- Email: [email protected]
Healthy Lifestyle Characteristics Among Adults in the United States, 2000
Methods: A randomized clinical outpatient feeding study was conducted over 4 weeks with weight/calories held constant. Participants were 120 adults 30 to 65 years of age with prestudy LDL-C 130 to 190 mg/dl, BMI ⬍31 kg/m2, usual dietary saturated fat intake at least 10% of calories, and otherwise general good health. Two diets were compared: the Low-Fat diet and the Low-Fat Plus diet, designed to be identical in total fat, saturated fat, protein, carbohydrate, and cholesterol content, consistent with former American Heart Association (AHA) Step I guidelines. The Low-Fat diet was relatively typical of a low-fat U.S. diet provided in prepared food items such as reduced-fat cheeses and frozen lasagna, and low-fat and sugar-rich snacks. The Low-Fat Plus diet incorporated considerably more vegetables, legumes, and whole grains, consistent with the 2000 AHA revised guidelines and was supplemented with butter, cheese and eggs to increase the saturated fat and cholesterol content of the Low-Fat diet. Primary outcomes were the change in fasting lipid parameters. Results: There was no difference between groups at baseline for the following: 50% were women, mean age was 48 years, mean BMI 2 kg/m2, LDL-C 150 mg/dl, HDL-C 47.5 mg/dl. Four-week changes in the Low-Fat and Low-Fat Plus groups were ⫺9.2 mg/dl versus ⫺17.6 mg/dl for total cholesterol (p⫽0.01) and ⫺7.0 mg/dl versus ⫺13.8 mg/dl for LDLC (p⫽0.02); between-group differences were ⫺9 mg/dl (95% CI, ⫺2 to ⫺15 mg/dl) and ⫺7 mg/dl (CI, ⫺2 to ⫺12 mg/dl) for total and LDL-C respectively. The two diet groups did not differ significantly in HDL-C and triglyceride levels. Conclusions: Previous national dietary guidelines primarily emphasized avoiding saturated fat and cholesterol; as a result, the guidelines probably underestimated the potential LDL cholesterol-lowering effect of diet. In this study, emphasis on including nutrient-dense plant-based foods, consistent with recently revised national guidelines, increased the total and LDL cholesterol-lowering effect of a low-fat diet. Perspective: The findings are consistent with the known lipidlowering effects of fruits, vegetables and grain, each of which is high in soluble fiber. The latter binds bile and increases LDL receptor activity. The mean values favor the Low-Fat Plus group, but there was a wide variability of individual patient response to both diets, which has been shown in other diet trials and clinical experience. The variation in response to low dietary fat with or without high fiber has several mechanisms including fat absorption and genetic variations such as apo E genotype. Interestingly, a diet high in fiber has anti-inflammatory effects as measured by a decrease in C-reactive protein. MR
cholesterol improve the ability to identify subclinical atherosclerosis in young adults? Methods: The Bogalusa Heart Study was a longitudinal examination of the natural history of atherosclerosis in children and young adults conducted between 1973 and 1994. The relationship between advanced lipoprotein testing and carotid intimal media thickness (IMT) was determined in the 1995–1996 follow-up study in a sample of 311 randomly selected adults 20 to 38 years of age. Lipoprotein testing was performed by the vertical-spin density-gradient ultracentrifugation method (VAP, Vertical Auto Profile-I, Atherotech, Birmingham, AL) on stored blood. Primary end points were the relationship between standard and novel risk factors by comparing C-statistics from area under the receiver-operating characteristic curves (AUCs) derived from multivariable regression models. Results: Subjects were 42.4% men; 67.5% were white, mean age was 32.1 years, mean LDL-C 123 mg/dl, HDL-C 48 mg/dl, and triglycerides 111 mg/dl. Mean composite carotid IMT was 0.735⫾0.10 mm, and an