"Our mantra for exercise is regular, varied and vigorous."
- Leela Kunhiraman, DipIBLM, RPSGT, Health Education Coordinator
Why Focus on Lifestyle?
Therapeutic lifestyle changes involving diet, exercise and stress reduction have been shown to improve longevity and reduce risk for chronic disease.
In the Intervene phase of the AIM to Prevent program, the South Asian Heart Center provides expert counseling focused on personalized lifestyle changes. We know that lifestyle changes are easier said than done. That is the reason why, in the Manage phase of AIM to Prevent, the Center has trained heart health coaches to help participants make and sustain lifestyle habits. All aspects of the AIM to Prevent program, from advanced screening to lifestyle coaching are evidence-based.
The Evidence on Lifestyle
According to the Alameda Seven1, a study of 7,000 people in Alameda County, CA over 25 years found seven healthy lifestyle habits that promote successful aging. Going from three to seven of these habits extends longevity by eleven years.
According to the Swedish Study2, a study of 20,721 healthy individuals over 11 years, showed that a combination of healthy diet and lifestyle practices has a significant impact on primary prevention of myocardial infarction (MI) where 80% of heart attacks preventable with positive lifestyle habits alone.
Finally, according to INTERHEART3, a large case-control study of acute myocardial infarction (MI) in 52 countries with 15,152 cases and 14,820 controls showed that nine clinical and poor lifestyle factors accounted for 90% of heart attacks.
The Role of Stress
Stress is defined as feeling irritable, anxious, or as having sleep difficulties as a result of conditions at work or at home. Psychological stress results from the inability of an individual to creatively overcome challenges. Physiological stress results from the inability of the body to maintain balance or steady state.
Studies on stress have shown a strong correlation with increase in risk for heart attacks, dyslipidemia, inflammation and obesity.
Intervene with Lifestyle M.E.D.S.
The key to prevention of heart attacks and diabetes is early and comprehensive assessment followed by personalized lifestyle intervention. The Alameda Seven, INTERHEART, and the Swedish prevention study, illustrate the benefits of good lifestyle behaviors and the disease consequences of poor lifestyle.
Alameda Seven, Swedish prevention study, and INTERHEART illustrate the benefits of good lifestyle behaviors and the disease consequences of poor lifestyle.
Meditation
Exercise
Diet
Sleep
Derived from hallmark studies, these therapeutic components are most relevant for risk reduction in South Asians and are, therefore, the key offering in the AIM to Prevent program.
Other habits like smoking and excessive alcohol consumption, are also important to reduce risk. The South Asian Heart Center refers participants who seek help with these habits to the many dedicated resources available within the community.
M - Meditation
A growing body of scientific research supports the health benefits of meditation. Meditation is a simple mind-body process which leads to deep relaxation and stress reduction. Meditation helps in managing chronic conditions such as heart disease, high blood pressure, cancer, and depression.
The South Asian Heart Center's mantra for meditation
Daily practice of restful alertness
Mantra for Meditation: Daily practice of restful alertness
Goal: Meditate for 20 minutes, twice daily
Meditation is a sit-down, eyes-closed, conscious technique, practiced in one of the following ways: Concentration where you focus on an object, contemplation where you observe the object, and transcendental where you lose the object. The South Asian Heart Center suggests you develop the habit of meditation, and recommends Transcendental Meditation for stress reduction because of evidence showing its effectiveness in addressing cardiovascular mortality.
Resources
Evidence
Sustained practice of meditation or restful alertness has been shown to reduce angina (chest pain) in patients with coronary artery disease.7 The benefits of Transcendental Meditation (TM) for prevention and management of disease are widely researched and well documented. Stress reduction with the regular practice of TM in high risk CAD patients is associated with a 47% reduction in all cause mortality, heart attacks, and stroke and a 61% reduction in events in those patients who practice the technique regularly.8 Research shows that a direct change in state of consciousness through TM extends human life and reverses age-related declines.9 TM is associated with decreased hypertension and atherosclerosis, decreased hospitalization rates and improvements in risk factors including decreased smoking and cholesterol and shows promise as an effective prevention and treatment method for CAD.10
E - Exercise
Exercise is structured physical activity and falls into the following categories: aerobic, strength, and balance and flexibility. Unstructured physical activity such as climbing stairs, gardening, playing with children, also counts. It is important to include the different types of exercise into your daily practice.
The South Asian Heart Center's mantra for exercise
Regular, varied, and vigorous
Mantra for Exercise: Regular, varied, and vigorous
Goal: 150 minutes of physical activity per week
It is not necessary to have a gym membership to receive benefits of exercise. Home-based programs do in fact have greater adherence than gym-based programs.
Evidence
Aerobic and resistance exercise along with a weight reduction diet results in greater mobilization of abdominal fat and improved functional capacity.11 Fitness is the most important predictor of longevity. Each added minute in an exercise stress test was shown to enhance longevity by 8%.12 Sedentary lifestyle habits, such as extended television viewing, increase risk for coronary artery disease.13
Amount and Regularity of Exercise Matters
The NIDDK's Diabetes Prevention Program results indicate that millions of high-risk individuals can delay or avoid developing Type 2 diabetes by losing weight through regular physical activity. Weight loss and physical activity lower the risk of diabetes by improving the body's ability to use insulin and process glucose.
Amount, not intensity is most important for lipid profile improvements.14 35-40 minutes a day of brisk walking is associated with a CAD risk reduction of over 50%.14 Physical activity and risk of coronary heart disease in India.15
According to the National Heart, Lung and Blood Institute (NHLBI), adults need to do at least 150 minutes of moderate-intensity aerobic activity on a weekly basis to realize health benefits.
Exercise timing makes a difference
The "weekend warrior" and risk of mortality.16 Training in the fasted state improves glucose tolerance during fat-rich diet.17
Benefits of adopting healthy lifestyle
People who adopt a healthy lifestyle even in middle-age, experience a prompt benefit of lower rates of cardiovascular disease and mortality.18
Partnerships
1 hour free orientation and beginner physical training class, plus a 12-week training program at a discounted rate with exercise physiologists
D - Diet
Good nutrition is another key lifestyle ingredient in the prevention of heart disease and diabetes. Sensible selections and substitutions to the traditional diet may be necessary to make it heart healthy.
The South Asian Heart Center's mantra for diet
More greens than grains
Mantra for Diet: More greens than grains
Goal: 2 fistfuls of vegetables/day, 1 fistful of fruit/day, 12 nuts/day, zero sugared drinks
The South Asian Heart Center encourages high-fiber, plant based foods, limited consumption of refined carbohydrates, animal fats and processed foods, and discourages sweet beverages and fried snacks.
The Center recommends at least 3 sit down meals per day, inclusive of breakfast, and suggests consuming a fistful of fruit, 12 nuts, and a minimum of two fistfuls of vegetables per day.
Resources
Evidence
The Center's recommendations on dietary changes are based on evidence behind the importance of increasing consumption of vegetables and fruits, limiting intake of fats and reducing simple carbohydrates to decrease risk of heart disease.
Vegetables and Fruits
Most fruits and vegetables are low in calories and high in fiber, making them heart healthy. Variety is as vital as quantity because no single fruit or vegetable can provide all of the nutrients you need to be healthy. Consuming fruit and vegetables ≥3 times/day vs <1 time/day is associated with a 27% lower stroke incidence, 42% lower stroke mortality, 24% lower ischemic heart disease mortality, 27% lower cardiovascular disease mortality & 15% lower all-cause mortality.18 Analysis of cohort studies reveals a real benefit to consuming more than 5 servings/day of fruit and vegetables19 to protect against coronary artery disease.
