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

Examples of overall healthy diets

The DASH diet

Appel, Sacks et al NEJM 1997

% 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

Calories / Body weight

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

Measurement of metabolic rate

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

Fruits and vegetables

Low in calories

Rich in micronutrients

Rich in fiber

Rich in potassium

Rich in phytochemicals

Fruits and vegetables

Relative risk for every extra 5 servings

Ann Intern Med 2001;134:1106-14

Should potatoes and corn be classified nutritionally as

vegetables ?

“5 a day” ?

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

1 dollar = 600 Cal of junk food1 dollar = 50 Cal of fruit

The “healthy choices” fallacy:

Fiber

Fiber

Everything that enters the GI system and leaves unmodified

CelluloseCellulose

PectinPectin HemicelluloseHemicellulose

GumsGums

Non digestible complex carbohydrates

Refined Vs Whole-grain cereals

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

Dietary fats

Fatty acid nomenclature

CO

OC C C C CCC

Alphacarbon

Carboxyl groupcarbon

Omega carbon

Many different 18-carbon fatty acids !

OH

Cholesterol

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

Omega 3 fatty acids

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

However…Situation of world fish stocks – 1950 - 2000

The solution ?

??Omega 3-rich liquid vegetable oilsOmega 3-rich liquid vegetable oils

Transgenics ???Transgenics ???

Saturated – Monounsaturated –

Polyunsaturated fats

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

N Engl J Med 1997;337:1491-9N Engl J Med 1997;337:1491-9

Impact of dietary fats on

CHD risk

Trans fats

Trans fats

N Engl J Med 2006;354:1601-13.N Engl J Med 2006;354:1601-13.

Grams of trans fat in a typical serving

N Engl J Med 2006;354:1601-13.N Engl J Med 2006;354:1601-13.

Trans fats – impact on blood lipids

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

Nutritionally sweetened beverages

New Engl J Med 2009; Sep 16

Trends in beverage consumption in the US

Sweetened beverages and CHD

Am J Clin Nutr 2009;89:1037-42Am J Clin Nutr 2009;89:1037-42

Sodium

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% -

What’s the effect of adding sodium restriction to the

DASH diet ?

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

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.)

Thank youThank you