Keys to a Better, Longer Life

Laurence S. Sperling, M.D., FACC, FACP,FAHAProfessor of Medicine (Cardiology)

Professor of Global HealthDirector- Center for Heart Disease Prevention

Emory University President , American Society for Preventive Cardiology

Chairman of ACC Cardiometabolic Working GroupChairman of The U.S. National Cardiometabolic Alliance

About the Presenter

Laurence S. Sperling, MD, FACC,FACP,FAHAProfessor of MedicineDirector of The Center for Heart Disease PreventionEmory University School of MedicineAtlanta, GA

DISCLOSURESNo potential conflicts related to this presentation

Living better and longer?

• David Murdock-87 (now 92) yo billionaire-dropped out of school at 14 / homeless at 22-acquired Dole 1985

• Wants to live to 125• Eats abundance of

fruits/veg, seafood, egg whites, beans and nuts

• Brisk walks on treadmill ; light wts 3X/wk

NY Times Magazine, 3/6/11

Walking the Talk: “L” for longevity

• Dole – world’s largest producer of fruits and vegetables

• Headquarter’s , Westlake Village, CA– Subsidized cafeteria / healthy food choices– Free access to company gym / personal training

subsidized• On site Four Seasons Hotel

– The California Health and Longevity Institute– Room service menus with “L-shaped” symbols

designating dishes that promote longevity

NY Times Magazine, March 16,2011

Atlanta Journal ConstitutionMarch 17, 2011

• Goals?–Longer?–Better?–Both?

Focus on CV Health: The Health/Disease ContinuumJACC 2015;66:960-7

NormalLow risk

NormalHigh risk

Predisease

Earlydisease

Latedisease

Health Promotion & Disease Prevention

Contemporary Medicine

HEALTH

DISEASE

Optimal Health ??

Our 2020 Impact Goal

“By 2020, to improve the cardiovascular health of all

Americans by 20 % while reducing deaths from

cardiovascular diseases and stroke by 20 %.”

<100100-125≥126Children12 - 19 yo

<100100-125, or DM treated to goal≥126Fasting Glucose - Adults

<90th %ile90th - 95th %ile or SBP ≥120 or DBP ≥80>95th %ileChildren 8 - 19 yo

<120/<80SBP 120-139 or DBP 80-89 or treated to goal

SBP ≥140 or DBP ≥90Blood Pressure - Adults

<170170-199≥200Children 8-19 yo<200200-239 or treated to goal≥240Total Cholesterol - Adults

5-8 Factors2-4 Factors0-1 Factors Children 5-19

5-8 Factors2-4 Factors0-1 Factors Healthy Diet Score - Adults

150+ mins/week moderate or 60+ mins/wk vigorous

1-149 mins/wk moderate or 1-59 mins/wk vigorousNoneChildren 12-19 yo

150+ mins/week moderate or 60+ mins/wk vigorous

1-149 mins/wk moderate or 1-59 mins/wk vigorousNonePhysical Activity - Adults

<85th %ile85th - 95th %ile>95th %ileChildren 8-19 yo

<2525-29.9≥30Body Mass Index - Adults

NeverEver, ExperimentingIn Prior 30 DaysChildren 12-19 yo

Never or Quit ≥12 monthsFormer, <12 monthsYesCurrent Smoking - Adults

Optimal HealthIntermediate HealthPoor HealthMetric

CV Health Metric Definitions

Physiologic Variables :Prehistoric vs. Current Western Societies

<5%1.20.6% decline/yr in BMD in postmenopausal women

<10%2722BMI, age 60

<1%230 mg/dL120 mg/dLSerum cholesterol, age 60

<5%80 mm Hg70 mm HgDiastolic BP, age 60

<1%145 mm Hg110 mm HgSystolic BP, age 60

Current Western Pop. < Prehistoric AverageWestern

SocietiesPrehistoric

Physiologic Variable

Law MR and Wald NJ. BMJ. 2002;324:1570-1576.

