nutrition and cardiovascular diseases carlos o. mendivil-anaya, md
TRANSCRIPT
Nutrition and cardiovascular diseases
Carlos O. Mendivil-Anaya, MD
Human Pathophysiology1Harvard Extension School
www.vascularweb.org
Atherosclerosis manifests clinicallyaccording to the affected arteries
In cerebral arteries:stroke
In the aorta:A. aneurism
In the coronary arteries:
Angina, MI
In arteries of the limbs: PAD
CVD top cause of death worldwide
World Deaths in millions
% of deaths
Coronary heart disease 7.20 12.2
Stroke and other cerebrovascular diseases
5.71 9.7
Lower respiratory infections 4.18 7.1
Chronic obstructive pulmonary disease
3.02 5.1
Diarrheal diseases 2.16 3.7
HIV/AIDS 2.04 3.5
Tuberculosis 1.46 2.5
Trachea, bronchus, lung cancers 1.32 2.3
Road traffic accidents 1.27 2.2
Prematurity and low birth weight 1.18 2.0 www.who.org
“Maintaining a healthy diet and lifestyle offers the greatest potential of all known approaches for
reducing the risk for CVD in the general public.
This is still true in spite of major advances in clinical
medicine”American Heart Association, 2006
Focus should be placed on the general quality of the diet, rather than on individual nutrients, foods or food groups
If a specific (supposedly “beneficial”) food is added to, rather than used to displace, other food from the diet, the additional calories can lead to weight gain
More than a “diet plan”, there should be a lifestyle prescription
Overarching
principles
• Consume an overall healthy diet.s
• Aim for a healthy body weight.
• Aim for recommended levels of LDLc, HDLc
and TG.
• Aim for a normal blood pressure.
• Aim for a normal blood glucose level.
• Be physically active.
• Avoid use of and exposure to tobacco
products.
Goals of diet and lifestyle modifications for CVD risk
reduction
% of CaloriesFat 30,4
Saturated 8,0Monounsaturated (Oleic) 12,6Polyunsaturated 4,5
Linoleic acid 3,6Linolenic acid 0,84
Alcohol 5,8Protein 16,2Fiber (g/d) 18,2Cholesterol (mg/d) 203
Examples of overall healthy diets
The Lyon Heart Study diet
Circulation 1999;99:779-85
Recommendations
1. Calories / Body weight2. Fruits and vegetables3. Fiber4. Fish5. Dietary fats6. Beverages7. Salt/sodium8. Alcohol
Overweight and obesity are independent risk
factors for CVD
Arch Intern Med. 2002;162:1867-1872
Data from Framingham study
The energy balance of your body
In Out
Dietaryintake
BASALMETABOLIC
EXPENDITURE
AD
AP
TIV
E
TH
ER
MO
GE
NE
SIS
PH
YS
ICA
LA
CT
IVIT
Y
ST
OR
AG
E(A
DIP
OS
E T
ISS
UE
)
Almostfixed
So how much energy do I need after all?
Harris-Benedict equations
BMR = 66 + (13.7 * wt in kg) + (5 * ht in cm) - (6.8 * age in years)
BMR = 655 +
(9.6 * wt in kg) + (1.8 * ht in cm) - (4.7 * age in years)
Want actual daily expenditure?
Multiply by activity factor
Physical activity is very effective for maintenance of
weight lossn=191 womenDiet= 1200-1500 Cal
Arch Intern Med. 2008;168:1550-1559
Fruits and vegetables
Low in calories
Rich in micronutrients
Rich in fiber
Rich in potassium
Rich in phytochemicals
Composition matters
20% carbvegetables20% carb
vegetables10% carb
vegetables10% carb
vegetables5% carb
vegetables5% carb
vegetables
ChardSpinachLettuceTomatoCabbageCauliflowerRadishCucumberBroccoli
ChardSpinachLettuceTomatoCabbageCauliflowerRadishCucumberBroccoli
OnionSquashCarrotBeetPeasGreen beans
OnionSquashCarrotBeetPeasGreen beans
PotatoesYuccaCornPlantainsTubers
PotatoesYuccaCornPlantainsTubers
5% carbfruits
5% carbfruits
CantaloupeWatermelonCantaloupeWatermelon
10% carbfruits
10% carbfruits
OrangeGrapefruitTangerineLimePapayaPinneapleGuavaPeachStrawberryBlackberryRaspberryCherry
OrangeGrapefruitTangerineLimePapayaPinneapleGuavaPeachStrawberryBlackberryRaspberryCherry
15% carbfruits
15% carbfruits
ApplePearMangoGranadillaPlumKiwi
ApplePearMangoGranadillaPlumKiwi
20% carbfruits
20% carbfruits
GrapeFigBanana
GrapeFigBanana
Composition matters
Fiber
Everything that enters the GI system and leaves unmodified
CelluloseCellulose
PectinPectin HemicelluloseHemicellulose
GumsGums
Non digestible complex carbohydrates
Whole-grain intake is inversely related with
CHD riskData from Nurses’ Health Study
Am J Clin Nutr. 1999;70:412-9Am J Clin Nutr. 1999;70:412-9
Fatty acids of medical importance
SaturatedSaturated
UnsaturatedUnsaturated
Blood-cholesterol raising
Blood-cholesterol neutral
Monounsaturated
Polyunsaturated
Lauric
Myristic
Palmytic
Oleic
6
3
Linoleic-Linolenic
Plant oils
Fish and seafoods
-linolenic
EPADHA
Estearic
+ … trans fats+ … trans fats
Fatty acids of medical importance
SaturatedSaturated
UnsaturatedUnsaturated
Blood-cholesterol raising
Blood-cholesterol neutral
Monounsaturated
Polyunsaturated
Lauric
Myristic
Palmytic
Oleic
6
3
Linoleic-Linolenic
Plant oils
Fish and seafoods
-linolenic
EPADHA
Estearic
+ … trans fats+ … trans fats
12345
Inhibition of platelet aggregation
Reduction of TG concentrations (high doses)
Reduction of proinflammatory citokines
Slight increase in HDL cholesterol
Increase in blood fluidity
Effects of omega-3 fatty
acids
6Stabilization of the membrane of myocytes (antiarrhytmic)
0.35 0.52 0.67 0.83 1.02
Risk of MI in Costa Rica by decile of α-linolenic
n=3294
1.000.750.500.25
1.25
1.50
Median alpha-linolenic in adipose tissue
Baylin A et al, Circulation 2003Baylin A et al, Circulation 2003
OR
OR
The solution ?
