Lifestyle Implementation for Cardiovascular Disease Prevention: A Focus on Smoking Cessation, Diet, and Physical Activity
Oluwaseun E. Fashanu
Gowtham R. Grandhi
Erin D. Michos
INTRODUCTION
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the United States and the world despite large public health and healthcare expenditures.1 Despite several advancements in pharmacologic management of CVD and the use of such therapies (eg, statins) in primary prevention, there remains an excess risk of incident CVD and CVD-related mortality, which may be partly attributed to patients’ poor lifestyle choices. Promotion of a healthy lifestyle throughout one’s life span is the foundation for all preventive efforts. Previous declines in CVD morbidity and mortality of decades past now appear to be blunted, likely in part because of unfavorable lifestyle behaviors. This led the American Heart Association (AHA) in 2010 to release their 2020 impact goals aimed at improving the cardiovascular (CV) health of all Americans by 20% while reducing deaths attributable to CVD by 20%.2 Although CVD mortality in the United States declined during the years 2000-2011, it then plateaued during 2011-2014 and ceased to decline altogether from 2013 to 2015.1,3 Furthermore, CVD mortality has risen among younger adults, particularly middle-aged women.3,4 This worrisome trend reflects the rise in the rates of obesity, diabetes, and physical inactivity in the United States and worldwide during this same period.1
Poor lifestyle choices such as cigarette use, unhealthy diet, obesity, and physical inactivity adversely impact the CV health of individuals.1 Promoting and establishing a healthy lifestyle can reduce the development of CVD risk factors in the first place (primordial prevention), delay the onset of CVD among individuals with risk factors (primary prevention), and prevent recurrent events among those with established clinical CVD (secondary prevention).
In an attempt to achieve their aforementioned 2020 impact goal, the AHA developed the concept of the “Life’s Simple 7,” defined by seven modifiable metrics that contribute to CV health, namely, the behavioral factors of smoking, diet, physical activity, and body mass index (BMI) and the health-related factors of blood pressure (BP), glucose, and cholesterol control.2 Optimal CV health is defined as the presence of ideal levels at least 5 of the seven metrics: not smoking/smoking cessation for more than 12 months, having a heart-healthy diet, optimal physical activity levels, BMI less than 25 kg/m2, BP less than 120/80 mmHg, glucose less than 100 mg/dL, total cholesterol less than 200 mg/dL in adults without the use of medications, and the absence of clinical CVD.2 Based on recent data, none of the U.S. adult population met ideal levels of all seven metrics, with only 5% meeting six ideal metrics, and approximately 41% having two or less.1 Several studies have shown an inverse dose-response association between having increasing numbers of these ideal metrics with CVD, non-CV diseases, and all-cause mortality.5,6,7 A 2017 meta-analysis by Guo et al., consisting of thirteen prospective cohort studies and 198,126 participants, showed that having the highest number of ideal CV health metrics was associated with a lower risk of CVD (relative risk [RR] 0.22, 95% confidence interval [CI] 0.11, 0.42), CVD mortality (0.30 [0.18, 0.51]), and all-cause mortality (0.54 [0.41, 0.69]).7 Similarly, each increase in ideal CV health metric was associated with a 19% lower risk of CVD mortality and 11% lower risk of all-cause mortality.7
This chapter presents lifestyle interventions for CVD prevention, with a particular focus on three metrics of the Life’s Simple 7: smoking cessation, diet, and physical activity. Such underaddressed lifestyle changes will need to become a greater focus in managing and improving CV health globally.
SMOKING
Smoking leads to oxidative stress, increased sympathetic activation, endothelial dysfunction and injury, inflammation, and hypercoagulable states, conferring increased atherogenesis and thrombosis risk with resultant CVD.8 Smoking cessation reduces the risk of CVD morbidity and mortality, as well as all-cause mortality, compared to continued smoking.9 There has been a decline in the proportion of U.S. adults who smoke in recent years.1 Nevertheless, in 2019, about 34.1 million—representing 14.0% of U.S. adult population—continued to smoke cigarettes, similar to estimates from 2018.10,11 Despite the known deleterious effects of smoking, including pulmonary disease, CVD, and cancer, tobacco users continue to do so partly because of the addictive nature of nicotine, the active substance in tobacco. Cigarette smoking remains the leading cause of preventable disease and mortality in the United States
according to the 2020 U.S. Surgeon General report and has been the focus of public health interventions in recent times.9 Exposure to secondhand smoke also has its health consequences.1 There is no safe level of smoking. Smoking even just one cigarette daily confers nearly half the risk of coronary heart disease (CHD) and stroke as smoking 20 cigarettes daily.12
according to the 2020 U.S. Surgeon General report and has been the focus of public health interventions in recent times.9 Exposure to secondhand smoke also has its health consequences.1 There is no safe level of smoking. Smoking even just one cigarette daily confers nearly half the risk of coronary heart disease (CHD) and stroke as smoking 20 cigarettes daily.12
Although smoking cessation decreases CVD risk, former smokers still have higher risk than never smokers.13 The effects of smoking cessation on CHD risk reduce by half after the first year of quitting and equates that of never smokers after about 15 years of quitting. For stroke reduction, this takes about 5 to 15 years to equate the risk of never smokers.9 Cigarette smoking worsens atherosclerosis and is associated with subclinical atherosclerosis markers, including ankle-brachial index, carotid intima-media thickness, and coronary artery calcification (CAC).14 Though smoking cessation may slow the progression of subclinical atherosclerosis, it does not appear to be able to reverse it. Hence, the importance of avoiding cigarette use altogether if possible.
