Role of diet in management of cardiovascular diseases like HTN, CAD & CHF
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ROLE OF DIET IN MANAGEMENT OF
CARDIOVASCULAR DISEASES LIKE HTN, CAD & CHF
SPEAKER : DR VIVEK MAHAJAN
PRECEPTOR: DR YASHPAUL SHARMA
IMPACT OF NUTRITION ON THE GLOBAL CVD BURDEN
WHO: CVD causes 33%(18 million) of deaths worldwide (www.who.int)
CVD accounted for 32 percent of all deaths in 2000 in India BMJ 2004; 328:807
Diet & lifestyle changes have led to increase in overweight & obesity
Obesity increases incidence of type 2 diabetes
Increased risk of CVD consequently
Estimated 30% of deaths from coronary heart disease due to unhealthy diets (National Heart Forum 2002)
EVIDENCE OF NUTRIENT EFFECT AND CARDIOVASCULAR RISK
Testing specific nutrient effects is complicated
Inherent difficulties of conducting randomized, controlled clinical endpoint trials for nutritional interventions
Nutrients generally cannot be subjected to the same evidence-based criteria that are used to assess drug treatments
Imprecision of the dietary information
Difficulty of correcting for confounding effects of other health behaviors
EFFECTS OF SPECIFIC FOOD CATEGORIES ON CARDIOVASCULAR DISEASE
FRUITS AND VEGETABLES
3 or more servings/day vs less than 1/day a/w 27% reduction in CV risk
Am J Clin Nutr 2002; 76:93
Graded risk reduction associated with higher intakesThe Physicians' Health Study. Int J Epidemiol 2001; 30:130
The Women's Health Study. Am J Clin Nutr 2000; 72:922
At least 5 portions/day of a variety of fruits and vegetables recommended
WHOLE GRAINS
Whole grains a/w reduced CV risk Effect may be related to fiber intake
--Arch Intern Med 2004; 164:370
--Am Coll Cardiol 2002; 39:49
Vitamins, phytoestrogens, phenols, omega-3 fatty acids, resistant starch, and minerals may contribute
27 % reduction in CHD risk with whole grain consumption Recommended intake of at least 3 servings/day for cardiovascular
health -- J Am Coll Nutr 2000; 19:291S
FIBERS
Viscous (soluble) forms of dietary fiber reduce LDL Insoluble fiber does not significantly affect LDL
J Nutr 1999;129:1457S-66S
Increase in viscous fiber of 5–10 g/d accompanied by 5 % reduction in LDL
Federal Register 1998;63:8103-21
Federal Register 1997;62:28234-45
In a meta-analysis of 67 trials related to oats, pectin, guar, and psyllium, significant reduction in total and LDL cholesterol noted for all sources of viscous fiber in ranges of 2–10 grams per day
Am J Clin Nutr 1999;69:30-42
NUTS
Good sources of MUFAs, fiber, minerals & flavonoids
Walnuts rich in PUFAs (linoleic and alpha-linolenic acid) --J Nutr 2002; 132:1062S
Nut consumption a/w reduced CV risk
Women consuming 5 oz/week had 35 % lower risk of nonfatal MI than those eating less than 1 oz/month
--Arch Intern Med 2002; 162:1382.
Men consuming twice/week or more had 47% reduction in risk for SCD & 30 percent reduction in total CHD mortality compared with those who rarely or never consumed nuts
--J Nutr 2002; 132:1062S
Almond have beneficial effects on plasma lipoproteins --Circulation 2002; 106:1327
FISH
Species with high ω3 FA confer protection from IHDs Circulation 2002; 106:2747
Intake of small quantities a/w 17% reduction in CHD mortality risk & 27 % reduction in risk for nonfatal MI,
Each additional serving/wk associated with a further reduction of 3.9% in CHD mortality
Am J Prev Med 2005; 29:335
ω3 FATTY ACIDS
Increased plasma levels of Eicosapentaenoic acid (EPA) & Docosahexanoic acid (DHA) predicted reduction in SCD
N Engl J Med 2002; 346:1113.
1 g/day ω3 FAs lowered overall risk of death and of coronary death from 6.8% to 4.8%
Lancet. 1999;354:447–455.
