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Keys to a Better, Longer Life
Laurence S. Sperling, M.D., FACC, FACP,FAHAProfessor of Medicine (Cardiology)
Professor of Global HealthDirector- Center for Heart Disease Prevention
Emory University President , American Society for Preventive Cardiology
Chairman of ACC Cardiometabolic Working GroupChairman of The U.S. National Cardiometabolic Alliance
About the Presenter
Laurence S. Sperling, MD, FACC,FACP,FAHAProfessor of MedicineDirector of The Center for Heart Disease PreventionEmory University School of MedicineAtlanta, GA
DISCLOSURESNo potential conflicts related to this presentation
Living better and longer?
• David Murdock-87 (now 92) yo billionaire-dropped out of school at 14 / homeless at 22-acquired Dole 1985
• Wants to live to 125• Eats abundance of
fruits/veg, seafood, egg whites, beans and nuts
• Brisk walks on treadmill ; light wts 3X/wk
NY Times Magazine, 3/6/11
Walking the Talk: “L” for longevity
• Dole – world’s largest producer of fruits and vegetables
• Headquarter’s , Westlake Village, CA– Subsidized cafeteria / healthy food choices– Free access to company gym / personal training
subsidized• On site Four Seasons Hotel
– The California Health and Longevity Institute– Room service menus with “L-shaped” symbols
designating dishes that promote longevity
NY Times Magazine, March 16,2011
Atlanta Journal ConstitutionMarch 17, 2011
• Goals?–Longer?–Better?–Both?
Focus on CV Health: The Health/Disease ContinuumJACC 2015;66:960-7
NormalLow risk
NormalHigh risk
Predisease
Earlydisease
Latedisease
Health Promotion & Disease Prevention
Contemporary Medicine
HEALTH
DISEASE
Optimal Health ??
Our 2020 Impact Goal
“By 2020, to improve the cardiovascular health of all
Americans by 20 % while reducing deaths from
cardiovascular diseases and stroke by 20 %.”
<100100-125≥126Children12 - 19 yo
<100100-125, or DM treated to goal≥126Fasting Glucose - Adults
<90th %ile90th - 95th %ile or SBP ≥120 or DBP ≥80>95th %ileChildren 8 - 19 yo
<120/<80SBP 120-139 or DBP 80-89 or treated to goal
SBP ≥140 or DBP ≥90Blood Pressure - Adults
<170170-199≥200Children 8-19 yo<200200-239 or treated to goal≥240Total Cholesterol - Adults
5-8 Factors2-4 Factors0-1 Factors Children 5-19
5-8 Factors2-4 Factors0-1 Factors Healthy Diet Score - Adults
150+ mins/week moderate or 60+ mins/wk vigorous
1-149 mins/wk moderate or 1-59 mins/wk vigorousNoneChildren 12-19 yo
150+ mins/week moderate or 60+ mins/wk vigorous
1-149 mins/wk moderate or 1-59 mins/wk vigorousNonePhysical Activity - Adults
<85th %ile85th - 95th %ile>95th %ileChildren 8-19 yo
<2525-29.9≥30Body Mass Index - Adults
NeverEver, ExperimentingIn Prior 30 DaysChildren 12-19 yo
Never or Quit ≥12 monthsFormer, <12 monthsYesCurrent Smoking - Adults
Optimal HealthIntermediate HealthPoor HealthMetric
CV Health Metric Definitions
Physiologic Variables :Prehistoric vs. Current Western Societies
<5%1.20.6% decline/yr in BMD in postmenopausal women
<10%2722BMI, age 60
<1%230 mg/dL120 mg/dLSerum cholesterol, age 60
<5%80 mm Hg70 mm HgDiastolic BP, age 60
<1%145 mm Hg110 mm HgSystolic BP, age 60
Current Western Pop. < Prehistoric AverageWestern
SocietiesPrehistoric
Physiologic Variable
Law MR and Wald NJ. BMJ. 2002;324:1570-1576.