IMT of ⱖ0.781 was considered the highest quartile. Seventy-five participants had incomplete data on the carotid IMT measures, and final comparisons were made in 236 participants with a complete data set. Lipid values obtained with advanced lipoprotein testing did not predict carotid intima-media thickness better than traditionally measured lipids. A model using traditional lipoprotein measures (AUC, 0.754 [95% CI, 0.690 – 0.812]) did not differ significantly from a model using advanced lipoprotein measures (AUC, 0.779 [CI, 0.662– 0.871]) for prediction of carotid intima-media thickness (p⬎0.2). Subclass pattern of LDL, LP (a) cholesterol, intermediate-density lipoprotein cholesterol, highdensity lipoprotein cholesterol subclasses and very-lowdensity lipoprotein subclasses did not improve the performance of models for prediction of carotid intimamedia thickness. Conclusions: Advanced lipoprotein testing using verticalspin density-gradient ultracentrifugation did not improve prediction of carotid intima-media thickness in young adults and may not be useful for assessing cardiovascular risk in this population. Perspective: This study, conducted in young adults, does not refute the findings that LDL particle size and number are better risk predictors than LDL-C for coronary events and event reduction in response to treatment in middle-aged and elderly persons with and without coronary disease. But it should give pause to those who use advanced lipoprotein testing with Lp(a), VAP, NMR spectroscopy, or gradient gel electrophoresis as a routine screening tool. MR
Advanced Lipoprotein Testing Does Not Improve Identification of Subclinical Atherosclerosis in Young Adults: The Bogalusa Heart Study
Healthy Lifestyle Characteristics Among Adults in the United States, 2000
Tzou WS, Douglas PS, Srinivasan SR, et al. Ann Intern Med 2005;142:742–50.
Reeves MJ, Rafferty AP. Arch Intern Med 2005;165:854 –7.
Study Question: Does lipoprotein particle size (LDL and HDL) and novel lipoproteins such as lipoprotein(a) (Lp[a])
Study Question: What is the distribution of healthy lifestyle characteristics among adults in the US?
ACC CURRENT JOURNAL REVIEW August 2005
13
Methods: National data for the year 2000 were obtained from the Behavioral Risk Factor Surveillance System, which consists of annual, statewide, random digit-dialed household telephone surveys. Four healthy lifestyle characteristics (HLCs) were defined as nonsmoking, healthy weight (BMI 18.5–25.0), consuming five or more fruits and vegetables per day, and regular physical activity (ⱖ30 min for ⱖ5 times per week). The four HLCs were summed to create a healthy lifestyle index (range, 0 – 4), and the pattern of following all four HLCs was defined as a single healthy lifestyle indicator. We report prevalences of each HLC and the indicator by major demographic subgroups. Results: In data from more than 153,000 adults, the prevalence (95%CI) of the individual HLCs was as follows: nonsmoking, 76.0% (75.6 –76.4%); healthy weight, 40.1% (39.7– 40.5%); five fruits and vegetables per day, 23.3% (22.9 –23.7%); and regular physical activity, 22.2% (21.8 – 22.6%). The overall prevalence of the healthy lifestyle indicator (i.e., having all four HLCs) was only 3.0% (95%CI, 2.8 –3.2%), with little variation among subgroups (range, 0.8 –5.7%). Conclusions: These data illustrate that a healthy lifestyle— defined as a combination of four HLCs—was undertaken by very few adults in the US, and that no subgroup followed this combination to a level remotely consistent with clinical or public health recommendations. Perspective: These data will be very useful for clinicians, local governments, insurance carriers and employers involved in efforts to reduce cardiovascular disease risk. The very costly major public health efforts targeting smoking cessation, exercise, and a healthy diet need to be reassessed with an emphasis on young people and families, and possibly rewarding good behavior by decreasing their cost of health insurance. MR