5.5 gm/mth of EPA plus DHA (equivalent to one portion of fatty fish/wk) a/w 50% lower incidence of SCD
Enrichment of membrane phospholipids with ω3 FA results in reduction in risk for abnormal cardiac electrical conductivity
Am J Clin Nutr 2000; 71:208S
Antiplatelet & antiinflammatory effects Reduction in plasma triglycerides at higher doses
Circulation 2002; 106:2747
THE FRENCH PARADOX AND RED WINES
High intake of SFAs but low CHD incidence & mortality
Relative immunity of the French to CHD attributed in part to their custom of drinking wine with meals
Red wine polyphenolic extracts (RWPE) mediate a vaso-relaxant effect via NO release
2 anthocyanins (delphinidin & petunidin), a flavonol (quercetin) and a stilbene (resveratrol) inhibit endothelin-1 synthesis
RWPE reduce ICAM-1, VCAM-1 and selectin expression
Increase HDL and decrease in ox-LDL
ALCOHOL
1-2 drinks/day strongly & consistently a/w lower CHD risk than either abstention or higher intakes Rev Cardiovasc Med 2002; 3:7
Similar relationship with CHD regardless of type of alcoholic beverages consumed BMJ 1996;312:731-6
Major benefit of alcohol consumption related to an increase in HDL Reduced fibrinogen, platelet aggregation & inflammation
(Eur J Clin Nutr 2002; 56:1130) (Circulation 2003; 107:443) (Arterioscler Thromb Vasc Biol 2006; 26:995)
38,077 male health professionals free of cardiovascular disease f/u for 12 yrs Compared to men who consumed < once/week, men who
consumed alcohol 3-5 or 5-7 d/wk had decreased risks of MI Risk similar among men who consumed <10 g/d and those who
consumed 30 g or more. No single type of beverage conferred additional benefit
Physicians' Health Survey 87,938 men A 5.5-year follow-up
Circulation 2000;102:500-505
INTERHEART STUDY
RESVERATROL
Red wine, berries, peanuts & grapes
Polyphenolic compound Belongs to class Phytoestrogens Antioxidant & weak oestrogenic
activity Preconditioning effect rather
than direct protectionMol Int. Feb 2006 vol 6(1) 36-47
GARLIC
Beneficial effects on serum cholesterol, TG levels and on BP
Reducing platelet aggregation and increasing fibrinolytic activity
Sulphur-containing flavone compounds major health promoting components
J Nutr. 2006 Mar;136(3 Suppl):736S-740S
PLANT STANOLS/STEROLS
Plant sterols isolated from soybean and tall pine-tree oils Hydrogenating sterols produces plant stanols Available in commercial margarines
Plant-derived stanol/sterol esters at dosages of 2–3 g/day lower LDL-C levels by 6–15% with little or no change in HDL or TG levels
Am J Clin Nutr 1999;69:403-10
Metabolism 1999;48:575-80.
Circulation1997;96:4226-31
Projected that their use should double the beneficial effect on CHD risk achieved by reducing dietary saturated fatty acids and cholesterol
West J Med 2000;173:43-7
SOY PROTEIN
Derived by processing of the soybean Isoflavones, fiber, and saponins
Review of 16 trials: Soy protein included in a diet low in saturated fatty acids and cholesterol can lower levels of total cholesterol & LDL in individuals with hypercholesterolemia
Federal Register 1998;63:62977-3015.
Federal Register 1999;64:57699-733
25 g/day soy protein in a diet low in SFAs and cholesterol lowers LDL cholesterol levels by 5%
Metabolism 2000;49:67-72. about 5 percent
DIETARY INTERVENTION TRIALS
SATURATED FATTY ACIDS
Causal relationship between total & LDL cholesterol levels and CHD
Saturated fatty acids increase LDL concentrations
Palmitic acid (C16:0) found in meats, dairy fat, palm oil, is the most common saturated fatty acid.
Palm oil major fat source in Latin America, Asia, Europe
Western diets with dairy fat & meat contain myristic acid
Tropical oils: coconut or palm kernel oils, have mainly lauric acid
Myristic acid : strongest effect on LDL f/b lauric & palmitic acids.
WHAT SHOULD REPLACE SATURATED FATS?
Controversy
whether carbohydrate or unsaturated oils should replace the energy from saturated and trans unsaturated fat?