Prevalence of Ideal CV Health / Relationship with CVD Incidence
• 12,744 from ARIC (’87-’89)• 20 yr incidence of CVD• 0.1% had ideal CV Health !• Event rate / ideal health metrics
– 0 7– 3.9 per 1000 6– 37.1 per 1000 0
Folsom, AR et al. JACC 2011;57:1690-6
Status of CV Health Across America
• 2009 BRFSS, > 350K,self report
• 3.3% with ideal CV health (A) ;– 1.2% Oklahoma– 6.9% DC
• 9.9% with poor CV health (B: 0-2 metrics)
• Large disparities by age, gender, education, ethnicity
Fang J, et al. J Am Heart Assoc 2012;DOI.1161
Social Determinants of Health: Zip Code vs. Genetic Code?
• Health varies at a very LOCAL level
• Life expectancy in Atlanta
Keys to a Better and Longer Life
• No tobacco• Ideal wt / nutrition• Regular activity• Alcohol in moderation ?
15
Causes # (%) in 1990 # (%) in 2000
Tobacco 400,000 (19) 435,000 (18)
Poor diet and physical activity (obesity) 300,000 (14) 400,000 (17)
Alcohol consumption 100,000 (5) 85,000 (4)
Microbial agents 90,000 (4) 75,000 (3)
Toxic agents 60,000 (3) 55,000 (2)
Motor vehicle accidents 25,000 (1) 43,000 (2)
Firearms 35,000 (2) 29,000 (1)
Sexual behavior 30,000 (1) 20,000 (<1)
Illicit drug use 20,000 (<1) 17,000 (<1)
Total 1,060,000 (50) 1,159,000 (48%)
Mokdad AH et al. JAMA 2004;291:1238-1245
Tobacco Use: Most Preventable Cause of Death
Most preventable causes of death in the U.S. in 1990 and 2000
16
Tobacco Cessation Recommendations
Complete cessation
No environmental tobacco smoke exposure
Goals 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
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Smith SC Jr. et al. JACC 2006;47:2130-9
Scientific American 2004;14(3):20
Ideal BMI / Nutrition - “speedo” sign
PREVALENCE OF METABOLIC SYNDROME
• NHANES III - metabolic syndrome– 24% of men; 23.4% of
women– 42% of individuals > age 60
• Underscores need to control obesity epidemic /improve physical activity
» Ford E et al, JAMA.2002;287:356-359.
0
10
20
30
40
50
60
Men Women
Pe
rce
nt
TotalWhitesBlacksHispanics
Narayan et al., JAMA, 2003
Lifetime Risk of Diabetes from Birth According to Sex and Race/Ethnicity, USA
Diabetes: the growing global burden
1Adapted from IDF. E-Atlas. Available at: www.eatlas.idf.org (accessed 05.03.07).2Diabetes Atlas, third edition © International Diabetes Federation, 2006.
IDF:2
• Diabetes currently affects 246 million people worldwide• It is expected to affect 380 million by 2025
1Prevalence estimates of diabetes mellitus 2025202520252025
No data
< 2%
2–5%
5–8%
8–11%
11–14%
14–17%
> 17%
Endothelial Dysfunction, Oxidative Stress and Inflammation in Obesity
Van Gaal LF, et al. Nature 2006; 444:865-880
22
Prevalence of Obesity in U.S. Adults
1991 1996
2006
No Data <10% 10–14% 15–19% 20–24% 25-29% >30%
CDC Overweight and Obesity
Percentage of State Obese (BMI > 30)
2008
“SUPER SIZE ME”Morgan Spurlock
• Documentary- eating at McDonald’s 1 month ; reduced physical activity
• Up to 5000 calories/day• BP increased from 120/80
to 150/100• TC increased from 165 to
230• Weight increased 24
pounds
Supersizing: Hidden Toll on Pocketbook
• Single fast food meal– 927 to 1324 kcal (extra $0.67)– 73% more calories / 17% price– 36 grams adipose
• Calculated costs (1 yr) > short-term value– Increase auto fuel, maintenance food, health
care costs by $3.10-$7.72
• Close RN and Schoeller DA. Jl Am Coll Nutrition 2006;25(3):203-209
Ban on Sugar-Sweetened Beverages ?