Results: Follow-up ranged from 0.04 years to 10.2 years. About 60% of subjects were over age 65, and 35% of men and 57% of women had a BMI ⬎30. A previous myocardial infarction was reported in 37.8% and the remainder reported angina pectoris. Higher adherence to the Mediterranean diet by 2 units was associated with a 27% lower mortality rate among persons with prevalent coronary heart disease at enrollment (total deaths, 131; adjusted mortality ratio, 0.73; 95%CI, 0.58 – 0.93). The reduced mortality was more evident and amounted to 31% (total deaths, 85; adjusted mortality ratio, 0.69; 95%CI, 0.52– 0.93) when only cardiac deaths were considered as the relevant outcome. Associations between individual food groups contributing to the Mediterranean diet score and mortality were generally not significant. Conclusions: Greater adherence to the traditional Mediterranean diet is associated with a significant reduction in mortality among individuals diagnosed as having coronary heart disease. Perspective: Epidemiologic and clinical trials have shown the benefit of diets high in fish, fiber, and fruits and vegetables, each of which is increased in the Mediterranean. The benefit is beyond that attributable to change in lipids and includes a decrease in CRP and putative antiarrhythmic properties of 3-omega PUFAs. This study did not address the relative benefits of wine or other alcoholic beverages. MR
Dose-comparison Study of the Combination of Ezetimibe and Simvastatin (Vytorin) Versus Atorvastatin in Patients With Hypercholesterolemia: The Vytorin Versus Atorvastatin (VYVA) Study Ballantyne CM, Abate N, Yuan Z, King TR, Palmisano J. Am Heart J 2005;149:464 –73. Study Question: How does the combination of simvastatin and ezetimibe compare to graduated doses of atorvastatin in reducing LDL-C, achieving ATP-III goal, and lowering the CRP? Methods: A multicenter, double-blind, 6-week parallelgroup study randomized 1902 patients with LDL-C above ATP-III goal to atorvastatin (10, 20, 40, or 80 mg) or to ezetimibe/simvastatin (10/10, 10/20, 10/40, or 10/80 mg). Patients were stratified by prerandomization LDL-C level. Results: There was no difference between groups for the following: mean age 58.7 years, 52% male, 86% white, 46% (CHD) or CHD equivalent, and 36% 2⫹CRFs. At each milligram-equivalent statin dose comparison, and averaged across doses, ezetimibe/simvastatin provided greater LDL-C reductions (47–59%) than did atorvastatin (36 – 53%). Ezetimibe/simvastatin 10/40 and 10/80 mg also provided significantly greater HDL-C increases than atorvastatin 40 and 80 mg. Triglyceride reductions were similar for all comparisons. More ezetimibe/simvastatin than atorvastatin patients with CHD or CHD risk equivalents attained the ATP-III LDL-C goal of ⬍100 mg/dl and the optional
Mediterranean Diet and Survival Among Patients With Coronary Heart Disease in Greece Trichopoulou A, Bamia C, Trichopoulos D. Arch Intern Med 2005;165:929 –35. Study Question: Is there a relationship between the degree of adherence to the traditional Mediterranean diet and survival in persons with coronary heart disease? Methods: This was a population-based prospective investigation of 1302 Greek men and women followed for an average of 3.78 years (the European Prospective Investigation Into Cancer and Nutrition cohort). Information on usual dietary intakes during the year preceding enrollment was recorded through a validated food frequency questionnaire. Adherence to the Mediterranean diet was assessed by a 10-unit Mediterranean diet score that incorporates the salient characteristics. Proportional hazards regression was used to assess the relation of overall degree of adherence to the Mediterranean diet with mortality overall or by cause (cardiac vs. noncardiac).
