- Email: [email protected]
Diet, cardiovascular disease and oral health
CLINICAL PRACTICE
N U T R I T I O N
Diet, cardiovascular disease and oral health Promoting health and reducing risk Riva Touger-Decker, PhD, RD, FADA
ardiovascular disease (CVD) is one of the leading causes of death in the United States and globally.1,2 Although mortality resulting from CVD has declined during the past decade, its prevalence and the incidence of risk factors associated with CVD remain high.3,4 Approximately one American dies every 37 seconds of CVD.2 Investigators have outlined roles for oral health care professionals (OHCPs) in primary prevention of CVD through screening in the dental office.5-7 Although CVD risk screening is a valuable preventive approach to detect those at risk of developing disease and refer them accordingly, another preventive strategy is through education, encouragement and reinforcement of healthful lifestyle behaviors such as diet.8-12 The 2000 surgeon general’s report on oral health in America recommended dietary prevention strategies and supported the concept that “oral health is integral to general health.”13 More recently, Lamster and colleagues14 stated that “dentists can become advocates for a general health promotion and disease prevention message.” U.S. inventor Thomas Edison said, “The
C
ABSTRACT Background. Primary prevention of cardiovascular disease includes screening as well as education and riskreduction efforts. Methods. The author reviewed diet and nutritional risk factors for cardiovascular disease (CVD), as well as dietary approaches to reduce the risk of developing CVD. The author also presented applications for use in dental practice. Conclusions. The multifaceted relationship between diet/nutrition, CVD and oral health supports the role of CVD risk-reduction strategies in dental practice. Clinical Implications. Reinforcement of healthful lifestyle principles may help reduce patients’ risk of developing CVD and improve their systemic and oral health. Key Words. Diet; nutrition; obesity; cardiovascular diseases; periodontal diseases. JADA 2010;141(2):167-170.
Dr. Touger-Decker is a professor and the director, Division of Nutrition, New Jersey Dental School, and chair, Department of Nutritional Sciences, School of Health Related Professions, University of Medicine & Dentistry of New Jersey, 65 Bergen St., Room 157, Newark, N.J. 07107-3001, e-mail “[email protected]”. Address reprint requests to Dr. Touger-Decker.
JADA, Vol. 141
http://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
February 2010
167
CLINICAL PRACTICE
N U T R I T I O N
BOX 1
BOX 2
Modifiable risk factors for cardiovascular disease.* dHigh blood pressure dHigh cholesterol levels dOverweight and obesity dPhysical inactivity dPoor diet (high in cholesterol; sodium; total, saturated and/or trans fats; and/or calories)
or less of total calories
dDaily saturated fat intake should be less than 7% of total daily calories 200 milligrams
* Sources: McDermott,1 Stampfer and colleagues,8 American Heart Association Nutrition Subcommittee,9 Gidding and colleagues.10
doctor of the future will give no medication, but will interest his patients in the care of the human frame, diet and in the cause and prevention of disease.”15 Can OHCPs foster this interest among patients to prevent CVD by caring for the human frame with a healthful diet and lifestyle? I will focus on risk-reduction strategies that OHCPs can introduce into their practice settings through promotion of dietary guidelines and healthful behaviors to reduce the risk of developing CVD. DIET AND NUTRITIONAL RISK FACTORS
Among the primary modifiable risk factors for CVD are overweight, obesity (in particular, abdominal obesity), high serum cholesterol levels, type 2 diabetes mellitus and poor diet (Box 11,8-10). Overweight and obesity (as assessed by body mass index [BMI] or waist circumference) also are independent risk factors for type 2 diabetes mellitus and hypertension. Even small amounts of weight loss without a return to ideal body weight can reduce the risk of developing CVD and these comorbid conditions. A total cholesterol level of greater than 200 milligrams per deciliter, a lowdensity lipoprotein cholesterol level of greater than 100 mg/dL and/or a high-density lipoprotein cholesterol level of less than 40 mg/dL reflect dyslipidemia, which can increase a person’s risk of developing CVD. Dietary risk factors include a diet high in total fat (> 30 percent of calories), saturated fats or trans fats; dietary cholesterol (> 300 mg/day); sodium; and calories in excess of needs. Waist circumference, as a more accurate estimate of abdominal obesity than BMI or weight alone, is assessed by using a tape measure at the midpoint between the lowest rib and the iliac crest.16,17 Values greater than 40 inches in men and greater than 35 inches in women reflect a high risk of developing CVD. JADA, Vol. 141
