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DASH DIET Convention Theme: Bringing Global Trends in Cardiology Closer to Home Tripartite Colloquium: Diet and Sports in Cardiovascular Disease Topic:

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Presentation on theme: "DASH DIET Convention Theme: Bringing Global Trends in Cardiology Closer to Home Tripartite Colloquium: Diet and Sports in Cardiovascular Disease Topic:"— Presentation transcript:

1 DASH DIET Convention Theme: Bringing Global Trends in Cardiology Closer to Home Tripartite Colloquium: Diet and Sports in Cardiovascular Disease Topic: DASH DIET May 23, :30-11:00 AM Crowne Plaza Galleria, Manila Ballroom B Mandaluyong City

2 Brussels, Milk & Health 2011 Disclosure Statement of Financial Interest No financial interest, arrangement or affiliation with one or more organizations that can be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3 Brussels, Milk & Health 2011 OUTLINE Cardiovascular Disease and Hypertension Lifestyle Modifications to Prevent and Control Hypertension Evidences on Impact of Diet and Nutrition on Hypertension: DASH TONE DASH-SODIUM TOHP OMNIHEART META-ANALYSIS ON DAIRY INTAKE PREMIER Summary

4 Global CVD Deaths On The Rise World Health Organization: The Global Burden Of Disease update 2004

5 Leading Causes of Mortality in the Philippines (2000)* Cause Tot. Dial Rate (/100,000) % of total deaths 1. Diseases of the heart60, Diseases of the vascular system48, Malignant neoplasms36, Pneumonia32, Accidents32, Tuberculosis, all forms27, Chronic obstructive pulmonary diseases and allied conditions 15, Conditions originating in the perinatal period15, Diabetes mellitus10, Nephritis, nephritic syndrome and nephrosis7, *Field Health Service Information System. DOH Publications. Department of Health, Republic of the Philippines.

6 Leading Causes of Morbidity in the Philippines (2001)* Cause TotalRate (/100,000) 1. Diarrhea845,5261, Bronchitis/bronchiolitis694, Pneumonia652, Influenza499, Hypertension 5. Hypertension318, Pulmonary tuberculosis110, Diseases of the heart47, Malaria40, Measles24, Chickenpox24, *Field Health Service Information System. DOH Publications. Department of Health, Republic of the Philippines.

7 Global Mortality: Leading Attributable Risk Factors Attributable Mortality in Millions (Total 55.9 Million) High BP Tobacco High cholesterol Underweight Unsafe sex Low fruit and vegetable intake High body mass index (BMI) Physical inactivity Alcohol Unsafe water, S&H* Developing high mortality Developing lower mortality Developed *Sanitation and hygiene. The World Health Report 2002: reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization; 2002.

8 Risk factor% Cont % CasesOR (99% CI) adj for all other risk factors ApoB/ApoA-1 (5 v 1) (2.81, 3.76) Curr smoking (2.58, 3.19) Psychosocial (2.21, 3.22) Diabetes (2.07, 2.71) Hypertension (1.74, 2.10) Abd Obesity (3 v 1) (1.45, 1.80) Veg & fruits daily (0.62, 0.79) Exercise (0.76, 0.97) Alcohol Intake (0.82, 1.02) All combined (90.2, 185.0) All combined (extremes)333.7 (230.2, 483.9) Modifiable Risk Factors for Atherosclerosis: Initial Myocardial Infarction - Overall World Population INTERHEART. Lancet, Sept. 2004

9 Risk of Acute Myocardial Infarction Associated with Exposure to Multiple Risk Factors SmkDMHTN APoB/A all4 +O+PSAll RFs OR (99% CI) INTERHEART. Lancet, Sept. 2004

10 Risk Factor ODDS RATIO (95% CI) p value 1. HPN a. HPN (-) vs HPN (+) a. HPN (-) vs HPN (+) ( )< Hx of DM a. DM (-) vs DM (+) ( )< WHR a. WHR Tertile 1 vs 2 b. WHR Tertile 1 vs ( ) ( ) < Smoking a. Never vs former b. Never vs current c. Never vs former + current d. Never vs current ( ) 2.40 ( ) 2.20 ( ) 4.92 ( ) < ApoB/ApoA1 Ratio a. Tertile 1 vs Tertile 2 b. Tertile 1 vs Tertile ( ) 3.49 ( ) < Depression a. D (-) vs D (+) 1.77 ( ) Risk of Acute Myocardial Infarction Associated with Risk Factors in the Philippines (Cases-788 M:F=79:21 Control- 424 M:F=78:22)

11 Risk Factor ODDS RATIO (95% CI) p value 7. Physical regular exercise1.74 ( ) Level of education a. < = 8 yrs vs trade/coll/univ0.22 ( )< Stress a. Never vs some periods b. Never vs several periods 0.16 ( ) 0.13 ( ) < BMI Tertile a. BMI Tertile 1 vs 2 b. BMI Tertile 1 vs ( ) 1.57 ( ) Risk of Acute Myocardial Infarction Associated with Risk Factors in the Philippines (Cases-788 M:F=79:21 Control- 424 M:F=78:22)

12 Modifiable Risk Factors InterstrokeInterheart 1.Hypertension (2.64)1. APoB:A1 LDL/HDL 2. Cardiac (2.38)2. Current Smoking 3. Current Smoking (2.09)3. Psych. Stress Depression 4. APoB:A1 LDL/HDL (1.89)6. DM 5.WHR (1.65)4. Hypertension 6.Alcohol (1.51 [>30 cans/mo])5. WHR 7.DM (1.36)7. Lack of exercise 8.Diet (1.35)8. Lack of fruits and vegetables 9. Psych. Stress (1.30) Depression (1.35) 9. Lack of small amount of alcohol 10. Reg. PA (0.69)

13 NNHeS I & II: 2003 & 2008 : Prevalence of Atherosclerosis- Related Risk Factors & Diseases Risk factors Prevalence (C.I. ) in % Hypertension16.4 ( )20.6 ( ) Diabetes by FPG and Hx4.6 ( )5.2 ( ) Smoking35.9 ( )31.0 ( ) Dyslipidemia62.3 ( )72.0 ( ) Obesity (BMI 30) Overweight (BMI 25) 4.7 ( ) ( ) 21.4 Obesity by WHR,M12.0 ( )10.2 ( ) Obesity by WHR, F53.0 ( )65.6 ( ) 2003 – Dans A, MoralesD, et al. Phil J Intern Med 2005;43: – Sy, R, Morales, D, et al. for publication - Journal of Epidemiology 2012

14 Brussels, Milk & Health 2011 How do we prevent and manage hypertension without drugs?

15 Lifestyle Modifications to Prevent/Manage HPN MODIFICATIONRECOMMENDATIONREDUCTION (RANGE) Wt reduction Maintain normal body wt. (BMI kg/m 2 )5-20 mmHg/10kg wt loss Adopt DASH eating plan Consume a diet rich in fruits, veg., & low fat dairy products w/ a reduced content of saturated & total fat mmHg Dietary Na + reduction Reduce dietary Na# intake to no more than 100mmol/day (2.4g Na# or 6g NaCl) 2-8 mmHg Physical activityEngage in regular aerobic physical activity such as brisk walking (at least 30min/day, most days of the week) 4-9mmHg Moderation of alcohol consumption Limit consumption to no more than 2 drinks (1 oz or 30mL ethanol; e.g. 24 oz beer, 10 oz wine or 3 oz 80-proof whiskey) per day in most men & to no more than 1 drink/day in women & lighter wt persons 2-4mmHg DASH, Dietary Approaches to Stop Hypertension * For overall CV risk reduction, stop smoking The effects of implementing these modifications are dose & time dependent, & could be greater for some individuals