ACC CURRENT JOURNAL REVIEW August 2005
14
cholesterol improve the ability to identify subclinical atherosclerosis in young adults? Methods: The Bogalusa Heart Study was a longitudinal examination of the natural history of atherosclerosis in children and young adults conducted between 1973 and 1994. The relationship between advanced lipoprotein testing and carotid intimal media thickness (IMT) was determined in the 1995–1996 follow-up study in a sample of 311 randomly selected adults 20 to 38 years of age. Lipoprotein testing was performed by the vertical-spin density-gradient ultracentrifugation method (VAP, Vertical Auto Profile-I, Atherotech, Birmingham, AL) on stored blood. Primary end points were the relationship between standard and novel risk factors by comparing C-statistics from area under the receiver-operating characteristic curves (AUCs) derived from multivariable regression models. Results: Subjects were 42.4% men; 67.5% were white, mean age was 32.1 years, mean LDL-C 123 mg/dl, HDL-C 48 mg/dl, and triglycerides 111 mg/dl. Mean composite carotid IMT was 0.735⫾0.10 mm, and an IMT of ⱖ0.781 was considered the highest quartile. Seventy-five participants had incomplete data on the carotid IMT measures, and final comparisons were made in 236 participants with a complete data set. Lipid values obtained with advanced lipoprotein testing did not predict carotid intima-media thickness better than traditionally measured lipids. A model using traditional lipoprotein measures (AUC, 0.754 [95% CI, 0.690 – 0.812]) did not differ significantly from a model using advanced lipoprotein measures (AUC, 0.779 [CI, 0.662– 0.871]) for prediction of carotid intima-media thickness (p⬎0.2). Subclass pattern of LDL, LP (a) cholesterol, intermediate-density lipoprotein cholesterol, highdensity lipoprotein cholesterol subclasses and very-lowdensity lipoprotein subclasses did not improve the performance of models for prediction of carotid intimamedia thickness. Conclusions: Advanced lipoprotein testing using verticalspin density-gradient ultracentrifugation did not improve prediction of carotid intima-media thickness in young adults and may not be useful for assessing cardiovascular risk in this population. Perspective: This study, conducted in young adults, does not refute the findings that LDL particle size and number are better risk predictors than LDL-C for coronary events and event reduction in response to treatment in middle-aged and elderly persons with and without coronary disease. But it should give pause to those who use advanced lipoprotein testing with Lp(a), VAP, NMR spectroscopy, or gradient gel electrophoresis as a routine screening tool. MR
Advanced Lipoprotein Testing Does Not Improve Identification of Subclinical Atherosclerosis in Young Adults: The Bogalusa Heart Study
Healthy Lifestyle Characteristics Among Adults in the United States, 2000
Tzou WS, Douglas PS, Srinivasan SR, et al. Ann Intern Med 2005;142:742–50.
Reeves MJ, Rafferty AP. Arch Intern Med 2005;165:854 –7.
Study Question: Does lipoprotein particle size (LDL and HDL) and novel lipoproteins such as lipoprotein(a) (Lp[a])
Study Question: What is the distribution of healthy lifestyle characteristics among adults in the US?
ACC CURRENT JOURNAL REVIEW August 2005
13
Methods: National data for the year 2000 were obtained from the Behavioral Risk Factor Surveillance System, which consists of annual, statewide, random digit-dialed household telephone surveys. Four healthy lifestyle characteristics (HLCs) were defined as nonsmoking, healthy weight (BMI 18.5–25.0), consuming five or more fruits and vegetables per day, and regular physical activity (ⱖ30 min for ⱖ5 times per week). The four HLCs were summed to create a healthy lifestyle index (range, 0 – 4), and the pattern of following all four HLCs was defined as a single healthy lifestyle indicator. We report prevalences of each HLC and the indicator by major demographic subgroups. Results: In data from more than 153,000 adults, the prevalence (95%CI) of the individual HLCs was as follows: nonsmoking, 76.0% (75.6 –76.4%); healthy weight, 40.1% (39.7– 40.5%); five fruits and vegetables per day, 23.3% (22.9 –23.7%); and regular physical activity, 22.2% (21.8 – 22.6%). The overall prevalence of the healthy lifestyle indicator (i.e., having all four HLCs) was only 3.0% (95%CI, 2.8 –3.2%), with little variation among subgroups (range, 0.8 –5.7%). Conclusions: These data illustrate that a healthy lifestyle— defined as a combination of four HLCs—was undertaken by very few adults in the US, and that no subgroup followed this combination to a level remotely consistent with clinical or public health recommendations. Perspective: These data will be very useful for clinicians, local governments, insurance carriers and employers involved in efforts to reduce cardiovascular disease risk. The very costly major public health efforts targeting smoking cessation, exercise, and a healthy diet need to be reassessed with an emphasis on young people and families, and possibly rewarding good behavior by decreasing their cost of health insurance. MR