dDaily fat intake (from all sources) should be 25% to 35%
dDaily dietary cholesterol intake should be less than
dSmoking dType 2 diabetes
168
National Cholesterol Education Program’s Therapeutic Lifestyle Changes diet.*
http://jada.ada.org
dDaily sodium intake should be limited to 2,400 mg dDaily calorie intake should be set at a level to achieve or maintain a healthful weight and to reduce blood cholesterol level
* Source: National Heart, Lung, and Blood Institute, National Institutes of Health.17
Hague and Touger-Decker18 addressed weight screening by OHCPs, and Greenberg and colleagues5 addressed CVD screening. If OHCPs do screen patients for CVD risk, their discussion of the results can be a teachable moment for patients regarding risk-reduction strategies. Beyond screening, OHCPs can integrate approaches to helping patients reduce modifiable risk factors for CVD in the dental office. DIET AND NUTRITIONAL RISK-REDUCTION STRATEGIES
The 12th-century philosopher Maimonides said, “No disease that can be treated by diet should be treated with any other means.”19 Recently, some have suggested charging higher health insurance premiums to people with a certain BMI20 to curb the obesity epidemic, and many states are considering imposing large taxes on sugared beverages.21 However, taxing select foods and people on the basis of their weight will not solve either the obesity or the CVD epidemic. Educating consumers about healthful lifestyle habits can lead to improved diets and lifestyle behaviors. Through education, OHCPs, like other health care professionals, can play a role in primary prevention of CVD. Diet and physical activity. The National Cholesterol Education Program’s Therapeutic Lifestyle Changes (TLC) model17 advocates a diet that is low to moderate in total fat and low in saturated fat, cholesterol, sodium and calories to attain and ABBREVIATION KEY. AHA: American Heart Association. BMI: Body mass index. CVD: Cardiovascular disease. OHCPs: Oral health care professionals. TLC: Therapeutic Lifestyle Changes.
February 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
CLINICAL PRACTICE
BOX 3
N U T R I T I O N
BOX 4
Dietary approaches to addressing cardiovascular disease (CVD) risk reduction. DETERMINE Body mass index and weight status CVD risk INFORM With a healthful diet, you can make positive strides to reduce your risk of developing CVD Modest weight loss, even 5-10 pounds, can reduce blood pressure, blood sugar and disease risk
Screening tools and patient education resources. SCREENING TOOLS
dNational Cholesterol Education Program
Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (Myocardial Infarction and Coronary Death) “http://hp2010.nhlbihin.net/atpiii/calculator.asp? usertype=prof”
dAmerican Heart Association
Heart Attack-Coronary Heart Disease-Metabolic Syndrome Risk Assessment “www.americanheart.org/presenter.jhtml?identifier= 3003499”
EDUCATE Diets rich in fruits, vegetables and whole grains can contribute to a reduced risk of developing CVD
dNational Heart, Lung, and Blood Institute
Increasing healthful fat sources such as nuts and seeds while reducing saturated fats found in meats, butter and whole milk can reduce the risk of developing CVD
dUnited States Department of Agriculture, Center for
TRY TO PROVIDE Resources to help patients make positive lifestyle changes to reduce their CVD risk Referrals to primary care providers for further evaluation as appropriate Referrals to registered dieticians for medical nutrition therapy as appropriate Reinforcement of messages to reduce CVD risk
Calculate Your Body Mass Index “www.nhlbisupport.com/bmi/”
Nutrition Policy and Promotion MyPyramid Tracker “www.mypyramidtracker.gov/”*
PATIENT EDUCATION
dAmerican Dietetic Association
Eat Right Nutrition Tips “www.eatright.org/public/content.aspx?id=206”
dAmerican Heart Association
HeartHub for Patients: Take Control “www.hearthub.org”
