1. Nutrition and Cardiovascular Disease (CVD)
4 September 2015
HME102 Public Health Medicine
Prof Caryl Nowson

2. Learning Objectives
Describe the nutritional risk factors contributing to CVD risk
Understand the evidence base indicating that lifestyle risk factors contribute to CVD risk including:
Dyslipidemia
Hypertension
Type 2 diabetes
(Obesity covered elsewhere)
Describe the nutritional population approaches being implemented worldwide to reduce CVD risk
Understand the systemic factors that prevent individual nutritional behaviour change
Describe the recommended dietary approaches to reduce CVD risk at the individual and population level in Australia

3. Cardiovascular Disease
Heart, Stroke & Vascular Disease
30% of 58 million deaths globally (2005)
equal to infectious diseases, nutritional deficiencies, maternal and perinatal conditions combined
46% deaths < 70 years
Kills more Australians than any other disease group
3.67 million Australians affected
1.10 million long term disability as a result
Increased by 18.2% over last decade
Aboriginal &Torres Strait Islanders 2.6x likely to die
More disadvantaged groups more likely to die

4. CVD Risk factors
90% of all Australians have at least 1 risk factor for heart, stroke and vascular disease
60% overweight or obese
54% insufficiently active
51% high blood cholesterol
30% high blood pressure
13% drink at levels harmful to health
8% have diabetes
(AIHW NHS )

5. Dyslipidemia Abnormal: Total cholesterol >5.5 mmol/L
HDL cholesterol <1.0 mmol/L men,< 1.3 mmol/L women
LDL cholesterol > 3.5 mmol/L
Serum total cholesterol = LDL + HDL + Triglycerides
High serum LDL cholesterol – atherogenic
High serum Triglycerides –atherogenic
Low HDL cholesterol – atherogoneic

6. Dyslipidemia: Australia
2011–12: 1/3 adults (32.8% or 5.6 million people) high total cholesterol levels and high LDL levels
Only 10.1% self-reported having high cholesterol as a current long-term health condition
Further 19.1%: total cholesterol level close to the abnormal cut off (5.0–5.4 mmol/L range)
Proportion of people with high total cholesterol peaked at 55–64 years (47.8%)
Overall there was no significant difference in rates of total cholesterol for men and women.

7. Dyslipidemia: lifestyle risk factors
Current smokers more likely high cholesterol (38.1% v never smoked 30.4%)
Obese adults (37.0% v 25.8% normal weight or underweight)
84.7% with high total cholesterol also high LDL cholesterol, and high triglycerides (22.9% compared with 9.5%)
Hypertensives: higher total cholesterol that those with normal blood pressure (40.8% v 31.0%)
High levels of LDL cholesterol were more common among men (35.0%) than women (31.6%)
Those with high LDL cholesterol were more likely to have high triglycerides than those with normal LDL levels (15.7% compared with 11.7%)
No association between high LDL cholesterol and lower than normal HDL 'good' cholesterol.

8. Dyslipidemia: lifestyle factors
↓ serum cholesterol - ↓ CHD
↓0.5mmol/L (about 10%) mean population serum cholesterol results in 12.6% ↓ coronary events
↓ 0.6 mmol/l serum cholesterol - ↓ IHD: 54% at 40 years, 39% 50yrs (Law)
Saturated fats & Trans fats: ↑Total - LDL cholesterol
Cochrane review: Small, potentially important CVD risk reduction with ↓ saturated fat
Replacing saturated fat with polyunsaturated fat: useful strategy
Obesity: ↑Total - LDL cholesterol
Exercise: ↑HDL cholesterol
Moderate Alcohol: ↑HDL cholesterol BUT !!
Omega-3 fatty acids: inversely related: arrhythmia, sudden cardiac death, thrombosis
Cochrane Database Syst Rev Jun 10;6:CD Reduction in saturated fat intake for cardiovascular disease. (15 randomised controlled trials (RCTs))
Reviews lipid level alterations on cardiovascular morbidity and mortality indicating that changes in blood lipids do affect cardiovascular risk (Briel 2009; De Caterina 2010; Robinson 2009; Rubins 1995; Walsh 1995)
Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ. 1994; 308:3 BMJ Feb 5;308(6925):

