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Lifestyle Interventions to Reduce Cardiovascular Risk PDF

263 Pages·2014·2.2 MB·English
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Lifestyle Interventions to Reduce Cardiovascular Risk Systematic Evidence Review From the Lifestyle Work Group, 2013 Contents Foreword...................................................................................................................................... vii  Lifestyle Work Group .................................................................................................................... ix  Section 1: Background and Description of the NHLBI Cardiovascular Risk Reduction Project ..................................................................................................................................... 1  A.  Background ....................................................................................................................... 1  B.  Lifestyle Work Group Report ............................................................................................. 2  Section 2: Process and Methods Overview ................................................................................. 3  A.  Evidence-Based Approach ............................................................................................... 3  i.  Overview of the Evidence-Based Methodology .......................................................... 3  ii.  System for Grading the Body of Evidence .................................................................. 4  B.  Critical Question-Based Approach .................................................................................... 5  Section 3: CQ1—Dietary Patterns and Macronutrients: Blood Pressure and Lipids .................. 7  A.  Introduction/Rationale ....................................................................................................... 7  B.  Selection of Inclusion/Exclusion Criteria ........................................................................... 7  C.  Literature Search Yield ..................................................................................................... 8  i.  Dietary Pattern Evidence ............................................................................................ 9  D.  CQ1 Evidence Statements ................................................................................................ 9  i.  Dietary Patterns .......................................................................................................... 9  ii.  Dietary Fat and Cholesterol ...................................................................................... 17  Section 4: CQ2—Sodium and Potassium: Blood Pressure and CVD Outcomes ..................... 21  A.  Introduction/Rationale ..................................................................................................... 21  B.  Selection of Inclusion/Exclusion Criteria ......................................................................... 21  C.  Literature Search Yield ................................................................................................... 23  D.  CQ2 Evidence Statements .............................................................................................. 23  i.  Sodium and Blood Pressure ..................................................................................... 23  ii.  Sodium and CHD/CVD Outcomes ............................................................................ 30  iii.  Potassium and Blood Pressure and CHD/CVD Outcomes ....................................... 33  Section 5: CQ3—Physical Activity: Lipids and Blood Pressure ................................................ 35  A.  Introduction/Rationale ..................................................................................................... 35  B.  Selection of Inclusion/Exclusion Criteria ......................................................................... 35  C.  Literature Search Yield ................................................................................................... 36  D.  CQ3 Evidence Statements .............................................................................................. 37  i.  Physical Activity and Lipids ....................................................................................... 37  ii.  Physical Activity and Blood Pressure ........................................................................ 40  Section 6: Gaps in Evidence and Future Research Needs ....................................................... 45  A.  Diet .................................................................................................................................. 45  B.  Physical Activity .............................................................................................................. 45  Appendixes  Appendix A.  Methods for Lifestyle Questions ................................................................ A–1  Appendix B.  Critical Question 1 Methods ...................................................................... B–1  Appendix C.  Critical Question 2 Methods ...................................................................... C–1  Appendix D.  Critical Question 3 Methods ...................................................................... D–1  Appendix E.  