Role of diet in management of cardiovascular diseases like HTN, CAD & CHF

ROLE OF DIET IN MANAGEMENT OF

CARDIOVASCULAR DISEASES LIKE HTN, CAD & CHF

SPEAKER : DR VIVEK MAHAJAN

PRECEPTOR: DR YASHPAUL SHARMA

IMPACT OF NUTRITION ON THE GLOBAL CVD BURDEN

WHO: CVD causes 33%(18 million) of deaths worldwide (www.who.int)

CVD accounted for 32 percent of all deaths in 2000 in India BMJ 2004; 328:807

Diet & lifestyle changes have led to increase in overweight & obesity

Obesity increases incidence of type 2 diabetes

Increased risk of CVD consequently

Estimated 30% of deaths from coronary heart disease due to unhealthy diets (National Heart Forum 2002)

http://www.who.int/

EVIDENCE OF NUTRIENT EFFECT AND CARDIOVASCULAR RISK

Testing specific nutrient effects is complicated

Inherent difficulties of conducting randomized, controlled clinical endpoint trials for nutritional interventions

Nutrients generally cannot be subjected to the same evidence-based criteria that are used to assess drug treatments

Imprecision of the dietary information

Difficulty of correcting for confounding effects of other health behaviors

EFFECTS OF SPECIFIC FOOD CATEGORIES ON CARDIOVASCULAR DISEASE

FRUITS AND VEGETABLES

3 or more servings/day vs less than 1/day a/w 27% reduction in CV risk

Am J Clin Nutr 2002; 76:93

Graded risk reduction associated with higher intakesThe Physicians' Health Study. Int J Epidemiol 2001; 30:130

The Women's Health Study. Am J Clin Nutr 2000; 72:922

At least 5 portions/day of a variety of fruits and vegetables recommended

WHOLE GRAINS

Whole grains a/w reduced CV risk Effect may be related to fiber intake

--Arch Intern Med 2004; 164:370

--Am Coll Cardiol 2002; 39:49

Vitamins, phytoestrogens, phenols, omega-3 fatty acids, resistant starch, and minerals may contribute

27 % reduction in CHD risk with whole grain consumption Recommended intake of at least 3 servings/day for cardiovascular

health -- J Am Coll Nutr 2000; 19:291S

FIBERS

Viscous (soluble) forms of dietary fiber reduce LDL Insoluble fiber does not significantly affect LDL

J Nutr 1999;129:1457S-66S

Increase in viscous fiber of 5–10 g/d accompanied by 5 % reduction in LDL

Federal Register 1998;63:8103-21


In a meta-analysis of 67 trials related to oats, pectin, guar, and psyllium, significant reduction in total and LDL cholesterol noted for all sources of viscous fiber in ranges of 2–10 grams per day

Am J Clin Nutr 1999;69:30-42

NUTS

Good sources of MUFAs, fiber, minerals & flavonoids

Walnuts rich in PUFAs (linoleic and alpha-linolenic acid) --J Nutr 2002; 132:1062S

Nut consumption a/w reduced CV risk

Women consuming 5 oz/week had 35 % lower risk of nonfatal MI than those eating less than 1 oz/month

--Arch Intern Med 2002; 162:1382.

Men consuming twice/week or more had 47% reduction in risk for SCD & 30 percent reduction in total CHD mortality compared with those who rarely or never consumed nuts

--J Nutr 2002; 132:1062S

Almond have beneficial effects on plasma lipoproteins --Circulation 2002; 106:1327

FISH

Species with high ω3 FA confer protection from IHDs Circulation 2002; 106:2747

Intake of small quantities a/w 17% reduction in CHD mortality risk & 27 % reduction in risk for nonfatal MI,

Each additional serving/wk associated with a further reduction of 3.9% in CHD mortality

Am J Prev Med 2005; 29:335

ω3 FATTY ACIDS

Increased plasma levels of Eicosapentaenoic acid (EPA) & Docosahexanoic acid (DHA) predicted reduction in SCD

N Engl J Med 2002; 346:1113.

1 g/day ω3 FAs lowered overall risk of death and of coronary death from 6.8% to 4.8%

Lancet. 1999;354:447–455.