Prevalence of Ideal CV Health / Relationship with CVD Incidence

• 12,744 from ARIC (’87-’89)• 20 yr incidence of CVD• 0.1% had ideal CV Health !• Event rate / ideal health metrics

– 0 7– 3.9 per 1000 6– 37.1 per 1000 0

Folsom, AR et al. JACC 2011;57:1690-6

Status of CV Health Across America

• 2009 BRFSS, > 350K,self report

• 3.3% with ideal CV health (A) ;– 1.2% Oklahoma– 6.9% DC

• 9.9% with poor CV health (B: 0-2 metrics)

• Large disparities by age, gender, education, ethnicity

Fang J, et al. J Am Heart Assoc 2012;DOI.1161

Social Determinants of Health: Zip Code vs. Genetic Code?

• Health varies at a very LOCAL level

• Life expectancy in Atlanta

Keys to a Better and Longer Life

• No tobacco• Ideal wt / nutrition• Regular activity• Alcohol in moderation ?

15

Causes # (%) in 1990 # (%) in 2000

Tobacco 400,000 (19) 435,000 (18)

Poor diet and physical activity (obesity) 300,000 (14) 400,000 (17)

Alcohol consumption 100,000 (5) 85,000 (4)

Microbial agents 90,000 (4) 75,000 (3)

Toxic agents 60,000 (3) 55,000 (2)

Motor vehicle accidents 25,000 (1) 43,000 (2)

Firearms 35,000 (2) 29,000 (1)

Sexual behavior 30,000 (1) 20,000 (<1)

Illicit drug use 20,000 (<1) 17,000 (<1)

Total 1,060,000 (50) 1,159,000 (48%)

Mokdad AH et al. JAMA 2004;291:1238-1245

Tobacco Use: Most Preventable Cause of Death

Most preventable causes of death in the U.S. in 1990 and 2000

16

Tobacco Cessation Recommendations

Complete cessation

No environmental tobacco smoke exposure

Goals Recommendations

Ask about tobacco use at every visit

In a clear, strong, and personalized manner, advise the patient to stop smoking

Urge avoidance of exposure to second-hand smoke at work and home

Assess patient’s willingness to quit smoking

Develop a plan for smoking cessation and arrange follow-up

Provide counseling, pharmacologic therapy, and referral to a formal cessation program

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Smith SC Jr. et al. JACC 2006;47:2130-9

Scientific American 2004;14(3):20

Ideal BMI / Nutrition - “speedo” sign

PREVALENCE OF METABOLIC SYNDROME

• NHANES III - metabolic syndrome– 24% of men; 23.4% of

women– 42% of individuals > age 60

• Underscores need to control obesity epidemic /improve physical activity

» Ford E et al, JAMA.2002;287:356-359.

0

10

20

30

40

50

60

Men Women

Pe

rce

nt

TotalWhitesBlacksHispanics

Narayan et al., JAMA, 2003

Lifetime Risk of Diabetes from Birth According to Sex and Race/Ethnicity, USA

Diabetes: the growing global burden

1Adapted from IDF. E-Atlas. Available at: www.eatlas.idf.org (accessed 05.03.07).2Diabetes Atlas, third edition © International Diabetes Federation, 2006.

IDF:2

• Diabetes currently affects 246 million people worldwide• It is expected to affect 380 million by 2025

1Prevalence estimates of diabetes mellitus 2025202520252025

No data

< 2%

2–5%

5–8%

8–11%

11–14%

14–17%

> 17%

Endothelial Dysfunction, Oxidative Stress and Inflammation in Obesity

Van Gaal LF, et al. Nature 2006; 444:865-880

22

Prevalence of Obesity in U.S. Adults

1991 1996

2006

No Data <10% 10–14% 15–19% 20–24% 25-29% >30%

CDC Overweight and Obesity

Percentage of State Obese (BMI > 30)

2008

“SUPER SIZE ME”Morgan Spurlock

• Documentary- eating at McDonald’s 1 month ; reduced physical activity

• Up to 5000 calories/day• BP increased from 120/80

to 150/100• TC increased from 165 to

230• Weight increased 24

pounds

Supersizing: Hidden Toll on Pocketbook

• Single fast food meal– 927 to 1324 kcal (extra $0.67)– 73% more calories / 17% price– 36 grams adipose

• Calculated costs (1 yr) > short-term value– Increase auto fuel, maintenance food, health

care costs by $3.10-$7.72

• Close RN and Schoeller DA. Jl Am Coll Nutrition 2006;25(3):203-209

Ban on Sugar-Sweetened Beverages ?

