The Role of Lifestyle in Secondary Prevention of Coronary Heart Disease in Patients With Type 2 Diabetes


      It is unclear whether standard cardiac rehabilitation programs (i.e. moderate changes in diet and exercise) are of benefit to coronary heart disease (CHD) patients with diabetes. These patients not only tend to have more comorbidities, but are also less likely to be referred to such programs than CHD patients without diabetes. This report reviews the role and practicalities of lifestyle interventions in the secondary prevention of CHD in patients with diabetes, with a special focus on results from our 2 multisite comprehensive lifestyle change interventions.These interventions emphasize a very-low-fat, high-complex-carbohydrate diet, moderate exercise, stress management and group support. We conclude that participation in a multicomponent secondary prevention program employing the above interventions may be of benefit not only to CHD patients in general, but in particular to those with CHD and diabetes.


      On ne sait pas très bien si les programmes de réadaptation cardiologique standard (c.-à-d. modifications modérées de l'alimentation et exercice) profitent aux patients atteints de maladie coronarienne et de diabète. Non seulement ces patients ont-ils tendance à avoir plus de maladies concomitantes, mais ils sont moins susceptibles d'être adressés à de tels programmes que ceux qui sont atteints de maladie coronarienne mais pas de diabète. Ce compte rendu passe en revue le rôle et la valeur concrète des interventions touchant le mode de vie pour la prévention secondaire de la maladie coronarienne chez les patients atteints de diabète et met l'accent sur les résultats de nos deux interventions multicentriques et exhaustives sur le mode de vie. Ces interventions comportaient une alimentation très faible en gras et riche en glucides complexes, de l'exercice d'intensité modérée, la gestion du stress et un groupe de soutien. Nous avons conclu que la participation à un programme de prévention secondaire comportant les diverses interventions ci-dessus pourrait profiter non seulement aux patients atteints de maladie coronarienne en général, mais en particulier à ceux atteints de maladie coronarienne et de diabète.


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        • McKinlay J.
        • Marceau L.
        US public health and the 21st century: Diabetes mellitus.
        Lancet. 2000; 356: 757-761
        • Zimmet P.
        • Alberti K.G.
        • Shaw J.
        Global and societal implications of the diabetes epidemic.
        Nature. 2001; 414: 782-787
        • Hu F.B.
        • van Dam R.M.
        • Liu S.
        Diet and risk of Type II diabetes: the role of types of fat and carbohydrate.
        Diabetologia. 2001; 44: 805-817
        • Haskell W.L.
        Cardiovascular disease prevention and lifestyle interventions: effectiveness and efficacy.
        J Cardiovasc Nurs. 2003; 18: 245-255
        • Surwit R.S.
        • Schneider M.S.
        Role of stress in the etiology and treatment of diabetes mellitus.
        Psychosom Med. 1993; 55: 380-393
        • Garg A.
        • Bantle J.P.
        • Henry R.R.
        • et al.
        Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus.
        JAMA. 1994; 271: 1421-1428
        • Haffner S.M.
        • Lehto S.
        • Ronnemaa T.
        • et al.
        Mortality from coronary heart disease in subjects with type 2 diabetes and in non-diabetic subjects with and without prior myocardial infarction.
        N Engl J Med. 1998; 339: 229-234
        • Third Report of the National Cholesterol Education Program
        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
        • Lee W.L.
        • Cheung A.M.
        • Cape D.
        • et al.
        Impact of diabetes on coronary artery disease in women and men: a meta-analysis of prospective studies.
        Diabetes Care. 2000; 23: 962-968
        • D'Agostino R.B.
        • Russell M.W.
        • Huse D.M.
        • et al.
        Primary and subsequent coronary risk appraisal: New results from The Framingham Study.
        Am Heart J. 2000; 139: 272-281
        • Marso S.P.
        • Ellis S.G.
        Coronary heart disease and diabetes mellitus.
        in: Braunwald E. Harrison's Advances in Cardiology. McGraw-Hill, New York, NY2003: 200-207
        • Costacou T.
        • Mayer-Davis E.J.
        Nutrition and prevention of type 2 diabetes.
        Annu Rev Nutr. 2003; 23: 147-170
        • Knowler W.C.
        • Barrett-Connor E.
        • Fowler S.E.
        • et al.
        Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
        N Engl J Med. 2002; 346: 393-403
        • Tuomilehto J.
        • Lindstrom J.
        • Eriksson J.G.
        • 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
        • Toobert D.J.
        • Glasgow R.E.
        • Nettekoven L.A.
        • et al.
        Behavioral and psychosocial effects of intensive lifestyle management for women with coronary heart disease.
        Patient Educ Couns. 1998; 35: 177-188
        • 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
        • Ornish D.
        Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project.
        Am J Cardiol. 1998; 82: 72T-76T
        • Ornish D.
        Intensive lifestyle changes in management of coronary heart disease.
        in: Braunwald E. Harrison's Advances in Cardiology. McGraw-Hill, NewYork, NY2002: 43-52
        • Koertge J.
        • Weidner G.
        • Elliott-Eller M.
        • et al.
        Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project.
        Am J Cardiol. 2003; 91: 1316-1322
        • Ornish D.
        • Scherwitz L.W.
        • Billings J.H.
        • et al.
        Intensive lifestyle changes for reversal of coronary heart disease.
        JAMA. 1998; 280: 2001-2007
        • Toobert D.J.
        • Glasgow R.E.
        • Strycker L.A.
        • et al.
        Biologic and quality-of-life outcomes from the Mediterranean Lifestyle Program: a randomized clinical trial.
        Diabetes Care. 2003; 26: 2288-2293
        • Lindström J.
        • Louheranta A.
        • Mannelin M.
        • et al.
        The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity.
        Diabetes Care. 2003; 26: 3230-3236
        • Hu F.B.
        • Willett W.C.
        Optimal diets for prevention of coronary heart disease.
        JAMA. 2002; 288: 2569-2578
        • Anderson J.W.
        • Randles K.M.
        • Kendall C.W.
        • et al.
        Carbohydrate and fiber recommendations for individuals with diabetes: a quantitative assessment and meta-analysis of the evidence.
        J Am Coll Nutr. 2004; 23: 5-17
        • Liu S.
        • Manson J.E.
        • Stampfer M.J.
        • et al.
        A prospective study of whole-grain intake and risk of type 2 diabetes mellitus in US women.
        Am J Public Health. 2000; 90: 1409-1415
        • Fung T.T.
        • Hu F.B.
        • Pereira M.A.
        • et al.
        Whole-grain intake and the risk of type 2 diabetes: a prospective study in men.
        Am J Clin Nutr. 2002; 76: 535-540
        • Chandalia M.
        • Garg A.
        • Lutjohann D.
        • et al.
        Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus.
        N Engl J Med. 2000; 342: 1392-1398
        • Jarvi A.E.
        • Karlstrom B.E.
        • Granfeldt Y.E.
        • et al.
        Improved glycemic control and lipid profile and normalized fibrinolytic activity on a low-glycemic index diet in type 2 diabetic patients.
        Diabetes Care. 1999; 22: 10-18
        • Stratton I.M.
        • Adler A.I.
        • Neil H.A.
        • et al.
        Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.
        BMJ. 2000; 321: 405-412
        • Position of the American Dietetic Association and Dietitians of Canada
        Vegetarian diets.
        J Am Diet Assoc. 2003; 103: 748-765
        • Canadian Diabetes Association Clinical Practice Guideline Expert Committee
        Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada.
        Can J Diabetes. 2003; : S27-S31
        • Standards of medical care for patients with diabetes mellitus
        Diabetes Care. 2003; 26: S33-50
        • Hu F.B.
        • Stampfer M.J.
        • Solomon C.
        • et al.
        Physical activity and risk for cardiovascular events in diabetic women.
        Ann Intern Med. 2001; 134: 96-105
        • Sato Y.
        • Nagasaki M.
        • Nakai N.
        • et al.
        Physical exercise improves glucose metabolism in lifestyle-related diseases.
        Exp Biol Med (Maywood). 2003; 228: 1208-1212
        • Albright A.
        • Franz M.
        • Hornsby G.
        • et al.
        American College of Sports Medicine position stand. Exercise and type 2 diabetes.
        Med Sci Sports Exerc. 2000; 32: 1345-1360
        • Surwit R.S.
        • van Tilburg M.A.
        • Zucker N.
        • et al.
        Stress management improves long-term glycemic control in type 2 diabetes.
        Diabetes Care. 2002; 25: 30-34
        • Blumenthal J.A.
        • Babyak M.
        • Wei J.
        • et al.
        Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men.
        Am J Cardiol. 2002; 89: 164-168
        • Writing committee for the ENRICHD Investigators
        Effects of treating depression and low perceived social support on clinical events after myocardial infarction:The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial.
        JAMA. 2003; 289: 3106-3116
        • O'Farrel P.
        • Murray J.
        • Huston P.
        • et al.
        Sex differences in cardiac rehabilitation.
        Can J Cardiol. 2000; 16: 319-325
        • Suresh V.
        • Harrison R.A.
        • Houghton P.
        • et al.
        Standard cardiac rehabilitation is less effective for diabetics.
        Int J Clin Pract. 2001; 55: 445-448
        • Banzer J.A.
