Coronary heart disease remains the leading killer of men and women in the United States. Coronary heart disease also represents one of the quintessential lifestyle-related diseases. Many of the major risk factors for coronary heart disease, including elevated cholesterol, high blood pressure, cigarette smoking, an inactive lifestyle, and obesity, have very significant lifestyle-related components. In part I of this review, the authors discussed the rationale for using lifestyle medicine strategies as part of a comprehensive approach to preventing, reducing the risk, or treating coronary heart disease. In part II, the authors focus on practical strategies for incorporating lifestyle medicine techniques into clinical practice. The overall framework is based on the American College of Cardiology's Bethesda Conference, which places risk factors into 4 categories depending on the likelihood that modifying a particular risk factor will result in lowering the risk of coronary heart disease. The authors have similarly grouped lifestyle medicine strategies to explore how these interventions can be employed in each of the classes of interventions defined by the American College of Cardiology. Although the authors recognize that individual clinicians have time constraints which affect utilization of lifestyle medicine strategies, the best outcomes can be achieved by combining these interventions with more traditional modalities for reducing the risk, preventing, or treating coronary heart disease.
Yarnall KS, Pollack KI, Östbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention?Am J Pub Health. 2003;93:635-641.
2.
Chobanian AV, Bakris G, Black H, et al, and the National Health High Blood Pressure Education Program Coordinate Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA. 2003;289:2560-2571.
3.
Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final Report. Circulation. 2002;106:3143-3421.
4.
US Department of Health and Human Services. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, Md: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.
5.
A Report of the Surgeon General on Physical Activity and Health. Rockville, Md: US Department of Health and Human Services, Centers for Disease Control; 1999.
6.
Pate R, Pratt M, Blair S, et al. Physical activity and public health: a recommendation from Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402-407.
7.
Institute of Medicine. Weighing the Options: Criteria for Evaluating Weight Management Programs. Washington, DC: National Academy Press; 1994.
8.
Eckel R. Obesity and heart disease: a statement for the healthcare professionals from the Nutrition Committee, American Heart Association. Circulation. 1997;96:3248-3250.
9.
Fletcher G, Blair S, Blumenthal J, et al. AHA medical/scientific statement. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. AHA Scientific Council. Circulation. 1992;86:340-344.
10.
Ockene JK, Quirk ME, Goldberg RJ, et al. A resident's training program for the development of smoking intervention skills. Arch Intern Med. 1988;148:1039-1045.
11.
Mojonnier ML, Hall Y, Brkson DM, et al. Experience in changing food habits of hyperlipidemic men and women. JADA. 1988;77:140-148.
12.
Dunbar J. Assessment of medication compliance: a review. In Haynes RB, Mattson ME, Engebretson TO, eds. Patient Compliance to Prescribed Antihypertensive Medication Regimen. USDHHS Pub. No. (NIH) 81-2101. Washington, DC: USDHHS;1988.
13.
Greenfield S, Kaplan SH, Ware JE, et al. Patients' participation in medical care: effects on blood pressure sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448-457.
14.
Schulman BA. Active patient orientation and outcomes in hypertensive treatment: application of a socio-organizational perspective. Med Care. 1979;17:267-280.
15.
Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, DeVellis RF, Sandles RS. Improving dietary behavior: the effectiveness of tailored messages in primary care settings. Am J Public Health. 1984;84:783-787.
16.
Glynn TJ, Manley MW, Cullen JW, Mayer JW. Cancer prevention through physician interventions. Semin Oncol. 1990;17:391-401.
17.
Ford AS, Ford WS. Health education and the primary care physician: the practitioner's perspective. Soc Sci Med. 1983;17:1505-1512.
18.
National Center for Health Statistics. Health, United States 1987. USDHHS Pub. No. 88-1232. Washington, DC: US Department of Health and Human Services, Public Health Service; 1988.
19.
Fiore M, Novotny T, Lynn W, et al. Methods used to quit smoking in the United States: do cessation programs help?JAMA. 1990;263:2760-2765.
20.
Rippe J, Aronne L, Gilligan V, et al. Public policy statement on obesity and health. Nutr Clin Care. 1998;1:15-29.
21.
Ockene JK. Physician-delivered interventions for smoking cessation: strategies for increasing effectiveness. Prev Med. 1987;16:723-737.
22.
Wilson PW, D'Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837-1847.
23.
Pearson TA, McBride PE, Miller NH, Smith SC. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 8. Organization of preventive cardiology service. J Am Coll Cardiol. 1996;27:1039-1047.
24.
Annual smoking attributable mortality, years of potential life lost, and economic costs—United States, 1995-1999. MMWR Morb Mortal Wkly Rep. 2004;51:300-302.
25.
Reducing Risk, Promoting Healthy Life: World Health Report 2002. Geneva, Switzerland: World Health Organization; 2002.
