介绍了代谢紊乱和代谢综合征的行为干预方法：饮食控制、锻炼、控制体重。
Lifestyle Interventions: Dietary Therapy, Physical Activity, Weight Control Neil J. Stone, M.D.
2010
Now
Primary Prevention: Status and Goals in 2010
NCEP. Adult Treatment Panel III Report. 2001.
Moderate physical activity
Vegetable intake of >3 servings
Saturated fat <10% of calories
Primary Prevention: Status and Goals in 2010
Fruit >2 servings/d
Smoking cessation
Healthy weight
2010
Now
NCEP. Adult Treatment Panel III Report. 2001.
Primary Prevention: Crucial Opportunity to Reduce the Burden of CHD
Law MR et al. BMJ 1994;308:367-372.
Age 70
Reduction in risk in men with 10% reduction in total cholesterol (10 cohort studies)
Age 50
Age 40
Primary Prevention: Adverse Life Habit Changes
Atherogenic diet
Sedentary lifestyle
Obesity
Expert Panel. JAMA 2001;285:2486-2497.
Primary Prevention—Rx: Therapeutic Lifestyle Changes (TLC)
Therapeutic diet to lower LDL-C
Physically active on a daily basis
Weight control
Expert Panel. JAMA 2001;285:2486-2497.
Primary Prevention—Rx: TLC Measures to Lower LDL-C
Saturated fats (<7% total calories) and cholesterol (<200 mg/d)
Also therapeutic options:
Plant stanols/sterols (2 g/d)
Increased viscous fiber (10–25 g/d)
Expert Panel. JAMA 2001;285:2486-2497.
Total Fat...Why a range?
Primary emphasis is to reduce saturated fats
Total fat should range 25–30% for most cases
Those with metabolic syndrome
Avoid very high fat intakes
Avoid very low fat intake (low HDL-C, high TG)
Total fat intake can range from 30–35% if extra fat is unsaturated
May reduce some lipid and nonlipid risk factors
Clinical judgment required.?
Therapeutic Lifestyle Changes: Nutrient Composition of TLC Diet
* Lower trans fatty acids
** Emphasize complex sources
LDL-C Response to Step II Diet: beFIT
178 Women / 231 Men Dietary fat 25%; saturated fat 7.5%
LDL reduction ? High cholesterol only: –7.6 to 8.8%
LDL reduction ? Combined hyperlipidemia: –8.1%
Walden CE et al. Arterioscler Thromb Vasc Biol 1997;17:375-382.
DELTA I Dietary Trial
Subjects: age 22 to 67
Different groups of subjects:
White, black
Women: younger and postmenopausal
Men: younger, older
AAD
Low Sat
Results:
Compared to average American diet, when saturated fat fell from 15% to 6.1%, LDL-C fell by 11%
Negative aspects:
HDL-C fell from 52.2 to 46.2
Lp(a) rose from 15.5 to 18.2
Ginsberg HN et al. Arterioscler Thromb Vasc Biol 1998;18:441-449.
Total Fat
Sat Fats
LDL
New Options to Lower LDL-C
Avoid
Trans fatty acids*
Add
Dietary fiber
Plant sterol/stanol ester margarines
Expert Panel. JAMA 2001;285:2486-2497.
* Keep trans fatty acids low
Trans Fatty Acids (TFA)
TFA more densely packed than cis forms
Usual intake: only 2–3% of energy
If consumed in high amounts: ? LDL-C; ? HDL-C
Examples of TFA Stick margarine, cookies, biscuits, white bread
Lichtenstein AH et al. N Engl J Med 1999;340:1933-1940
Conclusion: Consume products low in saturated and TFA
Plant Sterol/Stanol Esters
Sterols are essential components of cell membranes
Cholesterol exclusively an animal sterol
We ingest almost as much plant sterols as we do dietary cholesterol
Stanols absorbed even less well
Plant sterols/stanols lower cholesterol
Interfere with micellar absorption of cholesterol
No malabsorption of fat
Law MR et al. BMJ 2000;320:861-864.
Plant Sterol/Stanol Esters
If 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:
Age LDL-C reduced by:
50–59 21 mg/dl or 0.54 mmol/l
40–49 17 mg/dl or 0.43 mmol/l
30–39 13 mg/dl or 0.33 mmol/l
Law MR et al. BMJ 2000;320:861-864.
Esterification of Stanols
Plant Stanol
Crystalline powder
Restricted fat solubility
Melting range 140–150oC
R C -
= O
3
5
6
O
3
5
6
HO
17
Esterification
Fat-Soluble Plant Stanol
Treatment with Stanol Ester Margarine
-2
Cholesterol (mg/dl)
Study Period (mo)
2
4
8
10
Miettinen TA et al. N Engl J Med 1995;333:1308-1312.
?1995 Massachusetts Medical Society. All rights reserved.
0
12
14
6
Sitostanol-ester margarine
Plant Sterols/Stanols: Efficacy in Lowering LDL-C
Dose: Maximum is 2 g/d
Meta-analysis results:
LDL-C lowering about 9–13%
Lowering greater in elderly
Additive to statin therapy
Used in various population groups
Well-tolerated
May decrease LDL-C adjusted carotenoids
Law M et al. BMJ 2000;320:861-864.
Lichtenstein AH et al. Circulation 201;103:1177-1179
Dietary Adjuncts
TLC for patients with LDL-C = 160
Walden CE et al. Arterioscler 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.
The Spectrum of CHD Risk
Expert Panel. JAMA 2001;285:2486-2497.
“More higher risk patients brought into the algorithm”
Metabolic
Syndrome
Elevated
LDL-C
Glucose ?110–125
Abdominal Obesity
? HDL-C
? BP
TG ?150
The Metabolic Syndrome
Constellation of major risk factors, life-habit risk factors and emerging risk factors
Over-represented among populations with CHD
Clue is distinctive body-type with increased abdominal circumference (although some leaner men and women with abdominal obesity without increased waist)
Metabolic Syndrome as a Secondary Goal after LDL-C
Expert Panel. JAMA 2001;285:2486-2497.
* Men: >40 in (102 cm); women >35 in (88 cm)
Metabolic Syndrome as a Secondary Goal after LDL-C
Expert Panel. JAMA 2001;285:2486-2497.
Circ. = circumference measured at level of the iliac spine
Clustering of Risk Factors Incorporated into the Metabolic Syndrome
Includes risk factors not routinely measured
Insulin resistance
Small dense LDL
Endothelial dysfunction
Abnormal sympathetic nervous activity
Prothrombotic markers—PAI-1, fibrinogen
Proinflammatory markers such as CRP
Does Treating the Metabolic Syndrome Make a Difference? Finnish Diabetes Prevention Study
Design
522 middle-aged overweight (BMI 31)
172 men and 350 women
Mean duration 3.2 years
Intervention Group: Individualized counseling
Reducing weight, total intake of fat and saturated fat
Increasing uptake of fiber, physical activity
Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.
Treating the Metabolic Syndrome
Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.
Benefit of Treating the Metabolic Syndrome
Tuomilehto J et al. N Engl J Med 2001;344:1343-1350.
Intervention
Control
After 4 years — risk of diabetes reduced by 58%
11%
23%
(6–15 CI)
(17–29 CI)
% with Diabetes
Goals of Weight Loss
1. Reduce body weight in the short term
2. Maintain a lower body weight for the long term
3. Prevent further weight gain — minimum goal
Obesity Education Initiative. Clinical Guidelines on the Identification, Evaluation