9. 1. Which of the following foods does NOT contain significant amounts of saturated fatty acids? A. Whole roasted chicken B. Shortbread biscuits C. Full cream milk D. Cheddar Cheese E. Home cooked chips in Canola oil

10. Saturated Fats Stearic acid: C18:O saturated fat
Solid at room temperature.
mainly found in animal products
Animal-based sources of saturated fats:
Dairy foods – such as butter, cream, regular-fat milk and cheese
Meat – such as fatty cuts of beef, pork and lamb, processed meats like salami, and chicken (especially chicken skin)
Plant-derived saturated fats:
Palm oil, Cooking margarine, Coconut, Coconut milk and cream
Deep fried take away foods, Cakes, Biscuits, Pastries and pies
Oleic acid:C18:1w9
mono unsaturated fat
Oleic acid:C18:2w6
poly unsaturated fat

11. Trans fatty acids (TFA) in Australia
Unsaturated fat that behaves like a saturated fat.
Naturally occurring TFA: dairy products, beef, veal, lamb
Artificial, synthetic, industrial or manufactured trans fats: hydrogenated or partially hydrogenated vegetable fats
Since 2007, manufactured TFA intakes declined 25-45%
Mean manufactured TFA intake < 0.4 g/day
Mean total TFA from both ruminant and manufactured ~ % of total dietary energy:,
>90% Aust. population TFA intakes <1% (WHO) pop. goal
60% to 75% of TFA intake derived from ruminant foods: low fat options reduce intake
To Avoid trans fat
Choose polyunsaturated and monounsaturated spreads and margarines, lean meat trimmed all visible fat. low or no fat dairy foods
limit foods and take-away meals (deep-fried and baked foods: biscuits, pastries, pies)
Avoid ”hydrogenated oils” or “partially hydrogenated vegetable oils” in the ingredients list.
unsaturated fatty acid molecule: trans double bond between carbon atoms, which makes the molecule kinked.

12. Diabetes Prevention: Lifestyle
Diabetes Prevention Program (DPP)
3,234 subjects, age 51, BMI 34.0 kg/m2
impaired glucose tolerance
Randomised to intensive lifestyle modification, metformin or placebo: follow-up 2.8 yrs
Diabetes incidence:
11.0% placebo
7.8% metformin
4.8% lifestyle intervention (58% reduction)
Weight loss was only 7% of initial body weight
>30mins per day activity
<30% energy from fat
<10% energy from saturated fat
Fibre >15g/1000kj

13. 13

14. 14

15. Meta-analysis: Lifestyle Interventions
49% decrease in incidence of T2DM for lifestyle intervention vs standard advice
Gillies et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis BMJ 2007; 334

16. 2. How often do you add salt in cooking. A. Never B. Rarely C
2. How often do you add salt in cooking? A. Never B. Rarely C. Sometimes D. Often

17. 3. How often do you add salt at the table. A. Never B. Rarely C
3. How often do you add salt at the table? A. Never B. Rarely C. Sometimes D. Often

18. 4. What are the dietary recommendations for the number of grams of salt per day for the general population? A. 1 gram (~17mmol sodium) B. 2 grams (~35mmol sodium) C. 3 grams (~52mmol sodium) D. 4 grams (~70mmol sodium) E. 5 grams (~86mmol sodium) F. 6 grams (~100mmol sodium) G. 7 grams (~120mmol sodium)

19. 5. Which of the following the major food groups make the largest contribution to average intakes of dietary sodium in Australia? A. Vegemite and savoury spreads B. Soft Drinks C. Breads and Cereals D. Fish and Seafood

20. Hypertension Australia (>140/90mmHg)
Men more likely to have hypertension than women (23.4% v 19.5%)
Hypertension:
42.6% aged 65 years
5.5% aged years 

21. Effects of High Blood Pressure
Relationship between BP and CVD is continuous, graded, independent, & causative
↑CVD by times
Hardening of the arteries
Stroke
Myocardial infarction
Congestive Heart Failure
Peripheral arterial disease
Kidney damage: Chronic Renal Failure
Retinopathy
Blindness
No signs or symptoms until dangerously high
MMcMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J. Blood pressure, stroke, and coronary heart disease. Lancet 1990;335:

22. Stroke & Hypertension: Australia
Strokes
40,000 stroke each year
70% first ever stroke
leading cause of long-term disability in Adults
Strokes cause 9% all deaths
Risk of stroke (& CHD) increases with BP
Hypertension
Most common chronic disease
1 in 4 males & 1 in 6 females (25-65yrs)

23. Evidence based Guidelines
Treat hypertensive persons > 60 yrs: BP <150/90 mm Hg
yrs diastolic goal < 90 mm Hg;
Others BP < 140/90 mm Hg (based on expert opinion)
Same goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults
Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014;311(5):

24. Definition of Hypertension > 140/90 mmHg
Lifestyle
modifications
Abolition of age-adjusted targets: but treatment of elderly individualised
2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens Jul;31(7):

25. Prevention: to reverse increasing prevalence
Changes in the Prevalence and Control of Hypertension in the United States (1988–2004).
Chobanian AV. Shattuck Lecture. The hypertension paradox--more uncontrolled disease despite improved therapy. N Engl J Med Aug 27;361(9):
2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens Jul;31(7):

26. US Guidelines: management of Hypertension
Lifestyle modification
Endorsed the recommendations of the Lifestyle Work Group: :
Combine Dietary Approaches to Stop Hypertension (DASH) diet with reduced sodium intake
< 2,400 mg of sodium (6g salt) per day, noting that limiting intake to 1,500 mg (4g salt/d) can result in even greater reduction in BP
2. Even without achieving these goals, reducing sodium intake by 1,000 mg (2.5g salt)/day lowers blood pressure.
Physical activity.
Moderate to vigorous physical activity for approximately 160 minutes per week (three to four sessions a week, lasting ~40 minutes per session).
Weight loss. The JNC 8 panel endorsed maintaining a healthy weight in controlling blood pressure
Alcohol intake received no specific recommendations
Eckel RH, et al AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol Nov 7. pii: S (13) doi: /j.jacc
Thomas G1, Shishehbor M, Brill D, Nally JV Jr New hypertension guidelines: one size fits most? Cleve Clin J Med Mar;81(3): doi: /ccjm.81a
James PA, Oparil S, Carter BL, et al Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013;doi: /jama

27. Key Evidence-based AHA/ACC Guideline on Lifestyle Management to Reduce BP
Eckel RH, et al AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol Nov 7. pii: S (13) doi: /j.jacc

28. Relationship between body weight, exercise and BP in Australia
Of those with hypertension:
three-quarters (76.3%) were overweight/obese
42.7% reported doing no exercise in the last week
Of those without hypertension:
one-half (53.1%) were overweight/obese
32.5% reported doing no exercise in the last week.

29. Lifestyle modifications: BP
BP-lowering effects of targeted lifestyle modifications can be equivalent to drug monotherapy
Major drawback: low level of adherence over time
Lifestyle changes may safely and effectively:
delay or prevent hypertension in those without hypertension
delay/prevent medical therapy in grade 1 hypertensive patients
contribute to BP reduction in hypertensives already on medication
reduce number and doses of antihypertensive agents
2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens Jul;31(7):

30. 20 ‘salt free’ societies
Intersalt study: average (mean) blood pressure of about 200 people of all ages from three of the ‘salt free’ societies
Yanomama, Brazil 96/61mmHg
Xingu, Brazil 99/62 mmHg
Asaro, Papua-New Guinea 108/63 mmHg
Courtesy Dr. Trevor Beard (deceased)

31. Tukisenta in PNG have lifelong normal BP living at home
Courtesy Dr. Trevor Beard (deceased)

32. Prehypertension in Port Moresby
Courtesy Dr. Trevor Beard (deceased)

33. Recommended intake general population ~<6g salt/day
Sodium to salt
To convert sodium to salt, multiply the sodium figure in milligrams (mg) by 2.5 and then divide by 1,000.
Link to video summary
sodium (mg)
6000
salt (g)
15.0
sodium (mmol)
100.0
87.0
65.2
43.5
26.1
17.4
13.0
8.7
sodium (mg)
2300
2000
1500
1000
600
400
300
200
salt (g)
5.8
5.0
3.8
2.5
1.5
1.0
0.8
0.5
Recommended intake general population ~<6g salt/day
Recommended intake at risk population ~<5g salt/day