Cessation Advice/Treatment
Despite the proven benefits of smoking cessation, advice to quit by clinicians and prescriptions given for smoking cessation pharmacotherapies remain suboptimal.15 In a nationally representative U.S. survey, the proportion of smokers who reported receiving physician advice to quit smoking was 60% in 2006 to 2007 and only modestly increased to 65% by 2014 to 2015.15 As outlined in the 2019 American College of Cardiology (ACC)/AHA Guideline for the Primary Prevention of CVD, tobacco use should be assessed at every healthcare visit and individuals who smoke be counseled to quit (Class of Recommendation [COR] I, Level of Evidence [LOE] A).16 As little as 3 minutes of assessment and counseling at each visit is recommended. One approach that has been shown to be effective is the Five A’s method: Ask, Advise, Attempt, Assist, and Arrange (Table 97.1). Several modifications of the Five A’s approach such as AAC (Ask, Advise, Connect) and AAR (Ask, Advise, Refer) may also be effective.
A variety of U.S. Food and Drug Administration-approved tobacco cessation pharmacotherapy, five nicotine replacement therapies (NRTs) and two non-nicotine oral medications (Table 97.2), and behavioral interventions are available to help with quitting.16 A combination of both counseling and pharmacotherapy is recommended to maximize the success of quitting in nonpregnant individuals. Data on the safety of NRT in pregnant or breastfeeding mothers are limited, so NRT should be used with caution. A report by the U.S. Preventive Services Task Force found mixed results concerning the risk of preterm delivery and mean birth weight among pregnant individuals using NRT. Some studies showed a lower risk of preterm delivery and higher mean birth weight, whereas others did not find any associations.17 Nevertheless, cessation counseling advice remains crucial. Individualized short text messaging on cessation and web-based interventions have been shown to be effective. Public policies impact smoking cessation at the population level. Interventions such as the introduction of Tobacco 21 laws, which increases the age of being able to purchase cigarettes from 18 to 21 years, smoking policies such as the smoke-free indoor laws, tobacco education campaigns, cessation advise from healthcare providers, and the provision of quit lines (ie, free coaching over the phone) are effective.
TABLE 97.1 Five A’s Approach to Counseling Against Tobacco Use | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
TABLE 97.2 U.S. Food and Drug Administration-Approved Pharmacotherapies for Smoking Cessation | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Electronic Nicotine Delivery Systems
Electronic nicotine delivery systems (ENDS), also known as electronic cigarettes, e-cigarettes, or vape pens, are devices that produce aerosolized nicotine, flavored liquid, and solvents inhaled by users. They are usually battery operated, and they
have become more popular among U.S. youths (most especially the flavored brands). Given the relatively new introduction of electronic cigarettes since 2007 to the United States and multiple varieties, the long-term effects on CV health are not well established. However, there is concern about the potential harmful effects of metals, such as lead and arsenic, as well as the unregulated amounts of nicotine (ranging for 0 mg/mL to as high as 59 mg/mL) these devices expose to users.18,19 There is also an increased risk of nicotine addiction and progression to traditional cigarettes with electronic cigarette use, making their increased uptake among youths and never smokers concerning. According to a Centers for Disease Control and Prevention report, there was a 49% and 78% increase in electronic cigarette use among middle and high school students, respectively, between 2017 and 2018, partly eliminating prior progress made in the decline in use of tobacco products in these groups.20
have become more popular among U.S. youths (most especially the flavored brands). Given the relatively new introduction of electronic cigarettes since 2007 to the United States and multiple varieties, the long-term effects on CV health are not well established. However, there is concern about the potential harmful effects of metals, such as lead and arsenic, as well as the unregulated amounts of nicotine (ranging for 0 mg/mL to as high as 59 mg/mL) these devices expose to users.18,19 There is also an increased risk of nicotine addiction and progression to traditional cigarettes with electronic cigarette use, making their increased uptake among youths and never smokers concerning. According to a Centers for Disease Control and Prevention report, there was a 49% and 78% increase in electronic cigarette use among middle and high school students, respectively, between 2017 and 2018, partly eliminating prior progress made in the decline in use of tobacco products in these groups.20
Electronic cigarettes have been touted as a substitute for combustible cigarette cessation; however, substantial evidence for this is lacking. Five trials (n = 3117) reported inconsistent findings on the effectiveness of electronic cigarettes on smoking cessation at 6 to 12 months among smokers when compared with placebo or NRT, and none suggested higher rates of serious adverse events.17
Electronic cigarette use also adds to the dilemma of dual use of tobacco products. Dual use of tobacco products is the concurrent use of traditional cigarettes with other tobacco-containing products such as cigars, pipes, hookah, tobacco leaves, snuff, and electronic cigarettes. In 2013 to 2014, electronic cigarettes in addition to traditional cigarettes seemed to be the more common combination among young and adult dual users based on the Population Assessment of Tobacco and Health study.21 It is therefore essential that healthcare providers ascertain electronic cigarette use in addition to traditional cigarettes during clinic visits while counseling against quitting.