??Omega 3-rich liquid vegetable oilsOmega 3-rich liquid vegetable oils
Transgenics ???Transgenics ???
Dietary fats and blood lipids(meta-analysis of 60
controlled trials)
Mensink..Katan. Am J Clin Nutr 2003;77:1146Mensink..Katan. Am J Clin Nutr 2003;77:1146
Grams of trans fat in a typical serving
N Engl J Med 2006;354:1601-13.N Engl J Med 2006;354:1601-13.
Increase in risk for every extra 2% Calories from trans
fatty acids
N Engl J Med 2006;354:1601-13.N Engl J Med 2006;354:1601-13.
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Costa Rica: Risk of myocardial infarction for the combined
effect of - linolenic and trans fatty acids in adipose tissue
LowMed
MedHigh
HighLow
-Linolenic acid
Trans fatty acids
Baylin et al, Circulation 2003
OR
OR
Weeks
B 1 2 3 4 5 6 7,8
Effect of the DASH diet on blood pressure
N Engl J Med 1997;336:1117N Engl J Med 1997;336:1117
Control Diet
Control Diet
Fruits & Veg
Fruits & Veg
DASH Diet
DASH Diet
122
124
126
128
130
132
134
78
80
82
84
86
Sys
toli
cS
ysto
lic
Dia
stoli
cD
iast
oli
c
Sacks et al. Clin Cardiol 1999;22:6-10Sacks et al. Clin Cardiol 1999;22:6-10
Possible Contributors to DASH BP Effects
Fruits VegetablesNutsFewer sweets & sugar-containing drinks
More VegetablesLow-fat Dairy ProductsFishLess red meatLess saturated fatFewer sweets and sugary drinksNutrients interactions / unknown?
B
P
-50% -
-100% -
Effect of Sodium Level on Systolic Blood Pressure
Sys
toli
c B
lood
P
ress
ure
(m
mH
g)
Higher Intermediate Lower
Sodium Level
-2.1
-1.3-1.7
-4.6
-6.7Control Diet
-3.0DASH Diet
Sacks F et al. N Engl J Med 2001;344:3Sacks F et al. N Engl J Med 2001;344:3
120
125
130
135
Alcohol rises HDL
cholesterol
% c
hang
e in
HD
Lc
Circulation. 2005;112:1406-1413 Circulation. 2005;112:1406-1413
Moderate alcohol consumption reduces atherosclerosis
OR o
f cor
onar
y at
hero
scle
rosis
Arch Intern Med. 2004;164:2355-2360. Arch Intern Med. 2004;164:2355-2360.
So why don’t we prescribe
alcohol ?1. Can be addictive
2. High intake has serious consequences:
- Hypertriglyceridemia
- Hypertension
- Liver damage
- Physical abuse
- Vehicular and work accidents
- Increased risk of breast cancer
Summary of recommendations- Balance calorie intake and physical activity to
achieve or maintain a healthy body weight.
- Consume a diet rich in vegetables and fruits.
- Choose whole-grain, high-fiber foods.
- Consume fish, especially oily fish, at least twice a
week.
- Limit your intake of saturated fat to 7% of energy,
trans fat to 1% of energy, and cholesterol to 300 mg per day by:
* choosing lean meats and vegetable
alternatives* selecting fat-free (skim), 1%-fat, and low-
fat dairy products* minimizing intake of partially
hydrogenated fats.
- Balance calorie intake and physical activity to achieve or maintain a healthy body weight.
- Consume a diet rich in vegetables and fruits.
- Choose whole-grain, high-fiber foods.
- Consume fish, especially oily fish, at least twice a
week.
- Limit your intake of saturated fat to 7% of energy,
trans fat to 1% of energy, and cholesterol to 300 mg per day by:
* choosing lean meats and vegetable
alternatives* selecting fat-free (skim), 1%-fat, and low-
fat dairy products* minimizing intake of partially
hydrogenated fats.
Circulation 2006;114:82-96Circulation 2006;114:82-96
- Minimize your intake of beverages and foods with
added sugars.
- Choose and prepare foods with little or no salt.
- If you consume alcohol, do so in moderation.
- When you eat food that is prepared outside of the
home, follow the Diet and Lifestyle Recommendations.
- Minimize your intake of beverages and foods with
added sugars.
- Choose and prepare foods with little or no salt.
- If you consume alcohol, do so in moderation.
- When you eat food that is prepared outside of the
home, follow the Diet and Lifestyle Recommendations.
Summary of recommendations
(cont.)