dNational Heart Lung and Blood Institute maintain a healthful weight; increased physical activity; and referral to a registered dietician as first steps in reducing CVD risk (Box 2). Likewise, the American Heart Association (AHA) guidelines on adult nutrition and lifestyle goals for CVD risk reduction9,10,12 support diet as the first line of defense in lessening the risk of developing, as well as treating, CVD and include similar suggestions for limiting intake of total and saturated fat. However, in contrast to the TLC diet’s focus on nutrients and energy, the AHA recommendations for CVD risk reduction9 include specific food group suggestions. These recommendations encourage a balance in energy intake and physical activity to achieve and maintain a healthful weight; a diet rich in fruits, vegetables, whole grains and other high-fiber foods; consumption of fish two or more times a week; intake of less than 300 mg of cholesterol daily with minimal consumption of trans fats and partially hydrogenated fats; consumption of foods with reduced or no salt; and minimal intake of foods and fluids with added sugars. The recommendations also encourage consumers to select lean meats and vegetable protein alternatives and consume fatfree and low-fat dairy products. If people consume alcohol, they should do so in moderation. Reducing added sugars. In 2009, the AHA
Health Information for the Public “www.nhlbi.nih.gov/health/index.htm”
dNational Heart Lung and Blood Institute
Introduction to the TLC Diet “www.nhlbisupport.com/cgi-bin/chd1/step2intro.cgi”
dNutrition.gov
“www.nutrition.gov”
dUniversity of Medicine & Dentistry of New Jersey Institute for Nutrition Interventions: Health and Wellness Site “http://shrp.umdnj.edu/programs/INI/Health/index.htm” * This site may change with the release of the 2010 Dietary Guidelines sometime in 2010.
issued a scientific statement recommending a reduction in intake of added sugar to no more than 50 percent of discretionary calorie consumption per day in an effort to attain and maintain a healthful body weight and to reduce the risk of developing CVD.22 One can calculate discretionary calories by subtracting calories needed to meet daily nutrient needs from total estimated energy (calorie) needs to maintain weight. This recommendation refers only to sugars (as solids, syrups or other liquids) added to foods in processing, preparation or service. Both the AHA and TLC approaches recommend weight loss for overweight people through diet and physical activity. Removing the word “diet,” with its negative connotations, from our vocabulary and replacing it with “healthful eating” is a positive first step in adopting new lifestyle behaviors. Box 3 provides JADA, Vol. 141
http://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
February 2010
169
CLINICAL PRACTICE
N U T R I T I O N
an approach to CVD risk reduction in the dental office. OHCPs can place AHA and TLC consumer education materials in office waiting areas to help educate patients about healthful lifestyles, CVD risk reduction and the associations between oral and systemic health. Box 4 lists online sources of CVD screening tools and other resources for consumers and health care professionals. Clinicians and patients can use the U.S. Department of Agriculture’s MyPyramid tracker as a self-assessment tool to analyze diet quality and plan a diet consistent with the CVD dietary risk-reduction strategies reviewed in this report. KEY MESSAGES
As the obesity and CVD epidemics continue, it is incumbent on all health care professionals to integrate strategies to ameliorate these diseases. As advocates for oral and systemic health, OHCPs— along with other health care professionals—can integrate primary prevention and risk-reduction strategies into their practices. Box 3 provides key talking points that OHCPs can use with patients. In addition, clinicians can reinforce dietary goals (Box 2) during initial and periodic examinations. CONCLUSION
OHCPs have the unique opportunity to help mitigate the CVD epidemic with risk-reduction approaches in the dental care setting. For example, it may be helpful to place signs in the waiting area that state, “As a service to patients, this office provides health promotion screening and education.” In addition, OHCPs can pose global questions to patients about diet quality in five minutes or less and educate them via suggested statements (Box 3). Working as integral members of the health care team, OHCPs can contribute to health promotion and primary prevention of CVD. ■ Disclosure. Dr. Touger-Decker did not report any disclosures. The Nutrition section is published in collaboration with the Nutrition Research Scientific Group of the International Association for Dental Research. 1. McDermott MM. The international pandemic of chronic cardiovascular disease. JAMA 2007;297(11):1253-1255. 2. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee (published correction appears in Circulation 2009;119[3]:e182). Circulation 2009;119(3):e21-e181. 3. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005; 293(15):1861-1867. 4. Stamler J, Stamler R, Neaton JD, et al. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged
170
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http://jada.ada.org
men and women. JAMA 1999;282(21):2012-2018. 5. Greenberg BL, Glick M, Goodchild J, Duda PW, Conte NR, Conte M. Screening for cardiovascular risk factors in a dental setting. JADA 2007;138(6):798-804. 6. Greenberg BL, Glick M, Goodchild J, Duda P, Conte N, Conte M. The potential role of dentists in identifying patients’ risk of experiencing coronary heart disease events. JADA 2005;136(11):1541-1546. 7. Jontell M, Glick M. Oral health care professionals’ identification of cardiovascular disease risk among patients in private dental offices in Sweden. JADA 2009;140(11):1385-1391. 8. Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000;343(1):16-22. 9. American Heart Association Nutrition Subcommittee; Lichtenstein A, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee (published correction appears in Circulation 2006;114[23]:e629). Circulation 2006;114(1):82-96. 10. Gidding SS, Lichtenstein AH, Faith MS, et al. Implementing American Heart Association pediatric and adult nutrition guidelines: a scientific statement from the American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular Disease in the Young, Council on Arteriosclerosis, Thombosis and Vascular Biology, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research. Circulation 2009;119(8):1161-1175. 11. Lewis CE, McTigue KM, Burke LE, et al. Mortality, health outcomes and body mass index in the overweight range: a science advisory from the American Heart Association. Circulation 2009;119(25): 3263-3271. 12. Harris WS, Mozaffarian D, Rimm E, et al. Omega-6 fatty acids and risk for cardiovascular disease: a scientific advisory from the American Heart Association Nutrition Subcommittee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Cardiovascular Nursing; and Council on Epidemiology and Prevention. Circulation 2009;119(6):902-907. 13. U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general—executive summary. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. “www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Report/ ExecutiveSummary.htm”. Accessed Dec. 29, 2009. 14. Lamster IB, DePaola DP, Oppermann RV, Papapanou PN, Wilder RS. The relationship of periodontal disease to diseases and disorders at distant sites: communication to health care professionals and patients (published correction appears in JADA 2008;139[12]:1588). JADA 2008; 139(10):1389-1397. 15. Edison T. Quotations: ayurvedic concepts. Available at: “www. quotegarden.com/ayurveda.html”. Accessed Dec. 29, 2009. 16. National Institutes of Health, National Heart, Lung, and Blood Institute, North American Association for the Study of Obesity. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, Md.: National Heart, Lung, and Blood Institute; 2000. NIH publication 00-4084. “www.nhlbi.nih.gov/ guidelines/obesity/prctgd_c.pdf”. Accessed Dec. 29, 2009. 17. National Heart, Lung, and Blood Institute, National Institutes of Health. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Bethesda, Md.: National Heart, Lung, and Blood Institute; 2002. NIH publication 02-5215:v1-18. “www.nhlbi.nih.gov/guidelines/cholesterol/ atp3full.pdf”. Accessed Dec. 28, 2009. 18. Hague AL, Touger-Decker R. Weighing in on weight screening in the dental office: practice approaches. JADA 2008;139(7):934-938. 19. BrainyQuote. Maimonides M. “www.brainyquote.com/quotes/ quotes/m/maimonides326756.html”. Accessed Dec. 29, 2009. 20. Leonhardt D. Fat tax. The New York Times Magazine. August 12, 2009. “www.nytimes.com/2009/08/16/magazine/ 16FOB-wwln-t.html?scp=1&sq=fat percent20tax&st=cse”. Accessed Dec. 29, 2009. 21. Brownell KD, Frieden TR. Ounces of prevention: the public policy case for taxes on sugared beverages. N Engl J Med 2009;360(18): 1805-1808. 22. Johnson RK, Appel LJ, Brands M; American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and Prevention. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 2009;120(11): 1011-1020.