NUTRITION AND DIET
Dietary Guidelines
Diet is recognized as one of the most important determinants of overall health, and as such, dietary guidelines for the purposes of heart disease prevention have been in place and evolving since the 1970s in the United States.22 Suboptimal diet has been associated with nearly 50% of death secondary to heart diseases, stroke, and type 2 diabetes and shown to affect health regardless of age, sex, and sociodemographic characters.23,24 The 2019 ACC/AHA Guideline for the Primary Prevention of CVD endorses (1) increased consumption of vegetables, fruits, legumes, and whole grains; (2) moderate consumption of vegetable oil, nuts, seafood, low-fat dairy, and lean meats; and (3) avoiding or restricting processed meats, saturated fats, trans-fats, salt, refined carbohydrates, and sugar-sweetened beverages (Table 97.3).16,25 Additionally, it recommends plant-based and Mediterranean diets that share similarities, such as a high intake of fiber, antioxidants, vitamins, minerals, polyphenols, and monounsaturated and polyunsaturated fatty acids; and low intake of salt, refined sugar, carbohydrates with high glycemic load, and saturated and trans-fats.
TABLE 97.3 Components of Heart-Healthy Diet | ||||||||
|---|---|---|---|---|---|---|---|---|
|
Macronutrient Approaches to Optimize Health
Dietary Carbohydrates and Sugars
Dietary carbohydrates are the main source of energy. Whole grains are unprocessed and are a good source of fiber and micronutrients in contrast to refined grains that lack the outer layers of the edible kernel. Consumption of whole grains such as whole grain bread, oatmeal, breakfast cereal, brown rice, unrefined maize and sorghum is associated with greater risk reduction of CVD and all-cause mortality when compared to minimal benefit with refined grain such as white bread, white rice, and refined breakfast cereal. Most importantly, studies have shown a dose-response benefit in CVD risk and all-cause mortality with whole grain consumption.26,27
Supplementary sugars (other than naturally occurring sugars in milk and fruits) such as corn syrup, raw or brown sugar, and honey are often added to foods and beverages when processed or packaged. A majority of the added sugars are obtained from sugar-sweetened beverages (sodas, fruit drinks, energy/sports drinks), candy, cakes, and sweetened dairy products. Yang et al. reported a significant association between CVD mortality and increased added sugar consumption, with a 2.75-fold increase in hazard ratio (HR) for CVD deaths among individuals with greater than 25% of daily calorie consumption from added sugars when compared with individuals with less than 10% of daily calorie consumption.28 Therefore, the ACC/AHA, the European Society of Cardiology, and the U.S. Departments of Agriculture and Health and Human Services dietary guidelines emphasize whole grain consumption and minimizing refined sugars and added sugars.16,25,29,30
Dietary Fats
Dietary fat comprises unsaturated fat, saturated fat, and trans-fat. Similar to carbohydrates, different fats have been found to have differential association with CVD and all-cause mortality. Unsaturated fats, which include monounsaturated
and polyunsaturated fatty acids, are predominantly found in vegetable oils, seeds, nuts, olives, and fish. These are often referred to as “healthy fats” because they are associated with reduced CVD risk and overall mortality, whereas trans- and saturated fats—primarily found in animal fats such as fatty meats, milk, and processed foods like margarine, butter, and cheese—have been associated with increased risk of most CV outcomes.
and polyunsaturated fatty acids, are predominantly found in vegetable oils, seeds, nuts, olives, and fish. These are often referred to as “healthy fats” because they are associated with reduced CVD risk and overall mortality, whereas trans- and saturated fats—primarily found in animal fats such as fatty meats, milk, and processed foods like margarine, butter, and cheese—have been associated with increased risk of most CV outcomes.
Using combined data from two large prospective cohort studies of 126,233 participants with a follow-up of over 25 years, Wang et al. demonstrated lower mortality with monounsaturated (HR 0.89 [0.84, 0.94]) and polyunsaturated fats (HR 0.81 [0.78, 0.84]).31 Conversely, trans-fats had the highest total mortality (HR 1.13 [1.07, 1.18]) closely followed by saturated fats (HR 1.08 [1.03, 1.14]). Additionally, Wang et al. demonstrated that substituting saturated and trans-fats with unsaturated fats resulted in significant reduction in mortality, particularly with polyunsaturated fatty acids. Thus, the 2019 ACC/AHA Primary Prevention Guideline recommends replacing saturated fat with dietary monounsaturated and polyunsaturated fats to reduce atherosclerotic CVD risk (COR IIa, LOE B—Non-randomized) and that trans-fats should be avoided (COR III—harm, LOE B—Nonrandomized).16
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