Mayor Bloomberg proposes Prohibit sugary beverage
sales > 16 oz.Significant debate and
pushback…… NY Times 5/31/12
Nov. 4, 2014Berkeley, CA1s t U.S. city to approve
penny-per-once tax
Obesity Epidemic
• Obesity In the US (BMI ≥30)– > 30% of population
• Obesity Worldwide– One Billion Overwt
(BMI ≥ 25)– 300 Million Obese
Mokdad AH et al. JAMA 1999;282:1519-22.
Serdula MK et al. JAMA 1999;282:1353-58.
World Health Organization
28
Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht2 (in)
The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH/NHLBI/NAASO. October, 2000. NIH publication No. 00-4084.
*Measurement of waist circumference is most helpful in this category
Weight Category BMI (kg/m2)
Normal 18.5-24.9
Overweight* 25.0-29.9
Obesity (Class I) 30.0-34.9
Obesity (Class II) 35.0-39.9
Obesity (Class III) >40.0
BMI=Body mass index
Overweight and Obese States: Definition Using the Body Mass Index
29Whitaker RC et al. NEJM 1997;337:869-873
BMI=Body mass index
Adul
t Obe
sity
at
Age
21-
29 Y
ears
(%)
Age of Child (Yrs)
Body Mass Index: Risk of Developing Obesity in Adulthood
Eat less at dinner and you will live to 90
Ancient Chinese Proverb
Caloric restriction and Longevity
• Rodent model: 30-60% reduction calories early in life increases max life span by 30-60%
• Rhesus monkey: 30% caloric reduction– 20 yr f/u with ? (3 fold) survival advantage (Wisconsin
PRC)• Caloric restriction in humans (with adequate
nutrient intake) – beneficial metabolic, hormonal, functional changes
Fontana L and Klein S, JAMA 2007;297:986-994Coleman RJ, et al. Science 2009
Nature publication( online- August 29, 2012)
• Caloric Restriction in (121) Rhesus Monkeys
• 25 yr study • National Institute
of Aging………
Mattison JA, et al. Nature 2012
Impact of caloric restriction on health and survival of Rhesus monkeys
Mattison JA, et al. Nature 2012
Diets and CVD
“Good nutrition is essential. The problem is we still don’t know what to eat.”
J. Willis HurstNotes from a Chairman1987
Problem with “Diets”
• Semantic confusion– “Diet” from Latin diaeta…..a way of life
• Fad Diets– >95% who lose wt on diet gain it back– Many focus on composition – restriction/complexity predict failure
• McGuire M et al. Journal Consulting and Clinical Psych 1999 67;2:177-85.
Mediterranean Diet….Key Component?
Hu FB. N Engl J Med. 2003;348:2595-2596.
37Trichopoulou A et al. NEJM 2003;348:2595-6
Variable # of Deaths/ # of Participants
Fully Adjusted Hazard Ratio (95% CI)
Death from any cause
275/22,043 0.75 (0.64-0.87)
Death from CHD
54/22,043 0.67 (0.47-0.94)
Death from cancer
97/22,043 0.76 (0.59-0.98)
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
High adherence to a Mediterranean diet is associated with a reduction in different causes of death
Primary Prevention of Cardiovascular Diseasewith a Mediterranean Diet
Estruch R et al. N Engl J Med 2013;368:1279-1290.
