行为干预：饮食控制、锻炼、控制体重课件（PPT 46页）.ppt

1、Slide SourceLipidsOnlinewww.lipidsonline.orgSlide SourceLipidsOnlinewww.lipidsonline.org0%20%40%60%80%NCEP. Adult Treatment Panel III Report. 2001. Slide SourceLipidsOnlinewww.lipidsonline.org0%20%40%60%80%NCEP. Adult Treatment Panel III Report. 2001. Slide SourceLipidsOnlinewww.lipidsonline.org-60%

2、-40%-20%0%Law MR et al. BMJ 1994;308:367-372.Slide SourceLipidsOnlinewww.lipidsonline.orgnAtherogenic dietnSedentary lifestylenObesityExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgnTherapeutic diet to lower LDL-CnPhysically active on a daily basisnWeight controlEx

3、pert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgnSaturated fats (7% total calories) and cholesterol (200 mg/d)nAlso therapeutic options: Plant stanols/sterols (2 g/d) Increased viscous fiber (1025 g/d)Expert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.l

4、ipidsonline.orgnPrimary emphasis is to reduce saturated fats nTotal fat should range 2530% for most casesnThose with metabolic syndromenAvoid very high fat intakesnAvoid very low fat intake (low HDL-C, high TG)nTotal fat intake can range from 3035% if extra fat is unsaturatednMay reduce some lipid a

5、nd nonlipid risk factorsnClinical judgment required. Slide SourceLipidsOnlinewww.lipidsonline.orgSlide SourceLipidsOnlinewww.lipidsonline.orgn178 Women / 231 MenDietary fat 25%; saturated fat 7.5%nLDL reduction High cholesterol only: 7.6 to 8.8%nLDL reduction Combined hyperlipidemia:8.1%Walden CE et

6、 al. Arterioscler Thromb Vasc Biol 1997;17:375-382.Slide SourceLipidsOnlinewww.lipidsonline.org age 22 to 67nDifferent groups of subjects:nWhite, blacknWomen: younger and postmenopausalnMen: younger, older-20%-10%0%10%20%30%40%nCompared to average American diet, when saturated fat fell from 15% to 6

7、.1%, LDL-C fell by 11%nHDL-C fell from 52.2 to 46.2nLp(a) rose from 15.5 to 18.2Ginsberg HN et al. Arterioscler Thromb Vasc Biol 1998;18:441-449.Total FatSat FatsLDLSlide SourceLipidsOnlinewww.lipidsonline.orgnAvoidnTrans fatty acids*nAddnDietary fibernPlant sterol/stanol ester margarinesExpert Pane

8、l. JAMA 2001;285:2486-2497.* Keep trans fatty acids lowSlide SourceLipidsOnlinewww.lipidsonline.orgnTFA more densely packed than cis formsnUsual intake: only 23% of energynIf consumed in high amounts: LDL-C; HDL-CnExamples of TFAStick margarine, cookies, biscuits, white breadLichtenstein AH et al. N

9、 Engl J Med 1999;340:1933-1940Slide SourceLipidsOnlinewww.lipidsonline.orgnSterols are essential components of cell membranesnCholesterol exclusively an animal sterolnWe ingest almost as much plant sterols as we do dietary cholesterolnStanols absorbed even less wellnPlant sterols/stanols lower chole

10、sterolnInterfere with micellar absorption of cholesterolnNo malabsorption of fatLaw MR et al. BMJ 2000;320:861-864.Slide SourceLipidsOnlinewww.lipidsonline.orgnIf 2 g of plant sterol or stanol is added to average daily portion of margarine, it has variable effect on LDL-C by age group:n Age LDL-C re

11、duced by: 5059 21 mg/dl or 0.54 mmol/l 4049 17 mg/dl or 0.43 mmol/l 3039 13 mg/dl or 0.33 mmol/lLaw MR et al. BMJ 2000;320:861-864.Slide SourceLipidsOnlinewww.lipidsonline.orgPlant StanolnCrystalline powdernRestricted fat solubilitynMelting range 140150oCR C - = OOHOSlide SourceLipidsOnlinewww.lipid

