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Best Diet for CHD Prevention Dr. Thomas G. Allison Mayo Clinic Rochester.

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Presentation on theme: "Best Diet for CHD Prevention Dr. Thomas G. Allison Mayo Clinic Rochester."— Presentation transcript:

1 Best Diet for CHD Prevention Dr. Thomas G. Allison Mayo Clinic Rochester

2 Fatty Streaks in Aorta of 19-Year Old Male

3 Advanced Lesion with Large Lipid Core

4 Plaque Rupture with Torn Cap


6 Major Statin Trials 50210 LDL-C (mg/dL) 7019017015013011090 0 5 10 15 20 25 % with CAD event WOSCOPS AFCAPS CARE 4S LIPID HPS PROSPER Secondary Mixed Primary ASCOT-LLA PROVE IT TNT JUPITER


8 Nissen, S. E. et al. JAMA 2004;291:1071-1080. Intravascular Ultrasound Images at Baseline and Follow-up REVERSAL Trial

9 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

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

11 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?

12 East Finland

13 Mortality from Coronary Heart Disease Men 35-64 Years (1969-1994) Puska P: Cardiovasc Risk factors 6:203-10, 1996 Cardiac death rates have dropped by 75%! North Karelia All Finland Per 100,000 800 700 600 500 400 300 200 100 CP999299-39 Now 80%

14 Trends in Womens Lifestyles 1980-82 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

15 Trends in Womens Lifestyles 1980-82 versus 1992-94 38% increase in overweight (BMI>25) –average BMI 24.5 26.1 kg/m 2 22% increase in glycemic load

16 Regional Diets with Low CHD Rates Seventh Day Adventist Japanese Rural Chinese Eskimo Mediterranean

17 Crete

18 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

19 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

20 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

21 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


23 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: Lancet1990;336:129-133

24 Original Dean Ornish Plan Fats (<10%) 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 Fruits Vegetables Ban All oils All meats Olives Avocados Nuts – seeds High or low fat products Sugar – syrup – honey Alcohol Ban All oils All meats Olives Avocados Nuts – seeds High or low fat products Sugar – syrup – honey Alcohol CP1095424-1 Moderate exercise Stress reduction Smoking cessation No calorie restriction

25 Lifestyle Heart Trial 1-Year Results Not powered (or randomized) for clinical events

26 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

27 CP1059685-22 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 beverage recommendations 6 glasses of water Wine in moderation Vegetables Beans, legumes & nuts MonthlyMonthly WeeklyWeekly DailyDaily 2000 Oldways Preservation & Exchange Trust

28 Lyon Heart Study - Lipids

29 Lyon Heart Study p<.0001 p<.0002 Results consistent with DART and Moradabad trials

30 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?

31 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

32 Other Features of TLC Diet NutrientRecommended Intake Polyunsaturated fatUp to 10% of total calories Monounsaturated fat Up to 20% of total calories Total fat25–35% of total calories Carbohydrate50–60% of total calories Fiber20–30 grams per day ProteinApproximately 15% of total calories Total calories (energy)Balance energy intake and expenditure to maintain desirable body weight/ prevent weight gain

33 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 2003:290:502-510


35 Results

36 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

37 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

38 BMJ 2004;329:1447-1450 (18 December), doi:10.1136/bmj.329.7480.1447 Oscar H Franco, scientific researcher 1, Luc Bonneux, senior researcher 2, Chris de Laet, senior researcher 1, Anna Peeters, senior researcher 3, Ewout W Steyerberg, associate professor 1, Johan P Mackenbach, professor 1 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

39 Ingredients Percentage reduction (95% CI) in risk of CVDSource 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 effect76 (63 to 84)

40 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)


42 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?

43 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: fatproteinCHO –Diet 1 20% 15%65% –Diet 220% 25%55% –Diet 340% 15%45% –Diet 440% 25%35% 750 kcal per day caloric deficit Sacks FM et al. NEJM 2009;360:859-873




47 Bon Appetit!


49 Comments? Questions?

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