Diets and CVD: The evidence ?• Low-Carbohydrate Diets
– Short-term Wt loss; long-term effects unknown• Glycemic Index / Diets
- guide to decreased consumption of energy dense carbs• Very-Low Fat Diets
– Possible decrease in CV events; concerns about sustainability
• Mediterranean Diet– Primary and secondary prevention; reduction in metabolic
syndrome ; healthy; sustainable • DASH
– Decreased HTN; similar to Mediterranean
Modified from Parikh P, McDaniel M, Ashen D, Miller J, Sorrentino M, Blumenthal R, Sperling LS. Diets and CV Disease: An Evidence-Based Assessment, JACC 2005;45:1385
Dept. HHS & USDA 8th Dietary GLs
Summary:1. Healthy eating pattern
across lifespan2. Focus on variety, nutrient
density, and amount3. Limit calories from added
sugars, sat. fats. Reduce Na intake
4. Shift to healthier food & beverage choices
5. Support healthier eating patterns for all
USDA Nutrition Guidelines – June 2011
• 7 Key Messages1. Enjoy food but eat less2. Avoid oversized
portions3. half plate fruits/vegs4. Water over sugary
drinks5. Fat free /low-fat milk6. Compare sodium in
foods7. > half grains whole
U.S. News & World Report38 Diets rated(available evidence)
Panel of 20 experts
7 parameters (1-5 scale)
ST wt lossLT wt lossDiabetesHeart healthEase of complianceNutritional completenessHealth risks
U.S. News Best Diets• DASH TLC Mayo Mediterranean Wt Watchers
• Volumetrics Jenny Craig Biggest loser Ornish
• Vegetarian Slim fast Fat belly Nutrisystem
• Abs South beach Vegan eco-Atkins
• GI Zone macrobiotic Medifast
• Atkins Raw food Dukan Paleo
U.S. News Best Diets- (2014 Update)
• Reviewed……– Traditional Asian Diet– Anti-Inflammatory Diet (Andrew Weil)– Engine 2 Diet (Esselstyn)– Flexitarian Diet
U.S. News Best Diets- 2015 & 2016
2015– HMR (Health Management Resources) Diet– The Body Reset Diet– The Supercharged Hormone Diet
2016– MIND Diet– Whole 30 Diet– Fertility Diet
U.S. News Best Diets
• Overall Best– DASH– TLC– Mayo Clinic– Mediterranean– Weight watchers
U.S. News Best Diets
• Heart-Healthy– Ornish (?)– TLC– DASH– Mediterranean– Vegan
U.S. News Best Diets
• Best Weight Loss Diets– Weight Watchers– HMR Program– Biggest Loser– Jenny Craig
Need Exercise ?
Exercise…..
The Magical Ingredient
Exercise : Important part of Prevention and Lifestyle Therapy
Physical activityHealthy eatingIdeal weight
Psychosocial factorsFamilial predisposition
LipidsHypertension
Smoking cessationDiabetes
+Primordial
ASAACE-IRehab
β-blockers+Primary
Secondary
Primary
Primordial
NCEP ATP III. JAMA. 2001;285:2486-2497.
0
10
20
30
40
50
60
70
1 2 3 4 5
Dea
th R
ate
(per
10,
000)
Fitness Level (Low to High)
Blair SN et al. JAMA 1989; 262:2395-401
MenWomen
13,344 healthy men and women followed for 8 years
Low physical fitness is associated with increased mortality
Physical Activity:Effect on Mortality
Benefits-Regular Physical Activity
• Reduces risk of dying prematurely ( heart disease)
• Reduces risk of heart disease and colon cancer ( up to 50%)
• Reduces risk of developing type 2 diabetes 50%
• Helps prevent/reduce hypertension• Helps control weight / lower the risk of
becoming obese by 50% • Promotes psychological well-being, reduces
stress, anxiety and depression
http://www.healthypeople.gov
Shear and Atherogenesis
ROS NONOROS
Non-laminar shear
Laminar shear
Many US Adults Are Physically Inactive
25%
38%22%
15% Regular Vigorous Activity(3x/week, >20 minutes)
Surgeon General’s Report on Physical Activity, 1996
Irregularly Active
Sedentary
Regular, Sustained Activityof Any Intensity
(5x/week, >30 minutes)
Our “Toxic” Environment
57
Pedometer-Determined Physical Activity in Healthy Adults
• < 5000 steps/day: ‘sedentary lifestyle index‘• 5000-7499 steps/day: 'low active' • 7500-9999: 'somewhat active' • > or =10000 steps/day: 'active'• > 12500 steps/day: 'highly active'
Tudor-Locke, et al. Sports Medicine 2004;34:1-8.