Mayor Bloomberg proposes Prohibit sugary beverage

sales > 16 oz.Significant debate and

pushback…… NY Times 5/31/12

Nov. 4, 2014Berkeley, CA1s t U.S. city to approve

penny-per-once tax

Obesity Epidemic

• Obesity In the US (BMI ≥30)– > 30% of population

• Obesity Worldwide– One Billion Overwt

(BMI ≥ 25)– 300 Million Obese

Mokdad AH et al. JAMA 1999;282:1519-22.

Serdula MK et al. JAMA 1999;282:1353-58.

World Health Organization

28

Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht2 (in)

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH/NHLBI/NAASO. October, 2000. NIH publication No. 00-4084.

*Measurement of waist circumference is most helpful in this category

Weight Category BMI (kg/m2)

Normal 18.5-24.9

Overweight* 25.0-29.9

Obesity (Class I) 30.0-34.9

Obesity (Class II) 35.0-39.9

Obesity (Class III) >40.0

BMI=Body mass index

Overweight and Obese States: Definition Using the Body Mass Index

29Whitaker RC et al. NEJM 1997;337:869-873

BMI=Body mass index

Adul

t Obe

sity

at

Age

21-

29 Y

ears

(%)

Age of Child (Yrs)

Body Mass Index: Risk of Developing Obesity in Adulthood

Eat less at dinner and you will live to 90

Ancient Chinese Proverb

Caloric restriction and Longevity

• Rodent model: 30-60% reduction calories early in life increases max life span by 30-60%

• Rhesus monkey: 30% caloric reduction– 20 yr f/u with ? (3 fold) survival advantage (Wisconsin

PRC)• Caloric restriction in humans (with adequate

nutrient intake) – beneficial metabolic, hormonal, functional changes

Fontana L and Klein S, JAMA 2007;297:986-994Coleman RJ, et al. Science 2009

Nature publication( online- August 29, 2012)

• Caloric Restriction in (121) Rhesus Monkeys

• 25 yr study • National Institute

of Aging………

Mattison JA, et al. Nature 2012

Impact of caloric restriction on health and survival of Rhesus monkeys

Mattison JA, et al. Nature 2012

Diets and CVD

“Good nutrition is essential. The problem is we still don’t know what to eat.”

J. Willis HurstNotes from a Chairman1987

Problem with “Diets”

• Semantic confusion– “Diet” from Latin diaeta…..a way of life

• Fad Diets– >95% who lose wt on diet gain it back– Many focus on composition – restriction/complexity predict failure

• McGuire M et al. Journal Consulting and Clinical Psych 1999 67;2:177-85.

Mediterranean Diet….Key Component?

Hu FB. N Engl J Med. 2003;348:2595-2596.

37Trichopoulou A et al. NEJM 2003;348:2595-6

Variable # of Deaths/ # of Participants

Fully Adjusted Hazard Ratio (95% CI)

Death from any cause

275/22,043 0.75 (0.64-0.87)

Death from CHD

54/22,043 0.67 (0.47-0.94)

Death from cancer

97/22,043 0.76 (0.59-0.98)

Diet Evidence:Primary Prevention

22,043 adults evaluated for adherence to a Mediterranean diet, with points given for high consumption of vegetables, legumes, fruits, nuts, cereal, and fish

and points subtracted for high consumption of meat, poultry, and dairy

High adherence to a Mediterranean diet is associated with a reduction in different causes of death

Primary Prevention of Cardiovascular Diseasewith a Mediterranean Diet

Estruch R et al. N Engl J Med 2013;368:1279-1290.