12、sonline.org200210220230240250Cholesterol (mg/dl)Miettinen TA et al. N Engl J Med 1995;333:1308-1312.1995 Massachusetts Medical Society. All rights reserved.Slide SourceLipidsOnlinewww.lipidsonline.orgnDose: Maximum is 2 g/dnMeta-analysis results:nLDL-C lowering about 913%nLowering greater in elderly

13、nAdditive to statin therapynUsed in various population groupsnWell-toleratednMay decrease LDL-C adjusted carotenoidsLaw M et al. BMJ 2000;320:861-864.Lichtenstein AH et al. Circulation 201;103:1177-1179Slide SourceLipidsOnlinewww.lipidsonline.orgnTLC for patients with LDL-C = 160Walden CE et al. Art

14、erioscler Thromb Vasc Biol 1997;17:375-382.Jenkins DJ et al. Curr Opin Lipidol 2000;11:49-56.Cato N. Stanol meta-analysis. Personal communication, 2000.Slide SourceLipidsOnlinewww.lipidsonline.orgExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgnConstellation of majo

15、r risk factors, life-habit risk factors and emerging risk factorsnOver-represented among populations with CHDnClue is distinctive body-type with increased abdominal circumference (although some leaner men and women with abdominal obesity without increased waist)Slide SourceLipidsOnlinewww.lipidsonli

16、ne.orgExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgnIncludes risk factors not routinely measurednInsulin resistancenSmall dense LDLnEndothelial dysfunctionnAbnormal sympathetic nerv

17、ous activitynProthrombotic markersPAI-1, fibrinogennProinflammatory markers such as CRPSlide SourceLipidsOnlinewww.lipidsonline.orgnDesignn522 middle-aged overweight (BMI 31)n172 men and 350 womennMean duration 3.2 yearsnIntervention Group: Individualized counselingnReducing weight, total intake of

18、fat and saturated fatnIncreasing uptake of fiber, physical activityTuomilehto J et al. N Engl J Med 2001;344:1343-1350.Slide SourceLipidsOnlinewww.lipidsonline.orgTuomilehto J et al. N Engl J Med 2001;344:1343-1350.Slide SourceLipidsOnlinewww.lipidsonline.orgTuomilehto J et al. N Engl J Med 2001;344

19、:1343-1350.0%5%10%15%20%25%Slide SourceLipidsOnlinewww.lipidsonline.org1. Reduce body weight in the short term2. Maintain a lower body weight for the long term3. Prevent further weight gain minimum goalObesity Education Initiative. Clinical Guidelines on the Identification, Evaluation and Treatment

20、of Overweight and Obesity in Adults: the Evidence Report. Bethesda, Md.: NIH, 1998Slide SourceLipidsOnlinewww.lipidsonline.org1. Rate of weight lossn10% reduction in body weight in 6 months of therapynRate is 12 lbs per weekSlide SourceLipidsOnlinewww.lipidsonline.org1. Include a moderate amount of

21、physical activity on most, if not all days of the week2. Additional health benefits can be derived from greater amounts of activity3. Emphasis is on amount not intensityU.S. Dept. of Health and Human Services. Physical Activity and Health:A Report of the Surgeon General. Atlanta, Ga: Centers for Dis

22、ease Control and Prevention, 1996.Slide SourceLipidsOnlinewww.lipidsonline.org1. Scheduled physical activity a. Walking, treadmill, jogging, walking dog b. Swimming, biking, volleyball2. Lifestyle physical activity a. Walk more stairs at work, walking for errands, parking farther away in parking lot