Work-Related Physical Activity among Cardiovascular Specialists
Abd T, Kobylivker, A, Perry A,, Miller III J,, Sperling L. Clin Cardiol 2012 35,2,78-82
Methods: All participants were from an academic tertiary center (N=28)• 8 cardiothoracic (CT) surgeons • 7 general cardiologists • 5 procedural cardiologists • 8 cardiac anesthesiologistsDemographic information• age • resting heart rate• blood pressure • body-mass index • waist circumference • past medical and social historySubjects were asked to wear a spring levered pedometer on their hip for two weeks while at work and to record the total number of steps as well as number of hours worked each day.
Introduction :Current recommendations by the American Heart association, the American College of Sports Medicine, and the US Surgeon General are a minimum 30 minutes of moderate physical activity on 5 days each week .This goal has been equilibrated with 10000 steps per day. This study examines work-related physical activity (PA) among cardiovascular (CV) specialists
Results: The average daily steps walked during work were 6540, 6039, 5910 and 5553 for general cardiologists, CT surgeons, procedural cardiologists and Cardiac anesthesiologists, respectively. There were no statistically significant differences in the average number of steps taken per day among the groups. However, CT surgeons worked 12.4 hours/day compared to 9.3 hours/day by the cardiac anesthesiologists (p=0.03). There were no significant differences in the demographic characteristics among any of the groups.
Conclusions: Work-related PA of CV specialists do not meet the recommended guidelines. Given their busy work schedule, obtaining the recommended PA might be a challenge for them. Cardiovascular specialists must engage in additional, out-of-hours exercise in order to achieve the adequate amount of daily required physical activity.
SpecialtyDaily steps hr of work steps/hr
CT surgeons 6038.8 12.4 478.2Cardiac
anesthesiologist 5553.3 9.3 594.9
General cardiologists 6540.1 10.1 683.6procedural
cardiologists 5910.4 10.8 542
Average 6010.6 10.65 574.6Attendings 6539 10.8 544.4
Fellows 5810 10.8 608.3
Average daily steps and work hours for study population
02468
101214
CT surgeonsCardiac AnesthGeneral CardProcedural Car
Daily steps in thousands Hours of work
Physical Inactivity: A Call to Arms
10,000 Steps Daily 30 minutes most days
Alcohol : An ounce of prevention?
Alcohol and Total Mortality
Thun et al. Alcohol consumption and mortality among middle-aged and elderly US adults. NEJM 1997; 337:1705.
What is a unit?
12 oz 14g alcohol150 calories
1.5oz14g alcohol100 calories
5oz13g alcohol110 calories
= =
Does beverage type matter?
• French paradox– Lower CHD mortality then expected – red wine consumption ?– polyphenols and flavinoids -
antithrombotic and antioxidant properties • Systematic review shows that all beverage
types associated with lower rates of CHD.
Eapen DJ et al. Current Treatment Options in CV Medicine 2011
Mechanisms of Alcohols Benefit• Enhanced insulin sensitivity• Resveratrol ??• Anti inflammatory • Antioxidant • Antithrombotic
Eapen DJ et al. Current Treatment Options in CV Medicine 2011
Keys to a better longer life
Effective ?
