best diet for chd prevention dr. thomas g. allison mayo clinic rochester
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Best Diet for CHD Prevention
Dr. Thomas G. Allison
Mayo Clinic Rochester
Fatty Streaks in Aorta of 19-Year Old Male
Advanced Lesion with Large Lipid Core
Plaque Rupture with Torn Cap
Major Statin Trials
50 210
LDL-C (mg/dL)
70 190170150130110900
5
10
15
20
25
% w
ith
CA
D e
ven
t
WOSCOPS
AFCAPS
CARE
4S
LIPID
HPS
PROSPER
Secondary
Mixed
Primary
ASCOT-LLA
PROVE IT
TNT
JUPITER
SIMVASTATIN: CAUSE-SPECIFIC MORTALITY
Risk ratio and 95% CISTATIN PLACEBOCause ofdeath (10269) (10267) STATIN better STATIN worse
CHD 577 701
Other vascular 214 242
ALL VASCULAR 791 943(7.7%) (9.2%)
17% SE 4.4reduction(2P<0.0002)
Neoplastic 352 337
Respiratory 93 111
Other medical 76 91
Non-medical 16 21
ALL NON-VASCULAR 537 560(5.2%) (5.5%)
5% SE 5.9reduction
ALL CAUSES 1328 1503(12.9%) (14.6%)
12% SE 3.5reduction(2P<0.001)
0.4 0.6 0.8 1.0 1.2 1.4
Nissen, S. E. et al. JAMA 2004;291:1071-1080.
Intravascular Ultrasound Images at Baseline and Follow-up
REVERSAL TrialREVERSAL Trial
Limitations to Pharmacologic Lipid Management
• Cost of treatment– Not an issue if generic drug will control LDL-C– Treatment cost ~ $1000 per year if non-generic
agent needed
• Not all patients tolerant of statins– Myalgia most common complaint (5-15%)– Alternative drugs (intestinal agents, niacin, fibrates)
have limited effect on LDL-C, limited outcome data
• Benefits of add-on drug therapy not established
International Comparisons
44
54
57
87
100
202
420
638
0 100 200 300 400 500 600 700
Korea
China - Rural
Japan
France
China - Urban
USA
Hungary
Russia
CHD Death Rates/100,000(Men ages 35-74)
International rates not due to differences in statin therapy rates!
2002 AHA Heart and Stroke Statistical Update
Diets and CAD: What’s the Evidence?
• Dietary therapy can be an alternative to pharmacologic management of lipids in primary prevention
• Important adjunctive therapy in secondary prevention
• What is the best diet for CHD prevention?
East Finland
Mortality from Coronary Heart DiseaseMen 35-64 Years (1969-1994)
Puska P: Cardiovasc Risk factors 6:203-10, 1996Puska P: Cardiovasc Risk factors 6:203-10, 1996
Cardiac death ratesCardiac death rateshave dropped by 75%!have dropped by 75%!
NorthKarelia
AllFinland
Per100,000
800
700
600
500
400
300
200
100
CP999299-39
Now 80%
Trends in Women’s Lifestyles1980-82 versus 1992-94
• 31% decline in CHD incidence across all ages– 41% decrease in smoking (27% 16%)– Diet changes
• 31% decrease in trans fatty acid intake• 69% increase in P/S ratio• 90% increase in cereal fiber• 180% increase in -3 fatty acids• 12% increase in folate
Nurses’ Health Study -- Hu et al: NEJM 2000;343:530-537
Trends in Women’s Lifestyles1980-82 versus 1992-94
• 38% increase in overweight (BMI>25)– average BMI 24.5 26.1 kg/m2
• 22% increase in glycemic load
Regional Diets with Low CHD Rates
• Seventh Day Adventist
• Japanese
• Rural Chinese
• Eskimo
• Mediterranean
Crete
Adherence to Mediterranean Diet and Survival in a Greek Population
• Prospective, population-based investigation of CHD mortality versus diet
• 22,043 healthy adults in Greece• 44-month follow-up• Diet assessed by 10-point scale (0-9)
– vegetables, legumes, fruits and nuts, cereals, fish, alcohol, monounsaturated/saturated fat ratio (+)
– meat, poultry, dairy products (-)Trichopoulou A et al, NEJM 2003:348:2599-2608
Results• Two single nutrients predicted CHD death
– Fruits and nuts: +200 g/day = 18% reduction– Monounsaturated/saturated fat ratio:
+0.5 = 14% reduction
• 2-point increase in Mediterranean diet score– 25% reduction in total mortality– 33% reduction in CHD mortality– 24% reduction in cancer mortality
• Adjusted for age, sex, WHR, energy expenditure, smoking, BMI, potato and egg consumption, and total caloric intake
Epidemiologic Studies
• Inherently flawed• Problems with ascertainment of both
independent (diets) and dependent (mortality, heart attacks, etc.) variables
• Not all non-dietary variables can be measured (and none controlled)
