9 Weight loss is similar among diet programs, but hard to sustain because of poor long-term compliance *Ratio of individuals completing the study to those enrolled Dansinger, ML et al. JAMA 2005;293:43-53 Lifestyle Heart Trial • 41 male and female CHD patients • Randomized to <10% fat diet, exercise and meditation (Rx group) vs. Step 1 diet • At one year 37% LDL-C reduction, 22% weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography) • At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35) Ornish et al. Lancet 1990; 336:129-133, and JAMA 1998; 280:2001-2007. Evidence for Current Cardiovascular Disease Prevention Guidelines Diet, Cardiovascular Events, and Guidelines Diet Evidence: Effect on Lipid Parameters and CRP 46 dyslipidemic patients randomized to a low fat diet, a low fat diet and lovastatin (20 mg), or a dietary portfolio* for 4 weeks Change from Baseline (%) 30 LDL-C 20 LDL-C:HDL-C CRP 10 Low fat diet 0 Statin -10 Dietary portfolio* -20 -30 -40 -50 0 2 Weeks 4 0 2 Weeks 4 0 2 4 Weeks A diversified diet improves lipid parameters and CRP levels *Enriched in plant sterols, soy protein, viscous fiber, and almonds Jenkins DJ et al. JAMA 2003;290:502-10 Diet Evidence: Effect on Blood Pressure Dietary Approaches to Stop Hypertension (DASH) Group 459 hypertensive patients randomized to 1 of 3 diets for 8 weeks Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) A diversified diet improves blood pressure Appel LJ et al. NEJM 1997;336:1117-24 Pre-diabetic Conditions: Benefit of Lifestyle Modification Diabetes Prevention Program (DPP) 3,234 patients with elevated fasting and post-load glucose levels Percent developing diabetes randomized to placebo, metformin (850 mg bid), or lifestyle modification* for participants 3Allyears Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac ) Placebo Metformin (n=1073, p<0.001 vs. Plac) Placebo (n=1082) Cumulative incidence (%) Incidence of DM (%) 40 40 Metformin Lifestyle modification 30 30 20 20 10 10 00 0 0 0 1 1 22 3 3 44 Years from randomization Years Lifestyle modification reduces the risk of developing DM *Includes 7% weight loss and at least 150 minutes of physical activity per week Knowler WC et al. NEJM 2002;346:393-403. Diabetes Prevention Program: Reduction in Diabetes Incidence Diet Evidence: Benefits of Fruits and Vegetables Nurses’ Health Study and Health Professional’s Follow-up Study 126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes* Increased fruit and vegetable intake reduces CV risk *Includes nonfatal MI and fatal coronary heart disease CV=Cardiovascular, MI=Myocardial infarction Joshipura KJ, et al. 2001 Ann Intern Med134:1106-14 Diet Evidence: Benefits of Whole Grains and Fiber 336,244 persons followed for 6-10 years to assess the relationship between dietary fiber intake and adverse CV outcomes RR=0.73, P<0.001 Increased dietary fiber intake reduces CV risk CV=Cardiovascular, CHD=Coronary heart disease Pereira MA et al. Arch Int Med 2004;164:370-76 Diet Evidence: Primary Prevention 22,043 adults evaluated for adherence to a Mediterranean diet, with points given for high consumption of vegetables, legumes, fruits, nuts, cereal, and fish and points subtracted for high consumption of meat, poultry, and dairy Variable # of Deaths/ # of Participants Fully Adjusted Hazard Ratio (95% CI) Death from any cause 275/22,043 0.75 (0.64-0.87) 54/22,043 0.67 (0.47-0.94) 97/22,043 0.76 (0.59-0.98) Death from CHD Death from cancer High adherence to a Mediterranean diet is associated with a reduction in death Trichopoulou A, et al. NEJM 2003;348:2595-6 Diet Evidence: Secondary Prevention Lyon Diet Heart Study 605 patients following a MI randomized to a Mediterranean* or Western** diet for 4 years A Mediterranean diet reduces cardiovascular events *High in polyunsaturated fat and fiber, **High in saturated fat and low in fiber De Lorgeril M et al. Circulation 1999;99:779-785 w-3 Fatty Acids Evidence: Primary and Secondary Prevention Japan Eicosapentaenoic acid Lipid Intervention Study (JELIS) 18,645 patients with hypercholesterolemia randomized to EPA (1800 mg) with a statin or a statin alone for 5 years Years w-3 fatty acids provide CV benefit, particularly in secondary prevention CV=Cardiovascular, EPA=Eicosapentaenoic acid *Composite of cardiac death, myocardial infarction, angina, PCI, or CABG Yokoyama M et al. Lancet. 