Download Integrating the New AHA/ACC Guidelines with

Integrating the New AHA/ACC Guidelines with Lifestyle Behaviors:
Real-World Application
Gretchen Benson, RD, CDE
Saturday, March 5, 2016
8:00 a.m. – 8:45 a.m.
Integrating the New AHA/ACC Guidelines with Lifestyle Behaviors: Real-World Application will
cover the 2013 American Heart Association/American College of Cardiology guidelines focused
on lifestyle modifications to reduce cardiovascular risk, overweight/obesity, assessment of
cardiovascular risk, as well as the management of blood cholesterol in adults. The guidelines
presented a significant shift in thinking for both providers and patients in terms of treating to risk
rather than specific targets.
The presentation aims to answer the question, ‘How do we, as professionals, make sense of all
the guidelines and make recommendations for our patients?’
a) Individualize
b) Help patients see that lifestyle matters
c) Help patients set realistic lifestyle goals
Ultimately the goal of the presentation is to provide real-world solutions for coaching patients.
References:
1. Eckel, R. H., Jakicic, J. M., Ard, J. D., de Jesus, J. M., Miller, N. H., Hubbard, V. S., ... &
Nonas, C. A. (2014). 2013 AHA/ACC guideline on lifestyle management to reduce
cardiovascular risk: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Journal of the American College of
Cardiology, 63(25_PA), 2960-2984.
2. VanWormer, J. J., Johnson, P. J., Pereira, R. F., Boucher, J. L., Britt, H. R., Stephens,
C. W., ... & Graham, K. J. (2012). The Heart of New Ulm Project: using communitybased cardiometabolic risk factor screenings in a rural population health improvement
initiative. Population Health Management,15(3), 135-143.
3. Benson, G. A., Sidebottom, A., VanWormer, J. J., Boucher, J. L., Stephens, C., &
Krikava, J. (2013). HeartBeat Connections: a rural community of solution for
cardiovascular health. The Journal of the American Board of Family Medicine, 26(3),
299-310.
4. Stone, N. J., Merz, C. N. B., ScM, F. A. C. C., Blum, F. C. B., McBride, F. P., Eckel, F. R.
H., ... & Shero, F. S. T. (2013). 2013 ACC/AHA guideline on the treatment of blood
cholesterol to reduce atherosclerotic cardiovascular risk in adults. Circulation. 129(25
SUPPL. 1)
5. James, P. A., Oparil, S., Carter, B. L., et al. (2014). 2014 evidence-based guideline for
the management of high blood pressure in adults: report from the panel members
appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507-520.
6. Miedema, M. D., Sidebottom, Abbey C., Sillah, A., Benson, G., Boucher, J., Knickelbine,
T., VanWormer, J.J. (2014). The Implications of the Recent American College of
Cardiology/American Heart Association Guidelines for the Treatment of Blood
Cholesterol on a Rural Community: The Heart of New Ulm Project. Poster session
presented at the American Heart Association Scientific Sessions, Chicago, IL.
7. American Diabetes Association. Cardiovascular disease and risk management. Sec. 8.
In Standards of Medical Care in Diabetes-2016. Diabetes Care 2016;39(Suppl. 1):S60–
S71.Jensen, M. D., Ryan, D. H., Apovian, C. M., Ard, J. D., Comuzzie, A. G., Donato, K.
A., & Loria, C. M. (2014). 2013 AHA/ACC/TOS guideline for the management of
overweight and obesity in adults. Circulation, 129(25 SUPPL. 1).
8. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics
(NCHS). (2009-2010) National Health and Nutrition Examination Survey Data.
Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention. http://wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx
Presenter Disclosure
Disclosed no conflict of interest.
Integrating the AHA/ACC
Guidelines with Lifestyle
Behaviors: Real-world Application
Gretchen Benson, RD, LD, CDE
Objectives
‣ Personalize nutrition and physical activity approaches for
individuals with diabetes.
‣ Individualize statin therapy recommendations for patients with
diabetes.
2013 AHA/ACC clinical practice
guidelines
1)
2)
3)
4)
Assessment of cardiovascular risk
Management of blood cholesterol in adults
Lifestyle modifications to reduce cardiovascular risk
Management of overweight and obesity in adults
‣ Identify strategies to help patients lower their blood pressure.
ASCVD Risk Estimator
2013 AHA/ACC Cholesterol Guideline for Statin Therapy
‣ Known clinical ASCVD
‣ Age < 75, high intensity (> 50% LDL lowering)
‣ Age > 75 , moderate intensity (30-50% LDL lowering)
‣ LDL > 190 mg/dl, age > 21
‣ High intensity
‣ Type 1 or 2 DM, age 40-75: Moderate intensity
‣ If Risk > 7.5 %, then high intensity
‣ No CAD or DM, age 40-75:
‣ Risk > 7.5%, moderate to high intensity
‣ Risk 5-7.5%, consider moderate intensity statin if LDL > 160 mg/dl, has family
history, CRP > 2, CAC > 300 or 75%, ABI < .9, or high lifetime risk.