5.5 gm/mth of EPA plus DHA (equivalent to one portion of fatty fish/wk) a/w 50% lower incidence of SCD

Enrichment of membrane phospholipids with ω3 FA results in reduction in risk for abnormal cardiac electrical conductivity

Am J Clin Nutr 2000; 71:208S

Antiplatelet & antiinflammatory effects Reduction in plasma triglycerides at higher doses

Circulation 2002; 106:2747

THE FRENCH PARADOX AND RED WINES

High intake of SFAs but low CHD incidence & mortality

Relative immunity of the French to CHD attributed in part to their custom of drinking wine with meals

Red wine polyphenolic extracts (RWPE) mediate a vaso-relaxant effect via NO release

2 anthocyanins (delphinidin & petunidin), a flavonol (quercetin) and a stilbene (resveratrol) inhibit endothelin-1 synthesis

RWPE reduce ICAM-1, VCAM-1 and selectin expression

Increase HDL and decrease in ox-LDL

ALCOHOL

1-2 drinks/day strongly & consistently a/w lower CHD risk than either abstention or higher intakes Rev Cardiovasc Med 2002; 3:7

Similar relationship with CHD regardless of type of alcoholic beverages consumed BMJ 1996;312:731-6

Major benefit of alcohol consumption related to an increase in HDL Reduced fibrinogen, platelet aggregation & inflammation

(Eur J Clin Nutr 2002; 56:1130) (Circulation 2003; 107:443) (Arterioscler Thromb Vasc Biol 2006; 26:995)

38,077 male health professionals free of cardiovascular disease f/u for 12 yrs Compared to men who consumed < once/week, men who

consumed alcohol 3-5 or 5-7 d/wk had decreased risks of MI Risk similar among men who consumed <10 g/d and those who

consumed 30 g or more. No single type of beverage conferred additional benefit

Physicians' Health Survey 87,938 men A 5.5-year follow-up

Circulation 2000;102:500-505

INTERHEART STUDY

RESVERATROL

Red wine, berries, peanuts & grapes

Polyphenolic compound Belongs to class Phytoestrogens Antioxidant & weak oestrogenic

activity Preconditioning effect rather

than direct protectionMol Int. Feb 2006 vol 6(1) 36-47

GARLIC

Beneficial effects on serum cholesterol, TG levels and on BP

Reducing platelet aggregation and increasing fibrinolytic activity

Sulphur-containing flavone compounds major health promoting components

J Nutr. 2006 Mar;136(3 Suppl):736S-740S

PLANT STANOLS/STEROLS

Plant sterols isolated from soybean and tall pine-tree oils Hydrogenating sterols produces plant stanols Available in commercial margarines

Plant-derived stanol/sterol esters at dosages of 2–3 g/day lower LDL-C levels by 6–15% with little or no change in HDL or TG levels

Am J Clin Nutr 1999;69:403-10

Metabolism 1999;48:575-80.

Circulation1997;96:4226-31

Projected that their use should double the beneficial effect on CHD risk achieved by reducing dietary saturated fatty acids and cholesterol

West J Med 2000;173:43-7

SOY PROTEIN

Derived by processing of the soybean Isoflavones, fiber, and saponins

Review of 16 trials: Soy protein included in a diet low in saturated fatty acids and cholesterol can lower levels of total cholesterol & LDL in individuals with hypercholesterolemia

Federal Register 1998;63:62977-3015.


25 g/day soy protein in a diet low in SFAs and cholesterol lowers LDL cholesterol levels by 5%

Metabolism 2000;49:67-72. about 5 percent

DIETARY INTERVENTION TRIALS

SATURATED FATTY ACIDS

Causal relationship between total & LDL cholesterol levels and CHD

Saturated fatty acids increase LDL concentrations

Palmitic acid (C16:0) found in meats, dairy fat, palm oil, is the most common saturated fatty acid.

Palm oil major fat source in Latin America, Asia, Europe

Western diets with dairy fat & meat contain myristic acid

Tropical oils: coconut or palm kernel oils, have mainly lauric acid

Myristic acid : strongest effect on LDL f/b lauric & palmitic acids.

WHAT SHOULD REPLACE SATURATED FATS?

Controversy

whether carbohydrate or unsaturated oils should replace the energy from saturated and trans unsaturated fat?