Diets and CVD: The evidence ?• Low-Carbohydrate Diets

– Short-term Wt loss; long-term effects unknown• Glycemic Index / Diets

- guide to decreased consumption of energy dense carbs• Very-Low Fat Diets

– Possible decrease in CV events; concerns about sustainability

• Mediterranean Diet– Primary and secondary prevention; reduction in metabolic

syndrome ; healthy; sustainable • DASH

– Decreased HTN; similar to Mediterranean

Modified from Parikh P, McDaniel M, Ashen D, Miller J, Sorrentino M, Blumenthal R, Sperling LS. Diets and CV Disease: An Evidence-Based Assessment, JACC 2005;45:1385

Dept. HHS & USDA 8th Dietary GLs

Summary:1. Healthy eating pattern

across lifespan2. Focus on variety, nutrient

density, and amount3. Limit calories from added

sugars, sat. fats. Reduce Na intake

4. Shift to healthier food & beverage choices

5. Support healthier eating patterns for all

USDA Nutrition Guidelines – June 2011

• 7 Key Messages1. Enjoy food but eat less2. Avoid oversized

portions3. half plate fruits/vegs4. Water over sugary

drinks5. Fat free /low-fat milk6. Compare sodium in

foods7. > half grains whole

U.S. News & World Report38 Diets rated(available evidence)

Panel of 20 experts

7 parameters (1-5 scale)

ST wt lossLT wt lossDiabetesHeart healthEase of complianceNutritional completenessHealth risks

U.S. News Best Diets• DASH TLC Mayo Mediterranean Wt Watchers

• Volumetrics Jenny Craig Biggest loser Ornish

• Vegetarian Slim fast Fat belly Nutrisystem

• Abs South beach Vegan eco-Atkins

• GI Zone macrobiotic Medifast

• Atkins Raw food Dukan Paleo

U.S. News Best Diets- (2014 Update)

• Reviewed……– Traditional Asian Diet– Anti-Inflammatory Diet (Andrew Weil)– Engine 2 Diet (Esselstyn)– Flexitarian Diet

U.S. News Best Diets- 2015 & 2016

2015– HMR (Health Management Resources) Diet– The Body Reset Diet– The Supercharged Hormone Diet

2016– MIND Diet– Whole 30 Diet– Fertility Diet

U.S. News Best Diets

• Overall Best– DASH– TLC– Mayo Clinic– Mediterranean– Weight watchers

U.S. News Best Diets

• Heart-Healthy– Ornish (?)– TLC– DASH– Mediterranean– Vegan

U.S. News Best Diets

• Best Weight Loss Diets– Weight Watchers– HMR Program– Biggest Loser– Jenny Craig

Need Exercise ?

Exercise…..

The Magical Ingredient

Exercise : Important part of Prevention and Lifestyle Therapy

Physical activityHealthy eatingIdeal weight

Psychosocial factorsFamilial predisposition

LipidsHypertension

Smoking cessationDiabetes

+Primordial

ASAACE-IRehab

β-blockers+Primary

Secondary

Primary

Primordial

NCEP ATP III. JAMA. 2001;285:2486-2497.

0

10

20

30

40

50

60

70

1 2 3 4 5

Dea

th R

ate

(per

10,

000)

Fitness Level (Low to High)

Blair SN et al. JAMA 1989; 262:2395-401

MenWomen

13,344 healthy men and women followed for 8 years

Low physical fitness is associated with increased mortality

Physical Activity:Effect on Mortality

Benefits-Regular Physical Activity

• Reduces risk of dying prematurely ( heart disease)

• Reduces risk of heart disease and colon cancer ( up to 50%)

• Reduces risk of developing type 2 diabetes 50%

• Helps prevent/reduce hypertension• Helps control weight / lower the risk of

becoming obese by 50% • Promotes psychological well-being, reduces

stress, anxiety and depression

http://www.healthypeople.gov

Shear and Atherogenesis

ROS NONOROS

Non-laminar shear

Laminar shear

Many US Adults Are Physically Inactive

25%

38%22%

15% Regular Vigorous Activity(3x/week, >20 minutes)

Surgeon General’s Report on Physical Activity, 1996

Irregularly Active

Sedentary

Regular, Sustained Activityof Any Intensity

(5x/week, >30 minutes)

Our “Toxic” Environment

57

Pedometer-Determined Physical Activity in Healthy Adults

• < 5000 steps/day: ‘sedentary lifestyle index‘• 5000-7499 steps/day: 'low active' • 7500-9999: 'somewhat active' • > or =10000 steps/day: 'active'• > 12500 steps/day: 'highly active'

Tudor-Locke, et al. Sports Medicine 2004;34:1-8.