What does this mean for our patients with diabetes?
Implications of the 2013 AHA/ACC Guidelines for the
Treatment of Blood Cholesterol in a Rural Community:
The Heart of New Ulm Project
‣Approximately 3 in 5 middle-age residents qualify for statin
therapy
‣ Only 2/3 of those individuals were taking a statin
‣ Infrequent use of high intensity statins
‣30% of residents found ineligible by the guidelines were
taking a statin  opportunity to decrease statin use in
those at low risk
American Diabetes Association. Cardiovascular disease and risk management. Sec. 8. In Standards of Medical
Care in Diabetes-2016. Diabetes Care 2016;39(Suppl. 1):S60–S71.
Challenges of the guidelines
1. Challenge for providers and patients to change thinking: treat
based on risk level rather than target LDL.
2. Challenge to get risk estimator into EMR.
3. Challenge to keep lifestyle behavior as a high priority.
Michael D Miedema MD, MPH1,2, Abbey C. Sidebottom MPH3, Arthur Sillah MPH3 Gretchen Benson BA1, Jackie Boucher MS1, Tom
Knickelbine MD2, Jeffrey J. VanWormer PhD4. Hearts Beat Back: The Heart of New Ulm Project is a collaborative partnership of Allina
Hospitals & Clinics, the Minneapolis Heart Institute Foundation, the New Ulm Medical Center and the city of New Ulm. The Circulation.
2014; 130: A15632 .
Lifestyle is essential
The cholesterol guidelines clearly state, "It must be emphasized
that lifestyle modification (i.e., adhering to a heart-healthy diet,
regular exercise habits, avoidance of tobacco products, and
maintenance of a healthy weight) remains a critical component
of health promotion and ASCVD risk reduction, both prior to
and in concert with the use of cholesterol-lowering drug
therapies."
Lifestyle Recommendations
Nutrition Recommendations
‣ Blood Pressure
‣ Emphasis on food patterns vs. individual
nutrients
‣ Nutrition
‣ DASH Diet
‣ Physical Activity
‣ Obesity
Lifestyle & JNC 8
Key Take-aways:
‣ Dietary Approaches to Stop Hypertension (DASH), AHA diet, or
the USDA Food Pattern
‣ More vegetables, fruit, low-fat dairy, poultry, fish, legumes, nontropical vegetable oils and nuts.
‣ Less sweets, sugar-sweetened beverages and red meats.
‣ Sodium reduction
Sodium Guidelines
Challenge:
• 9 out of 10 Americans consume too much.
• The average American consumes over 3400 mg/day.
• Most people don’t track their sodium.
‣ Positive reductions in blood pressure & LDL
‣ No impact on TG, HDL ↓
‣ Mediterranean Diet
‣ Positive reductions in blood pressure
‣ No consistent effect on lipids
Sodium Recommendation
AHA/ACC: Consume no more than 2400mg/day
 1500 mg/day is desirable
ADA & Dietary Guidelines: Reduce sodium to less than 2300 mg/day.
Top 10 Sodium Sources
1. Breads and rolls
2. Cold cuts and cured meats
3. Pizza
4. Poultry
5. Soups
6. Sandwiches
7. Cheese
8. Pasta dishes
9. Meat dishes
10.Snacks
First Step Sodium Reduction
Recommendation: Reduce by at least 1000 mg/day
Result: Reduces CVD events by 30%.
Real-world Solution
Divide daily sodium recommendation into # of meals and snacks
typically eaten each day.
‣ If patient reports eating 3 meals and 1 snack a day, recommend
<600 mg per meal/snack.
‣ Then look at some typically eaten foods and compare.
Compare sodium content:
1 cup canned green beans 800mg
1 cup frozen green beans = 4mg
Saturated Fat
AHA/ACC recommendation:
Aim for no more than 5-6% of calories from saturated fat.
Result: ↓LDL 11–13 mg/dL
Real-world solutions:
‣ Explain that the preference for salt is learned.
‣ Read labels, identify high sodium foods and find lower sodium options.
‣ Make lower sodium requests at restaurants: ask that salt not be added
and ask for foods without toppings or served on the side.
Saturated Fat – Conflicting Views
Dietary Guidelines for Americans recommendation: <10%
Saturated Fat
‣ Mediterranean pattern compared to minimal dietary advice resulted in
no consistent effect on plasma LDL–C, HDL–C, and TG1.
‣ Consuming healthful fats (polyunsaturated fats) instead of
saturated fat lowers the risk for CAD whereas replacing the
saturated fat with carbohydrates may increase the risk.