If saturated fat (e.g., 25 g or 10% of total daily energy intake) is replaced by carbohydrate, monounsaturated fat, or polyunsaturated fat, LDL will decrease by 13 mg/dL, 15 mg/dL, or 18 mg/dL, respectively
Arterioscler Thromb. 1992;12:911–919.
So is replacement with any of these logical?
Annu Rev Nutr. 1995;15: 473–493
LOW FAT APPROACH
Trial n Dietary Intervention
Diet Fat %
P and S Fat, %
Dur yrs
Change in Sr
Chol, %
Change in CHD,
%
MRC (low fat)
123 male MI patients
Reduce total fat
22 NR 3 - 5 +5
DART1989
1015 male MI patients
Reduce total fat
32 NR 2 - 4 - 9
WHI2006
19,541 women
Reduced total fat
29P = 6; S
= 108 - 1 0
DIETARY INTERVENTION TRIALS OF LOW FAT APPROACH
WOMEN'S HEALTH INITIATIVE (WHI) RANDOMIZED CONTROLLED DIETARY MODIFICATION TRIAL
Dietary pattern low in total fat, along with increased intakes of vegetables, fruits & grains
50,000 postmenopausal women randomized to intervention group receiving regularly scheduled individualized dietary consultations
Comparison group receiving diet-related education materials only.
JAMA 2006; 295:655
Reduction in total fat intake between the intervention and control groups (28.8 % vs 37 % of calories) (p<0.001)
No significant effects of the intervention on CHD, stroke, or CVD were observed during the 8-year follow-up
Lack of benefit on CVD endpoints might be related to minimal change in LDL due to counterbalancing effects of saturated fat and polyunsaturated fats.
Modulation of total dietary fat intake within the range consumed in general population does not alter CVD risk
JAMA 2006; 295:655
WOMEN'S HEALTH INITIATIVE (WHI) RANDOMIZED CONTROLLED DIETARY MODIFICATION TRIAL
HIGH DIETARY PUFA APPROACH
DIETARY INTERVENTION TRIALS OF HIGH PUFA APPROACH
Trial n Dietary Intervention Diet Fat %
P and S Fat, %
Dur yrs
Change in Sr
Chol, %
Change in CHD, %
Finnish Mental Hosp Study
1979
676 men without CHD
↓saturated fat, ↑polyunsaturated fat 35 P = 13;
S = 9 6 - 15 - 44
Los Angeles Veteran Study
1959
424 men; no e/o CHD
↓saturated fat, ↑polyunsaturated fat 40 P = 16;
S = 9 8 - 13- 20 in CHD,- 31CV events
Oslo Diet-Heart Study1969
206 male MI patients
↓saturated fat, ↑polyunsaturated fat 39 P = 21;
S = 9 5 - 14 - 25
MRC (soy oil)1970
199 male MI patients
↓saturated fat, ↑polyunsaturated fat 46 P : S = 2 4 - 15 - 12
Minnesota Coronary Survey
4393 men 4664 women
↓saturated fat, ↑polyunsaturated fat 38 P = 15;
S = 9 1 - 14 0
HIGH PUFA TRIALS
Corn, safflower, sunflower & soybean oils prescribed to hypercholesterolemic patients in the 1960s and 1970s.
Patients instructed to drink the vegetable oils, as well as to use them in cooking or salads
PUFAs studied mainly ω6 class and not include the ω3 PUFAs from fish
Linoleic and α-linolenic acids increased in these trials.
Coronary events are reduced by 2% for every 1% reduction in total cholesterol Am J Cardiol. 1995;76:10C–17C
INCREASE DIEATRY ω3 FATTY ACID STRATEGY
DIETARY INTERVENTION TRIALS OF ω3 FA
Trial n Dietary Intervention
Durn yrs
Change in Chol
Level, %Change in CHD, %
DART1989
1015 male MI patients
Fish twice per week or fish oil (1.5 gm/d) 2 NR
- 16 on CHD events- 29 in total mortality
GISSI-Prevenzione
1999
5666 MI patients,
primarily men
Fish oil (EPA + DHA 1 gm/d) or mustard oil (ALA, 2.9 gm/d)
3.5 0- 30 in CV death
- 45 in sudden death
Indian1992
242 MI patients,
primarily men
Fish oil (EPA, 1.08 gm/d) 1 0
- 30 in fish oil group- 19 in mustard oil gp
WHOLE DIET INTERVENTION TRIALS
STANDARD WESTERN DIET
Total fat 38% Saturated fat 17% Monounsaturated fat 14% Polyunsaturated fat 7% Carbohydrates 42% Protein 20% Cholesterol 400 mg/day
STEP 1 DIET
Reduced total fat intake to 30% Saturated fat10% Dietary cholesterol 300 mg Replacing saturated fat mainly with carbohydrate. Monounsaturated 15% Polyunsaturated fat 10% similar to the initial diet Protein 15%
LOW-FAT DIET
Total fat 20% Saturated fat 7% Monunsaturated and polyunsaturated fats decreased to 10% and
5%, Carbohydrate increased to 65%. Protein 15% Cholesterol is reduced to 200mg/day
MEDITERRANEAN DIET
Saturated fat replaced with veg oils (olive, canola, corn, safflower or sunflower oil, or oils from nuts
Contain mainly monounsaturated and polyunsaturated fatty acids.
