voeding in de praktijk rotterdam, 30 june 2015 · same association for low-fat dairy no association...
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Diet, blood pressure and cardiovascular
diseases
Marianne Geleijnse, PhD
Voeding in de Praktijk
Rotterdam, 30 June 2015
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Blood pressure (BP) rises with age
2
Age (years)
BP (
mm
Hg) Systolic BP
Diastolic BP
SBP 90 120 = +30 mmHg
SBP 120 130 = +10 mmHg
Total lifetime > 40 mmHg
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Blood pressure (BP) rises with age
3
Age (years)
BP (
mm
Hg) Systolic BP
Diastolic BP
SBP 90 120 = +30 mmHg
SBP 120 130 = +10 mmHg
Total lifetime > 40 mmHg
Prevention starts here
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BP and cardiovascular diseases (CVD)
4
About half of CVD events in people with “normal” BP (SBP <140)
Pooled data from over 1 million adults. Prospective Studies Collaboration. Lewington et al, Lancet 2002.
Ris
k o
f str
oke m
orta
lity
Systolic BP (mmHg)
“Hypertension”
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Population-based approach for CVD
prevention
5 Whelton et al, JAMA 2002.
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No obesity
Physically active
No alcohol
High intake
of plant foods
No salt
6 Mancilha-Carvalho et al, J Hum Hypertens 1989 Oliver et al, Circulation 1975
BP in Yanomami Indians (Brazil)
No BP rise
with age
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Body weight
7 Neter et al, Hypertension 2003
Meta-analysis: pooling of 25 weight loss trials
Type of intervention:
diet and/or physical activity
Effect on systolic BP:
● All trials: -4.4 mmHg
● Weight loss ≤5 kg: -3 mmHg
● Weight loss >5 kg: -7 mmHg
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8
Randomized controlled trial:
Half of the people randomly assigned to the intervention group
(less calories and/or more physical activity to achieve weight loss)
Half of the people assigned to the control group (e.g. regular diet)
(effect on BP)
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9
Bariatric surgery versus non-surgical
treatment for obesity
Effect on weight loss (and BP)
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10
Bariatric surgery versus non-surgical
treatment for obesity: meta-analysis
Gloy et al, BMJ 2013
Effect on body weight (kg)
Effect on systolic BP (mmHg)
Bariatric surgery Control Bariatric surgery Control
Dixon 2008 -20.3 -5.9 -6.0 -1.7
Dixon 2012 -27.8 -5.1 -7.3 -5.9
O’Brien 2010 -34.6 -3.0 -12.5 -20.3
Ikramuddin 2013 -28.5 -7.9 -12.0 -8.8
Mingrone 2012 -45.5 -7.0 -20.3 -21.6
Schauer 2012 -27.3 -5.4 -3.8 -3.9
Approx. reduction -30 kg -5 kg
-10 mmHg -10 mmHg
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11
Bariatric surgery versus non-surgical
treatment for obesity: meta-analysis
Gloy et al, BMJ 2013
Effect on body weight (kg)
Effect on systolic BP (mmHg)
Bariatric surgery Control Bariatric surgery Control
Dixon 2008 -20.3 -5.9 -6.0 -1.7
Dixon 2012 -27.8 -5.1 -7.3 -5.9
O’Brien 2010 -34.6 -3.0 -12.5 -20.3
Ikramuddin 2013 -28.5 -7.9 -12.0 -8.8
Mingrone 2012 -45.5 -7.0 -20.3 -21.6
Schauer 2012 -27.3 -5.4 -3.8 -3.9
Approx. reduction -30 kg -5 kg
-10 mmHg -10 mmHg
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Is it the body fat, or...?
Physical activity lowers BP by 3-5 mmHg
Baena et al, J Hypertens 2014
Cornelissen et al, Hypertension 2011
Healthy weight-loss diet: more whole grains, fruit &
vegetables, less alcohol, less sugared beverages...