Mediterranean Diet, Lifestyle, and 10 yr Mortality in Elderly Europeans
• Healthful Lifestyle Factors• Prospective study, 2300
• Adhering to Med diet, mod. Alcohol, physical activity, and non-smoking associated with lower risk all-cause mortality (65% reduction)
– Kim T, et al. JAMA 2004;292:1433-39
70
Modification Recommendation Approximate SBP Reduction Range
Weight reduction Maintain normal body weight (BMI=18.5-25)
5-20 mmHg/10 kg weight lost
DASH eating plan
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 most days of the week
4-10 mmHg
Moderate alcohol <2 drinks/day for men and <1 drink/day for women
2-4 mmHg
JNC VII Lifestyle Modifications for BP Control
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
BMI=Body mass index, SBP=Systolic blood pressure
Lifetime Risk for ASCVD by RF Strata Age 50
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
50 60 70 80 900
0.1
0.2
0.3
0.4
0.5
0.6
0.7
50 60 70 80 90Attained Age
Adj
uste
d C
umul
ativ
e In
cide
nce
5%
36%
50%
69%
8%
27%
50%
Men Women
46%
39%
≥2 Major RFs1 Major RF≥1 Elevated RF≥1 Not Optimal RFOptimal RFs
Lloyd-Jones, Circulation 2006
NYC Leading Public Health Initiatives2002 – ban smoking in
bars/restaurants2005-ban on trans fats2008- 1st city to require
calorie counts on menus2011- ban on smoking most
outdoor areas** Mayor + NYC Health
Dept. cite NYC’s rising life expectancy as proof these measures working
NY Times- May 31, 2012
Centenarians (100 + Club)• Per capita greatest # in Okinawa• 5 contributing factors
– Diet- grains, fish, veg– Low stress– Highly active– Supportive community– spirituality
• Genetics?– Higher glutathione reductase / catalase– FOX03A polymorphism
• Supercentenarians…..> 110
Wilcox D, et al. Jl Gerontology 2008;63Andersen HR, et al Age Ageing 1998;27
AJC 8/26/11• Besse Cooper
turns 115 in Monroe, Ga.
• “I mind my own business…..and I don’t eat junk food.”
Associate Press 1/20/16• World’s oldest
man, Yasutaro Koide, died at 112 in Nagoya, Japan.
• Secret to a long life“not to smoke,drink, or overdo it.”
World’s oldest person• Susannah Mushatt
Jones, 116• Born in Alabama-
parents sharecroppers• Resides in Vandalia
Senior Center in Brooklyn, N.Y.
• “never smoked, drank, partied, worn makeup or dyed hair.”
Wikipedia
Intangibles…….Zest for life?
• When asked in his late 90’s if his doctor knew he still smoked…..
• Burns said “No…he’s dead”
BETTER LONGER LIFE?“POLYPILL” OR PUBLIC HEALTH
• A strategy to reduce CVD by more than 80%…..– 5 agents in single tablet ;
age > 55• Statin• Aspirin• 3 BP meds at half-dose
• A strategy to reduce CVD by more than 80%…..
Wald N and Law, MR. BMJ 2003;326:1419
KEYS TO A BETTER LONGER LIFE…..
• Nurse’s Health Study, 84,000 women• Low-risk (3%) group
– Not smoking ; >1/2 glass EtoH per day– BMI < 25 ; top 1/3 for healthy diet– Moderate physical activity > 30 min/day
• Each factor independently predicted risk• RR 0.17 ; 82% of events attributed to lack
of adherence to low risk patternStampfer, MJ et al. N Engl J Med 2000 343(1):16-22
“Things do not happen. They are made to happen.”
John F. Kennedy
PREVENTIVE CARDIOLOGY • Primary and secondary
prevention clinics• HeartWise Risk Reduction
Program• Optimal Living• Women’s Heart Program• Subclinical markers of
atherosclerosis• Screenings and Risk
Factor management • LDL apheresis• Housestaff / fellow
training program• Clinical and Translational
Science Research• Centenarian Clinic
Emory University
American Society for Preventive Cardiology: www.aspconline.org
New This Fall
Thanks……