Total fat content remains at 38%
Dietary cholesterol is reduced to 100 mg/day
Arterioscler Thromb. 1992;12:911–919
PREDICTED EFFECTS ON CORONARY ARTERY DISEASE
Circulation. 1999;99:779–785
Olive oil rich in MUFAs
Extravirgin olive oil contains a considerable amount of phenolic compounds, hydroxytyrosol and oleuropein, having antioxidant & other potent biological activities
Refined olive oil contains less phenolic compounds : large fraction of potentially beneficial bioactive compounds(such as flavonoids) lost in processing
Eurolive project: Ongoing research on phenolic compound hydroxytyrosol for anti-platelet effect
LYON DIET HEART STUDYMEDITERRANEAN DIET TRIAL
423 patients with documented CAD f/u mean of 3.8 yrs
Experimental diet: increased amounts of fruits, vegetables, legumes, and fiber
Reductions of meats, butter, and cream (but not cheese)
Margarine enriched in alpha-linolenic acid, ω3 FA precursor of longer chain EPA & DHA found in fatty fish.
Total fat approximately 31 percent in both diets.
.
Circulation.1999;99:779–785
Significant reductions occurred in all outcome measures: All-cause mortality (56 percent) Cardiac mortality (65 percent) Nonfatal myocardial infarction (70 percent)
Particularly important role for increased omega-3 fatty acid intake was responsible
LYON DIET HEART STUDYMEDITERRANEAN DIET TRIAL
Circulation.1999;99:779–785
MEDITERRANEAN DIET
INDIAN HEART STUDY
Fruit & vegetable intake 3 times higher in the experimental than in the control group
Total fat intake 24% - 26% of energy in both groups
Experimental group had higher intake of polyunsaturated fats, fiber, vitamins C and E, carotene, and potassium
Experimental group had lower intake of SFAs and cholesterol
Carbohydrates shifted from refined to complex sources
2 to 3 days after the acute myocardial infarction
BMJ. 1992;304:1015–1019.
Body weight, LDL, TG, BP & serum glucose significantly decreased, and HDL increased in experimental group
Significant reduction in coronary events of 36% in experimental grp after only 12 weeks
After 1 year of treatment, significant decreases in All-cause mortality by 45% Coronary deaths by 42%, Nonfatal myocardial infarction by 38%
The vegetarian diet also reduced ventricular ectopy
INDIAN HEART STUDY
BMJ. 1992;304:1015–1019.
LIFESTYLE AND DIETARY MODIFICATION TRIALS
LIFE-STYLE HEART TRIALEXTREME LOW FAT & LIFE STYLE MODIFICATION
Vegetarian diet with 10 percent total fat
Aerobic exercise training, stress management, smoking cessation, and psychosocial support
48 men with coronary artery disease were allocated to intervention and control groups
35 completed a 5-year follow-up
JAMA 1998; 280:2001
Av diameter stenosis decreased by 7.9% in experimental grp compared to control group which had 11.8% increased after 5 years (p = 0.001)
25 cardiac events in 28 experimental grp pts vs 45 events in 20 control grp patients during the 5yr f/u (RRR for any event for control group, 2.47 [95 % CI, 1.48-4.20])
Intervention program vs control resulted in significant 40% versus 1% reduction of LDL &17% versus 4% reduction in body weight
No significant changes in HDL, TG or BP
LIFE-STYLE HEART TRIALEXTREME LOW FAT & LIFE STYLE MODIFICATION
JAMA 1998; 280:2001
CARBOHYDRATE BASED DIET TRIALS
CARBOHYDRATES
Important determinant of glycemic index is glucose content of carbohydrates
Bread and baked goods, and sugars in juices and soda have high glycemic index
Whole grains, beans, nuts, and vegetables have lower glycemic index, probably because the digestion and absorption of the glucose is slow.
HDL decreases when dietary fat is replaced by carbohydrates, whatever the type of carbohydrate
High glycemic index foods cause glucose & insulin to increase substantially
Low glycemic index foods cause less increase in TGs
DIETARY APPROACHES TO STOP HYPERTENSION (DASH) DIET
27%-fat diet vs typical US diet 38% Fruits, vegetables, and low-fat dairy products Only small amounts of sweets and sugar-containing
beverages Did not increase fasting triglycerides Favorable changes in total and LDL cholesterol Reduced HDL cholesterol 10-y risk decreased by 12.1% in DASH diet group compared with
0.9% increase in risk in control diet group (P < 0.01)
Am J ClinNutr. 2001;74:80–89.
TRANSUNSATURATED FATTY ACID BASED DIETS
TRANS-UNSATURATED FATTY ACIDS
Trans unsaturated FAs formed from naturally occurring cis unsaturated FAs during hydrogenation process
Most trans unsaturated FAs in diet are analogues of oleic acid, the main cis MUFA in diet
LDL increases and HDL decreases when oleic acid is replaced by trans FAs
Worse than the effects of carbohydrate, which decreases both LDL & HDL
Worst effects on blood lipids among all dietary FAs Increased risk of CHD in people consuming these FAs
Am J Med. 2002;113(Suppl 9B):13S–24S
DIETARY CHOLESTEROL
DIETARY CHOLESTEROL
Meta-analyses confirm the LDL-raising action of dietary cholesterolAm J Clin Nutr1992;55:1060-70
BMJ 1997;314:112-7
Meta-analysis: dietary cholesterol raises TC:HDL ratioAm J Clin Nutr 2001;73:885-91
Serum Cholesterol changes by10 mg/dL per 100 mg dietary cholesterol per 1000 kcal
Arteriosclerosis 1988;8:95-101. Western Electric Study: dietary cholesterol increases heart disease
risk independently of its effect on serum LDL levelsArch Pathol Lab Med 1988;112:1032-40
No significant association between frequency of reported egg consumption and CHD
JAMA 1999;281:1387-94
DIETARY TRIALS: CONCLUSIONS
Decreasing saturated fat lowers LDL cholesterol. Replacing SFA with carbohydrate lowers HDL as much as it lowers
LDL. TGs increase with high glycemic index sugars and starches. Fish oil FAs lower TGs Replacing SFAs with MUFAs or PUFAs lowers HDL only slightly and
does not increase TGs Trans unsaturated fats produced by hydrogenating vegetable oil
increase LDL and decrease HDL The most favorable overall changes in plasma lipid concentrations
are produced by replacing saturated and trans unsaturated fats with unhydrogenated MUFAs or PUFAs
DIETARY THERAPY THAT REDUCED CVD
Replacing saturated fat with polyunsaturated vegetable oil
Mediterranean diet after myocardial infarction
Indian vegetarian diet after myocardial infarction
Fish oil after myocardial infarction
WEIGHT REDUCING DIETARY STRATEGIES
WEIGHT REDUCING DIETS
Low-carbohydrate diet (<35 gm of carbohydrate per day)
Atkins diet stricter limitation (20 g/d) for first 2 wks Gradual increase of 5 g/wk to achieve wt loss 2 lb (0.9 kg)/wk
until a weight within 5-10 lb (2.3 to 4.5 kg) of the goal achieved Carbohydrate intake then further increased by 10 g/wk until
weight loss ceases
Reduced-fat diet Fat<30% of the total caloric intake
Variable Low-Carbohydrate Diet Reduced-Fat Diet
Food choices Highly restricted Moderately restricted
Initial rate of wt loss Rapid Gradual
Weight loss Dependent on duration Dependent on duration
Weight maintenance Unproven over the long term Unproven over the long term
LDL No change Decrease
HDL Greater increase Increase
Triglycerides Greater decrease Decrease
Potential long-term concerns