34. Salt and cardiovascular outcomes
10-15yr follow-up of patients in the Trials of Hypertension
Prevention I and II (TOHP I and TOHP: effects of lifestyle modifications including salt restriction
10-15yrs post trial: salt reduction 25% lower incidence CV events
The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels: results of the Trials of Hypertension Prevention, phase I. JAMA 1992;267: Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure: the Trials of Hypertension Prevention, phase II. Arch Intern Med 1997;157: Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the Trials of Hypertension Prevention (TOHP).BMJ 2007;334:
Cumulative incidence CVD by salt intervention group (TOHP) I and II adjusted for age, sex, and clinic.

35. Salt-Sensitivity A family history of high blood pressure
high resting heart rate
>15% of ideal body weight
Elevated blood pressure (older)
>50% those over age 60 hypertensive
black Americans
low plasma renin activity

36. Nutrients associated with BP
Sodium
Potassium
Calcium
Magnesium
Chloride
Alcohol
Vegetarian diet
Fibre
Fat (total) P:S ratio
Fish oils
Caffeine
Variety of vitamins eg. Vit C ?
Other dietary factors eg. Garlic ?
Appel, et al. Effects of Protein, Monounsaturated Fat, and Carbohydrate Intake on Blood Pressure and Serum Lipids: Results of the OmniHeart Randomized Trial. JAMA 2005:294(19), p 2455–2464

37. Past Diet versus Current Diets50
100
150
200
250
300
Past
Present
Na & K mmol/day
K (mmol)
282 70
Na (mmol) 30
150

38. DASH (Study 1)
Dietary patterns, rather than of individual nutrients (NEJM, 1997): significantly and quickly lowered blood pressure (n=459)
Hypertensives: Fall 11/5 mmHg
Normotensives: Fall 6/3 mmHg
DASH diet: low in saturated fat, total fat, and cholesterol
more fruits, vegetables, and low fat dairy foods, includes whole grains, poultry, fish, and nuts. Reduced in red meat, sweets, and sugar- containing beverages, rich in K, Ca, Mg, protein, fibre
BP reductions: no change in weight, alcohol or Na intake
3,000mg sodium/day 7.5g salt Na(130mmol/day)

39. 8-10 serves wholegrain bread/cereals
Dietary Pattern: DASH
SERVES PER DAY
2-3 serves
Mono/poly oils
(avoid butter)
3 serves Low Fat Dairy
(3 cups)
3-4 Fruit
4-5 Vegetables
8-10 serves wholegrain bread/cereals

40. Maximum: 2 alcohol drinks/day Maximum: 4 caffeine drinks/day
Dietary Pattern: DASH
SERVES PER WEEK
3 red meat
(max)
3 fish
4 nuts/seeds
Maximum: 2 alcohol drinks/day
Maximum: 4 caffeine drinks/day
1 legume

41. DASH-sodium (Study 2) 2 different eating patterns 412 participants
57% women, 57% African Americans
SBP mmHg, DBP mmHg (41% hypertensive)
“Usual” diet or the DASH diet
3,300mg (143mmol) sodium (~8g salt)
2,400mg (104mmol) sodium (~6g salt)
1,500mg (65mmol) sodium (~4g salt)

42. DASH-Sodium SBP (mmHg) 104 65 143 Na (mmol) 135 130 125 Control -2***
Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approachesto Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2000
DASH-Sodium
135
125
130
-7***
Control
-2***
-6***
-5***
SBP (mmHg)
-5***
DASH
-2*
-1*
-2** -3
8g salt
104
6g salt 65
4g salt
143
Na (mmol)

43. Salt & Health: Population Approach

44. Effect of processing on salt content/100g
0.1 g salt
4 g salt
0g salt
1.5g salt
0.2g salt
4g salt
5g salt
500
1000
1500
2000
2500
corn
cornflakes
milk
processed cheese
wheat
bread
lean pork
lean ham
bacon
25 times
20 times
Range g salt
500 times
40 times
500 times
0g salt
mg sodium/100g
0g salt