Work-Related Physical Activity among Cardiovascular Specialists

Abd T, Kobylivker, A, Perry A,, Miller III J,, Sperling L. Clin Cardiol 2012 35,2,78-82

Methods: All participants were from an academic tertiary center (N=28)• 8 cardiothoracic (CT) surgeons • 7 general cardiologists • 5 procedural cardiologists • 8 cardiac anesthesiologistsDemographic information• age • resting heart rate• blood pressure • body-mass index • waist circumference • past medical and social historySubjects were asked to wear a spring levered pedometer on their hip for two weeks while at work and to record the total number of steps as well as number of hours worked each day.

Introduction :Current recommendations by the American Heart association, the American College of Sports Medicine, and the US Surgeon General are a minimum 30 minutes of moderate physical activity on 5 days each week .This goal has been equilibrated with 10000 steps per day. This study examines work-related physical activity (PA) among cardiovascular (CV) specialists

Results: The average daily steps walked during work were 6540, 6039, 5910 and 5553 for general cardiologists, CT surgeons, procedural cardiologists and Cardiac anesthesiologists, respectively. There were no statistically significant differences in the average number of steps taken per day among the groups. However, CT surgeons worked 12.4 hours/day compared to 9.3 hours/day by the cardiac anesthesiologists (p=0.03). There were no significant differences in the demographic characteristics among any of the groups.

Conclusions: Work-related PA of CV specialists do not meet the recommended guidelines. Given their busy work schedule, obtaining the recommended PA might be a challenge for them. Cardiovascular specialists must engage in additional, out-of-hours exercise in order to achieve the adequate amount of daily required physical activity.

SpecialtyDaily steps hr of work steps/hr

CT surgeons 6038.8 12.4 478.2Cardiac

anesthesiologist 5553.3 9.3 594.9

General cardiologists 6540.1 10.1 683.6procedural

cardiologists 5910.4 10.8 542

Average 6010.6 10.65 574.6Attendings 6539 10.8 544.4

Fellows 5810 10.8 608.3

Average daily steps and work hours for study population

02468

101214

CT surgeonsCardiac AnesthGeneral CardProcedural Car

Daily steps in thousands Hours of work

Physical Inactivity: A Call to Arms

10,000 Steps Daily 30 minutes most days

Alcohol : An ounce of prevention?

Alcohol and Total Mortality

Thun et al. Alcohol consumption and mortality among middle-aged and elderly US adults. NEJM 1997; 337:1705.

What is a unit?

12 oz 14g alcohol150 calories

1.5oz14g alcohol100 calories

5oz13g alcohol110 calories

= =

Does beverage type matter?

• French paradox– Lower CHD mortality then expected – red wine consumption ?– polyphenols and flavinoids -

antithrombotic and antioxidant properties • Systematic review shows that all beverage

types associated with lower rates of CHD.

Eapen DJ et al. Current Treatment Options in CV Medicine 2011

Mechanisms of Alcohols Benefit• Enhanced insulin sensitivity• Resveratrol ??• Anti inflammatory • Antioxidant • Antithrombotic

Eapen DJ et al. Current Treatment Options in CV Medicine 2011

Keys to a better longer life

Effective ?