If saturated fat (e.g., 25 g or 10% of total daily energy intake) is replaced by carbohydrate, monounsaturated fat, or polyunsaturated fat, LDL will decrease by 13 mg/dL, 15 mg/dL, or 18 mg/dL, respectively

Arterioscler Thromb. 1992;12:911–919.

So is replacement with any of these logical?

Annu Rev Nutr. 1995;15: 473–493

LOW FAT APPROACH

Trial n Dietary Intervention

Diet Fat %

P and S Fat, %

Dur yrs

Change in Sr

Chol, %

Change in CHD,

%

MRC (low fat)

123 male MI patients

Reduce total fat

22 NR 3 - 5 +5

DART1989


Reduce total fat

32 NR 2 - 4 - 9

WHI2006

19,541 women

Reduced total fat

29P = 6; S

= 108 - 1 0

DIETARY INTERVENTION TRIALS OF LOW FAT APPROACH

WOMEN'S HEALTH INITIATIVE (WHI) RANDOMIZED CONTROLLED DIETARY MODIFICATION TRIAL

Dietary pattern low in total fat, along with increased intakes of vegetables, fruits & grains

50,000 postmenopausal women randomized to intervention group receiving regularly scheduled individualized dietary consultations

Comparison group receiving diet-related education materials only.

JAMA 2006; 295:655

Reduction in total fat intake between the intervention and control groups (28.8 % vs 37 % of calories) (p<0.001)

No significant effects of the intervention on CHD, stroke, or CVD were observed during the 8-year follow-up

Lack of benefit on CVD endpoints might be related to minimal change in LDL due to counterbalancing effects of saturated fat and polyunsaturated fats.

Modulation of total dietary fat intake within the range consumed in general population does not alter CVD risk

JAMA 2006; 295:655

WOMEN'S HEALTH INITIATIVE (WHI) RANDOMIZED CONTROLLED DIETARY MODIFICATION TRIAL

HIGH DIETARY PUFA APPROACH

DIETARY INTERVENTION TRIALS OF HIGH PUFA APPROACH

Trial n Dietary Intervention Diet Fat %

P and S Fat, %

Dur yrs

Change in Sr

Chol, %

Change in CHD, %

Finnish Mental Hosp Study

1979

676 men without CHD

↓saturated fat, ↑polyunsaturated fat 35 P = 13;

S = 9 6 - 15 - 44

Los Angeles Veteran Study

1959

424 men; no e/o CHD


S = 9 8 - 13- 20 in CHD,- 31CV events

Oslo Diet-Heart Study1969



S = 9 5 - 14 - 25

MRC (soy oil)1970


↓saturated fat, ↑polyunsaturated fat 46 P : S = 2 4 - 15 - 12

Minnesota Coronary Survey

4393 men 4664 women


S = 9 1 - 14 0

HIGH PUFA TRIALS

Corn, safflower, sunflower & soybean oils prescribed to hypercholesterolemic patients in the 1960s and 1970s.

Patients instructed to drink the vegetable oils, as well as to use them in cooking or salads

PUFAs studied mainly ω6 class and not include the ω3 PUFAs from fish

Linoleic and α-linolenic acids increased in these trials.

Coronary events are reduced by 2% for every 1% reduction in total cholesterol Am J Cardiol. 1995;76:10C–17C

INCREASE DIEATRY ω3 FATTY ACID STRATEGY

DIETARY INTERVENTION TRIALS OF ω3 FA

Trial n Dietary Intervention

Durn yrs

Change in Chol

Level, %Change in CHD, %

DART1989


Fish twice per week or fish oil (1.5 gm/d) 2 NR

- 16 on CHD events- 29 in total mortality

GISSI-Prevenzione

1999

5666 MI patients,

primarily men

Fish oil (EPA + DHA 1 gm/d) or mustard oil (ALA, 2.9 gm/d)

3.5 0- 30 in CV death

- 45 in sudden death

Indian1992

242 MI patients,

primarily men

Fish oil (EPA, 1.08 gm/d) 1 0

- 30 in fish oil group- 19 in mustard oil gp

WHOLE DIET INTERVENTION TRIALS

STANDARD WESTERN DIET

Total fat 38% Saturated fat 17% Monounsaturated fat 14% Polyunsaturated fat 7% Carbohydrates 42% Protein 20% Cholesterol 400 mg/day

