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1 Lifestyle Management Evidence and Guidelines Andrew P. DeFilippis, Ty J. Gluckman, Catherine Campbell, Suzanne Hughes, Gregg Fonarow, & Roger S. Blumenthal

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2 Cigarette Smoking Cessation Evidence and Guidelines

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3 Smoking Prevalence in the United States MMWR 1999;48:998 National Center for Health Statistics-1998 %

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4 Causes# (%) in 1990# (%) in 2000 Tobacco400,000 (19)435,000 (18) Poor diet and physical activity (obesity)300,000 (14)400,000 (17) Alcohol consumption100,000 (5)85,000 (4) Microbial agents90,000 (4)75,000 (3) Toxic agents60,000 (3)55,000 (2) Motor vehicle accidents25,000 (1)43,000 (2) Firearms 35,000 (2)29,000 (1) Sexual behavior30,000 (1)20,000 (

7 12-24 Years Old 25+ Years Old Less than 66-1516-2526+ Percent Reporting >1 Indicators of Nicotine Dependence, by Age and Intensity of Smoking Substance Abuse and Mental Health Services Administration; United States, National Household Survey on Drug Abuse, 1991/1992. Cigarette Smoking Cessation: Nicotine Dependence

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8 Minutes Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch 5 10 15 20 25 30 0 2 4 6 8 10 12 14 Balfour DJ et al. Pharmacol Ther 1996;72:51-81 Increase in nicotine concentration (ng/ml) Cigarette Smoking Cessation: Nicotine Replacement Plasma nicotine concentrations

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9 Limited Behavioral Support Greatest Benefit with Combination Therapy InterventionEffect Size95% CI Nicotine gum5%4-6% Nicotine transdermal patch5%4-7% InterventionEffect Size95% CI Nicotine gum8%6-10% Nicotine transdermal patch6%5-8% Nicotine nasal spray12%7-17% Nicotine inhaler8%4-12% Nicotine sublingual tablet8%1-14% Intensive Behavioral Support West R et al. Thorax 2000;55:987-999 Silagy C et al. Cochrane Database Syst Rev 2002;CD000146 CI=Confidence interval

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10 Jorenby DE et al. NEJM 1999;340:685-91 Cigarette Smoking Cessation: Primary Prevention Placebo (n=160) NRT (n=244) Bupropion (n=244) Nicotine patch and Bupropion (n=245) Abstinence rate at 6 months 18.8%21.3%34.8% a,b 38.8% a,c,d Abstinence rate at 12 months 15.6%16.4%30.3% a,c 35.5% a,c,e a p

18 Prevalence of Obesity in U.S. Adults 1991 1996 2006 No Data 30% CDC Overweight and Obesity Percentage of State Obese (BMI > 30)

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19 Risk of Hypertension Increases with BMI Systolic BP >140 mm Hg (%) Body Mass Index Canadian Guidelines for Healthy Weights. Cat No. H39- 134/1989E; 1988:69 BP=Blood pressure

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20 BMI in Youth Predicts Adult Obesity Whitaker RC et al. NEJM 1997;337:869-873 BMI=Body mass index Adult Obesity at Age 21-29 Years (%) Age of Child (Yrs)

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21 Risk of DM Increases with Body Mass Index Body Mass Index Incidence of DM (Per 1,000 Person-Years) Knowler WC et al. Am J Epidemiol 1981;113:144-156 DM=Diabetes mellitus

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22 Mhurchu N et al. Int J Epidemiol 2004;33:751-758 0.5 1.0 2.0 4.0 162024283236 Body Mass Index (kg/m 2 )* Hazard Ratio 0.5 1.0 2.0 4.0 162024283236 0.5 1.0 2.0 4.0 162024283236 Hemorrhagic CVA Ischemic CVA Ischemic Heart Disease CV Risk Increases with BMI CV=Cardiovascular BMI is calculated as the weight in kg divided by the BSA in meters 2.

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23 Very low fat Ornish (Reversal diet and Prevention diet) Vegetarian with 10% calories from fat. No cooking oils, avocados, nuts, and seeds. High fiber. No caloric restriction. Pritikin Very low-fat (primarily vegetarian) diet based on whole grains, fruits, and vegetables Intermediate Sugar Busters 30% protein, 40% fat, 30% carbohydrates (low glycemic index) Zone 30% protein, 30% fat, 40% carbohydrates Diet Evidence: Treatment Programs

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24 Diet Evidence: Treatment Programs (Continued) Very low carbohydrate Atkins (Induction and Maintenance) 1 st 2 weeks (

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25 160 overweight and obese patients randomized to the Atkins, Zone, Weight Watchers, or Ornish diets for 1 year Weight loss is similar among diet programs, but hard to sustain because of poor long-term compliance Dansinger ML et al. JAMA 2005;293:43-53 Diet Evidence: Primary Prevention 20/40* 26/40* 21/40* 0 369 Atkins Zone Weight Watchers Ornish Wt loss (lbs) *Ratio of individuals completing the study to those enrolled

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26 Goals Recommendations Calculate BMI* and measure waist circumference Monitor response to treatment BMI 18.5 to 24.9 kg/m 2 Women: