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Can Lifestyle Modifications
Can Lifestyle Modifications
Using Therapeutic Lifestyle
Using Therapeutic Lifestyle
Changes (TLC) Reduce Weight
Changes (TLC) Reduce Weight
and the Risk for Chronic Disease?
and the Risk for Chronic Disease?
Introduction: TLC is an effective lifestyle therapy targeting low-
Overweight and obesity are complex health problems density lipoprotein cholesterol (LDL), a risk factor
for coronary heart disease.5 Fortunately, the
that affect more than two-thirds of U.S. adults.1 health benefits of TLC do not stop there. Along
There are many with lowering LDL, TLC also improves risk factors
health conditions associated with the metabolic syndrome and
associated with diabetes, including blood pressure, high-density
overweight and lipoprotein cholesterol (HDL), serum triglycerides,
obesity including 6-10
hypertension, blood glucose, and weight status (Table 1).
coronary heart Table 1. TLC–Summary of Physiological Effects
disease, and type 2
diabetes.2 Therefore, LDLHDL Triglycerides Blood GlucoseWeight
it is likely that health pressure
care practitioners ↓ ↔/↑↓ ↓ ↓ ↓
will be advising
overweight or obese This research brief for the health care practitioner
individuals who reviews TLC as an effective lifestyle therapy for
also have additional improving the risk factors associated with an
health conditions. overweight status, coronary heart disease, and
The challenge for diabetes. This brief will begin with a review of the
many practitioners is choosing an appropriate weight relationship between overweight and chronic disease,
management therapy that will simultaneously address followed by a description of TLC and a scientific
these multiple health conditions. Fortunately, lifestyle review of how the different TLC components work
changes including healthy eating patterns, increased to promote weight management and reduce chronic
physical activity, and weight management often disease risk. Finally, suggestions will be provided
improve the risk factors associated with obesity. for practitioners to use when counseling individuals
One such lifestyle approach, Therapeutic Lifestyle on how to begin using TLC as a healthy lifestyle
Changes (TLC) is recommended by various health approach.
organizations (American Diabetes Association, An overview of the following topics is provided:
American Heart Association, and The Obesity What are the Health Risks Associated with
Society, among others) as a sound therapeutic Overweight and Obesity?
strategy for overweight or obese persons at risk for What is TLC?
type 2 diabetes and/or coronary heart disease.3, 4
Research to Practice Series, No. 7
How Does the Current U.S. Dietary Fat and Of concern is the tendency for diabetes and coronary
Cholesterol Consumption Compare to TLC heart disease risk factors to co-occur in those
Recommendations? who are overweight or obese, thus complicating
Why Does TLC Recommend Reducing Intakes of treatment options. An estimated 64% and 72% of
Saturated Fat, Trans Fat, and Cholesterol while overweight and obese Americans, respectively, have
Increasing Consumption of Monounsaturated and hypertension, elevated cholesterol, or both.14 A study
Polyunsaturated Fats? examining more than 1.9 million members of a large
What Other Dietary Options Can Help Reduce managed care program found hypertension, elevated
Coronary Heart Disease Risk? total cholesterol, and/or diabetes to commonly
co-occur in more than 40% of those diagnosed with
What are the Benefits of Increased Physical one of these conditions.18
Activity and Weight Management?