Less calories → less salt
12
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• Intake in most western countries: 7-12 g/day
- in the Netherlands: 9 g/day
Webster et al, J Hypertension 2011;29:1043-1050
• World Health Organization: max. of 5 g/day
WHO Forum on Reducing Salt Intake in Populations, Paris 2006
• The human body needs 0.5 g/day
Salt intake
What we eat: 3 kg pp per year
What we need: 9 tablespoons per year
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Salt trial in chimpanzees
14 Denton et al, Nat Med 1995
• Intervention group: gradual increase in salt intake up to 15 g/day
during 20 weeks
• Control group: 0.5 g salt per day
• Systolic BP: +26 mmHg
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KaNa trial
36 adults with untreated elevated BP
During 4-week periods:
● Salt pills (5 12 g/d)
● Potassium pills (2 5 g/d)
● Placebo pills
15
Fully controlled diet
Salt intake: 5 g/d (WHO guideline)
Gijsbers et al, J Hum Hypertens 2015, Feb 12
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Effects on 24-hour systolic BP
105
110
115
120
125
130
135
140
145
150
22 24 2 4 6 8 10 12 14 16 18 20
SBP
, mm
Hg
Hour
Sodium Potassium Placebo
Gijsbers et al, J Hum Hypertens 2015, Feb 12
+7 mmHg
11 mmHg
-4 mmHg
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Potassium in the diet
17
Intake in Dutch adults: 3.5 g/d Intake in Yanomami: ~8 g/d
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Plant foods
Rich in:
● Potassium
● Fiber
● Vitamin C
● Folate
● Carotenoids
● Polyphenols
● Magnesium
● Nitrate
● ...
and relatively low in calories
18
May all lower BP
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Fruit and vegetables
Randomized trial in 690 healthy adults (UK)
Advice to eat 5+ portions of fruit and vegetables
Daily consumption before the study: 3.4 portions
Increase during 6 months:
● Intervention group: +1.4 portion
● Control group: +0.1 portion
Effect on systolic BP: -4.0 mmHg
19 John et al, Oxford Fruit and Vegetable Study Group. Lancet 2002
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Whole grains
Randomized trial in 197 healthy adults (UK)
16 weeks, 3 groups:
20
Tighe et al, Am J Clin Nutr 2001
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Whole grains
Trial in UK men and women aged ~52 years
16 weeks, 3 groups:
21
Effect of whole grains on
systolic BP: -4.5 mmHg
Tighe et al, Am J Clin Nutr 2001
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Pulses
Meta-analysis of 8 randomized trials
Lentils, chickpeas, peas, beans and/or lupin kernels vs.
isocaloric control
22
Effect on systolic BP: -2.3 [-4.2, -0.3]
Jayalath et al, Am J Hypertens 2014
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Nuts
23
Meta-analysis of randomized trials
Mohammadifard et al, Am J Clin Nutr 2015
Effect on systolic BP
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Cocoa
24
Rich in polyphenols, including
epicatechin, which may improve
the health of the blood vessels
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Cocoa and BP (Zutphen Elderly Study)
Tertile of cocoa intake (g/d)
P for trend
<0.36 (n=165)
0.36-2.30 (n=149)
>2.30 (n=156)
Systolic BP (mmHg)
150.0
148.8
146.9
0.06
Diastolic BP (mmHg)
84.3
83.8
82.3
0.03
Buijsse et al, Arch Intern Med 2006
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Meta-analysis of chocolate or cocoa trials
Ried et al. BMC Medicine 2010
Effect on systolic BP: -3.2 [-2.1, -1.2]
versus
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27
FLAVO study
• Randomized trial in 35 healthy older adults
• Pills with epicatechin (cocoa flavonoid) or placebo, for 4 weeks
• Effect on 24-h systolic BP: -2.4 mmHg (NS)
• Effect on vascular health: flow-mediated
dilation improved by 1.1% (p=0.07)
• Improvement in insulin sensitivity (p=0.04)
Dower et al, Am J Clin Nutr 2015
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Meat and fish
Insufficient number of randomized trials.
Observational evidence that processed meat
increases BP (because of salt?).
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Fish oil
Meta-analysis of 36 randomized trials of fish oil
supplementation
High fish oil doses (~4 g/d)
Effect on systolic BP:
● All trials: -2.1 mmHg
● In hypertensives: -4.0 mmHg
● In normotensives: -1.0 mmHg
29 Geleijnse et al, J Hypertens 2002
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Alcohol
Alcoholic beverages (all types) increase BP by ~1 mmHg
per 10 g/d alcohol
Puddey & Beilin, Clin Exp Pharmacol Physiol 2006
Meta-analysis of randomized trials of alcohol reduction:
Overall effect on systolic BP: -3.3 mmHg
Xin et al, Hypertension 2001
31
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Milk
Lack of randomized trials of (non-fortified) milk and BP
Meta-analysis of dairy supplementation trials and
cardiometabolic risk factors
Benatar et al, PLoS One 2013
32
Effect on systolic BP
Low-fat dairy
beneficial for BP?