February 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
N U T R I T I O N
Diet, cardiovascular disease and oral health Promoting health and reducing risk Riva Touger-Decker, PhD, RD, FADA
ardiovascular disease (CVD) is one of the leading causes of death in the United States and globally.1,2 Although mortality resulting from CVD has declined during the past decade, its prevalence and the incidence of risk factors associated with CVD remain high.3,4 Approximately one American dies every 37 seconds of CVD.2 Investigators have outlined roles for oral health care professionals (OHCPs) in primary prevention of CVD through screening in the dental office.5-7 Although CVD risk screening is a valuable preventive approach to detect those at risk of developing disease and refer them accordingly, another preventive strategy is through education, encouragement and reinforcement of healthful lifestyle behaviors such as diet.8-12 The 2000 surgeon general’s report on oral health in America recommended dietary prevention strategies and supported the concept that “oral health is integral to general health.”13 More recently, Lamster and colleagues14 stated that “dentists can become advocates for a general health promotion and disease prevention message.” U.S. inventor Thomas Edison said, “The
C
ABSTRACT Background. Primary prevention of cardiovascular disease includes screening as well as education and riskreduction efforts. Methods. The author reviewed diet and nutritional risk factors for cardiovascular disease (CVD), as well as dietary approaches to reduce the risk of developing CVD. The author also presented applications for use in dental practice. Conclusions. The multifaceted relationship between diet/nutrition, CVD and oral health supports the role of CVD risk-reduction strategies in dental practice. Clinical Implications. Reinforcement of healthful lifestyle principles may help reduce patients’ risk of developing CVD and improve their systemic and oral health. Key Words. Diet; nutrition; obesity; cardiovascular diseases; periodontal diseases. JADA 2010;141(2):167-170.
Dr. Touger-Decker is a professor and the director, Division of Nutrition, New Jersey Dental School, and chair, Department of Nutritional Sciences, School of Health Related Professions, University of Medicine & Dentistry of New Jersey, 65 Bergen St., Room 157, Newark, N.J. 07107-3001, e-mail “[email protected]”. Address reprint requests to Dr. Touger-Decker.
JADA, Vol. 141
http://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
February 2010
167
CLINICAL PRACTICE
N U T R I T I O N
BOX 1
BOX 2
Modifiable risk factors for cardiovascular disease.* dHigh blood pressure dHigh cholesterol levels dOverweight and obesity dPhysical inactivity dPoor diet (high in cholesterol; sodium; total, saturated and/or trans fats; and/or calories)
or less of total calories
dDaily saturated fat intake should be less than 7% of total daily calories 200 milligrams
* Sources: McDermott,1 Stampfer and colleagues,8 American Heart Association Nutrition Subcommittee,9 Gidding and colleagues.10
doctor of the future will give no medication, but will interest his patients in the care of the human frame, diet and in the cause and prevention of disease.”15 Can OHCPs foster this interest among patients to prevent CVD by caring for the human frame with a healthful diet and lifestyle? I will focus on risk-reduction strategies that OHCPs can introduce into their practice settings through promotion of dietary guidelines and healthful behaviors to reduce the risk of developing CVD. DIET AND NUTRITIONAL RISK FACTORS
Among the primary modifiable risk factors for CVD are overweight, obesity (in particular, abdominal obesity), high serum cholesterol levels, type 2 diabetes mellitus and poor diet (Box 11,8-10). Overweight and obesity (as assessed by body mass index [BMI] or waist circumference) also are independent risk factors for type 2 diabetes mellitus and hypertension. Even small amounts of weight loss without a return to ideal body weight can reduce the risk of developing CVD and these comorbid conditions. A total cholesterol level of greater than 200 milligrams per deciliter, a lowdensity lipoprotein cholesterol level of greater than 100 mg/dL and/or a high-density lipoprotein cholesterol level of less than 40 mg/dL reflect dyslipidemia, which can increase a person’s risk of developing CVD. Dietary risk factors include a diet high in total fat (> 30 percent of calories), saturated fats or trans fats; dietary cholesterol (> 300 mg/day); sodium; and calories in excess of needs. Waist circumference, as a more accurate estimate of abdominal obesity than BMI or weight alone, is assessed by using a tape measure at the midpoint between the lowest rib and the iliac crest.16,17 Values greater than 40 inches in men and greater than 35 inches in women reflect a high risk of developing CVD. JADA, Vol. 141