Results: Follow-up ranged from 0.04 years to 10.2 years. About 60% of subjects were over age 65, and 35% of men and 57% of women had a BMI ⬎30. A previous myocardial infarction was reported in 37.8% and the remainder reported angina pectoris. Higher adherence to the Mediterranean diet by 2 units was associated with a 27% lower mortality rate among persons with prevalent coronary heart disease at enrollment (total deaths, 131; adjusted mortality ratio, 0.73; 95%CI, 0.58 – 0.93). The reduced mortality was more evident and amounted to 31% (total deaths, 85; adjusted mortality ratio, 0.69; 95%CI, 0.52– 0.93) when only cardiac deaths were considered as the relevant outcome. Associations between individual food groups contributing to the Mediterranean diet score and mortality were generally not significant. Conclusions: Greater adherence to the traditional Mediterranean diet is associated with a significant reduction in mortality among individuals diagnosed as having coronary heart disease. Perspective: Epidemiologic and clinical trials have shown the benefit of diets high in fish, fiber, and fruits and vegetables, each of which is increased in the Mediterranean. The benefit is beyond that attributable to change in lipids and includes a decrease in CRP and putative antiarrhythmic properties of 3-omega PUFAs. This study did not address the relative benefits of wine or other alcoholic beverages. MR
Dose-comparison Study of the Combination of Ezetimibe and Simvastatin (Vytorin) Versus Atorvastatin in Patients With Hypercholesterolemia: The Vytorin Versus Atorvastatin (VYVA) Study Ballantyne CM, Abate N, Yuan Z, King TR, Palmisano J. Am Heart J 2005;149:464 –73. Study Question: How does the combination of simvastatin and ezetimibe compare to graduated doses of atorvastatin in reducing LDL-C, achieving ATP-III goal, and lowering the CRP? Methods: A multicenter, double-blind, 6-week parallelgroup study randomized 1902 patients with LDL-C above ATP-III goal to atorvastatin (10, 20, 40, or 80 mg) or to ezetimibe/simvastatin (10/10, 10/20, 10/40, or 10/80 mg). Patients were stratified by prerandomization LDL-C level. Results: There was no difference between groups for the following: mean age 58.7 years, 52% male, 86% white, 46% (CHD) or CHD equivalent, and 36% 2⫹CRFs. At each milligram-equivalent statin dose comparison, and averaged across doses, ezetimibe/simvastatin provided greater LDL-C reductions (47–59%) than did atorvastatin (36 – 53%). Ezetimibe/simvastatin 10/40 and 10/80 mg also provided significantly greater HDL-C increases than atorvastatin 40 and 80 mg. Triglyceride reductions were similar for all comparisons. More ezetimibe/simvastatin than atorvastatin patients with CHD or CHD risk equivalents attained the ATP-III LDL-C goal of ⬍100 mg/dl and the optional
Mediterranean Diet and Survival Among Patients With Coronary Heart Disease in Greece Trichopoulou A, Bamia C, Trichopoulos D. Arch Intern Med 2005;165:929 –35. Study Question: Is there a relationship between the degree of adherence to the traditional Mediterranean diet and survival in persons with coronary heart disease? Methods: This was a population-based prospective investigation of 1302 Greek men and women followed for an average of 3.78 years (the European Prospective Investigation Into Cancer and Nutrition cohort). Information on usual dietary intakes during the year preceding enrollment was recorded through a validated food frequency questionnaire. Adherence to the Mediterranean diet was assessed by a 10-unit Mediterranean diet score that incorporates the salient characteristics. Proportional hazards regression was used to assess the relation of overall degree of adherence to the Mediterranean diet with mortality overall or by cause (cardiac vs. noncardiac).
ACC CURRENT JOURNAL REVIEW August 2005
14