STEP 1 DIET

Reduced total fat intake to 30% Saturated fat10% Dietary cholesterol 300 mg Replacing saturated fat mainly with carbohydrate. Monounsaturated 15% Polyunsaturated fat 10% similar to the initial diet Protein 15%

LOW-FAT DIET

Total fat 20% Saturated fat 7% Monunsaturated and polyunsaturated fats decreased to 10% and

5%, Carbohydrate increased to 65%. Protein 15% Cholesterol is reduced to 200mg/day

MEDITERRANEAN DIET

Saturated fat replaced with veg oils (olive, canola, corn, safflower or sunflower oil, or oils from nuts

Contain mainly monounsaturated and polyunsaturated fatty acids.

Total fat content remains at 38%

Dietary cholesterol is reduced to 100 mg/day

Arterioscler Thromb. 1992;12:911–919

PREDICTED EFFECTS ON CORONARY ARTERY DISEASE

Circulation. 1999;99:779–785

Olive oil rich in MUFAs

Extravirgin olive oil contains a considerable amount of phenolic compounds, hydroxytyrosol and oleuropein, having antioxidant & other potent biological activities

Refined olive oil contains less phenolic compounds : large fraction of potentially beneficial bioactive compounds(such as flavonoids) lost in processing

Eurolive project: Ongoing research on phenolic compound hydroxytyrosol for anti-platelet effect

LYON DIET HEART STUDYMEDITERRANEAN DIET TRIAL

423 patients with documented CAD f/u mean of 3.8 yrs

Experimental diet: increased amounts of fruits, vegetables, legumes, and fiber

Reductions of meats, butter, and cream (but not cheese)

Margarine enriched in alpha-linolenic acid, ω3 FA precursor of longer chain EPA & DHA found in fatty fish.

Total fat approximately 31 percent in both diets.

.

Circulation.1999;99:779–785

Significant reductions occurred in all outcome measures: All-cause mortality (56 percent) Cardiac mortality (65 percent) Nonfatal myocardial infarction (70 percent)

Particularly important role for increased omega-3 fatty acid intake was responsible

LYON DIET HEART STUDYMEDITERRANEAN DIET TRIAL

Circulation.1999;99:779–785

MEDITERRANEAN DIET

INDIAN HEART STUDY

Fruit & vegetable intake 3 times higher in the experimental than in the control group

Total fat intake 24% - 26% of energy in both groups

Experimental group had higher intake of polyunsaturated fats, fiber, vitamins C and E, carotene, and potassium

Experimental group had lower intake of SFAs and cholesterol

Carbohydrates shifted from refined to complex sources

2 to 3 days after the acute myocardial infarction

BMJ. 1992;304:1015–1019.

Body weight, LDL, TG, BP & serum glucose significantly decreased, and HDL increased in experimental group

Significant reduction in coronary events of 36% in experimental grp after only 12 weeks

After 1 year of treatment, significant decreases in All-cause mortality by 45% Coronary deaths by 42%, Nonfatal myocardial infarction by 38%

The vegetarian diet also reduced ventricular ectopy

INDIAN HEART STUDY

BMJ. 1992;304:1015–1019.

LIFESTYLE AND DIETARY MODIFICATION TRIALS

LIFE-STYLE HEART TRIALEXTREME LOW FAT & LIFE STYLE MODIFICATION

Vegetarian diet with 10 percent total fat

Aerobic exercise training, stress management, smoking cessation, and psychosocial support

48 men with coronary artery disease were allocated to intervention and control groups

35 completed a 5-year follow-up

JAMA 1998; 280:2001

Av diameter stenosis decreased by 7.9% in experimental grp compared to control group which had 11.8% increased after 5 years (p = 0.001)

25 cardiac events in 28 experimental grp pts vs 45 events in 20 control grp patients during the 5yr f/u (RRR for any event for control group, 2.47 [95 % CI, 1.48-4.20])

Intervention program vs control resulted in significant 40% versus 1% reduction of LDL &17% versus 4% reduction in body weight

No significant changes in HDL, TG or BP

LIFE-STYLE HEART TRIALEXTREME LOW FAT & LIFE STYLE MODIFICATION

JAMA 1998; 280:2001

CARBOHYDRATE BASED DIET TRIALS

CARBOHYDRATES

Important determinant of glycemic index is glucose content of carbohydrates

Bread and baked goods, and sugars in juices and soda have high glycemic index

Whole grains, beans, nuts, and vegetables have lower glycemic index, probably because the digestion and absorption of the glucose is slow.