Research to Practice: Suggestions for The metabolic syndrome—a clustering
Incorporating TLC into a Healthy Lifestyle. of multiple risk factors associated with
overweight and obesity
What are the Health Risks Associated It is now known that
with Overweight and Obesity? when certain chronic
Overweight (BMI 25–29.9 kg/m2) and obesity (BMI disease risk factors
2 co-occur (abdominal
≥30 kg/m ) are independent risk factors for several obesity, low HDL,
chronic disease conditions including coronary heart elevated fasting
disease, hypertension, elevated cholesterol, and glucose, and elevated
diabetes.11-13 The prevalence of these conditions
increases as BMI increases. Based on NHANES III triglycerides), there
data, hypertension, total cholesterol, and low HDL is an increased risk
14 for cardiovascular
are positively associated with BMI (Figure 1). The disease and
risk for developing diabetes also increases with diabetes. The
increasing weight.15 Compared to a healthy weight
person, an overweight individual is 3 times more metabolic syndrome
likely to develop diabetes within 10 years.16 This is a defined cluster
risk rises dramatically to 23 times the risk at the of three or more
2 16 these chronic disease
higher BMI levels (BMI ≥35 kg/m ). Individuals with risk factors (Table 2) that are often accompanied by
diabetes are also at an increased risk of developing insulin resistance.5
coronary heart disease.5 Coronary heart disease
comprises more than 50% of all cardiovascular Metabolic syndrome increases the risk for coronary
disease-related events in U.S. adults and is the heart disease and diabetes 2- to 6-fold and 3.5-
17 19-21
leading cause of diabetes-related death. fold, respectively. Based on NHANES III data,
an estimated one-fourth of U.S. adults have the
metabolic syndrome.22 Furthermore, based on the
Body Mass Index and Coronary Heart Disease Risk Factors National Cholesterol Education Program (NCEP)
45 criteria listed in Table 2 an estimated 86% of adults
40 age 50 and older with type 2 diabetes have the
) 35 metabolic syndrome.23
30
25 The beneficial health effects of weight loss
20
Prevalence (%15 A 10- to 20-pound weight loss often improves
10 blood pressure, blood cholesterol, and triglyceride
Coronary Heart Disease Risk 5 levels.24-27 Weight loss is also an effective therapy
0 for reducing the risk of diabetes. A subanalysis of a
<25.0 25.0– 27.0 27.1– 29.9 >30.0
Body Mass index (kg/m2) Diabetes Prevention Program cohort comprised of
Elevated Blood Pressure Reduced HDL Elevated Cholesterol adults with impaired glucose tolerance receiving an
intensive lifestyle intervention, found a 16% reduction
Figure 1. BMI and prevalence of coronary heart disease risk in risk for developing diabetes for every kilogram
14
Figure 1. BMI and prevalence of coronary heart disease
factors. Adapted from Brown et al., 2000. 14
risk factors. Adapted from Brown et al., 2000. 2
Table 2. NCEP Criteria for Metabolic Syndrome* Box 1. TLC Components:
Risk Factor Defining Level • Diet
Abdominal obesity Waist Circumference – Reduced intakes of saturated fats,
Men ≥40 in trans fats, and cholesterol.
Women ≥35 in
Triglycerides ≥150 mg/dL – Dietary options for maximizing LDL
HDL cholesterol reduction and reducing coronary
Men <40 mg/dL heart disease risk (plant
Women <50 mg/dL stanols/sterols, increased soluble
Blood Pressure ≥130/85 mmHg fiber, and fish).
Fasting glucose ≥100 mg/dL • Weight management
Adapted from National Cholesterol Education Program • Increased regular physical activity
(NCEP), ATP III Final Report.5
*A diagnosis of metabolic syndrome is made when 3 or more In addition to lowering LDL, a TLC-like eating plan
of the risk factors are present. has also been shown to positively affect blood
pressure and serum triglyceride levels with little or
of weight loss, independent of diet and physical
28 no effect on HDL levels.6 These effects are further
activity. Weight loss has a similar effect on the risk enhanced by weight reduction and increased physical
for developing hypertension. In another observational
5, 31
study, a Framingham Study cohort composed of activity in overweight individuals (Table 1). This
overweight, middle-aged adults without hypertension, is especially important for those with diabetes and/or
found that a moderate weight loss of 15 pounds the metabolic syndrome.
or more reduced the long-term risk of developing TLC is a comprehensive lifestyle approach that
29
hypertension by 28%. Furthermore, in a clinical includes specific dietary recommendations (TLC
study of individuals with metabolic syndrome, weight diet), weight management, and increased physical
reduction was shown to reduce elevated triglycerides, activity. The TLC diet component emphasizes
systolic and diastolic blood pressure, serum glucose, reducing dietary cholesterol (<200 mg/day), saturated
and total cholesterol.30 fats (<7% of total calories), and trans fats (lower
intake) (Table 3). Total fat comprises 25–35%
What is TLC?
