Lifestyle Interventions to Reduce Cardiovascular Risk

263 Pages·2014·2.2 MB·English

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