26.
Jha P, Chaloupka FJ. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington, DC: World Bank; 1999.
Office of Smoking and Health. Percentage of Smoking Prevalence Among Adults 18 Years of Age and Older, 1955-1994. Atlanta, Ga: National Center for Chronic Disease and Prevention, Centers for Disease Control and Prevention; 1996.
29.
A clinical practice guideline for treating tobacco use and dependence: a US publication health service report. The Tobacco Use and Dependence Clinical Practice Guidelines Panel, Staff, and Consortium Representatives. JAMA. 1997;278:1759-1766.
30.
US Preventive Services Task Force. Guide to Clinical Preventive Services. 3rd ed.Rockville, Md: Agency for Healthcare Research and Quality; 2000-2003.
31.
Thomson CC, Rigott NA. Hospital and clinic based smoking cessation interventions for smokers with cardiovascular disease. Prog Cardiovasc Dis. 2003;45:459-479.
32.
National Center for Health Statistics. Health, United States, 2002. Hyattsville, Md: US Prevention; 2002.
33.
Guidelines for using serum cholesterol, high density lipoprotein cholesterol, and triglyceride levels as screening tests for preventing coronary heart disease in adults. American College of Physicians. Ann Intern Med. 1996;124:515-517.
34.
Hajjar I, Kolchen TA. Trends in prevalence, awareness, treatment and control of hypertension in the United States, 1988-2000. JAMA. 2003;290:199-206.
35.
Vasan RS, Beisor A, Seahandri S, et al. Residual lifestyle risk for developing hypertension in middle aged women and men. The Framingham Heart Study. JAMA. 2002;287:1003-1010.
36.
Burt V, Whelton P, Roccella EG, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey. 1988-1991. Hypertension. 1995;25:305-313.
37.
Heyka R. Obesity and hypertension. Nutr Clin Care. 1998;1:30-37.
38.
Stevens V, Corrigan S, Obarzanke E, et al. Weight loss intervention in phase I of the trials of hypertension prevention. Arch Intern Med. 1993;153:849-858.
39.
National Education Blood Pressure Education Program Work Group. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med. 1993;153:186-208.
40.
Stepniakowski K, Egan BM. Additive effects of obesity and hypertension to limit venous volume. Am J Phys. 1995;268:R562-R568.
41.
Appel LJ, Moore TJ, Obarzanke E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med. 1997;336:1117-1124.
42.
Sacks FM, Svetkey LP, Vollmer WM, et al. Effects of blood pressure of reduced dietary sodium and Dietary Approaches to Stop Hypertension (DASH) diet. DASH Sodium Collaborative Research Group. N Engl J Med. 2001;344:3-10.
43.
ACSM Position Stand. Physical activity, physical fitness, and hypertension. Med Sci Sports Exer. 1993;25:i-x.
44.
Marmot MG, Elliott P, Shipley MJ, et al. Alcohol and blood pressure. The INTERSALT Study. Br Med J. 1994;308:1263-1263.
45.
Kaplan NM. Systemic hypertension: therapy. In Braunwald E, ed. Heart Disease. 5th ed.Philadelphia: W. B. Saunders; 1997.
46.
Giannattasio C, Mangoni AA, Stella ML, et al. Acute effects of smoking on radial artery compliances in humans. J Hypertens. 1994;12:691-691.
47.
Eisenberg DM, Delbanco TL, Berkey CS, et al. Cognitive behavioral techniques for hypertension: are they effective?Am J Hypertens. 1993;4:416-416.
48.
Collaborative meta analysis of randomized trials of antiplatelet of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71-86.
49.
Aspirin for the primary prevention of cardiovascular events: recommendation and rationale. Ann Inter Med. 2002;136:157-160.
50.
Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360:7–22.
51.
Shepherd J, Blauw GJ, Murphy MB, et al, and the PROSPER study group. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomized controlled trial. PROspective Study of Pravastatin in the Elderly at Risk. Lancet. 2002;360:1623–1630.
52.
Sever PS, Dahlof B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet. 2003;361:1149–1158.
53.
Cannon CP, Braunwald E, McCabe CH, et al, and the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350:1495–1504.
54.
Rader DJ. Infl ammatory markers of coronary risk. N Engl J Med. 2000;343:1179-1182.
55.
Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730-1737.
56.
Teo KK, Yusuf S, Pfeffer M, et al. Effects of long-term treatment with angiotensin converting enzyme inhibitors in the presence or absence of aspirin: a systematic review. Lancet. 2002;360:1037-1043.
57.
Rippe JM. Obesity as a risk factor for heart disease: an overview. Nutr Clin Care. 1998;1:3-14.
58.
Manson JE, Willett WC, Stampler JM, et al. Body weight and mortality among women. N Engl J Med. 1995;333:677-685.