16 Lifestyle Modifications to Prevent/Manage HPN MODIFICATIONRECOMMENDATIONREDUCTION (RANGE) Wt reduction Maintain normal body wt. (BMI kg/m 2 )5-20 mmHg/10kg wt loss Adopt DASH eating plan Consume a diet rich in fruits, veg., & low fat dairy products w/ a reduced content of saturated & total fat mmHg Dietary Na + reduction Reduce dietary Na# intake to no more than 100mmol/day (2.4g Na# or 6g NaCl) 2-8 mmHg Physical activityEngage in regular aerobic physical activity such as brisk walking (at least 30min/day, most days of the week) 4-9mmHg Moderation of alcohol consumption Limit consumption to no more than 2 drinks (1 oz or 30mL ethanol; e.g. 24 oz beer, 10 oz wine or 3 oz 80-proof whiskey) per day in most men & to no more than 1 drink/day in women & lighter wt persons 2-4mmHg DASH, Dietary Approaches to Stop Hypertension * For overall CV risk reduction, stop smoking The effects of implementing these modifications are dose & time dependent, & could be greater for some individuals

17 Brussels, Milk & Health 2011 Question What is the impact of total diet and nutrition on blood pressure in untreated pre-hypertensive, hypertensive and normotensive individuals? What are the evidences?

18 Brussels, Milk & Health 2011 DASH trial: Dietary Approaches to Stop Hypertension 459 subjects with pre- or mild hypertension During 8 weeks: 1) standard US diet 2) healthy fruit-and-vegetable diet more potassium, magnesium, nuts, fiber 3) combination (= DASH) diet diet 2 with low-fat dairy, more fish, less total fat, less SFA, less cholesterol Appel et al, N Engl J Med 1997;336:

19 Brussels, Milk & Health 2011 Appel et al, N Engl J Med 1997;336: DASH trial + less fat, less saturated fat, less cholesterol, more fish

20 Brussels, Milk & Health 2011 Effect on SBP/DBP, compared to control diet: Fruits & vegetables diet (#2): -2.8/-1.1 mmHg Combination (=DASH) diet (#3): -5.5/-3.0 mmHg Appel et al, N Engl J Med 1997 DASH trial results NOTE: Population-wide reduction in systolic BP of 2 mmHg: 6% reduction in stroke mortality 6% reduction in stroke mortality 4% reduction in coronary heart disease mortality 4% reduction in coronary heart disease mortality Whelton et al, JAMA 2002;288:

21 Brussels, Milk & Health 2011 DASH – Effect on BP Levels

22 Zuivelstichting 11/04/08 WCC Dubai – 19 April 2012 *Corresponding salt (NaCl) intake levels: 8.3, 6.3 and 3.8 g/d DASH Diet is effective at all levels of salt intake DASH trial: Appel et al, New Engl J Med 1997;336: ; DASH-Sodium trial: Sacks et al, New Engl J Med 2001;344: DASH-Sodium trial Sodium intake (g/d)*

23 Hypertensives (n=169) Normotensives (n=243) Salt restriction alone8.3 / 4.4 mmHg5.6 / 2.8 mmHg Salt restriction + DASH diet11.5 / 5.7 mmHg7.1 / 3.7 mmHg Comparable to medication Sacks et al, N Engl J Med 2001;344:3-10. DASH-Sodium trial results

24 Fruit and vegetable diet reduces blood pressure Combination of fruit and vegetable diet with the following reduces blood pressure even more: - low-fat dairy, less saturated fat, less cholesterol more fish and less salt Combination diet reduces blood pressure -the higher the baseline blood pressure is -more in hypertensive than normotensive

25 Appel LJ, Espeland MA, Easter L, et al. Arch Intern Med 2001; 161:685

26 Reduced sodium

27 Appel LJ, Espeland MA, Easter L, et al. Arch Intern Med 2001; 161:685 Reduced sodium

28 Appel LJ, Espeland MA, Easter L, et al. Arch Intern Med 2001; 161:685

29

30 N= yrs old <140/83-89 Obese Interventions Usual care Salt restriction Weight reduction BP control Results: Salt restriction mEq Na intake 4.4 and 2.0 kg wt loss (6 & 36 mos) Vs. usual care, BP lower by: 3.7/2.7 mmHg with wt loss 2.9/1.6 mmHg with Na restriction 4.0/2.0 with both interventions Arch Intern Med 1997;157:657

