Risk Factors: Measure and Modify Nina Radford MD Cardiovascular Medicine Department Director, Clinic Research Cooper Clinic, Dallas Texas

Health Screening Values Total Cholesterol HDL, High Density Lipoprotein LDL, Low Density Lipoprotein Triglycerides Glucose Blood Pressure BMI, Body Mass Index Waist Circumference

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209

Chart 2-6. Prevalence estimates of meeting at least 5 criteria for Ideal Cardiovascular Health, US adults (age-standardized), overall and by sex and race, and US children (unadjusted), by sex, National Health and Nutrition Examination Survey (NHANES) 2005–2006 (baseline available data as of January 1, 2010).

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209

Basics of the Cholesterol Profile Total Chol. = LDL + HDL + VLDL LDL: Low Density Lipoprotein HDL: High Density Lipoprotein VLDL: Very Low Density Lipoprotein

LDL Cholesterol Elevated LDL is a risk factor for heart disease and stroke. An LDL level > 160 mg/dL is high risk. An LDL level mg/dL is moderate risk An LDL level <130 mg/dL is lower risk. An LDL level <100 mg/dL is optimal.

HDL Cholesterol An HDL level < 40 mg/dL in adults is considered low and is a risk factor for HD and stroke. An HDL level > 60 mg/dL is considered protective against heart disease.

Triglycerides (TG) TG are the chemical form in which most fat exists in food as well as in the body. They're also present in blood plasma and, in association with cholesterol, form the plasma lipids. TG in plasma are derived from fats eaten in foods or made in the body from other energy sources like carbohydrates. Calories ingested in a meal and not used immediately by tissues are converted to TG and transported to fat cells to be stored. Hormones regulate the release of TG from fat tissue so they meet the body's needs for energy between meals.

Triglycerides: The National Cholesterol Education Program guidelines for triglycerides are: NormalLess than 150 (125) mg/dL Borderline-high150 to 199 mg/dL High200 to 499 mg/dL Very high500 mg/dL or higher These are based on fasting triglyceride levels.

The Lipid Profile: Modify Diet. Exercise. Medication.

Cholesterol Metabolism: Genes and Environment Cholesterol in our blood comes from two sources: external (the diet) and internal (production by the liver). Lifestyle is always important even if medications are needed. Sometimes the family history trumps even the best lifestyle efforts.

Continue On The Road To A Healthy Heart Reduce cholesterol in the diet Plant stanols/sterols Soluble fiber Weight loss

Where is the Cholesterol in My Food? Found ONLY in food of animal origin and NEVER in foods of plant origin, even if they contain fat – Full-fat dairy products – Fatty meats – Egg yolks – Organ meats – Animal fats – lard, butter – Shellfish

Stanols/Sterols* 2 grams per day Promise activ Benecol Cholest Off * May enhance LDL lowering by an average of 10%

Soluble Fiber Oats: 3 grams per day* 1.5 cups cooked oatmeal/day or 3 plain packets instant Psyllium: 7 grams per day* Metamucil (1Tbsp. Sugar-free/day) Konsyl (2 heaping tsp./day) Beans, fruits, vegetables * Supported by research to lower LDL 3-7%.

Blood Pressure <80 and <120Normal 80 – 89 or 120 – 139 Prehypertension 90 – 99 or 140 – 159 Stage 1 Hypertension >100 or >160 Stage 2 Hypertension Diastolic BP Systolic BP BP Classification JNC VII,

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209  age,  ethnicity,  family history of hypertension,  genetic factors,  greater weight,  lower physical activity,  tobacco use,  psychosocial stressors,  sleep apnea,  dietary factors (including dietary fats, higher sodium intake, lower potassium intake)  excessive alcohol intake, Risk Factors for High Blood Pressure

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 High Blood Pressure is common! Age-adjusted prevalence trends for high blood pressure in adults.