Abbreviations and Acronyms ..................................................................... E–1  References ......................................................................................................................... R–1  LIFESTYLE INTERVENTIONS TO REDUCE CARDIOVASCULAR RISK: SYSTEMATIC EVIDENCE REVIEW FROM THE LIFESTYLE WORK GROUP, 2013 iii List of Tables Table 1. Evidence Quality Grading System ................................................................................. 4  Table 2. PICOTS Approach for CQ1 ........................................................................................... 8  Table 3. Summary of Supporting Evidence for ES1 and ES2 ................................................... 11  Table 4. Summary of Supporting Evidence for ES1 and ES2 ................................................... 12  Table 5. Food Composition of DASH Diet vs. Control Diet ........................................................ 13  Table 6. Macronutrient Composition of DASH Diet vs. Control Diet .......................................... 13  Table 7. Macronutrient Composition and Lipid Effects in DASH, DASH-Sodium, and DELTA .................................................................................................................................. 18  Table 8. PICOTS Approach for CQ2 ......................................................................................... 22  Table 9. Effects of Sodium Reduction on Systolic/Diastolic Blood Pressure (mmHg) in the DASH-Sodium Trial ........................................................................................................ 26  Table 10. PICOTS Approach for CQ3 ....................................................................................... 36  Table A–1. Quality Assessment Tool for Controlled Intervention Studies ............................... A–6  Table A–2. Quality Assessment Tool for Systematic Reviews and Meta-Analyses .............. A–10  Table A–3. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies .............................................................................................................................. A–13  Table A–4. Quality Assessment Tool for Case-Control Studies ............................................ A–20  Table A–5. Evidence Quality Grading System ....................................................................... A–30  Table A–6. Examples of Simple Queries ............................................................................... A–32  Table A–7. Attributes and Their Values ................................................................................. A–34  Table A–8. Common Macro Queries Used in Search Strategies .......................................... A–35  CQ1 Summary Table B–1. Mediterranean Style Dietary Pattern ............................................ B–6  CQ1 Summary Table B–2. DASH Dietary Pattern and DASH Variations .............................. B–13  CQ1 Summary Table B–3. DASH Pattern Subgroups: Sex ................................................. B–18  CQ1 Summary Table B–4. DASH Pattern Subgroups: Race/Ethnicity ................................. B–22  CQ1 Summary Table B–5. DASH Pattern Subgroup: Hypertension Status ......................... B–27  CQ1 Summary Table B–6. DASH Pattern Subgroup: Age ................................................... B–32  CQ1 Summary Table B–7. Glycemic Index/Load .................................................................. B–35  CQ1 Summary Table B–8. Dietary Fat and Cholesterol ........................................................ B–39  Table B–9. Critical Question 1 Studies Rated as Poor, With Rationale ................................. B–45  CQ2 Summary Table C–1. Overall Sodium and Blood Pressure Outcomes ........................... C–6  CQ2 Summary Table C–2. Different Levels of Sodium ......................................................... C–11  CQ2 Summary Table C–3. Sodium and Other Dietary Changes .......................................... C–13  CQ2 Summary Table C–4a. Sodium and Subpopulation: Sex ............................................. C–18  CQ2 Summary Table C–4b. Sodium and Subpopulation: Race/Ethnicity ............................ C–27  CQ2 Summary Table C–4c. Sodium and Subpopulation: Age ............................................. C–36  iv LIFESTYLE INTERVENTIONS TO REDUCE CARDIOVASCULAR RISK: SYSTEMATIC EVIDENCE REVIEW FROM THE LIFESTYLE WORK GROUP, 2013 CQ2 Summary Table C–4d. Sodium and Subpopulation: Hypertension Status ................... C–40  CQ2 Summary Table C–5. Sodium and CVD Outcomes: Trials or Observational Followup of Trials .............................................................................................................. C–46  CQ2 Summary Table C–6. Sodium and CVD Outcomes: Observational Data .................... C–51  CQ2 Summary Table C–7. Potassium and Blood Pressure and CVD Outcomes ................. C–64  CQ2 Summary Table C–8. Potassium and CVD Outcomes .................................................. C–68  Table C–9. Critical Question 2 Studies Rated as Poor, With Rationale ................................ C–81  CQ3 Summary Table D–1. Aerobic Exercise and LDL-C ........................................................ D–3  CQ3 Summary Table D–2. Resistance Exercise and LDL-C .................................................. D–4  CQ3 Summary Table D–3. Aerobic Exercise and HDL-C ....................................................... D–4  CQ3 Summary Table D–4. Resistance Exercise and HDL-C .................................................. D–5  CQ3 Summary Table D–5. Aerobic Exercise and Blood Pressure .......................................... D–5  CQ3 Summary Table D–6. Resistance Exercise and Blood Pressure .................................... D–6  Table D–7. Critical Question 3 Studies Rated as Poor, With Rationale ................................... D–7  List of Figures Figure B–1. PRISMA Diagram Showing Selection of Articles for Lifestyle Critical Question 1 .......................................................................................................................... B–5  Figure C–1. PRISMA Diagram Showing Selection of Articles for Lifestyle Critical Question 2 .......................................................................................................................... C–5  Figure D–1. PRISMA Diagram Showing Selection of Articles for Lifestyle Critical Question 3 .......................................................................................................................... D–2  LIFESTYLE INTERVENTIONS TO REDUCE CARDIOVASCULAR RISK: SYSTEMATIC EVIDENCE REVIEW FROM THE LIFESTYLE WORK GROUP, 2013 v Foreword In 1977, the National Heart, Lung, and Blood Institute (NHLBI) issued the first of several clinical practice guidelines (CPGs) as part of its core mission, which is to provide global leadership for a research, training, and education program to promote the prevention and treatment of heart, lung, and blood diseases and enhance the health of all individuals so that they can live longer and more fulfilling lives. Guidelines from the National High Blood Pressure Education Program, the National Cholesterol Education Program, the Obesity Education Initiative, as well as from other similar programs and initiatives, have addressed a variety of topics, including, but not limited to, cholesterol, blood pressure, obesity, asthma, and von Willebrand disease. Over the years, health care systems and providers have used these guidelines for the prevention, detection, evaluation, and treatment of cardiovascular disease risk factors, and lung and blood diseases. In 2008, NHLBI convened expert panels to update the existing clinical guidelines on cholesterol, blood pressure, and overweight/obesity, by conducting rigorous systematic evidence reviews. At the same time, three crosscutting work groups—on lifestyle, risk assessment, and implementation—were convened to develop additional systematic evidence reviews to support the work of the expert panels. The impetus for these guidelines was the recognition that despite the enormous progress over the last 60 years, cardiovascular disease remains the leading cause of death in the United States. While the updates were underway, the Institute of Medicine (IOM) issued two reports that established new "best practice" standards for generating systematic evidence reviews and developing clinical guidelines. The reports underscore that these are two distinct, yet related, activities that require careful intersection and coordination. Accordingly, NHLBI’s role in the guidelines updates transitioned to completing a systematic evidence review for each topic and collaborating with other organizations to prepare and issue the related clinical guidelines. Since implementing the new collaborative partnership model for developing guidelines based upon NHLBI- sponsored systematic evidence reviews, four of the five Expert Panels/Work Groups have worked successfully with the American Heart Association (AHA), the American College of Cardiology (ACC), The Obesity Society (TOS), and other professional societies to develop new cardiovascular disease prevention CPGs for lifestyle, risk assessment, cholesterol, and obesity. The new guidelines—published in November 2013 by the AHA, ACC, and TOS, and endorsed by other professional societies—provide a valuable updated roadmap to help clinicians and patients manage CVD prevention and treatment challenges. We appreciate the outstanding work and dedication of the expert panels and work groups that developed the systematic evidence reviews that formed the basis for the guidelines. These systematic evidence reviews are the products of one of the most rigorous evidence-based systematic reviews conducted to date. We look forward to continuing to develop accurate and timely evidence reviews, fueled by our investment in primary research on the prevention and treatment of cardiovascular disease as well as implementation science, to improve public health. The following systematic evidence report is available as a public resource. Gary H. Gibbons, M.D. Director National Heart, Lung, and Blood Institute LIFESTYLE INTERVENTIONS TO REDUCE CARDIOVASCULAR RISK: SYSTEMATIC EVIDENCE REVIEW FROM THE LIFESTYLE WORK GROUP, 2013 vii

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ES6. Among adult men and women at all BP levels, including hypertensive individuals, aerobic physical activity decreases systolic and diastolic BP, on average, by 2–5 mmHg and 1–4 mmHg, respectively. Typical interventions shown to be effective for lowering BP include aerobic physical activity o
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