31 Other associations with high salt intake independent of blood pressure 1. Renal Hyperfiltration Reduced effect of calcium channel blockers & ACE inhibitors on proteinuria Increased calcium excretion 2. Cardiac Left ventricular hypertrophy Increased heart rate 3. Metabolic Insulin resistance 4. Cancer Stomach cancer 5. Respiratory Asthma

32 Salt reduction prevents future cardiovascular events Low salt intake in the elderly decreased cardiovascular events. Combination of weight loss and sodium restriction has better BP reduction. Appel LJ, Espeland MA, Easter L, et al. Arch Intern Med 2001; 161:685

33 OMNIHEART Study: three healthy diets with different macronutrients Appel et al, JAMA 2005;294:

34 Zuivelstichting 11/04/08 WCC Dubai – 19 April 2012 Appel et al, JAMA 2005;294: OMNIHEART Study: three healthy diets with different macronutrients

35 OMNIHEART (DASH-type of diets that differ in main type of macronutrient) Period 1 6 weeks Period 2 6 weeks Period 3 6 weeks Randomization to 1 of 6 sequences Washout Period 2–4 wk Washout Period 2-4 wk BP, Lipids: Run-In 6 days Participants Ate Study Food Screening / Baseline Participants Ate Their Own Food Appel et al, JAMA 2005

36 Brussels, Milk & Health 2011 OMNIHEART: Effect on Systolic BP CARB* PROT UNSAT CARB* PROT UNSAT All (n = 164) Baseline mean = mmHg Hypertension (n = 32) Baseline mean = mmHg p = p = p = p = p = p = * CARB similar to DASH diet Appel et al, JAMA 2005

37 Brussels, Milk & Health 2011 OMNIHEART: Effect on Systolic BP CARB* PROT UNSAT CARB* PROT UNSAT All (n = 164) Baseline mean = mmHg Hypertension (n = 32) Baseline mean = mmHg p = p = p = p = p = p = * CARB similar to DASH diet Appel et al, JAMA 2005 Slightly higher BP on carbohydrates than on protein or monounsaturated fat

38 Brussels, Milk & Health 2011 Dairy intake can be related to cardiovascular risk in different ways Inflammation Endothelial dysfunction Immune Dysfunction Coagulation Platelet reactivity Dyslipidemia Diabetes Hypertension Smoking CVD

39 Zuivelstichting 11/04/08 Dairy and blood pressure May be beneficial due to… Calcium (Van Mierlo et al. J Hum Hypertens 2006) Potassium (Geleijnse et al. J Hum Hypertens 2003) Dairy proteins, amino acids (Altorf-van der Kuil et al. PLoS ONE 2010) –BUT: adverse effect of salt (e.g. in cheese), added sugars (e.g. yoghurts), saturated fat and natural trans fats on cardiovascular health WCC Dubai, April 2012

40 Zuivelstichting 11/04/08 JM Geleijnse - 2 nd Kurume Epidemiology Colloquium Appel et al, N Engl J Med 1997;336: DASH trial Additional BP reduction of 2.7 mmHg attributable to low-fat dairy? + less fat, less saturated fat, less cholesterol, more fish

41 Brussels, Milk & Health 2011 Does dairy intake influence the long- term risk of hypertension? Meta-analysis of 9 prospective population-based cohort studies Verberne LDM, Soedamah-Muthu SS, Ding EL, Engberink MF, Geleijnse JM. Submitted for publication.