59.
Rimm EB, Stampler MJ, Giovannucci B, et al. Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US men. Am J Epidemiol. 1995;141:1117-1127.
60.
Garrison RJ, Castelli WP. Weight and thirtyyear mortality of men in the Framingham Study. Ann Int Med. 1985;103:1006-1009.
61.
World Health Organization. Prevention and Management of the Global Epidemic of Obesity. Report of the WHO Consultation on Obesity No. 10. Geneva, Switzerland: WHO; 1997.
62.
Chan JM, Rimm EB, Colditz GA, et al. Obesity, fat distribution, and weight gain as a risk factor for clinical diabetes in men. Diabetes Care. 1994;17:961-969.
63.
Pouliot MC, Despres JP, Lemieux S, et al. Waist circumference and abdominal sagittal diameter: best simple anthropometric indexes of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men. Am J Cardiol. 1994;73:460-468.
64.
Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the Third National Health and Nutrition Examination Survey. JAMA. 2002;287:356-376.
65.
Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends 1960-1994. Int J Obes Relat Metab Disord. 1998;22:39-47.
66.
Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723-1727.
67.
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; 1998.
68.
Finkelstein EA, Fiebelkorn IC, Wang G. National medical spending attributable to overweight and obesity. How much, and who's paying?Health Aff (Millwood). 2003;22(Web suppl).
69.
Rippe JM. The case for medical management of obesity: a call for increased physician involvement. Obes Res. 1998;6:23S-33S.
70.
Knowler WC, Barrett-Connor E, Fowler SE, et al, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403.
71.
Wadden TA, Butryn ML, Ryme KJ. Efficacy of lifestyle modification for long-term weight control. Obes Res. 2004;12(suppl):151S-162S.
72.
Klem M, Wing R, McGuire M, et al. A descriptive study of individual successful at long-term maintenance of substantial weight loss. Am J Clin Nutr. 1997;66:239-246.
73.
Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. Am J Clin Nutr. 1990;52:800-807.
74.
Jakicic JM, Winters C, Lang W, Wing RR. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women: a randomized trial. JAMA. 1999;282:1554-1560.
75.
Wadden TA, Vogt RA, Foster GD, Anderson DA. Exercise and the maintenance of weight loss: 1-year follow-up of a controlled clinical trial. J Consult Clin Psychol. 1998;66:429-433.
76.
Rippe JM, Hess S. The role of physical activity in the prevention and management of obesity. J Am Diet Assoc. 1998;98:S31-S38.
77.
Rippe JM, Crossley S, Ringer R. Obesity as a chronic disease: modern medical and lifestyle management. J Am Diet Assoc. 1998;98:S9-S15.
78.
Nonas CA. A model for chronic care of obesity through dietary treatment. JADA. 1998;98:S16-S22.
79.
National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2000. Atlanta: Centers for Disease Control and Prevention; 2002.
80.
Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose and impaired glucose tolerance in US adults. The Third National Health and Nutritional Examination Survey, 1988-1994. Diabetes Care. 1998;21:518-524.
81.
Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the US population, 1971-1993. Diabetes Care. 1998;21:1138-1145.
82.
Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348:383-393.
83.
Arauz-Pacheo C, Parrott MA, Raskin P. Treatment of hypertension in adults with diabetes. Diabetes Care. 2003;26(suppl): S80-S82.
84.
Tumoilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343-1350.
Rimm EB, Williams P, Foster K, et al. Moderate alcohol intake and lower risk of coronary heart disease: meta-analysis of effects on lipids and haemostatic factors. BMJ. 1999;319:1523-1528.
87.
Ness AR, Powles JW. Fruit and vegetables, and cardiovascular disease: a review. Int J Epidemiol. 1997;26:1-13.
88.
Joshipura KJ, Ascherio A, Manson JE, et al. Fruit and vegetable intake in relation to risk of ischemic stroke. JAMA. 1999;282:1233-1239.
89.
Drusseldorp E, van Elderen T, Maes S, et al. A meta-analysis of psycho educational programs for coronary heart disease patients. Health Psychol. 1999;18:506-519.
90.
Anderson R. Deaths: Leading Causes for 2000. National Vital Statistics Reports. Vol. 50, no. 16. Hyattsville, Md: National Center for Health Statistics; 2002.
91.
Grady D, Herrinton D, Bittner V, et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II). JAMA. 2002;288:49-57.
92.
Postmenopausal hormone replacement therapy for the primary prevention of chronic condition: recommendations and rationale. US Preventive Services Task Force. Am Fam Physician. 2003;67:358-364.
93.
Ockene IS, Ockene JK. Prevention of Coronary Heart Disease. Boston: Little, Brown; 1992.
94.
Prochaska JO. Changing for Good. New York: Avon Books; 1994.