• Assumes constancy of exposure to dietary factors
Diet-Heart Studies with Outcomes
Location N Year f/u
England (Rose) 80 1965 2y
Middlesex 264 1965 5y
Oslo 412 1966 5y
London 393 1968 5y
Sydney 458 1978 5y
DART 2033 1989 2y
Moradabad 505 1992 1y
LHT (invite) 48 1998 5y
Leon 423 1999 4y
Intervention
control v corn oil v olive oil
control v low fat
control v low fat + PUF
control v soya-bean oil
control v low fat + PUF
low fat v fish v fiber
low fat v fruit/veg+fish+fiber
control v ultra-low fat
control v Mediterranean
-25% -20% -15% -10% -5% 0% 5% 10% 15% 20% 25% 30%
Risk Change
Cholesterol Change
Rose - olive oil (MCE)
Rose -- corn oil (MCE)Middlesex (MCE)
Oslo (MCE) p < .05
London (MCE)
Sydney (death) p < .05
DART - low fat (death)
DART - fish (death) p < .05
Dart - fiber (death)
LHT (MCE)
LHT (MCE + revascularization) p < .001
Moradabad (MCE) p < .01
Moradabad (death) p < .01
Leon 1994 (MCE) p < .001
Leon 1999 (MCE) p < .001
n = 2033
n = 458
n = 2033
n = 2033
n = 393
n = 423
n = 605
n = 505
n = 505
n = 48
n = 48
n = 412
n = 264
n = 52
n = 54
Lifestyle Heart Trial
• Randomized invitational design (recruitment in ~1987)
• 28 experimental patients, 20 usual care
• Intervention:– vegetarian, low fat diet (10% fat, 5 mg
cholesterol/day) – smoking cessation, moderate exercise, stress
managementOrnish et al: Lancet1990;336:129-133
Original Dean Ornish Plan
Fats (<10%)Fats (<10%)
Nonfat dairy products – yogurt, cheese, egg whitesNonfat dairy products – yogurt, cheese, egg whites
Nonfat products – cereal, soups, tofu, crackers, egg beatersNonfat products – cereal, soups, tofu, crackers, egg beaters
Whole grain – corn, rice, oats, wheat, etcWhole grain – corn, rice, oats, wheat, etc
Beans and legumesBeans and legumes
FruitsFruits
VegetablesVegetables
Ban
All oilsAll meatsOlivesAvocadosNuts – seedsHigh or low fat productsSugar – syrup – honeyAlcohol
Ban
All oilsAll meatsOlivesAvocadosNuts – seedsHigh or low fat productsSugar – syrup – honeyAlcohol
CP1095424-1
Moderate exerciseStress reductionSmoking cessation
No calorie restriction
Lifestyle Heart Trial 1-Year Results
Variable Experimental Control p <
LDL mg/dl 95 ± 60 157 ± 45 .0072
HDL mg/dl 37 ± 15 51 ± 15 ns
Progression 18% 53%
Regression 82% 42% stenosis -2.2% +3.4% .001
Not powered (or randomized) for clinical events
Lyon Heart Study
• 423 patients randomized post-MI 1988-92
• Mediterranean diet vs “prudent diet” (Step 1) prescribed by patients’ physicians
• Planned 5-year follow-up
• Study terminated early (4 years) due to favorable interim analysis -- final report on 423 patients
de Lorgeril et al, Circ 1999;99:779-785
CP1059685-22
The Traditional Healthy
Mediterranean Diet Pyramid
The Traditional Healthy
Mediterranean Diet Pyramid
Meat
Sweets
Eggs
Poultry
Fish
Cheese & yogurt
Olive oil
Fruits
Bread, pasta, rice, couscous, polenta,other whole grains & potatoes
Daily physical activity
Daily beverageDaily beveragerecommendationsrecommendations
Daily beverageDaily beveragerecommendationsrecommendations
6 glasses6 glassesof waterof water
6 glasses6 glassesof waterof water
Wine inWine inmoderationmoderation
Wine inWine inmoderationmoderation
VegetablesBeans,legumes& nuts
MonthlyMonthlyMonthlyMonthly
WeeklyWeeklyWeeklyWeekly
DailyDailyDailyDaily
2000 Oldways Preservation & Exchange Trust2000 Oldways Preservation & Exchange Trust2000 Oldways Preservation & Exchange Trust2000 Oldways Preservation & Exchange Trust
Lyon Heart Study - Lipids
Control Experimental
Cholesterol 239 ± 40 239 ± 41
HDL 49 ± 13 50 ± 13
LDL 163 ± 38 161 ± 36
Triglycerides 154 ± 73 171 ± 75
Lyon Heart Study
020406080
100120140160180200
Primary Primary +Secondary
All Endpoints
Control
Experimental
p<.0001
p<.0001
p<.0002
Results consistent with DART and Moradabad trials
Search for the Perfect CHD Prevention Diet
• The Lifestyle Heart Trial achieved marked LDL-C lowering, but adversely affected HDL-C
• The Leon Heart Study lowered CHD risk without affecting lipid levels
• Can we design a diet that lowers LDL-C without lowering HDL-C while providing the heart protective nutrients?