42 Brussels, Milk & Health 2011 Search in Medline, Embase, Scopus + hand search Inclusion: Population-based prospective studies in adults 9 cohort studies were included Contacted authors for additional data supply Convert units of exposure into grams/day e.g. an US serving of milk per day = 247g/d Methods

43 Brussels, Milk & Health 2011 Study characteristics 9 prospective studies (3 from USA, 6 from Europe) Total of 57,256 subjects (sample sizes ranged from ,886) Total of 15,367 cases of incident hypertension* Follow-up ranged from 5-15 years Mean age: 48 years Men and women 50/50 (+one study only women) * Defined as BP 140/90 mmHg (130/85 mmHg in CARDIA), or use of anti-hypertensive drugs

44 Brussels, Milk & Health 2011 Pooled relative risk for 9 studies: 0.97 ( ) Similar results for milk and milk products (8 studies) Total dairy (per 200 g/d) and risk of hypertension in 9 studies

45 Brussels, Milk & Health 2011 Pooled relative risk: 0.96 ( ) Results for high-fat dairy: pooled RR= 0.99 ( ) Low-fat dairy (per 200 g/d) and risk of hypertension

46 Brussels, Milk & Health 2011 Meta-analysis of dairy and CVD (Soedamah-Muthu et al, Am J Clin Nutr 2011)

47 Brussels, Milk & Health 2011 Meta-analysis of CVD and total mortality RR for milk per 200 ml/d (~1 glass) AJCN 2011 CHD CVD Total mortalityStroke -6% sign -13% NS 0% -1% NS

48 Brussels, Milk & Health 2011 Limitations More prospective data needed: Dairy intake and stroke Specific dairy groups like cheese and yoghurt Outside Europe and USA Meta-analysis depends on the quality of underlying studies Residual confounding by physical activity and dietary factors (e.g. fruits & vegetables) Inaccuracies in the assessment of (types of) dairy intake

49 Brussels, Milk & Health 2011 Dairy intake is associated with a 3% lower risk of hypertension per 200 g/d NOTE: cannot be extrapolated to intakes over 800 g/d (because of lack of data) Mainly attributable to low-fat dairy and milk (products) No association with high-fat dairy Dairy intake conclusions

50 Brussels, Milk & Health 2011 Guidelines Results are in line with European and US dietary guidelines that recommend a daily intake of ~700 ml of milk (products), preferably low-fat dairy

51 PREMIER trail: Behavioral Interventions N=810 BP: /80-95 mmHg Schemes: 1.Established behavioral intervention (EBI) Wt loss, physical activity, limit Na & alcohol 2. DASH plus EBI 3. One-time advice only Results: EBI & + DASH vs. advice only 6 th mo:12 and 17% vs. 26% 18 th mo: 22 and 24 vs. 32 Patients prepare own food in DASH grp in this study Elmer et al Ann Int Med 2006;144:485

52 Bibbins-Domingo K, Chertow GM, Coxson PG, et al. N Engl J Med 2010; 362:590

53 Brussels, Milk & Health 2011 Bibbins-Domingo K, Chertow GM, Coxson PG, et al. N Engl J Med 2010; 362:590

54 Brussels, Milk & Health 2011 Bibbins-Domingo K, Chertow GM, Coxson PG, et al. N Engl J Med 2010; 362:590

55

56 INTERVENTION ADVICE BP EFFECT Weight reduction: Maintain normal body weight (BMI 18.5–24.9 kg/m 2 ) 5–20 mmHg DASH eating plan: Diet rich in fruits, vegetables, and low-fat dairy products 8–14 mmHg with a reduced content of saturated and total fat Dietary sodium reduction: Reduce dietary sodium intake to 100 mmol per day 2–8 mmHg (2.4 g sodium or 6 g sodium chloride) Physical activity: Regular aerobic physical activity such as brisk walking 4–9 mmHg (at least 30 minutes per day, most days of the week) Moderation of alcohol use: Intake of 2 drinks per day in men and 1 drink per day 2–4 mmHg in women Diet and lifestyle recommendations Chobanian et al. 7th JNC report. Hypertension 2003;42;

57 Conclusion Healthy diet and lifestyle are extremely important for the prevention and treatment of hypertension and the prevention and control of cardiovascular events and its complications

58

59 Brussels, Milk & Health 2011 World Health Report 2002: Reducing risks, promoting healthy life Systolic BP >115 mmHg: responsible for 49% of ischemic heart disease responsible for 62% of strokes number 1 attributable risk for death throughout the world


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