1. Calciuria (renal stones, ↓ bone mass)2. Relatively high-protein content (patients
with renal or hepatic disease)3. Atherogenicity (high saturated fat, trans fat,
and cholesterol levels and relative absence of fruits, vegetables, and whole grains
None
WEIGHT REDUCING DIETS
Up to 6 mths, av. wt. loss higher for diets with very-low-carbohydrate content (<35 g/d) than diets with usual amounts of carbohydrate but restricted in total fat
N Engl J Med 2003; 348:2057
Higher protein and/or lower carbohydrates content, especially simple sugars & rapidly digested starches with lower glycemic effects, increase satiety
Evidence for longer-term efficacy of such diets is lacking
Declining compliance by the end of one yearAnn Intern Med 2004; 140:778
`
Long-term safety and overall health effects of such diets
CALCULATING THE CALORIES
SEDENTARYMODERATELY
ACTIVEVERY ACTIVE
LOSE WEIGHT 15 kcal/kg 20kcal/kg 25kcal/kg
MAINTAIN 20kcal/kg 25kcal/kg 30kcal/kg
GAIN WEIGHT 25kcal/kg 30kcal/kg 35kcal/kg
To lose 1lb/wk, reduce calorie intake by 500 kcal/dayTo lose 2lb/wk, reduce calorie intake by 1000 kcal/day
1kg=2.2lb
DIET IN MANAGEMENT OF HYPERTENSION
DIETARY SODIUM
High intake of sodium results in increase in BPCirculation 1998; 98:613
Reducing Na intake by 80 mmol (1.8 g)/d yields SBP & DBP reductions of 4 & 2 mm Hg in hypertensive patients
JAMA 1998; 279:1383
Trials of Hypertension Prevention Sodium reduction, alone or combined with weight loss, can lower the
incidence of hypertension by about 20 percentArch Intern Med 1997; 157:657
Trials of Nonpharmacologic Interventions in the Elderly Reduced salt intake with or without wt loss significantly reduced BP &
need for antihypertensive medication in older personsJAMA 1998; 279:839
In both trials total sodium intake to about 100 mmol/day
DIETARY PATTERNS
DASH reduced SBP & DBP by 5.5 and 3 mm Hg more than did a control diet of equal Na content
DASH-sodium study, progressive sodium restriction in the DASH diet (from 150 to 100 mmol/d and 50 mmol/d) further BP
DASH diet with the lowest Na intake led to SBP 7.1 mm Hg lower in pts without hypertension and 11.5 mm Hg lower in pts with hypertension
However, most of the blood pressure reduction could be accounted for by the DASH diet rather than additional sodium restriction
Arch Intern Med. 2009;169(9):851-857
CARDIA STUDY
4304 young adults
Followed for more than 15 years
Multicenter, population-based, prospective study of CVD risk
Diets rich in whole grains, refined grains, fruits, vegetables, and nuts or legumes inversely related to BP
Positive effects of red and processed meat intake on blood pressure were observed.
Am J Clin Nutr 2005; 82:1169
OTHER DIETARY FACTORS AFFECTING BLOOD PRESSURE
Alcohol Observational data demonstrated relationship between heavy
drinking (3 or more standard drinks/d) and higher BPJ Cardiovasc Risk 2003; 10:21
Minerals: Ca, Mg, K Clinical trials: beneficial impact of K-supplements on BP Evidence for Ca & Mg is less consistent (only observational) K suppn of diet with 60-120 mmol/d reduced SBP & DBP by 4.4
& 2.5mmHg in HTNsive & by 1.8 & 1mmHg in normotensive pts The preferred strategy for increasing mineral intake is through
foods rather than supplements
Meta-analysis: JAMA 1997; 277:1624
Meta-analysis: JAMA 1998; 279:1383
Fish and alpha-linolenic acid Hypertension 2005; 45:368
Whole grains (in particular, oats J Nutr 2001; 131:1465
Protein (in particular, soy and total vegetable protein) JAMA 2003; 290:1029.
Hypertension 2001; 38:821
J Nutr 2002; 132:1900.
