Best Diet for CHD Prevention

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Best Diet for CHD Prevention

• Dr. Thomas G. Allison
• Mayo Clinic Rochester

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Fatty Streaks in Aorta of 19-Year Old Male
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Advanced Lesion with Large Lipid Core
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Plaque Rupture with Torn Cap
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Major Statin Trials
PROVE IT
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4S
Secondary
HPS
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Mixed
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PROSPER
with CAD event
Primary
LIPID
CARE
10
WOSCOPS
TNT
5
ASCOT-LLA
JUPITER
AFCAPS
0
50
210
70
190
170
150
130
110
90
LDL-C (mg/dL)
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REVERSAL Trial
Intravascular Ultrasound Images at Baseline and
Follow-up
Nissen, S. E. et al. JAMA 20042911071-1080.
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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

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International Comparisons
2002 AHA Heart and Stroke Statistical Update
(Men ages 35-74)
International rates not due to differences in
statin therapy rates!
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Diets and CAD Whats 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?

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East Finland
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Mortality from Coronary Heart DiseaseMen 35-64
Years (1969-1994)
800
700
600
Now 80
500
Per100,000
NorthKarelia
400
300
AllFinland
200
100
Puska P Cardiovasc Risk factors 6203-10, 1996
CP999299-39
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Trends in Womens 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
2000343530-537
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Trends in Womens Lifestyles1980-82 versus
1992-94

• 38 increase in overweight (BMIgt25)
• average BMI 24.5 ? 26.1 kg/m2
• 22 increase in glycemic load

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Regional Diets with Low CHD Rates

• Seventh Day Adventist
• Japanese
• Rural Chinese
• Eskimo
• Mediterranean

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Crete
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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 20033482599-2608

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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

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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

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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/vegfishfiber
• control v ultra-low fat
• control v Mediterranean

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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
  management

Ornish et al Lancet1990336129-133
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Original Dean Ornish Plan
Moderate exercise Stress reduction Smoking
cessation
No calorie restriction
Fats (lt10)
Nonfat dairy products yogurt, cheese, egg whites
Nonfat products cereal, soups, tofu, crackers,
egg beaters
Whole grain corn, rice, oats, wheat, etc
Beans and legumes
Ban All oils All meats Olives Avocados Nuts
seeds High or low fat products Sugar syrup
honey Alcohol
Fruits
Vegetables
CP1095424-1
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Lifestyle Heart Trial 1-Year Results
Not powered (or randomized) for clinical events
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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 199999779-785

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The Traditional Healthy Mediterranean Diet
Pyramid
2000 Oldways Preservation Exchange Trust
CP1059685-22
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Lyon Heart Study - Lipids
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Lyon Heart Study
plt.0002
plt.0001
plt.0001
Results consistent with DART and Moradabad trials
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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?

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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 lt7 of total calories
• Dietary cholesterol lt200 mg per day
• LDL-lowering therapeutic options
• Plant stanols/sterols (2 g per day)
• Viscous (soluble) fiber (1025 g per day)
• Weight reduction
• Increased physical activity

NCEP
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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 2535 of total calories
• Carbohydrate 5060 of total calories
• Fiber 2030 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

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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-up
• Jenkins DJA et al, JAMA 2003290502-510

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Results
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SummaryBest 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

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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 CHOs
• Satiety from monounsaturated fats, proteins
• Highly palatable
• Variety of foods and seasonings

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BMJ  20043291447-1450 (18 December),
doi10.1136/bmj.329.7480.1447
The limits of medicine
The Polymeal a more natural, safer, and probably
tastier (than the Polypill) strategy to reduce
cardiovascular disease by more than 75
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
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Ingredients Percentage 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)
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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)

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Weight Loss Controversy

• Americans have substituted refined CHOs 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?

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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 deficit

Sacks FM et al. NEJM 2009360859-873
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Bon Appetit!
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• Comments?
• Questions?