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Toronto Notes 2019 Health Promotion and Counselling
Cardiovascular Disease Prevention
Table 4. Dietary Guidelines for Reducing Risk of Cardiovascular Disease
Family Medicine FM7
Fat, Carbohydrates, Protein
Omega-3 Fatty Acid Rich Foods
Salt
Alcohol
Dietary Approaches
Recommendations
Overall fat intake: 26-27% of total energy Saturated fat: 5-6% of total energy
Trans fat: reduce intake, replace with MUFA or PUFA
Carbohydrates: 55-59% of total energy Protein: 15-18% of total energy
≥2 servings/wk of fish (especially oily fish like salmon)
≤2,400 mg/d
≤3 drinks/d for men, max 15/wk ≤2 drink/d for women, max 10/wk
DASH diet (Dietary Approaches to Stop Hypertension), recommended by the American Heart Association (AHA)
Diet: high in vegetables/fruits, low-fat dairy, whole grains, poultry, fish, and nuts;
Low in sweets, sugar-sweetened beverages, red meats
Macronutrients: low in saturated/total fat and cholesterol; high in potassium, magnesium, calcium, protein, and fibre
Mediterranean diet (fruits, vegetables, whole grains, legumes, nuts, olive oil, and herbs)
Effects
Lower LDL
Decreased sudden death, death from CAD Lower TG
Lower BP
Combining decreased sodium intake with the DASH diet (see below) achieves even greater BP-lowering effects
Decreased risk of hypertriglyceridemia, HTN, osteoporosis, certain cancers
Lower BP, lower LDL
Osteoporosis Canada Recommendations for Calcium and Vitamin D Daily Requirements • Vitamin D: 800-1,000 IU for individuals age
<50 yr, 800-2,000 IU for individuals ≥50 yr • Calcium: 1,000 mg daily from all sources
for individuals 19-50 yr and pregnant/ lactating women; 1,200 mg daily for individuals >50 yr (recommended to obtain calcium from nutrition whenever possible vs. supplementation)
Effectiveness of Behavioural and Pharmacologic Treatment for Overweight and Obesity in Adults CMAJ Open 2014;2:E306-17
Purpose: To evaluate the effectiveness of behavioural and pharmacological treatments for overweight and obese adults.
Methods: Review of RCTs of primary-care-
relevant behavioural (diet, exercise, lifestyle) and pharmacological (orlistat, metformin) treatments with or without behavioural interventions in overweight or obese adults with 12 month follow-up from baseline for weight outcomes or harms. Secondary health outcomes (total cholesterol, LDL, fasting blood glucose, incidence of type 2 DM, systolic and diastolic BP) were also studied. Results: 68 RCTs were included, and showed
that intervention participants had greater weight loss (-3.02 kg, 95% CI -3.52 to -2.52), waist circumference reduction (-2.78, -3.34 to -2.22) and body mass index reduction (-1.11, -1.39 to -0.84). Relative risk for weight loss of 5% or greater body weight was 1.77 (1.58 to 1.99, NNT 5, 95% CI
4-7). Incidence of type 2 DM was lower among pre-diabetic intervention participants.
Conclusion: Behavioural and pharmacological treatments for overweight and obese adults may lead to clinically important reductions in weight and type 2 DM incidence in pre-diabetics.
Losing Weight
• Aim for caloric intake 500-1000 kcal/d less than total daily energy expenditure (TDEE)
• 3500 kcal energy expended/lb of fat burned, results in 1-2 lb (0.5-1 kg) weight loss per week
• Achieved by combination of increased activity and/or decreased caloric intake
Low BMI Associations
• Osteoporosis
• Eating disorders
• Under-nutrition
• Pregnancy complications
Adverse Medical Consequences of Obesity
MUFA = monounsaturated fatty acids; PUFA = polyunsaturated fatty acids
Eckel RH, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013
Dietary approaches to stop hypertension (DASH), available from: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/dash_brief.pdf
Lichtenstein AH, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation 2006;114:82-96
Obesity
2015 Canadian Task force on Preventive Health Care Recommendations
• body mass index (BMI) = weight (kg)/height (m)2 = weight (lbs)/height (in)2 x 703; poor predictor of obesity
• waistcircumference(WC)=flexibletapeplacedonhorizontalplaneatiliaccrest;normaldependson ethnic background
• increasedWCforBMI25-35increasestheriskofcardiovasculardiseaseandtype2diabetes
Table 5. Classification of Weight by BMI, Waist Circumference, and Associated Disease Risks in Adults
Disease Risk* Relative to Normal Weight and Waist Circumference
BMI (kg/m2)
Obesity Class
Men ≤102 cm (40 in) Women ≤88 cm (35 in)
Increased
High
Very High Extremely High
Men >102 cm (40 in) Women >88 cm (35 in)
High
Very High
Very High Extremely High
Underweight Normal Overweight Obesity Class I Obesity Class II
Obesity Class III
(Extreme Obesity)
<18.5
18.5-24.9
25.0-29.9
30.0-34.9 I
35.0-39.9 40.0 +
II III
* Disease risk for type 2 diabetes, hypertension, and CVD
From: Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks, National Institute of Health, National Heart Lung and Blood Institute, Obesity Education Initiative, http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm
Epidemiology
• 20.2%ofCanadiansaged18andolder(excludingpregnantwomen)wereobesein2014(StatsCan, 2014)
• obesity remains higher in Aboriginal populations compared with non-Aboriginal populations with 25.7% of Aboriginal adults (excluding First Nations on-reserve) estimated to be obese (CCHS 2007/2008)
• closetoathirdof5-17-year-oldswereidentifiedasoverweightorobese(2009to2011CHMS)
• overweightandobesityratesinchildrenaredirectlyproportionaltoscreentime(seeExercise,FM10)
• Type 2 DM • • CAD • • Stroke • • HTN • • Gallbladder •
disease • • Non-alcoholic •
Dyslipidemia Osteoarthritis Sleep apnea Certain cancers CHF
Low back pain Increased total mortality
steatohepatitis
• Pregnancy complications