        • Maguire T.E.
        • Kennedy C.M.
        • et al.
        Results of cardiac rehabilitation in patients with diabetes mellitus.
        Am J Cardiol. 2004; 93: 81-84
        • Milani R.V.
        • Lavie C.J.
        Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events.
        Am J Med. 1996; 100: 517-523
        • Verges B.
        • Patios-Verges B.
        • Cohen M.
        • et al.
        Effects of cardiac rehabilitation on exercise capacity in type 2 diabetic patients with coronary artery disease.
        Diabet Med. 2004; 21: 889-895
        • Pischke C.R.
        • Weidner G.
        • Elliot-Eller M.
        • et al.
        Comparison of coronary risk factors and quality of life in coronary artery disease patients with vs. without diabetes mellitus.
        Am J Cardiol. 2006; (In press.)
        • Sumner M.
        • Weidner G.
        • Merritt-Worden T.
        • et al.
        The effect of comprehensive lifestyle changes on diabetic patients in the Multisite Cardiac Lifestyle Intervention program (MCLIP).
        Presented at: American Psychosomatic Society Annual Meeting, Vancouver, British Columbia, Canada2005
        • Anderson R.J.
        • Freedland K.E.
        • Clouse R.E.
        • et al.
        The prevalence of comorbid depression in adults with diabetes: a meta-analysis.
        Diabetes Care. 2001; 24: 1069-1078
        • Lustman P.J.
        • Anderson R.J.
        • Freedland K.E.
        • et al.
        Depression and poor glycemic control: a meta-analytic review of the literature.
        Diabetes Care. 2000; 23: 934-942
        • de Groot M.
        • Anderson R.
        • Freedland K.E.
        • et al.
        Association of depression and diabetes complications: a meta-analysis.
        Psychosom Med. 2001; 63: 619-630
        • Frasure-Smith N.
        • Lesperance F.
        • Gravel G.
        • et al.
        Social support, depression, and mortality during the first year after myocardial infarction.
        Circulation. 2000; 101: 1919-1924
        • Clouse R.E.
        • Lustman P.J.
        • Freedland K.E.
        • et al.
        Depression and Coronary Heart Disease in Women with Diabetes.
        Psychosom Med. 2003; 65: 376-383
        • Ades P.A.
        Cardiac rehabilitation and secondary prevention of coronary heart disease.
        N Engl J Med. 2001; 345: 892-902
        • Toobert D.J.
        • Strycker L.A.
        • Glasgow R.E.
        • et al.
        If you build it, will they come?. Reach and Adoption associated with a comprehensive lifestyle management program for women with type 2 diabetes.
        Patient Educ Couns. 2002; 48: 99-105
        • O'Loughlin J.L.
        • Paradis G.
        • Gray-Donald K.
        • et al.
        The impact of a community-based heart disease prevention program in a low-income, inner-city neighborhood.
        Am J Public Health. 1999; 89: 1819-1826
        • Glasgow R.E.
        • Toobert D.J.
        • Hampson S.E.
        Participation in outpatient education programs: how many patients take part and how representative are they?.
        Diabetes Educator. 1991; 17: 376-380
        • Jack L.
        Beyond lifestyle interventions in diabetes: A rationale for public and economic policies to intervene on social determinants of health.
        J Public Health Manage Pract. 2005; 11: 357-360
        • Hogan P.
        • Dall T.
        • Nikolov P.
        Economic costs of diabetes in the US in 2002.
        Diabetes Care. 2003; 26: 917-932
        • O'Brien J.A.
        • Patrick A.R.
        • Caro J.J.
        Cost of managing complications resulting from type 2 diabetes mellitus in Canada.
        BMC Health Serv Res. 2003; 3: 7
        • Palmer A.J.
        • Roze S.
        • Valentine W.J.
        • et al.
        Intensive lifestyle changes or metformin in patients with impaired glucose tolerance: modeling the long-term health economic implications of the diabetes prevention program in Australia, France, Germany, Switzerland, and the United Kingdom.
        Clin Ther. 2004; 26: 304-321
      1. Agency for Healthcare Research and Quality website. HCUPnet, Healthcare Cost and Utilization Project. Available at: Accessed December 19, 2005.

        • Perelson G.
        • Day B.
        • DeVries A.
        • et al.
        Reduced healthcare costs among cardiac patients making changes in diet and lifestyle: Results from three years of claims utilization of patients and matched controls.
        in: Presented at: 6th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke2005 (Washington, DC, United States.)
      2. Medicare Preventive Services, Centers for Medicare and Medicaid Services website. Medicare Lifestyle Modification Program Demonstration Project. Federal Register Notice— January 5, 2000. Available at: Accessed December 19, 2005.