TLC is the lifestyle component of the Third Report Table 3. Dietary Recommendations for TLC Diet
of the NCEP Adult Treatment Panel (ATP) III Component TLC Diet
guidelines5 that focuses on diet, weight management, Total fat 25-35% of total calories*
and increased physical activity (Box 1). The ATP Saturated fat <7% total calories
III guidelines specifically target LDL because of Polyunsaturated fat Up to 10% of total calories
its strong, positive correlation with coronary heart Monounsaturated Up to 20% of total calories
disease risk.5 Although drug fat
therapy may also be used, Trans fat Lower intake
ATP III places a major Carbohydrate** 50-60% of total calories
emphasis on TLC as Dietary fiber 20-30 grams per day
an essential therapy Protein 15-25% of total calories
for persons at risk Cholesterol <200 mg/day
for coronary heart Sodium <2,300 mg/day
disease.5 The Dietary options
cumulative effect Plant sterols/stanols Add up to 2 grams per day
of the TLC diet Soluble fiber Increase 5-10 grams per day
components listed in Fish (fatty fish) Include in weekly eating plan
Box 1 can reduce LDL * ATP III allows an increase of total fat to 35% of total calories
by 25-30% compared and a reduction of carbohydrate to 50% in persons with
to a typical U.S. metabolic syndrome and/or at risk for type 2 diabetes.
dietsimilar to the ** Carbohydrate should derive predominantly from foods rich in
5 complex carbohydrates including grains (especially whole
effect of drug therapy.
grains) and fruits and vegetables.
3
of total calories, with up to 20% coming from 2004 report of the
monounsaturated fats and 10% from polyunsaturated Continuing Survey
fats. Finally, optional nutrient considerations for of Food Intakes
maximizing LDL reduction and reducing coronary of Individuals
heart disease risk include complementing the diet (CSFII), the latest
with stanols/sterols (2 g/day) and viscous (soluble) estimated median
fibers (5–10 g/day), and including fish (especially oily intake of total
fish such as salmon, tuna, and mackerel) as part of dietary fats in the
one’s overall eating plan. United States is
The following sections describe each of the TLC approximately 33
components (TLC diet, weight management, and percent of total
increased physical activity) in detail and how each calories.33 While
affects the risk factors associated with coronary heart this number is
disease, type 2 diabetes, and metabolic syndrome. within the TLC
recommendations
How Do the Current U.S. Dietary Fat and for total fat intake,
Cholesterol Intakes Compare to TLC TLC’s second
Recommendations? criterion for fat
intaketypes of fatsis not being met. As shown
Fats play diverse roles in the body. Not only do fats in (Table 4), Americans are consuming more than
insulate the body against the elements, but they also the recommended amounts of saturated fat and
serve as an energy source for the body. In addition, cholesterol.34
fats are a crucial component of the cell membranes More about trans fats and dietary cholesterol
that surround each of the billions of cells in the body. Trans fats have received much attention lately due to
Because of the important roles dietary fats play in their negative effect on coronary heart disease risk.36
maintaining health, it is important to consume both Most trans fats in the United States diet are produced
the proper amount and types of fat. Fats are the during the partial hydrogenation of vegetable oils.32
most concentrated source of energy (calories) in Hydrogenation is a food manufacturing process
the diet, providing nine calories per gram compared that turns liquid vegetable oils into the more solid
to four calories per gram for either protein or margarines. This process also makes the fats
carbohydrates. As previously mentioned, TLC more stable and less likely to turn rancid, which is
recommends that dietary fats make up 25–35% of a an especially favorable characteristic for fats used
person’s total daily calories. 5 The minimum value in deep fat frying. Hydrogenation adds hydrogen
protects against energy and nutrient deficiencies, atoms to a fat molecule. The more hydrogen
elevated triglyceride levels, and lower HDL-C levels atoms that are added to a fat molecule, the more
while the upper limit helps curb saturated fat intake “hydrogenated” and solid the fat becomes. Trans
and excess energy consumption.32 According to a fats are produced when the fat molecule is not
completely hydrogenated, or in other words “partially-
hydrogenated.” Of note, although a small amount of
naturally occurring trans fats are also found in dairy
products and meats, these trans fats do not appear
to negatively affect cholesterol levels to the same
degree as those derived from partially-hydrogenated
vegetable oils.36
Cholesterol is a “fat-like” substance that also plays
an integral role in cell membrane structure. In
addition, cholesterol is required for the production
of bile acids (used in fat digestion) and steroid
hormones (e.g., estrogen and testosterone). The
body is able to produce all of the cholesterol it
needs on a daily basis.5 Therefore, unlike the daily
requirement for dietary fats, cholesterol does not
need to be acquired through the diet. The current
4
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