2007;369:1090-8 w-3 Fatty Acids Evidence: Secondary Prevention Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (GISSIPrevenzione) 11,324 patients with a history of a MI randomized to w-3 polyunsaturated fatty acids [PUFA] (1 gram), vitamin E (300 mg), both or none for 3.5 years w-3 fatty acids provide significant CV benefit after a MI CV=Cardiovascular, MI=Myocardial infarction, NF=Non-fatal, PUFA=Polyunsaturated fatty acids GISSI Investigators. Lancet 1999;354:447-455 Adult Treatment Panel (ATP) III Dietary Recommendations Nutrient Recommended Intake Saturated fat* <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 (esp. complex carbs) Fiber 50%–60% of total calories 20–30 g/d Protein Cholesterol ~15% of total calories <200 mg/d *Trans fatty acids also raise LDL-C and should be kept at a low intake Note: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-97 American Heart Association (AHA) Nutrition Committee Dietary Recommendations Recommendations for Cardiovascular Disease Risk Reduction • Balance calorie intake and physical activity to achieve or maintain a healthy body weight • Consume a diet rich in fruits and vegetables • Consume whole-grain, high-fiber foods • Consume fish, especially oily fish, at least twice a week • Limit intake of saturated fat to <7%, trans fat to <1% of energy, and cholesterol <300 mg/day by: – Choosing lean mean and vegetable alternatives – Choosing fat free (skim), 1% fat, and low-fat dairy products, – Minimizing intake of partially hydrogenated fats • Minimize intake of beverages and foods with added sugar • Choose and prepare foods with little or no salt (AHA 2011 rec. <1500mg/d) • If alcohol is consumed, do so in moderation AHA Nutrition Committee. Circulation 2006;114:82-96 N-3 Fatty Acid Recommendation American Dietetic Association 2007 For those without heart disease • Two 3.5 oz svgs/wk of fatty fish are assoc with 30-40% reduced risk of death from cardiac events. Grade II Fair N-3 Fatty Acids American Dietetic Association 2007 For those with heart disease • Approx 1g/d of DHA & EPA from fatty fish OR supplement decreases the risk of death from cardiac events. Grade II Fair N-3 Fatty Acid Recommendation American Dietetic Association 2007 • Consume both marine & plant sources . Fatty fish: two 3.5 oz serving/wk (salmon, herring, sardines) or 1.5 g ALA/day eg 1 TBS canola, 1/2 TBS ground flax seeds. Dietary Guidelines Primary Prevention I IIa IIb III Women should consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods; consume fish, especially oily fish,* at least twice a week; limit intake of saturated fat to <10% of energy, and if possible to <7%, cholesterol to <300 mg/d, alcohol intake to no more than 1 drink per day, and sodium intake to <2.3 g/d (approximately 1 tsp salt). Consumption of trans-fatty acids should be as low as possible (eg, <1% of energy) *Pregnant and lactating women should avoid eating fish potentially high in methylmercury Mosca L et al. Circulation 2007;115:1481-501 Dietary Guidelines (Continued) Secondary Prevention I IIa IIb III I IIa IIb III Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg per day). Encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 gram per day) for risk reduction may be reasonable for patients with known CAD. Smith SC