Soy isoflavone and polyphenols in dark chocolate can also promote blood pressure reduction
J Clin Endocrinol Metab 2001; 86:3053
Substitution of either protein or MUFA for carbohydrate substantially decreases BP in prehypertensive and stage 1 hypertensive subjects
JAMA 2003; 290:502
OTHER DIETARY FACTORS AFFECTING BLOOD PRESSURE
DIET IN HEART FAILURE
Sodium restriction (2 to 3g/d) recommended in all pts HF & preserved or depressed EF.
Restriction (<2g/d) in moderate to severe HF. Fluid restriction (<2 l/day) in hyponatremic patients (<130 mEq/l) or
if fluid retention is difficult to control Caloric supplementation recommended for patients with advanced
HF & unintentional weight loss or muscle wasting (cardiac cachexia) Anabolic steroids not recommended because of volume retention. The use of dietary supplements (nutraceuticals) should be avoided
lack of proven benefit potential for significant interactions with proven HF therapies
DIET IN HEART FAILURE
Braunwald`s Heart Disease, 8th Edition, chapter 25
DASH DIET IN HEART FAILURE
36019 pts aged 48 to 83 years
Without baseline HF, DM or MI
Women in top quartile of the DASH diet score based on ranking DASH diet components had 37% lower rate of HF
Diets consistent with the DASH diet are associated with lower rates of HF
No studies in HF patients
Arch Intern Med. 2009;169(9):851-857
AHA GUIDELINES
EVOLUTION OF RECOMMENDATIONS
ATP 1 and 2 (2000) NCEP/ AHA guidelines STEP 1 diet for those with high cholesterol STEP 2 diet recommended when the blood cholesterol does not
improve after 3-month trial of STEP 1 diet
ATP 3 (MAY 2001) American Heart Association accepted and endorsed this report Began incorporating recommendations into its materials on
dietary & lifestyle change Recommended the TLC (Therapeutic Lifestyle Change) diet
THERAPEUTIC LIFESTYLE CHANGE
AHA GUIDELINES FOR FISH INTAKE
Recommended consumption of 2 portions of fish/wk
Salmon, mackerel, albacore tuna, swordfish, herring, sardines, lake trout
Significant quantities of contaminants including methylmercury, polychlorinated biphenyls, & dioxin
FDA guidelines for maximal intakes for children & women of childbearing age
Recommendation of 2 portions/wk falls within these guidelines
AHA GUIDELINES FOR ω3 FA
Supplemental EPA plus DHA at doses of up to 1 gm/day may be considered for risk reduction in patients with CHD in consultation with their physician
Supplements also could be a component of the medical management of hypertriglyceridemia, a setting that requires even larger doses (2 to 4 gm/day)
Circulation 2002; 106:2747
AHA GUIDELINES FOR ALCOHOL INTAKE
Men who drink alcohol may consume up to 2 alcoholic beverages/day
Women no more than one/day, in part because of alcohol-related breast cancer risk.
Potential hazards: habituation to alcohol, adverse effects such as hepatotoxicity and aggravation of hypertriglyceridemia
Favorable benefit/risk ratio of other dietary practices and therapeutic interventions
Individuals should not begin to consume alcohol as a means of reducing coronary disease risk
Circulation 2006; 114:82
NON BENEFICIAL THERAPIES
Folate supplementation in established vascular disease : no evidence of clinical benefit
N Engl J Med 2006; 354:1578
N Engl J Med 2006; 354:1567
Beta-carotene CARET study, non-sig 26% increase in CV mortality NEJM1996;334:1150-5
Alpha-Tocopherol, Beta Carotene Cancer Prevention Study, had no beneficial effect JAMA 2004; 291:565
Linxian study China: non-sig 10% decrease in CV mortality J Natl Cancer Inst 1993;85:1483-92
Vit E supplementation not beneficial GISSI Lancet 1999; 354:447
Women's Health Study JAMA 2005; 294:56
SU.VI.MAX trial Arch Intern Med 2004; 164:2335
THANK YOU
HAPPY HOLI
PREDICTED CHANGES IN CORONARY HEART DISEASE
∆LDL →1 mg/dL→ ∆CAD 1% N Engl J Med. 1989;321:1311–1316
∆ HDL → 1 mg/dL → ∆ CAD2% in men,3% in women.
Circulation. 1989;79:8–15.
∆ TG → 88 mg/dL (1 mmol/L) → ∆CAD 14% in men, 37% in women
J Cardiovasc Risk. 1996; 3:213–219
MEDITERRANEAN DIET
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