‣ PREDIMED Prevention Trial showed a 30% reduction in MI, stroke
and CV death on Mediterranean diet (9-10% calories from saturated
fat)2.
‣ Li and colleagues found type of carbohydrate plays a critical
role.
Challenge: Less than 12% of adults met the goal of less than 7%.
Real-world solution: Meet patients where they are at and help them
set realistic goals.
Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013
Estruch, Ramón, et al. "Primary prevention of cardiovascular disease with a Mediterranean diet." New England Journal of Medicine 368.14 (2013): 1279-1290.
‣ Replacing saturated fats with processed CHO  Ø CHD risk
‣ Replacing saturated fats with whole grains  ↓9% CHD risk
Replace saturated fats with polyunsaturated first, followed by
monounsaturated and whole grains.
Jakobsen MU, Dethlefsen C, Joensen AM, et al. Intake of carbohydrates compared with intake of saturated fatty acids and risk of myocardial
infarction : importance of the glycemic index 1 – 3. Am J Clin Nutr. 2010
Li Y, Hruby A, Bernstein AM, et al. Saturated Fats Compared With Unsaturated Fats and Sources of Carbohydrates in Relation to Risk
of Coronary Heart Disease. J Am Coll Cardiol. 2015;66(14):1538-1548.
Real-world solution
‣ ↑ foods with natural oils, such as seafood, nuts/seeds in place
of some meat and poultry
‣ Use vegetable oils in place of solid fats (butter, lard, stick
margarine, shortening) for food preparation
‣ In mixed dishes, substitute more vegetables in place of higher
saturated fat items like meat or cheese
What We Eat in America (WWEIA) Food Category analyses for the 2015 Dietary
Guidelines Advisory Committee. Estimates based on day 1 dietary recalls from WWEIA,
NHANES 2009-2010.
Trans Fat
Recommendation: Reduce percent of calories from trans fat.
Result: lowers LDL with little or no impact to HDL & TG
Challenge: Nutrition Facts label may list 0 trans fat but the food
may <.5 gm/serving.
Real-world Solution: avoid foods with partially hydrogenated oil in
the ingredient list.
Physical Activity
2013 AHA/ACC Lifestyle Guideline
Recommendation: Do aerobic activity 3-4 times a week for 40 minutes
at moderate to vigorous intensity.
Results: Lowers LDL, non-HDL and blood pressure.
Real-world solutions:
‣ Aim for a minimum of 10 minute bouts.
‣ Make it enjoyable.
‣ Change it up.
‣ Exercise with a friend.
‣ Use a tracker or app to monitor physical activity.
Healthy Dietary Patterns
‣ Focus on overall eating patterns rather than individual nutrients, taking
into consideration personal and cultural preferences.
‣ Eat more fruits, vegetables, legumes, nuts, whole grains, low-fat dairy,
poultry and fish.
‣ Limit sweets, sugar-sweetened beverages, red meats, and processed
foods.
‣ Nourish the body throughout the day when energy is most needed.
‣ Adapt calorie level to personal needs.
Physical Activity
2016 Standards of Medical Care in Diabetes
‣ Aerobic exercise 150 min/week of moderate-intensity aerobic
physical activity (50–70% of maximum heart rate) spread over 3
days/week with no more than 2 consecutive days without exercise.
‣ Limit the amount of time they spend being sedentary-break up time
(> 90 min.) spent sitting.
‣ Resistance training twice a week unless contraindicated.
Obesity Guideline Highlights
‣ Monitor BMI and assess readiness to change.
‣ Emphasize sustained weight loss of 3-5% to produce clinically
meaningful health benefits.
‣ Consume fewer calories (500 less/day) and increase physical
activity based personal preferences.
‣ Exercise 2 ½ hours per week
‣ Accountability: ≥6 month intervention and 1 year maintenance.
‣ Consider prescribing pharmacotherapy or bariatric surgery.
Making Sense of the AHA/ACC Guidelines
‣ Spirit of the guidelines vs letter of the guidelines.
‣ Make it matter for patients.
‣ Assist patient in finding internal motivation by asking – What is
most important to you?
‣ Individualize! Individualize! Individualize!
Questions?
Questions?
Real-world Solution-5 A’s
Ask - Would it be okay if we discussed your weight?
Assess - On a scale of 1-10, with 10 being 100% ready to take
action, how ready are you to lose weight?
Advise - Emphasize personal risks and the benefits of 5% to
10% weight loss (10-15 lb.)
Agree on SMART goals (specific, measurable, achievable,
rewarding, and timely.)
Assist - Arrange follow-up or refer to credible resources and
programs.
Acknowledgements
‣ Joy Hayes, MS, RD, CDE
‣ Michael Miedema, MD
‣ Hearts Beat Back: The Heart of New Ulm Project
heartsbeatback.org