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4% lower risk of developing hypertension per glass of milk Same association for low-fat dairy No association for high-fat dairy
Milk
33
Meta-analysis of 7 prospective cohort studies of habitual milk
consumption and risk of hypertension
~48,000 individuals, of whom ~15,000 developed hypertension during
5-15 years of follow-up
Soedamah-Muthu et al, Hypertension 2012
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Coffee
Three meta-analyses of randomized trials
34
Intervention Effect on systolic BP
Jee et al
Hypertension 1999
3-8 cups/d
vs. no coffee or decaf
+2.4 mmHg
Noordzij et al,
J Hypertens 2005
3-8 cups/d
vs. no coffee or decaf
+1.2 mmHg
Steffen et al,
J Hypertens 2005
2-6 cups/d (incl. decaf)
vs. no coffee
-0.6 mmHg
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Coffee
Three meta-analyses of randomized trials
35
Intervention Effect on systolic BP
Jee et al
Hypertension 1999
3-8 cups/d
vs. no coffee or decaf
+2.4 mmHg
Noordzij et al,
J Hypertens 2005
3-8 cups/d
vs. no coffee or decaf
Caffeine pills (~410 mg/d*)
vs. placebo pils
+1.2 mmHg
+4.2 mmHg
Steffen et al,
J Hypertens 2005
2-6 cups/d (incl. decaf)
vs. no coffee
-0.6 mmHg
*Amount in ~5 cups of coffee
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Why BP effect of coffee ≠ caffeine pills?
Not related to caffeine dose (similar in coffee and caffeine trials)
Coffee contains potassium and magnesium
● 5 cups of coffee per day: 26% of K intake and 12% of Mg intake in the NL
Coffee has a high antioxidant capacity and contains polyphenols,
e.g. chlorogenic acid may improve blood vessel health?
Pellegrini et al, J Nutr 2003
Geleijnse JM, (letter), JAMA 2006
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Salt workshop – RIVM Bilthoven 7-8 Nov 2013
Coffee, cola and risk of hypertension in
the Nurses’ Health Study
Winkelmayer et al, JAMA 2006
Combined prospective cohort data of NHS I and NHS II
~156,000 US women of whom ~20,000 developed hypertension
during 12 years of follow-up
Risk of hypertension:
● 10% lower for 4 or more cups/day of coffee
● 30-40% higher for 4 or more glasses/day of sugared cola
Winkelmayer et al, JAMA 2005
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Tea
Meta-analysis of 11 randomized trials Greyling et al, PLoS One 2014
Black tea consumption of 400-1800 mL/day vs. control drink (e.g. hot water)
Tea provided ~240-1500 mg/day of flavonoids
Effect on systolic BP: -1.8 mmHg
38
Meta-analysis by Liu et al, Br J Nutr 2014: • All tea: -1.8 mmHg • Green tea: -2.1 mmHg • Black tea: -1.4 mmHg
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Vegetarian diet
39
Meta-analysis of 7 randomized trials of lacto-ovo
or vegan diets compared with omnivorous diets
Yokoyama et al, JAMA Intern Med 2014
Effect on
systolic BP
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Salt workshop – RIVM Bilthoven 7-8 Nov 2013
DASH trial
Appel et al, N Engl J Med 1997
459 US adults with elevated BP
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Salt workshop – RIVM Bilthoven 7-8 Nov 2013
Appel et al, N Engl J Med 1997;336:1117-1124.
DASH trial
-2.8 mmHg
-5.5 mmHg Appel et al, N Engl J Med 1997
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Effect on systolic BP
Hypertensives (n=169)
Normotensives (n=243)
Salt restriction alone 8.3 mmHg 5.6 mmHg
Salt restriction + DASH diet 11.5 mmHg 7.1 mmHg
Comparable to medication
DASH-Sodium trial
Sacks et al, N Engl J Med 2001
DASH diet combined with less salt
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Why go for a healthy diet?
43
• Reduces BP and risk of CVD, but also risk of
obesity, cancer, osteoporosis, dementia, etc.
• Far more cost-effective than medication
• No side effects
• Can start early in life
• No only for primary prevention,
but also for those on drug treatment
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The impact of diet & lifestyle on BP
Weight loss
More physical activity
Less salt, more potassium
More fruit & vegetables
Whole grains in stead of refined grains
Less alcohol
Less sugar-sweetened beverages, less meat?
More low-fat dairy, nuts, seeds, pulses, cocoa, tea, fish?
44
10 mmHg?
20 mmHg?
30 mmHg?
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Can we close the gap?
45
-40 mmHg
Systo
lic B
P (
mm
Hg)
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Questions?
46