dDaily fat intake (from all sources) should be 25% to 35%
dDaily dietary cholesterol intake should be less than
dSmoking dType 2 diabetes
168
National Cholesterol Education Program’s Therapeutic Lifestyle Changes diet.*
http://jada.ada.org
dDaily sodium intake should be limited to 2,400 mg dDaily calorie intake should be set at a level to achieve or maintain a healthful weight and to reduce blood cholesterol level
* Source: National Heart, Lung, and Blood Institute, National Institutes of Health.17
Hague and Touger-Decker18 addressed weight screening by OHCPs, and Greenberg and colleagues5 addressed CVD screening. If OHCPs do screen patients for CVD risk, their discussion of the results can be a teachable moment for patients regarding risk-reduction strategies. Beyond screening, OHCPs can integrate approaches to helping patients reduce modifiable risk factors for CVD in the dental office. DIET AND NUTRITIONAL RISK-REDUCTION STRATEGIES
The 12th-century philosopher Maimonides said, “No disease that can be treated by diet should be treated with any other means.”19 Recently, some have suggested charging higher health insurance premiums to people with a certain BMI20 to curb the obesity epidemic, and many states are considering imposing large taxes on sugared beverages.21 However, taxing select foods and people on the basis of their weight will not solve either the obesity or the CVD epidemic. Educating consumers about healthful lifestyle habits can lead to improved diets and lifestyle behaviors. Through education, OHCPs, like other health care professionals, can play a role in primary prevention of CVD. Diet and physical activity. The National Cholesterol Education Program’s Therapeutic Lifestyle Changes (TLC) model17 advocates a diet that is low to moderate in total fat and low in saturated fat, cholesterol, sodium and calories to attain and ABBREVIATION KEY. AHA: American Heart Association. BMI: Body mass index. CVD: Cardiovascular disease. OHCPs: Oral health care professionals. TLC: Therapeutic Lifestyle Changes.
February 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
CLINICAL PRACTICE
BOX 3
N U T R I T I O N
BOX 4
Dietary approaches to addressing cardiovascular disease (CVD) risk reduction. DETERMINE Body mass index and weight status CVD risk INFORM With a healthful diet, you can make positive strides to reduce your risk of developing CVD Modest weight loss, even 5-10 pounds, can reduce blood pressure, blood sugar and disease risk
Screening tools and patient education resources. SCREENING TOOLS
dNational Cholesterol Education Program
Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (Myocardial Infarction and Coronary Death) “http://hp2010.nhlbihin.net/atpiii/calculator.asp? usertype=prof”
dAmerican Heart Association
Heart Attack-Coronary Heart Disease-Metabolic Syndrome Risk Assessment “www.americanheart.org/presenter.jhtml?identifier= 3003499”
EDUCATE Diets rich in fruits, vegetables and whole grains can contribute to a reduced risk of developing CVD
dNational Heart, Lung, and Blood Institute
Increasing healthful fat sources such as nuts and seeds while reducing saturated fats found in meats, butter and whole milk can reduce the risk of developing CVD
dUnited States Department of Agriculture, Center for
TRY TO PROVIDE Resources to help patients make positive lifestyle changes to reduce their CVD risk Referrals to primary care providers for further evaluation as appropriate Referrals to registered dieticians for medical nutrition therapy as appropriate Reinforcement of messages to reduce CVD risk
Calculate Your Body Mass Index “www.nhlbisupport.com/bmi/”
Nutrition Policy and Promotion MyPyramid Tracker “www.mypyramidtracker.gov/”*
PATIENT EDUCATION
dAmerican Dietetic Association
Eat Right Nutrition Tips “www.eatright.org/public/content.aspx?id=206”
dAmerican Heart Association
HeartHub for Patients: Take Control “www.hearthub.org”