Jr. et al. JACC 2006;47:2130-9 JNC VII Lifestyle Modifications for BP Control Modification Recommendation Approximate SBP Reduction Range Maintain normal body weight (BMI=18.5-24.9) 5-20 mmHg/10 kg weight lost Diet rich in fruits, vegetables, low fat dairy and reduced in fat 8-14 mmHg Restrict sodium intake <2.4 grams of sodium per day 2-8 mmHg Physical activity Regular aerobic exercise for at least 30 minutes on most days of the week 4-9 mmHg Moderate alcohol consumption <2 drinks/day for men and <1 drink/day for women 2-4 mmHg Weight reduction Adopt DASH eating plan BMI=Body mass index, SBP=Systolic blood pressure Chobanian AV et al. JAMA. 2003;289:2560-2572 You Can Now Receive Medicare Reimbursement for Nutrition Counseling • The Centers for Medicare and Medicaid Services (CMS) has issued a decision memorandum that will allow you to be reimbursed for providing Medicare beneficiaries with intensive behavioral therapy for obesity, defined as a body mass index (BMI) ≥30. • The agency suggests that more than 30% of the Medicare population will likely qualify for the new benefit. Intensive behavioral therapy for obesity consists of the following: • Screening for obesity in adults using BMI measurement calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/m2) • Dietary (nutritional) assessment • Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise To be eligible for reimbursement, the counseling should follow the “Five-A’s” format: • Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods. • Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits. • Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior. • Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate. • Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment. • Providing that a Medicare beneficiary is obese, competent, and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician, or other primary care practitioner, and in a primary care setting, CMS covers: • One face-to-face visit every week for the first month • One face-to-face visit every other week for months 2-6 • One face-to-face visit every month for months 7-12, if the beneficiary meets the 3 kg weight loss requirement as discussed below • At the six-month visit, you must reassess the patient’s obesity and document the amount of weight lost. To be eligible for additional face-toface visits occurring once a month for an additional six months, patients must have lost at least 3 kg (6.6 lbs) over the course of the first six months of intensive therapy and should be documented in the record. For patients who do not achieve this minimum weight loss during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six-month period. • Source: Decision memo for intensive behavioral therapy for obesity (CAG-00423N). Centers for Medicare & Medicaid Services Website. https://www.cms.gov/medicare-coverage-database/details/nca-decisionmemo.aspx?NCAId=253 . Published November 29, 2011. Accessed November 30, 2011. Evidence for Current Cardiovascular Disease Prevention Guidelines Physical Activity Evidence and Guidelines Physical Activity Recommendations Goal: 30 minutes 7 days/week, minimum 5 days/week I IIa IIb III I IIa IIb III I IIa IIb III Assess risk with a physical activity history and/or an exercise test, to guide prescription Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, HF) RCT Trial Assessment of Pedometer Interventions N=277; 8 Trials Pedometer increased steps by 2500/day Bravata, DM et al. JAMA 2007; 298:2296-2304 Adverse Effects of Physical Inactivity Physical Inactivity Inflammation Dyslipidemia Age Hypertension Diabetes Mellitus Smoking Obesity Hypercoagulability Genetics Atherosclerosis Novel Risk Factors Exercise Evidence: Effect on Body Composition 173 sedentary, overweight (BMI >24 kg/m2) post-menopausal women randomized to moderate