23、s b. Housework, gardening U.S. Dept. of Health and Human Services. Physical Activity and Health:A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, 1996.Slide SourceLipidsOnlinewww.lipidsonline.orgnReverse changes of insulin resistance and metabolic syndromenRai

24、se HDL-C (can see increase of 1.6 mg/dl from a 10-lb weight loss)Dattilo AM et al. Am J Clin Nutr 1992;56:320-328.Slide SourceLipidsOnlinewww.lipidsonline.org-8-7-6-5-4-3-2-10Higgins M et al. Acta Med Scand Suppl 1988;723:23-36.Slide SourceLipidsOnlinewww.lipidsonline.orgnMegavitamins (adverse effec

25、ts shown for supplements of beta-carotene, no convincing clinical trial benefit for vitamin E supplementation)nFishnPlant sources of omega-3 fatty acidsnFruits and vegetables Slide SourceLipidsOnlinewww.lipidsonline.orgnBeta CarotenenNo proof of benefit in 3 trialsnOne stopped prematurely (CARET)nVi

26、tamin EnNo proof of benefit in 2 large trialsnHOPE Trial Natural vitamin EnGISSI Prevention Synthetic vitamin EAlpha-Tocopherol, Beta-Carotene Cancer Prevention Study Group. N Engl J Med 1994;330:1029-1035. Hennekens CH et al. N Engl J Med1996;334:1145-1149. Omenn GS et al. N Engl J Med 1996;334:115

27、0-1155. HOPE Study Investigators. N Engl J Med 2000;342:154-160. GISSI-Prevenzione Investigators. Lancet 1999;354:447-455.Slide SourceLipidsOnlinewww.lipidsonline.orgnOmega-3 Fatty AcidsnDART: 29% reduction in deathnGISSI: Significant reduction of one of two combined endpointsn“Mediterranean Diet”nL

28、yon Trial: Multiple differences in diet; diet was low in animal, dairy fat, high in plant-based omega-3 fatty acids, fiberBurr ML et al. Lancet 1989;2:757-761. GISSI-Prevenzione Investigators.Lancet 1999;354:447-455. de Longeril M et al. Circulation 1999;99:779-785.Slide SourceLipidsOnlinewww.lipids

29、online.orgBurr ML et al. Lancet 1989;2:757-761. GISSI-Prevenzione Investigators.Lancet 1999;354:447-455. 0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%Slide SourceLipidsOnlinewww.lipidsonline.org708090100de Lorgeril M et al. Circulation 1999;99:779-785.1999 Lippincott Williams & Wilkins. % Without EventSlide

30、SourceLipidsOnlinewww.lipidsonline.orgde Lorgeril M et al. Circulation 1999;99:779-785.Slide SourceLipidsOnlinewww.lipidsonline.orgnStepwise approachnResourcesnClinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (download from web for palm-based m

31、aterial)nSurgeon Generals Report on Physical ActivitySlide SourceLipidsOnlinewww.lipidsonline.orgnEmphasize reduction in saturated fat and cholesterolnReduce animal/high fat dairynGet lower fat food if eats outnRegular physical activityExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlineww

32、w.lipidsonline.orgnEvaluate LDL-C responsenIntensify LDL-C lowering with dietary adjunctsnPlant stanols/sterolsnIncreased fiber intakeExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgnAt all stages of dietary therapy, physicians are encouraged to refer patients for:n

33、Medical nutrition therapynRegistered dietitians/other qualified nutritionistsExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgnEvaluate LDL-C responsenInitiate therapy for metabolic syndromenIntensify weight managementnPhysical activitynConsider drug Rx if LDL-C goal

34、 not achievedExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.orgnTherapeutic Lifestyle Changes can lower LDL-C so medication not required or increase not needednCan treat metabolic syndromenLowers TGnRaises HDL-CnReduces risk of diabetesnProvides overall healthful lifestyleExpert Panel. JAMA 2001;285:2486-2497.Slide SourceLipidsOnlinewww.lipidsonline.org