dNational Heart Lung and Blood Institute maintain a healthful weight; increased physical activity; and referral to a registered dietician as first steps in reducing CVD risk (Box 2). Likewise, the American Heart Association (AHA) guidelines on adult nutrition and lifestyle goals for CVD risk reduction9,10,12 support diet as the first line of defense in lessening the risk of developing, as well as treating, CVD and include similar suggestions for limiting intake of total and saturated fat. However, in contrast to the TLC diet’s focus on nutrients and energy, the AHA recommendations for CVD risk reduction9 include specific food group suggestions. These recommendations encourage a balance in energy intake and physical activity to achieve and maintain a healthful weight; a diet rich in fruits, vegetables, whole grains and other high-fiber foods; consumption of fish two or more times a week; intake of less than 300 mg of cholesterol daily with minimal consumption of trans fats and partially hydrogenated fats; consumption of foods with reduced or no salt; and minimal intake of foods and fluids with added sugars. The recommendations also encourage consumers to select lean meats and vegetable protein alternatives and consume fatfree and low-fat dairy products. If people consume alcohol, they should do so in moderation. Reducing added sugars. In 2009, the AHA
Health Information for the Public “www.nhlbi.nih.gov/health/index.htm”
dNational Heart Lung and Blood Institute
Introduction to the TLC Diet “www.nhlbisupport.com/cgi-bin/chd1/step2intro.cgi”
dNutrition.gov
“www.nutrition.gov”
dUniversity of Medicine & Dentistry of New Jersey Institute for Nutrition Interventions: Health and Wellness Site “http://shrp.umdnj.edu/programs/INI/Health/index.htm” * This site may change with the release of the 2010 Dietary Guidelines sometime in 2010.
issued a scientific statement recommending a reduction in intake of added sugar to no more than 50 percent of discretionary calorie consumption per day in an effort to attain and maintain a healthful body weight and to reduce the risk of developing CVD.22 One can calculate discretionary calories by subtracting calories needed to meet daily nutrient needs from total estimated energy (calorie) needs to maintain weight. This recommendation refers only to sugars (as solids, syrups or other liquids) added to foods in processing, preparation or service. Both the AHA and TLC approaches recommend weight loss for overweight people through diet and physical activity. Removing the word “diet,” with its negative connotations, from our vocabulary and replacing it with “healthful eating” is a positive first step in adopting new lifestyle behaviors. Box 3 provides JADA, Vol. 141
http://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
February 2010
169
CLINICAL PRACTICE
N U T R I T I O N
an approach to CVD risk reduction in the dental office. OHCPs can place AHA and TLC consumer education materials in office waiting areas to help educate patients about healthful lifestyles, CVD risk reduction and the associations between oral and systemic health. Box 4 lists online sources of CVD screening tools and other resources for consumers and health care professionals. Clinicians and patients can use the U.S. Department of Agriculture’s MyPyramid tracker as a self-assessment tool to analyze diet quality and plan a diet consistent with the CVD dietary risk-reduction strategies reviewed in this report. KEY MESSAGES
As the obesity and CVD epidemics continue, it is incumbent on all health care professionals to integrate strategies to ameliorate these diseases. As advocates for oral and systemic health, OHCPs— along with other health care professionals—can integrate primary prevention and risk-reduction strategies into their practices. Box 3 provides key talking points that OHCPs can use with patients. In addition, clinicians can reinforce dietary goals (Box 2) during initial and periodic examinations. CONCLUSION
OHCPs have the unique opportunity to help mitigate the CVD epidemic with risk-reduction approaches in the dental care setting. For example, it may be helpful to place signs in the waiting area that state, “As a service to patients, this office provides health promotion screening and education.” In addition, OHCPs can pose global questions to patients about diet quality in five minutes or less and educate them via suggested statements (Box 3). Working as integral members of the health care team, OHCPs can contribute to health promotion and primary prevention of CVD. ■ Disclosure. Dr. Touger-Decker did not report any disclosures. The Nutrition section is published in collaboration with the Nutrition Research Scientific Group of the International Association for Dental Research. 1. McDermott MM. The international pandemic of chronic cardiovascular disease. JAMA 2007;297(11):1253-1255. 2. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee (published correction appears in Circulation 2009;119[3]:e182). Circulation 2009;119(3):e21-e181. 3. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005; 293(15):1861-1867. 4. Stamler J, Stamler R, Neaton JD, et al. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged
170
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February 2010
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