intensity exercise vs. stretching for 1 year Total Body Fat Intra-abdominal Fat Moderate exercise reduces total and intra-abdominal fat Note: Minutes per week spent in moderate-intensity sports activity (low-active, 135 min/wk; intermediately active, 136-195 min/wk; and highly active, >195 min/wk) Irwin ML et al. JAMA 2003;289:323-330 Exercise Evidence: Effect on Lipid Parameters Year and Lipid Level (mg/dL) Baseline 1 3 5 Change from Baseline TC Men Women 214 239 213 223 210 209 196 193 8% 20%* LDL-C Men Women 138 155 134 135 131 120 118 102 15% 34%* HDL-C Men Women 37 47 40 50 41 55 39 56 5% 20%† TG Men Women 200 188 197 190 199 174 202 171 NS Lipids *P=0.0001 for change in women vs men †P=0.03 for change in women vs men HDL-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol, TG=Triglyceride Warner JG et al. Circulation 1995;92:773-777 Exercise Evidence: Effect on Lipid Parameters Look AHEAD Trial 5,145 patients aged 45-74 years with type 2 DM and BMI 25 kg/m2 (27 kg/m2 if taking insulin) randomized to an intensive lifestyle intervention (ILI) involving group and individual meetings to achieve and maintain weight loss through decreased caloric intake and increased physical activity versus diabetes support and education (DSE) ILI DSE P value LDL (mg/dL) -5.2 ± 0.6 -5.7 ± 0.6 0.49 HDL (mg/dL) 3.4 ± 0.2 1.4 ± 0.1 <0.001 Triglycerides (mg/dL) -30.3 ± 2.0 -14.6 ± 1.8 <0.001 % Metabolic Syndrome -14.7 ± 0.8 -7.1 ± 0.7 <0.001 Intensive lifestyle intervention results in greater improvements in lipid parameters BMI=Body mass index, DM=Diabetes mellitus Look AHEAD investigators. Diabetes Care 2007;30:1374-83 Exercise Evidence: Effect on Obesity and Diabetes Mellitus (DM) Nurse’s Health Study Exercise reduces the incidence of obesity and DM Hu FB et al. JAMA 2003;289:1785-91 Exercise Evidence: Effect on Coronary Heart Disease Risk Vigorous exercise* Walking P=0.008 P=0.004 Relative Risk of CHD Relative Risk of CHD Women’s Health Initiative Observational Study 1.0 0.8 0.6 0.4 0.2 0.0 1 2 3 4 5 1.0 0.8 0.6 0.4 0.2 0.0 1 2 3 4 5 Quintiles of activity (MET-hour/week**) *Includes aerobics, aerobic dancing, jogging, tennis, and swimming laps **Average active hours per week energy expenditure per activity CHD=Coronary heart disease Manson JE et al. NEJM 2002;347:716-25 Physical Activity: Secondary Prevention Observational study of self-reported physical activity in 772 men with CHD Moderate exercise is associated with reduced mortality CHD=Coronary heart disease, CVD=Cardiovascular disease Wannamethee SG et al. Circulation 2000;102:1358-1363 Cardiac Rehabilitation: Benefits Following a Myocardial Infarction (MI) Effect of cardiac rehabilitation in randomized controlled trials following a MI 1.5 Pooled Odds Ratio 1.15 1 0.76 * 0.75 * 0.5 0 All Cause Death CV Mortality Nonfatal Recurrence Cardiac rehabilitation reduces CV events after a MI *p<0.0125 CV=Cardiovascular Oldridge NB et al. JAMA 1988;260:945-950 Cardiac Rehabilitation: Benefit of Secondary Prevention Programs Meta-analysis of 63 randomized clinical trials evaluating cardiac secondary prevention programs with or without exercise programs All cause mortality Recurrent myocardial infarction Secondary prevention programs provide CV benefit CV=Cardiovascular Clark AM et al. Ann of Intern Med 2005;143:659-72 Evidence for Current Cardiovascular Disease Prevention Guidelines Cigarette Smoking Cessation Evidence and Guidelines NCDs, tobacco control and the FCTC • Tobacco causes 1 in 6 of all NCD deaths • By 2015 the WHO estimates tobacco will cause 6.4 million deaths a year • Tobacco use impedes economic and social development • the WHO Framework Convention on Tobacco Control (FCTC) is a set of internationally negotiated, legally binding, evidence-based tobacco control measures – implementation of the FCTC must be