HDL decreases when dietary fat is replaced by carbohydrates, whatever the type of carbohydrate

High glycemic index foods cause glucose & insulin to increase substantially

Low glycemic index foods cause less increase in TGs

DIETARY APPROACHES TO STOP HYPERTENSION (DASH) DIET

27%-fat diet vs typical US diet 38% Fruits, vegetables, and low-fat dairy products Only small amounts of sweets and sugar-containing

beverages Did not increase fasting triglycerides Favorable changes in total and LDL cholesterol Reduced HDL cholesterol 10-y risk decreased by 12.1% in DASH diet group compared with

0.9% increase in risk in control diet group (P < 0.01)

Am J ClinNutr. 2001;74:80–89.

TRANSUNSATURATED FATTY ACID BASED DIETS

TRANS-UNSATURATED FATTY ACIDS

Trans unsaturated FAs formed from naturally occurring cis unsaturated FAs during hydrogenation process

Most trans unsaturated FAs in diet are analogues of oleic acid, the main cis MUFA in diet

LDL increases and HDL decreases when oleic acid is replaced by trans FAs

Worse than the effects of carbohydrate, which decreases both LDL & HDL

Worst effects on blood lipids among all dietary FAs Increased risk of CHD in people consuming these FAs

Am J Med. 2002;113(Suppl 9B):13S–24S

DIETARY CHOLESTEROL

DIETARY CHOLESTEROL

Meta-analyses confirm the LDL-raising action of dietary cholesterolAm J Clin Nutr1992;55:1060-70

BMJ 1997;314:112-7

Meta-analysis: dietary cholesterol raises TC:HDL ratioAm J Clin Nutr 2001;73:885-91

Serum Cholesterol changes by10 mg/dL per 100 mg dietary cholesterol per 1000 kcal

Arteriosclerosis 1988;8:95-101. Western Electric Study: dietary cholesterol increases heart disease

risk independently of its effect on serum LDL levelsArch Pathol Lab Med 1988;112:1032-40

No significant association between frequency of reported egg consumption and CHD

JAMA 1999;281:1387-94

DIETARY TRIALS: CONCLUSIONS

Decreasing saturated fat lowers LDL cholesterol. Replacing SFA with carbohydrate lowers HDL as much as it lowers

LDL. TGs increase with high glycemic index sugars and starches. Fish oil FAs lower TGs Replacing SFAs with MUFAs or PUFAs lowers HDL only slightly and

does not increase TGs Trans unsaturated fats produced by hydrogenating vegetable oil

increase LDL and decrease HDL The most favorable overall changes in plasma lipid concentrations

are produced by replacing saturated and trans unsaturated fats with unhydrogenated MUFAs or PUFAs

DIETARY THERAPY THAT REDUCED CVD

Replacing saturated fat with polyunsaturated vegetable oil

Mediterranean diet after myocardial infarction

Indian vegetarian diet after myocardial infarction

Fish oil after myocardial infarction

WEIGHT REDUCING DIETARY STRATEGIES

WEIGHT REDUCING DIETS

Low-carbohydrate diet (<35 gm of carbohydrate per day)

Atkins diet stricter limitation (20 g/d) for first 2 wks Gradual increase of 5 g/wk to achieve wt loss 2 lb (0.9 kg)/wk

until a weight within 5-10 lb (2.3 to 4.5 kg) of the goal achieved Carbohydrate intake then further increased by 10 g/wk until

weight loss ceases

Reduced-fat diet Fat<30% of the total caloric intake

Variable Low-Carbohydrate Diet Reduced-Fat Diet

Food choices Highly restricted Moderately restricted

Initial rate of wt loss Rapid Gradual

Weight loss Dependent on duration Dependent on duration

Weight maintenance Unproven over the long term Unproven over the long term

LDL No change Decrease

HDL Greater increase Increase

Triglycerides Greater decrease Decrease

Potential long-term concerns

1. Calciuria (renal stones, ↓ bone mass)2. Relatively high-protein content (patients

with renal or hepatic disease)3. Atherogenicity (high saturated fat, trans fat,

and cholesterol levels and relative absence of fruits, vegetables, and whole grains