Therapeutic Lifestyle Changes in LDL-Lowering Therapy
Major Features
• TLC Diet (Step 2+)– Reduced intake of cholesterol-raising nutrients (same as
previous Step II Diet)• Saturated fats <7% of total calories• Dietary cholesterol <200 mg per day
– LDL-lowering therapeutic options• Plant stanols/sterols (2 g per day)• Viscous (soluble) fiber (10–25 g per day)
• Weight reduction • Increased physical activity
NCEP
Other Features of TLC Diet
Nutrient Recommended Intake• Polyunsaturated fat Up to 10% of total calories• Monounsaturated fat Up to 20% of total calories• Total fat 25–35% of total calories• Carbohydrate 50–60% of total calories• Fiber 20–30 grams per day• Protein Approximately 15% of total calories• Total calories (energy) Balance energy intake and expenditure
to maintain desirable body weight/prevent weight gain
Dietary Portfolio
• 46 healthy, hyperlipidemic adults randomized – Low saturated fat diet– Low saturated fat diet + Lovastatin 20 mg/day– Diet portfolio (based on Step 2+)
• Phytosterols 1.0 g/1000 kcal
• Soy protein 21.4 g/1000 kcal
• Viscous fiber 9.8 g/1000 kcal
• Almonds 14 g/1000 kcal
• 4-week follow-upJenkins DJA et al, JAMA 2003:290:502-510
Results
Summary:Best CHD Prevention Diet
• Low in saturated fat and cholesterol
• High in monounsaturated fat
• Fish 2+ servings per week– Or omega-3 fatty acids supplement
• Fresh fruits and vegetables 7+ servings/day
• Whole grains in place of refined flour and sugar
Best CHD Prevention Diet
• Nuts 14+ grams/1000 kcal• Added soy protein, soluble fiber, phytosterols• Low glycemic index, especially if overweight• Calorie control should be automatic
– Low caloric density CHO’s– Satiety from monounsaturated fats, proteins
• Highly palatable– Variety of foods and seasonings
BMJ 2004;329:1447-1450 (18 December), doi:10.1136/bmj.329.7480.1447
Oscar H Franco, scientific researcher1, Luc Bonneux, senior researcher2, Chris de Laet, senior researcher1, Anna Peeters, senior researcher3, Ewout W Steyerberg, associate professor1, Johan P Mackenbach, professor1 1 Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands, 2 Belgian Health Care Knowledge Centre (KCE), Wetstraat 155, B-1040, Brussels, Belgium, 3 Department of Epidemiology and Preventive Medicine, Monash University Central and Eastern Clinical School, Melbourne, Australia
The Polymeal: a more natural, safer, and probably tastier (than the Polypill)strategy to reduce cardiovascular disease by more than 75%
The limits of medicine
IngredientsPercentage reduction (95% CI) in risk of CVD Source
Wine (150 ml/day) 32 (23 to 41) Di Castelnuovo et al (MA)6
Fish (114 g four times/week) 14 (8 to 19) Whelton et al (MA)7
Dark chocolate (100 g/day) 21 (14 to 27) Taubert et al (RCT)8
Fruit and vegetables (400 g/day) 21 (14 to 27) John et al (RCT)10
Garlic (2.7 g/day) 25 (21 to 27) Ackermann et al (MA)11
Almonds (68 g/day) 12.5 (10.5 to 13.5)Jenkins et al (RCT),15 Sabate et al (RCT)16
Combined effect 76 (63 to 84)
Other Aspects of Polymeal• Men at age 50 would live an average of 6.6 years
longer• Women at age 50, 4.8 years longer• Cost of polymeal estimated at $28.10/week• Addition of other components such as oat bran or
olive oil would only enhance effect• No obvious contraindications to combining
polymeal with polypill (or any subset of components)
Weight Loss Controversy
• Americans have substituted refined CHO’s for fats over the past 20 years– Linked to obesity
• Low CHO versus low fat for weight loss– Atkins versus Ornish
• Much speculation, many popular books• Published data only in past 4-5 years• Does losing weight necessarily mean lowering
CHD risk?
Effect of Varying Fat, Protein, and CHO Content on Weight Loss
• 811 overweight adults randomized to 3 weight loss diets for 2 years
• Varying content: fat protein CHO– Diet 1 20% 15% 65%– Diet 2 20% 25% 55%– Diet 3 40% 15% 45%– Diet 4 40% 25% 35%
• 750 kcal per day caloric deficitSacks FM et al. NEJM 2009;360:859-873
Bon Appetit!
• Comments?
• Questions?