accelerate Tobacco Cessation Recommendations Goals Complete cessation No environmental tobacco smoke exposure I IIa IIb III Recommendations Ask about tobacco use at every visit In a clear, strong, and personalized manner, advise the patient to stop smoking Urge avoidance of exposure to second-hand smoke at work and home Assess patient’s willingness to quit smoking Develop a plan for smoking cessation and arrange follow-up Provide counseling, pharmacologic therapy, and referral to a formal cessation program Smith SC Jr. et al. JACC 2006;47:2130-9 Cigarette Smoking Cessation Evidence: Risk of Non-fatal Myocardial Infarction* RR (95% Cl) Study Aberg, et al. 1983 0.67 (0.53-0.84) Herlitz, et al. 1995 0.99 (0.42-2.33) Johansson, et al. 1985 0.79 (0.46-1.37) Perkins, et al. 1985 3.87 (0.81-18.37) Sato, et al. 1992 0.10 (0.00-1.95) Sparrow, et al. 1978 0.76 (0.37-1.58) Vlietstra, et al. 1986 0.63 (0.51-0.78) Voors, et al. 1996 0.54 (0.29-1.01) 0.1 Ceased smoking 1.0 Continued smoking 10 *Includes those with known coronary heart disease Critchley JA et al. JAMA 2003;290:86-97 Tobacco Cessation Algorithm Ask and document tobacco use status Current User Recent Quitter (<6 months) Advise Provide a strong, personalized message Assess Readiness to quit in next 30 days Ready Not Ready Assist: Negotiate plan • STAR** • Discuss pharmacotherapy • Social support • Provide educational materials Prevent Relapse • Congratulate successes • Encourage • Discuss benefits experienced by patient • Address weight gain, negative mood, and lack of support Increase Motivation • Relevance to personal situation • Risks: short and long-term, environmental • Rewards: potential benefits of quitting • Roadblocks: identify barriers and solutions • Repetition: repeat motivational intervention • Reassess readiness to quit **STAR Arrange Follow-up to check plan or adjust meds • Call right before and after quit date • Weekly follow-up x 2 weeks, then monthly x 6 months • Ask about difficulties (withdrawal, depressed mood) • Build upon successes • Seek commitment to stay tobacco-free Set quit date Tell family, friends, and coworkers Anticipate challenges: withdrawal, breaks Remove tobacco from the house, car etc. The term “Psychosocial” broadly categorizes factors which are: • Psychologic – e.g, anxiety, depression • Psychosocial – e.g., work stress, discrimination, emotional support • Social-structural – e.g., socioeconomic status, social integration, neighborhood effects Screening for Psychosocial Risk: AHA Science Advisory on Depression (Lichtman J et al. Circulation 2008) • The recommendations, which are endorsed by the American Psychiatric Association, include: – early and repeated screening for depression in heart patients – the use of two questions to screen patients – if depression is suspected the remaining questions are asked (9 questions total) – coordinated follow-up for both heart disease and depressive symptoms in patients who have both. From: Lichtman J et al., Circulation 2008 My Life Check Assessment My Life Check Assessment My Life Check Assessment CONCLUSIONS 1) The increasing epidemic of obesity, diabetes, and inadequate attainment of CVD prevention goals necessitates improved efforts at therapeutic lifestyle management. 2) Therapeutic lifestyle changes are a crucial and necessary part of any cardiovascular risk reduction effort 3) Healthcare providers and facilities need to provide patients with adequate access to lifestyle experts, including registered dietitians, exercise specialists, and stress management personnel to address lifestyleassociated CVD risk in patients 4) Recent legislation allowing for wider reimbursement for lifestyle management, medical nutrition therapy in particular, should be a motivation for healthcare providers to ensure that these resources are available.