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 Hypertension is associated with shorter overall life expectancy, shorter life expectancy free of CVD, and more years lived with CVD. — Total life expectancy was 5.1 years longer for normotensive men and 4.9 years longer for normotensive women than for hypertensives of the same sex at 50 years of age. — Compared with hypertensive men at 50 years of age, men with untreated BP 140/90 mm Hg survived on average 7.2 years longer without CVD and spent 2.1 fewer years of life with CVD. Similar results wereobserved for women. Why Prevent or Treat High Blood Pressure?

Lifestyle Modification and BP Modification SBP reduction (range) Weight reduction 5 – 20 mmHg/10 kg weight loss DASH eating plan 8 – 14 mmHg Sodium reduction 2 – 8 mmHg Physical activity 4 – 9 mmHg Moderation of alcohol 2 – 4 mmHg

Normal level< 100 mg/dL Impaired fasting glucose (prediabetes): mg/dL Diabetes > 126 mg/dL Glucose (blood sugar)

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 It is estimated that 18,300,000 Americans > 20 years of age have physician diagnosed DM. An additional 7,100,000 adults have undiagnosed DM and about 81,500,000 adults have prediabetes. The prevalence of prediabetes in US adults is nearly 37%.

Diabetes Trends Among US Adults, 1994, 2000 and % CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 The increasing prevalence of obesity is driving an increased incidence of type 2 DM. There has been a doubling in the incidence of DM over the past 30 years, most dramatically during the 1990s and primarily among individuals with a BMI > 30 kg/m 2.

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 Chart Age-adjusted prevalence of physician-diagnosed diabetes mellitus in adults ≥ 20 years of age by race/ethnicity and sex (National Health and Nutrition Examination Survey: 2005–2008). NH indicates non-Hispanic. Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute.

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 — At least 65% of people with diabetes die of some form of heart disease or stroke. — Heart Disease death rates among adults with diabetes are 2 to 4 times higher than the rates for adults without diabetes. Why Prevent Diabetes?

Diabetes Prevention Program Study  25 yrs old, overweight, glucose Lifestyle vs medication vs nothing Lifestyle: – lose  7% weight, – calories day, low fat, –  150 min activity per week Preventing Diabetes The DPP Research Group, NEJM 346: , 2002,

Placebo – nothing new Metformin – Drug Lifestyle – weight loss (8 lbs),diet,exercise Chance of Developing Diabetes Risk reduction 31% by drug 58% by lifestyle The DPP Research Group, NEJM 346: , 2002

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 Obesity is a strong predictor of sleep-disordered breathing, itself strongly associated with the development of CVD, as well as with myriad other health conditions, including numerous cancers, nonalcoholic fatty liver disease, gallbladder disease, musculoskeletal disorders, and reproductive abnormalities. Recent calculations suggest that the gains in life expectancy from smoking cessation are beginning to be outweighed by the loss of life expectancy from obesity. Why avoid unhealthy weight gain?

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 Metabolic syndrome refers to a cluster of risk factors for CVD and type 2 DM. Metabolic syndrome is diagnosed when ≥ 3 of the following 5 risk factors are present: — Fasting plasma glucose ≥ 100 mg/dL or undergoing drug treatment for elevated glucose. — HDL cholesterol < 40 mg/dL in men or < 50 mg/dL in women or undergoing drug treatment for reduced HDL cholesterol. — Triglycerides ≥ 150 mg/dL or undergoing drug treatment for elevated triglycerides. — Waist circumference ≥ 40 in men or ≥ 35 in women in the United States. — BP ≥ 130 mm Hg systolic or ≥ 85 mm Hg diastolic or undergoing drug treatment for hypertension or antihypertensive drug treatment in a patient with a history of hypertension.

Components of Fitness Cardiovascular Strength Flexibility

Heart Disease and Stroke Statistics 2011 Update. Circulation 2011;123;e18-e209 Chart Prevalence of regular leisure-time physical activity among adults ≥18 years of age by race/ethnicity and sex (National Health Interview Survey: 2009). Percentages are age- adjusted. “Regular leisure-time physical activity” was defined as 3 sessions per week of vigorous activity lasting at least 20 minutes or 5 sessions per week of light or moderate activity lasting at least 30 minutes. NH indicates non-Hispanic. Data derived from Pleis et al.7

Physical Activity: Get it where ever you can find it