The half-day program covered healthy eating, how to prescribe exercise, evidence about stress reduction, and other lifestyle topics, as part of the American College of Cardiology's focus on prevention.
How serious are the nation’s cardiologists about prevention? At a half-day “intensive” on helping patients lead healthier lifestyles, held Saturday during the American College of Cardiology 65th Scientific Session, there was not a seat to be had.
Three hours into program, attendees still lined the walls to hear about plant-based diets, to learn how to bill when counseling patients about exercise, and to watch a powerful debate on the usefulness of e-cigarettes for patients trying to quit tobacco.
Attendees credited ACC President Kim Allan Williams, MD, who helped open the program, with giving the topic attention at the premier meeting of the 52,000 member organization; one panelist called it a “seismic shift.” Williams spoke about the connection between poor eating and the burden of coronary heart disease (CHD), which he said causes 1 American to have a CHD event every 34 seconds.
But change is possible, he said. In the 1960s and 70s, Finland suffered the highest coronary mortality rate in the world–but the country set out to change its diet, and did. Finland cut CVD mortality by half by boosting consumption of fruits and vegetables, cutting dairy and meat intake, and curbing smoking. Williams also pointed to a 2003 study in JAMA that found a controlled, plant-based diet to be just as effective as a statin in lowering low-density lipoprotein (LDL) levels among patients with hypercholesterolemia.1
During a panel discussion that followed, Caldwell Esseltyn, MD, who has tried to bring a plant-based diet to the public with Prevent and Reverse Heart Disease, said other eating patterns may be better than a typical American diet. But nothing compares to what happens when those with early heart disease adopt a plant-based diet.
“What happens to obesity? Gone. What happens to diabetes? Gone. What happens to hypertension? Gone,” he said.
Change From Within. Michael Miller, MD, FACC, of the University of Maryland School of Medicine, discussed the effects of stress and environment on CVD, and what patients can do. He listed 9 “population” factors that contribute to acute myocardial infarction, and nearly all were related to lifestyle: smoking, diabetes, abdominal obesity, vegetable and fruit intake, exercise, alcohol use–and one called “psychosocial,” which described how well a patient processes stress.
Studies on stress reduction tend to be small, Miller said, but signs of stress are everywhere. Heart attack deaths spike after events like earthquakes, for example. “We know stress is a factor–how to quantify it is a problem,” he said.
Not every patient is going to have a CV event, but getting them to relax can improve biomarkers: meditation and prayer lift serotonin levels, yoga improves GABA, watching a funny movie releases endorphins, listening to music produces dopamine, and having a massage or a hug produces oxytocin, a bonding hormone.
Trimming stress has positive CV effects by reducing inflammation, improving arterial function and promoting beta cell regeneration, Miller said. Relaxation strategies don’t replace traditional care, “but they can certainly add additional benefits for our patients.”
Exercise is “Real Medicine.” Â Merle Myerson, PhD, EdD, FACC, FNLA, offered both evidence on the benefits of exercise and practical advice–how to bill for spending a session giving patients a “prescription” for physical activity.
Exercise boosts the body’s ability to use oxygen efficiently, and its benefits have been researched since the 1950s. But it’s not as simple as just telling at-risk patients to get up and move, Myerson said. She outlined how patients must be screened and stratified based on their disease level, and some will need medical clearance before they can start.
Those who have not been exercising can start with a light walk, while others can progress to a round of golf or a day of vacuuming. More vigorous activity like cycling or shoveling snow is reserved for those who have some CV fitness, using a calculation that includes a patient’s age. Ideally, patients will get 150 minutes a week of moderate activity or 75 minutes a week of vigorous activity.
“The progression should be gradual, for duration, frequency and intensity,” Myerson said.
Taking on Tobacco. Valentin Fuster, MD, of Mount Sinai Hospital and the editor of the Journal of the American College of Cardiology, called on fellow cardiologists to renew the fight against cigarettes, since they represent the single most obvious source of preventable disease. While overall US smoking have declined since the 1964 report to the Surgeon General, rates remain higher among the poor and are climbing around the world.
Only a combination of tactics will work–tobacco taxes, creating smoke-free environments, improved FDA regulation, and even a “UN high-level meeting on tobacco use.”
Getting patients to quit matters, because a patient who quits stops smoking by age 40 gains 9 years of life, while one who quits at age 50 gains 6 years. Tobacco is insidious because it kills people slowly, unlike fast-moving disease like a virus. “It is the routine, every day nature of tobacco death that makes it so easy to ignore,” Fuster said.
He did not underestimate the difficulty of battling tobacco companies, which he said have caused the “pandemic” and are now exploiting middle- and low-income countries as wealthier nations give up the habit. “It is time to act on the unacceptability of the damage caused by the tobacco industry,” Fuster said. “Business as usual is insufficient.”
K. Michael Cummings, PhD, MPH, of the Medical University of South Carolina, continued, saying that the $4 that government collects in taxes for a pack of cigarettes still “subsidizes” the industry when one considers that same pack costs $36 in healthcare.
An intense discussion on the value of e-cigarettes followed, with Cummings citing CDC statistics that show teenagers are taking up “vaping” at an alarming pace, amid fears this a gateway to tobacco or drugs.
Neal Benowitz, MD, of the University of California San Francisco (UCSF) Center for Tobacco Control Research and Education, said while it is always preferable for a cigarette user to quit using any nicotine, “as long as they do not smoke cigarettes, clearly e-cigarettes are less hazardous than regular cigarettes from my perspective.”
He acknowledged this a “huge area of debate,” and said the quit rates through e-cigarettes are “substantially higher” if smokers use them as a temporary replacement for tobacco, not as a supplement. Data presented with the panel showed 64% of adult smokers have tried them. Panelist Johan Ambrose, MD, FACC, of UCSF Fresno agreed there was a role for e-cigarettes in helping adults quit, but they needed to be kept away from teenagers.
Rajat Barua, MD, PhD, of the Kansas City VA Medical Center, said his objection to e-cigarettes is their lack of regulation and that no one is sure what’s in them.
Cummings remained opposed, and said despite the presence of the Affordable Care Act, too many payers treat smoking cessation less favorably than other disease. “Our goal should be the elimination of tobacco.”
Jenkins DJA, Kendall CWC, Marchie A, et al. Dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA. 2003;290(4):502-510.