Whole Grains
Most carbohydrate intake should come from whole grains rather than refined grains to help prevent Type 2 diabetes.20
Fats
Healthy fats like Omega-3 fatty acids add to the primary prevention effects of statin therapy.21 A cooking oil that is high in monounsaturated fat such as olive or canola oil seems to offer significant protection against heart disease.22 Unhealthy trans fats (foods that list hydrogenated shortening in ingredients, or reheated cooking oil) can detrimentally increase LDL while decreasing HDL.23
Soft Drinks
Soft drink consumption is associated with higher prevalence and incidence of multiple metabolic risk factors.24 Consumption of more than 1 soft drink a day increases the incidence of metabolic syndrome, obesity, waist circumference and blood pressure.
Timing and Number of Meals
Studies indicate that eating breakfast can significantly lower cardiovascular disease risk.25 Skipping breakfast is associated with a 450% increased risk of obesity, as was greater frequency of eating breakfast or dinner away from home and eating ≥ 4 meals/day vs ≤ 3 meals/day is associated with a 45% lower risk of obesity.26
S - Sleep
Sleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of most voluntary muscles. At the same time, sleep is also a heightened anabolic state, accentuating the growth and rejuvenation of the immune, nervous, skeletal and muscular systems.
The South Asian Heart Center's mantra for sleep
Routine of restful sleep
Mantra for Sleep: Routine of restful sleep
Goal: 7-8 hours per night
The consequences of insufficient or fragmented sleep are neurobehavioral and performance deficits in addition to cardio-metabolic problems like, obesity, Type 2 DM, and hypertension, which in turn lead to increased morbidity/mortality and a decreased quality of life.
Resources
Evidence
During sleep, the brain is still active, performing a variety of biological maintenance tasks that keeps the body performing in peak condition. Sleep occurs in a series of recurring sleep stages that are very different from one another. From deep sleep to dreaming sleep, they are all vital for your body and mind. Without enough hours of restful sleep, you will not feel restored and recharged, and are bound to feel stressed and ill-prepared to meet the challenges of the day.
Studies on sleep have shown the impact of sleep duration (both deprivation and excess) and disorders on diabetes, hypertension, obesity, coronary artery disease and mortality.
Sleep Duration
Short and long sleep durations increase the risk of developing diabetes,27, 28 independent of confounding factors indicating that sleep duration may represent a novel risk factor for diabetes. Sleep durations of ≤ 5 hours per night were associated with a significantly increased risk of hypertension.29 Short and long self-reported sleep durations are independently associated with a modestly increased risk of coronary events.30 Modest associations between short sleep duration and difficulties maintaining sleep and incident heart attacks were seen in middle-aged women.31
Coaching
A unique aspect of South Asian Heart Center's AIM to Prevent program is the use of trained health coaches to engage actively with participants pursuing therapeutic lifestyle changes. Unlike traditional methods where health care providers merely recommend behavior modifications, the Center's coaches get better compliance because they gauge the readiness of participants, understand their reasons for ambivalence, and encourage behavioral change one step at a time.
Heart health coaching is optional to participants after completion of comprehensive screening, individualized risk assessment and behavioral recommendations. Coaches contact enrolled participants regularly for the first year (and annually thereafter) to provide encouragement with behavior change, troubleshoot challenges and assess adherence.
What is unique about the Center's personalized and culturally sensitive coaching and case management program is that the coaches are South Asian community volunteers who undergo specific training. Their effectiveness stems from their ability to relate well to the participants' needs based on their own personal experience, or that of friends and family, with the epidemics, and to understand the challenges of lifestyle changes within the cultural context. Using volunteers to coach participants keeps program costs under control and makes it possible for a dedicated program like the Center's, to scale and have greater impact.
Evidence
Health coaching has been shown to improve compliance, reduce costs and improve health outcomes.32 The use of individualized health coaching has been shown to be an effective strategy for reducing cardiovascular disease risk factors.33, 34 Culturally tailored interventions improve diabetes mellitus care by reducing ER visits.35 Intensive lifestyle intervention has been shown to lead to significant weight loss and therefore reduction in needed medication, improvement of cardiovascular risk factors, and better diabetes control, in Type 2 DM patients.36