Mediterranean Diet, Lifestyle, and 10 yr Mortality in Elderly Europeans

• Healthful Lifestyle Factors• Prospective study, 2300

• Adhering to Med diet, mod. Alcohol, physical activity, and non-smoking associated with lower risk all-cause mortality (65% reduction)

– Kim T, et al. JAMA 2004;292:1433-39

70

Modification Recommendation Approximate SBP Reduction Range

Weight reduction Maintain normal body weight (BMI=18.5-25)

5-20 mmHg/10 kg weight lost

DASH eating plan

Diet rich in fruits, vegetables, low fat dairy and reduced in fat

8-14 mmHg

Restrict sodium intake

<2.4 grams of sodium per day 2-8 mmHg

Physical activity Regular aerobic exercise for at least 30 minutes most days of the week

4-10 mmHg

Moderate alcohol <2 drinks/day for men and <1 drink/day for women

2-4 mmHg

JNC VII Lifestyle Modifications for BP Control

Chobanian AV, et al. JAMA. 2003;289:2560-2572.

BMI=Body mass index, SBP=Systolic blood pressure

Lifetime Risk for ASCVD by RF Strata Age 50

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

50 60 70 80 900

0.1

0.2

0.3

0.4

0.5

0.6

0.7

50 60 70 80 90Attained Age

Adj

uste

d C

umul

ativ

e In

cide

nce

5%

36%

50%

69%

8%

27%

50%

Men Women

46%

39%

≥2 Major RFs1 Major RF≥1 Elevated RF≥1 Not Optimal RFOptimal RFs

Lloyd-Jones, Circulation 2006

NYC Leading Public Health Initiatives2002 – ban smoking in

bars/restaurants2005-ban on trans fats2008- 1st city to require

calorie counts on menus2011- ban on smoking most

outdoor areas** Mayor + NYC Health

Dept. cite NYC’s rising life expectancy as proof these measures working

NY Times- May 31, 2012

Centenarians (100 + Club)• Per capita greatest # in Okinawa• 5 contributing factors

– Diet- grains, fish, veg– Low stress– Highly active– Supportive community– spirituality

• Genetics?– Higher glutathione reductase / catalase– FOX03A polymorphism

• Supercentenarians…..> 110

Wilcox D, et al. Jl Gerontology 2008;63Andersen HR, et al Age Ageing 1998;27

AJC 8/26/11• Besse Cooper

turns 115 in Monroe, Ga.

• “I mind my own business…..and I don’t eat junk food.”

Associate Press 1/20/16• World’s oldest

man, Yasutaro Koide, died at 112 in Nagoya, Japan.

• Secret to a long life“not to smoke,drink, or overdo it.”

World’s oldest person• Susannah Mushatt

Jones, 116• Born in Alabama-

parents sharecroppers• Resides in Vandalia

Senior Center in Brooklyn, N.Y.

• “never smoked, drank, partied, worn makeup or dyed hair.”

Wikipedia

Intangibles…….Zest for life?

• When asked in his late 90’s if his doctor knew he still smoked…..

• Burns said “No…he’s dead”

BETTER LONGER LIFE?“POLYPILL” OR PUBLIC HEALTH

• A strategy to reduce CVD by more than 80%…..– 5 agents in single tablet ;

age > 55• Statin• Aspirin• 3 BP meds at half-dose

• A strategy to reduce CVD by more than 80%…..

Wald N and Law, MR. BMJ 2003;326:1419

KEYS TO A BETTER LONGER LIFE…..

• Nurse’s Health Study, 84,000 women• Low-risk (3%) group

– Not smoking ; >1/2 glass EtoH per day– BMI < 25 ; top 1/3 for healthy diet– Moderate physical activity > 30 min/day

• Each factor independently predicted risk• RR 0.17 ; 82% of events attributed to lack

of adherence to low risk patternStampfer, MJ et al. N Engl J Med 2000 343(1):16-22

“Things do not happen. They are made to happen.”

John F. Kennedy

PREVENTIVE CARDIOLOGY • Primary and secondary

prevention clinics• HeartWise Risk Reduction

Program• Optimal Living• Women’s Heart Program• Subclinical markers of

atherosclerosis• Screenings and Risk

Factor management • LDL apheresis• Housestaff / fellow

training program• Clinical and Translational

Science Research• Centenarian Clinic

Emory University

American Society for Preventive Cardiology: www.aspconline.org

New This Fall

Thanks……