None

WEIGHT REDUCING DIETS

Up to 6 mths, av. wt. loss higher for diets with very-low-carbohydrate content (<35 g/d) than diets with usual amounts of carbohydrate but restricted in total fat

N Engl J Med 2003; 348:2057

Higher protein and/or lower carbohydrates content, especially simple sugars & rapidly digested starches with lower glycemic effects, increase satiety

Evidence for longer-term efficacy of such diets is lacking

Declining compliance by the end of one yearAnn Intern Med 2004; 140:778

`

Long-term safety and overall health effects of such diets

CALCULATING THE CALORIES

SEDENTARYMODERATELY

ACTIVEVERY ACTIVE

LOSE WEIGHT 15 kcal/kg 20kcal/kg 25kcal/kg

MAINTAIN 20kcal/kg 25kcal/kg 30kcal/kg

GAIN WEIGHT 25kcal/kg 30kcal/kg 35kcal/kg

To lose 1lb/wk, reduce calorie intake by 500 kcal/dayTo lose 2lb/wk, reduce calorie intake by 1000 kcal/day

1kg=2.2lb

DIET IN MANAGEMENT OF HYPERTENSION

DIETARY SODIUM

High intake of sodium results in increase in BPCirculation 1998; 98:613

Reducing Na intake by 80 mmol (1.8 g)/d yields SBP & DBP reductions of 4 & 2 mm Hg in hypertensive patients

JAMA 1998; 279:1383

Trials of Hypertension Prevention Sodium reduction, alone or combined with weight loss, can lower the

incidence of hypertension by about 20 percentArch Intern Med 1997; 157:657

Trials of Nonpharmacologic Interventions in the Elderly Reduced salt intake with or without wt loss significantly reduced BP &

need for antihypertensive medication in older personsJAMA 1998; 279:839

In both trials total sodium intake to about 100 mmol/day

DIETARY PATTERNS

DASH reduced SBP & DBP by 5.5 and 3 mm Hg more than did a control diet of equal Na content

DASH-sodium study, progressive sodium restriction in the DASH diet (from 150 to 100 mmol/d and 50 mmol/d) further BP

DASH diet with the lowest Na intake led to SBP 7.1 mm Hg lower in pts without hypertension and 11.5 mm Hg lower in pts with hypertension

However, most of the blood pressure reduction could be accounted for by the DASH diet rather than additional sodium restriction

Arch Intern Med. 2009;169(9):851-857

CARDIA STUDY

4304 young adults

Followed for more than 15 years

Multicenter, population-based, prospective study of CVD risk

Diets rich in whole grains, refined grains, fruits, vegetables, and nuts or legumes inversely related to BP

Positive effects of red and processed meat intake on blood pressure were observed.

Am J Clin Nutr 2005; 82:1169

OTHER DIETARY FACTORS AFFECTING BLOOD PRESSURE

Alcohol Observational data demonstrated relationship between heavy

drinking (3 or more standard drinks/d) and higher BPJ Cardiovasc Risk 2003; 10:21

Minerals: Ca, Mg, K Clinical trials: beneficial impact of K-supplements on BP Evidence for Ca & Mg is less consistent (only observational) K suppn of diet with 60-120 mmol/d reduced SBP & DBP by 4.4

& 2.5mmHg in HTNsive & by 1.8 & 1mmHg in normotensive pts The preferred strategy for increasing mineral intake is through

foods rather than supplements

Meta-analysis: JAMA 1997; 277:1624

Meta-analysis: JAMA 1998; 279:1383

Fish and alpha-linolenic acid Hypertension 2005; 45:368

Whole grains (in particular, oats J Nutr 2001; 131:1465

Protein (in particular, soy and total vegetable protein) JAMA 2003; 290:1029.

Hypertension 2001; 38:821

J Nutr 2002; 132:1900.

Soy isoflavone and polyphenols in dark chocolate can also promote blood pressure reduction

J Clin Endocrinol Metab 2001; 86:3053

Substitution of either protein or MUFA for carbohydrate substantially decreases BP in prehypertensive and stage 1 hypertensive subjects

JAMA 2003; 290:502

OTHER DIETARY FACTORS AFFECTING BLOOD PRESSURE

DIET IN HEART FAILURE

Sodium restriction (2 to 3g/d) recommended in all pts HF & preserved or depressed EF.