45. Salt in foods Low salt product <120mg/100gm have a look at Bread
Pasta sauces
Cheese slices
Breakfast cereals
Biscuits

46. Sodium/ salt targets: Adults (4-6g/day)
World Health Organization
< 5 g salt/d (<87 mmol Na+) as a population nutrient intake goal
Australian division of World Action on Salt & Health (AWASH)
- less than 6g salt/d (< 100 mmol Na+)
National Heart Foundation
less than 6g salt/d (< 100 mmol Na+)
less than 4g salt/d (< 70 mmol Na+) if high BP or existing CVD
Suggested Dietary target (NH&MRC)
- less than 4g salt/day (< 70 mmol Na+)
Upper Limit (NH&MRC)
- less than 6g/d (100mmol Na+)
Diet Nutrition and the Prevention of Chronic Disease Report of the joint WHO/FAO expert consultation WHO Technical Report Series, No. 916 (TRS 916
NHMRC. Nutrient Reference Values for Australia and New Zealand including Recommended Dietary Intakes. National Health and Medical Research Council, 2004 National Heart Foundation of Australia Position Statement The relationships between dietary electrolytes and cardiovascular disease November 2006)

47. % meeting salt/sodium targets MCC study (2008/09)
Men 178 (67) ~ 10g salt
N=376
women 134 (51) ~ 8g salt
N=407
AWASH & NHF < 6g salt/d (< 100 mmol Na+) Huggins et al. MJA 2011;195(3):
Suggested Dietary target (NH&MRC) & NHF: high BP or existing CVD <4g salt/d (< 70 mmol Na+, (~2000mg Na+)

48. Salt: Population Effect
Average Australian/NZ Intake:
>9.0g salt
5g salt (2300mg Na+) reduction
↓ 5mmHg SBP
↓ 3mmHg DBP (J Hum Hyper 2000;18(4s)s126
3 g/day (51mmol Na) reduction in salt:
In hypertensives:
↓ stroke deaths 14%
↓ coronary deaths 9%
In normotensives:
↓ stroke deaths 6%
↓ coronary deaths 4%
He F, MacGregor G. Effect of longer-term modest reduction on blood pressure. A meta-analysis.
Implications for public health. J Human Hypertens 2000;18 (Suppl. 4):S126

49. 9.5g 8.6g 8.1g Australia Target 12 years 5 years 4 years 3 years
The UK Food Standards Agency (FSA) started working
with the food industry in 2003 and launched its consumer
education campaign in 2005
Salt intake (g/day) 2011/12
Both
9.1
men
9.8
women
7.1
9.5g
8.6g
8.1g
Target
12 years
5 years
4 years
3 years

50. Recent Australian Initiatives
The Victorian Health Promotion Foundation: Salt Reduction Partnership Group - George Institute for Global Health, The Heart Foundation, Deakin University, and the Victorian Department of Health,
The action plan has the ambitious goal of reducing the average daily salt intake of Victorian adults and children by 1 gram by 2018 with four intervention strategies: generating public debate, raising consumer awareness, strengthening policy initiatives, and supporting food industry innovation. The action plan, launched in March 2014, is supported by significant investment and a robust evaluation strategy.

52. Key Lifestyle Changes: reduce CVD
Low intake trans fats, saturated fats
Saturated fat <10% Energy, Mono-unsaturated fat 7-10% Energy
<1% energy trans fats
Omega-6 Fatty acids 5-8% Energy, Omega-3 Fatty acids 1-2% Energy
Fish 1-2 serves/week
Reduce Daily Salt by 1/3
Maximum 5g/day or 100mmol Na+
Eat at least 7 serves/day (400g fruit/vegetables)
Wholegrain breads/cereals & pulses
>20g dietary fibre
Maintain body weight in normal range: Reduce body weight if overweight
Maximum of 3 standard alcohol drinks/day
Physical Activity at least 30min/day moderate level most days
Population wide approaches
Food supply low trans fats, saturated fats
Food supply lower sodium content Cheap readily available fruit/vegetables/education
Systems approach: healthy environments for eating and physical activity