Restriction (<2g/d) in moderate to severe HF. Fluid restriction (<2 l/day) in hyponatremic patients (<130 mEq/l) or

if fluid retention is difficult to control Caloric supplementation recommended for patients with advanced

HF & unintentional weight loss or muscle wasting (cardiac cachexia) Anabolic steroids not recommended because of volume retention. The use of dietary supplements (nutraceuticals) should be avoided

lack of proven benefit potential for significant interactions with proven HF therapies

DIET IN HEART FAILURE

Braunwald`s Heart Disease, 8th Edition, chapter 25

DASH DIET IN HEART FAILURE

36019 pts aged 48 to 83 years

Without baseline HF, DM or MI

Women in top quartile of the DASH diet score based on ranking DASH diet components had 37% lower rate of HF

Diets consistent with the DASH diet are associated with lower rates of HF

No studies in HF patients

Arch Intern Med. 2009;169(9):851-857

AHA GUIDELINES

EVOLUTION OF RECOMMENDATIONS

ATP 1 and 2 (2000) NCEP/ AHA guidelines STEP 1 diet for those with high cholesterol STEP 2 diet recommended when the blood cholesterol does not

improve after 3-month trial of STEP 1 diet

ATP 3 (MAY 2001) American Heart Association accepted and endorsed this report Began incorporating recommendations into its materials on

dietary & lifestyle change Recommended the TLC (Therapeutic Lifestyle Change) diet

THERAPEUTIC LIFESTYLE CHANGE

AHA GUIDELINES FOR FISH INTAKE

Recommended consumption of 2 portions of fish/wk

Salmon, mackerel, albacore tuna, swordfish, herring, sardines, lake trout

Significant quantities of contaminants including methylmercury, polychlorinated biphenyls, & dioxin

FDA guidelines for maximal intakes for children & women of childbearing age

Recommendation of 2 portions/wk falls within these guidelines

AHA GUIDELINES FOR ω3 FA

Supplemental EPA plus DHA at doses of up to 1 gm/day may be considered for risk reduction in patients with CHD in consultation with their physician

Supplements also could be a component of the medical management of hypertriglyceridemia, a setting that requires even larger doses (2 to 4 gm/day)


AHA GUIDELINES FOR ALCOHOL INTAKE

Men who drink alcohol may consume up to 2 alcoholic beverages/day

Women no more than one/day, in part because of alcohol-related breast cancer risk.

Potential hazards: habituation to alcohol, adverse effects such as hepatotoxicity and aggravation of hypertriglyceridemia

Favorable benefit/risk ratio of other dietary practices and therapeutic interventions

Individuals should not begin to consume alcohol as a means of reducing coronary disease risk


NON BENEFICIAL THERAPIES

Folate supplementation in established vascular disease : no evidence of clinical benefit

N Engl J Med 2006; 354:1578

N Engl J Med 2006; 354:1567

Beta-carotene CARET study, non-sig 26% increase in CV mortality NEJM1996;334:1150-5

Alpha-Tocopherol, Beta Carotene Cancer Prevention Study, had no beneficial effect JAMA 2004; 291:565

Linxian study China: non-sig 10% decrease in CV mortality J Natl Cancer Inst 1993;85:1483-92

Vit E supplementation not beneficial GISSI Lancet 1999; 354:447

Women's Health Study JAMA 2005; 294:56

SU.VI.MAX trial Arch Intern Med 2004; 164:2335

THANK YOU

HAPPY HOLI

PREDICTED CHANGES IN CORONARY HEART DISEASE

∆LDL →1 mg/dL→ ∆CAD 1% N Engl J Med. 1989;321:1311–1316

∆ HDL → 1 mg/dL → ∆ CAD2% in men,3% in women.

Circulation. 1989;79:8–15.

∆ TG → 88 mg/dL (1 mmol/L) → ∆CAD 14% in men, 37% in women

J Cardiovasc Risk. 1996; 3:213–219

MEDITERRANEAN DIET

Documents

Role of diet in management of cardiovascular diseases like HTN, CAD & CHF